later writers have attended more than their predecessors, to turning the cut edges of the intestine inwards, so as to bring the serous surfaces external to the cut edges in contact, when the ligatures are duly tightened—an important addition to the operative process. It remains to be p ved, from observations and from trials made on man, whether the mode of proceeding which refrains from passing the needle and thread through the inner or mucous membrane, or that which effects this object, is the best. I am of opinion that the continued suture through all the coats of the intestine is the best; and shall continue to think so until it shall be proved that the ligature passes into the bowel in both methods; a result which is doubted, when the inner membrane remains intact." P. 26. A punctured wound of the intestine, or one not more than a third of an inch in length does not call for interference; and even when the external wound is large we must not make it still larger for the purpose of investigating the condition of the intestines, unless any portion of these protrude, their contents are discharged, or hæmorrhage occurs. If, however, in the course of two or three hours' time we find the belly swelling from effusion or extravasation of blood, prompt interference gives our patient the only chance. The external wound must then be enlarged, the effused matters sponged up, and the bowel or artery secured by suture. So, too, we may have to re-open and even enlarge a wound which has already been closed by suture over a wounded intestine, providing swelling and ungovernable inflammation indicate this procedure. If, when we are enabled to examine the wound of the intestine, we find this to be very small, but not filled up by the mucous membrane of the gut, a tenaculum may be pushed through both cut edges, and a small silk ligature passed around, below the tenaculum, so as to include the opening in a circle, a mode of proceeding I have adopted from analogy, with success, in the external jugular vein, without impairing its continuity." Or one, two, or more continuous stitches may be made with a very fine needle and silk, cut off in either case close to the bowel. If the person survive, the threads or sutures will be carried into the canal. When the intestine is largely injured, longitudinally or transversely, or is more or less completely divided, the continuous suture, as already stated, is to be preferred to all others. When, after wounds of the abdomen, considerable hæmorrhage occurs, the wounded vessel must be sought for. If the blood comes from one of the mesenteric arteries, or the epigastric, the wound is to be enlarged, until the bleeding artery is exposed, when ligatures are to be placed on its divided ends, if they both bleed. I have seen this vessel tied several times with success." There is a much greater degree of danger attendant on wounds of the small intestines, than of the large ones; that is, recoveries more frequently follow wounds of the colon in its various parts, and of the rectum, than of the jejunum or ileum. In his third Lecture, Mr. Guthrie relates several examples of recovery after the most serious injuries by musket-balls penetrating the abdomen; and, alluding to the dictum of the late Dr. Thomson, founded on what he had seen after Waterloo, that the less the operations of Nature are interfered with the better the chance of recovery, properly observes that this is correct only in the absence of clear indications for interference. "When 1847] Wounds of the various Viscera. 95 they are present, the do-nothing system is generally followed by death. A well-regulated interference is likely to be more successful." Effusion of Blood into the Abdomen.-Petit the younger first pointed out that extravasations of blood were not diffused over and between the entire surfaces of the intestines, provided the person outlived the period of extravasation; and that general effusion only took place shortly before or immediately after death. When blood is effused in only moderate quantities, and is circumscribed by the compression of the abdominal parietes, it may be evacuated by the wound if this be sufficiently open, and the patient may recover if the accompanying inflammation is not propagated along the peritoneum, or becomes subdued. If its quantity be very small it may become absorbed; but where this is not the case it may then became a source of irritation. Petit and Larrey showed that it is then soon surrounded by fibrin, and thus cut off from the general cavity-a pouch or foyer, restrained within certain bounds, being thus formed. It now, however, ceases to be bland and harmless, and may, like any other foreign body, excite inflammation and suppuration. This occurs at a later period only, at the 10th, 12th, or a later day, after perhaps the original inflammatory symptoms have all subsided. With the general symptoms, pain and swelling near the wound manifest themselves, and sometimes fluctuation may be at once distinguished. If an incision be deemed advisable, it will be better first to pass down an exploring needle or a very fine trochar, and if this indicates that a bloody, purulent, or other fluid, is distending the abdomen, the original wound should be enlarged, or a more dependent opening made at once. The formation of these pouches, reservoirs or foyers are, however, so rare in the natives of our northern climate, that Mr. Guthrie looks upon them as very exceptional occurrences. Artificial Anus.—Mr. Guthrie enumerates some of the various procedures which have been devised for the relief of this disgusting infirmity, but adds nothing from the stores of his own experience. In truth, as he remarks, this portion of surgery has been almost exclusively cultivated on the continent, where the infirmity is far more prevalent than in this country. Whether the reason of this he assigns, namely, that the "hardy natives of Britain and Ireland seldom outlive the processes ending in mortification," is the correct one, we know not; but their seldomer outliving these, appears to us, at the least, a singular proof of their greater hardiness. Wounds of the other Viscera.-We can only cursorily glance at Mr. Guthrie's numerous observations upon these. Wounds of the Liver are very serious, though not necessarily fatal; a few persons recovering altogether, some imperfectly, and more dying either during the immediate or the secondary inflammatory action which is set up. Pain in the right shoulder and cramps of the muscles of the arms are common symptoms, joined to those of ordinary peritonitis. Several cases of recovery after severe wounds, giving rise to the discharge of blood and bilious coloured fluids, are related; but all the cases in which the gall-bladder was wounded proved fatal. Wounds of the Stomach are generally fatal, except when they are confined to its upper and anterior part, in which case the patient may survive. If the wound is small, it must be treated by the continuous suture, just as that of the intestines; and if the external aperture through which its contents are effused is too small to admit of the wound in the organ being sown up, it should be enlarged. This is, however, only a suggestion for the prevention of otherwise a certain death, Mr. Guthrie never having put it into force yet. In cases of wounds of this organ, the greatest caution in allowing food, especially of a solid character, must be long observed. In allusion to a case of idiopathically inflamed stomach, not marked by pathognomic symptoms, and in which suppuration had converted the coats of the organ into the appearance of a honey-comb, Mr. Guthrie makes the following general observation. "If there be a symptom more generally observable than another in all cases of dangerous wounds of the abdomen, it is anxiety--not only of the mind, as shewn by the countenance in a very expressive manner, but of the body, as demonstrated by the great uneasiness. In some cases it is a more certain sign than the pulse of great mischief; in others, more distinctive than pain, which is sometimes referred to a part unaffected; and is in all indicative of the necessity of a corresponding attention on the part of the practitioner; for, while it is present, although other symptoms be mild, the patient is in imminent danger." P. 55. Cases of fistulous openings into the stomach are by no means rare. Dr. Watson has collected, in the American Journal of Medical Sciences, for 1844, many instances of such, and of incisions made into the organ accidentally or for the removal of knives, &c. "Ploucquet, in his Bibliotheca, has enumerated nearly a hundred writers under the head Pantaphagus,' who have related such cases, and as many more under the heads Vulnus' and Ventriculus,' and Hevin, in the 1st. vol. of the Memoires de l'Academie de Chirurgie, has related some of the most interesting cases of those who have swallowed knives, &c. up to his time." Incised wounds of the stomach were rarely met with during the Peninsular war. Gunshot wounds were not unfrequent, and so fatal that, while Baron Percy estimates the successful cases as 4 or 5 in 20, Mr. Guthrie only calculates one-half of these. Wounds or rupture of the Spleen are usually fatal, from the abundant hæmorrhage they give rise to. Mr. Guthrie, during the Peninsular war, heard of no case, in which the spleen protruded through a wound, which recovered; although instances are related by authors in which this organ was successfully removed after injury. Wounds from bayonets, swords, &c., are not always fatal, since cicatrices are sometimes found in the organ corresponding to the external wound. Wounds of the Kidney are not so fatal as those of the spleen, although the complications they eventually give rise to render them scarcely less dangerous. Owing to the lingering character of some of the results, these are often unknown, the patient being lost sight of. The opinion once entertained, that wounds of the bladder are necessarily fatal, is now known to be erroneous; and when this organ is wounded below, or where it is not covered by peritoneum, patients recover often almost unaided. Dr. Thomson saw fourteen cases recovering at Brussels after Waterloo, in which the bladder had been penetrated by musket-balls. Mr. Guthrie has never seen a case 1847] Seymour's Thoughts upon several Diseases. 97 recover after the urine has found its way into the general cavity of the abdomen, the patient generally dying in from three to six days. Treatment of Injuries of the Abdomen.—Mr. Guthrie protests against the practice once in vogue of bleeding a patient immediately after the injury, thus delaying the necessary reaction, and preventing the agglutinative process which may prevent inflammation extending to the peritoneum. The abstraction of blood must entirely be guided by the existence of inflammation; and although, on the occurrence of this, very large quantities may have to be taken away, he is certain that he has seen cases in which depletion has been injurious from excess, the marks of intense inflammation after death having been wanting. However, in various parts of his work, he shows that he is an advocate for a very free use of the lancet, the employment of entire abstinence, and the other usual means of subduing violent inflammatory action, which is the character traumatic peritonitis, occurring in robust subjects, usually puts on. Indeed the idea, during our perusal of the cases, has several times occurred to us, that the subsequent reparative power was, in all probability, impaired in many of these, by the energy of the prior proceedings, and that the substitution of large doses of opium, after at least the first bleeding, and the permission of a somewhat better diet, would have better vanquished the enemy. However the powers of opium in analogous cases is of comparative recent discovery, and the battle-field, with all its dreadful privations, is not the place we look for other than surgical achievements. The axiom that no purgative medicine whatever should be given to a person with a penetrating wound of the abdomen," is strongly and justly insisted upon. We have perused Mr. Guthrie's work with great pleasure, and strongly recommend it to the notice of our readers, distinguished, as it is, by the same independent spirit of observation, and the ability and originality which characterize his other productions. THOUGHTS ON THE NATURE AND TREATMENT OF SEVERAL By Edward J. Octavo, pp. 260. THE contents of this volume consist of four papers on the interesting subjects of-Diseases of the Stomach-Gout-Mental Derangement-and Sciatica. We shall at once proceed to examine the observations of our author upon each in succession, selecting those parts that are of most value, and pointing out, as we go along, what seem to be the chief merits and defects of the work. The first chapter might have been more appropriately entitled, "Thoughts or observations on some of the more common symptoms of Diseases of the Stomach;" this being the real nature and scope of its contents. The first symptom that is considered is pain, and uneasiness in the epigastric re NEW SERIES, NO. XI. VI. H gion. It is technically known by the names of cardialgia, gastrodynia, gastralgia, &c. The cause is very different in different cases. Very often it is dependent upon an undue amount of acid secretion in the stomach. In such cases, there is not unfrequently, at the same time, great irritability of the heart, giving rise to many symptoms simulating those of organic disease of this organ. Inordinate pulsation in the epigastric region is a common accompaniment of this state. All the symptoms, however, give way to the use of antacids with sedatives, or of mild stomachic medicines. Dr. Seymour gives the preference to a powder composed of rhubarb, calumba, cinnamon, and carbonate of soda-taken before dinner or at bedtime, for a fortnight at least. When the cardialgia is not accompanied with heartburn or vomiting, "it may be believed to arise from the stomach being thrown into irregular contraction." The best remedy in such a case is a combination of the trisnitrate of bismuth and magnesia. The hydrocyanic acid, also, may often be used with much advantage. If the bowels are torpid, mild aperients will be required every second night or so. "Where the pain has resisted this treatment, and the emaciation is very great, so as to give alarm lest there should exist organic disease, as of fungus or cancer, the best remedy is a grain of opium thrice daily, the bowels being kept open by means of injections; the food being animal principally, and in small quantity." P. 7. The case of the poor Italian, quoted in illustration of this practice, is set down as an example " of over-secretion of acid in the stomach," cured by opium. It might be so; but the report of the case does not bear this opinion out. Pain of the stomach immediately after taking food is not unfrequently indicative of gouty derangement of the system. Even then, Dr. Seymour appears to think highly of the use of opium (a grain three times a day), the bowels being kept open by enemata. From its well-known effects of usually increasing the formation of urea and uric acid, it will be always right to associate its use with that of alkaline medicines. Pyrosis or waterbrash, when dependent upon a merely functional derangement of the stomach, is best treated with the compound kino powder, gr. v. ter die; the diet to be light and nourishing, and weak brandy and water allowed as a beverage. This symptom, however, is not unfrequently an accompaniment of medullary carcinoma of the stomach-a form of cancer, which, alas! often attains to a most serious extent, before the presence of organic mischief has been even so much as suspected. "It is, therefore," Dr. Seymour observes, "incumbent on the physician, when there is waterbrash, and especially if the patient be upwards of thirty, to enquire particularly as to the state of the epigastrium.' Another cause of severe pain at the pit of the stomach is the presence of a gall-stone, either in the gall-bladder, or in its passage along one of the bile-ducts. As a matter of course, if the free excretion of the bile is interrupted, symptoms of jaundice supervene; but, as long as there is no decided obstruction, the fæces and urine may retain their healthy colour, and the skin not exhibit any icteric tinge. In another set of cases, which generally occur in those-women more especially-who are "broken by servitude or distressed by wayward affec |