in which year he embarked for America as surgeon-major of the Royal Marine, and was constantly engaged down to the battle of Waterloo, where he was severely wounded. From that period to the present time he has not been idle; the volume which he has recently published bears ample testimony to this. Although rather obstinately attached to many of the doctrines and practices of former times, and unwilling to admit the value of some of the modern discoveries, it is impossible to refuse the highest praise to his numerous works, all of which bear the stamp of great practical value. Everywhere we meet with a clear detail of facts in all their points of view, a quick discernment of their real importance, a fair spirit of deduction applied to practice, and a sound judgment based upon the results of an immense experience.

When we think of the grandeur of the scenes on which Baron Larrey acted with a zeal which has never been surpassed; when we call to mind how many times the same problems of military surgery were brought under his persevering attention, and remember the multitude and variety of the operations which he has performed himself, or which have been performed under his immediate inspection, it is impossible not to rest with an entire confidence on the recollections of so colossal a practice, and we feel a degree of hesitation in questioning the propriety of any of his opinions and precepts. The further that we are removed from that memorable epoch of battles, and victories, and disasters, during which the genius of war converted the whole of Europe into one vast theatre of clinical surgery, the more highly will be estimated the importance of works replete with precepts dictated, so to speak, on the field of battle, like the bulletins of the Emperor himself. Never probably again will so many and so varied striking events be compressed into the career of one life; and never, we trust, will there be so ample a field of instruction in all the numerous departments of military surgery. He who from Egypt to Waterloo has stanched the wounds alike of conqueror and conquered, he who for thirty years has personified in himself the heroism of humanity, and has drawn around him all the distinguished men who have contributed during that time to advance the progress of our art, like rays all verging to or springing from one centre, diffusing among them the light of his own intelligence, cannot but be regarded with singular interest and admiration. It is not in his published works alone that we are to seek for the proofs of his presiding mind; we must compare the state of military surgery at the beginning of our revolutionary war with its present highly improved condition, and examine the numerous works of those men who have been formed under his guidance, to appreciate fully the mighty good that Larrey has done. The same remark is applicable to another bright ornament of modern surgery in France, we mean M. Dupuytren: his published works are far from being a complete expression of the striking individuality of his career and of the benefits which he conferred on medical science.

The recently-published volume of Baron Larrey closes the series of the voyages and campaigns, which he has so well described. It contains, besides, a new notice of the immoveable apparatus for the treatment of fractures and certain wounds of the soft parts, and sets in a striking point of view the advantages of its adoption in the surgery of actual warfare. There is also a reprint of the interesting memoir on the physical constitution of the Arabs. which was read some time ago at the Institute; the accuracy of the description has been amply borne out by the testimony of our military surgeons in Algiers, &c., and affords a striking proof that the illustrious author could extend his observation beyond the field of professional labour, and that he viewed every object around him with the keen glance of a philosopher.

Since the disaster of Waterloo, Larrey has visited Great Britain,-the Pyrenees, where on a pious journey to his native village he had the happiness of meeting his first teacher, a venerable priest now ninety years old: for, like Broussais, he was a child of the church,-Italy, which he had once traversed with our

victorious armies, and Rome, where he met Napoleon's august mother, who, though blind, at once recognised the voice of one of the legatees of her illustrious son.

Wherever he went, he inspected with the greatest care all the hospitals, medical schools, museums, &c., taking notes of what he saw and heard, and comparing them with the results of his own individual experience. In England, especially, he made himself thoroughly acquainted with all the details of the medical service, and modes of instruction adopted there, and with the various charitable and other institutions of the country; and, on his return to France, he drew up a report on the state of the English barracks and hospitals, which he communicated to the minister of war.

Let us join him in offering our homage to our confreres on the other side of the channel for the distinguished reception which he met with every where among them; in all the hospitals he was received as a master, and honoured as one of the glorious heroes of the imperial Iliad—a useful lesson to ourselves, who are too apt to be just only to the dead.

The caustic genius of the French character often prevents the due appreciation of talent in our own country: we seem to be unwilling to leave alone the glories achieved under our own eyes; and, like our ancestors who, in a day of puerile rage, destroyed the statues and other ornaments of our cathedrals, we, to gratify our sarcasm or ingratitude, too frequently attack the bright fame of our cotemporaries. Alas! we must confess, that even some of his illustrious patients, men who owed their lives to his skill and humanity, have too often forgotten their benefactor in the tranquil life of peace. We could mention the name of one general, who was saved by him more than thirty years ago, and who has been all that time trying to learn gratitude, and has not yet succeeded in acquiring it. It would seem that the Emperor had had a presentiment of such conduct, and that, as a recompense to his friend, he decreed by his will immortality to the name of Larrey.-Gazette Medicale.

ON THE FORMATION OF AN ARTIFICIAL ANUS: DISCUSSION AT
THE ROYAL ACADEMY.

M. Amussat stated that he had performed the operation in three different cases, since the date of his former communication to the Academy.*

In the first case the patient was affected with a cancer of the omentum, and the diseased mass was found on dissection to have compressed the colon, where it is about to form its sigmoid flexure; there was complete retention of the fæcal matters. M. Amussat established an artificial anus in the ascending portion of the intestine, following the plan recommended by Callisen. Having exposed the bowel on its posterior surface, in the right lumbar region, he first passed a thread through it with the view of securing it to the edges of the wound; he then opened it with a trochar, and afterwards extended the aperture in a longitudinal direction. A quantity of fæcal matter was at once discharged. Some time afterwards evacutions took place by the natural passage.

In the second case, the patient, sixty years of age, had, from the same cause as in the preceding instance, an obstruction of the bowels which had continued for nearly fifty days; the cancerous affection was seated at the upper part of the For a length of time nothing had been discharged per anum except liquid matters mixed with blood and mucosity. M. Amussat established an opening in the descending portion of the colon, and immediately a quantity of

rectum.

* Vide Medico-Chirurgical Review, for April, 1840, p. 539.

fæculent matter escaped from the wound. The bowels remained inactive; and, although no inflammatory re-action followed, the patient died on the 10th day after the operation, from the progress of the cancerous disease.

The third case occurred in a man who had been in excellent health, until suddenly seized with an obstruction of the bowels. The cause could not be discovered; and it was almost impossible to say whether the obstruction was situated in the large or in the small intestines. In this case, the operation of Littre was performed, although M. Amussat is not favourable to it upon the whole, but gives the preference to that recommended by Callisen. By opening the cæcum on its anterior surface, in the present case, he thought that there was a better chance of discovering the seat of the obstruction, whether it was in this bowel, or whether it was higher up. Having exposed the cæcum, he first secured it in its place by means of a thread passed through it, and then made an opening into it. The patient, who was in a state of extreme prostration, died in the course of twentyfour hours after the operation. On dissection, it was found that the obstruction was situated about the point of union of the transverse and descending portions of the colon. It had probably been induced by the irritation caused by a chickenbone which was found lodged there.

M. Amussat stated that the patient, on whom he had operated after Callisen's plan two years ago, remained in perfect health.

M. Gimelle, one of the surgeons of the Hôtel des Invalides, considered that M. Amussat had rendered an important service to surgery by restoring the operation of making an opening into the intestine without wounding the peritoneum; but he could not understand his motives for adopting the plan of Littre in the third case, where it is admitted that the seat of the constriction could not be determined before the operation.

It is to be remembered that Littre proposed his method only under more favourable circumstances; viz. when the distended bowel projected outwardly, and thus presented itself directly, as it were, to the scalpel.

M. Amussat said that the patient in question, in whose case he had been condemned for operating, was able to retain three enemata. It was therefore, he thought, presumable that the obstruction was situated high up; and, as it was impossible to discover its exact position, he was naturally led to prefer the plan which enabled him to reach as high a portion of the gut as possible. The difficult point for the surgeon to determine is how he should act under such circumstances; if nothing is done, the patient is almost inevitably lost; and if an operation is attempted, he (the surgeon) is exposed to the reproach of having hastened the fatal termination. We have seen that one of my patients, whose death appeared to be imminent, has been saved, and still lives to bear testimony to the success of the operation.

M. Velpeau:-In canvassing the difficult question at present before the Academy, it should be borne in mind that there is a very marked difference in different cases as to the length of time during which an obstruction of the bowels may continue with impunity: this holds good both in disease and in health. One thing has especially struck me in listening to the observations of M. Amussat; some of his patients have had alvine evacuations by the natural passage a few days after the performance of the operation. Now how should this be, if there was an actual and veritable obstruction? And, if such an obstruction did not exist, why operate at all? We have been told that one of his patients has survived for two years, and is still in good health; and yet this patient was pronounced to have scirrhus of the intestine. In what way are we to understand that the operation has been the means of prolonging his life? and how are we to imagine that the establishment of an artificial anus should be a cure for cancer? M. Amussat attributes the constriction of the bowel in his third case to the presence of a small bone found in the obstructed part; but may we not suppose that the stricture was of anterior date, and was rather the No. 87. 18

cause than the effect of the lodgment of the bone? The difficulty of forming an exact diagnosis as to the seat of the disease is extreme, and, in spite of the interesting observations now read to us, is still quite as great in my opinion as ever. When should we operate? This is the embarrassing question; at least in cases of cancerous affections of the bowels. As to the obstruction of the bowels from other causes, as for example in the last case narrated by M. Amussat, the operation is certainly indicated on principle; but then how are we to determine the exact seat of the lesion? And, setting apart those cases where we can determine this, I do not believe that the operation of Callisen, so much recommended by M. Amussat, can ever be generally applicable.

M. Amussat replied to the objections adduced by his honourable colleague. As to the circumstance of the bowels relieving themselves by the natural passage after the formation of an artificial anus, it deserves to be mentioned that this occurred not only in my cases, but also in those reported by Littre. The expla nation is probably this: the cancerous mass becomes more and more softened until ultimately it is detached, and then the passage which it obstructed becomes comparatively free. His doubts as to the real nature of the lesion in the case of the patient who still survives, appear to me unreasonable, as my diagnosis at the time was confirmed by MM. Recamier, Foville, and Breschet. The slow prognosis of the disease may be accounted for by supposing that there is an incarcerated cancer of the parietes of the rectum.(?)

M. Guersent mentioned two cases of obliteration of the intestines: the first occurred in the famous dancer Goyon, who had been long afflicted with a tumor in the rectum. He died in a state of extreme emaciation in the Maison de Santé; and after death it was found that the gut was completely obstructed by a cancerous ring or constriction. In the second case, symptoms of strangulation came on quite suddenly, and no external tumor could be detected. On dissection,

a cervical vertebra of a fowl was found placed across the intestine, so as quite to interrupt the passage of the feculent matter.

M. Lagneau.-It has been said that the re-establishment of the alvine evacuations by the natural passage, after the performance of the operation, cannot be easily accounted for, if the obstruction had been a veritable one. But let us consider that, after the discharge of the fæces by the artificial opening, the irritation which their presence caused gradually subsides, and, the parietes of the intestine becoming freed from their previous engorgement, the passage is thus restored for the transmission of their contents.

M. Cornac expressed his regret at not having been present at the reading of M. Amussat's paper. He had travelled with the patient on whom the operation had been successfully performed two years ago, and could bear ample testimony to the health which he now enjoyed. The patient, in his joy at having been saved by the operation, has often said that if Talma and Broussais had been treated in a like mannner, they might perhaps have been living at the present time. M. Breschet. I perfectly agree with the preceding speaker in the view which he takes of the operation and of its results, and most willingly give the credit due to M. Amussat for the happy modification of it which he has introduced. But I cannot agree with him in his regret that it was not performed on Talma and Broussais. I saw both those illustrious men in their last illness, and do not hesitate to affirm that neither was in a condition for such an operation to be attempted. Talma was visited by Dupuytren, who completely coincided in this opinion, and expressly stated, that in his judgment there was nothing that could be done; for, besides the disease of the bowels, there existed an aneurism of the heart, which would in all probability have speedily carried him off, perhaps suddenly, and on the stage, in one of those parts in which he used to display so much pathos, that of Orestes for example.

After a few words from M. Cornac, disclaiming all imputations on any of the

medical attendants of those distinguished individuals, M. Begin rose to express his dissent from the opinions of M. Breschet. Far from thinking, said he, that the disease of Talma did not admit of the establishment of an artificial anus, it was on visiting him that I conceived the first idea of it. In my opinion his case was eminently favourable to the success of such an operation, as there was no cancerous degeneration of the bowels, but only a simple constriction at the upper part of the rectum. I am aware that there existed at the same time an aneurism of the heart; but such a complication was not in itself sufficient to forbid making an attempt to relieve the local disease; and I had formed the project, which I communicated to Dupuytren, to pierce the pouch in which the fæcal matters were lodged, and to open in the rectum an artificial anus by means of this puncture.

M. Amussat expressed his concurrence in these sentiments of M. Begin. The case of Talma, although he had not had an opportunity of seeing him during life, had always seemed to him to have been favourable to such an operation as he has proposed. Not only was the disease of the bowels not of a cancerous character, but Nature herself had commenced a process of self-relief, there being found on dissection an ulceration on the walls of the constricted portion, or rather on the septum which separated the pouch containing the fæcal matters from the lower part of the gut.

As to the case of Broussais, I saw him, continued M. Amussat, in his last moments, and can state confidently that there was an almost complete stoppage of the bowels at the time of his death there had been no discharge for 21 days. The operation was therefore in my opinion quite admissible, and indeed it was on the occasion of my visiting this illustrious patient that I first thought of the plan of my method. I did not dare however to make the first attempt on so distinguished a person.

M. Breschet, in opposition to what had just been said of the case of Broussais, stated that, so far from there being a complete obstruction of the bowels, there were from time to time considerable evacuations, debacles, which the patient himself predicted would take place at particular times. It is easy now to say that the operation was indicated, and to form a diagnosis of the case a posteriori, after the dissection has revealed the nature of the existing lesion: but circumstances were very different during the life of the patient, and it will always be a most embarrassing question to decide as to the propriety of attempting an operation, when the diseased part cannot be reached with the finger.

M. Gerdy. The operation which M. Begin proposed in the case of Talma appears to me to be very rational, and I have several times performed it with success on infants with imperforate anus, whether the gut was deficient for some extent, or was nearly closed at its orifice. By leaving a canula in the artificial canal, we may avoid all risk of extravasation taking place. In the case of adults affected with an obstruction of the bowels, it is to be remembered, as already alluded to by M. Velpeau, that it may exist for a great length of time in some persons without being attended with dangerous consequences. We have all heard of a surgeon of Rochefort, who, during a voyage from France to Senegal and back again to France, had not one alvine evacuation, until he returned home. He lived for a length of time with this unusual condition of the bowels in very good health.

M. Begin stated that the chance of extravasation was much greater in such a case as that of Talma, than it could possibly be in cases of imperforate anus or rectum occurring in new-born infants. In Talma's case the serous coat of the distended pouch and that of the lower part of the gut were opposed to each other, and hence any instrument passed through the septum must necessarily have penetrated the peritoneum.