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M. Lisfranc succeeded in completely over-! throwing his adversary.) You say, page I146, " that ’if childhood is but little fa-vourable to lithotrity, old age, on theother hand, combines the greater part ofinverse conditions-for example, large-ness, moderate irritability of the bladder,dilatability and size of the urethra." Icannot agree with this doctrine; it seemsto me altogether erroneous; for I havefound that in the old person the prostategland is almost always in a state of moreor less considerable engorgement, whichmust of necessity produce narrowing ofthe prostatic portion of the urethra, andcreate an obstacle to lithotrity. I have,during the lapse of fifteen years, employeda great number of bodies for my course ofpractical surgery; we have often been

supplied with subjects from the old man’shospital, and I have almost invariablyfound this engorgement, which can be

anything but a favourable condition forthe introduction of instruments into thebladder.

M. BLANDIN was considerably embar-rassed by this. He could not deny thefrequency of prostatic engorgement in theold patient, and was obliged to contenthimself with the reply, that the operationof lithotrity performed on people advancedin life was very often attended with suc-cess, and quoted the practice of BaronHeurteloup, where, in thirty-eight casestreated by percussion, twenty-three be-longed to individuals from sixty to eightyyears of age. Besides, in another part ofthe thesis, he had noticed engorgementsof the prostate.M. LISFRANC, finally, did not think that

lithotomy in the female was so simple orso successful an operation as M. Blandinrepresented it. The statistical results in-dicated a contrary judgment. Frere Come,in thirty-three operations on the female,lost seven cases, and left six incomplete.M. BLANDIN always regarded lithotomy

in the female as an operation attendedwith little danger; he had seen about tencases operated on in the hospitals andprivate practice, and only saw one death.Besides, all the masters in surgery, andall the best authors, consider it as veryseldom fatal in the female; he was notaware of the cases published by FrereCome.

* In our analysis of the thesis of M. Blandin, wehave omitted reference to some poirts which subse-quently became the subject of controversy betweenthe author ahd the other candidates, because, al

though they may possess interest when mooted in thediscussion, they did not, by their importance, clain’a place iu a useful digest of the thesis.—ED. L.

THESIS OF M. SANSON.

(Sustained July 25th.)ON THE ADVANTAGES AND DISADVAN-

TAGES OF IMMEDIATE UNION OF

WOUNDS.—Pp. 113.

THIS subject broaches a point which isgreatly in dispute between the French andEnglish surgeons. The favour with whichHunter’s doctrine is received and followed

up in England, constitutes the chief dif-ference of practice between the surgeonsof both nations.’ Let us therefore hastento see in what point of view it is regardedby one of the best practitioners in theFrench capital.M. Sanson commences by a definition

of immediate union, which he calls " theoperation by which the surgeon places incontact the opposite points of a wound, todetermine adhesion without suppura.tion,or with the least suppuration possible,"and then proceeds to expose the pheno-mena accompanying wounds without sup-puration, and compare them with the ac-cident of suppurating wounds, in order todetermine the relative advantages, &c.

Chaps. I. II. & III.—The first and secondchapters contain a good description of thelocal and general phenomena exhibited bywounds which unite without suppurating.The third enumerates the conditions fa-vourable to union by the first intention,which are,

1st. The existence of life in the two sur-faces, and a free circulation.

2nd. The wound must be recent; theshorter time it has been exposed to theair, the more apt it is to heal without sup-puration.

3rd. The wound must be exempt fromcontusion. However, says the author,very justly,’the action of a contusing body,though even violently applied, does notalways render union by the first intentionimpossible. Amongst the wounded ofJuly 1830, M. Sanson treated a young manwho had the middle of the thigh traversednear its centre by a ball; there was noeschar; the wound united in a few daysby the first intention, and the two orifices; alone suppurated. Huter and Larrey haveseen several similar cases.

4th. Foreign bodies in the wound are an- obstacle.

5th. The conditions of age influencethe facility of union or non-union; it is

, more easy the younger the individual is.6th. Conditions of season and climate;

e witness the brilliant success obtained in

Egypt by Baron Larrey and by Clot Bey.7th. Finally, a most important condition

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is, that the surfaces of the wound be re- tained in immediate contact, during thewhole time necessary for the organizationof the coagulahle lymph.Means for favouring union by the first

intention:—lst. Situation of the parts ;2nd. Agglutinatives ; 3rd. Bandages ; 4th.Suture. An examination of the cases inwhich suture is applicable. Surgeons ge-nerally agree to reject the suture from thetreatment of wounds of the limbs ; how-ever, Delpech has lately employed themafter the great operations, without the in-conveniences generally attributed to them.

Cliol). IV.—General means proper toassure the success of immediate union. Itis not enough to place the surfaces in con-tact ; the surgeon must endeavour to re-move all complications which may dis-turb the process of union. These mostcommonly are,-pain, excess or absence ofinflammation, general debility, derange-ment of the primse viae.

Chapx. V.—Local Phenomena of Suppurat- c

ing Wounds.—Three main. circumstances 1

may vary the march of a suppurating t

wound, without changing the essential

phenomena. These aie, l8t, A consider- 1able separation of the edges of a simple wound, abandoned to itself; 2nd. An ex- 1

tensive loss of substance; 3rd. Contusion 1or disorganization of various tissues. Here follows a full description of the j

phenomena observed in these three cases:The change of aspect in the wound; theformation of a thin fine membrane at thebottom, which soon becomes the pyogenicmembrane ; the formation of small fleshyvascular masses called granulations ; thecontraction of the wound, depending onthe remarkable retractile property of thegranulations ; cicatrization ; and the unionof the divided tissues by a thin layer of a Ifibro-cellular matter, the " tissue inodu ,laire" of Delpech. So much for the first Icare. In the second, the process is slower,and varies according to the different tis- ‘sues; in the third, the elimination of thedisorganized parts must take place, before Iany attempt at healing goes on. !

Chap. VI.-Genei-al Phenomena of Sup -purating Wounds.—1. Development of thetraumatic fever, or during a later periodthe patient is exposed to accidents of adreadful nature, which have been attri-buted in turns to phlebitis or purulent ab-sorption. 2. Action of the wound on thebrain or general economy, wasting theforce of the patient, occasioning hecticfever, &c.

Resumé.—From the preceding observa-tions it follows, that when a wound is heal-ed by the first intention, we obtain the fol-lowing advantages :-1. The solution oj

continuity is reduced at once to the

smallest limits. 2. The united parts arewithdrawn from the action of the air, &c.3. Little local inflammation, pain, &c.4. The treatment, of short duration, is notlikely to derange the health of the patient..’). After a cure the cicatrix is linear, and .

does not impede action of subjacent mus-cles. - In suppurating wounds we haveas disadvantages,-1. The long exposureof the wound to the air, &c. giving rise topain, irritation, &c., and, as a consequence,severe traumatic fever. 2. The danger of itsreaction on the head or principal viscera =however, says M. Sanson, in the greaterpart of cases, we have merely the consti-tutional fever. 3. Fnally, the accidents

of too great suppuration, and the lengthof the disease. As to the dangers of

phlebitis, he proposes to speak of it pre-; sently, noticing, however, that the ac-

, cident most frequently occurs after am-

putations, and in cases of wounds com-bined with fracture. Besides these in-

- conseniences, there is the danger ofhospital gangrene coming on, and the ex-r tent of the cicatrix.

Here are decided advantages of unionby the first intention, considered gene-rally. But to decide the question of thethesis with any accuracy, it is necessaryto establish some division of wounds, andconsider union in each; the author, there-fore, distinguishes, 1st, wounds properlyso called; 2nd, wounds made by the sur-geon, excepting amputations; 3rd, am-putations.

-

Chap TTIL-Union considered in Wounds, properly so called Historicview.-Union bythe first intention employed by Hippo-crates, Celsus, &c. afterwards abandonedthe origin of a mixed method, which con-sisted in uniting a great part of deepwounds, and maintaining the other partopen, by means of a tent, which mightfavour the discharge of the fluids, andavoid the inconveniences arising from

their stagnation.It is now generally admitted, that unionby the first intention should be tried.1. For all wounds produced by cut-

ting instruments, whenever the edges canbe brought together, and the wound doesnot contain a foreign body, &c. The le-! sion of a considerable artery is no db-’ stacle, for the traject of the thread alonemay suppurate.

i ; 2. For contused wounds. When the contusion is feeble, or not violent, it affects: only the superficial parts.

A contusion, though it might be judged- enormous from the cause producing it,does not always contra-indicate immediate- union; and here the author draws a prac-f tical distinction of value. Bodies pro-

jected by powder, do not always produce,

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wounds which represent the form and size of the projectile; they sometimes give Irise to extensive lacerations, irradiatingfrom the wound itself. Here immediateunion may be tried. The author has seen IM. Larrey, in cases where one or even

both jaws have been carried away, andwhere all the soft parts of the face werehorribly lacerated, succeed in reducingthe wound to a simple one, by cuttingaway the edges and angular projec-tions, &c.

3. Wounds arising from divulsion.When a portion of the body has been sud-denly torn away, the only way to diminishthe extent of the wound is to apply atonce all the, parts that can be broughttogether.

Immediate union should not be tried,1. In poisoned wounds;2. In incised wounds, if they are so ir-

regular, &c., that the opposite surfacescannot be brought together without leav-ing intervals, unless the intervals be soplaced that any fluid collected may beevacuated by a counter-opening;

3. Where there is a foreign body in thewound or effused blood &c. which can-not be completely removed;

4. In cases of injury to a duct, whereunion would produce effusion;

5. In cases where it would requiregreat force to bring the edges of thewound together;

6. Gunshot-wounds (as a general rule)and contused wounds. Having thus es-tablished the indications and counter-indications of immediate union, M. San-son describes the rules of dressing. Inall cases, he advises to wait until the flowof blood be completely arrested before thewound is closed; he also cuts off one endof the ligature; where the wound is ex-tensive and the ligatures numerous, he as-sembles them in different bundles to bebrought out at the corresponding angles.In order to moderate the inflammation,M. Sanson praises much the application 01cold water for three or four days, so as tckeep up a constant low temperature, joinedto humidity.These generalities laid down, the author

examined wounds in the different region;of the body.Wounds of the Integuments of the Skull

- Simple incised wounds to be united aonce, and covered with a compress dippe(in cold water. When the wound present!a flap, the base of which is downwardthe point generally retracts and leave;some part of the bone denuded. Here thE

’

suture should be employed. Petit recommended making a counter-overture at thEbase of the flap to prevent the accumulaon of pus, &c., but M. Sanson does no

think that necessary. But these woundsare often attended with dangerous com.plications, as intolerable pain from in-

complete division of the nerves, inflam-

mation extending under the aponeurosis,and terminating in suppuration, denuda.tion of the skull, meningitis, &c. The

development of these accidents may, in

many cases, be prevented by leeches, ap-plied behind the ears for several days,and sinapisms to the lower extremities,with laxatives or diluents to the intes-tinal canal; but if in spite of these meansinflammation declares itself, we should nothesitate to remove all the means em-

ployed for union, and to divide the tissuesdown to the very bone.

Wounds of the Face and Neck-penetrat-ing Wounds of the Cleest.-w’hen these areaccompanied by effusion of blood intothe chest, surgeons are divided on thetreatment. Pare advised keeping thewound open, to prevent the accident ofsuffocation, &c.; others, amongst whomis one of the judges, act diametrically op-posite, and close the wound in order to

stop the hemorrhage. M. Sanson doesnot attempt to resolve this question orgive a decided opinion.

Penetrating Wounds of tlee Abdomen areto be united immediately whenever theviscera are free, easily reduced, and pre-serve their integrity.

Wounds of the Limbs.—Under favour-able conditions, all these wounds shouldbe united by the first intention. Larreyhas proved that incised wounds penetratinginto joints, and even injuring the bone,may be cured by immediate union. Hedivides at first, to discharge any blood ef-fused into the cavity of the joint, removesany portion of bone or cartilage injured,and then fixes the limb immoveably. Inthis way he cured, at Cairo, a wound ofthe shoulder-joint. There was no sup-puration, and the limb preserved itsmotions. A more important question isto decide whether or not we ought totryimmediate union in wounds complicatedwith fracture, and surgeons are muchdivided in opinion upon this point. Thenumerous cases of unsuccess where unionhas been tried, induce many to prefer am-putation. However, there are certainlycases of exception : thus whenever thefracture and wound are free from contu-sion, or when the fracture is indirect,and the wound is produced by the frag-ments being driven outwards, it is easyto reduce the injury to the conditionsof a simple fracture. M. Sanson hastreated several cases of compound fractureof this kind successfully, by closing thewound and employing cold to prevent in-flammation. In all other cases it is ge- .

693

nerally admitted that amputation is re-

quired ; however, the remarkable resultsobtained by the immoveable apparatus ofM. Larrey, again render the question un-decided, and new facts are required.

PART II.

On t7te Immediate Union of Wounds re-sulting from Surgical Operations, exceptAmputations.—Immediate union is appli-cable to a vast number of surgical opera-tions, which the author examines, butwhich we cannot even enumerate here.The cases to which it is not applicable are,according to M. Sanson,

1. When the operation has been per-formed to evacuate a fluid, or where anatural duct is obliterated, as after tre-

panning for effusion, bronchotomy, &c.2. When it is right to obtain cicatriza-

tion from the deep towards the superficialparts, as in nstulse in ano.

3. When a foreign body is not extractedby the first incision made, but it is neces-sary to operate a second time.

4. When it is probable that suppurationis inevitable.

5. When a duct is opened and the ef-fusion of its fluid is inevitable.

6. When we wish to destroy adhesionsbridles, &c.

8. When it is necessary to re-establisla duct or an obliterated orifice.

PART III.

On the Advantages and Disadvantages ofImmediate Union after Amputations.From the preceding brief sketch of the

opinions detailed by M. Sanson in thethesis before us, it will be seen that the

practice of French surgeons, with respectto the union of wounds, &c., differs verylittle from that followed in England. Inthe treatment of amputations, however,the difference is much more marked. andif success be taken as a criterion of the

two methods, the superiority undoubtedlyrests with English practice. We have nomeans of obtaining the results of ampu-tations performed at the London hospi-tals ; but we may say, without fear, thatthe mortality, on an average, has neveramounted to one-third of those operatedupon,-the result of the practice of two ofthe most celebrated surgeons in France,MM. Dupuytren and Roux.The honour of applying immediate union

after amputations belongs, says M. Sanson,to Lowdham; the process was improved byCheselden in England, and by Petit andLouis in France, who gave a better form to

the stumps ; it soon became the favouritepractice in England, and also in Germany,where it was vigorously advocated byLangenbeck and Graefe. In Italy the par-tisans and opponents were nearly equally

divided. In France it was adopted by

Desault, and practised by Baron Percy,who, after the affair of Neubourg, ob-tained wonderful success by this method(ninety-two amputations, eighty-six cures).At the present day, in Fiance, it is recom-mended by Professors Dubois and Riche-rand, and Maunoir of Geneva; while Pel-letan, Boyer, and Larrey, reject it; MM.Dupuytren and Roux employ it only in afew particular cases.

To what are we to attribute such a dif-ference of opinions ? Is the question re-solved by the results ?

In a thesis of M. Avery, 353 cases ofamputation are collected from the prac-tice of Alanson, Freer, Kenedy, Lucas,Percy, Lawrence, Maunoir, Dubois, andHammick; the number of deaths wereeighteen, or nearly one-twentieth. Again,in ninety-five amputations, thirty-eighttreated by immediate union by M. Rouxand Dupuytren, (who lost one-third,) andfifty-seven treated in the same mannerafter the siege of Antwerp (one-sixthlost), the average of deaths was about

one-fifth; and if we examine the practiceof Alanson, Lawrence, Percy, &c., we findthat some did not lose a single patient inthirty-six operations, while others lost

f one-ninth, one-tenth, one-fourteenth, &c.If we add the cases of Roux, Dupuy

tren, and Larrey, to those quoted above,we have 448 operations and thirty-eighte deaths, or one-twelfth.

Such are the statistical details given byM. Sanson, but from which he draws noconclusion whatever; he seems to us,

however, to have neglected a most im-portant element of comparison-viz. thestatistical results of amputations treatedby the second intention, which he couldeasily have had from the Hôtel Dieu, LaCharité, La Pitie, &c. If we mistake not,M. Dupuytren, who treats his patients bya mixed method, loses one-fourth, a pro-

portion very much more unfavourablethan one-twelfth.

We now arrive at the termination ofthe thesis, in which the author gives a

resume of the advantages and disadvan-tages of immediate union after amputa-tion.The advantages have already been no-

ticed under the head of wounds in gene-ral ; it is unnecessary to recur to them.

694

The inconveniences evinced by the oppo-nents are :-

1st. Hemorrhage.—Pelletan has muchinsisted on the danger of bleeding, whichhe says is more frequent after union bythe first intention. M. Sanson regardsthis objection as of little value. Now-a-days the ligature is so perfected, that any danger from its relaxation, or prematuredivision of the vessel, is slight. Besides,the inferior angle of the wound may beleft open, so as to give exit to any fluid.

2nd. Purulent Collections.-This also isan objection of Pelletan, which the au-thor shows to be unfounded.

3rd. The sudden Suppression of a Lozzg-standing Suppuration.—This is not appli-cable to amputations practised for recentinjuries, &c. Where the suppuration isof such a kind as to improve the generalhealth (and this may happen), it shouldnot be suddenly suppressed. ,

4th. Phleuatis.-This M. SANSON regardsas the most important point of the ques-tion : viz., to determine whether immediateunion is more favourable to the develop-ment of phlebitis than the method ofallowing the wound to suppurate, becausethe greater number by far of patients whodie after amputations in the hospitals, arecarried off by phlebitis. This accidentmay occur after any kind of dressing, butit remains to see if one species may notfavour it more than others. Two circum-stances seem more particularly to pre-dispose to phlebitis : viz., suppuration, andthe stagnation of purulent matter. Nowfrom the nature of an amputation, &c., insome suppuration at least is inevitable, andit is also a necessary consequence thatthe pus stagnates more or less; the skinhas always a greater tendency to unitethan the deeper parts, the pus is retained,alters in quality, and is absorbed; hencewith all its advantages, immediate unionhas the great disadvantage of placing thewound in circumstances most favourableto the development of phlebitis. On thisaccount many French surgeons place aslip of lint all along the lips of the wound,and endeavour to heal the deep-seatedparts first. This mixed method, which M.SAKSON regards as the most ratiollal inthe present state of surgery, is that em-ployed by BOYER, LARREY, Roux, Du-PUYTREN, &c. Nl’e cannot hope to obtainby it the rapid cures which sometimesresult fiom the method of primary union,but these rapid cures are rare; the greaterpart of the cases require three weeks ora month, and the mixed method demandsvery little mote time.

Such is a brief analysis of M. SANSON’Sopinions on union by the first intention.

We have not now time to discuss them,but leave our readers to judge whether, ashe asserts, immediate union exposes moreto phlebitis, than union by suppuration.The doctrine laid down in the conclusionof the Thesis seems to be universallyadmitted in France, for not one of the

argumentators objected to the fundamentalproposition by which immediate union ofthe whole stump after amputations is

rejected. The French surgeons, then, en.deavour to heal by the first intention the

bottom of the wounds, while they forcethe surface to suppurate.

(To be continued),

THE LANCET.

London, Saturday, Aug. 9, 1834.

Tii-c managing Committee of Christ’s

Hospital, alarmed at the discussions whichhave recently taken place relative to the

management of that institution, have, itis said, taken legal advice, in order to

ascertain the extent of their responsi-bility either to the Parliamentary Medi-cal Committee, or to any of the establish-ed tribunals of the country. If the con-

duct of these managers had not been

marked by absurd practices generally,we should give no credit to this iumouredabsurdity; but after the ridiculous, not to

say pernicious, mode in which they haveconducted the affairs of the establishment,we are almost inclined to give credence to

reports of any act of folly that may be im-

puted to such a body. It is further al

leged, in certain quarters, that Mr. WAR-BURTON is disinclined to scan with a

penetrating eye the medical departmentof Christ’s Hospital, on the ground thatthe entire proceedings of that establish-ment were subjected to an examinationbefore the charity-commissioners, whosereport has, for some years, been before

Parliament and the country. Not hav-

ing seen a copy of the evidence elicited

by those commissioners, we are unable to