THE Medico-Chirurgical Review, No. XLII. [NO. 2 OF A DECENNIAL SERIES.] JULY 1, TO OCTOBER 1, 1834. LECONS ORALES DE CLINIQUE CHIRURGICALE, FAITES A L'HOTEL DIEU DE PARIS. Par M. le Baron Dupuytren, Chirurgien en Chef. Recueillies et publiées par une Societé de Médecins. Tomes 2 et 3:—à Paris, 1832, 1833. [Continued from page 91, of No. 37.] Ir is not, perhaps, necessary to enter into the reasons, which have occasioned the long interval between the former and the present notice of M. Dupuytren's lectures. These lectures have formed a staple article with our contemporaries, at least, with that portion of them whose visits are not few and far between; we mean the weekly journals. Yet these journals have presented them at such lengthened intervals, that the chain of connexion and interest is broken, and they resemble scattered and insulated pearls, rather than a close and well-arranged tissue, valuable in its construction as well as its material. We would recommend all whose education enables them to understand the French language, and whose means permit them to purchase the volumes containing the lectures, not to rest contented with mere translations. We have no hesitation in expressing our opinion, that the Leçons Orales will become a standard work, and will be found in the libraries of all accomplished surgeons. But we cannot acquiesce in the extravagant eulogy which some of our contemporaries have heaped upon it, nor do we feel constrained or inclined to admit, that it throws into the shade the efforts of modern English surgeons. A candid and rational consideration will lead, we apprehend, to a more moderate appreciation of its merits. It will probably be perceived to display the peculiar excellencies and defects of the present style of surgical works in France. There will be seen the abundance of all that is deducible from anatomy and pathology-the accurate description-and, in general, the just diagnosis; but there will be also seen the absence of that acquaintance with the powers of remedies, and the want of that decision and judgment in their application, which honourably distinguish the British school of Medicine. A critical examination will discover, in many instances, another faultone almost peculiar to the French nation. It is a fickleness and inconstancy in reasoning, as in character-a levity which has marked the disposition of the Gaul from the days when Cæsar first conquered and studied the VOL. XXI. No. 42. 26 aboriginal tribes. The French medical or surgical writer of the present day, always talks of a rigorous attention to facts, and inculcates the neces sity of absolute induction; yet, in some way or other, it usually happens that his conclusions exhibit the powers of his imagination, rather than the strength and sobriety of his judgment. French works are too often insufferably diffuse, the language and the taste encouraging the "copia fandi." The tired reader struggles through innumerable pages, where the verbiage surrounds him like the tall thick grass of an Indian prairie, concealing the prospect, and almost obscuring the sky. We cannot be accused of a wish to depreciate continental literature or foreign science. Few have laboured with more zeal or more anxiety to diffuse an acquaintance with both among our brethren. But we trust we are possessed of sufficient patriotism to award justice to our native land, and to claim for her the respect and the praise which are her due. It appears to us ridiculous to assert that English surgeons are below the level of their brethren on the Continent. We would wish to be informed what modern French or German works can be ranked above that of Mr. Brodie on the joints or can be deemed superior to those of Sir Astley Cooper on frac tures and dislocations, and on diseases of the testis? If there be such, we confess that we are unacquainted with them. The memoirs and the lectures of M. Dupuytren display a smaller share of the defects, and a more preponderating amount of the merits of the French school of surgery, than those of his contemporaries. His mind is cast in the English mould, or, rather, his observation and his vast experience have contributed to diminish that fanciful spirit which distinguishes the greet majority of his countrymen. In perusing his observations, we feel that we are holding converse with a practical man, and we do not appear to be regarding the declamatory candidate for the Concours. Our former notice of the second volume of the Leçons Orales was carried to the last article contained in it-one devoted to the subject of gun-shot wounds. The third volume of M. Dupuytren's lectures contains eighteen articlesthe fourth exhibits fifteen more. The latter forms the completion of the work. We have recommended all who can readily read and translate the French language, to purchase the volumes in their native form. But possibly many are insufficiently acquainted with that language, and probably more can ill afford the sum to which the work amounts. We think then we shall be doing an acceptable service to our readers, in presenting, in as connected and condensed a manner as our limits and the subjects will permit, an analysis of the two concluding volumes, and of the article on gunshot wounds in the second. The émeutes of Paris have given the surgeons of that peaceable capital considerable opportunities of observing the accidents of war. The works of Dr. Hennen and of Mr. Guthrie, familiar as they are to the profession, and embodying as they do the whole of what is known on the injuries of which they treat, will render a copious and particular notice of the Baron's obser The price of the four volumes is one pound, eight shillings, and four-pence. vations superfluous. We shall limit this portion of our task to selection of what may be novel, curious, or important. ON GUN-SHOT WOUNDS. This article occupies two hundred pages of the work. M. Dupuytren commences with some general observations on the effects of fire-arms, and remarks that they depend on two principal circumstances:-the nature of the charge, and the distance at which the piece is fired. Without following M. Dupuytren through his remarks on the action of the different varieties of fire-arms, and his exposition of the laws which regulate the course and the arrest of balls, we may glance at one or two particulars. If a piece is charged with powder but no wadding, the explosion is inconsiderable, yet sufficient to contuse the skin severely, when the charge is received at a short distance. But if wadding is employed, the injury which it produces is determined by the quantum of resistance, and the situation of the body struck. A case of this description occurred to M. Dupuytren. Two individuals quarrelled, and one in the heat of passion discharged his gun, which was loaded with powder only, into the abdomen of the other, who immediately fell dead. The piece had been discharged at the distance of a foot or two. On examining the deceased, the clothes were found tornthe anterior wall of the abdomen penetrated by a hole of more than an inch in diameter-the intestine wounded-and the wadding of the piece in the cavity of the belly. Suicides frequently forget to load the pistol with ball. The parieties of the mouth are violently distended by the rarefaction of the air. Sometimes the wadding traverses the palatine vault. If the direction of the fire is backwards, the vertebral column offers effectual resistance, but the soft palate is torn, and sometimes the inferior maxillary bone is broken. Small shot of different dimensions operates in two manners-that is, it strikes en masse, or after it has spread. In the former case, its action is more dangerous than that of a single ball, because it lacerates extensively the parts into which it is impelled; but where it has spread, the discharge must, of course, have been remote, and comparatively little mischief is inflicted. Much, however, must depend on the part which is injured. If the eye be struck with a single grain of shot, it is irretrievably lost. Passing over some pages of familiar remark, we may pause to listen to the observations of the Baron on the action of clothing in modifying the effect of balls, and on the injury produced by what has been termed their wind. Articles of dress, especially when wollen, protect in some degree the parts they cover. The hole made by a ball in clothes is always smaller than that in the skin. The ball often enters a limb to a considerable depth, without occasioning any perforation in the dress, which is, consequently, carried before it. In 1814, a French soldier, who was wounded before the walls of Paris, was carried to the Hôtel Dieu. On examining the upper portion of the leg, some pieces of cloth were found buried in the bone. pulling at these with some force, a kind of wadding was extracted, containing a ball inclosed in a part of the soldier's gaiter. Amongst the wounded received at La Pitié, in July 1830, was a patient who presented a nearly similar occurrence. On A ball had entered the abdomen, carrying before it a part of the shirt, by means of which the bullet was extracted; the patient recovered. The difference of size between the wound in the clothing and that in the skin, depends on their respective elasticity. The circumstance should be remembered, as an unacquaintance with it gave rise to the idea that Charles XII. of Sweden was assasinated. The ball had pierced the border of the monarch's hat, and entered the anterior part of the cranium, the opening in which was much larger than that in the hat. The notion of serious injury from the wind of the ball arises from the difference of elastic resistance in various tissues of the body. If a projectile, nearly spent, or at least much diminished in force, strikes obliquely on a rounded surface, like the thigh, it may pursue its course, without leaving any mark upon the trowser of the wounded man. The limb which has been struck is rendered numb and powerless, and the person falls. On examining the thigh the bone is discovered to be broken, the soft parts disorganized, and the skin apparently uninjured. The fact would seem to be, that the muscles, at the time when the limb is struck, are in a state of tension, and yield to the violence more readily than the elastic skin. If, instead of a limb, the chest should be the striken part, instantaneous death may be the consequence, and a careful examination may be necessary to disclose its cause. One ball may inflict several wounds, in consequence of its impinging on some hard substance at first, and being thereby broken into two or more portions. Thus a ball struck the lower part of the spine of the tibia in the right leg, and was divided by it into two pieces. Each, diverging a little, passed through the calf, and lodged in the fleshy part of the left leg, which happened to be placed behind the other. The observations of the Baron on the lodgment of balls, and on their travelling propensities, are deserving of attention. When a ball is lodged in any organ or tissue, it either excites inflammation and suppuration, or it does not. If none is occasioned, a cyst is formed, attached on its exterior to the surrounding tissue, and resembling on its internal surface a serous membrane; thus the ball is enclosed in a serous cyst. This is a fact of practical importance, for, in performing an operation for the extraction of a ball, if the cyst is left behind, an accumulation of serum in its cavity ensues, and an encysted tumor is the consequence. In removing the ball, the cyst must either be dissected out, or it must be dressed in the interior with lint, in order to produce suppuration and granulation. If inflammation is excited by the ball, the cyst, instead of secreting serum, gives rise to pus, and ultimately fistulous sinuses are formed, connecting the interior of the cyst with some internal cavity, or with the surface of the body. When balls travel, their progress may be rapid or slow. If the former, they leave no traces of their passage in the organs which they traverse. If the latter, they are surrounded by the serous apparatus just described. Bodies of all forms may shift their quarters in the body, though such as are narrow and pointed will do so with more ease than those which are spherical and obtuse. M. Dupuytren cautions the surgeon to be satisfied of the situation of the foreign body at the time when he performs the operation. If he cuts in a direction where he may have felt it the preceding day, it is possible that it may have removed in the interim. Balls usually travel from the interior towards the surface, but sometimes they pursue the contrary route. We may pause for a few moments at the Baron's description of the injuries inflicted by balls upon the bones. Sometimes, merely a contusion is produced; but this is more serious than it seems, for the periosteum is destroyed, or inflames, and necrosis may ensue. That the bones should be fractured in various ways, and shattered in various degrees, can scarcely be productive of surprise. But it might not be anticipated that the resistance of bone would be sufficient to break or divide a ball. When the latter impinges on an angle of bone, such is occasionally the fact. A ball which struck the spine of the tibia has been separated into two portions, which, traversing the leg, made their exit at separate apertures behind. similar division has been witnessed, in cases of injury of the flat bones. Swiss soldier was wounded by a ball, which fractured the right parietal bone, and was divided into two; one portion made its escape through the integuments, whilst the other penetrated the brain, and lodged on the tentorium cerebelli. At the same period, there was in the Hôtel Dieu a patient in whom a ball, having broken the occipital bone, was split into two portions, which still remained slightly united, and were arrested at the opening, over which they were placed, as it were, astraddle. A nearly M. Dupuytren relates a case, in order to shew how difficult it sometimes is to determine if a ball has entirely escaped, or has partially lodged. A Parisian was wounded by a ball, which penetrated above the clavicle, and made its exit behind, near the inferior angle of the scapula. The ball presented no other peculiarity than that of being rather flattened on one facet. The patient appeared to be cured, but, on examining him some time afterwards, a hard substance was felt near the posterior wound. An incision was made on it, and a portion of ball was removed. On weighing this, with what seemed the entire ball, the compound weight was found to be that of an ordinary bullet. M. Dupuytren relates some cases to exhibit the extraordinary course of balls. So many have been recorded by Dr. Hennen, Mr. Guthrie, and other surgical writers, that we do not think it necessary to pursue the subject. The Baron has little to say, or at least he says but little, on that serious affection denominated, perhaps not quite correctly, hospital gangrene. He states that in 1814, when the Hôtel Dieu was extremely crowded, many cases of this description occurred; but that, in 1830, when the wards were not too full, and the arrangements were improved, few instances were met with. Contused wounds are those which are most frequently affected with this species of gangrene, and, in 1830, the hands and the feet were the parts in which it commonly appeared. severe. The compound fractures produced by gun-shot are usually dangerous and We perceive no novelty in M. Dupuytren's description of the immediate consequences of injuries of this description. We may cite one remark, on the period at which secondary hæmorrhage; from the pressure of a fragment of bone, is observed. It is usually late, and subsequent to that at which bleeding from the separation of sloughs is noticed. M. Pelletan saw a case, in which the hæmorrhage occurried on the 70th day. We may rest for a moment to listen to the lecturer's description of the different conditions which fragments or splinters of fractured bones may ex |