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Influence of TeMtperam.eK<.&mdash;From analyses made by Lecanu z’’

on men and women of different temperaments, it appearsthat in the sanguineous the amount of red corpuscles is

larger than in the lymphatic, the other constituents remain-ing in about the same proportion; the same has been ob-served between subjects of strong and those of weak con-stitutions.

Clinical LecturesON THE

G R A V I T Y A N D T R E A T M E N T O FG U N S H O T W O U N D S,

DELIVERED BY

M. VELPEAUAT THE "HOPITAL DE LA CHARITE," PARIS, AND OCCASIONED BY

THE GREAT NUMBER OF WOUNDED BROUGHT INTO THE HOSPITAL

AFTER THE CONFLICT OF FEBRUARY, 1848.Translated, expressly for THE LANCET,

By VICTOR DE MERIC, M.D., M.R.C.S.E.

LECTURE III.

iNCISIONS EXTRACTION OF FOREIGN BODIES; ARTIFICIAL COM-PRESSION OF ARTERIES ; BLOODLETTING.

Now that we have sufficiently considered the subject of Idilatation, I have to offer you a few words on the practice ofmaking incisions to relieve tightness and distention along thetrack of the ball. The question is, whether this line of prac-tice is a legitimate and warrantable one 1 I do not think so,and must add that the distention and strangulation which theparts are alleged to suffer in cases of gunshot injuries aremostly imaginary. You may convince yourselves of thecorrectness of my views on this subject, by observing thewounded which have lately been brought to this hospital.Most of these poor fellows have had their limbs shot com-pletely through; the wounds of a great proportion of themare narrow and deep, and upon none of the patients are thereany signs of distention to be seen. You will find, even in theimmediate vicinity of the wound, or within the latter, verylittle oedema; its margins are, on the contrary, flaccid anddepressed. It was formerly the custom with all surgeons tomake the incisions I am speaking of, and as this practice wasuniversally adhered to, cures were attributed to it whichcertainly would have been effected without the interferenceof the knife. Very curious and interesting comparisons wereinstituted in 1830 relative to the practice of these incisions:Dupuytren, at the Hotel Dieu, used them largely, whilst Lis-franc, at La Pitie, never had recourse to them at all. As for my-self, I freed the parts upon two patients only, at St. Louis, towhich hospital I was then attached. Now both methods yieldedsimilar results. "Bwhat are we, then, to conclude from thesecomparative statements t thinkwe lIlaysafelytake it as a near

approach to the truth,that incisions are, in general, not necessaryto prevent distention and strangulation of parts. Now the nextquery is, Whether the act of freeing the textures prospec-tively is fraught with any danger ? I am prepared to answerthis in the aftirmative, at least as regards most cases of gun-shot wounds; and I have no doubt that we should hazard thelife of our patient very materially, if we were to lay open thewhole trajet of the ball, as advised by Dupuytren. Supposethe projectile had run through a very fleshy part, as the thigh,for instance, what would be the result of free incisions in thatregion ? Why, we would evidently run the risk of dividingimportant nerves or vessels, and give rise to very alarminghmmorrhage. I would, then, to sum up what I have said onthis subject, lay it down as a rule, that the practice of making

incisions, in order to free apprehended engorgement and dis-tention, as resulting from gunshot injuries, does not rest onsound principles, and should decidedly not be indiscriminatelyadhered to. The use of the knife should be restricted topeculiar circumstances, where its interference is of obviousutility; thus, incisions may be made in order to facilitate theextraction of foreign bodies which the surgeon finds it diffi-cult to reach; or to get rid of the distention of an aponeurosiskept on the stretch by an effusion, and which might deter-mine troublesome strangulation of the parts; or, lastly, wheresuch tightening and strangulation have actually occurred.

Extraction of Foreign Bodies.-Is it incumbent upon us toextract immediately any foreign body that may be lodged ina gunshot wound? Some surgeons think so, and I am inclinedto agree with them, reserving, however, a few restrictions.If, for instance, the foreign body lies free and unconnected inthe wound, and its extraction will not produce further mis-chief, get rid of it by all means. But it often happens thatthese foreign bodies are still connected with the tissues; thusmay bony fragments, m commmutme tractures, adhere stronglyby some points of their surface either to the shaft of the bone,or to the periosteum, or to any of the textures connected withthe osseous structure, whilst other splinters of bone are quitedetached. The latter should be, of course, removed at once;whilst the former should not be disturbed, and their extrac-tion postponed. Some of the fragments are sometimes verysmall, and could hardly be seized; the eliminating processshould, in such cases, be left to Nature; they will commonlybe cast off by suppuration, as are, in fact, all the tissues whichthe violence of the contusion has changed into an eschar.Now what are we to do with regard to the balls? t It happensso often that they cannot be discovered, in spite of the mostdiligent search, that it will be advisable not to troubleourselves much about them. If a ball strikes the frontof the chest, and comes obliquely in contact with a rib,its course may suffer a complete deviation, follow the con-vexity of the rib, and lodge in the back, close to the ver-tebral column, without penetrating the chest at all. Nowwhat would be the advantage of searching for it in sucha case, and thereby make two wounds instead of one 1 If, onthe other hand, the ball has actually entered the chest, wemust not suppose that the danger of such an injury lies in thepresence of the ball within the thoracic cavity; it is the lesionof the viscera which principally puts the life of the patient inperil. Now, supposing the contents of the chest reallywounded, and that we were to enlarge the wound in order tosearch for the ball, we would by this procedure facilitate theentrance of air through the aperture made by the projectile,and its reception into the track of the ball, from which we,on the contrary, should carefully exclude it. The most dan-gerous complications would ensue from such a practice. Ifthe ball were lodged in the groin or axilla, it would be equallyhazardous to attempt immediate extraction, on account of thevessels and nerves which might be wounded by this operation.Balls are moreover foreign bodies, the presence of whichthe tissues bear very well. Larrey gives the case of an oldsoldier, upon whom a ball was found incarcerated in the rootof the lung; it had remained in that situation for thirteenyears, and had had no prejudicial effect on the man’s health.I myself extracted a ball, a little time ago, from the ham of a.patient; it had been lodged in that region since 1813, and hadnot given rise to any accidents.

Balls, as you are probably aware, whatever may be thepart where they are arrested, get surrounded by a sort of bagor cyst, which separates them from the neighbouring textures,and prevents them from causing the irritation and innamma-tion which foreign bodies generally give rise to.

A1"tificial Cornpression of Arteries.-BVe have seen that

haemorrhage is one of the most fearful complications whichaccompany gunshot wounds. If the haemorrhage is imme-

diate, the means of stopping it are so well known that I need

60

not dwell upon them. But, as I pointed out before, h2amor-rhage is mostly secondary,-that is to say, it occurs only whenthe clot which had plugged up the vessels falls off. Now thissecondary haemorrhage is very dangerous in most cases, andoften kills the patient in a few minutes; but we shall dreadthis complication still more when we recollect that a suddenand fatal gush of blood may take place when we least thinkof it, and without any premonitory symptom. This fact hasnaturally led surgeons to inquire whether it would not beadvisable, in those cases where we suspect that a large arteryhas been wounded, to use a prophylactic compression on thecourse of the vessel, by means of a tourniquet. I do not ap-prove of this method, for if the compression is powerfulenough completely to stop the circulation through thevessel, it may give rise to gangrene; and we know thatgunshot wounds are, by their very nature, sufficiently ex-posed to sphacelus, so that it would be hardly justifiable tomake the patient run an additional risk. If, on the otherhand, the compressive force is not sufficient to obliterate thevessel, it is quite useless, and hurtful besides, on account ofthe pain which it occasions.

Bloodletting.-Abstraction of blood, both locally and gene-rally, have been strongly recommended by a great number ofsurgeons, especially by those who do not advocate the practiceof incisions. Venesection has been employed by some prac-titioners immediately after the receipt of the injury, andrepeated several times over, with a view of obviating localinflammation and general reaction. These measures, gentle-men, are very advisable within certain limits; but they maybe fraught with much danger-nay, they may rapidly bringon a fatal issue, if not applied with prudence and moderation;for when the patient arrives at the suppurative stage, if hehave been weakened by bleeding, he will not be able to bearthe drain of suppuration, and you are aware that in gunshotwounds the suppurative process, along with the eliminationof the sloughs, cannot be prevented, and are inevitable; weshould therefore husband the strength of our patient, and notbleed him too much. You must not, in fact, have recourse tovenesection merely because your patient is labouring under agunshot wound, but you should be guided by the usual indi-cations for the abstraction of blood. Thus it will beadvisable to bleed immediately after the wound has been in-flicted, when the latter involves parts abundantly providedwith cellular tissue, if the patient is plethoric, and above all,if the wound has penetrated a splanchnic cavity. Bleedingmav also be used in a later stage if the reaction is too violent.or if the inflammatory fever is too intense. Local bleedinghas likewise been extensively used in cases of gunshot wounds,by means of the cupping-glasses or leeches. When cuppingwas resorted to, it was employed to answer two ends. Theglasses were applied on the wound itself, the margin of thelatter having previously been slightly scarified. This was in-tended to pump up and draw out the poison, just as it is nowdone with wounds really and truly poisonous, or with thoseresulting from the bites of snakes. This mode of applyingcupping-glasses is now quite abandoned, as the idea that gun-shot wounds are venomous is entirely given up. This practiceis, however, not bad in itself, since there is really, as I haveshown, a sort of poison generated in most gunshot injuries.As for myself, I do not use cupping at all;’ I prefer injections,which are much better calculated to cleanse the wounds, bywashing away all those putrid substances which might provenoxious to the economy. The other end which was held inview when cupping-glasses were applied in the ordinarymanner, was to control the pretty intense inflammationwhich sometimes springs up around the wound; but thescarificator, as well as the exhausted glasses, are too pain-ful in such cases, and they may advantageously be re-

placed by leeches. But you must notice that the latterare not advisable, except the inflammation be consider-able ; and there is no doubt that Dupuytren was quiteright when he condemned, in strong terms, the abuseto which the application of leeches was carried. Lisfrancused to apply them five or six times consecutively aroundgunshot wounds, not because there was any particular in-dication for such a course, but from principle, and a priori,in order, as he said, to combat the likelihood of distention inthe part, and to render incisions unnecessary. To convinceyourselves that this was bad practice, you should rememberthat distention and strangulation in the track of a gunshotwound are very rare; not one of the wounded we have in thehouse offered us any example of such symptoms, and thoseupon whom I performed amputation were equally exemptfrom it. I prescribed leeches for one of these patients only,not because there was distention, but on account of the in-

flammation which sprang up around the wound. We must,in fact, beware of carrying the abstraction of blood, by meansof leeches, too far; they depress the organism as well asgeneral bleeding, and when the patient, thus weakened, reachesthe suppurative period, we find the pus unhealthly, sanious,and scanty; colliquative diarrhaea sets in, and soon carrieshim off. To sum up, then, it may be said, that no absoluteor general rule can be framed for the treatment of gunshotwounds. We should use incisions when the parts are actuallyover-distended and strangulated, which complications happenvery rarely; we should have recourse to local or generalabstraction of blood when bleeding is clearly indicated, andwe must finally do nothing a priori, or to satisfy any in-geniously contrived theories.

Hospital Reports.HOTEL DIEU, ORLEANS.

Vertical Dislocation of the Patella.THis is the twelfth vertical luxation of the rotula hitherto

recorded. It happened to a man of sixty, who fell under acab and got his legs entangled in the wheel. When raised,he could not stand upright, and M. Debron found the limb,half an hour after the accident, in the following state:-Theknee flexed to within a third of the right angle ; a slightabrasion, extending from the calf of the leg to the spot where,in the normal state, the inner border of the patella is situ-ated ; extension incomplete and painful; the anterior aspectof the joint very prominent, on account of the patella beingplaced with its inner border against the condyles, and itsouter margin under the skin; its anterior aspect turned in-wards, posterior or articular outwards; the skin depressed oneither side of the projecting edge; the ligamentum patellmon the stretch and drawn a little outwards, and the patella im-movable. M. Debron reduced this vertical external luxationin the following manner, according to the principles laid downby Valentin:-One assistant holding the thigh, another heldthe leg, and raised the heel so as to extend the leg upon thethigh, the latter being flexed upon the pelvis. The patientbeing placed upon a low bed, says M. Debron, I took mystation on the external side of the knee, and whilst supportingthe posterior aspect of the joint with my left arm, I forciblypushed the patella inwards with the palm of my right hand,flattening it, at the same time, against the external condyles;the bone, by a single continued effort, snapped back into itsplace. I then gave directions to have the limb placed on aninclined plane, and soothing compresses to be applied to thejoint. One month afterwards the cure was complete. If thetwelve cases of this peculiar luxation, says M. Debron, beexamined, there will be found seven vertical external, (theanterior surface of the patella turned inwards,) and five ver-tical internal, (the same anterior surface turned outwa1’ds.)In these twelve cases, reduction has been particularly difficultor impossible five times; three times reduction has kept amedium between a degree of ease and much difficulty; andfour times only it has been easy. Amongst the very difficultcases, three had been produced by external violence actingdirectly on the patella; in the medium cases, two were owingto external causes, and four to muscular action. In the easilyreduced cases, three were caused by external violence, andone by muscular power. One case remains doubtful. Themost important question referring to this unusual luxation, isto determine which mode of reduction is the most effectual.The choice lies between the method of Valentin and that ofCoze, or the manner of reduction advised by Mr. HerbertMayo, which has lately been re-introduced by M. Malgaigne.The choice is not of much importance in a practical point ofview, for they are both alike easy and harmless, and can evenbe employed one after the other, if necessary. Still the twomethods rest upon theories directly opposed to each other;for the first argues upon the slackening of the muscles con-nected with the patella, and the second upon the tension ofthe same. The obstacles in the way of the vertical reductionare-1. The tension and dragging of the tendons inserted inthe patella-namely, the tendon of the quadriceps above, andthe ligamentum patellaa below; 2. the sinking of the borderof the patella, which becomes posterior, into the superiorcondyloid depression (as M. Malgaigne calls it) ; 3. the ten-sion of the partly torn capsular ligament, which, in themanner of a rope, keeps down the patella very tightly in itsvicious position. M. Debron, in an able paper (recently pub-lished), examines successively every one of these three causes;