|| Maîttrise Education
M.O. Baron, what prompted you to become a surgeonM.O. Baron, what prompted you to become a surgeon?
G.D. I came to Paris in 1789, to study at the Collège de la Marche, in the Rue de la Montagne Sainte-Geneviève. Four years later, the college was closed down in the Revolution, just as I had nearly completed my Arts course. I was 16, and had to choose a career. I opted for the army, and was going to enlist in a volunteer regiment. However, in order to do so, I needed my parents' consent, so I walked all the way back to Limoges, where they lived. My parents were adamant that I should go into one of the liberal professions, to continue a family tradition. My father was an advocate, and my grandfather had been a surgeon at Pierre-Buffières, a little village four miles from Limoges. My father decided that I should be a surgeon.
M.O. Who were your first teachers?
G.D. I started Anatomy with Boyer, at the Charité hospital, and Chemistry with Vauquelin and Bouillon-Lagrange. When I was 18, I took an exam to become prosector at the Ecole de Santé. I was taught by Pinel at the Salpétrière, and then went to Corvisart's departement. He put me in charge of post mortems, and also recommended me to Leclerc, the famous professor of Physiology. I think I may say without fear of contradiction that I became Leclerc's most efficient team member: some of the papers we wrote together bear witness to that.
M.O. What was your financial situation when you started out?
G.D. Initially, it was grim. I lived in a small, sparsely furnished room five floors up. My family was not affluent, and I had to manage as best I could, on my own. Sometimes, I would eat only every other day, and if there was no fuel to heat the room, I would have to work in bed. But, goodness, was I proud. One day, Saint-Simon, the great thinker and social reformer, came to see me in my garret, since he was trying to convert young doctors to his views. He was struck by the poverty in which I was living, and, as he was going, pretended to "accidentally" leave a wad of 200 francs on the cold stove. I saw it, ran after him, and promptly handed his charitable donation back to him in the street. He was dumbfounded.
M.O. Let us go back to your career...
G.D. In 1801, the post of chief demonstrator in Anatomy became vacant, I applied for it, and was unanimously accepted. As a result, I was able to dedicate myself to teaching, and to carry out a number of research projects. I organized the practical teaching of anatomy, and raised it to an unparalleled standard. The first thing that needed attending to was a regular supply of bodies for dissection. There was such a shortage at the time that it looked as if, in future, students would be taught anatomy in lectures on skeletons. Next, the dissecting rooms needed sorting out, to establish some discipline. All this allowed me to get a first idea of a hitherto unknown subject - Pathology. I was able to collect almost 1000 pathology specimens, and to launch a famous Pathology course at the Ecole Pratique.
M.O. I gather you followed in the footsteps of the late lamented Xavier Bichat, and finished his Treatise of Pathology...
G.D. Yes - Bichat was interested in this vast subject, but all too often, he would write what he imagined rather than what he had observed. I think that everything he wrote had a touch of poetry about it. I, on the other hand, have always relied on in-depth studies and sound evidence. I determine the proportion of the diseased organs, the exact nature of the lesions, their features, the way in which they relate to the external aspect of the subject, and their frequency of occurrence; I also study the way in which different lesions will occur at different times of the year, in different ages, and in the two sexes. By the age of 30, I was famous.
M.O. Why did you part company with Théophile Laënnec?
G.D. Laënnec was my student, and he served me, for a while, with great respect and assiduity. Incidentally, it was with him and with Bayle that I founded the Anatomical Society, back in 1803. Laënnec became increasingly interested in anatomical research, to which I had introduced him, and which he was engaged in under my authority. He published much in the Journal de Médecine, and I still remember his work on the subdeltoid synovial bursa, a structure which he claimed to have discovered. He then developed a this great urge to work on his own, and - in defiance of the rules of academic propriety and the respect one owes one's teachers - he started writing his own treatise of pathology, and give his own public lectures. Not only had he abused the confidence I had placed in him, he then started developing preposterous theories of his own regarding the classification of lesions capable of affecting all the body systems.
M.O. When were you appointed surgeon at the Hôtel-Dieu?
G.D. I sat the selection exam in 1802, for the post of Assistant Surgeon at that hospital. The exam was particularly tough, and I do admit that Alexis Boyer's support at that time was extremely helpful. I found myself working with Pelletan, who was Surgeon-in-Chief, and with Giraud, his second in command. A few years later, Giraud resigned, and I was able to take the post of Deputy Surgeon-in-Chief at the Hôtel-Dieu.
M.O. Talking of Boyer - could we, for the benefit of our readers, go back briefly to the circumstances in which you broke off your engagement to Mademoiselle Boyer?
G.D. You have an amazing cheek! It all happened many years ago, yet some of the slanderous remarks then made about me appear to still linger in people's minds. So perhaps the time has come to put the record straight. Alexis Boyer was my teacher. At the same time, he considered me to be his future son-in-law, and thought that I should marry his eldest daughter, Adelaïde. He strongly encouraged my courtship. However, it soon became clear to myself and to my intended that we were not very fond of each other. The problem was that Papa Boyer had arranged for the wedding to take place on 25 January 1810 - without any regard to my qualms about this match. So as not to upset him, and, equally, so as not to force Adelaïde into a match that she did not want any more than I did, I asked for the hand of her younger sister Gabrielle. However, her father would not hear of it, and told me how to go about buying the wedding rings. I can only assume that he was so obdurate because he had got the Emperor to agree to sign the wedding contract. The night before what, to him, was still the wedding day, he sent me a note saying that he was surprised not to have seen me at the eve-of-wedding dinner. So I immediately wrote back to tell him that Adelaïde did not love me, and that she had told me a few days earlier that she did not want to get married just to obey her parents. I once more offered to marry Gabrielle. Boyer went ahead with the wedding, which no honourable person could have gone through with, and screamed that I had let him down when I did not turn up. To this day, there are those who say that I am an unscrupulous careerist. I wonder whether these detractors have any idea of how painful the decision was, and how it could have blighted my professional prospects.
M.O. Let us go back to your career. Before you were appointed Professor of Surgery, there were some stormy debates. Why was that?
G.D. There were several applicants for the post, the main ones being Roux, Marjolin, Tartra, and Dupuytren. The thesis required as part of the application had to be submitted by 26 January, 1812. When the deadline came, the Board of Examiners granted me a few extra days, as a very special favour. This was for a very simple reason: an accident at the printers had delayed the printing of my manuscript, and my publisher had furnished the Board with a certificate to say that the delay was beyond my control. The other candidates objected violently, and I was insulted in public. However, the examination proceeded eventually. My thesis on lithotomy was considered to be a model of surgical anatomy. There then followed a half-hour lecture, which I had 24 hours to prepare. The subject was amputations. This in turn was followed by an operation on a cadaver, and, finally, another half-hour lecture. In this final lecture, Roux dealt with simple fractures of the femur; Marjolin, with primary dislocation of the hip joint; Tartra, with tibial fractures near the ankle joint; and I myself, with elbow dislocation. The Board was chaired by Pelletan, with whom I had clashed on several occasions in the past, and who could not be accused of favouring me. He must have said something like, "As the final arbiter in this examination, I must set aside my ill feelings about all the wrong that Mr. Dupuytren has done me. In this contest of surgeons, I am certain that he has shown himself to be the best."
M.O. So that made you Deputy Surgeon-in-Chief at the Hôtel-Dieu, and the holder of a major chair at the Faculty of Medicine...
G.D. That is true. However, I do not remember the three years before Pelletan stood down in 1815 as a very pleasant time. Pelletan had a very conventional approach to surgery, and mistrusted all things new. Every time I tried to use the progress of science for the benefit of a patient, he would countermand my advice, and in the end, it was the patient who suffered. However, he was the chief surgeon, and I owed him obedience. He had also supported me in my attempts to get the professorial appointment, and I did not want to make the old man's life a misery. Still, it was a very awkward situation, since, in the lecture theatre, he would analyze the cases he presented in a way that was utterly wrong, and finish up with total misdiagnoses. I could have left it there, and done nothing about his misconceptions; however, his conclusions involved decisions on the management of the patients, and more often than not it was I who had to give the treatment. This is why, on several occasions, I had publicly to contradict him, since what he was proposing to do to the patient was so dangerous, and the potential damage done to the profession was so great. However, I did my best to keep relations reasonably civil, and to respect the hierarchy as much as possible, whilst waiting for his forthcoming retirement.
M.O. And then?
G.D. And then he conceived the idea of bringing in his son, to keep the post of chief surgeon in the family. His son Gabriel had formerly been a surgeon with the Imperial Guard, and had been prisoner of war in Russia for quite a long time. His papa unearthed some long-forgotten rules at the Faculty, under which Junior could be appointed clinical assistant at the Hôtel-Dieu. The old man was not one of those surgeons who remain clear-sighted and steady-handed into their old age; but at least he had got to where he was by a due process of selection and appointment. Gabriel, on the other hand, did not have any, but any, of the qualities required by candidates for the post. That was the straw that broke the camel's back: I decided that I would no longer cover up the ghastly things my chief was perpetrating. And since he was mistrusting me more and more, he had to put his own decisions into action, with disastrous results.
M.O. Could you give an example of what happened?
G.D. For instance: There was this Russian soldier who had been stabbed in the upper thigh with a pitchfork, and had a large swelling beneath the inguinal ligament. Pelletan did the operation. Blood came gushing out, because the femoral artery had been pierced. Lisfranc was assisting. He had been taught by me how to do arterial compression; so he pressed on the common iliac artery, and the bleeding stopped. Pelletan thought that he was working on the iliac artery, and went to ligate this vessel. He made two incisions above the inguinal ligament, and put the needle through. He took the abdominal wall, tightened the suture, and did a double knot. Then, despite Lisfranc's protestation, he had the iliac compression released. There was massive bleeding, because the artery had not been included in the ligature. Pelletan panicked, stuffed masses of lint into the wound, right down into the abdomen. The patient died a few hours later. At post mortem, it was found that the ligature was far too anterior, and had missed the vessel by as much as an inch.
M.O. How did you come to be appointed Surgeon-in-Chief at the Hôtel-Dieu?
G.D. After a long run of bungled operations, the Faculty, and then the Board of Governors, were at long last stirred into action; and one fine morning, while Pelletan was doing his usual ward round, he was told that he was out. There were several candidates for the post, and following a vote by the Hospital Board, they were ranked as follows: Boyer, Dubois, Dupuytren, Marjolin, and Richerand. Boyer had already once declined to go to the Hôtel-Dieu, and had also been the Emperor's surgeon, which made him politically less than ideal. Dubois had been obstetrician to the Empress, and was equally suspect as a Bonapartist. This is how I came to be appointed Surgeon-in-Chief at the Hôtel-Dieu, by order of the Ministry of the Interior, on 9 September, 1815. At long last, the post I had spent twenty years working towards was mine, and mine for good.
M.O. Could you just explain to our readers what your workload is, by taking them through a typical day at your hospital?
G.D. I come in at 7 o'clock in the morning, in the summer; in winter, I arrive at 8. A bell is rung to warn everybody that I am there, and my nurses help me out of my overcoat, take my hat, and help me put on my big white apron. My students are waiting in St. Agnes ward, where I usually start the ward round. First, I do a roll call of the juniors and the dressers. It is well known that I will not tolerate people coming in late or being absent without good cause. Anyone that offends against these rules is struck off, and will not be readmitted. There is one junior per ward, and one in special charge of post mortems. The juniors are totally responsible for the actions of the dressers, and have to give an account of what has been done. Surrounded by my medical staff, and by several doctors from home and abroad, I then start my ward round. First, St. Agnes and St. John wards, then St. Bernard and St. Paul. I obviously cannot stop and see every single patient; however, I make a point of examining any new arrivals and any recently operated patients, doing the dressings myself. Incidentally, to stop a rumour that has been going round far too long, allow me to point out that "multiple-occupation" beds went out at the Hôtel-Dieu years ago. Every patient has his own bed, with white curtains around, and I insist on absolute cleanliness. Proper white bedlinen is the most important factor in the successful treatment of patients.
M.O. You are famous as a diagnostician...
G.D. I consider history-taking to be of the utmost importance. However, great skill is required, since the sick are such terrible liars. Once the history has been taken, I perform a detailed physical examination. I will not make a diagnosis unless a logical and strict analysis of the facts allow me to make the necessary deductions. I have been wrong on occasions, but I think that I have been wrong less often than the others. During the ward round, I have to do some simple procedures that need doing there and then - lancing an abscess, for example, incising a paronychia, or a phlegmon, or a fistula. When the round is over, I go to the lecture theatre on the side of the hospital that looks out over the square in front of Notre Dame. A host of students and colleagues will be waiting for me there. I give a clinical lecture almost every day.
G.D. It is true that, by dint of sheer hard work, I have amassed knowledge and experience of the highest quality. However, knowledge alone does not allow one to captivate an audience. One must, first of all, get them to be silent. I find that the best way of doing this is to start out by speaking in a very soft voice; your listeners then have to be absolutely silent in order to hear anything. Only once I have obtained this do I raise my voice, so as to make my arguments heard. The lecture itself has to be clear and methodical, in order to make the audience listen attentively; also, the points made have to be repeated time and time again, to make sure that they are understood at least once. Above all, in order not to lose one's audience, and to make sure that what one has to give actually goes across, one has to curb one's rhetoric. One needs the thing so many of my all-too-eloquent colleagues lack: a simple, sober discourse.
G.D. That's when the operations start. The decision to operate is a very major one, which must be taken only if there is no other way of treating the patient concerned. Two things must never be put at risk: the patient's life, and the good name of one's profession. One must take every hygienic precaution, and insist on absolute cleanliness. Before deciding to operate, I make sure that there is not an ongoing epidemic. I ensure that the patient has the greatest possible confidence in his surgeon and in the decision that this surgeon has taken. There are two sorts of operations. Some are performed on healthy organs: there, one has to work with the utmost anatomical precision, and there must not be any unforeseen accident. Others are done as emergency procedures. They are far more numerous. When the patient is brought into the operating theatre, I explain to those present what sort of case it is, what I am going to do, and what the prognosis is. One must not make the least little cut without good cause, and without being able to account for it. Sometimes, one may even have to stand in an awkward or ungainly position so as to allow the students a better view. Also, one has to keep talking to the patient, to enable him to bear with this ordeal.
G.D. I assure it is not that I disdain human blood, or that I am insensitive of the patients' suffering, and deaf to their cries. However, a surgeon who relinquishes his air of impassive serenity during surgery will frighten the patient a great deal more, and will not be able to cope as well as required with any complications that may arise. My students will tell you that, on numerous occasions, I have stopped operating, despite the sarcastic remarks that this produced.
G.D. Most certainly not. The junior in charge of post mortems brings me this morning's specimens. I want to know the cause of death in each case, so as to be able to refine my surgical procedures; and I am still going to publish my textbook of pathology. After that, I still have my free clinic to run, where all the destitute can come to see me.
G.D. I beg your pardon. Let me tell you that of all the hours I spend at the hospital, those spent in the treatment of the poorest of the poor are the most precious to me. I would not give up this task for anything. I know what it is to be poor, and well remember the simple people I used to meet, whose unstinting willingness to help others still moves me profoundly. I would like to see one those rich men who complain that I charge too much for surgery - I would like to see him, alone in Paris, without a penny to bless himself with, without friends, without anyone that will lend him money, and forced to scrape a living by sheer hard work.
G.D. At the end of the morning, I walk home. I live in the Place du Louvre, so I walk along the Seine, nibbling the little bread roll which the hospital administration has been so generously providing to the chief surgeons since time immemorial. In the afternoon, I see private patients, and attend meetings of the Faculty or of the learned societies.
M.O. Baron, could you tell us once more about your involvement following the assassination attempt on the Duc de Berry?
G.D. The details of what happened during that tragic night are in the evidence I gave to the Chamber. An unauthorized version of my report was printed in the newspapers, with serious mistakes and omissions, which I subsequently had to correct. I think it would be appropriate to go over these events again, to show what really happened. On the evening of the 13th of February, 1820, the Duc de Berry was leaving the Opera, when he was stabbed in the right chest by a fanatic called Louvel. The prince had the courage and the strength to pull the weapon out himself, but the blood came gushing out, and he fainted. The duty doctors of the Opera, who would sit through the shows, could not be found. The first to arrive on the scene was M. Drogart, a medical student. With the help of the Duc d'Orléans, he undressed the prince and suggested a blood-letting. Just as he was about to perform this procedure, Dr. Blancheton arrived. He noticed that the victim was severely dyspnoeic, and removed the blood clot from the entry wound; he also extended the wound slightly at its lower edge. This produced a small amount of black blood. Dr. Blancheton was convinced that there was an effusion of blood inside the chest, and, in an attempt to reduce its effects, performed a first blood-letting, removing a few grammes of blood. At this point, Dr. Lacroix arrived. He bled the victim's other arm, and did not manage to obtain very much more blood from that site. A third attempt at bleeding was thereupon made, in the foot; this was no more productive than the first two tries. However, it was felt that blood had to be removed, and people went off to find cupping glasses to apply over the wound. Meanwhile, Dr. Bougon sucked out the wound, despite the objections of the prince, who thought that the assassin's weapon might well have been poisoned. After all this, the prince appeared to be breathing a little more easily; his pulse, which was very weak, became stronger; there was a little more colour in his cheeks; and he found it easier to breathe and to talk. That was when I arrived on the scene.
G.D. I found myself surrounded by the Duchesse de Berry, the Duchesse d'Angoulême, the duke and duchess of Orléans, the Duc de Bourbon, government ministers, and a number of courtiers. The Duc de Berry gave me his hand and said, "Dr. Dupuytren, I am in terrible pain." He was lying on his right side, very pale and drawn, short of breath, covered in cold sweat, with blood soaking the bed he was lying on. On examination, his left hemithorax showed normal resonance, while on the right nothing could be heard, and there was considerable dullness. The question was: where was the blood coming from? Since there had been neither haemoptysis nor subcutaneous emphysema, I presumed that the lung must be intact. However, the victim's condition was deteriorating alarmingly. So, with my medical colleagues, I retired briefly, to discuss what should be done. Nobody was in favour of closing the wound. One could have waited to see what effect the treatment thus far provided would produce; however, the results so far had been less than encouraging, since the prince's condition had worsened. I decided to try and staunch the effusion that was causing the symptoms, and to attempt an evacuation of the collected blood, if that was possible. I was going to go straight to the source of the bleeding, so that time, nature, and the surgeon's skill could counter the injury more effectively. Since this would involve high-risk surgery, the victim's father - the brother of His Majesty - was asked for his consent. He said, "I entrust my son to your skilled hands." I therefore made a skin incision, and, with my finger, followed the wound track to the opening in the intercostal muscles. I found that the dagger had gone right through the intercostal space, and had been thrust in so violently that the ribs on either side had been considerably notched. The presence of a haemothorax was confirmed; however, I was unable to find the source of the bleeding. Once the stab wound had been enlarged, a copious quantity of blood poured out, and the victim breathed more easily. All this had been very painful, and the prince had tried several times to push us out of the way.
M.O. Did you have to explore the wound further?
G.D. Doctors Baron, Roux, and Dubois had just arrived, and we had another discussion. We unanimously agreed that it would be pointless to manage the victims along the lines already tried. The victim was too weak for us to consider any of the other customary treatments, such as revulsives, cupping, bleeding, or leeches. Taking him back to the Elysée Palace was out of the question. It was decided that the prince should be left where he was; that his body would be positioned leaning to the right, so as to facilitate drainage of the blood; that his symptoms would be closely observed, with a view to relieving them if at all possible, and to taking more decisive action should the condition worsen to the point where this was required. A bulletin to this effect was drafted, and handed to the President of the Council of Ministers, for transmission to his Majesty the King. The victim's condition was, by now, hopeless. The bulletins issued at hourly intervals showed that the outlook was dire. I remained by the prince's side, and held his hand. Shortly before he died, he said to me, "Dr. Dupuytren, I am greatly touched by what you have done for me, but it will not allow me to live. I am fatally wounded. The dagger has pierced my heart."
G.D. I performed the post mortem, together with Roux. We found that the right chest wall had been pierced between the fifth and the sixth rib. The right lung had only two lobes - a not uncommon anatomical variant; the dagger had gone through its front portion. These two injuries were not responsible for the heavy bleeding and the subsequent demise of the patient. The fatal injury was a stab wound to the pericardium and the right atrium. The dagger had, in fact, gone right through the atrium. In order to penetrate to this depth, it must have bent the chest wall. It had finished up in the central tendon of the diaphragm, without piercing that structure. Two litres of blood had collected in the right hemithorax.
G.D. The prince was doomed. However, this did not stop my colleagues criticizing me. I was being told by all and sundry that I had been indecisive, inexperienced, insufficiently in control; it was said that I had been wrong in daring to probe a penetrating chest wound, since this could have caused more bleeding and broken down adhesions that might otherwise have contained the haemorrhage. Barely two weeks after the tragic events, Larrey gave a paper (written some time earlier) at a Faculty Society meeting, on the importance of closing chest wounds. The following year, at the autumn session of the Academy of Medicine, Richerand made a hurtful remark about the torture that the poor prince had been made to suffer. In 1823, the Surgical Section offered a prize of 1000 francs, in a competition to find the best way of treating chest injuries. The prize was not awarded, and the Section insisted that the question should be kept on the agenda. It was obvious that deliberate attempts were being made to discredit me. Later, at the Section's public meeting in January 1825, Richerand returned once again to this subject; and finally, in August 1828, the Academy awarded a gold medal to Dr. Briot, for a paper on The Preferred Management of Penetrating Chest Wounds, which advised abstention from treatment or, at most, suturing of the entry wound.
G.D. Let us not stir up this past unpleasantness. The facts of the matter are abundantly clear. Louis XVIII, wishing to thank me for what I had done for his nephew, conferred upon me a hereditary baronetcy, by Letters Patent of 17 April, 1821. And when Charles X ascended the throne, I was appointed First Surgeon to His Majesty the King.
G.D. On Wednesday, 28 June, there was firing almost all the way along the right bank of the Seine, that is to say from the arsenal and the Célestin barracks to the Louvre. Shots were ringing out all the time in the Rue Saint-Antoine, the Place de Grève and all its side streets, in the Place du Châtelet, the Innocents market, the Rue Saint-Honoré, and, above all, the Palais Royal. Some cannon shots were also heard, and there were many bodies lying in the streets.
G.D. One hundred and ten casualties were taken to our hospital, and by midnight 17 had died of injuries that were so severe that nothing could be done for them. Most of these unfortunate victims had been wounded over at the Place de Grève or the Place du Châtelet. Almost all of them had been shot, virtually at point blank range, by the Royal guard, the cuirassiers, the elite gendarme troops, or the lancers. Some of the casualties had huge wounds caused by case shot or grapeshot. People were being brought to the square outside Notre-Dame on stretchers by their comrades in arms, followed by a throng of friends, relatives, and, above all, gawpers. The crowd would invade the wards, and cause an uproar that was doing the patients no good at all. I had to take steps in order to control the situation. Many major operations had to be performed there and then. I therefore thought that surgery should best be done in a makeshift operating theatre, so as to spare the patients the sight and sound of the new casualties being operated on. However, the layout of the hospital, and the large numbers of patients flooding in, made it impossible to implement this plan. We were forced to operate in the wards, as the casualties were being brought in. I did most of the procedures: opening up wounds, extracting bullets, dressing fractures, and amputating limbs. The fitting of the first appliances I left to trusted members of my staff.
G.D. From the start, wounded soldiers of all the different regiments were coming in, and being put into wards with ordinary civilians. I thought it important not to segregate them in a separate ward. This would have hampered the running of the hospital, and I also hoped that putting them side by side with the people they had fired on would disperse any remaining feelings of hostility. The way things worked out proved me right: a few days later, they were all fraternizing.
G.D. Two hundred and four casualties were brought in to the Hôtel-Dieu during the 29th; some 20 of them died that day, having been too severely injured for the surgeons to be able to save them. As more and more casualties were coming in, the hospital operation was stepped up. Fully trained doctors were working flat out at the most menial dressing tasks; everything was under control; and the hospital administration gave its full support to the hard-working surgeons. Several of the casualties that came in that day were referred to the Pitié hospital, which was central enough and big enough to provide a useful facility. The ones who went there were mainly the walking wounded. We had some 60 of these cases. Once their wounds had been dressed, they were very happy to move out and make room at the Hôtel-Dieu for those in greater need of emergency care. An even larger number were discharged home.
G.D. We had to use the wards for the casualties. This is why the administration immediately cleared out all the patients occupying these wards. On Thursday, 29 July, 362 patients were transferred to the Bicêtre and Salpétrière hospitals. The day before the uprising, there had been 952 patients at the Hôtel-Dieu. Admissions on the Thursday were fewer in number than were transfers to other hospitals, so that, by Thursday evening, we had 771 patients. During the following days, there were more discharges than admissions. The wards accommodating the casualties were never fully occupied. A much more important aspect is the way hospital patients are fed: physicians and surgeons have been complaining for a long time about the poor quality of hospital food. Obviously, hospitals should not be lavish - but, equally, hospitals cannot be run as if they were barracks. Patients can do without bread, wine, and meat; but the Lenten foods - vegetables, pulses, potatoes - may be difficult to digest even for healthy people; patients would be even less likely to tolerate them; and convalescents, whose digestive tract cannot cope with such coarse foods, have often suffered serious complications as a result of their hospital diet. I took this matter to the Board of Governors, and soon those patients who were well enough were given fish and fresh vegetables, as well as white meat - chicken or veal. They were also allowed good quality wine. With this much improved diet, patients were seen to recover more quickly.
G.D. We only had one collarbone fracture, and that had been caused by a blow from a rifle butt, when the victim was rushing forward to disarm a Swiss guard. Shoulderblade fractures were much more common. Most of the large penetrating chest wounds were associated with shoulderblade injuries. Because of its position, its shape, and its role in the body, this bone may be fractured without any major ill effects, and does not require any specific treatment. Strictly speaking, however, this is true only of the flat portion of the bone: if the fracture involves the portion that forms part of the shoulder joint complex, things become more serious. If there is a missile injury through the shoulder joint, and the joint surfaces have been disrupted, we know from experience that the entire limb must be amputated. This is one of the most demanding procedures that a surgeon may be called upon to perform. I have done this operation twice, and both these patients are alive and well today. A third patient refused his consent. For five weeks, he suffered from a string of complications, and several times very nearly died. So, in the end, he accepted the procedure, since he felt that this was his last chance. The unfortunate man died eight days later, a victim of his own obstinacy and deafness to all entreaties. Upper arm fractures are much less serious, unless there is extensive soft-tissue involvement. The bone is reasonably superficial, so splinters caused by the missile injury can be readily extracted, and dressings can be properly applied. Splintering of the forearm bones, the wrist, or the bones of the hand by a bullet, with soft-tissue damage and torn arteries, will have to be managed with sufficiently proximal amputation. The surgeon must bear in mind that these tissues are extremely sensitive; that inflammation, which is bound to set in, will often be followed by gangrene; and that most of these patients will die as a result of ill-advised attempts to preserve a limb which, all too often, will be useless anyway. During the storming of the Tuileries, a tapestry worker, a family man with a large number of small children, had his right wrist smashed by a case-shot bullet. He was told that his only chance of survival was to have his hand amputated. The poor man asked, "Who will feed my children? They live by the work of my hands." Then, after a moment's hesitation, he said, "Cut it off. Let's hope my country will look after my children." He is alive and well today.
G.D. When a cannon ball has taken off part of the thigh, shattered bones, and, as it were, started an amputation, the surgeon must complete the job. This is horribly mutilating surgery. Amputation through the hip joint leaves an enormous wound. Large vessels will have been cut, large nerves divided - and yet, there are those who have lived to bear witness to the efficacy of this procedure. Missile trauma of the femur is always a serious injury, because the thigh bone is a very compact structure. Its hardness gives it strength; however, if the causative agent is very powerful, the bone will disintegrate into a large number of fragments, which will make it impossible to obtain proper healing. Also, there will be massive inflammation, and copious production of bad pus. The victim will go downhill, and is virtually doomed. Amputation is the only way in which these dire consequences can be prevented, which is why the procedure has to be resorted to in a great many cases of this nature. If the missile has gone through the knee, opening up the joint and damaging the joint surfaces, amputation is a must. Every time surgeons have abstained from amputation, for more or less valid reasons, the patient's further course has shown that decision to have been ill-advised. It is wrong to cite the case of a very well-known contemporary, who refused an above-knee amputation following such an injury, and who made a full recovery. Miracles should not be considered in decision-making processes; and, as things stand, there is no evidence to show that, in the case cited, the projectile had actually gone into the joint.
G.D. That is very true. The main thing to do following such injuries is to prevent potentially fatal complications. If the projectile has caused fractures of the leg bones, it all depends on the actual site, and on the extent of the damage. The upper part of the tibia is quite bulky, with a high proportion of cancellous bone. A projectile may go through it without causing a fracture. In 1814, a French soldier shot below the Paris city walls was admitted to the Hôtel-Dieu. When I examined the upper part of his leg, I found bits of canvas lodged in the bone. I heaved on the ends, and delivered a sort of pouch containing a complete bullet within part of the victim's gaiter. I still have the specimen. In the mid-portion of the tibia, bullets will, more often than not, cause the bone to shatter - in other words, there will be comminution of the kind seen in the femur. There will be many splinters, which will need to be removed with care, to speed the patient's recovery. If healing is left entirely to nature, it will take very much longer. In the clashes in the Place de Grève on the Wednesday morning of the uprising, a typesetter had his leg shot through by a bullet. He was a very highly-strung individual, and it proved difficult to control his nervous problems, which were the chief immediate features of his condition, ruling out the amputation that should have been performed. Later on, there were complications, which were grossly exaggerated in the patient's mind. On 31 August, he died after several bouts of fever. All this goes to show that, in many of these missile injuries, amputation of the injured body part is vital in order to prevent fatal complications.
G.D. That is a very good question. Amputation produces a clean wound, without any potentially deleterious foreign bodies; it also provides direct access for any further treatment. However, we must bear in mind that such a large wound, inflicted, as it were, on a previously healthy individual who has not had the time to adjust to this new state of affairs, will affect the entire body in a very major way. We are treating a dangerous condition by a means that is itself inherently dangerous, but which does offer the victim as well as the surgeon a greater chance of success.
G.D. History has shown that mass-casualty disasters and emergencies tend to occur in city centres. What happened here in Paris during the uprising underlines the need for centrally located hospitals. Imagine what it would have been like if the large numbers of casualties would have had to be taken to hospitals a long way away. As it was, we were close to the theatre of action, and the casualties could be treated virtually on the spot. Even so, many of them died. However, but for the availability of a central facility, it is obvious that there would have been a great many more fatalities. However, one of our architects has spoken out against the Hôtel-Dieu. As I see it, this is because the hospital is seen in the light of what it was, rather than of what it is nowadays. In the past, it was hellhole where huge numbers of destitute patients were thrown together under unspeakably primitive conditions, and died like flies. They were the victims of an outmoded system that had been allowed to operate far too long, until the final years of the 18th century. Nowadays, every trace of these past ills has been eradicated, and the Hôtel-Dieu can stand comparison with any other surgical facility in Europe. It is a temple to the surgeons' art. However, history has shown that even the greatest temples may be destroyed.
G.D. And yet, I have to turn away applicants all the time. Some may feel that they are being harshly treated; however, that shows that I am keen to teach them. In order to transmit knowledge, one has to have authority; and my students need to serve their master and their patients humbly, diligently, and attentively, in order gradually to acquire the fundamentals of my craft.
G.D. That was the best thing he could do. He was a very able disciple, but he was wasting his time at the Hôtel-Dieu.
G.D. So - was I telling a lie?
G.D. Lisfranc is a jealous and aggressive sort of person, which makes him adopt a bad attitude to the entire faculty. He has been so appallingly rude that I refuse to comment on his behaviour. He has made me out to be a tyrant. You only need to consider what has been going on to see that this allegation is without substance: I have delegated responsibility for part of my Department to Drs Breschet and Sanson. These members of my staff are showing themselves worthy of the trust I have put in them.
G.D. I would say that they are fifty per cent right.
Traîtrise Orthopédique n°100' - January, 2001
Images de Paris du Moyen-Age à nos jours. (Illustrations used with permission of the publisher, SAND, Paris)
Maîtrise Orthopédique n° 100 - January 2001
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