THE Medico- Chirurgical Review, N? XXXVI. JANUARY 1 to APRIL 1, 1833. I. Lkcons Oiialks de Cliniquk Chirurgicalk, faites a l'H6tbl/ Dikit dk Paris. Par M. le Baron Dupuytren, Chirurgien en Chef. Recueillies et publiees par une bociete ae meaecins. ?(Clinical Lectures on Surgery, delivered at the Hotel vdavila@example.org. By Baron Dupuytren.) Tome I. Paris, 1832. A COMPARISON of modern medical literature with that which has preceded it, exhibits the most striking difference in the pre- ponderance of facts over opinions and theories. That a disrelish for the latter, and consequent taste for the former, is increasing, not only among medical readers, but in society in general, is equally evident. Intelligible facts will alone sell, whether in the form of Penny Magazines, or in treatises written by Brewsters or Cabbages. The few medical works which have escaped the des- troying hands of trunk-makers, or the conversion into " shrouds for pilchards and red herrings," are those alone which have con- tained a large preponderance of facts. The few theories in which Hippocrates indulged, or the occasional opinions of Sydenham as to the proximate causes of diseases, are rescued from the oblivion to which they would have been necessarily consigned from their absurdity, only by their being appended to practical remarks which will ever continue valuable, as the expression of facts dis- covered by close observation. The description of diseases by Cel- sus and Aretseus are pregnant with instruction, and will last as long as medicine continues to be studied; but who now, except for amusement, or as a matter of history, peruses the wild theories, of Paracelsus, or many of the more modern medical vagaries of -Darwin or Beddoes. Not that such imaginative men of genius are without their ultimate use, by setting inferior intellects at work 111 channels which they would never have beaten out for them- selves. This increased attention to the importance of facts in stu- dying disease cannot be promoted more effectually, than by clini- cal instruction, fully carried into effect as it is in the French hos- pitals. No plan is more adapted for testing the merits of the doctrines of the Professor, or of estimating the advantages of the No. XXXVI. . U 290 Mkdico-chikurgical Review. [April I treatment he pursues. The value of any mode of practice, as laid down in lectures, can alone be tested by experiment; in clinical instruction, the principles are illustrated by actual practice, and the vacant bed, the " dead-house" table, the distorted limb, or un- expected post-mortem appearances, are facts which cannot be hidden, and which, on a large scale, can never be set aside by specious reasonings. That this teaching by example, and illus- trating general principles by actual cases, is the mode of all others the most calculated to make a permanent impression on the mind of the student, few will be disposed to deny. We were, therefore, glad to see the announcement of a work purporting to be the cli- nical lectures of Baron Dupuytren, who, as a professor of clinical surgery to the School of Medicine in Paris, stands without a rival. The printed lectures have not the sanction of M. Dupuytren's name, but, as the most important cases have been furnished by MM. les Docteurs Marx, Paillard, and Fournier, pupils and friends of the Baron, it is not probable that they are published without his approbation. Considerable difficulty must have been expe- rienced by the reporters in the compilation of these lectures, from the disjointed way in which they are frequently delivered. The report of the progress of the most remarkable cases, with the ob- servations it may suggest, being given daily. If M. Dupuytren. has in his wards many similar cases of particular interest, he makes them the excuse for a surgical disquisition on the peculiar disease; if this requires a lengthened discussion, he resumes it daily, after giving the report of the cases under treatment. Thus, in process of time, his clinical lectures embrace every topic in surgery. Two thick octavo volumes are just published, containing these lectures,, with a promise that the subject will be continued. The plan which M. Dupuytren adopts, in order to arrange the arguments on both sides, or the diagnostic signs in the clearest manner, for the in- struction of his class, by putting questions which he himself an- swers, has not been interfered with. These volumes must, there- fore, contain much elementary matter, which would be deemed su- perfluous in a written treatise; in the analysis which we intend to give, we shall of course omit all such particulars, and, by prun- ing and compressing, we shall endeavour to put our readers in possession of all that is new or valuable. Art. I.?On Permanent Retraction of the Fingers. The cause of this peculiar retraction of the fingers, and particularly of the ring* fingers, has been attributed by different authors to rheumatism, gout, external violence, fracture?to the effects of inflammation of the tendons of the flexor muscles, or to a species of anchylosis. Boyer, in his Traite des Maladies Chirurgicales, denominates it crispatura tendinum, but describes it very superficially. It affects those individuals whose occupation causes 1833] M. Dupuytreiis Clinical Lectures on Surgery 291 them to make a point-d'appui of the palm of the hand. Thus, it has been observed in coachmen, who are obliged constantly to use the whip?in keep- ers of wine-shops, who are continually tapping- their wine-casks?in masons, who grasp stones with the extremities of their fingers?in farmers, and, in one instance, in a man with a large correspondence, who took particular pains in sealing his letters. We remember to have seen it in both the hands ?f an inferior officer in the revenue service, who had been accustomed to' steer, for a long series of years, the Custom-house boats, and, consequently, to hold the ropes continually in the palms of each hand. It commences by the individual perceiving that he can extend with less ease the fingers of the affected hand; the first phalanx of the ring finger is first retracted, but, at this time, its palmar surface presents no nodosity, its two last phalanges are straight and moveable, although the first is bent at a greater or less angle, and cannot be rendered straight by the most violent force. One person, in order to cure this, lifted with the finger different weights, until he supported 150 ibs. without extending the phalanx. When the ring finger is very con- siderably bent, the skin is thrown into folds, whose concavities are towards the fingers, and convexities towards the radio-carpal articulation; this is owing to the natural adherence of the skin with the diseased parts beneath, and not to any disease of the skin itself, which dissection proves is unaffected. On touching the palmar surface of the ring finger, a tense cord is felt, ex- tending from the top of the finger to the superior extremity of the palm of the hand ; this almost entirely disappears on bending the finger. On en- deavouring to extend the finger, it will be seen that the tendon of the pal- maris brevis is put in action, and that this motion is extended to the supe- rior part of the palmar aponeurosis; the continuity of these parts explains their simultaneous action. At this period, the adjoining fingers cannot be completely extended, the patient can grasp only small substances, and, if he squeezes them strongly, he feels acute pain ; whilst his hand remains at rest, there is no pain, but it comes on if he extends his fingers forcibly.: Dupuytren has been consulted in upwards of thirty or forty cases, and he has been in the habit, in his clinical lectures, of bringing forward the opinions of a crowd of authors, as to the nature of the retraction; these, or the arguments against them, we shall not here enter into, but proceed at once to the detail of the dissection, which explained to the Baron the cause of the deformity, which had not hitherto been suspected. M. Dupuytren having obtained the arm of a man who had just died, and ?whom he knew was subject to this affection, commenced the dissection by taking off" the whole of the skin from the palm of the hand, and the palmar surfaces of the fingers; the folds and wrinkles entirely disappeared, shewing clearly that the disease was not situated in the skin itself. On exposing the palmar aponeurosis, it was found stretched, retracted, and diminished in length;.from its inferior part proceeded the kind of cords which were at- tached to the sides of the affected finger. On endeavouring to extend the fingers, the aponeurosis became tense and crackled ; on cutting the prolon- gations of it, which were attached to the sides of the fingers, the contraction ceased, the fingers returned to their usual state of demi-flexion, and the least effort completely extended them. In order to leave no part unexamined which might be implicated in this affection, M. Dupuytren exposed the ten- dons, and found their size, their mobility, and their polished surfaces per-' U 2 29*2 Mkdico-chirurgical Rkview. [April 1 fectly natural; as well as the bones, the ligaments, and the joints themselves, in a completely normal state ; he was then justified in concluding that the contraction was owing to an unnatural tension of the palmar aponeurosis, produced by a contusion of the part, the consequence of the too strong and too prolonged action of a hard body in the palm of the hand. The diversity of opinions as to the cause of this deformity has necessarily produced much uncertainty in the employment of therapeutic agents. M. Bennati, in con- sulting Sir A. Cooper as to the case of an Italian, named Ferrari, who was subject to this retraction, was told by him that it was incurable. Such is also the opinion of many other surgeons. M. Dupuytren had tried fumigations of emollient vapours, cataplasms, leeches, mercurial frictions, douche baths of every sort and temperature, without success. In one case he tried per- manent extension by a machine contrived for the purpose, but the pain it produced was so severe that he abandoned it. The flexor tendons have been divided in two instances, but to no purpose; and in one case the patient's life was endangered by the inflammation extending along the sheath of the tendons. Shortly after these operations M. Dupuytren was consulted in the following case. In 1811, M. L., a wine merchant of Paris, having received a stock of wine from the South, assisted his workmen in arranging the casks one upon another in his cellars. In raising a very heavy cask by placing his left hand beneath its prominent edge, formed by the ends of the staves* he felt a cracking, and a slight pain in the palm of the hand. Increased sensibility and stiffness remained for some time, but these symptoms gradually disap- peared. The accident was almost forgotten, when he observed a slight re- traction of the ring-finger towards the palm of the hand, so that he was unable to extend it as much as the others. There was no pain, and he neg- lected the slight deformity, which every year became more marked. At the commencement of the year 1831, the little and ring fingers were completely flexed, and applied to the palm of the hand; the second phalanx was folded on the first, and the extremity of the third touched the middle of the cubital border of the palmar surface. The skin was thrown into folds, and drawn towards the base of the two retracted fingers. M. L. now consulted several practitioners, who recommended the division of one or both of the flexor tendons; subsequently M. Dupuytren was consulted, who immediately stated that the disease was not situated in the tendons, but in the palmar aponeu- rosis, a division of which would produce a free motion of the fingers. The operation was thus performed. The hand being firmly fixed, M. Dupuytren commenced by making a transverse incision, of ten lines in length, opposite the articulation of the phalanx of the ring finger with its metacarpal bone; the bistoury divided at first the skin, and next the palmar aponeurosis, with an audible cracking sound; the finger immediately straightened itself, and could be extended with almost as much ease as when in the natural state. "Wishing to avoid the pain of a new incision, the operator endeavoured to continue the division of the aponeurosis by introducing the bistoury in a transverse direction, deeply beneath the skin of the side of the cubital border of the hand, in order to liberate the little finger, but in vain. He then made a transverse incision opposite the articulation of the first and of the second phalanx of the little finger, and thus detached its extremity from the palm of the hand, but the rest of the finger remained firmly flexed. The skin and 1833] M. Dupuytrens Clinical Lectures on Surgery. 293 aponeurosis was next divided by an incision opposite the articulation of the phalanx with the metacarpal bone; this produced a partial but not a complete restoration of the flexibility of the part. A last transverse incision was then made opposite the middle of the first phalanx itself, and this must have divided the insertion of the palmar aponeurosis, as the little finger could immediately be extended with the greatest facility. The incisions, which bled hut little, were dressed with dry charpie, and the little and ring fingers were extended by means of an apparatus fixed to the back of the hand. The day of the operation and the following night were passed with little or no pain. During the next day the hand became slightly swollen, owing to the clumsiness of the instrument. Another was then substituted, consisting of a half-cylinder of pasteboard, terminated by four metal rods, which could be lengthened or shortened at pleasure, and which were surmounted with a kind of thimbles to embrace the ends of the fingers. The patient found at first some relief, but in the evening the pain and swelling returned. He was ordered to have his hand sprinkled constantly with a solution of acetate of lead in cold water, without removing the apparatus. This diminished the Pain and swelling. Without giving the daily report of the progress of the case, it will be sufficient to state that suppuration became established, and the wounds, at the end of about twenty days, were completely cicatrized. The machine was used for more than a month, and when it was removed the fingers were found, with the exception of the temporary stiffness, oc- casioned by continual extension, to be so flexible as to allow the patient to hend them easily. A month after this M. L. only employed the machine during the night, and the articulations were becoming so supple as to show that the tendons remained healthy, and that in process of time the motions of the fingers would be completely re-established. M. Dupuytren repeated this operation Dec. 5th, on a coachman, aged 40, who applied to him for the relief of the deformity which existed in both hands. When he came to the hospital his fingers were so bent that they Were not more than an inch and a half distant from the palm of the hand, the skin of the palm forming folds whose concavity was turned towards the fingers. On extending the phalanges, the cords passing from the fingers to the palm were very evident. The patient being seated, M. Dupuytren held the right hand, and made with a bistoury two semi-circular incisions, the one at the base of the ring finger, in order to divide the two digital prolonga- tions of the palmar aponeurosis which were attached to this finger, and the other an inch and a quarter beneath the former in the palm of the hand, to make a second section of this digital prolongation, and to separate it by its base, from the body of the palmar aponeurosis. The ring finger was immediately restored to its normal position. The patient becoming very weak, the operation on the left hand was deferred until another day. The hand was dressed in the same manner as was adopted in the preceding case, and the result will most probably be similar. Although three facts are not sufficient to establish a general doctrine, yet, by awakening the attention of surgeons, they may be of considerable benefit to science, by multiplying the observations on the causes, signs, effects, and treatment of this disease, and chiefly in the operation which has here been proposed and adopted. In conclusion, M. Dupuytren recommends caution, lest a false application of these observations may be made, by sup- posing that till retractions of the fingers resemble these, and require the 294 Medico-chirurgicax Review. [April 1 same operation. In a subsequent clinical lecture (Art. XVII.) this subject is resumed, as there were several cases in the hospital illustrating- the different species of retraction of the finger. ] st Case. A boy, aged 14, admitted under M. Sanson for a white swelling1 of the ankle-joint; has also retraction of the little finger of the left hand, of very long standing. There is not the least motion in the articulations of the phalanges with each other, but the junction of the first with the meta- carpal bone is perfectly free; on bending the finger backwards there is no palmar cord; hence the disease is in the articulations of the phalanges. 2d Case. In this individual the two last fingers are constantly bent to- wards the palm of the hand, but they are easily extended, and there is no cord. This is owing to a sabre-wound on the back of the hand having divided the two extensor tendons. A contused wound may produce a simi- lar effect. 3d Case. In this patient the little finger is curved into an arc of a circle, the articulations are unaffected, there is no palmar cord, and the tendons of the flexors and extensors are sound. The retraction depends on a disease of the skin which has destroyed its palmar surface to a great extent: this was owing to a contused wound from the wheel of a carriage. The wound was cicatrized by placing the edges in contact, not by the production of a new cutaneous tissue;?a narrow cicatrix and retraction of the finger was the consequence. Burns of the palmar surface improperly treated by neglecting to ex- tend the fingers, is a frequent cause of their contraction. But in these eases there are no prominent hard cords extending from the fingers to the palm. Retraction from deformity of the articular surfaces of the phalanges, occasioned by certain occupations, is not uncommon. Women who con- stantly knit, and who are consequently obliged to retain the little finger separate from the others, and strongly bent during a very long time, in order to support the thread they employ, have often a retraction of this finger from deformity of the corresponding articular surfaces of the first and second and second and third phalanges. This was very common in France, and is still so in Germany, where the women of Berlin and Dresden knit whilst walking. 4th Case. A strong young woman, a lace-maker, has the four last fingers of each hand retracted towards the palm, forming the fourth of a circle; the articulations of the phalanges with the metacarpal bones are free. The fingers may be bent backwards; this shows no cord. The second phalanges however cannot be bent backwards on the first, owing to a deformity of their articular surfaces, produced by the occupation of the patient. 5th Case. This patient is a tailor ; such persons are obliged to keep the fingers of the right hand constantly bent. In this instance it is impossible to straighten the ring finger, and such attempts produce pain, but nothing indicates disease in the palmar surface. The retraction depends on the pre- sence of a ganglion, or accidental serous kyst, at the articulation of the first with the second phalanx. Wounds of the flexor tendons may be mistaken for this retraction, but the prominence of the cord formed by the aponeurosis is much more superficial, nor does it yield to extension ; whilst in extending the finger contracted by a divided flexor tendon, the tendon of the palmaris brevis is depressed, and the prominence almost entirely disappears. 6th Case. The middle finger of this patient is curved into half an arc of 1833] M. Dupuytren's Clinical Lectures on Surgery. 295 a circle; from its pulp a cicatrix passes to its border, in which is felt a round and hard cord, which is the tendon. This displacement and retraction was produced by the surgeon having- opened the sheath of the tendon, in making an incision for a whitloe. 7th Case. This patient has the palmar surface of the third phalanx strongly bent on the second, of the indicator finger of the right hand. There is complete anchylosis of the articulation. A wound on the dorsal surface had penetrated the joint, and inflammation, with its usual consequences, followed. 9 th Case. A ball from a pistol passed through the fore-arm of this pa- tient, without fracturing the bones. The cubital nerve was divided, and paralysis of the internal side of the arm, and two last fingers, followed. M. Dupuytren enlarged the wound immediately, simple dressings were applied, aud the wound cicatrized in the course of a month; but the paralysis re- mained, as well as retraction of the two fingers. The articulations are free, but, on our endeavouring to extend the fingers, there is much resistance and pain at the cicatrix. This is produced by the loss of substance which the flexor muscles have sustained. This lecture which is especially valuable, from its clearly proving the na- ture of an affection hitherto unsuspected, illustrates the clear and methodical manner in which M. Dupuytren arranges his cases for the elucidation of his subject. Art. II.?On Cataract. In following the plan we have laid out, of only placing before our readers the peculiar views of M. Dupuytren, or striking and instructive facts, illus- trating modes of treatment which are commonly adopted, we shall pass over the descriptions of the various forms of cataract, which are perhaps better described, and, we cannot help thinking, more accurately known, by our own writers on ophthalmic surgery. Many facts observed at the Hotel Dieu, have induced M. Dupuytren to admit an hereditary disposition to cataract. The following illustration tends to prove the disposition to the disease, as well as the success of the operator in removing it. An elderly woman, accompanied by part of her family, presented herself at the hospital. She stated that, when between 60 and 70 years of age, her sight became impaired; 18 months afterwards, both her crystalline lenses were entirely, opaque. M. Dupuytren depressed one, and the ope- ration was so completely successful, that at the age of 80 she saw well. The sight of her daughter began to be impaired at 28 years of age ; in a short time she could only distinguish day from night, but the pupils were moveable and the eyes healthy. At the age of 30, M. Dupuytren performed a similar operation to that to which her mother submitted, and with the same success. The daughter of this woman, aged 17, had also two cata- racts, for which the Baron successfully operated; and, at the same time, the grandmother brought to the Hotel Dieu two of her other grandchildren, in the elder of whom the crystalline lenses had begun to become opaque, whilst the younger saw objects as if through a cloud, the precursory symp- tom of the family disease. M. Dupuytren has operated on a large number of congenital cataracts, 296 Mkdico-ghikurgical Rkview. [April 1 but he has never seen those surprising- effects of which so many authors have spoken, nor has he heard, from the lips of the patients whose sight he has restored, those marvellous reasoning's on the distance, form, and colour of objects, the recital of which has produced so many metaphysical specu- lations. He has, on the contrary, almost always remarked, that those blind from cataract, which existed either from birth or during many years, so that they were accustomed to the exercise of but four senses, were generally em- barrassed by the acquisition of the fifth ; they experienced difficulty in com- bining the action of it with the others, and they showed frequently so great an unwillingness to employ it, that he has been obliged several times to de- prive them of one, or even two of their senses, in order to force them to use that of sight. He thus stopped up the ears of a child, who guided itself either by sound, or by the impressions it received by its hands, which it carried before its body constantly, like tentacula. M. Dupuytren prefers depression of a cataract to extraction, and has rarely recourse to this ope- ration, unless the alteration which the lens or the membrane has undergone is such as to render absorption impossible. In surgery, as in medicine, the same methods of treatment cannot be employed, in every case, to compass the same end, and no precepts are more irrational than those which recom- mend one operation in all cases. Relatively to age, and the degree of energy of the absorbent system, it would appear that it is better to operate on chil- dren by depression, and on old people by extraction. In children, the func- tions of life are carried on with all their energy, the actions of composition, and of decomposition are executed with astonishing rapidity, the crystalline is always softer than at an advanced age, and, when placed under the ne- cessary conditions, is instantly absorbed ; in the aged, on the contrary, the reverse of this is the case?absorption has lost great part of its energy, ex- halation predominates, whilst the lens is harder, and absorbed with greater difficulty. M. Dupuytren has found crystalline lenses perfectly unabsorbed, although depressed for upwards of two years, in old people who had died of other diseases. But there are other conditions which favour the operation of depression in both ages ; children are rarely docile, or can distinguish between that which is hurtful or advantageous to them, and their consequent resistance to an operation on the eyes renders extraction difficult, and may produce an evacuation of the vitreous humour. In old people, the eye may be deeply imbedded in the orbit, or the borders of this cavity may be very prominent, or the globe of the eye be of small size, and in such cases ex- traction is particularly difficult. Individuals are seen, of all ages, in whom, owing to an aberration in the motions, or in the conformation or relations of the organ, this operation is one of great difficulty; in others, the eye is agitated by rapid and convulsive motions ; finally it is a constant observa- tion, that when an individual is deprived of sight for some time, he loses, with the habit of seeing-, the habit of looking, the motions of the globe no longer obey his will, and the difficulties of extraction are consequently in- creased. Such are some of the considerations which induce M. Dupuytren to prefer the operation of depression. He regards the operation of absorp- tion, or that of breaking" up the lens, as a modification of that of depression, and that one or the other is to be employed, according to circumstances, that whilst a hard cataract cannot be broken up, a soft one cannot be de- pressed. The needle which M. Dupuytren uses combines the properties of 1833] M. Dupuytren's Clinical Lectures on Surgery. 297 the old lance-shaped needle with the needle of Scarpa. Its blade is narrow, elongated, and bent at the extremity, its point is very acute, and both its edges sharply cutting1, the size of its shaft is exactly proportioned to that of its blade, so that it is equally formed for penetrating-, dividing*, seizing1, and displacing-, readily yielding to the hand, and moving without effort, or with- out allowing the aqueous humour to escape. For extraction, M. Dupuytren uses Richter's knife. When the crystalline is depressed, M. Dupuytren ex- amines carefully whether the capsule is perfectly black and detached; if some fragments still remain, he carries them into the anterior chamber. If the cataract is membranous, either partial or complete, with or without opacity ?f the lens, the operation is conducted in the same manner. The milky ca- taract requires to be broken up. If the softening is so complete, that the foment the capsule is torn a thick fluid fills the anterior chamber, so as to obscure the remaining steps of the operation, M. Dupuytren waits until ab- sorption renders the eye again clear. About 23 years ago, M. Dupuytren was led to introduce the needle through the cornea to depress a cataract, as his patient was a young girl whose eyes he could not fix, owing to a convulsive action of their muscles. He was not aware that this had been attempted previously; subsequently, the favourable mode in which the Germans spoke of this operation, or kera- tonyxis, induced him t-o put it to the test of experience. The consequences at ?which he arrived are, 1st, That it is not more easy than the operation of pierc- 'ng the sclerotic. 2d, That the situation of the hand of the operator, and his needle, being between his eye and his patient's, prevents him from following the motion of his instrument or of the cataract with facility, especially when, in depressing it, the hand as well as the handle of the needle requires elevation. 3d, That the pupillary margin impedes the motion of the needle, both in depression, and in detaching the portions of capsule which adhere so often to the ciliary processes. 4th, That keratonyxis neither prevents the ner- vous nor inflammatory consequences which result occasionally from the pos- terior operation, and which have been so much dwelt on by the Germans. 5th, That iritis is a more frequent consequence, owing to the greater fatigue which the iris undergoes in this operation. 6th, That it is sometimes fol- lowed by an opaque cicatrix?in some instances, a blemish, in others, an obstacle to vision. 7th, finally, That the results of both are very similar. A table is given of the result of 21 operations by keratonyxis, 17 of which "were successful; this does not differ much from the results of the posterior operation. M. Dupuytren by no means concludes that keratonyxis should be abandoned, but regards it as a new resource, preferable, in some few cases, to the ordinary method of depression. The circumstances in which it would be indicated are, prominence of the orbit, narrowness of the opening of the eyelids, smallness and depression of the globe, excessive mobility of this or- gan, and especially when caused by those convulsive motions to which chil- dren, affected with congenital cataract, and adults with central membranous cataract, are peculiarly liable. The following are the general principles on which M. Dupuytren conducts the treatment of his patients, before, during, and after the operation. Previously to the operation, particular attention is paid to the state of the atmosphere and the prevailing diseases ; thus, if ophthalmias are extremely common, the operation is delayed. The general health of the patient is to 298 Medico-ciiirurgicaz. Review. [April 1 be carefully examined ; if any rheumatic affection is present, an operation is often followed by severe inflammation; it is advisable, in the first place, to attack the rheumatism, and, if it is decided to operate when some vague pains are still present, a blister should be applied to a part at some distance from the head. If there is pulmonary catarrh, the paroxysms of coughing not only produce a greater flow of blood to the head, but they may cause the cataract to rise into its old situation. If the stomach is affected, vomit- ing may act in the same mechanical manner, whilst, from the sympathy which exists between the stomach and the eyes, various morbid complications may be expected. Diarrhoea and constipation contra-indicate the operation : it should not be performed during an attack of piles; and, if practised after the disease has ceased, the slightest symptoms of sanguineous congestions of the head should be combated by leeches to the anus. Even when there ex- ists no complication, M. Dupuytren never neglects preparatory means, which are, perhaps, as important as manual dexterity. These consist in the pre- scription of baths, emollient lavements, and drinks, general or local bleed- ing, according to the circumstances, and the constitution of the patient; from time to time, small doses of castor oil, and, if the eye is very mobile, and is likely to be irritated by the approach of instruments, it is of service to habituate it beforehand to the operation, by simulating the various move- ments that will be required. More particularly when M. Dupuytren per- forms keratonyxis, he dilates the pupil, by dropping between the lids, on the preceding evening, some drops of a solution of extr. belladonnas, or lauro-cerasus. M. Dupuytren always performs the operation whilst the pa- tient is lying in bed, with his head elevated; this maintains the eye, as well as the whole body, in a perfect state of rest?it counteracts the tendency to syncope which sometimes occurs, and it prevents the motion of the patient from causing the cataract to remount into its former situation. He at- taches considerable importance to this precaution. Subsequently to the operation, low diet and absolute repose are enjoined. If the patient is san- guineous, and there is a tendency to congestion about the head, he bleeds, &c. If there is a disposition to vomiting, which is almost always the case in children, he gives an anodyne. If there is much agitation, or nervous symptoms, lavements, with some drops of laudanum, are very useful. In those cases where both eyes are affected, M. Dupuytren never operates on more than one at the same time, the reasons of which are very obvious. It is by no means an infrequent occurrence, that the cataract remounts, and this is the most serious objection to the operation. Under such circum- stances, it is better to depress it again, as, if left to itself, it is absorbed very slowly. In some subjects, there is so great a tendency to this rising of the lens, that M. Dupuytren has been obliged to repeat the operation four times at an interval of some months. Part of a cataract, or many portions of it, may rise in the same manner, requiring, in some instances, mechanical re- moval from the axis of vision. The lens, when diseased, appears more sus- ceptible of displacement than before it had lost its transparence ; sometimes it is wholly displaced, passing into the anterior or posterior chambers?? sometimes, remaining only partially fixed, it floats about, obstructing in- completely the pupillary opening. By such displacements, patients with ca- taract have suddenly recovered their sight after a brisk movement, or a blow in the head or eye. Some individuals have possessed the power of making 1833] M. Dupuytren's Clinical Lectures on Surgery. 299 the lens pass from one chamber of the eye to the vdavila@example.org. The follow- ing curious case, extracted from the work of Demours on the diseases of the eyes, proves this. The patient, in the presence of the author and two other surgeons, caused the opaque lens to pass into the anterior chamber, and afterwards to return behind the iris. The cataract was formed at six years of age, and towards puberty, gradually descended behind the iris. At 18 years of age it was not to be seen, but was buried in the disorganized vitreous humour. At the age of 19, during an active military service, this body passed before the iris, and pro- duced such constant pain, that the young man obtained his discharge. M. Demours was consulted and recommended extraction, but as the patient wished to avoid the operation, he advised him to dilate the pupil with belladonna, to remain lying on his back for 24 hours, and from time to time to place his head with the vertex lower than the neck, so as to favour the return of the lens behind the iris. When the lens was no longer visible, he ordered a few drops of vinegar to be dropped into the eye, to excite inflammation and consequent contraction of the pupil. This was followed with the success he expected. For 8^ years the patient was free from this singular accident j but during the last two years it has returned three or four times a month. If inadvertently he suddenly depresses his head, the lens passes before the lris; he then is in pain, and incapable of occupation, until, by lying on the ground, his chin elevated, and the summit of his head depressed, he forces it back by strongly rubbing the globe with the upper eyelid. M. Dupuytren enters at some length into the complications of cataract with adhesions of the iris, and permanent contraction of the pupil, and recommends the em- ployment of belladonna when the effusion of lymph is recent, but when it is organized, he directs the adhesions to be broken down with the needle previously to depressing the lens. In displacements of the crystalline lens, M. Dupuytren recommends, as a general rule, that no operation should be attempted unless the presence ?f the foreign body causes inflammation. The following case shows the adaptation of a new operation to peculiar circumstances, and illustrates not only the skill of the operator, but the resources of a first-rate surgeon. A soldier, aged 34, was received into the Hotel Dieu, the 2d Nov. 1819, having the anterior chamber of the left eye completely filled with the pearly opaque lens, which had passed through the iris whilst the patient was strongly depressing his head. The eye was red, inflamed, painful, and Catering, with intense head-ache. Bleeding from the arm, a warm-bath, and a purgative, relieved these symptoms, and two days after the following operation was performed. The patient being placed in bed, with his head elevated by pillows, the operator plunged the needle into the sclerotica, about two lines from its junction with the cornea, passed it from the pos- terior into the anterior chamber, hooked the crystalline lens, withdrew it into the posterior chamber, and depressed -it in the vitreous humour. The patient could immediately see the hand of the surgeon, and distinguish his assistants. The results were most successful, the patient left the hos- pital six days after with a perfectly clear pupil, seeing well, and experiencing no pain. Such are M. Dupuytren's principal ideas on cataract. We have given them perhaps at greater length than our space will well permit, considering 300 MHDIGO- CHI HUltGICA L Review. [April 1 the value of the remaining- matter, as we were the more anxious to make our readers acquainted with his views on this subject, as they differ in some points from those of our modern ophthalmic surgeons. By them extraction is generally performed, and, as our eye institutions testify, with great suc- cess ; but the difficulty of the operation, and the experience required before the surgeon becomes a sure and successful operator, is allowed by all. Pope's apothegm on different forms of government, that? Whate'er is best administered, is best, may be applied with some restrictions to varieties in surgical operations. No one who has seen an experienced surgeon pass bis knife steadily through the cornea, and extract the lens without injuring- any other part of the organ, will deny that such an operation so performed, is more workman-like and physiologically correct than that of thrusting- a needle through the sclerotic, choroid, and retina, and breaking up a considerable portion of the vitreous humour by forcing the opaque lens into it; or that it possesses many advan- tages over the slower method of passing the needle through the cornea, and subjecting the lens to the tedious process of absorption, which indeed, in many instances, is not available. But it should be recollected that this dex- terity was not acquired except by such a share of practice as falls to the lot of comparatively few, and that there is some truth in the strong, but exagge- rated observation of Wenzel, that a hatful of eyes must be lost before expert- ness is obtained in extraction. This should reconcile the provincial surgeon under whose care the poor necessarily fall, who are not unfrequently dis- abled by this affection, and to whom vision is almost necessary to existence, to a more simple mode of proceeding, which, although it offers many disad- vantages, possesses the superiority of being more easy of execution. We are very far from agreeing with M. Dupuytren as to the peculiar advantages of the posterior over the anterior operation; we have stated his arguments, many of which, we think, anything but satisfactory, at length; but we have not now space to discuss them. To those who may wish to see the principal advantages of the anterior operation, we would recommend the perusal of an excellent and practical paper published by Dr. Jacob in the 4th volume of the Dublin Hospital Reports. M. Dupuytren has unaccountably passed over without observation the unfavourable nature of those cases which are com- plicated with adhesions and consequent contractions of the pupil. He gives directions for breaking them down previously to depression ; but how often are they complicated with a disorganized state of the retina, and how rarely is the patient benefited by the removal of the opaque lens. Art. III.?On Inflammatory,|Scrophulous, and Venereal Enlargements of the Testicle. This article is devoted to the description of these three affections in order to prevent the unnecessary extirpation of the organ, a practice but too com- mon in Paris. One surgeon indeed of great reputation is said to remove every testicle which is the seat of chronic enlargement. In this country more caution is observed, and these glands are rarely extirpated, unless the enlargement is of a well-marked malignant character, before every other means of cure have been tried. In performing the operation, M. Dupuytren 1833] M. Dupuytreris Clinical Lectures on Surgery. 301 makes a most extensive incision from the inguinal ring*, to below the infe- rior extremity of the tumour. He transfixes the spermatic cord with a tena - culum previously to dividing1 it below that instrument; he applies two or three points of suture to the divided scrotum. Inflammation of the body of the testicle is attended with much greater enlargement, and is more easily cured, than when the epididymis is affected. The structure of the parts ex- plains this. In such cases M. Dupuytren employs at first a vigorous anti- phlogistic treatment, such as repeated venesection and leeching, baths, low diet; by these means the swelling is dissipated generally in eight or ten days. If the enlargement commences in the chronic form, or if it passes from the acute to the chronic stage, he prescribes resolutives, such as dia- chylon, or mercurial plasters, together with derivatives, such as purgatives, every two or three days ; for this purpose he uses calomel, or castor oil, sulphate of soda, &c. The scrophulous enlargement of the testicle com- mences frequently in exactly the same manner as the simple inflammatory; it does not however yield to the ordinary means, and is prolonged indefi- nitely ; it exists often with other affections of the same nature in a scrophu- lous habit. The tubercular degeneration affects generally the fibro-cellular structure surrounding the epididymis, as well as the substance of the gland. The tubercles increase slowly, and may remain three or four years ; these are diagnostic marks. The scrophulous enlargement is less hard than the scirrhous, and harder than the inflammatory; it is without heat and redness, giving a sense of weight, and " engourdissementthe subcutaneous cel- lular tissue is generally free. The tumour is commonly unequal and irregu- lar, whilst in schirrus it is globular, and the epididymis knotty. As the disease progresses, parts of the testicle become softened ; so that when touched they feel soft: these are gradually elevated and ulcerate, discbarg- 'ng a serous pus, and a cheesy scrophulous matter. This state may remain for years. If medicine fails, the testicle becomes soft, and fungoid, and extirpation alone can cure the disease; that is, if it is confined to this organ. Treatment. The inflammatory symptoms having been subdued, constitu- tional remedies should be adopted The residence of the patient should be in a dry and elevated place, exposed to the South. He should be covered with flannel from head to foot, and use dry frictions; he should take exer- cise in the open air, and as much as possible in the sun; his diet should be strengthening-, consisting of brown meats, game, and antiscorbutic vegeta- bles, avoiding mineral and vegetable acids, sour and especially farinaceous yegetables. Iodine may be employed in doses of an eighth to half a grain |n mint water, or frictions with hydriodate of potash. Salt, sulphur, or loduretted douche baths may be used, particularly when there are fistulous sores. If, notwithstanding these remedies, the disease proceeds, and the testicle becomes soft, fungoid, and full of scrophulous deposits, or if it threatens to pass into scirrhus, which is rare, extirpation should be employed without hesitation, or the patient is exposed to some fatal organic disease. Patients constantly present themselves with enlargement of the testicle, for which they can assign no cause; they have received no blow, nor other external injury. If the tumour is elongated and cylindrical, if it causes no lancinating pains when touched, if the patient has had former venereal 302 Mbdico-chirurgicax. Review. [April 1 affections, if he states that, after being- six, twelve, or eighteen months affected, the testicle has returned to its normal state, and the other has enlarged, there are strong- presumptions in favour of the venereal nature of the dis- ease ; the enlargement shifting from one testicle to the other is a pathog-- nomonic symptom. In cases where the disease returns after castration, if a cancerous testicle has been removed, the cord almost always becomes af- fected; but, in syphilitic enlargement, the remaining testicle is the seat of the affection. When there are other syphilitic symptoms, such as eruptions, nodes, &c. the diagnosis is more clear. If there is doubt, it is better to adopt a syphilitic treatment during six weeks or two months, than risk an operation. M. Dupuytren's antisyphilitic treatment consists of the compound decoction of sarsaparilla and the following pills? Jk. Hydrargyri oxymur .... gr. ^ to ? Opii gr. ss. Extr. Guaici........ gr. ij. M. Fiat pilula, ter quotidie sumenda. Art. IV.?Traumatic Emphysema. Two cases of emphysema, from fracture of the ribs, are detailed ; one of these was mild?the other severe and fatal; they very fairly illustrate the subject, and introduce some useful remarks, but, as there is nothing novel in the article, we shall pass on to a case of traumatic emphysema of the eyelids. A workman, aged 25, whilst excavating, had the right anterior part of his head, his neck, and chest covered by the falling-in of the earth. On being extricated, he merely felt slight pain at the root of the nose, to which he paid little attention, and continued his work. About a quarter of an hour afterwards, having endeavoured to blow his nose, the eyelids became suddenly and considerably tumefied, so that the eye was entirely covered. On touching the part, there was evident crepitation. M. Dupuytren consi- dered that the external violence had ruptured the pars plana of the ethmoid bone, or the os unguis, and that, through this opening, the air passed from the nasal fossae into the internal structure of the eyelids. The reason why the emphysema did not appear immediately after the accident, but not until the man had endeavoured to blow his nose, was, probably, that the fracture of the bone was unattended, at first, with destruction of the soft parts which line it, and which formed an obstacle to the transmission of air ; but that subsequently, the patient having, by his efforts to blow his nose, driven a strong current of air against these parts, they had given way, and esta- blished a communication between the nasal fossae and the eyelids. Bleed- ing from the nose is a usual symptom in such cases, but in this it did not occur. Venesection was employed, and wet compresses were applied to the base of the orbit. M. Dupuytren recommended the patient to avoid blow- ing his nose, coughing, or any other effort which could renew the passage of the air through the presumed opening. On the third day the crepitation had diminished, and, on the
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