THE

Medico-Chirurgical Review,

No. XXXVI.

JANUARY 1, TO APRIL 1, 1833.

I.

LECONS ORALES DE CLINIQUE CHIRURGICALE, FAITES A L'HÔTEL DIEU DE PARIS. Par M. le Baron Dupuytren, Chirurgien en Chef. Recueillies et publiées par une Société de Médecins.-(Clinical Lectures on Surgery, delivered at the Hôtel Dieu at Paris. By Baron Dupuytren.) Tome I. Paris, 1832.

À COMPARISON of modern medical literature with that which has preceded it, exhibits the most striking difference in the preponderance 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 Babbages. The few medical works which have escaped the destroying hands of trunk-makers, or the conversion into "shrouds for pilchards and red herrings," are those alone which have contained 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 discovered by close observation. The description of diseases by Celsus and Aretæus 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 in channels which they would never have beaten out for themselves. This increased attention to the importance of facts in studying disease cannot be promoted more effectually, than by clinical instruction, fully carried into effect as it is in the French hospitals. No plan is more adapted for testing the merits of the doctrines of the Professor, or of estimating the advantVOL. XVIII. No. 36. 26

ages of the 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 unexpected 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 illustrating 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 clinical 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 experienced 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 observations 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. 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 instruction of his class, by putting questions which he himself answers, has not been interfered with. These volumes must, therefore, contain much elementary matter, which would be deemed superfluous in a written treatise in the analysis which we intend to give, we shall of course omit all such particulars, and, by pruning and compressing, we shall endeavour to put our readers in possession of all that is new or valuable,

Thus,

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 Traité des Maladies Chirurgicales, denominates it crispatura tendinum, but describes it very superficially. It affects those individuals whose occupation causes

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 keepers 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 of 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 lbs. without extending the phalanx. When the ring finger is very considerably 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 palmer surface of the ring finger, a tense cord is felt, extending 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 endeavouring to extend the finger, it will be seen that the tendon of the palmaris brevis is put in action, and that this motion is extended to the superior 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. M. 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 attached to the sides of the affected finger. On endeavouring to extend the fingers, the aponeurosis became tense and crackled; on cutting the prolongations 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 tendons, and found their size, their mobility, and their polished surfaces