559

RECORD

OF THE

CONCOURS HELD AT PARIS,IN JUNE 1834,

To supply the Vacancy in the Chair of

CLINICAL SURGERY, OCCASIONED BY THE DEATH OF BARON

BOYER.

(Continued from page 537.)

LECTURE BY 11T. BERARD.

First Patient. - LUXA7‘ION OF THE IIu-MERO-SCAPULAR ARTICULATION, DOWN-WARDS AND FORWARDS.

The first patient presented to M. BE-RARD (Fils) was marked on the back of thethigh with a large cicatrix, the result of aburn carried to the third degree; it was

very irregular in form, but did not exhibitany tendency to the formation of bridles,which led the speaker to lay down as ageneral principle, that cicatrices formedon the side of extension, have not the sametendency to the production of bridles andretractions, as those which take placeon the side of flexion. This was not the

only injury; the patient exhibited another,much more interesting, and to which thespeaker immediately applied himself. Thepatient, in this case, was a mason, andwhile ascending a ladder, he fell from aconsiderable height on his left side. Ongetting up he felt a good deal of pain inthat side and along the arm, but therewas no loss of sensation. On examina-tion of the injured limb, the followingparticulars were remarked, which leaveno doubt on the nature of the affection.In the first place, the left arm hangsdown by the side, and is longer than theopposite one by six or eight lines. Thiswas ascertained by measuring the distancebetween the acromion process and the ole-cranon ; the height of the anterior parietesof the axilla seemed increased, and the armprojected from the side about three inches. IOn examining the axilla, it was easy todistinguish the presence of a solid body inthat space. The motions of the joint areextremely limited (here the speaker en-tered into the study of the motions of thelimb, but forgot rotation altogether),and if the surgeon acts upon it with theleast force, he gives a great deal of pain.It was impossible to draw the arm awayfrom the side, or to bring it forward with-out immense suffering to the patient. Onpressing the fingers over the surface of

the shoulder-joint, a depression was felt onits superior parietes, along which thefibres of the deltoid muscles were drawn,tense and rigid. In the axilla, there wasnot that hollow which presents itself in ahealthy state, but the hand discovered around, hard tumour, which followed themotions of the arm, and seemed to becontinuous with the body of the bone.The nature of this affection is easily ga-

thered from the preceding symptoms ; itis a luxation of the humero-scapular arti-culation, downwards and forwards. Letus now endeavour to prove that it can beno other lesion than the one which wehave indicated. In the first place, wesay it is a luxation and not a fractureof the surgical head of the humerus,which sometimes simulates sufficientlya luxation of the joint. (Here M. BE-RARD enumerated, in a very clear manner,the distinctive symptoms between luxa-tion downwards, and fracture of the neckof the humerus, and particularly insistedon the impeded motion and absence ofcrepitation in the present case.) It is nota fracture of the neck of the scapula, anaccident which might have been easilyproduced by the manner in which thepatient fell on his shoulder; for if thatwere the case, it would not be a matter of

any difficulty to establish the existence ofcrepitation. How is this luxation produced,and what is its mechanism ? The shoulder-

joint may be dislocated in two ways, i. e.,under two different circumstances. In somecases the ligament and capsule surround-ing the joint are extremely lax, eitherconstitutionally or in consequence of somedisease, and when the arm is abducted, thesimple contraction of the deltoid andsupra-spinati muscles is sufficient to makethe head of the bone slip out of the ill-

protected joint, and produce luxation.This, however, is a very rare accident,and in our patient there is no presump.tion of the parts being in this state oflaxity and weakness. More frequently,the individual, receiving a fall on his sidefrom some height, the arm is extendedand receives the shock; at the same time,the different muscles which pass from thetrunk to the body of the bone contractviolently, the arm is acted upon by a.

mechanical power, and the head of thebone is drawn down into the axilla. Thiseffect arises from the nature of the joint,the violence, and the contraction of the, muscles, all combined. The arm, in fact, ismade to represent a kind of lever; the re-sistance is in the articulation, the power isat the insertion of the pectoral, latissimusdorsi muscles, &c., and the fixed point is1 that which happens to strike against thef ground. Now as the distance between

560

the power and prop is measured by nearly Ithe whole length of the arm, the head of Ithe bone must be drawn down with very Iconsiderable force, and we can thus under-stand why luxations are so often producedin this manner. In the case which nowoccupies our attention, the capsular liga-ment is lacerated, and the head of the bonemay be felt in the axilla. Is there an in-complete luxation?-Here the speakerentered into some considerations on thisspecies of dislocation, and commenced bydenying the existence of that which SirA. Cooper has described. He supported,however, the idea of an incomplete luxa-tion ; and affirmed that authors recordnumerous examples of it, but that in thepresent case the luxation was complete,the head of the bone resting on the neck ofscapula. M. BERARD now gave a rapidsketch of the anatomy of the joint, its i

muscles and ligaments, and then askingwhat circumstances favoured the disloca-tion, remarked that it is infinitely morefrequent than any of the others, and that thecourses contributing to its production are,first, the little depth of the glenoid cavity;secondly, the immense extent and varietyof the motions of the upper extremity; and,thirdly, the poBver of certain muscles in-serted near the head of the bone, as thegreat pectoral, the teres major, latissi-mus dorsi, &c. Besides, the lower portionof the capsular ligament is very little pro-tected by tendons or muscles. The onlyone which we have in this situation is thelong head of the triceps, and this does notoffer any great protection.M. BERARD now proceeded to describe

the accidents which may accompany or Icomplicate luxation of the shoulder-joint,and spoke, in turn, of fracture, effusions of blood, paralysis from pressure on the Inerves in the axilla, &c.; and remarked, ,that the present case was free from anyunpleasant complications of this kind, thesensation and motion being quite perfect.The luxation was therefore simple, andeasily recognised. We may now ask, hesaid, what would take place if it were notreduced. The head of the bone: is gra-dually drawn up by the contraction of themuscles, and ascends under the great pec-toral, to be lodged below the clavicle ; thearticulation itself becomes altered, and intime effaced. Besides these, other changestake place; the cartilage covering thehead of the humerus is absorbed, and thesurface on which the bone rests forms anew kind of articulation called the falsemoveable joint. In other cases the headof the humerus may unite with the bone

upon which it rests, the vessels may be.come continuous from one structure to

the other, and true anchylosis take place.

The prognosis of the injury depends onthe extent of these different chanbes, andthe extent of these different changes, andthe manner in which the motion of thelimb is altered. In all cases, the motions

are more or less circumscribed, and insome there is no possibility of communi-cating to the limb the least change of po-sition. I In one remarkable instance, thehead of the bone was driven in betweenthe ribs, and rested upon the pleura; thepreparation is still preserved at the schoolof Berlin. Up to what period may wehope to reduce a luxation ? In the lec.tures of M. DUPUYTREN, which havebeen lately published, we find a table ofluxations, reduced from the earliest periodto two years, but M. BERARD thinks thatreduction is in general impossible after

three or four weeks. Here the speakernoticed the exaggerated account given byauthors of the immobility of the limb incases of luxation ; the fact is, for the firstday or two the limb, as in the present

case, presents a great degree of motion inalmost all directions, and if we were to, look for fixity as an essential symptom,we should often fall into error. The prog-nosis is favourable; first, because the dis-

, location is recent, and one easily reduced;and, secondly, because it is not accom-

panied by any accident or complication.. Now comes the principal question, that

1 I of treatment. The indications are simple,- and easily seized. We have to reduce they luxated extremity, and combat any in-: fiammatory symptoms which may appear.t As to the instruments formerly employedfor the reduction of luxations, we shalle only say of them that they are olrl andr bad, and need never be had recourse to.

G, Sir A. CoopER describes a method which

)f is very easy and simple; the patient ise I placed on his back on the ground; the

1, surgeon places his heel in the axilla,y makes extension by drawing the limb to-4e wards him, and uses his heel also to guidet. the bone into the socket. A principle muchd insisted on by Sir A. Coorur, and whichLe deserves particular attention, is to devise)t some means of drawing off the patient’si- attention, and thus taking the muscular

te system by surprise, at the moment we areabout to reduce the joint ; this is often in-le dispensably necessary, and M. BERARDin has imitated the English surgeon withes great success. But we should speak ofie the preparatory treatment to which the

ie patient is to be submitted; if the luxationa be of long standing, and very difficult tose reduce, or if the patient be nervous, weid

must first employ certain general means,

ne before we have recourse to mechanicale. force. In the first class we may placeto general blood-letting, proportioned to the:e. age and strength of the patient, and

561

drawn from a large orifice; this may be I

repeated if necessary, and other measures i

proper to weaken the muscular strengthof the patient employed; hot-baths con-tinued for several hours are also useful,and we may imitate with advantage thepractice of the English surgeons who givefrequently repeated doses of tartar emetic,not to produce vomiting, but merely tokeep up nausea, and this is a powerfulmeans of reducing muscular force.

M. BERARD now proceeded to describe,at length, the manner of reducing the dis-location with which his patient was af- e

fected. As to counter-extension, he adopts vthe views of BoYER. In speaking of ex- t’

tension, he examined with some minute- bness the most proper point for applying it, o

and concluded in favour of extension made fabove the elbow, as recommended by the 1: xEnglish surgeons, instead of the practice gcommonly followed in France, where the ( cforce is applied to the humerus indirectly, c

through the medium of the forearm and t

elbow-joint. The speaker here took an i

opportunity of combating the advice given i

by many authors, of drawing the limb in ia direction the reverse of that by which itpassed out of the joint; this, said M. BE- fRARD, is a very irrational doctrine, and is i

not, moreover, supported by experience. 1As the action of the muscular system is in imost cases the cause of dislocation, and of Ithe difficulty experienced in reducing thebone, nothing is more proper to excitecontraction of the muscles, and, conse-quently, increase the difficulties alreadyexisting, than to make extension in a lineopposite to the direction of the chief mus-cies which act on the displaced bone;hence M. BERARD prefers the method ofreduction lately described by Dr. MAL-GAIGNE, to all others; he has now triedthis method on six occasions at the hospi-tal St. Antoine, and always succeeded inreducing the dislocation with a facilityand readiness which no one that had notwitnessed the operation could imagine.This method consists in elevating the armas much as possible, and drawing the headof the bone upwards, in the direction ofthe fibres of the deltoid muscle; by thismeans the deltoid, pectoral, and othermuscles surrounding the joint, are notirritated or put on the stretch; we have,consequently, very little muscular con-

traction to overcome, and the head of thebone is easily drawn on a level with theglenoid cavity, and enters without the

slightest difficulty. M. BERARD had latelyan opportunity of testing the efficacy ofthis method, in a case of much difficulty,where the reduction had been twice invain attempted by BovER’s manner, se-

conded by a general bleeding, warm-bath,and other preparatory measures.Having treated this part of his question

at much greater length than we pro-pose to give, M. BERARD concluded thehistory of the case, by examining the ac-cidents which may supervene after re-

duction of the dislocation, and the carewhich the patient may demand at thisperiod.Second Patient.-FTSTULA OF THE CHEEK.

- IMMOBILITY OF THE JAW.

The second patient submitted to theexamination of M. BERARD was affectedwith a fistulous orifice in the left cheek,the result of gangrene following a fever,by which he had been attacked at the ageof ten years ; the patient had also sufferedfrom a scorbutic affection, which contri-buted to render the gangrene more dan-gerous. He now presents a buccal fistula,capable of containing the little-finger, andcommunicating between the cheek and in-terior of the mouth. The jaw-bones arein close connexion with each other, and itis impossible to separate the correspond-ing teeth more than two or three lines.The inferior maxillary bone on the leftside seems atrophied, and the massetermuscle is also considerably diminished inbulk. It does not appear that the duct ofSteno is interested in the disease andobliterated. ’When that is the case, M.BERARD remarked that whenever the

patient eats, the surface of the ;cheek iscovered with an abundant liquid secretion,and becomes red and elevated in tempera-ture, and he named one of his relations whoexhibited this phenomenon after having

, been affected with an inflammation of theparotid gland, which terminated in ob-struction of the duct. In this case thereare manifestly two indications which pre-sent themselves to the surgeon; one, tot close, if possible, the fistulous orifice, theother to restore the mobility of the maxil-t lary bone. To fulfil the first, M. BERARD. proposed the taliacotian operation, or theI method proposed by M. Roux of St. Maxi-1 mien, which consists in making two paral-f lel incisions from the lower border ofs the wound towards the chin, turning upr the flap, and joining it to the edges of thet fistula, which are to be previously pared.e, It is to the latter operation that M. BE-- RARD gives the preference.e The second indication will be fulfilled,e b3· placing between the teeth two metallice plates parallel to one another, and capable.y. of being separated by the action of a)f screw. This apparatus had been already

employed for two days; but the speakern took occasion to remark, that it was em-

ployed on the healthy side of the jaw, and

562

demonstrated that it would be much more’rational and efficacious to use it on theside of the injury.

Here the hour for terminating the lec-ture surprised M. BrRARD before he had.time to investigate the causes of this im-.mobility of the jaw, and many other in-teresting questions connected with the

case. _

LECTURE BY M. LISFRANC.*

* Surgeon-in-Chief at the Hospital of La Pitie.

NOTHING could exceed the enthusiastic Imanner in which M. LISFRANC was received by the crowded auditory in theamphitheatre on assuming the chair al- Iloted to the candidate who is to speak. z,He seemed much affected by the testi-

monies of arfection shown to him by thetwo thousand students ; and, after a fewwords expressive of his gratitude for thesetokens of kind feeling, he commenced thelecture on his two patients.

First Patient.-INJURY OF TIIE LIVERAND PERITONEUM, FROM A KICK.The first patient whom we had to ex-

amine, Gentlemen, was a man 45 years ofage, now lying in the Salle St. Martha,No. 44, at the H6tel Dieu. He enjoyedexcellent health up to the day of his acci-dent ; he is strong in body and of a bilio-sanguineous temperament ; his persondoes not present any traces of his havingbeen affected by any anterior malady.Four days ago he received a violent con=tusion on the abdomen from the kick of ahorse which threw him immediately onthe ground; there was no loss of con-sciousness, however, attending the fall,and this should be kept in mind as a

matter of importance in tracing up the

history of this accident, and endeavour-ing to arrive at a correct diagnosis of thecase.

The man, as I said, was not deprived ofmotion or consciousness, but was able toget up without experiencing anything ex-cept some pain in the neighbourhood of thecontused part, which was not very severeor distressing. The symptoms succeedingthe injury did not present at first any-thing of an alarming nature, but to-dayhe was attacked with accidents of a violentcharacter. He was seized with frequentvomiting, ejecting a porraceous matter,no doubt arising from what he had eaten,mixed with a viscid secretion from thestomach; this was of a dirty-green colour,

and was not stercoral, at least I do notthink so. The abdomen was painful,tumid, &c. He also complains of a pain

ascending from the right hypochondriacregion to the shoulder; he is affected witha short dry cough, and his bowels are

obstinately confined. Our first care wasto make an attentive examination of theabdomen, particularly about the regionwhich had been the seat of the injury.The belly was considerably distended anddeveloped, particularly about the righthypochondriac region. Whence arose thetumefaction ? Was it produced by an ef-

fusion of liquid into the cavity of th- peritoneum, or did it arise from the pre-; sence of a gaseous matter? Here is a

question which deserves our attention, letus, therefore, proceed to examine it.

In order to clear up any doubt which

might exist, we had recourse to percus-sion of the abdomen, a means of greatutility in many cases of injury as well asdisease. One hand was placed on oneside of the abdomen, while with the otherwe practised percussion over the dif-ferent points of the parietes on the op-posite side. This manmuvre gave no in-dication of the presence of a liquid, andwhen we employed pressure on the abdo.men, we did not bear that gargouillementwhich is characteristic of gaseous matterin the intestines. The sound produced bypercussion was clear, like that rendered incases of tympanitis. (Here M. LISFRANCentered into a minute examination of thedifferent effusions which may take placeinto the cavity of the abdomen in con.sequence of external violence, and laiddown in a clear manner the several symp-toms by which they are accompanied anddistinguished.) External violence, actingon the parietes of the abdomen, may giverise to various accidents, of a more or lesssevere nature, and the effusion of fluidwhich results may be either primary orsecondary. Sometimes we have a rapideffusion of blood or other fluids, when anintestine, the stomach, &c., or a largevessel, has been severely injured and la-cerated ; at other times the effusion is slowand secondary, either because the viscushas been only partially injured, or, per-haps, because a small and narrow openinghas been made in the parietes of a greatvessel, giving rise to a small bleeding, &c.But before pursuing this inquiry further,

let us ask whether our patient is affectedwith peritonitis ; I would say no; or if itexist, it is very partial and insignificant.You know that when inflammation of theperitoneum exists to any extent and is

fully developed, the abdomen is alwayspainful on pressure ; the least touch is in-supportable, and the patient is incornmoded