to the extremities of the metacarpal bones, are exceedingly common; as
also wounds of the radial artery betwixt the thumb and forefinger, of
the arteria radialis indicis, and of the superficial volar branch. The
opening in the integuments and palmar aponeurosis is usually narrow,
and the hemorrhage copious; it is generally arrested by pressure, not
always well or efficiently applied. From these circumstances, blood
is extravasated extensively into the deep cellular tissue, blood
continuing to escape from the artery, and being either imperfectly
discharged, or completely confined. Great swelling, with tension and
acute tenderness, takes place; in fact, rapid inflammatory action is
kindled in the infiltrated parts, and unhealthy abscesses form; the
matter ultimately reaches the surface, but by that time ulceration or
partial sloughing has taken place at the wounded part of the vessel;
profuse and repeated hemorrhages take place, and are with difficulty
controlled. The patient becomes weak and pale. The greater part of
the forearm may become involved in the inflammation, terminating in
infiltration of the cellular tissue, and the formation of diffuse
abscesses.
In the first instance, instead of trusting to pressure,—which almost
uniformly disappoints expectation, does not prevent internal bleeding,
and leads to a severe form of inflammatory action,—it is better at
once to enlarge the wound, and tie the wounded vessel above and
below the injured point. Thus all bleeding is effectually prevented,
and the risk of unfavourable consequences done away with. But after
inflammatory swelling has commenced, such a proceeding is difficult,
often almost impossible, and generally fruitless. The parts are then
full of blood, lymph, serosity, and pus, separated from each other,
and changed both in appearance and structure; the vessel is either
not visible on account of the infiltration around, or its coats are
so diseased as to be incapable of holding a ligature. At any period,
it is unsafe and unwarrantable to dive, pretty much at random,
with a sharp needle, amongst tendons, nerves, arteries, and veins,
with the hope of so including the wounded branch. In some cases of
secondary bleeding—if no great inflammatory action has taken place,
and no abscesses have formed—the wound may be dilated freely, and
compression made on the bleeding point by dossils of lint filling the
wound completely, and supported by a bandage. This dressing, retained
for some days, often succeeds perfectly; permanent obstruction of the
vessel, and consolidation of the parts immediately around, having
been accomplished by the effusion and organisation of lymph. When
this method fails—and when the case is more advanced, with pain, and
swelling, and abscess—weakening of the circulation in the part is found
to be effectual. The main artery is to be obstructed at a distance from
the wounded part. It is needless to tie the radial, or the ulnar, or
both; for still blood will be poured in by the interosseous and its
anastomoses. The humeral must be secured in the middle of the arm, as
has been practised in many instances, and with uniform success. Thus
the bleeding is arrested until the wounded vessel recovers, and becomes
permanently closed by salutary effusion; then the inflammatory action,
and its consequences, in the surrounding parts, must be treated on the
general principles of surgery.
_Paronychia_, or _Whitlow_, designates inflammatory action and its
consequences, in the structures composing the fingers. The mere
surface may be the seat of the inflammation of the cellular tissue,
or the fibrous structure betwixt that and the sheath of the tendons;
or the firm and true sheath of the tendons, and the synovial surface;
or the investing membrane of the bone, the bone itself, and the
articulating surfaces and apparatus may be involved secondarily, or
from the first. The inflammatory action may commence in any of these
structures, but, if uncontrolled, ultimately attacks the greater
number, or all of them. The deeper seated the action, the more violent
are the symptoms, and the greater the danger to the member. In the
cutis vera of the fingers, there is a plentiful distribution of nerves
of sensation; and, consequently, in superficial whitlow, the pain is
often severe, with throbbing, and an occasional feeling of itching.
The part is swelled and red, and the redness is diffused. After a
short continuance, the swelling increases at some points, often about
the root of the nail, from effused fluid betwixt the cuticle and rete
mucosum; the fluid is sometimes serous, generally sero-purulent. In the
deeper-seated inflammation, the pain, throbbing, heat, and swelling,
are all greater. The pain is more intense, and almost intolerable,
allowing the patient little or no rest; and the throbbing extends
to the vessels of the hand and forearm. A considerable degree of
fever attends. The action either involves one phalanx, or extends
over the whole finger, and ultimately attacks the hand. The palm is
hard, pained, and swelled; and, in advanced cases, swelling takes
place above the annular ligament. Often the surface of the back of
the hand is also inflamed, and the cellular tissue loaded with serum.
The disease, if not actively and properly treated, terminates in a
very short time; in two or three days suppuration takes place, with
sloughing of the cellular tissue, of the sheaths of the tendons, and
of the tendons themselves. Either ulceration or necrosis—often both in
combination—occurs in the phalanges; or the apparatus of one or more
of the articulations is destroyed. Abscesses also form in the palm,
on the back of the hand and finger, and sometimes under the fascia of
the forearm. The separation of portions of one of the tendons is not
always followed by loss of motion in the finger; neither is exfoliation
of the greater part of the distal phalanx always attended with much
deformity or shortening, a nucleus being often left from which bone may
be reproduced. But destruction of the whole flexor or extensor tendons
of one of the middle or proximal phalanges, or destruction of one of
the articulations connecting them, is not only attended with great
suffering, but followed by total uselessness of the part. The wounds
may, after a tedious process, heal up; but the finger remains deformed
and immovable, in a contracted or extended position, as may be.
[Illustration]
[Illustration]
The disease may be occasioned by bruises or punctures, the instrument
with which the puncture is inflicted being impregnated, or not, with
some putrid animal matter. Violent inflammatory action almost uniformly
follows opening of the articulations, and also lacerated wounds over
the joints. Compound fractures and dislocations of the phalanges are
certainly followed by a severe form of inflammation. But the disease is
met with in all degrees of intensity, occurring without any assignable
cause. It prevails in spring and autumn; and is common in hard-working
people, in butchers, cooks, &c.
In superficial whitlow, the bowels must be attended to, and blood may
be abstracted locally, either by punctures or by the application of
leeches along the side of the finger, hot fomentation being assiduously
and regularly employed afterwards. Or the nitrate of silver may be
rubbed lightly over the discoloured parts; frequently the inflammation
may be arrested, and resolution speedily effected, by this simple
application, laxative or purgative medicines being at the same time
administered, as required. The collections which form are evacuated by
simple division of the cuticle, and this, when hard, should be clipped
away; poultices are used for a short time, and then the raw surface
is dressed simply, and the finger bandaged daily. The hand should be
kept constantly elevated. The swelling is soon reduced, the cuticle is
regenerated, and free motion of the finger returns gradually.
In more severe cases, fomentation and copious abstraction of blood
by leeching, at a very early stage, may effectually suppress the
inflammatory action; but patients seldom apply till after the
opportunity for this treatment has passed. When tension has occurred,
whether purulent matter has formed or not, a deep and free longitudinal
incision must be made, including the affected tissues. This is
uniformly followed by great relief, all the violent symptoms subside,
and the action is limited; the effusion, if any, escapes, and the
affected bloodvessels are emptied—further suppuration is prevented,
and the tissues are perhaps saved from destruction. Fomentation and
poultice are used till the swelling begins to disappear, and the
discharge to diminish; and the hardened cuticle is removed, when
detached. The cure is completed by bandaging, and such applications to
the wound as its appearance may render suitable. Should inflammation
recommence and extend, or abscess threaten in other parts, recourse
must again be had to free incision, followed by the treatment already
described.
Destruction of the articulating apparatus, with ulceration of the
opposed surfaces of the bones, is indicated by indolent swelling
around, by unhealthy and profuse discharge, by distinct grating being
produced on motion, and by marked and unnatural looseness of the joint.
In such circumstances, amputation of the finger above the diseased
part is fully warranted. But if the patient is obstinate in refusing
to submit, or if he is in that rank of life where stiffness of the
finger is of no great consequence, the member should be kept steady
in a convenient position, so as to favour anchylosis. By splints and
bandaging it is preserved in a state of semiflexion, so that, after
the cure by anchylosis, it may not be in the way when the patient
lays hold of anything, as it would be were it bent into the palm, nor
exposed when the other fingers are bent, as must be the case were it
kept quite straight. Still the finger is often very useless—worse
than useless—when stiff either from loss of the tendons or from
destruction of the joint; and more particularly when its position is
awkward. So much inconvenience does it give rise to, that patients,
who peremptorily refused amputation whilst the case was recent, often
return, after a tedious and painful cure by anchylosis, soliciting
removal of the deformed and annoying member. When the thumb, however,
is the seat of disease, it is of great moment to save any part of it.
A stiff joint in the thumb is of less consequence than in a finger;
it can still be brought to oppose the rest of the hand in seizing
and retaining hold of objects. To promote anchylosis, the affected
articulation must be kept at perfect rest, and for a very considerable
time. By pursuing this practice, the thumb, represented at page 397,
though in a very bad state, the joint being thoroughly disorganised,
was preserved. In severe cases of whitlow, all the fingers, the whole
hand, and even the wrist, long remain rigid; but the rigidity is
gradually dissipated by friction, and by motion, at first gentle and
passive.
Chronic thickening and contraction of the _palmar aponeurosis_ occurs
occasionally, and, in some cases, to such an extent as to disable the
hand almost entirely. The fingers are permanently bent, the palm is
hard, and the integument puckered. The most severe examples which I
have witnessed occurred in those who were in the frequent habit of
playing keyed or stringed instruments; in others no cause could be
assigned. Frictions with all kinds of oils and compound liniments,
plasters, ointments, &c., have been tried as remedies for this
affection, but in vain. The tendinous slips passing to the contracted
fingers have been divided, and the origin of the palmar fascia has been
cut across, but without permanent benefit. Indeed I believe the disease
to be incurable.
The term _Onychia_ is sometimes, and not without good reason,
designated _maligna_: it is applied to ulceration about the nail.
Some of such sores are small, and not indisposed to heal; others are
very obstinate. They occur at all periods of life, frequently during
infancy. They usually commence in a small and irritable tumour or
granulation by the side of the nail, or at its root, with swelling and
redness around. This may follow bruises or laceration and removal of
the nail, extravasation under it, and various injuries of the part. The
disease is also met with in the toes, most frequently the great one,
causing much lameness; then it is generally owing to the pressure of
tight shoes. In many cases the ulceration is extensive, shreds of the
nail projecting through the angry surface; there is considerable loss
of substance; the discharge is thin, bloody, acrid, and abominably
fetid; the edges of the sore are jagged, and the integuments around
are of either a bright or a dark red, according to the state of the
disease. Sometimes the bone is exposed, and involved in ulceration;
or, instead of having lost substance, it is found of an unusually
spongy and open texture, and with recent osseous matter superadded. A
violent burning pain attends the disease when advanced; the absorbents
are irritated and inflamed, and the glands enlarge along their course.
The general health is often impaired in consequence; frequently the
disease occurs in those of broken-up constitution, along with sores
and eruptions on other parts of the surface, ulcerations of the mucous
membranes, and other indications of cachexia.
[Illustration]
By judicious exhibition of purgatives, antibilious medicines, and
preparations of sarsaparilla, and by regulation of diet, the general
health may be improved. The edge of the nail, when in contact with the
ulcerated surface, must be removed—more especially when the great toe
is affected; not that any undue growth is the cause of the disease,
but because the sore, pressing on the sharp edge, produces much
pain, and keeps up the morbid action. About one-third in breadth of
the nail should be taken away; one blade of strong and sharp-pointed
scissors is passed along beneath the nail as far as its root, and
by rapid approximation of the other blade the part is divided; the
isolated portion is then laid hold of by dissecting forceps, or small
flat-mouthed pliers, and pulled away by the root. This should be
performed as quickly as possible, for the operation, though trifling,
is attended with most acute pain; it is quite effectual, the relief is
great, and almost immediate. The nail may also be removed by scraping
and paring; but this method is not so effectual as the preceding,
and almost equally painful. Afterwards the best application to the
ulcerated surface, as to other irritable sores, is the nitrate of
silver, either used solid and followed by poultice, or employed in the
form of lotion. The remedy is almost specific; very few cases prove
obstinate under it. Sometimes it may be of advantage to alternate it
with the black wash. In protracted and unyielding cases, removal of the
whole matrix of the nail has been proposed; the dissection is painful
and tedious, and its efficacy doubtful. When the sore is of a weak
character, discharging a glairy secretion, studded with soft flabby
granulations, connected with unsoundness of the neighbouring cellular
tissue, surrounded by undermined integument, and by considerable
boggy, soft swelling, free application of the caustic potass is highly
beneficial. When the bone is denuded, and involved in ulceration, the
phalanx should be amputated.
[Illustration]
Unhealthy children are subject to disease of the phalanges, and of
the metatarsal and metacarpal bones, excited by slight injury, or
originating without apparent cause. Often more than one bone is
affected. There is great swelling of the soft parts around the diseased
bone, indolent, and not painful; at first hard and white, afterwards
more yielding, and of a dark-red hue at one or more points. Imperfect
suppuration takes place, the integuments ulcerate, and the cavity of
the abscess leads to the exposed bone; a portion of this generally
dies, and is a long time in separating. Great addition of bony matter
is deposited around, in irregularly aggregated nodules; and a large
shell is so formed, partially investing the sequestrum. This affection
may be termed _scrofulous necrosis_.
Or the bone does not die, but is exposed and ulcerated superficially;
or a considerable cavity forms in its interior, apparently from
tubercular deposits and suppurative degeneration of the cancellated
structure. The secretion from the ulcerated surface is thin, acrid, and
often bloody; and new osseous matter is studded around. The surface of
the rest of the bone is unusually open in texture, whilst its interior
is condensed, and the cancelli are filled with lardy substance. This
form may be called _scrofulous caries_.
Abscesses in the soft parts form one after another, several of the
bones are often affected at the same time, superficial abscesses and
affections of the joints and bones often take place in other parts, and
the patient grows weaker and weaker.
Whilst the surgeon attends to the general health, and employs
palliative local applications, nature frequently effects a cure. The
sequestrum ultimately separates, or the ulceration gives way to more
healthy action. New bone fills up the cavity, the redundant osseous
deposit gradually diminishes, the openings in the integuments close,
and the swelling subsides. In some rare cases, it may be necessary to
take away the offending part, in consequence of the health alarmingly
declining.
_Collections in the Thecæ_ of the flexor tendons are occasionally met
with. Those of the thumb and forefinger are most frequently affected.
The swelling often attains considerable size. The fluid is colourless
and glairy, mixed with small cartilaginous bodies of a flattened form,
and the size of mustard seeds, or split peas. The swelling sometimes
extends under the annular ligament, and under the fascia of the
forearm. Alternate pressure on the different parts of the swelling is
attended by a very peculiar sensation. Motion of the parts is seriously
retarded.
Accumulation of the fluid is not prevented by any means. Puncture has
been practised successfully in several instances, in others a good
deal of inflammatory action followed. On the escape of the fluid, the
motions of the parts are so far regained.
_Ganglia_ are collections in the bursæ, of various sizes, about the
wrist. They are situated more frequently on the fore than on the back
part. Sometimes they occur, small, on the sides of the fingers. At
first they are attended with pain, afterwards with inconvenience only.
The swelling is usually globular; but when large, as on the back of the
wrist, the form is rendered irregular by the pressure of the tendons.
The cyst is generally of considerable thickness, the fluid glairy and
albuminous. They present an unseemly appearance, and when awkwardly
situated, retard the motions of the limb. Frequently they form without
apparent cause; sometimes they are attributed, and perhaps rightly, to
a twist or over-exertion of the wrist, like windgall in hard-wrought
horses, who have been put to work when young, and before their full
strength has been attained. The affection is most frequently met with
in females of the lower ranks; in them the structure of the limbs is
more delicate than in males, and they are often obliged to use great
exertions with the upper extremities before the growth of the body is
completed.
Friction is of no use. Continued pressure on the swelling, by coins or
small pieces of lead bound down for weeks or months, is very seldom
followed by cure. If the tumour is placed over a bone, sudden and
firm compression should be made with the thumb, so as to rupture the
cyst, or with the same view it may be struck sharply by an obtuse
body. The contents are thus extravasated into the cellular tissue, and
are speedily absorbed; the cyst inflames, and becomes obliterated.
Sometimes the excitement is insufficient for complete closure of the
cyst, and the swelling returns. When the cyst is thick, the tumour of
long duration, and the person impatient of pain, it may be punctured by
a cataract needle of any kind; one thin and double-edged is probably
the most convenient. The instrument is introduced through the skin,
at some distance from the swelling; and, by moving the point of the
needle after penetration, the cyst is divided freely. The needle is
withdrawn, and the orifice closed by the finger. The contents are
then squeezed into the cellular tissue, and this is followed by the
same favourable results as in the preceding method. Removal of such
tumours by dissection is unnecessary, and also attended with risk. I
have removed several large ones by incision; but the whole cyst can
seldom be taken away, and there is great risk of inflammation ensuing,
followed by sloughing of the tendons, or by rigidity of the part. From
my experience of the unfavourable consequences of incision, I should
not again adopt such a proceeding. Setons have been passed through the
swellings, but I cannot attest either their efficacy or their safety.
_Exostoses_ of the phalanges of the fingers are rarely met with.
Sometimes bony enlargement occurs, involving many of the phalanges
along with several of the metacarpal bones. In such cases, both hands
are often similarly diseased, and other parts of the osseous system
also affected. When the tumour is limited to one or two fingers of one
hand, then, to get rid of the deformity and inconvenience, the patient
may desire its removal. The whole of the bone affected should be taken
away, lest the disease be reproduced.
_Spina ventosa_, acute or chronic, more frequently the latter, is
sometimes met with in the metacarpal bones, or in the phalanges. The
same treatment is applicable here, as that already detailed in regard
to similar affections of the lower jaw. Amputation above the tumour may
sometimes be necessary.
The hands of infants are sometimes found deformed, turned inwards,
as the feet are more frequently. Some of the carpal bones are
compressed, from the awkward position of the limb, but become properly
developed, if the parts are placed in their proper position as soon
as the deformity is observed, and kept so. But the displacement is
unmanageable if long neglected. Congenital deficiency of the fingers is
a deformity and inconvenience, but cannot be remedied. Adhesion of one
or more of the fingers, even to their points, is met with occasionally
as a congenital affection. Separation is readily accomplished; but
the dressing requires to be carefully attended to. Adhesions may
result from careless management of extensive abrasion or ulceration,
or from a burn, and such are not so easily remediable. Superfluities
may be abridged. Some children are born with two thumbs or two little
fingers; these have generally only a cutaneous attachment to the rest
of the hand, and that is easily divided by the knife or scissors. The
redundancy should properly be removed by the obstetrical practitioner,
as soon as it is observed.
The Bursa over the Olecranon Process is liable to enlargement, by
gradual accumulation of the secretion, in consequence of habitual
pressure on the elbow. The contents are either serous or glairy,
usually the latter, and the swelling is indolent. But acute swelling
not unfrequently takes place in this situation, from external injury;
then the tumour is formed rapidly, there is heat and pain in the part,
and the integuments are discoloured around; in such cases the bursa
is filled with pure blood, or with a sero-purulent and bloody fluid.
Inflammation of the bursa often follows bruises and lacerated wounds,
and is apt to extend to the forearm and arm; causing extensive and
deep effusion, great tension of the parts, and severe constitutional
disturbance.