Part 53

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.

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.

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.

In the chronic cases of bursal enlargement, pressure is to be avoided; and by the permanent application of an ammoniacal or of a gum and mercurial plaster, absorption of the fluid may in general be procured—the swelling disappearing as gradually as it arose. If the collection is large and obstinate, repeated blistering may be had recourse to; and if that fail, a seton may be passed through the cavity. But the last-mentioned practice is sometimes followed by more action than is desirable, inflammation of the surrounding cellular tissue supervening, and abscesses forming, perhaps extensive. When the collection is purulent, a free opening is to be made into the bursa, and the case treated in other respects as a common abscess. If indolent swelling of the cellular tissue, and spongy thickening of the synovial surface of the bursa, remain after incision, the application of the caustic potass may be required. In extensive and acute inflammation spreading to the surrounding parts, free incisions are often necessary, along with proper constitutional treatment, in order to prevent destruction of the cellular tissue and skin.

_Venesection_, at the bend of the arm, is too often resorted to by thoughtless or ill-educated practitioners, to the detriment of the patient; as after accidents before reaction has occurred, in local pains not inflammatory, &c. It is very often had recourse to by those who have no correct ideas of the actions of the animal economy, who have not within their heads a peg to hang an idea upon; or, if they have, they are too lazy to think and to combine their ideas, so as to come to a proper conclusion regarding what is the most proper and judicious course to be pursued in any one case. They follow a routine, and bleeding is too generally the commencement of it.

But venesection is absolutely required in many cases, and must often be the principal dependence of the surgeon for removing or preventing evil consequences. After injuries, when the circulation has been restored, particularly when parts important to life are involved—in the first stage of inflammatory attacks, with violent constitutional disturbance—in inflammatory affection of vital or important organs—in these, bleeding is employed to an extent sufficient to control the action. But, even in such circumstances, the practitioner must be cautious not to push depletion too far, but to stop short at the proper time, so that the life of the patient may not be endangered, nor his health impaired, more by the treatment than by the disease.

Venesection is usually practised on either the basilic or the cephalic vein, or else on the median basilic or the median cephalic. The vein is made to rise by obstructing the return of the blood by a ligature on the arm, applied not so tight as to prevent the flow in the arterial branches. A vessel removed from the inner side of the tendon of the biceps,—that is to say, not over or near the brachial artery,—is to be preferred. But sometimes none sufficiently large or distinct can be perceived unless in that situation, and then great caution is necessary in making the puncture; the patient’s arm must be held very steady, and care taken that the instrument does not transfix the vein. The branch chosen should also be fixed; one which rolls under the finger is pierced with difficulty. The vessel is secured by the thumb of one hand placed immediately below the point to be punctured, whilst the lancet is held loosely betwixt the thumb and forefinger of the other; and the surgeon should by practice acquire the use of either hand for this and other minor operations, being thereby saved much trouble and awkwardness. The right hand is used for the right arm of the patient, the left for the left. The lancet should be in very good order, not too spear-pointed, fine, and with a keen edge. The blade, placed at right angles with the handle, and held lightly, as above mentioned, is entered perpendicularly to the vessel. The puncture is made deep enough to penetrate the vein, and then the edge is carried forward more than the point, that the opening in the integuments may be more free than that in the vein. The most convenient line of incision is obliquely across. The pressure of the thumb is relaxed whenever a utensil is conveniently placed for the reception of the blood; and the arm is kept in the same position as during incision, that the openings in the integument and vein may correspond. Unless this be attended to, the skin will overlap the puncture in the vessel, and thus the stream will be completely obstructed, or at least the blood will not come away so smartly as at first. The blood may also cease to flow quickly from over-tightness of the ligature, and from threatening of syncope; in the former case the ligature is adjusted, in the latter the patient is placed in the recumbent position. When the superficial veins are emptied, the blood flowing by those deep-seated is to be directed to the wound by muscular action; with this view the patient is made to grasp the lancet-case, or any other solid body, in his hand, and turn it round. If the opening in the integument is too small, the flow gradually diminishes, and at length stops, in consequence of blood being insinuated into the cellular tissue, coagulating, and so forming what is termed a thrombus, which plugs the wound. When a sufficient quantity has been obtained, the ligature on the arm is removed, and pressure made below the wound. The integuments around are washed and dried; and two or three small compresses of lint placed on the opening, one above the other, are retained by a riband or narrow bandage, applied in the form of the figure 8; the bandage should be so tight as to prevent the escape of blood, without arresting the flow towards the heart. The arm should be disused for a few hours; and after twenty-four or thirty-six hours, the bandage may be removed, when the opening will usually be found closed.

Besides puncture of the humoral artery, or of its branches, other unpleasant circumstances may follow this little operation. The thrombus—a small bloody tumour from infiltration into the cellular tissue around the opening in the vein—proves troublesome, as already remarked, by preventing the flow, and may render a fresh opening necessary, either in the same arm or in the other. Afterwards it generally disappears gradually by absorption; or the opening in the integuments may not close, and the coagulum be separated and discharged after some days.

Inflammation and abscess round the opening sometimes supervenes. It is treated by fomentation, poultice, and rest, and the matter must be evacuated by free incision. Inflammation of the surface, with diffuse infiltration into the cellular tissue, is also met with after venesection; the treatment of such an affection is the same as when it occurs in other situations and circumstances.

The symptoms and consequences of inflammation of the vein have been already detailed. The affection is attended with great pain, and with swelling from effusion into the cellular tissue around the course of the vessel; the integuments are inflamed and tense; sero-purulent secretion soon takes place in the infiltrated cellular tissue, both deep and subcutaneous, followed by sloughing, and separation of the skin from its subjacent connexions; even death of the muscular structure sometimes ensues—the pectoral muscles have been found black and soft. The local treatment must be active. Incisions are made early into tense parts to prevent internal mischief; and if the vein in the neighbourhood of the wound be filled with pus, it should be laid open freely. The evacuation of the matter affords great relief; afterwards bread poultices or water-dressings are to be applied to the wounds, the other parts should be assiduously fomented, and attention given to the position of the limb. The bowels are to be attended to, and the secretions promoted by mercurials with stimulants, as camphor with calomel, or the hydrargyrum cum creta. When the tongue gets moist at the edges, tonics and stimulants of a more permanent and powerful action are necessary.

I have not witnessed any bad effects of venesection attributable to puncture of the tendon or fascia, or to partial division of twigs of the cutaneous nerves. In spasmodic or painful affections arising from the latter cause, slight extension of the incision is recommended, so as to divide entirely the injured branch.

Inflammatory tumour of the _Mamma_ occurs generally during lactation;[44] and is attributable to injury, perhaps slight, during the then excited state of the secreting vessels—to sudden exposure to cold—to interruption to the flow of the secretion. It occurs, however, independently of this state—sometimes at the age of puberty, during the development of the gland—or at other periods of life, either spontaneously, or in consequence of external violence. The last class of cases are usually more severe than those first alluded to; some are more indolent than others; almost all are preceded by shivering. There is swelling of the part, a sensation of weight in it, and dull pain; then throbbing heat, and increase of suffering. The surface is inflamed, and the nipple concealed by the tumescence. The milk cannot be withdrawn. Fever attends, more or less violent. Such tumours seldom if ever subside or are resolved; suppuration takes place, and the matter generally comes to the surface at more than one point. This abscess originates in the substance of the gland; but collections occasionally form in the cellular tissue beneath the mamma, either spontaneously, as in bad constitutions, or in consequence of injury. In either case, and particularly in the latter, the swelling is great, and the suppuration extensive; troublesome and tedious sinuses remain unless early and free openings are made.

Leeching is of little use in mammary swelling during lactation; cold and evaporating lotions seem to do harm by producing determination from the surface to the deeper parts. The gland is to be kept as free from secretion as possible, and supported by a handkerchief tied round the neck; moderate diet should be enjoined, and laxatives given occasionally. Fomentations are beneficial at first, but are superseded by poultice when matter appears to have formed and to be making its way to the surface. Two or more openings are generally necessary, to afford free outlet to the matter; indeed, an incision is indicated wherever the integuments are elevated, thin, and shining. Afterwards poulticing is continued for some days, and succeeded by other suitable applications. The discharge seldom ceases, so long as the secretion of milk is encouraged.

Adolescent males are sometimes affected by troublesome fulness and uneasiness of the mammillæ. Little or no treatment is required, the inconvenience subsiding gradually and spontaneously.

Indolent enlargements of the mammary gland occur, though rarely. They sometimes attain an immense size; and are often attributable to the menstrual discharge having been inopportunely arrested. Such tumours have, from their great bulk, required extirpation.

Sarcomatous tumours of various kinds are met with, either in the cellular tissue under the mamma, or in the substance of the gland—tumours not of the gland, though in it. Such are generally traced to injury, as to a bruise by falling against the corner of a table or chair, an accidental push from the elbow of another, &c. Simple sarcoma is the most frequent formation; but I have encountered tumours, thus situated, of a worse nature—reproduced, though freely and fully removed; in fact, taken away along with the gland and neighbouring adipose substance.