Surgery of the Hand.
Selected writings of A. Jackson Howe.
The selection from the "Surgery of the Hand" is made to show the character of the articles which Professor Howe began years ago to contribute to the Eclectic Medical Journal and which were subsequently embodied, modified as time necessitated, into his "Art and Science of Surgery." This production is marked by the impress of a master of both surgery and writing. The style is direct and free and the language appropriate—points which apply to all that Dr. Howe wrote—even his earliest productions. Differing considerably from the set form of surgical article of the text-books, this paper constitutes more of an essay covering all the possible phases of injury to the hands and their possible complications in the briefest manner. This style of composition made his surgical articles easy to read and to remember. The element of personal experience also pervades his writings upon surgery, giving an added value to them not possessed by those compiled most largely from the works of others.—Ed. Gleaner.
SURGERY OF THE HAND.—The hand, on account of its complex construction and high functional endowment, requires some special rules or suggestions for the treatment of its diseases, injuries, malformations, and deformities. A distorted foot can generally be corrected by the division of contracted tendons and the application of proper apparatus. The success is often complete or satisfactory. Not always so with the hand or fingers. Adhesions take place between the tendons and their sheaths, which prevent motion; and the knife may divide nerves essential to the nutrition and function of the finger. The aponeuroses from slight injuries become atrophied, thickened, or puckered, so that not only the tendon distorts the finger, but all the subcutaneous investing tissues of the digit. A finger which is rigidly contracted from the effect of cellulitis, abscess, or the penetration of a needle, spicula of glass, iron, or wood, is seldom restored by surgical or other means. The use of apparatus does little permanent good, and the application of salves or ointments is next to folly.
Sometimes a peculiar distortion of the hand and fingers arises from an abnormal contraction of the flexor carpi radialis. This deformity may be overcome by dividing the above tendons near the wrist, and dressing the limb in a splint for a few days. I have always obtained satisfactory results from this operation. The spaces in the divided tendons fill up as they do after a club-foot operation, and no atrophy or paralysis follows.
Notwithstanding the unsatisfactory results which generally follow attempts to straighten morbidly contracted fingers, the hope of lifting the finger nails out of the palm of the hand, and the prospect of relief from the nettling of vessicles which are apt to form on rigidly flexed digits, will make almost any sufferer from these causes beg for all the benefit that can be obtained by an operation. A subcutaneous operation upon the finger is not very painful, yet it is best to employ an anaesthetic, so as not to be opposed or thwarted in attempts to break up adhesions about the joints and tendons. In dressing the finger the position of semiflexion is generally more desirable than complete extension, if anchylosis takes place. The patients wishes may be consulted in regard to the position he would prefer the finger to assume in the event of immobility. Fingers are often distorted by the cicatrices which follow burns. The texture of the skin and structures beneath is so altered that bands or bridles of modular tissue form and resist all attempts at restoration. All physicians are familiar with these peculiar cicatrices following burns. It does little good to resist their tendency to contract, or to cut the bridles across. Some good results have followed this treatment, yet it will fail much oftener than it will succeed. When the fingers have been denuded by fire, an attempt should be made to prevent the digits from uniting, though dressing the fingers apart is about all that can be done.
A narrow cicatrix may be entirely excised, and the edges of the wound brought together so as to cover the raw surface. In other cases a piece of normal elastic skin may be partially transplanted and twisted around from the neighboring parts to give flexibility. Anchyloses, alteration of articular surfaces, and marked atrophy of the finger may be considered as serious objections to surgical interference. In all cases of manual deformity it is best not to promise too much. The wounds necessarily inflicted in the execution of an operation upon the hand may be followed by untoward results.
Amputations.—In cases requiring amputation of parts of the hand the rule is to save as much as possible. A finger so badly crushed as to have parts of it slough away may still be retained and prove serviceable. I once saw a hand so badly mutilated by the accidental discharge of gun powder that an accomplished surgeon decided to amputate at the wrist. A stubborn resistance on the part of the patient to such a severe measure caused the medical attendant to attempt to save the thumb and little finger. The other fingers and part of their metacarpal bones were taken away. At length the wound healed, leaving the thumb and little finger in a useful condition. This fragmentary hand was worth infinitely more to the patient than any artificial substitute could be. A lacerated hand needs a careful examination before it is decided what parts require amputation. A poor patient who has a family depending upon him for support can ill afford to lose what a little attention or higher grade of surgical skill might save. In certain cases the metacarpal bones may require removal, though there may be no injury to the proximate fingers. The unsupported digits, however, are of little use, and often obstruct the practical working of the rest of the hand. If the periosteum can be preserved, and with it the hope of a reproduction of the bone, then the fingers should not be sacrificed.
In amputating a finger it is not necessary to have equal or well-formed flaps. The torn flesh on one side of the digit my furnish all the covering needed. These parts are well supplied with blood and nerve force, so that there is little danger of sloughing. Mere shreds of lacerated flesh will often form a good stump. Amputations may be performed at the joints of the fingers or between the articulations. There is little choice except that already given, "save as much as possible." In the removal of the terminal bone it is well to preserve the pulp of the finger in which the tactile sense is best developed.
Whitlow or Felon.—A forming whitlow should have the tincture of aconite root kept constantly applied to it. This will generally arrest the inflammatory action, but if it does not, and the suppurative stage be reached, a poultice should be used until the abscess or tense, distended parts need incising. After the pus is set free a poultice may be employed until a cerate dressing is more convenient. Any exuberant granulations that spring up during the healing process may be occasionally touched with a crystal of sulphate of copper, or any common caustic.
Extracting Broken Needles.—Fragments of needles sometimes remain imbedded in the hand for years without producing great inconvenience. At length the point will reach a tendon or sensitive structure and produce pain or excite alarm. Before commencing a search for the foreign body, let the patient point out, as near as possible, the place of entrance and the present seat of the fragment. Experimental pressure in various directions may excite a pricking sensation. The location of the needle should be opened by a V shaped incision, with sides about an inch in lengthy and the flap, beginning at the apex, dissected up. This exposed space is then to be carefully and thoroughly explored in order to find the needle which may be deeper or more distant than at first supposed. After the fragment has been found and removed, the flap is to be turned back and secured in place. If the patient is first put under the influence of an anesthetic the exploration can be more thorough and satisfactory. The dangers from hemorrhage and other accidents are not great.
Ulcers.—Intractable ulcers about the finger nails need an active caustic applied to the matrix of the nail. A thin spatula of wood dipped in nitric acid and carried to the bottom of the ulcerative surface will answer a good purpose. The removal of the nail altogether often serves to expedite the cure. After the vicious ulceration has ceased, the sore may be dressed with any common cerate. —HOWE, Eclectic Medical Journal, 1865.