On Whitlow. By DR. E. HAMILTON. 319

ART. X I V . - - 0 n Whitlow. By EDWARD HAMILTON, F.R.C.SI . , one of the Surgeons to Dr. Steevens' Hospital.

TH~ occurrence of an unusually severe form of paronychia during the past session has been noticed by many practitioners in this city. Having had a number of such eases simultaneously under treatment, which presented peculiar features, I have been induced to place them on record. The clinical history of inflammations about tae fingers teaches as that they present modifications dependent on the anatomical structure primarily attacked, as well as on the special type of the morbid action. Having regard to the structure engaged we can recognize four forms of the discase:--sub-cuticular, sub- cutaneous, thecal, and periosteal; bearing i1~ mind the established pathological fact that no matter in what tissue the inflammation takes its origin, it is liable to extend from one to another, so as, eventually, to implicate all the anatomical constituents of the hand. This classification was originally proposed by Garengeot, and I think each of these four varieties presents symptoms and patholo- gical characters sut~iciently marked to justify its separate con- sideration. The second ground of classification the peculiarity of the inflammatory process--is generally admitted in our systems of surgery ; and although most whitlows approach closely to the er~sipelatous type of disease, yet I think we meet with cases which may fairly be designated loMegmonous; while the examples which suggested this memoir were undoubtedly gangrenous, or, as that term has already been applied by Dr. Todd, in the Dublin Hospital Reports (1818, Vol. ii.) to a very peculiar and unusual form of disease affecting the hand, I would suggest the title furuncular, which also more clearly conveys an accurate idea of the changes which this type of the disease dcvelopes in its progress. The sub- euticular form is truly erysipelatous in its nature, and although usually a very simple and unimportant variety, may occasion results of a most troublesome and teazing kind. When the disease commences at or spreads to the vicinity of the nail, although attended at first with the mere smarting prickling pain of superficial inflammation, the suffering becomes most acute if' the matter extends under that structure. In this form of whitlow a very troublesome result of inflammation has been especially alluded to by John Hunter, and the accuracy of his delineation cannot be questioned. The small vesicle filled with sero-purulent fluid, which

320 On W]~itlow. By DR. E. HAMILTON.

is so apt to form at the side of the nail, bursts, and a granular, reddish fungus protrudes through the opening, as Hunter says, " l ike paint through a bladder," and being pressed by the edge of the nail, becomes most acutely sensitive, the slightest touch causing an amount of pain and suffering, almost inconceivable, as he says, " gives a greater idea of soreness, perhaps, than any other morbid part of the machine ever does." A lady who was under my care at the same time as the cases from which the drawings were taken, was unable to sleep for nights with the severity of the pain. This appearance is well depicted in Figures 1 and 2. " In other examples, ulceration spreads round the edge of the nail, which becomes embedded in the sore, giving rise to the intractable disease so graphically described by Abernethy. The treatment of this sub- cuticular paronychia, when free from complication, may be conducted on the ordinary principles of surgery, as applied to a local inflammation. These are the cases in which the application of the nitrate of silver, as advocated by Higginbotham, has been attended with most success. But, to be of use, it must be resorted to on the very outset of the inflammation, as I am convinced that the indiscriminate employment of this application at a later period is not only useless but positively pernicious ; if resolution does not take place, the parts are in a worse condition from its effects, the cuticle being thereby rendered denser and more contracted, presses most injuriously on the inflamed tissues beneath. A much more useful application, in the incipient stage of the disease, is the liquor ammonim acetatis, used under a cover of oiled silk, as a water dressing. I t softens the nail, and the fold of dense cuticle which surrounds its margin, renders the parts more pliant and yielding, and consequently less liable to irritate the tender surface around. The projecting papilla must be destroyed by the nitrate of silver applied in powder, strong solutions, or even the solid stick being ineffectual for that purpose.

I t is questionable how far the cases described in theDublin Hospital Reports; by Dr. Todd, are to be regarded as true paronychia. The symptoms were altogether peculiar, and indicated severe constitu- tional disturbance, which terminated in some cases fatally, while the local mischief seemed to point to some special interference with the circulation of the blood. I f grouped with paronychia, they would belong to the sub-cuticular variety; but the "paronl/chia cutanea gangrenosa" is so remarkable in its history, symptoms, and prognosis, that we are fully justified in classing it as a disease sui generis. I

Ou Whitlow. By DR. E. HAMILTON. 321

have myself seen but a single case in which the characters attributed to it were manifested.

The second or sub-cutaneous is by far the most frequent variety ; and in the majority of cases, where the disease attacks deeper structures, it extends to them from the sub-cutaneous areolar tissue; so that, in a practical view, it is the most important. A slight prick or contusion of thc skin, especially with certain external condltions--probably atmospheric, for all have noticed its tendency to be epidemlc--is followed by throbbing pain, heat, tenderness, and swelling. The peculiar sensation of throbbing arises fi'om an actual increase in the calibre of the arterial tubes, effected through the vaso-motor nerves, as may be felt by the fingers placed at each side. I f resolution does not quickly occur, suppuration ensues, which is usually limited, unless the constitution be finhealthy. In the early ~tage, no remedial measure equals the continuous hot water bath, as originally recommended by Platner ; but, to be of any use, it must be employed ahnost without intermission, boiling water being added to the bath until a temperature is tolerated which we could not a 2rlori suppose. This treatment, combined with saline purgatives and a careful search for and removal of foreign substances, will seldom fail to effect resolution. I f the disease resists this treatment, incisions must be resorted to, or it will extend to the fibrous structure beneath, and develop the third, or thecal, form of paronychia. In the cases which are here delineated, selected ti-om a number under observation at the same time, the tissues were infiltrated, not with pus, but an exudation substance, having all the characters of that found in anthrax and boils, and the appearance of the surfime, which is well portrayed in ~igures 3 and 4, reminds us forcibly of what is seen in these furun- cular forms of inflammation. The exudation substance was tough and matted into the meshes of the areolar tissue so firmly that repeated incisions were necessary to permit of its escape, small portions only appearing through the cut. The amount of constitu- tional disturbance was very great, indeed, and the symptoms of general irritation out of all proportion to the extent of the local mischief, patients becoming prostrated almost from the commence- ment. In this epidemic there was also manifested a remarkable tendency in the disease to recur after its apparent subsidence. From these repeated attacks of this peculiar inflammation, the soft struc- tures of the finger and hand became apparently disorganized, and converted into a substance resembling adipocere, tearing across on

VOL. XLVI., NO. 92, N.S. Y

322 On Whitlow. By DR. E. HAMILTON.

the least extension being made. In the treatment the state of the system from the first demanded a stimulant and nutritive regimen, with quinine and opiates at night. Incisions were made wherever tlle soft pulpy condition indicated the exudation deposit; and the employment of carefully adjusted pressure, applied day after day, to each finger separately, had a wonderful effect in checking the disease, and restoring the functions of the fingers, which appeared hopelessly disorganized. The great value of pressure in the treat- ment of anthrax and other furuncular inflammatlon, is now generally admitted by hospital surgeons, so that they do not hesitate to employ it in preference to every other means, even in the most unpromising cases. The resemblance, I might ahnost say the identity, of the pathological changes in these cases of whitlow and in anthrax, suggested to my mind the idea that a mode of treatment so eminently successful in the one would not fall in the other, and the result fulfilled my most sanguine expectations.

The thecal form rarely presents itself as a primary disease, but usually supervenes on inflammation attacking the soft parts, more especially of the ungual phalanx, where the various component tissues become blended, and is, generally, of traumatic origin. Here it is we meet with that characteristic deformity of the hand which is so familiar to every practical surgeon. The back of the hand swollen, red, glazed, and (edematous; its palmar aspect hard, brawny, or the cuticle soddened, the fingers semiflexed, the forearm above the annular ligament red and tense. The irritation, soon implicating the lymphatic gland, over the inner condyle, may spread even to those of the axilla. The constitution quickly sympathizes with the local mischief. The fibrous structures soon succumb to the intensity of the inflammation. The tendons slough, and the finger becomes stiff, and almost useless. Once the fibrous tissues have become i~irly involved in the morbid action, I believe all treat- mcnt is utterly unavailing, save and except prompt, free, and deep incisions. Occasionally, some benefit may be derived from leeching and fomentations, with active purgatives; but the risk of losing valuable time in the trial of these means counterbalances the prospect of their success. As to the place and mode of these incisions, the directions laid down by most surgeons, and usually followed, are--to cut on the anterior aspect of the finger in its middle line, ,~voiding the two distal creases, which indicate the position of the phalangeal articulations. The proximal crease does not correspond to a joint, and may be divided ; but it is not desirable

On Whitlow. By DR. E. HAMILTON. 323

or generally necessary to carry the knife much above it toward the palm, as the main digital arteries divide midway between this and the palmar or metacarpo-phalangeal crease, sometimes rather nearer the web of the fingers, and are irregular as to their position on the first phalanx, and hemorrhage would be a troublesome complication to this condition of the hand. The incision having terminated at the mark, a director may be passed beneath the palmar fascia, which will permit the escape of matter. Should it be necessary to divide this structure, which is not often the case, the end of the instrument should be a little bent, so as to keep it closely inclined to the deep surface of the fascia, after it has been introduced beneath it, and thus cause it to pass superficial to the nerves and blood vessels. This division of the structures in front of the finger, down to the bone, very frequently causes destruction of the tendons, loss of their synovial investment, and, as we too often see, a stiff and almost useless finger. Hence, I have been led to adopt the lateral incision, and I think with better results. The danger of wounding the digital arteries, as they run along the sides of the finger, which has been urged as an objection against this proceeding, may easily be avoided by ordinary care, as their position can be felt most distinctly, and the operator can keep behind them. To be effectual, an incision must be made at each side of the finger, of course keeping clear of the joints. These lateral incisions are peculiarly useful, when the inflammation, us it frequently does, shows a tendency to implicate the fibrous investment on the back of the phalanges. I have never seen a case in which division of the anterior annular ligament was warranted, and I should hesitate before adopting a proceeding so fraught with danger to the integrity of the wrist. Where the matter burrows upwards under the thscia to the forearm, an incision in the middle line, above the ligament, freely dividing the ~ascia, will enable the surgeon to pass his director beneath the ligament into the pahn, and make a track for the escape of inflammatory products.

In many instances we find the perlostium participate in the morbid action, causing necrosis of the phalanx ;bu t we meet with a sufficient number of cases in which the disease appears to have its origin in the bone or periosteum, to recognize the existence of true periosteal ioaronycltia. This affection is peculiarly apt to attack the ungual phalanx of the thumb, and is invariably associated with syphilitic taint or strumous diathesis. The soft tissues retaining their health for a considerable time, frequently until the bone is completely

x 2

324 Bothriocep/talus Latus, or Broad Tape Worm

necrosed, and acting as a foreign body, causes an abscess, on the opening of which the bone can be felt, bare, dry, and necrosed; it can be removed without much pain or difficulty. The parts rapidly recover their health, and assume a very remarkable appearance, the hall curving forward, as exhibited in the drawing, 1~o. 5. Constitutional treatment and perfect rest afford the only chance-- and small it is--of arresting its progress. The sooner the bone is removed, the sooner will the parts recover.

ART. X V . - Bothriocephalus Latus, or _Broad Tape Worm, its Occurrence in Ireland, with Remarks on its Claim for Admission into the List of our Indigenous Fauna. a By Dr. ~V. FRAZER, M.R.I.A., tIon. Member Montreal Medico-Chirurgical Society, &c.

TAPE worms are of rather rare occurrence in Ireland, though both T~cnla sollum and T. mediocanellata are met with, the latter being comparatively seldom seen, or, perhaps, it would be more correct to say, seldom recognized, for the first instance in which it was detected was recorded by myself in the Medical Press and Circular a few months since; I have reason to believe, however, that it has heretofore been confounded with the T. solium, and is far more common than generally supposed throughout the country. There can be no question that the broad tape worm, or bothriocephalus, is by far the rarest of this class of entozoa, for the fourth recorded case of its having been discovered in Ireland was described by me in the pages of the Press for April 10, 1867; the present case is, therefore, the fifth instance where it has fallen under medical observation, and it possesses peculiar interest from the fact, that whilst in almost every patient infested by this animal there are grounds for ascribing the verminatlon to some foreign and continental source, the patient from whom the present example was obtained had never travelled beyond the limits of Great Britain and Ireland. So far as can be ascertained, all the bothriocephali yet expelled were referable to B. latus; the species B. cordatus, common in dogs in l~orth Greenland, and occasionally finding entrance into the bodies of their masters in that bleak territory, has not been noticed in Ireland, at least in the human being.

* A Paper read before the l~atural F[istory Society of Ireland.