SELECTIONS.

SURGERY OF THE HAND-ESPECIALLY APPLIED TO RAILROAD INJURIES. Read before the American Surgical Association at Washington, D.C., May, 1884, by JOSEPH W. THOMSON M.D., Paducah, Ky. Man's usefulness and happiness in every calling in life depends to a great extent upon the hand. The hand is the most essential member of the body, as it is the means by which the intellect and genius of the mind are carried out and perfected. This makes the study of its anatomy and surgery of the first importance. Its perfect mechanism commands our admiration, and the beauty and symmetry of the human hand points conclusively to the high position man was intended to fill, and these suggestions taken together should invest the study of its injuries with much interest. Its constant exposure in every vocation, and more especially in this age of machinery, when the liability to such various injuries is so multiplied, demands on our part a thorough knowledge of its anatomy and surgery.

Every step made in the way of perfecting machinery increases the perils to the hand, and it remains for us to bring to bear every resource of investigation to establish a conservative practice in such wounds. The anatomy of the hand can only be thoroughly studied in the dissecting room. On the cadaver alone can we make ourselves familiar with its interesting and intricate regional anatomy. Practitioners so situated as not to be able to have the benefit of the study of the anatomical parts by dissection can secure a good knowledge by studying "Gray's Surgical Anatomy," "Holden's Guide," and Maclise's old, accurate and splendid plates. A thorough knowledge of the anatomy of the hand is essential as a foundation for the proper surgical management of its injuries.

The rich blood and lymph supply of the palm and the dense connective tissues cause the inflammatory action to be rapid in its course and soon becomes destructive to the soft tissues. As soon as the swelling and effusion require it, relief must be given to the distended tissues by a prompt and free incision, as by this treatment alone can the destruction of the parts be prevented. In cutting into the palm high up the surgeon must carefully bring to bear his anatomical knowledge and avoid wounding the palmar arches, which would result in troublesome and in some cases dangerous hæmorrhage.

Acute paronychia should be treated by prompt incision down through the periosteum, as neglect of this precaution is very liable to be followed by such destruction of the soft and bony tissues as to impair the functions of the finger or necessitate amputation. If the incision is early and thoroughly made relief with prompt recovery is generally the result. Wounds of the palmar arches are among the most difficult injuries we have to contend with, and to treat such wounds successfully often taxes

the ingenuity of the surgeon. The contrariety of opinions among the various surgical authors as to the proper treatment of wounds of the palmar arches is conclusive proof of the difficulties met with in this class of cases. In primary injuries a majority of opinions seem to be in favor of enlarging cautiously the wound and ligating the vessels. This may be proper in wounds of the superficial arch, but it does not seem admissible to extend the incision into the deeper fascia of the palm to secure the bleeding ends of the deep arch. In punctured wounds more especially is this rule applicable. Ligation of the principal vessel forming the arch, and compression of the opposite one, together with acute flexion of the forearm on the arm, will generally succeed in controlling the hæmorrhage. Ligation of both radial and ulna at the wrist and flexion of the arm is a good practice. If compression and other means have failed, and the palm and dorsum have become infiltrated and much swollen, it is sound practice to at once ligate the brachial artery, as it secures against further loss of blood.

A patient with wound of both arches by the plunge of a knife was brought to me one week subsequent to the injury. Too much pressure had been applied, resulting in infiltration and sloughing, so that when the pressure was lightened copious bleeding would result. I ligated both the radial and ulnar arteries at the wrist and elevated the arm. Pulsation continued in the wound, and on the fifth day after ligation of the vessels hæmorrhage recurred. I then flexed the arm on the forearm and secured it in that position with a roller bandage. After this the hæmorrhage did not recur, and the recovery was prompt and satisfactory. I am inclined to think that the advantage of acute flexion in wounds of the palmar arch is not properly appreciated by surgeons. In many cases bleeding from the superficial arch can be controlled by judiciously applied pressure and flexion of the forearm on the arm.

In cases of the bones of the hand, a free incision extending down to the bone will usually suffice. In necrosis of these bones, cutting down on the diseased structure and removing the detached portions is a very successful practice. It may require several operations to secure a good result, but pursuing this course will often prove successful. By these incisions we secure thorough drainage, which is so essential. When we consider the ample lymph and blood circulation in the hand we can readily appreciate the superior tissue-making element it possesses, and can, therefore, safely give proper credit to nature's reparative power in injuries and diseases of the hand. Experience teaches that amputation of the hand or any part of it is seldom required for the relief of necrosis. As a rule, preference should be given to secondary amputations in hand injuries.

Resection of the metacarpal bones has proven a very successful practice, especially to the extent of removing the fragments of bone and smoothing the sharpened ends. If due care is given to preserving the periosteum, reparation of the part will generally be prompt and thorough.

Resection of the phalanges is seldom admissible, except those of the distal row. When it seems necessary to remove the first and second phalanges, it is better to substitute amputation, as a useless finger would be the result of resecting those bones.

Excision of the carpal bones is of doubtful propriety, and can scarcely be considered an established operation. Prof. Lister has given much attention to excision of the wrist, and claims it to be a successful operation, but I think the majority of surgeons look upon the propriety of this operation with much doubt. Most cases will terminate well if properly treated by free incisions, drainage and removal of the dead portions of bones as they become detached. In amputation, to remove as limited a portion of the finger as possible is in the main proper, but exceptions should be made to this rule in amputating the middle and ring fingers, especially among the laboring class. Experience satisfies me that among that class it leaves the most useful hand to remove the middle and ring fingers at the metacarpo-phalangeal articulation, as a stump from amputation of these phalanges in the continuity or at the first phalangeal joint, the flexor and extensor muscles having been severed, renders the . hand comparatively useless, and is therefore much in the way of the laborer in performing his work.

Cut No. 1 exhibits the stump from amputation of the middle finger at the first phalangeal joint in July, 1883. This stump is comparatively useless, and from its position (as is plainly shown in the cut) is liable to be in the way when performing manual labor. The man informs me that he is so inconvenienced by the contact of the end of the stump with bodies that he handles, that he would much prefer that the finger was off at the knuckle joint.

The case represented by cut No. 2 presents the appearance of the hand with amputation of the middle finger at the metacarpo-phalangeal articulation. It will be observed that the hand is not very unseemly. The man assures me that the function of the hand is but little impaired, and that he does not meet with the inconvenience of other co-laborers with stumps from amputation of that finger. This man and the one represented with the stump of the middle finger are both still at work for the railroad with which I am connected as surgeon, and within the last week I have examined both hands and had them photographed.

I have endeavored to present photographs of hands representing the various amputations of the fingers, and the extent of the function retained by the hands after the respective amputations, occurring in my practice. My position as Chief Surgeon of the Chesapeake, Ohio & Southwestern Railroad for the past two years has enabled me to arrive at the conclusion that it is often better to amputate at the knuckle joint. There are numbers that I could instance in which I have amputated fingers at the first phalangeal joint or in the continuity of the bone two years ago, and since that time, who are still working for the company, and therefore my opportunities for observing have been good as to the usefulness or disadvantage of stumps from removing the middle and ring fingers. I am now convinced that it gives a better result to amputate those fingers at the knuckle joint.

But with the thumb, index and little fingers the golden rule should be adhered to, viz., remove the most limited portion that will suffice. The thumb can be brought in apposition with all the other fingers and the palm, and is therefore the most essential and useful of the digits. Prehension can be performed with the thumb as the only digit, and the wide range of its usefulness should make it a positive rule to save as much as possible, regardless of the beauty of the stump. The same rule should be applied in every case to the index and little fingers. The apposition of the thumb with even a short stump of the index finger is very perfect, and prevents much of the impairment of the hand that would result if the index finger were amputated at the metacarpo-phalangeal articulation. With the little finger and thumb only remaining, the functions of prehension and other essential movements can be readily performed.

Mr. C.'s case, for instance, illustrates. The left hand was caught between the side of the work bench and a circular saw. The friction, the result of the rapid revolutions of the saw, opened the joints of the middle and ring fingers, and comminuted the bones of the second and third phalanges of the index finger. The tissues for half an inch above the knuckle joint of the middle and ring fingers were much lacerated. The patient was brought to me one month subsequent to the injury. It was

now evident that the wounded parts would have to be removed. I amputated the middle and ring fingers at the metacarpo-phalangeal articulation, and the index finger at th first phalangeal joint.

Cut No. 3 shows the functions of the hand retained in grasping a tumbler. This case illustrates the usefulness of a hand with only the thumb, stump of the index finger and little finger remaining.

Cut No. 4 exhibits an unusual power possessed by the stump from amputation of the index finger at the first phalangeal articulation. It will be observed that the function of flexion and extension is good, which