ternal cause, as other tendons are not found subject to this disorder: but it may be owing to a puncture which has affected the tendon, together with the sheath, or even the sheath alone. These two parts, we know, are blended together at the third joint where the tendon is inserted into the bone: it is therefore no wonder if inflammation of the one should extend to the other. The inflammation spreads afterwards all over the hand and along the muscle from which the tendon arises, as far as to the fore arm, sometimes even to the whole arm, forming an erysipelatous inflation, which terminates under the arm-pit, and swells the axillary glands. The pain and fever are then very violent, attended sometimes with delirium and convulsions." (p. 419; Fr. edit., p. 547.) This tendinous and the cellular whitlow just described are continally running one into the other from continuous sympathy; and, under one or other form, or a compound of both, often appears the result of punctured wounds, (which will be heareafter considered, par. 328.) especially those most dangerous and often fatal received during dissection. The inflammation set up in the tendon or its sheath, and propagated from the one to the other, as described by LE DRAN, is always accompanied with inflammation of the neighbouring cellular tissue, and, as CHELIUS observes, often spreads to the periosteum, which, separating from the bone in consequence of the effusion of matter beneath it, and often participating in the slough of the theca and tendon, which not unfrequently, though not so constantly, happens in this disease, that we can agree in LE DRAN's definition, that it is "not a phlegmonous abscess, like the second kind, but a putrefaction either of the sheath alone or the tendon with it." Under these circumstances, the bone is destroyed and exfoliates, which is commonly a very tedious though not dangerous process.-J. F. S.]

Fourth. On the inflammation taking place in the periosteum; the pain is excessively severe, though not spreading over the hand and fore arm; the affected finger at the beginning is not at all swollen; it soon suppurates, and the bone is attacked.

The severe kinds of whitlow may be connected with each other inasmuch as a less may pass into a more severe form. In the spreading of the inflammation over the hand, painful swellings may occur in various parts.

A painful state, near the nail of the little finger, without any previously apparent inflammation, has been observed, which RICHTER calls the dry whitlow, in which the pain continues for minutes or hours, and then disappears for days or weeks. On amputation of the finger all the soft parts are found natural, but the bone converted into a mass resembling fat (a).

[ABERNETHY calls this Paronychia osseosa.

LE DRAN asserts "that this species of whitlow proceeds from a disease of the bone, in consequence of which the periosteum soon putrefies, or is attacked with an erysipelas which degenerates into a putrefaction: from whence it happens that, when making an opening, the bone is found bare and frequently carious." He observes that "the inflammation seldom extends over the fore arm, as described in the preceding kind." (p. 420; Fr. edit., p. 550.)

I do not recollect to have distinguished this disease, and doubt much whether the indications mentioned are sufficient for that purpose.-J. F. S.

ABERNETHY speaks of "an ulceration with great thickening at the end of the fingers, and toes, and pain particularly at night, which has been described under the name of Epinychia. It goes on producing disease of the skin, and no nail will grow, or perhaps the disease extends and leaves a little island of nail, and this I have seen plucked out as the cause of the disease, though it was really the only sound part. I have seen it go on for three years and not get well. It is the produce of an ill state of health." (b). I presume under this name ABERNETHY refers to the disease called by SAUVAGES (c) Epinyctis; he describes it, however, as a pustule rising in the night, resembling a boil, of a blackish red colour, crowding together three or four lines in diameter, affecting chiefly the legs, and very frequently painful, especially at night. He describes two species,-E. vulgaris, and E. pruriginosa.

JOHN PEARSON speaks of a Venereal Paronychia, which he describes as appearing in the form of a smooth, soft, unresisting tumour, of a dark red colour, and situated in the cellular membrane about the root of the nail. It is attended with an inconsiderable degree of pain in the incipient state; but, as suppuration advances, the pain increases in (a) ACRILL, Chirurgische Vorfalle, Gott., 1777, vol. P. 210. (b) MS. Lectures on Surgery. (c) Nosologia Methodica. Amsterdam, 1768. 4to. vol. i.

severity; its progress towards maturation is generally slow, and seldom completed. When the sordid matter it contains is evacuated, the nail is generally found to be loose, and a very foul, but exquisitely sensible ulcer, is exposed; considerable sloughs of cellular membrane, &c, are frequently exfoliated, so that the cavity of the sore is often very deep. The discoloured and tumid state of the skin commonly extends along the finger, considerably beyond the margin of the ulcer; in such cases, the integuments that envelop the finger become remarkably thickened, and the cellular membrane so firmly condensed as not to permit the skin to glide over the subjacent parts. The bone is not usually found in a carious state. This species of paronychia is more frequently seen among the lower class of people, when they labour under lues venerea, than in the higher ranks of life. It does not appear to be connected with any particular state of the disease, nor is it confined to one sex more than the other. In the Lock Hospital it occurs in the proportion of about one patient in five hundred." (pp. 85-7.) It is evident, however, that PEARSON is not quite satisfied as to the actual nature of this disease, which seems more to resemble onychia maligna than any other form of whitlow; for he proceeds :"When I adopt the name of venereal paronychia, it is not with the design of implying that this is a true venereal abscess, containing a fluid which is capable of communicating syphilis to a sound person. Its progress and cure seem to be unconnected with the increased or diminished action of the venereal poison in the constitution, and to be also uninfluenced by the operation of mercury. I consider the venereal disease as a remote cause which gives occasion to the appearance of this, as well as several other diseases, that are widely different from its own specific nature." (p. 88.)]

186. The causes of whitlow are in many cases unknown; it is often, however, very common at certain periods. Sometimes a general cause, as gout, and rheumatism, seems to give rise to it; but, in most cases, the cause is local, as contusion, sudden warming of the fingers after they have been chilled, injury with fine puncturing instruments, from splinters, and

so on.

To these causes GARENGEOT adds "the excrescences (or rather little shreds) which form about the nails, and are commonly known as hagnails." And he observes, "that workwomen using the needle are most subject to whitlow; though, on the other hand, they protect themselves by immediately sucking their finger, thus imitating the suckers of wounds, or certain irregular practitioners; because, by this proceeding they abstract the blood which escapes from the little vessels opened by the sharp instrument, and thus prevent any deposit, and consequently also abscess." (pp. 287, 8.) Another very common cause of whitlow is the impure soda often used by laundresses in washing linen, which often either irritates any small scratch or crack there may be in the skin of the finger, or even first produces a cleft which presents the appearance of a knife having been drawn through the cuticle down to the cutis, and then, irritating the latter, sets up considerable inflammation in the shape of whitlow.-J. F. S.

HUNTER takes the whitlow as an example of "the ulcerative process having no power over the cuticle, so that when the matter has got to that part it stops, and cannot make its way through till the cuticle bursts by distension." (p. 469.)]

187. The treatment of whitlow varies according to its different forms. In the first form, it may often be at the very onset dispersed by cold applications. If pus be formed, it must be soon evacuated, that it may not spread beneath the nail. If the nail, however, be loosened, it must be partially removed with the scissors, and a piece of linen spread with cerate must be laid between the edge of the nail and the soft parts, in order to prevent the irritation of the latter. If pus be collected beneath the nail, the latter must be scraped thin, so that it may be pierced with the bistoury, and the pus allowed to escape; or, if the nail be somewhat loose, it may be torn off. Generally, as it separates a new nail grows; it should be covered with wax, to give it a good shape.

[GIBSON says "venesection, both general and topical, may be required in the early stages of whitlow; leeches especially prove very serviceable in all cases, by abating pain and reducing the inflammation These remedies, however, are seldom sufficient to procure resolution; but this has often been accomplished by the early and repeated

applications of a blister. On the other hand, it must be stated that many patients derive no advantage whatever from the blister." He further, and very justly, notices :-" The same applications, I have observed, produce very opposite effects on different patients: thus I have known common linseed oil spread over a whitlow afford instantaneous relief in some cases, and, in others, so far from proving beneficial, aggravate all the symptoms. Soft soap or common brown soap, warmed and applied to the affected part, occasionally acts in a wonderful manner, assuaging the pain and subduing the swelling in a very short time. Poultices sometimes give relief, and are useful always in softening the skin and removing tension; but, when the swelling is very great, the pain intense, and matter evidently formed, the most effectual mode of easing the patient is to lay the part open freely with the knife." (p. 188.)

HUNTER observes, that "the application of poultices in these cases is of more benefit than in any other, because here they can act mechanically, viz. the moisture being imbibed by the cuticle as in a sponge, and thereby softening the cuticle, by which means it becomes larger in its dimensions, and less durable in its texture." He advocates of course the early opening of these abscesses; and, speaking of the fungus which almost invariably protrudes through, as also when the skin gives way of itself, he says:-" It is a common practice to eat this down by escharotics, as if it was a diseased fungus; but this additional pain is very unnecessary, as the destroying a part which has only escaped from pressure cannot, in the least, affect that which is within; and, by simply poulticing till the inflammation and, of course, the tumefaction subsides, these protruded parts are gradually drawn into their original situations." (p. 470.)

With the practice of freely opening the whitlow I fully concur, and the sooner it is done after suppuration has taken place, and the cuticle is raised like a blister from the true skin, the better. The suppuration takes place usually in twenty-four or forty-eight hours from the onset of the disease, and should be carefully watched that it may be punctured immediately the pus has been poured out. The longer cutting through the skin is delayed after this event, so much the worse; for, beside the separation of a larger extent of cuticle and even of the nail, and the continuance of violent pain from the pressure which the pent-up matter makes on the sensitive extremities of the nerves at the tips of the fingers, the pus presses also on the cutis and causes it to ulcerate, thereby rendering the cure at best tardy; and often producing a very ugly and tiresome sore. After the pus has been discharged by puncturing or cutting through the cuticle, it is best to notch out a little bit of the skin, to ensure a free and constant escape for the matter, otherwise the cut edges often become glued together by the drying of the pus between them, and then it again collects, and sometimes needs a fresh cut. If the pus be confined beneath the nail, as is sometimes the case, the nail having been scraped, it should then have a little hole carefully cut through it to let the matter out. It rarely happens that the whole nail at once separates from the true and highly sensible skin beneath, but is held sometimes at the root, side, or end according to the part at which the pus has been poured out. I do not think it advisable to thrust in lint to save the soft parts beneath, as scraping the centre of the nail, from root to tip, till it will bear scraping no longer without bleeding, or, in other words, till it is almost completely scraped through, allows the edge of the nail so to alter its place that little or no irritation is produced by it. All that is necessary is to give free vent to any matter which may exist, to keep the parts clear from any dirty or irritating substances and to prevent the loosened part of the nail (the movement of which causes much pain) being disturbed, which is best done by wrapping in a poultice, or covering with wax and oil dressing, for I am not disposed to remove any part of it so long as the cutis beneath continues suppurating, as the nail protects it best, just as the cuticle does a blister-sore, and, as the new nail forms, it gradually stretches beneath it, and then, but not till then, may portions of the old separating nail be cut off. If, however, as is sometimes the case, the loosened nail digs in and irritates the sore; if the cutis have ulcerated in consequence of the pus not having been evacuated sufficiently early, or, if it twist up, as it will occasionally do, and continually catch in the dressing, then it may be cut off. I am no advocate for tearing off the nail, nor any part of it, and I can scarcely imagine that in this form of the disease it is ever necessary.-J. F. S.

HIGGINBOTHAM advises brushing over the whitlow with nitrate of silver, and considers it very good practice. I have not, however, had any experience of it. GIBSON mentions that PERKINS of Philadelphia is said to have frequently removed whitlows in a very short time by an admixture of corrosive sublimate and white vitriol, applied to the part on lint steeped in tincture of myrrh, and suffered to remain for several days. GIBSON has tried the remedy in several instances, but cannot say it has answered his expectations in any one case. (p. 189.)]

188. The second form of whitlow requires, in consequence of the severity of the inflammation, bleeding or leeches to the affected finger, cold applications, and rubbing in mercurial ointment. If the cause of the whitlow be a puncture, it must be ascertained whether any splinter remain ; and, if so, it must be removed; also, if any noxious matter have penetrated into a wound, it must be carefully washed out with warm water. If resolution do not occur in the first three days, the affected part must be cut into. The patient is always thereby relieved, either by the escape of the pus, or, if the pus be not perfectly formed, by the division of the tough and tight skin, and by the bleeding. The cut should always be pretty free. Soothing poultices should be applied till the pain and swelling have subsided. If the skin be thinned to a great extent, and raised like a bladder, it must be removed as soon as the pus is discharged.

[The treatment of this is precisely similar to that directed for the previous form of the disease, excepting that, in the present case, it is always necessary to cut through the cutis as well as the cuticle, and relieve the tension of both at once; the pus, if the incision be made at the proper time, not having yet ulcerated through to the cutis, and poured itself beneath the cuticle.-J. F. S.]

189. The treatment of the third form of whitlow is the same as in the second, except that the incision must not be deferred beyond the third day; for, otherwise, the tendon will be destroyed. The cut must penetrate into the tendon sheath. The pain is usually quickly diminished by the application of soothing remedies. As the inflammation often spreads over the whole hand, if in any particular part pain, swelling, and fluctuation occur, it must be opened: and as, when the tendons are destroyed, the motions of the finger are lost, care must always be taken to keep it in a proper position. [The incision, when the sheath of the tendon is concerned, should always be made deeply and freely, and in the course of the tendon, as if that be divided longitudinally, no inconvenience accrues to the movement of the finger or toe, as would were it cut transversely. It must not be expected always to find pus flow in opening the tendonsheath; very frequently but a drop or two escapes, and sometimes none, the secretion not having been established. The anticipation of such occurrence is not, however, to be any bar to making the incision, as the immediate relief it affords, by getting rid of the tension, and emptying the vessels of the inflamed part, and checking the high constitutional disturbance almost always attending inflamed tendinous structures, is most remarkable. If the inflammation and suppuration be propagated to the palmar or plantar fascia, or further on the arm or leg, incisions through the fascia must be made, for the voidance of the pus. As this subject will be again treated of, in considering punctured wounds, it need not at present be further pursued. As regards the sloughing of the tendons of the fingers or toes, the extent to which they are destroyed is very great: indeed, I have known an instance of slough of the entire tendon, up to its junction with the muscular fibres, of one of the flexor muscles of a finger, of which the top had sloughed off. The straight position is best for the finger, when either flexor or extensor tendons has sloughed; but very commonly, for working persons, its immobility is so inconvenient, that it is necessary to amputate it at the knuckle.-J. F. S.]

190. The fourth form of whitlow must be treated the same as the previous forms; and, if the severe pain and tightness do not diminish, an early cut through the whole must be made, to prevent the destruction of the bone. This must be made where the pain is most severe, and must be carried down to the bone. The finger must be put in decoction of chamomile if the suppuration be sluggish; it must be bathed in lye (a), and soothing applications employed. The bone of the last finger-joint often separates, or may be removed frequently without pain, the finger retaining its form, though rather shorter. If the bone of the second or first joint be affected, the removal of the finger is necessary. However, under the pre

(a) Common mixture of crude potash and water.

ceding treatment of soothing poultices and bathing with chamomile, the most severe cases of this kind are often cured.

[For the cure of Epinychia ABERNETHY recommends the use of "a combination of arsenic and sulphur, which, together with some herbs, formed the principal part of a quack medicine called PLUNKET'S Epithema; that composition, however, was horribly painful, and produced the most horrible sloughs, not by decomposing the parts, but by exciting vehement action; I have, therefore, followed it so as to render it only a corrigent, and, in many cases, it will relieve without producing pain." For the same purpose he used also successfully the Aqua Arsenicalis of St. Bartholomew's Hospital, consisting of arseniate of potash, spirit, and mint water, which he considered to have an excellent corrigent effect on local diseased action. It is also well to use it mixed with basilicon; but care must be taken in its employment, for if the constitution become affected, as sometimes happens, it will make the patient very ill, and even cause temporary blindness.]

191. It is here proper to mention two diseased conditions which depend on changed form and direction or unnatural structure of the nail, or are therewith connected; growing of the nail into the flesh, and inflammation and suppuration of the surface producing the nail.

192. The Ingrowing of the Nail into the flesh depends less on an increase of the breadth of the nail, than on the pressing upwards of the soft parts. It is ordinarily consequent on squeezing together of the toes by tight shoes, especially if the nails be cut too short, and is almost confined to the great 1oe, specially to that side of it next the second toe. The irritation of the edge of the nail causes inflammation; at first, the secretion of a serous fluid which dries to a callous mass; subsequently suppuration and fungous excrescences spring up, which spread over the nail; the disease may even assume a carcinomatous character, or the inflammation may extend to the bone. The nail itself grows thicker, and is frequently softened at the ulcerated part. The pain in the severe form of this disease is always very great, and walking often becomes quite impossible.

[The commencement of this disease has been well-described by WARDROP, who says:"This affection is chiefly confined to the great toe. It frequently happens, when the foot is kept in a tight shoe, that the soft parts situated on the edge of the nail thicken, are pressed over it, and become more or less inflamed and painful. If the inflammation and thickening of the soft parts increase, the edge of the nail becomes at last completely imbedded in them, and its sharp edge, from the pressure of the body when resting on the foot, increases the inflammation, and produces suppuration of the contiguous soft parts. Thus the hard and sharp nail, by pressing on the surface which has become ulcerated, causes great pain and lameness, and in many cases, prevents the person from walking. The ulceration generally extends round a considerable part of the nail, and a fungus arises from this surface, accompanied by excessive irritability." (p. 130.) This, "the first variety," says DUPUYTREN, "consists of the ulceration sometimes of one, sometimes of both the lateral edges of the nail at once. It almost always happens on the outer edge. If the conformation of the nail be remembered, if the flatness of its body, the direction of its corners, its situation in the thickness of the skin which surrounds and covers it, we may easily conceive how a tight or ill made shoe, producing a constant pressure on the nail, will forcibly thrust its corners upon those parts of the skin where it rests. By degrees these corners, always more or less sharp and cutting, bury themselves into the skin, with the greater facility as the skin itself pushes upwards and outwards, and endeavours to cover them; finally, the irritation increases by walking, and produces a very painful inflammation. Such is really the most common cause of the incarnation of the outer edge of the great toe. The affection almost always commences at the point of union of the front with the side edge of the nail, and appears to be occasioned by the fold that forms in the flesh; as this interrupts the action of the scissors while cutting the nail, they are almost invariably checked before they can cut away the whole of its front edge, especially at that point where an angle is formed by union of the nail with its corresponding lateral edge. This allows the remaining nail to grow, which soon forms a sharp point, punctures, and cuts into the flesh, and gives a sort of signal of ulceration which soon spreads along the corresponding edge of the nail. So sure is it that this point is constantly found on the nails which have been