torn off. Scarcely has the nail cut itself into the skin it covers, than the pain becomes very severe; walking, and even standing, are unbearable; a serous or sero-purulent oozing establishes itself in the part affected, and, if the patient take exercise, the whole foot swells. The pain, however, continues increasing, the oozing becomes more abundant, and the sanious pus which escapes has a smell more fetid from mixing with the perspiratory humour of the feet. The patient, tormented with pain, is driven to raise the nail and cut it back; but this proceeding, though sometimes causing momentary relief, far from curing increases the difficulty of the treatment. Finally, if the disease be left alone, the ulcer produced sometimes runs into a cancerous state, sometimes is covered with enormous vegetations, sometimes even the inflammation is propagated to the periosteum, and soon gives rise to caries and necrosis of one or more phalanges." (p. 46.) DUPUYTREN also mentions that this disease is liable to be confused with some others, and instances a case which, for eight years, had been treated as if depending on gout. COLLES (a) observes, that "the colour of the fungus is rather florid; surface is smooth; the discharge is purulent, in small quantity, and tolerably healthy, unless the part have been irritated by too much exercise of the limbs, or by some external inflammation or local injury: there is little or no surrounding inflammation, no enlargement of the toe, and the pain is in general trifling, unless during exercise, when the weight of the body on the limb causes the nail to press into the soft substance of the fungus, which thus often induces considerable uneasiness and lameness. This disease does not appear to me to have any tendency to spread to, or to involve, the adjoining parts, as I have seen cases in which it has remained stationary for some months, and in one for two years; at the end of which period the symptoms were in no way more severe than at the commencement, although most writers assert that it generally passes into malignant onychia. The origin of this troublesome affection is usually attributed to the effects of a tight boot or shoe, or to some accident in cutting or breaking off the end of the nail; in many instances, however, no cause can be recollected or assigned for its occurrence." (p. 241.)

COLLES, however, speaks of the form of disease liable to be mistaken for gout as quite distinct from that just described. He says:-"There is another morbid affection which occasionally engages the anterior and inner angle of the great toe nail, and which causes considerable lameness and uneasiness, particularly on pressure; this affection is often mistaken for an attack of gout, especially in those persons where such an attack may be expected or even desired. In this disease there is no swelling or redness; but pain, on pressure, at the anterior and internal angle of the nail. On close examination of this spot, we find that this angle rests on a hard white mass of laminated, horny cuticle, which we can easily remove in bran-like scales, when we shall see a small cup-like cavity, without any ulceration or disease. The ungual angle appears thick and bulbous opposite this point, and the pain is caused by its pressing against this mass. *** I may remark I have never seen this disease engage the outer angle, neither have I seen that last described engage the inner angle of the toe-nail." (pp. 244, 5.)

193. In the slighter forms of this disease, it may always be easily relieved by inserting a slip of lead under the edge of the nail which is to be fixed, there by twisting round it a piece of sticking plaster; by which means the nail is raised and the flesh depressed. If there be fungous excrescences, these must be first removed with lunar caustic, or cut off with the knife. It would be too painful at once to insert the plate of lead beneath the edge of the nail; but it is also unnecessary, as its insertion under the front edge, if the nail be allowed to grow, gradually raises the hind part, and then the lead may be further introduced. When the nail has recovered its proper direction, it must not be cut too short nor rounded at the sides, but only shortened transversely. With these precautions, this treatment, recommended by DESAULT and RICHERAND, has, in almost all cases, answered my wishes. Introduction of charpie or wax beneath the edge of the nail is useless.

BIESSEY (b) scrapes the whole free surface of the nail till nearly its entire thickness is destroyed, particularly in the centre. Then he touches the scraped part five or six times,

(a) Observations on some Morbid Affections of the Nail of the Great Toe; in Dublin Journal of Medical Science, vol. xxiii. 1843.

(b) Remarks on Inverted Toe-Nail; in Philadelphia Journal of Medical and Physical Sciences, vol. ii. 1821.

more or less severely, with lunar caustic until the nail contracts completely, and draws out of the flesh. He then lays pads of charpie under the edge of the nail, till by its growth it stretches over the bulbous part of the toe. ZEIS (a) especially recommends the introduction of charpie under the edge of the nail, and the use of foot-baths.

[The treatment recommended by MEIGS (b) is very simple::-"Let a small pledget of lint, just large enough to cover all the granulations, and of sufficient thickness to act as a compress, be neatly adjusted, over which a roller of linen, three-quarters of an inch wide and eight or ten inches long, is to be applied, having one end previously spread with adhesive plaster. By this method we are enabled, with great ease, to make it not only act on the compress, which will destroy the granulations very rapidly, but, by confining the toe and nail, to prevent even the small degree of sliding motion or friction of the latter over the wounded part, thus doing away one principal cause of the disease. By pursuing this treatment, the patient will generally recover, even while walking about." (p. 266.)

ASTLEY COOPER says, that "the application of a blister will bring away the cuticle, and often the nail along with it." (p. 193.) I have tried this plan several times, but have rarely succeeded in inducing the separation of the nail.-J. F. S.]

194. It is not possible, however, in many cases to render assistance by this treatment, partly because the nail has gone in too deeply, and is too much covered with fungous growths, partly because it is too painful. Here the treatment proposed by DUPUYTREN is applicable. When the inflammation of the toe is diminished by poulticing, rest, and so on, a pair of straight sharp scissors, of which one branch is very pointed, must be thrust by a sudden motion from before backwards, from the front edge to the middle of the root of the nail, to at least three lines behind its hinder edge, thus dividing the nail into two halves. The diseased halves are then to be taken hold of and twisted round, all connexion destroyed, and the nail itself removed; the same must be done with the other half, if necessary. If the fungous excrescences are high, they must be destroyed with caustic, by which the skin beneath the nail dries, the sore surface disappears, and in from twenty-four to forty-eight hours is cicatrized. In olu persons the nail is generally not replaced; in young persons it sometimes reappears; a recurrence of the disease is, however, rarely to be feared.

[According to ScoUTTETEN (c), if it is determined to destroy the matrix of the nail, the point of a straight bistoury should be placed upon the middle of the diseased phalanx, about four lines from the edge of the nail, and the skin divided down to the nail. The cut should not penetrate deeper than the matrix, as this only is to be exposed. The edges of the wound are then to be raised from the nail and kept asunder by the introduction of charpie. On the day following the little wound must be filled with a caustic paste, (five parts of caustic potash, and six of quicklime, moistened with alcohol immediately before use,) and the dry phalanx covered with sticking plaster, the excrescences must be destroyed by the gradual application of the caustic; and, after the falling off of the slough, until the healing is complete, which takes place usually in twenty-four days, there is nothing to do except merely to cut away the exposed edges of the nail with scissors.

The following are PARE's and FAYE's treatment. The former consists in thrusting in a straight bistoury at the base of the soft parts which cover the nail, and dividing this part from before backwards to the edge of the nail, then the bistoury is to be turned to the other side, and the flap perfectly removed. Cauterization is to follow. In FAYE's method a V-shaped piece of the nail (first scraped thin) must be removed out of the front edge, and through the two edges a metal wire drawn and twisted together, by which the edges of the cut are approximated, and the in-growing edge of the nail raised up.

Of the various modes of treatment which have been recommended for the cure of the in-growing nail, compare MICHAELIS (d), SACHS (e), ZEIS (ƒ).

ASTLEY COOPER first proposed the operation of, "with a pair of scissors, slitting up the

(a) Cursory Remarks on Inverted Toe-Nail; in Philadelphia Journal of the Med. and Phys. Sciences, vol. ii. 1821.

(b) In DANZEL, Essai sur l'Ongle Incarné; suivi de la description d'un nouveau Procédé Opératoire. Strasbourg, 1836.

(c) Remarques sur le Cours d'Opérations de Chirurgie de M. DIONIS. 8vo. 1736.

(d) In Journal VON GRAEFE und VON WALTHER, vol. xiv. p. 24.

(e) Ibid, Vol. xxii. p. 108.
(f) Above cited.

nail on that side where the disease exists, and then with a pair of forceps turning back and completely removing the divided portion. This is a very painful operation certainly; but I have known persons get well by this treatment in ten days, where the complaint had for months resisted every other. The applications to be used after the operation are of little importance; poultices are the best, and these will be required but for a very limited period, for the irritating cause having been removed, the fungus will soon disappear." (pp. 192, 3.) Nearly the same plan was followed by DUPUYTREN, as above described.

I entirely concur, however, with the observations made by COLLES on this point. He says:-"This operation inflicts a great degree of suffering, because in this disease the nail is not, as in onychia, separated from the vascular and highly sensitive matrix, except only through a small extent of space, not more than a quarter of an inch at its external angle, and, therefore, the scissors pushed upwards between the nail and the adherent matrix, and the forcible evulsion of the former by the forceps, must cause exquisite pain, which, though of short duration, can be regarded as nothing short of actual torture.

*

I am by no means an advocate for this peculiarly painful and distressing operation, but, on the contrary, I believe we may be relieved from the necessity of performing it, and that we can, in all instances, effect a permanent cure by a very simple operation, and one comparatively free from suffering; namely, by confining the excision of the nail to so much only as is already detached from the matrix; all of this portion, as well as that imbedded in the fungus, must be removed." His operation consists in having the fungus pressed down with a spatula, and the edge of the portion of nail to be removed seized with strong flat-blade forceps; the flat end of a probe is then thrust beneath the nail as far as it will go, directing it towards the outer edge, and upon the pointed edge of a pair of stout crooked scissors is to be carried, with one stroke of which the detached portion of nail is cut off, and then drawn away by the forceps with moderate force. But, if this be insufficient, the probe is to be passed still higher, the scissors introduced again, and a second cut frees the nail: sometimes a sharp momentary pain occurs from the point of the scissors penetrating the sensitive matrix. The only dressing required is "a small bit of dry lint, to be pressed firmly between the fungus and the edge of the nail." In a few hours the toe is free from pain, and the patient can walk without any lameness or uneasiness in three or four days after the operation. The dressing continues perfectly dry, and need not be changed till the fourth day. At this time the fungus will be found much reduced in size, perfectly dry, and of a firmer consistence. * In the course of ten or fifteen days the fungus will have entirely disappeared, and the parts be restored to a healthy state. * * *The result of the operation is not in all cases so successful, for, in some instances, four or five days after the operation, the patient will complain of some uneasiness in the toe, when we shall find on examination that the dressing is moistened with a little discharge, and that a small portion of a whitish substance, like soft and swollen leather, is rising up through the fungus. This substance, may be, regarded as a sort of accessory ungual filament, arising close to the original nail, from the anterior and outer border of its matrix, and which is now altered in texture and direction; this filament is so soft that it breaks and tears, if caught by the common dissecting forceps." (pp. 243, 4.)]

*

195. The Inflammation and Suppuration of the Surface which produces the nail, (DUPUYTREN'S matrix of the nail,) which WARDROP has pointed out as a peculiar kind of whitlow, (Onychia maligna,) begins with dusky redness and swelling of the soft parts in the neighbourhood of the nail; an ichorous fluid oozes between the nail and soft parts; ulceration takes place at the root of the nail; the neighbouring parts become swollen, dusky red, and the pus which the sore secretes is ill-conditioned and stinking. The nail loses its colour, becomes gray or black, and does not grow, so that it shortens and loses half its width; sometimes it entirely disappears, and only a few streaks of horn are seen here and there; sometimes part is concealed under the fungating flesh; in many cases it is completely separated. This state may continue for many years, and the toe or finger become converted into a shapeless mass. This disease is frequently very painful, especially when touched; the fungations (which do not, as in simple ingrowing of the nail, arise on the side, but are seated at the root of the nail) bleed, on walking and standing.

[AS DUPUYTREN observes, "the formation of this second species will be better understood after saying a few words on the anatomical structure of the nail. Its adherent extremity, the only part at present needing study, is implanted in the skin in a peculiar manner; the latter, having passed on the dorsal surface of the nail, is reflected, and, having reached the hind end, divides, into two portions, the epidermis which covers the whole superficial layer, and the cutis which passes beneath the nail, and is continuous with the skin covering the free extremity of the finger. The cul de sac, in which this part of the nail is received, is called the matrix. It is, then, very important to be acquainted with this disposition of the organ, as fully explaining why the nail received into the flesh is, in many cases, only produced by the ramming in (refoulement) of its free extremity into the cul de sac. This alteration may take place in consequence of the running over, or fall of a heavy weight upon the great toe. Whatever may be the cause, the patient at first complains when walking of a pain which gradually increases; the kind of cul de sac, lodging the base of the nail, reddens and inflames, as well as the bottom of the fold which receives its lateral edges; ulceration is soon observed, which makes rapid progress; its form becomes semilunar, its edges elevated and hard, its base red, violet, and livid. The nail shortens and diminishes to half its size, sometimes even entirely disappears, and in its stead are observed, here and there, pencils of horny substance; often, also, part of the nail is hidden under fungous flesh. These fungosities serve to distinguish this disease, resulting from primitive alteration of the skin, from that consequent on the nail digging into the flesh. When the disease is caused by the nail, the fungosities originating from the inflammation occur on the front and sides of the nail; but when, on the contrary, it depends on the affection of the skin, the fungosities are always observed at the root of the nail. The colour of the nail in these cases is gray and black; sometimes it does not retain its ordinary connexions; the sore is generally bathed in a sanious or sanguinolent suppuration, and spreads far and wide a fetid smell. If the patient walk, or even remain standing upright, the fungosities bleed: every kind of shoe is unbearable, and the least rubbing is extremely painful. In general it is impossible to remain in the same place with persons who have this disease, as the stench which circulates around them, and clings to their clothes, is infectious and penetrating, being produced by the union of the ichorous pus oozing from the bottom of the ulcer, and the copious sweat which the feet of these patients secrete." (p. 61-4.)

COLLES mentions:-"When the original nail has been cast off, we usually see projecting from the sides, and tarsal border of the ulcer, a narrow plate of a white substance, not unlike white leather soaked in water; this sometimes forms one continuous shelf all around the ulcerated border, projecting in a peculiarly prominent manner, that is, rather at an angle to, instead of being a plane parallel with, the dorsal surface of the phalanx. In some cases this white substance (which is the result of an abortive attempt to produce a true nail) appears only in detached spots or flakes, the intermediate parts of the ulcerated margin being devoid of any such growths; they are most frequently seen at the posterior and anterior angles of the nail, but occasionally in other parts of the circumference. The surrounding integument is discoloured, being often of a livid or purplish tint; it is also indurated, and exudes a copious perspiration, of a peculiar heavy odour. This ulceration sometimes induces caries of the bone, and even extends to the phalangeal articulation." (p. 246.)

WARDROP says:-"In this state I have seen the disease continue for several years, so, that the toe or finger became a deformed bulbous mass. The pain is sometimes very acute, but the disease is more commonly indolent, and accompanied with little uneasiness. It affects both the toes and the fingers. I have only observed it on the great toe, and more frequently on the thumb than any of the fingers. It occurs, too, chiefly in young people; but I have also seen adults affected with it." (p. 136.)

"When the disease, more especially, attacks that part of the skin immediately beneath the nail, then," says DUPUYTREN, "is it observed to be raised by the development of little tumours, the presence of which cause pain in proportion as the pressure is more considerable. They are of different kinds, fibrous, cartilaginous, bony or vascular; and the proof of their development, simply depending on alteration of the cutis covering the nail, is, that if they are removed, without, also, taking away the skin from whence they spring, the skin generally, again, becomes diseased, ulcerates, and sooner or later requires complete removal." (p. 64.)—J. F. S.]

196. The causes of this disease are either local, mechanical, or chemical, for instance in persons having much to do with alkalies; or general, herpetic, but especially syphilitic, dyscracy. Several fingers and toes of both

hands and feet are then attacked at the same time; the disease commences sometimes with little sores in the clefts between the fingers or toes, which extend around the origin of the nails; these separate from their root. The disease ordinarily resists mercurials.

197. In the treatment of this disease internal remedies are to be employed, according to its different causes, and local, according to the degree of irritation; leeches, soothing applications, baths, and so on, and the foot kept quiet. ASTLEY COOPER recommended a grain of calomel and opium night and morning with decoction of sarsaparilla, and the application of lint steeped in lime water and calomel, (black wash,) covered with oiled silk. If this treatment be ineffectual, the nail with its secreting surface should, according to the opinion of both DUPUYTREN and COOPER, be removed. According to DUPUYTREN, the foot is to be steadied, and the diseased toe held with the left hand; a deep semicircular cut is then to be made with a straight bistoury three lines behind the skin in which the nail is supported, and parallel to its fold. An assistant then holds the toe, whilst the operator raises the flaps from behind forwards with a pair of forceps, and dissects away the skin which produces the nail; if any shreds of nail remain they must be gradually destroyed. This operation is very painful, but of short duration. The toe must be enveloped in pieces of linen perforated and spread with cerate, and a thin bundle of charpie with a compress put upon it; the patient put to bed, and the foot half bent laid on a pillow. The pain subsides some hours after the operation, and, on the third or fourth day, when the bandage is removed, the wound is found covered with good pus, and is then to be simply dressed. The granulations are to be touched from time to time with lunar caustic; if new shreds of horn are formed, they must be pulled out, and the part producing them be cut away. Usually in from fourteen to eighteen days the patient can return again to his business. The scar is a smooth thick nailless skin, which sometimes acquires a horny consistence. If the disease depends on syphilis, DUPUYTREN treats it with liq. hydr. nitr.

I must deny the assertion that in this disease the tearing out the nail and the employment of caustic are of no effect. I have in several instances torn out the nail, and merely employed soothing poultices and bathing, and have effected permanent cure. I, therefore, only have recourse to extirpation when the above treatment has not any permanent result.

[In regard to the treatment of this disease, WARDROP says:-"The only local treatment I have ever seen relieve this complaint has been the evulsion of the nail, and afterwards the occasional application of escharotics to the ulcerated surrace. But even this painful operation in some cases does not succeed, and will seldom be submitted to by the patient; he must, therefore, either continue lame or submit to the removal of the member. Other surgeons have cut out the soft parts at the root of the nail, an operation equally severe." In preference, therefore, WARDROP recommends the internal exhibition of mercury, which he has found beneficial, “in small doses at first, and gradually increased, so as in twelve or fourteen days sensibly to affect the gums. The sores, in general, soon assumed a healing appearanee after the system was in this state, and the bulbous swelling of the joint gradually subsided. The ulcers were dressed with wax ointment, so that the effects of the mercury might be watched; and, after the sore began to heal, a weak solution of the muriate of mercury and escharotics were occasionally used to clean the wound. The mercury was continued till the ulcers were perfectly healed, and, as is generally advisable under such circumstances, it was taken in smaller quantities for some time after the patients were apparently cured.” (p. 138.)

COLLES, admitting that "the complete removal of the entire of this diseased matrix does effect the cure in a very short space of time, provided the bone or joint is not diseased, (in which case amputation is inevitable,) and that subsequently rest and simple dressing will alone accomplish the healing process, the place of the nail being supplied by