— Pressure or a sharp blow causes the sac to rupture, the liquid being promptly absorbed. This rather brutal—and therefore unsurgical —method is now generally supplanted by subcutaneous divisions with a small bistoury, under strict antiseptic precau tions. The small incision being made, a piece of iodoform gauze is placed over the sac, and, pressure being exerted with the thumb, the fluid is quickly evacu ated and dispersed. Large tendinous tumors sometimes require excision.
Contraction of Tendons and Fascia.— DUTUYTREN'S CONTRACTURE. - This is an obstinate form of contraction affect ing principally the palmar fascia, pro longations of which, as is well known, run by the side of the fingers, and are attached to the periosteum of the first phalanx. By contracting, these pro longations gradually cause the fingers to close upon the palm of the hand and to remain in this position permanently. The ring-finger is usually that first in volved, but in the majority of cases the three fingers on the ulnar side of the hand are contracted, the index finger and thumb rarely. Either hand may be affected, but occasionally both become so flexed as to paralyze their usefulness. It usually begins as a small, hard mass near the metacarpo-phalangeal articula tion; contraction of the corresponding finger begins and proceeds until the nails fairly dip into the tissues of the palm.
Dupuytren's contracture has been traced to many causes: the rheumatic and gouty diathesis and other general conditions; but in practically all cases there is a history of local injury of a persistent kind, such as the continuous forcible handling cf a certain tool, the pressure of a cane-knob, etc. Again, it is occasionally observed after prolonged illness in which the general vitality of the organism has been severely taxed. It is rarely observed before middle age, and almost always in men. The patient is usually possessed of good general health.
Treatmeni.—The progress of the con traction is steady until the hand becomes totally crippled, and the only effective means at our disposal are surgical. Ef forts at extension are unavailing, but. when this is tried, thick elevations are seen to form in the palmar cavity and to push its superficial tissues upward. It is upon these bands that efforts at libera tion should be concentrated. A small tenotome should be introduced at various places under each, and the attachment of the bands to the overlying skin so freed as to permit of full extension of the fingers. A splint should then be applied and worn, not only until recovery of the wounds, but during several days subse quent thereto. Then daily passive mo tion and massage should begin, coupled with a mild galvanic current, until the motions of the fingers have been com pletely recovered.
In some cases it is necessary to obtain complete extension, to remove the hard ened palmar fascia. An incision is made along the length of each band, and the skin is carefully dissected up from the latter. This being done, the hard tissues constituting the band proper are sepa rated from their surroundings, then cut out as completely as possible. These eases need close watching, since the danger of recurrence is always great, and passive motion, massage, etc., should be resumed as soon as there is the least evi dence that the affection is returning.
Pendulum apparatus for contracted fingers and hand consists of an arrange ment that can be attached to the side of a table, applicable to increasing the motion of stiff finger-joints. Patients who resist any attempt at passive mo tion in the ordinary way, after a short time under the correction of the pendu lum apparatus obtain considerable mo tion. Nebel (Zeit. f. orth. Chir., p. 17, B. 5, 11. 1, '97).
TRIGGER-FINGER.—According to Fere, two groups of this disorder may be recog nized: the organic and the functional. The causes for the organic variety may be found in the tendons, fascia, muscles, -or in conditions which will tend to modify the directions of muscular action, and the movements of flexion and exten sion. The functional class may be re flex, following local irritation, or may be a local manifestation of certain neurop athies. Cases of this class may arise in dependently of any voluntary move ments.
The disease consists of a peculiar and sudden locking of the finger when it is flexed or extended to a certain point. It remains in the position acquired not withstanding ordinary efforts to bring it to another position. A powerful volun tary effort sometimes succeeds, however; but in some cases, the assistance of an other person is necessary. The disorder is usually limited to one finger, the middle finger being that most frequently affected. The majority of cases are ob served in females. The chances of re covery under appropriate treatment arc good.
Treatment.—The treatment of trigger finger, as outlined by Rieman, consists in the application of iodine, electricity, massage, passive motion, and fixation of the finger by means of a splint. In veterate cases have been treated by oper ation, which usually consists in remov ing whatever obstacle to free movement exists. If an underlying cause, like rheumatism or gout, is ascertainable, proper general methods are to be insti tuted. In cases accompanied by pro- 1 pounced pamsthesial phenomena, the use of ergot may be tried.