XLVII.

Case of Fungoid Tumor of the Hand.

By H. G. PRESTON, M. D.

Catharine Dwyer, aged thirty-two, servant girl, living in Johnstown, Montgomery county, came to the Albany City Dispensary July 15, 1871, and stated that she had been suffering intense pain in the right hand for the last six months, and had been using liniments for rheumatism, without relief. The patient could not move the fingers nor use the hand in any way.

At a prior visit to the dispensary, in my absence, one of the visiting physicians had bound on nitrate of silver crystals, which had destroyed the integuments. This application had mitigated the pain somewhat. On examination, the hand presented the appearance shown in the annexed diagram. The tumor was very red, enlarged and tender to the touch; the fingers could be moved easily without pain or affecting the tumor, which, through the aperture in the skin, presented a dirty, greyish-white appearance, and seemed to contain fluid, either serum or pus. As the patient could not bear a very thorough examination, an operation was postponed to the following day.

July 17.-Ether was administered, and I proceeded to make a thorough examination. The tumor was situated on the dorsum of the right hand, conical in shape, having a very broad base, firmly attached, and felt somewhat elastic. I introduced an exploring needle, and on discovering that it did not contain fluid, but was solid throughout, resolved to remove it. Two incisions were made, the longer one extending from the metacarpo-phalangeal articulation of middle finger to the wrist, the shorter crossing the above at right angles, over the apex or tumor. The flaps were then dissected back and the base found to grow from the sheath of the extensor communis digitorum, was dissected as clean as possible with the scapel, and the remaining irregularities trimmed down with the scissors. The hemorrhage was very profuse; and to be sure of removing any pieces of the mass that might have been concealed by it, I cauterized the whole cavity, especially the bottom, with nitrate of silver, which

also arrested the hemorrhage. The wound was left open, and flaxseed poultices applied. The tumor was about two inches in diameter, and about one and a half inches in depth. In structure it was soft and elastic, and under the microscope, presented fibro-plastic cells and granular matter.

July 20.-The hand not so painful, and the wound discharging. Same treatment was continued.

July 27.—Wound swollen and discharging freely. There was still pain, however, and the patient was very much discouraged. The physician to whom she had formerly applied, wished to amputate the hand, and her brother wished her to go to the hospital. I did not see anything more of the patient, until September 6, and supposed she had yielded to the wishes of her friends. I was surprised to find, however, that the wound had completely healed, and that the patient was free from pain, the hand being of its natural size, with all its motions perfect. The patient stated, that, on account of sickness in the family, she had not been able to get to town. The application of the poultice had been continued till a day or two before this, the last visit at the Dispensary.

XLVIII.

Report of Surgical Cases Treated at the Albany City Dispensary, with Remarks on the Treatment of Ulcers.

By H. G. PRESTON, M. D.

Since the establishment of a daily surgical clinic, sometime in last November, to July 1, 1871, one hundred and seventy-eight persons have been treated. The diseases, as in all dispensary practice, consisting mostly of minor surgery, as wounds, sprains and contusions, abscesses, paronychia and ulcers. There were, however, a few

exceptions, as follows: four cases of dislocation reduced; four cases of fracture set, two of which were treated in Arhl's porous splints, one of the ulna and radius at middle third, the other at the wrist, known as Collis' fracture.

Two cases of hydrocele were cured, one by the old method of injecting iodine, the other by external application of the same, decolorized with ammonia, and silicea internally. Two tumors were removed; one a cystic tumor of the scalp, the other a fungus growth on the back of the hand. (See page 349.) There was also one operation for ranula, consisting in cutting out part of the anterior wall of the sac, and filling the cavity with cotton saturated with iodine.

Anæsthetics have been administered four times, which was as often as was necessary, as we were obliged to send severer operations to the hospital, where, however, we hope soon to have accommodations for treating them.

Besides the above, there have been one or more of the following: Congenital phymosis, morbus coxarius, hernia reducible, indirect inguinal, umbilical irreducible hernia, caries, necrosis, stricture of nasal duct, tongue tied, varicose veins, ganglion, burns, inflammation of the different tissues of the eye and ear, gonorrhoea, and syphilis. There were forty-five wounds dressed, comprising all the recognized varieties, as incised, lacerated, contused, gun-shot, punctured and poisoned wounds. Some of these were extensive, and required a number of sutures. There were two or three very severe, lacerated wounds, one of which I will relate:

Michael S., aged ten years, came to the dispensary, November 10, for treatment. The mother stated that two or three days before his hand was caught in the hook of a pulley, and that nothing of any account had been done for it. The hook had entered the integument on the palmar surface, just behind the wrist, and had peeled the skin and palmar fascia off to the ends of the fingers, which were raw, being covered by only a strip of skin on the back. The wound was suppurating profusely, of a very offensive smell. The hand was placed on back splint, and each finger dressed separately, the whole hand kept moist with carbolic acid, one to twenty parts of water. The dressings were changed every day, and the lotion applied constantly, until the twenty-seventh, when suppuration had almost ceased, and carbolic acid salve was used instead of the lotion. The granulation had to be touched with nitrate of silver in two places, as they were too exuberant. On the sixth of December the hand was complelely healed, and the patient had perfect control of the fingers. The hand was not disfigured at all.

The treatment pursued in all abscesses was to open as soon as pus could be discovered, and, in paronychiæ, to lay them open to the bone immediately, and out of the nine cases there was not one unfavorable result.

There were about seventy-two ulcers treated, of almost every variety, shape and condition. Internal remedies were given, in symptomatic ulcers, for the peculiar disease they represented, but in idiopathic ulcers local treatment was principally relied on, and with success in every case, as far as we have been able to ascertain.

Ulcers of any variety, whether of idiopathic or symtomatic origin, may be divided, as regards their anatomico-vital peculiarities, into (1), those characterized by an excess of formative action, and, (2), those characterized by suppuration and disintegration of tissue, the proliferating and atonic ulcers of Billroth. Under the first variety are classed the irritable and fungus ulcer, both of which are cured in a few weeks; the irritable by warm baths and cataplasms wet with hamamelis; the fungus by astringents, as hydrastin, geraniin, etc., with compression, or terminate in the second, of which we have, consequently, a much larger number to treat, especially in dispensary practice.

The second variety may again be divided into, first, the callous ulcer, the one most frequently met, and most obstinate to treat. It is generally of long standing, with thick, indurated edges, sur

rounded by a sub-acute inflammation of the integuments, which are liable to disintegration from the slightest abrasion. The chief indications for treatment are to soften the edges and increase the vascularity of the parts. This may generally be done by warm baths, cataplasms; but sometimes it is necessary to incise the borders, in order to allow the ulcer to contract, and to stimulate the bottom with nitrate of silver. In case patients are obliged to be on their feet a greater part of the time, it is better to strap the limb from the toes to the knee with adhesive plaster, which may remain for three days, to commence with, and the intervals lengthened. At each dressing the ulcer may be sprinkled with the sesquicarbonate of potassa, to which I shall allude again. Second, the suppurating ulcer, characterized by disintegration of tissue, which, if very rapid, is called phagedenic. This is the most dangerous, and is generally symptomatic, especially of syphilis, and requires treatment by internal remedies, according to indications. The only external wash that should be used, where they are chronic and burning, is a weak solution of sesquicarbonate of potassa. Third, the fistulous ulcer, which results from a deep abscess, breaking externally, and the tract not healing. The quickest way to cure it is to lay it open and heal it from the bottom. It may also be cured by sesquicarbonate of potassa injections. This has been the treatment adopted at the dispensary, and, as far as I can ascertain, with unfailing success. As regards the internal treatment, there can be no general rule or medicine, prescribed.

As repeated mention of the sesquicarbonate of potassa has been made in this paper, and as it is a substance not in general use, a few words may not be out of place concerning it. It is made, either by evaporating a strong lye made from hickory or oak wood ashes, to dryness, or by evaporating a solution of the bicarbonate. When pure, it forms as a white powder. It should be kept well corked, as it readily attracts moisture. The powder may be sprinkled on dry, or it may be used in solution. It is mildly escharotic, but canses less pain than most caustics, and has as good, if not better, effect.

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