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FRACTURE OF TIP OF DISTAL PHALANX.
1158 No doubt the success which has attended the work of the bureau has been due to the fact that a careful selection of candidates is made in order to save time, trouble, and expense and disappointment to all concerned. No fees are charged to either employer or employed ; the bureau is maintained by voluntary contributions from members of the London Society for Women’s Service and from those who benefit by its All inquiries should be addressed to the services. secretary, Miss P. Strachey, London Society for Women’s Service, 58, Victoria-street, S.W. 1.
that the digital arteries and nerves are not severed. These operations can be performed under local anaesthesia. so
____
SILVER-SALVARSAN IN MULTIPLE SCLEROSIS. THE vogue which silver-salvarsan has enjoyed for
FRACTURE OF TIP OF DISTAL PHALANX.
I,
FRACTURE of the distal phalanx of a finger appears to have received no attention in this country, and to ’, American surgeons we are indebted for pointing out its importance. We have previously described the condition in an annotation.’ Dr. R. F. Maddren has now published a paper2 which throws further light on the subject. He points out that contusions of the fingers and toes are common, and that the usual expectant treatment affords relief in the majority of cases. But a minority do not do well. Throbbing pain continues for days. Swelling of the finger-tip and tenderness become marked, and after a varying period paronychia may develop. Such cases’ are not always the sequel of severe trauma. Dr. Maddren believes that in these cases the ungual tuberosity of the phalanx is fractured. The X rays will show a fracture in practically all the cases with marked symptoms as well as in many of the mild cases. These fractures give rise to prolonged disablement, which is explained The pulp of the finger-tip lies in a closed as follows. trabeculated connective tissue sac, which is least dense at the lateral borders. Hence extravasated blood often escapes to -the nail-bed and may give rise to subungual hsematoma. The blood-supply of the diaphysis of the phalanx comes from vessels which run parallel to the bone, one on each side -within When the sac is distended by the closed sac. cedema or extravasated blood the blood-supply may be cut off and necrosis result. The epiphysis is not affected because its blood-supply comes off before the vessels enter the sac. For the same anatomical reason Pain necrosis of the diaphysis occurs in whitlow. similar to, but less severe than, that of whitlow is produced. Swelling, due to oedema and haemorrhage, is generally present, and subungual haemorrhage if sufficient time has elapsed. Even a few minutes after the injury Dr. Maddren has never been able to elicit crepitus or to palpate the detached fragment. The X rays are the only means of positive diagnosis. The results of prompt operation in a series of 27 consecutive cases have been uniformly good. The cases occurred in male factory workers, and th’e average loss of time from work was only 6’3 days. Dr. Maddren recommends that as soon as the diagnosis is established an incision be made into the connective tissue sac. If the pressure is thus relieved its sequelae, pain and sepsis, will not supervene. The site and method of incision vary with the case. If there be blood under the nail it can sometimes be evacuated by inserting the tips of sharp-pointed scissors between the free edge of the nail and the nail-bed and by slightly opening the blades when the points have penetrated about one-eighth of an inch. This method has the objection that the tissues are opened through a field that can be only imperfectly sterilised. The more radical method of making two short longitudinal incisions through the eponychium and resecting a transverse strip of nail where it is thin and soft, is sometimes indicated when the blood is principally at the lunula. If no extravasation is seen beneath the nail a quarter-inch incision may be made with a small scalpel or cataract knife into the lateral aspect of the finger-tip, deep enough to enter the connective tissue sac. An attempt should be made to place this incision 2
1 THE LANCET, Oct. 18th, 1919, p. 699. Journal of the American Medical Association, Oct. 30th.
some time in Germany is reflected in the flow of publications on this drug during the past two years in the German medical press. It is still too early to strike a balance with respect to this drug in relation to the other members of the salvarsan group, but it is indicative of the favourable impression made by silversalvarsan that its exhibition has latterly been extended beyond the limits of the definitely syphilitic diseases. Undeterred by the flaws in the evidence connecting syphilis with multiple sclerosis, Dr. Ernst Speer,l of Jena, has recently treated 17 cases of this disease with intravenous injections of silver-salvarsan. His results were good, bad, and indifferent. The following case was one of the most hopeful :A soldier, aged 34, had suffered since 1917 from typical multiple sclerosis which had first manifested itself as a spastic spinal paralysis. The clinical picture was dominated by severe spasmodic contractions affecting both legs and preventing him from walking. On May 18th, 1920, he was given 0-05 g. of silver-salvarsan ; from May 21st onwards he was given 0’1 g. twice a week, and from June 14th he was given 0’15 g. twice a week. Altogether 2 g. were given over a period of eight weeks. He gained 7 kg., could walk with the help of two sticks, and the spasmodic contractions were appreciably reduced, no longer preventing him from,carry. ing out muscular exercises with his feet while he lay in bed. And, most striking of all, Babinski’s sign, which had been positive, was no longer demonstrable with certainty. But in another case the drug, so far from benefiting the patient, seemed to stir into fresh activity disease which had been stationary for a considerable period. The patient was a workman, aged 39, whose disease had begun in 1903. His symptoms included tremor of the limbs, ataxia, double irido-cyclitis, and slight dementia with euphoria. After the third injection of silver-salvarsan the severe tremor of the left arm from which he had previously suffered ceased altogether. The total amount of given was 2g. About eight weeks after completion of the treatment he became much worse ; great loss of weight, optic atrophy, paralyses, and general debility were observed, and the improvement in the condition of the left arm was not maintained. Grouping his cases in four classes, Dr. Speer shows that in six cases improvement was effected, in two there was improvement with complications, such as tachycardia and neurosis, in two there were complications without any compensatory improvement, and in as many as seven cases the disease seemed even to be aggravated by the treatment. Many physicians would have abandoned a line of research punctuated by so many failures, not to say disasters, but Dr. Speer is inclined to discount many of his failures on the score of the advanced stage of the disease at the time of treatment. As he quite rightly says, the prognosis for multiple sclerosis is at present so bad that the need for investigating new remedies is very great
silver-salvarsan
IT has been decided to hold an additional Final Examination for the Fellowship of the Royal College of Surgeons of England to commence on Feb. llth, 1921. 1
MINISTRY MITTEE.-The
Münch. med. Woch., Oct. 29th, 1920. OF
PENSIONS:
DEPARTMENTAL
Departmental Committee, which has
COM-
been into the administration of the Ministry of Pensions, held its first meeting at Cromwell House on Nov. 25th under the chairmanship of Major G. C. Tryon, M.P., Parliamentary Secretary to the Ministry. It was decided, in view of the very wide scope of the inquiry, to divide it into five sections, each of which will be dealt with by one of the following subcommittees, who will report to the main Committee: (a) Local War Pensions Committees and Regions; (b) Awards and Special Grants Committee; (c) Treatment and Medical Boards; (d) Pension Issue Office ; (e) Officers. Before proceeding to take evidence the’ members of the Committee will visit the branches of the Ministry and will examine the regional machinery. Major C. E. Breese, M.P., and Major C. F. Entwistle, M.P., M.C., LL.B., have been appointed members of the Committee.
appointed to inquire
,
that the digital arteries and nerves are not severed. These operations can be performed under local anaesthesia. so
____
SILVER-SALVARSAN IN MULTIPLE SCLEROSIS. THE vogue which silver-salvarsan has enjoyed for
FRACTURE OF TIP OF DISTAL PHALANX.
I,
FRACTURE of the distal phalanx of a finger appears to have received no attention in this country, and to ’, American surgeons we are indebted for pointing out its importance. We have previously described the condition in an annotation.’ Dr. R. F. Maddren has now published a paper2 which throws further light on the subject. He points out that contusions of the fingers and toes are common, and that the usual expectant treatment affords relief in the majority of cases. But a minority do not do well. Throbbing pain continues for days. Swelling of the finger-tip and tenderness become marked, and after a varying period paronychia may develop. Such cases’ are not always the sequel of severe trauma. Dr. Maddren believes that in these cases the ungual tuberosity of the phalanx is fractured. The X rays will show a fracture in practically all the cases with marked symptoms as well as in many of the mild cases. These fractures give rise to prolonged disablement, which is explained The pulp of the finger-tip lies in a closed as follows. trabeculated connective tissue sac, which is least dense at the lateral borders. Hence extravasated blood often escapes to -the nail-bed and may give rise to subungual hsematoma. The blood-supply of the diaphysis of the phalanx comes from vessels which run parallel to the bone, one on each side -within When the sac is distended by the closed sac. cedema or extravasated blood the blood-supply may be cut off and necrosis result. The epiphysis is not affected because its blood-supply comes off before the vessels enter the sac. For the same anatomical reason Pain necrosis of the diaphysis occurs in whitlow. similar to, but less severe than, that of whitlow is produced. Swelling, due to oedema and haemorrhage, is generally present, and subungual haemorrhage if sufficient time has elapsed. Even a few minutes after the injury Dr. Maddren has never been able to elicit crepitus or to palpate the detached fragment. The X rays are the only means of positive diagnosis. The results of prompt operation in a series of 27 consecutive cases have been uniformly good. The cases occurred in male factory workers, and th’e average loss of time from work was only 6’3 days. Dr. Maddren recommends that as soon as the diagnosis is established an incision be made into the connective tissue sac. If the pressure is thus relieved its sequelae, pain and sepsis, will not supervene. The site and method of incision vary with the case. If there be blood under the nail it can sometimes be evacuated by inserting the tips of sharp-pointed scissors between the free edge of the nail and the nail-bed and by slightly opening the blades when the points have penetrated about one-eighth of an inch. This method has the objection that the tissues are opened through a field that can be only imperfectly sterilised. The more radical method of making two short longitudinal incisions through the eponychium and resecting a transverse strip of nail where it is thin and soft, is sometimes indicated when the blood is principally at the lunula. If no extravasation is seen beneath the nail a quarter-inch incision may be made with a small scalpel or cataract knife into the lateral aspect of the finger-tip, deep enough to enter the connective tissue sac. An attempt should be made to place this incision 2
1 THE LANCET, Oct. 18th, 1919, p. 699. Journal of the American Medical Association, Oct. 30th.
some time in Germany is reflected in the flow of publications on this drug during the past two years in the German medical press. It is still too early to strike a balance with respect to this drug in relation to the other members of the salvarsan group, but it is indicative of the favourable impression made by silversalvarsan that its exhibition has latterly been extended beyond the limits of the definitely syphilitic diseases. Undeterred by the flaws in the evidence connecting syphilis with multiple sclerosis, Dr. Ernst Speer,l of Jena, has recently treated 17 cases of this disease with intravenous injections of silver-salvarsan. His results were good, bad, and indifferent. The following case was one of the most hopeful :A soldier, aged 34, had suffered since 1917 from typical multiple sclerosis which had first manifested itself as a spastic spinal paralysis. The clinical picture was dominated by severe spasmodic contractions affecting both legs and preventing him from walking. On May 18th, 1920, he was given 0-05 g. of silver-salvarsan ; from May 21st onwards he was given 0’1 g. twice a week, and from June 14th he was given 0’15 g. twice a week. Altogether 2 g. were given over a period of eight weeks. He gained 7 kg., could walk with the help of two sticks, and the spasmodic contractions were appreciably reduced, no longer preventing him from,carry. ing out muscular exercises with his feet while he lay in bed. And, most striking of all, Babinski’s sign, which had been positive, was no longer demonstrable with certainty. But in another case the drug, so far from benefiting the patient, seemed to stir into fresh activity disease which had been stationary for a considerable period. The patient was a workman, aged 39, whose disease had begun in 1903. His symptoms included tremor of the limbs, ataxia, double irido-cyclitis, and slight dementia with euphoria. After the third injection of silver-salvarsan the severe tremor of the left arm from which he had previously suffered ceased altogether. The total amount of given was 2g. About eight weeks after completion of the treatment he became much worse ; great loss of weight, optic atrophy, paralyses, and general debility were observed, and the improvement in the condition of the left arm was not maintained. Grouping his cases in four classes, Dr. Speer shows that in six cases improvement was effected, in two there was improvement with complications, such as tachycardia and neurosis, in two there were complications without any compensatory improvement, and in as many as seven cases the disease seemed even to be aggravated by the treatment. Many physicians would have abandoned a line of research punctuated by so many failures, not to say disasters, but Dr. Speer is inclined to discount many of his failures on the score of the advanced stage of the disease at the time of treatment. As he quite rightly says, the prognosis for multiple sclerosis is at present so bad that the need for investigating new remedies is very great
silver-salvarsan
IT has been decided to hold an additional Final Examination for the Fellowship of the Royal College of Surgeons of England to commence on Feb. llth, 1921. 1
MINISTRY MITTEE.-The
Münch. med. Woch., Oct. 29th, 1920. OF
PENSIONS:
DEPARTMENTAL
Departmental Committee, which has
COM-
been into the administration of the Ministry of Pensions, held its first meeting at Cromwell House on Nov. 25th under the chairmanship of Major G. C. Tryon, M.P., Parliamentary Secretary to the Ministry. It was decided, in view of the very wide scope of the inquiry, to divide it into five sections, each of which will be dealt with by one of the following subcommittees, who will report to the main Committee: (a) Local War Pensions Committees and Regions; (b) Awards and Special Grants Committee; (c) Treatment and Medical Boards; (d) Pension Issue Office ; (e) Officers. Before proceeding to take evidence the’ members of the Committee will visit the branches of the Ministry and will examine the regional machinery. Major C. E. Breese, M.P., and Major C. F. Entwistle, M.P., M.C., LL.B., have been appointed members of the Committee.
appointed to inquire
,