ABNORMAL CONDITIONS OF THE HAND. 



513 



ever keep in mind a case given on the authority 

 of Mr. Hey, who informs us Unit the celebrated 

 Mr. IllooinlirhJ reported to his class of pupils 

 at St. George's Hospital, London, that he knew 

 a surgeon increase the force of extension to 

 such a degree in attempting reduction of this 

 dislocation, that he tore off the thumb at the 

 second joint. 



The idea that a transverse section of the head 

 of the metacarpal bone presents an outline of a 

 cuneiform figure with the narrowest part of the 

 wedge towards the palm, or forwards, was first 

 advanced by Mr. Hey, and has subsequently 

 been adopted with too little reflection by many 

 writers: for our part we do not think that the 

 head of the metacarpal bone does present this 

 form assigned to it by Hey. But even al- 

 though it be conceded that it has occasionally 

 a form which would answer to the description 

 given by Mr. Hey, and that its cuneiform 

 figure would facilitate its gliding between the 

 lateral ligaments and forbid its return, surely 

 such an obstacle to the return of the bone 

 would suppose a state of integrity of both 

 lateral ligaments. In our experiments on the 

 dead subject, we found one of these lateral 

 ligaments invariably torn whenever a complete 

 luxation was effected ; but with the theory of 

 Hey, which seems to us quite unsupported by 

 the normal anatomy of the bone or the anatomy 

 of the accident, how can we reconcile the 

 observation, that when the first phalanx of the 

 thumb is dislocated to the palmar instead of 

 the dorsal aspect of the metacarpal bone, equal 

 difficulty of reducing the luxation has been 

 experienced by very eminent surgeons ' For 

 example, Velpeau says, " we have seen but 

 once the first phalanx of the thumb pass in 

 front of the first metacarpal bone. The sub- 

 ject of this accident was a woman aged forty- 

 five years ; the bone had been out for three 

 days, there was no inflammation." I thought, 

 says Velpeau, " that it was owing to some want 

 of skill in myself that I could not succeed in 

 reducing the luxation ; but M. Professor Bou- 

 gon also made fruitless efforts to effect it; 

 finally, M. Koux, with his well-known address 

 and ingenuity, was not more successful, and 

 the bone remained ever afterwards unre- 

 duced." B 



Upon the whole it would appear to us that 

 in the case of the dislocation of the first pha- 

 lanx of the thumb on the dorsum of the meta- 

 carpal bone, the cause of the difficulty we ex- 

 perience in reducing it will not be found either 

 in the mechanical resistance of the lateral liga- 

 ments or in the interposition of muscular or 

 fibrous parts between the extremities of the 

 dislocated bones, but that, whether the luxa- 

 tion be the common one backwards or the 

 more unusual one forwards, the vital cantrtirtion 

 of numerous muscles on a small and yielding 

 bone (whose ligaments have been lacerated) 

 will be the principal opposing force we have to 

 contend with. Most of these muscles will be 

 found to be favourably circumstanced for the 



* Velprau, Trails d'Anatoinie Jes Regions, 

 loin. i. p. 475, edit. 1825. 



opposition, for they are either inserted mto or 

 attached very close to the bones of the first 

 plialanxof the thumb: they are six in number; 

 some of them are of considerable length, and 

 regale force of both long and short 

 iiiiiseles constitutes a very powerful means of 

 maintaining displaced the hrst phalanx of the 

 thumb ; nor should it be forgotten, in estimat- 

 ing their force, that the very large supply of blood- 

 vessels and nerves which these muscles receive, 

 must add much more to the energy of their 

 contraction than the size and number of their 

 composing fibres would lead us to suppose. 



If such a view of the abnormal condition 

 of the different structures which compose this 

 articulation be correct, we should derive from 

 it the important practical precept, that when 

 we have one of those difficult cases to contend 

 with, our first effort should be to reduce, as 

 much as practicable, the irritability and vital 

 force of the muscles which act on the dis- 

 located bone before any of our mechanical 

 appliances be resorted to. When the general 

 system of the patient has been under the de- 

 pressing influence of the usual means, viz. 

 tartarized antimony, &C., and under these fa- 

 vourable circumstances the surgeon has with 

 patience and perseverance used all the force 

 that he deems expedient or justifiable, and has 

 not succeeded in replacing the bone, our expe- 

 rience would induce us to recommend that in 

 such a case no further measures should be had 

 recourse to. We have, in the museum of the 

 Richmond Hospital, a cast of the hand of a 

 man who had suffered this luxation sixteen 

 years before the cast was taken. The history 

 he gave the writer was briefly that he consulted 

 an eminent surgeon, who used all the means in 

 his power to reduce the dislocation, but could 

 not succeed; that the surgeon then proposed 

 to the man an operation which he explained, 

 and which from the patient's description of it 

 we may conclude consisted in laying bare the 

 head of the metacarpal bone and removing it, 

 as had been about that time recommended by 

 Mr. Evans, of Kettley near Wellington; the 

 man, however, refused to consent to the pro- 

 posal, and had good reason to be content with 

 his own determination, as he can now oppose 

 the point of the thumb to the other fingers, and 

 can follow his business, which is that of a plas- 

 terer, with very little inconvenience, affording 

 us a proof that the advice given by Sir A. 

 Cooper relative to irreducible dislocations of 

 the metacarpal bone, may be well extended to 

 the common dislocation backwards of the first 

 phalanx, viz. " that if the bone cannot be re- 

 duced by simple extension, it is best to leave 

 the case to that degree of recovery which nature 

 will in time produce, rather than divide the 

 muscles or run any risk of injuring the nerves 

 or the bloodvessels." 



The first phalanges of any of the other fin- 

 gers may be luxated backwards. The little 

 linger appears to us, after the thumb, the most 

 liable to this accident; it is sometimes difficult 

 to reduce. Mr. Romer, a p/ipil of the Rich- 

 mond Hospital, lately brought to the writer a 

 patient who was the subject of luxation of the 



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