514 



ABNORMAL CONDITIONS OF THE HAND. 



first phalanx of the little finger on the back of 

 its metacarpal bone. This patient was a female 

 about thirty-five years of age ; the bone had 

 been only a few hours luxated, and some inef- 

 fectual attempts had been previously made to 

 reduce it. The reduction was effected with 

 some little difficulty by at first increasing the 

 extension, and then by forcibly flexing the last 

 phalanx. In this case the long extensor tendon 

 of the little finger was displaced from its sheath 

 and groove, and lay on the ulnar side of the 

 metacarpal bone and luxated phalanx, and 

 never afterwards could be maintained in its 

 proper place. This accident is very easily re- 

 cognized, yet it has been occasionally left un- 

 reduced. 



It has been stated already that luxation of 

 the first phalanx of the thumb forwards may 

 occasionally happen, and we have also good 

 authority for supposing that a similar luxation 

 may occur to the phalanx of the index finger. 

 These accidents, however, are very rare ; the 

 middle, ring, and little fingers have never been 

 seen thus displaced ; indeed, Boyer seems to 

 think such an accident in these last, impossible 

 from the nature of their articulation with their 

 metacarpal bones. 



Luxation of the second, and third or distal 

 phalanges. The articulations of these pha- 

 langes being only covered by the skin and the 

 tendons of the flexor and extensor muscles, 

 their luxations are also very easily recognized. 

 In the luxation backwards, the only one which 

 we have had occasion to observe, the luxated 

 phalanx is turned to the side of extension, and 

 forms with the phalanx above it an angle more 

 or less open. When it is the second phalanx 

 which is luxated, the third is flexed by the 

 elongation of the tendon of the deep flexor, 

 and it is impossible to extend it or flex the 

 second. The reduction of these luxations is 

 generally easy if time be not allowed to elapse 

 between the occurrence of the luxation and the 

 period of attempting its reduction. 



II. DISEASED CONDITIONS. 



Caries and necrosis occasionally affect the 

 bones of the hand, but the complete descrip- 

 tions of these diseases, which have been else- 

 where given in this work,* render superfluous 

 here any special observations on these morbid 

 actions when they manifest themselves in the 

 region of the hand. The bones of the meta- 

 carpus and phalanges are very frequently de- 

 formed by a disease which (although it cannot 

 be said to be exclusively observed in these 

 bones) produces on the hand and fingers ap- 

 pearances too remarkable to be left unnoticed 

 in this place. 



The disease which we wish to describe as we 

 have seen it in the bones of the hand would be 

 by some designated as exostosis,f by others as 

 benign osteo-sarcoma, and others]: would be 



* See BONE, morbid anatomy. 



t See Scarpa, De Anatomia etPathologia ossium, 

 cum tabulis aeneis, tab. vi.Jig. 1, Exostosis ossium 

 plerorumque maims dexterae. 



$ Boyer, Maladies Chirurgicales, vol. Hi. p. 579. 



disposed to preserve the somewhat objection- 

 able but ancient name of spina ventosa. 



The metacarpal bones and the phalanges of 

 the fingers are the usual seat of this disease, 

 and in general many of them are simulta- 

 neously engaged in it; the shafts of the affected 

 bones are usually swelled out by the disease 

 into tumours somewhat of a globular form, the 

 articular extremities of the bones remaining 

 perfectly free. It is by no means unusual to 

 see the first and second phalanx of a finger 

 forming two distinct globular swellings, while 

 the last or distal phalanx is perfectly free from 

 enlargement. 



It has been already mentioned that these 

 tumours, when viewed externally, seem to have 

 a spheroidal form ; but when the integuments 

 of the bony shell which incloses the tumours 

 are removed, we discover on their palmar as- 

 pects the flexor tendons buried in deep grooves. 

 This is of course best seen when the disease 

 has existed long, and the tumours have attained 

 a considerable size. 



If we have an opportunity of examining ana- 

 tomically the phalanges while the disease is 

 yet in its early stage, we shall find reason to 

 conclude that the morbid process had com- 

 menced deep in the interior of the bone, and 

 that the tumour proceeding outwardly presented 

 itself first on that aspect of the phalanx, or me- 

 tacarpal bone, where there was the least resist- 

 ance opposed to it; hence we usually notice 

 these tumours, when small, shewing themselves 

 most on the dorsal aspect of these bones. As 

 the disease increases the)- swell out laterally, 

 and the whole circumference of the phalanx 

 would be equally expanded were it not for the 

 support given on the side of flexion by the 

 flexor tendons and their strong fibrous sheaths. 

 The integuments of these tumours preserve their 

 natural sensibility, and are at first freely move- 

 able over them ; but as the swellings gradually 

 increase and undergo a species of softening in 

 certain points, the integuments become adhe- 

 rent at these points, and circular openings are 

 formed in them which correspond to similar 

 circular apertures in the shell of the bone, and 

 through which the bony cy^ts discharge their 

 contents ; these swellings of the bones of the 

 hand, as far as we know, never degenerate into 

 any disease of a malignant nature ; but when 

 they attain a considerable size, and are exca- 

 vated by these cysts, and have large fistulous 

 orifices, the irritation they produce and the 

 discharge cause some febrile excitement of the 

 constitution, and amputation may become ne- 

 cessary. The following very remarkable case 

 clearly proves the non-malignant nature of this 

 disease; the history of it will serve well to illus- 

 trate the natural progress of this form of dis- 

 sease in the hand. 



A countryman of rather a delicate appear- 

 ance, aged twenty-four years, was admitted 

 into Jervis-street Hospital, July 22,1828, under 

 the care of Dr. O'Beirne. This man had an 

 enormous enlargement of the left hand, which 

 arose from a tumour, the principal seat of which 

 was in the first and second phalanges of the 

 middle finger, but the ring and index finger 



