tion of its inhabitants; the fate, alas! that has already been often deplored in many countries, and in many populous

cities.

(Signed)

WRIGHT POST, M. D.

WILLIAM HAMERSLEY, M. D.

JOHN NEILSON, M. D.

FELIX PASCALIS, M. D.

JOHN WATTS, JUN. M. D.

An Account of some Diseases of the Toes and Fingers, with Observations on their Treatment. By JAMES WARDROP, Esq. F. R. S. Edinb.

[From the London Medico-Chirurgical Transactions, Vol. V.]

I. Inflammation of the soft parts surrounding the nail of the toes. THERE are many diseases on which medical men seem to have bestowed little consideration, from the unimportance of the parts affected, as far as regards the life of the patient, but which nevertheless sufficiently disturb the comforts and enjoyments of those who are afflicted with them, to merit investigation.

There are no diseases to which this remark may be more justly applied than to some of those of the toes; and the subsequent observations have been made in order to give an account of some of those which have not hitherto been mentioned, and of recommending a treatment in others which may be found more successful than the means which have usually been employed.

The first of these diseases which shall now be considered, is where inflammation and suppuration take place in the soft parts contiguous to the nail, generally denominated, "the growth of the nail into the flesh."

This affection is chiefly confined to the great toe. It frequently happens, when the foot is kept in a tight shoe, that the soft parts situated on the edge of the nail thicken, are pressed over it, and become more or less inflamed and painful. If the inflammation and thickening of the soft parts increase, the

edge of the nail becomes, at last, completely imbedded in them, and its sharp edge, from the pressure of the body when resting on the foot, increases the inflammation and produces suppuration of the contiguous soft parts. Thus the hard and sharp nail, by pressing on the surface which has become ulcerated, causes great pain and lameness, and in many cases prevents the person from walking. The ulceration generally extends round a considerable part of the nail, and a fungus arises from this surface, accompanied by excessive irritability.

All those authors who have taken notice of this affection have considered a peculiarity in the growth or in the formation of the nail as the cause of the disease in the soft parts. The different modes of treatment therefore which have been proposed are directed to remedy this supposed deformity of the nail.

Some direct, that the edge of the nail which presses in upon the tender soft parts should be raised by placing underneath it a piece of tin-plate, and thinning the middle part of the nail by scraping it with a piece of glass; thus allowing the nail and its edge to take a turn upwards from the soft parts, and assume a new form. Others advise the edge of the nail to be cut away, so that it shall be out of the reach of the soft parts.

An accurate examination, and above all, observing attentively the progress of the disease, from its commencement, will be sufficient to prove that the nail undergoes no alteration in its shape, and that it has no further share in the production of this troublesome complaint than affording a mechanical resistance to the tender flesh, and becoming from its proximity to it a constant source of irritation.

I was led chiefly to make this remark, from observing on the great toe of a gentleman, whose nail was perfectly well formed, a considerable tumefaction and tenderness of the soft parts on the edge of the nail; to relieve which he was in the habit of cutting the nail very short, and removing that portion of the edge which had penetrated into the soft parts. From this operation, a temporary relief had always been obtained; but when the nail began to grow again, all the former uneasiness and inconvenience returned. It being probable, that in this case, the tenderness and swelling of the soft parts arose from, and were kept up by the pressure which those parts constantly made on

the fresh-cut edge of the nail, it occurred to me, that if the nail was allowed to grow of its natural size and shape, and some means taken to reduce the swelling of the soft parts, the disease might be removed. Accordingly the nail was allowed to grow, and the swollen parts were slightly touched with lunar caustic. The beneficial effects of this treatment were soon manifest. The caustic had the effect of producing an absorption of the thickened soft parts, the nail soon recovered its natural smooth edge, and the patient has never since had any uneasiness, except when from inattention he has accidentally cut the nail too short.

Soon after I had seen this case, an example of the disease in a much more advanced stage came under my observation. The soft parts on the edge of one side of the toe-nail, which was of its natural shape, were greatly swollen-suppuration had taken place where the nail was imbedded in them, and a painful fungus had arisen; so that the person was unable to rest the weight of the body on the affected foot.

After one application of the caustic the irritable state of the ulcer was removed; and in two days the fungus and swelling of the soft parts were greatly diminished; and by a second application these completely subsided. The nail was left untouched -and in a few days the patient was enabled to walk about, and he continued afterwards perfectly well.

In a third case the good effects of this mode of treatment were strikingly illustrated. A gentleman had for several years suffered great distress from inflammation and swelling of the soft parts, at the edge of the nail of the great-toe, and had during that time on many occasions for several weeks been unable to walk. He had frequently cut away all that portion of the nail which was imbedded in the diseased soft parts, and which appeared to him to be the cause of his complaint; and though from this treatment he experienced temporary relief, yet as soon as the nail began to grow again, all the former symptoms recurred. A few days after the nail had been in this manner cut away, he applied to me, and I rubbed the tender and swollen parts over with lunar caustic; this was followed by an immediate abatement of the pain and swelling; and by afterwards allowing the nail to grow, he has never since experienced the least uneasiness.

Perhaps the most remarkable instance of the beneficial effects of this mode of treatment, was that of a woman, who for ten years had been extremely lame in both feet, and who during that period had submitted to several painful operations of cutting out portions of the nail, without any permanent relief. The nails in this case were very thick and circular, so that they were deeply imbedded in the soft parts. The swelling of these, however, was completely subdued by frequent applications of the caustic; and in addition to this treatment I removed a portion in the form of a V from the middle of the nail, a practice common amongst soldiers, and which might perhaps in some degree serve to allow the external angles of the nail to yield and be raised from the swollen soft parts.

Besides these cases, I have had several opportunities of trying this practice, and it has been invariably followed by equal success.

From what has been said, it will be observed, that the chief point to be attended to in the treatment of this disease is, not to cut away any of the nail, but to reduce the swelling of the soft parts. I have generally found that one or more applications of the lunar caustic have had the effect of entirely removing the swelling of those parts. The caustic destroys the painful and irritable ulcerated surface, whilst at the same time it promotes absorption of the thickened parts. In some cases it has been thought necessary first to alleviate the accompanying inflammatory symptoms by the application of poultices, and in some instances also, the alumen ustum has been found to answer better than the caustic; but in all the cases, these means succeeded in curing the disease.

It may here be remarked, that in order to prevent either the recurrence or the formation of a disease of this kind, care should be taken not to cut off the corner of the nails, particularly that of the great-toe; for when this is done, the shoe presses the adjacent soft parts against the sharp edge of the nail, and thus produces pain and inflammation.

II. Of Ulceration at the Root of the Nails.

This disease appears to be a peculiar inflammation of the soft parts at the root of the nail, and probably those connected with the formation of that organ. It may properly be consider

ed as a species of Onychia or Panaris, and I have therefore denominated it the Onychia Maligna, from its very malignant character.

The commencement of this disease is marked by a degree of swelling of a deep red colour of the soft parts at the root of the nail. An oozing of a thin ichor afterwards takes place at the cleft formed between the root of the nail and soft parts, and at last the soft parts begin to ulcerate. The ulcer appears on the circular edge of the soft parts at the root of the nail, it is accompanied with a good deal of swelling, and the skin, particularly that adjacent to the ulcer, has a deep purple colour.

The appearance of the ulcer is very unhealthy, the edges being thin and acute, and its surface covered with a dull yellow or brown-coloured lymph, and attended with an ichorous and very fetid discharge. The growth of the nail is interrupted, it loses its natural colour, and at some places appears to have but little connection with the soft parts.

In this state I have seen the disease continue for several years, so that the toe or finger became a deformed bulbous mass. The pain is sometimes very acute, but the disease is more commonly indolent, and accompanied with little uneasiness. This disease affects both the toes and the fingers. I have only observed it on the great-toe, and more frequently on the thumb than any of the fingers. It occurs, too, chiefly in young people, but I have also seen adults affected with it.

The treatment of this disease has generally been considered as difficult and uncertain. In many cases all local applications have been so inefficacious that the amputation of the member has been had recourse to.

The only local treatment which I have ever seen relieve this complaint, has been the evulsion of the nail, and afterwards the occasional application of escharotics to the ulcerated surface. But even this painful operation, in some cases does not succeed, and will seldom be submitted to by the patient; he must therefore either continue lame, or submit to the removal of the member. Other surgeons have cut out the soft parts at the root of the nail, an operation equally severe.

A successful mode of treating this disease, by avoiding any of those painful resources, becomes therefore an object of imVOL. VI. No. 23.

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