ON 
Surgery of the Hand. 
BY 
E. T. EASLEY, A. M., M. D. 
LITTLE ROCK, ARK. / y 
FROM THE JULY NO. RICHMOND AND LOUISVILLE MEDICAL JOURNAL. 
LOUISVILLE, KY.: 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM PRINT, 
104 Green Street, 2d door west of Post-office. 
1877. ON 
Surgery of the Hand. 
BY 
E. T. EASLEY, A. M., M. D. 
9 "• 
LITTLE ROCK, ARK. 
FROM THE JULY NO. RICHMOND AND LOUISVILLE MEDICAL JOURNAL. 
LOUISVILLE, KY.: 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM PRINT, 
104 Green Street, 2d door west of Post-office. 
1877. SURGERY OF THE HAND. 
The scope of the present paper is designed to include briefly 
the several propositions; 1. Some account of the anatomy of 
the part; 2. The mortality from operations and injuries; 3. 
Conservatism as applied to its surgery; and 4. Some suggestions 
as to operative procedures. 
Man in his exalted station at the head of the Mammalia is 
classed in the distinct order Bimana, and is its solitary repre- 
sentative, for however the recent doctrine of evolution may 
have dignified the lower orders, the sincere physiologist must 
concede the truth of Sir Charles Bell's observation, that "we 
ought to define the hand as belonging exclusively to man." It 
is the exponent of his will, the interpreter of his thoughts, the 
indication of his capabilities. So high a place has been assigned 
the member in the economy that by common consent such 
figures, as "the labor of hands," "that which thy hand findeth to 
do," etc., have been accepted as properly denoting the working 
ability of the individual. Its admitted title to such high dis- 
tinction is founded on its symmetry, the excellence of its mech- 
anism, its perpetual employment, and the vast range of its use- 
fulness. Additionally it claims consideration of the medical 
man on account of its constant exposure, its consequent liability 
to accidents and the grievous character and extent of its inju- 
ries. The prominent peculiarity of the human hand, which in 
itself, according to Cuvier, constitutes the hand properly so 
called, is its power of prehension, a faculty dependent on the 
size and strength of the thumb, and only perfectly exhibited in 
man. The human hand, far superior to the part in any other 
animal, grasps readily all objects within its compass, even to 
the most minute, and the thumb may be brought in apposition 
to the extremities of the fingers, singly or at once. It is not, 
therefore, asserting too much to say that man's commanding 
eminence in the scale of existence is largely due to the com- 4 
SURGERY OF THE HAND. 
pleteness with which the hand responds to the suggestions of 
his mind. It follows necessarily that the organ claims a high 
interest in surgery and surgical anatomy. The practitioner who 
would undertake any serious operative procedure in a part so 
perfectly organized and important, ought not only to fortify his 
judgment with a knowledge of broad facts and principles, but 
he ought also to command a very accurate acquaintance with 
the structures involved. For this purpose, in the first place, 
nothing can supply the thorough work of the dissecting-room, 
and for the physician remote from the medical centres, the many 
splendid plates of regional anatomy are available; those of 
Maclise (17, 18 and 19) have perhaps never been excelled. 
Anatomically the metacarpo-phalangeal and phalangeal joints 
are all perfect examples of ginglymoid articulations, admitting 
only the two motions, flexion and extension. Two lateral liga- 
ments of great firmness, an anterior ligament less so, and the 
extensor tendon behind compose the ligamentous apparatus of 
each joint. The articulation of the first and second phalanx 
is indicated as precisely opposite the fold of skin on its palmar 
surface, that of the second and third a little below the same 
guide. The capsular ligament of the metacarpo-phalangeal 
joint is loose, which permits the position of the articula- 
tion to be seen by drawing on the finger. It will be 
found in the adult about an inch above the interdigital 
commissure. The radio-carpal joint is located in the di- 
rection of a curved line from one styloid process to the other 
about four lines in height, estimating from the middle of an 
imaginary base line between the given points. Variations in 
the contour of the hand are to be expected, but the directions 
given will for the most part be serviceable. The wrist, accord- 
ing to Gray, is most correctly designated an arthrodial joint, 
" since it is incapable of rotation, one of the characteristic move- 
ments of enarthrodial articulations." On the palmar face the 
skin is normally thick, and the subcutaneous cellular tissue, 
through which the arteries and nerves run, very abundant. 
From this surface, as we shall see further on, it is best when 
practicable to secure flaps for stumps in amputation. Underneath 
this dense structure, the synovial membrane everywhere invests SURGERY OF THE HAND. 
5 
and is reduplicated upon the tendons and ligaments, and its 
inflammation, to which it is subject, even on trivial provocation, 
becomes, owing to its extensive area, a matter of grave import. 
It may be as well to say something now of the nature and de- 
structive effects of this inflammation. Any effusion under the 
dense skin and connective tissue of the palm is prone to pass 
into suppuration hastily, and quickly imperils the integrity of 
the parts. The morbid action however limited, its nidus read- 
ily invades the contiguous structures, the confined pus pene- 
trates, literally burrows in all directions, until molecular death 
at some infirm point makes for it an outlet. Should the drain- 
age now be sufficient, the inflammation may be regarded as 
having spent its force, and the processes of repair, ever on the 
alert, will set themselves to the task of casting off effete mate- 
rial and building up the waste places. Fortunately, in this 
enumeration of disasters what is true of phagaedena in other 
localities may be stated here; the blood vessels hold out longest 
against its ravages, nevertheless they often give way, especially 
when antecedently diseased. It has been stated that a very 
slight cause may inaugurate such a course. My friend, Dr. 
Dibrell, has recently very kindly shown me a typical case of the 
sort. The trouble had been excited by the puncture of a small 
fish fin in one of the fingers, a mishap not uncommon on our 
Southern rivers. The inflammation becoming intense, the palm 
of the hand was rapidly disorganized, and the diseased action 
spreading around to the dorsal aspect, several of the phalan- 
geal bones were left exposed by the separating sloughs. When 
such inflammation of the part has once fairly begun, and the 
integument becomes hot and tense, there is no time to tempo- 
rize; immediate relief must be afforded. The most obvious and 
rational thing to do is to obtain free drainage by adequate in- 
cisions. If the cutting has been too long delayed, stimulating 
poultices may be required to promote the separation of tissue 
already dead. In the deeper forms of paronychia the morbid 
action is inclined to follow the course above described, and any 
expedient less decisive than an early and bold use of the knife 
is hardly palliative, and apt to result in destruction or perma- 
nent crippling of the phalanges implicated. Before splitting 6 
SUEGEEY OF THE HAND. 
the palm in the vicinity of the annular ligament the relations of 
the palmar arches and median nerve should be distinctly re- 
called; injury to the latter would result most likely in persist- 
ent pain and impairment of function, while wounding the ves- 
sels would give rise to bleeding troublesome to control. Physi- 
ologically considered, no arrangement could more perfectly 
subserve the purposes of sensibility and nutrition than that of 
the nerves and blood vessels in the forearm and hand. It can 
not be conceived that a piece of mechanism could more consum- 
mately realize the ends for which it was made. It is absolutely 
perfect. An exact knowledge of the relations of the very abundant 
vascular supply of the part is always essential. Operating in this 
fullness of knowledge, the surgeon is enabled not only to command 
haemorrhages, but secures for his stumps in amputation suffi- 
cient nourishment. The principal blood vessels and nerves of 
the forearm descend upon the anterior aspect of the wrist, and 
are distributed mostly to the palm of the hand, as on this sur- 
face a larger number and variety of structures are to be found 
than on the dorsal. The radial and ulnar arteries occupy 
respectively the borders indicated by their names; they are 
comparatively superficial; the ulnar least so, until it reaches the 
palm, where it forms the superficial palmar arch, and gives off 
branches of communication with the deep palmar arch of the 
radial vessel. The dorsal arch is formed by a radial branch 
and the posterior interosseous artery. So free is the anasto- 
mosis of these important vessels that in the hand, practically 
speaking, they may almost be regarded as one. It is obvious 
that bleeding from any considerable vessel in the hand may not 
be arrested by ligation of either the radial, ulnar or interosse- 
ous, when they must all be tied, or it may be necessary to 
secure the humeral vessel. What effect obstruction of any cur- 
rent would have upon the bleeding may be ascertained by 
pressure on the vessels supposed to supply the wounded point. 
Although Dr. Joseph Pancoast and others have ligated all three 
of the vessels at the same time, the exceeding difficulty of so 
complete an operation, and the extensive violence it is likely to 
inflict are manifest. Ligation of one branch with compression 
of the other may serve a useful purpose. In a case of wound SURGERY OF THE HAND. 
7 
of the radial between the metacarpal bones of the index finger 
and thumb, the haemorrhage was permanently arrested by liga- 
tion of the vessel in the wrist and compression applied to the 
ulnar point opposite. Unquestionably the great and im- 
portant rule distinctly laid down by John Bell, and so copiously 
illustrated by Guthrie, of enlarging the wound and ligating the 
vessel there, is not always appropriate or practicable in wounds 
of the palmar arches. The exceptions to this rule of practice 
are of course rare, for the plain reason that, however we may 
stop the direct current by tying the main trunk, such a meas- 
ure does not interfere with the anastomosing circulation. So 
free are the inosculations between the anastomosing vessels 
that ligation of the brachial often fails to stop the loss of blood. 
A second great principle in the treatment of wounded arteries 
must be insisted on in this instance-the ligature is to be ap- 
plied to both ends of the vessel. If a different course be 
adopted the bleeding will continue from the distal end uninter- 
rupted by the ligature on the proximal side of the wound. The 
ends of the vessel may be so retracted or obscured by swelling 
and coagula as to make it exceedingly difficult to tie either or 
both ends. Should the effort fail, graduated sponge compresses 
may be tried before treatment of the artery in the wound is 
abandoned. Of course when all minor resources prove abortive 
nothing remains but to secure the brachial, which is a safer and 
surer, as it is a less difficult, procedure than to tie the main 
arteries of the wrist. If bleeding in the hand has ceased no 
interference is justifiable; a clot may effect permanent occlusion. 
The people have a fashion of wrapping an immense bundle of 
rags, with soot, cobwebs or other foreign substances about the 
part; these become saturated with blood, and the flow is undi- 
minished. It is needless to say that such expedients are worse 
than futile. The wound should be cleansed, examined and 
more decisive measures taken, on the presumption that it is 
better to contend with an open than concealed enemy. It is to 
be remembered that the extreme flexion of the forearm upon 
the arm with compression at the point of injury is often entirely 
effective. While the superficial structures may be properly 
divided by exploratory incisions, it is a very questionable prac- 8 
SURGERY OF THE HAND. 
tice to extend them to the deeper parts of the palm. On the 
contrary, it seems wiser, especially if there be much infiltration, 
to resort to acupressure, or ligation at the wrist, or to proceed 
at once to the humeral vessel. The inosculations by which the 
circulation is maintained after obliteration of the brachial 
artery are those of the profundas and anastomotica. No anom- 
alies are more common than those which occur in the distribu- 
tion of the brachial; these irregularities should be well under- 
stood, and are said by Quain to occur as frequently as once in 
five cases. The older surgeons entertained great fears of pre- 
serving the integrity of the forearm after occlusion of the 
brachial, but more extended observation and statistics have 
proven their apprehensions unfounded. Reports from the Sur- 
geon General's Office (part second Surgical Vol., p. 446*) record 
seventy-six ligations of the brachial for shot flesh wounds. 
Twenty-one or 27.6 per cent, of these terminated in death, a 
fearful mortality and one outside of all proportion to the mag- 
nitude of the procedure. The table is not to be regarded as 
representing the fatality of the operation in itself considered, 
but as indicating the gravity of its complications. It is worthy 
of note that the thirteen ligations for primary haemorrhage 
were all successful, and that all of those, four in number, for 
bleeding from the palmar arches also terminated favorably. In 
the same work the death rate in ligations of the radial is laid 
down as one in five; of the ulnar as nearly one in three. There 
is one case of ligation of the superficial arch; recovery with 
anchylosis, and no instance in which the deep arch was tied. 
A number of examples are detailed of the spontaneous healing 
of arteries after shot injuries, and the fact reiterated that lacer- 
ated or shot wounds, if the artery is completely divided, effect 
almost perfect torsion. It is difficult to understand how the 
student of late military surgery can fail to see the advantages 
of torsion as a rational and physiological process. 
* I am glad to refer to this truly great work, because it affords me the 
pleasure of again expressing my gratitude to the gentlemen engaged in it for 
kindnesses received, and my admiration of their devoted and successful labors. 
Certainly it is by far the most exhaustive collection of medical facts and de- 
ductions ever made, and it must endure a monument of zeal and learning in 
the interests of the Profession. SURGERY OF THE HAND. 
9 
Surgeons of great eminence have differed widely in their 
views on the interesting and important subject of the treatment 
of haemorrhage from the palmar arches. The serious nature 
of the lesion and the fact that a fatal loss of blood has fre- 
quently occurred must justify the following citations of valuable 
opinions: The Surgeon General declares (op, cit. p. 437), " the 
subjects of such injuries are very unfortunate if they have not 
the services of a surgeon possessed of the requisite skill and 
courage to thoroughly explore the wound at the outset." Pro- 
fessors Gross and Agnew do not hesitate to advise that " the 
general rule for the treatment of wounded arteries should not 
be deviated from here, and that in recent punctured or incised 
wounds of the palmar arches, the wound should be enlarged 
and both ends of the bleeding vessel be tied; " the former of 
these distinguished authorities says (Surgery, vol. 2, p. 1017): 
" It is folly in such a case to tamper with the comfort and wel- 
fare of the patient by the use of compression." Lister lays 
down the same principle (Elements of Surgery, fourth edition, 
p. 400) in terms equally positive. " In the first instance," he 
says, " it is better to enlarge the wound, and tie the wounded 
vessel above and below the injured point." Mr. Erichsen 
(Sci. and Art. of Surgery, 1st American Edition, p. 181) and 
Sir William Fergusson (Practical Surgery, p. 221) urge that 
exploratory incisions should be very sparingly made, only in 
cases of very recent injury, and that every precaution should 
be taken not to inflict additional damage in the palm. Mr. 
Druitt (Modern Surgery, eighth edition, p. 623) says that liga- 
tion of the bleeding points is seldom practicable, that the pro- 
priety of enlarging the wound must depend on circumstances, 
"and can rarely be admissible about the centre of the palm." 
Mr. Bryant (Practice of Surgery, p. 213) allows the propriety 
of enlarging the wound in haemorrhage from the superficial 
arch, but records an unqualified dissent from such a proceeding 
when the bleeding is from the deeper vessels. Swain (Surgical 
Emergencies, p. 47) says : " In incised wounds of the palmar 
arch, the vessels can generally be secured. In punctured 
wounds it is not advisable to enlarge the wound, in order to 
secure the vessel, but a compress must be applied to the wound, 10 
SURGERY OF THE HAND. 
and a hard ball being placed in the palm, the fingers must be 
firmly bandaged over it. This failing, extreme flexion of the 
forearm on the arm, with a pad at the head of the elbow, will 
effectually compress the brachial, and prevent further haemor- 
rhage." J. W. Hulke (Holme's System, edition 1870, volume 
2, p. 759) observes, " a wound of the deep palmar arch, owing 
to its anatomical relations, can not be freely enlarged, therefore 
it is necessary to depart from the rule, almost universal else- 
where, of tying the vessel at the seat of injury, and to seek 
some other method of restraining the haemorrhage." Professor 
Pancoast (Operative Surgery, p. 67) says the bleeding points 
are to be secured if it be possible by separating the lips of the 
wound, which he admits may be dilated only a little with the 
knife. Authorities of distinction may be quoted for the opinion 
that ligation should never be practiced for bleeding from the 
hand. C. D. Arnott (" Lancet," volume 2, p. 141) remarks, 
" under no circumstances in haemorrhage from the palm is deli- 
gation of the arterial trunks on the cardiac aspect to be deemed 
necessary or attempted." Professor Von Pitha, to an account 
of a number of these cases, adds: " I was never forced to 
practice ligation, as the bleedings ceased on removal of coagula 
completely and permanently. The first thing to be done in 
such cases is to freely expose the bleeding vessel by enlarging 
the wound, and to boldly clear away all coagula." It may thus 
be seen that the discussion has attained considerable propor- 
tions, extreme views even having been entertained. Amid such 
contrariety of teaching and practice the student may well hesi- 
tate. The difficulty of formulating any precise rules for the 
conduct of such emergencies is apparent. Doubtless a due con- 
sideration should be given to the circumstances of each case. 
After a somewhat careful study of the subject, with proper 
allowance for the conditions of different cases, and conceding 
the general principle that each case should be treated on its in- 
dications, we may perhaps with some confidence venture to offer 
the following conclusions: 
1. If bleeding from the palm has ceased spontaneously, the 
coagula should on no account be disturbed; the forearm should 
be flexed and partial compression of the brachial effected, in SURGERY OF THE HAND. 
11 
the hope, generally well grounded, that natural haemostasis is 
to perfect permanent occlusion of the vessel. 2. If the haem- 
orrhage continues, all clots should be removed at once, the 
bleeding points exposed, and ligatures passed if practicable, that 
is to say; 3. In division of the superficial arch the wound may 
be cautiously enlarged, but no cutting for that purpose is ad- 
missible in the deeper fascia of the palm. 4. If it is found im- 
possible to secure the ends of the artery in the wound, flexion 
of the forearm and systematic compression is to be essayed be- 
fore cutting down upon the vessels in the wrist. 5. If the parts 
have become much infiltrated and boggy, and especially if the 
redness and swelling have extended to the tissues of the wrist, 
no time should be lost in any minor recourse, but the brachial 
is to be immediately secured. The ligation of the humeral vessel 
under such circumstances not only insures against further loss 
of blood, but is to be regarded as a measure strictly conserva- 
tive, and powerfully curative in its effect upon the rapidly 
spreading inflammation. In this connection it can not be out 
of place to refer to Professor H. F. Campbell's successful Hun- 
terian ligation for the relief of destructive inflammation, and 
his able papers on the subject.* It is proper also to add that 
in all the appropriate cases in which it has been tested the pro- 
cedure has proven eminently conservative. The application of 
the principle for our present purpose may be further illustrated. 
Given a wound in which either or both of the palmar arches 
are involved, from which blood still flows, in which the pain 
and engorgement are great, the tissues sodden, and the dis- 
charge foul, thin or ichorous, in such a case (not an infrequent 
one) the brachial artery should be immediately tied. Such a 
course, in this instance, not only relieves from the apprehension 
of haemorrhage more surely than any other, but promises to 
prevent or limit the disorganization of the important structures 
concerned. 6. It remains to be said that if ligation in the wrist 
be determined upon, it should first be practiced on the vessel 
supposed to supply the most direct current to the bleeding point, 
* Manual of Military Surgery, for the use of Confederate surgeons, Dr. S. 
P. Moore, Chapter III on the Arteries, Richmond, 1864. Richmond Medical 
Journal, April, 1866, Southern Journal Medical Sciences, August, 1866. 12 
SURGERY OF THE HAND. 
and that compression of the opposite artery should be attempted 
before it also is tied. 
The death rate of amputation in the hand is indicated by the 
general rule that the mortality increases precisely in proportion 
to the size of the part removed, and hence augments in exact 
progression as the operation approaches the trunk. This prop- 
osition, laid down by Malgaigne and established by the statistics 
of the Crimean war, is corroborated by the records of our own 
civil war, and by the uniform experience of all modern military 
surgeons. The circumstances of any given set of amputations 
being equal the rule is without exception. Circular No. 6 from 
the Surgeon General's office shows (and the statement is further 
elaborated in the last surgical volume) a percentage of mortality 
ranging from 1.60 to 85.71, as the operation proceeded upward 
toward the vital organs. The elementary and invaluable fact, 
the lesson taught is that every amputation should be done as 
far from the body as is consistent with a thorough removal of 
the injured or diseased structures, and that every additional 
inch sacrificed impairs by so much the character of a favorable 
prognosis. It is worthy of remark under this head that the 
size of the part amputated not only influences the general mor- 
tality, but also the particular cause of death. Now death fol- 
lowing the loss of one of the smaller parts, a finger or toe for 
instance, will usually be caused by some unhealthy state of the 
constitution, example erysipelas, whilst in one of the larger 
limbs, a fatal termination will oftenest be brought on by shock, 
secondary haemorrhage, or exhaustion from the abstraction of 
the amount of blood contained in the limb and that lost during 
the operation. In twenty-nine fatal cases of operations in the 
hand tabulated in the reports last mentioned, the causes of 
death were in four pyaemia, in four erysipelas, in two gangrene, 
in one tetanus, in eighteen different intercurrent maladies, as 
typhoid and camp fever and pleurisy. These records also show 
very conclusively the fallacy of the popular belief that the' 
wounds in question are specially liable to induce tetanus. Of 
11,369 shot injuries of the hand, only twenty-four cases of 
tetanus are reported, and four of these recovered. As con- 
tributing to the dead-list septicaemia ranks with erysipelas, gan- SURGERY OF THE HAND. 
13 
grene furnished half as many victims and complicating diseases 
unconnected with the wounds, nearly twice as many as all the 
other causes combined. It may be as well here as elsewhere to 
reassert the observation of Romberg, founded on large clinical 
experience, that no remedy has been discovered to exert decided 
control over the acute forms of tetanus, and that a certain, though 
small, percentage of the milder cases recover under any plan 
not positively injudicious. The deduction from these statistics 
with which we have now to do is that death in a vast majority 
of fatal cases does not result from the wound or operation in 
itself considered, but from accidental complication or disease. 
Knowing then the source from which most danger is to be ap- 
prehended, it becomes an obvious duty not only to study care- 
fully the patient's habit of life and constitution, but to eliminate 
as best we may all extraneous morbific or depressing influences. 
Other things being equal the provincial surgeon, with pure air 
and better subjects, is expected to furnish better results than 
can be obtained in the crowded wards of large hospitals. This 
mortality has been spoken of in general terms, and for ordinary 
purposes definitely enough, but for those who desire more pre- 
cise information I have arranged from authentic sources a 
TABLE OF MORTALITY OF OPERATIONS IN THE HAND 
AMPUTATIONS. 
NO. OF 
MORTALITY-PER 
CENTAGE. 
Fingers and parts of hand 
1,807 
1.60 
Digits only..?. 
6,870 
2. 
Digits and' ends of metacarpal bones 
'413 
3.2 
Fingers and corresponding metacarpals 
619 
7.6 
At the wrist 
66 
10.6 
Forearm (average in all parts of) 
1,734 
13.9 
Excision at wrist (partial and complete) 
96 
15.6 
The last operation is included for the purpose of remarking 
that it contrasts unfavorably with amputation in the forearm, 
which has only furnished in 1,734 cases a mortality ratio of 
13.9 per cent. Such a comparison, when the generally almost 
and sometimes quite useless character of the hand left after it 
is remembered, reduces the indications for the former procedure 
to still narrower limits. It is to be confessed, however, that 
the results achieved under Professor Lister's improved opera- 
tion ("London Lancet," 1865, volume I, page 335) have done 14 
SURGERY OF THE HAND. 
much to modify the unfavorable impression entertained of the 
excision. A larger experience is yet required to justify the 
hopes of the great teacher in its behalf. 
The general proposition so widely accepted that primary am- 
putations are attended with least mortality in military practice 
is well illustrated in the surgery of the hand. This may be 
seen by a glance at the following memoranda of 
RELATIVE FATALITY AS TO TIME OF OPERATION. 
AMPUTATION. 
PRIMARY. 
INTERMEDIARY. 
SECONDARY. 
No. 
Mortality. 
Per Cent. 
No. 
Mortality. 
Per Cent. 
No. 
Mortality. 
Per Cent. 
Forearm 
1,009 
9.6 
450 
23.5 
184 
15.7 
Wrist 
55 
9.2 
7 
14.3 
5 
Fingers 
Large. 
1.4 
Large. 
3.7 
Small. 
4. 
Hospital and private statistics, both in this country and in 
Europe, appear to establish the rule that secondary operations 
are to be regarded with most favor in civil practice. But the 
observations of Lidell, as suggested by Professor Hamilton, have 
rendered this doubtful. At any rate, the rule is subject to 
many exceptions, and ought not to be asserted dogmatically. 
It is likely that if only those amputations in civil life for trau- 
matic causes were examined, the result would be ascertained to 
favor primary operations. However the question may be de- 
cided as to other parts, there can be little hesitation, I think, 
in the case under consideration. I am clearly of the opinion 
that if an amputation be determined upon in the hand, the 
sooner it is done the better. There can be no just reason 
assigned for delay. The patient is not supposed to suffer seri- 
ously from shock or exhaustion, and will be more comfortable 
and in better condition altogether with a neat and clean stump 
than with a painful, it may be ragged and bleeding, wound. 
It has already been mentioned that an enlightened conserva- 
tion of parts should be constantly practiced as tending to dimin- 
ish the fatality of all amputations. While all recent surgical 
records incline to encourage a rational conservatism, they with 
equal emphasis condemn the weakness and indecision that would 
save limbs and sacrifice lives. To save life is the first, to save 
tissue the second duty of the surgeon. A proper apprehension SURGERY OF THE HAND. 
15 
of these facts elevates surgery to the dignity of a science; a de- 
parture from them degrades it to the level of a trade. No 
needless mutilation or retrenchment of structure is ever to be 
advised; the ablation must comprehend only what is indis- 
pensable for safety. The beauty of a stump, however desirable, 
is still a snare which should never betray the operator into 
losing sight of his main object, his first duty. If a part be con- 
demned on sound principles, life should not be imperiled in any 
effort to save it because extraordinary and accidental recover- 
ies under like circumstances have been reported. These cures, 
as they are sometimes called, are paraded as triumphs of skill, 
yet they are in truth anything else; the attendants have in 
reality nothing to boast of, and can take no credit for their 
sagacity. They are to be considered rare exceptions, and he 
who on the basis of an exception habitually deviates from the 
rule will soon find himself inextricably involved in difficulties 
and mistakes. It is nevertheless a welcome reflection that, 
while surgery encroaches upon new fields with original and 
modified procedures, its domain is enlarged and its freshest 
laurels won in the interests of a rational conservatism. Its 
path in this direction is disclosed alike by the authority of the 
ablest teachers and the most intrepid operators, precept and 
example. It may be said that the tourniquet, the application 
of the ligature, and the discovery of chloroform were chiefly 
instrumental in systematizing amputations. A rigid adher- 
ence to the great principle of the least sacrifice of parts is of 
still more recent date. Many of our predecessors certainly 
gave up too much of the body to the knife, and were too 
strongly biased by the idea of points of election in making their 
incisions. The fact is this phraseology is unfortunate as applied 
to ablation in the extremities; the point of election should be 
that of necessity, and the work of the knife scrupulously limited 
to the removal of structures hopelessly disorganized. The 
operation that does no more than this, that provides sufficient 
integument to cover the stump, and insures that the cicatrix is 
well located, is under all circumstances to be approved. That 
which does more imperils so much the chances of recovery and 
inclines to the nature of an experiment. As has been stated, it 16 
SUEGERY OF THE HAND. 
is within a comparatively recent period that severe fidelity to 
this doctrine has been observed. Mr. Lister, great and prac- 
tical as he was, said in 1846: " Operation near the ankle is 
inadmissible; sufficiency of soft parts for the protection of the 
stump can not be procured lower than the calf." And again: 
" I have long since come to the conclusion that the femur in 
amputation should not be sawn lower than its middle." We 
have advanced so far beyond the knowledge of this clear-headed 
surgeon that such dicta would now meet only the most deserved 
and unmeasured opprobrium. The teacher who ventured to 
lay down such precepts could not retain the respect of his asso- 
ciates. We have now learned that the loss of an amount of 
tissue apparently quite insignificant may turn the wavering 
balance of probabilities against the sufferer. All of the recent 
operations (in the foot for example) have been devised and prac- 
ticed to this end; that is to say, with the view of saving the 
largest portion possible of that valuable member. Hence when 
Hey's amputation will answer the purpose, Chopart's is not to 
be undertaken; when the latter can be made available, any major 
procedure is not to be entertained. Pirogoff's method in the 
hands of Hewson and others has given results in every way 
superior to those obtained by more extensive or higher mutila- 
tion. Operations and their modifications in the foot have mul- 
tiplied in the interests of the highest conservatism, always with 
the object of securing stumps as far removed from the trunk as 
practicable. If it be admitted that the principle is essential as 
relating to amputation in the lower extremity, that its claims 
are even more imperative in the surgery of the hand is a propo- 
sition that does not admit of debate. A single finger, a part of 
one or even the most deformed digit is better than none, while 
if the thumb can be saved it will always be found of great ser- 
vice. No apparatus has ever been devised that would even tol- 
erably compensate for the loss of phalanges. In a doubtful case, 
if the thumb alone is preserved, the surgeon is to be congratu- 
lated ; if a finger be saved with it a great deal has been accom- 
plished. If the retrenchment must include all the phalanges 
still the metacarpus is to be sedulously cared for, and a strong, 
firm palm (always of great value) secured if possible. In some SURGERY OF THE HAND. 
17 
avocations, as that of bakers, a strong smooth palm with flexi- 
ble wrist, although the rest of the hand be lost, is exceed- 
ingly useful. Resection of phalangeal bones, except the last 
in continuity, has rarely proven satisfactory; the portion of 
the finger below the excision usually being a useless append- 
age. As a rule it is better to abridge the finger by a phalanx 
than to attempt resection. When the indispensable importance 
of the thumb in prehension is considered, it is at once appar- 
ent that in any amputation the integument should be brought 
over the stump at the lowest possible point. The surgeon is on 
no account to be deluded into making higher flaps under the 
impression that they will afford more shapely or attractive 
workmanship. In shot or machinery wounds of the digits, it 
frequently happens that very little cutting is requisite to fashion 
the stumps, and in such cases the rough points of bone are to 
be trimmed with forceps, and the flaps formed with the least 
expense of sound skin. At times, unless the surgeon chooses 
to descend to a feeble effort at doing a "nice job," the procedure 
consists simply of making the bone smooth and adjusting the 
soft parts over it. It is a common and wise practice to saw 
splintered bone at a point high enough to include its entire cir- 
cumference, but the phalangeal and metacarpal bones appear to 
afford exceptions to the rule. Yet the exception is not to be 
stated too broadly, and ought to be subject to some reservation. 
If the patient be young, favorably conditioned, and the pro- 
cesses of repair likely to be active, it is almost certain that a 
smoothing down of the broken bone will be sufficient, and a 
useful amount of support for the soft tissues be saved. If, on 
the contrary, the subject is old, of bad or uncertain history, no 
chances are to be taken, but the division of the bone should 
embrace its entire dimensions. In figure 1 of the illustrations, 
the third and fourth metacarpals, although split nearly to the 
os magnum and unciform, only lost by the forceps a few lines 
of their points; had they been separated at the articulations, it 
is evident that so good a palm could not have been secured. 
In figure 2 a similar course was pursued, and left the man over 
one-half of a very useful phalanx. The same plan has been 
observed in other instances, and found to succeed admirably 18 
SURGERY OF THE HAND. 
In such cases as little additional violence as possible ought to 
be inflicted, and if the periosteum be carefully preserved, the 
healing will seldom if ever disappoint the surgeon's expecta- 
tions. Many of the precepts laid down for the removal of un- 
injured heads of bones are obnoxious to severe criticism. Too 
much trimming in the hand, with a view to giving it a more 
seemly shape, has been taught and practiced. It is doubtful 
in these operations of expediency if the part gains in symmetry 
so much as it loses in strength and usefulness. It is admitted 
that the heads of the metacarpals of the index and small fingers 
may be taken off or beveled to advantage, but there can be no 
valid reason for so treating those of the ring and medius, when 
the necessities of the case do not demand it. That the meta- 
carpal bone of the thumb should be spared any such needless 
ablation is sufficiently obvious. The rule which obtains in 
reference to the foot, that the toes are not to be amputated at 
the phalangeal articulations or in continuity, does not apply to, 
but is rather to be considered as reversed in the surgery of, the 
hand. A recent and distinguished systematic writer has said 
that, excepting the index finger, amputation should never be 
performed at the first phalangeal articulation. With this opin- 
ion I can by no means coincide. Every phalanx, or piece of 
one that can be preserved, should be, and no fraction of the 
finger thus saved will be found inconvenient or useless. The 
distal phalanges, although very liable to injury, and perhaps to 
a greater extent than the others subject to disease, really 
seldom require amputation. The removal of crushed portions 
of bone will ordinarily be sufficient, and in cases of necrosis from 
whitlow or the allied inflammations, exfoliation will usually 
leave a useful end to the finger. In regard to these destructive 
inflammations of the phalanges, it can not be too well remem- 
bered that early incision down to and through the periosteum 
is the most conservative of all measures, and saves both bone 
and soft structures from the disastrous effects of infiltration and 
pressure. If excision of diseased metacarpals becomes neces- 
sary, it is probably sound surgery to take away also the cor- 
responding digits, for under such circumstances these organs 
could be of little service, and being weak and deprived of sup- Figure 1. 
Figure 2. SURGERY OF THE HAND. 
19 
port might interfere seriously with those remaining. But the 
rule as customarily applied to the thumb must be of doubtful 
propriety. Other fingers may compensate in a considerable 
degree the loss of one; the loss of the thumb can never be sup- 
plied, and it is therefore a safe suggestion that it ought not to 
be cut off on such grounds as might determine the removal of 
a finger. Of course, if the metacarpal bone is removed, the 
utility of the thumb will be much diminished, but still it will 
be of more advantage to the hand than any apparatus hitherto 
made. It is insisted then that extractions of its metacarpal 
bone does not always necessitate amputation of the thumb. If 
the flexor and extensor tendons still retain a certain amount of 
influence, the part will be of great service. Besides, both Sir 
Wm. Fergusson and Mr. Syme ("Observations in Clinical Sur- 
gery," page 38) have reported interesting and successful in- 
stances in which the course now recommended was pursued, and 
other examples could be presented. In all these operations it 
ought to be recollected as a golden rule that the palm is not to 
be encroached upon when it can be avoided; incision in the 
palmar surface is never to be carried higher up than the fold 
of the joint. That through the phalangeal joints is a good and 
simple amputation, and in it as elsewhere the surgeon is to be 
guided by what skin he has to utilize to cover the stump. As 
a rule it is not best to take off the head of the proximal bone, 
but if there is a paucity of flap to cover it, its removal is advisa- 
ble. The two operations, of which the accompanying illustra- 
tions show the results, confirm so far as they go some principles 
already mentioned. 
Case I.-Figure 1. General B. L., of Dallas, Texas, aged 
forty-five, of fine general health and temperament, was wounded 
in September, 1875, by the discharge of a common fowling 
piece at close range, the hand powder-burned. The patient 
came into my hands through the courtesy of my friend Dr. 
Sutton. The charge of small shot, entering the dorsal aspect 
of the hand toward its ulnar border, had shattered the heads 
and part of the shafts of the third and fourth metacarpals, when 
taking a direction obliquely upward it had torn up the soft tissue 
and bones of the index, medius and ring fingers. The opera- 
tion consisted in the arrest of haemorrhage, removal of spiculae 20 
SURGERY OF THE HAND. 
of bone, cutting off tendons smoothly with the bottom of the 
wound, and adjusting the flaps. The head of the second meta- 
carpal was sawn off only because its presence increased the 
tension of the flap. The splintered shafts of the third and 
fourth metacarpals were simply trimmed down to a point at 
which they would give a useful amount of support, instead of 
being exarticulated at the os magnum and unciform. The ap- 
pearance of the member is pretty well represented in the figure, 
its utility and flexibility are all that could be expected or de- 
sired. In these material points it contrasts very strikingly with 
the cast of the result of a similar operation in the second surgi- 
cal volume of the History of the War, page 1022. The stump 
has never been painful, and healed quickly and smoothly. As 
will be seen the scar is altogether upon the dorsal aspect, the 
palmar surface being left to its accustomed use of opposing sub- 
stances brought in contact with it, without distress or incon- 
venience. This wound suppurated but little, and was treated on 
a strictly antiseptic plan, to the judicious management of which 
by Dr. Sutton the rapid recovery is largely to be credited. 
Case II.-Figure 2 is that of Mr. John H., of Little Rock, 
thirty-seven years old, a man of good habits and health. The 
wound, a lacerated one, was sustained while the patient was 
engaged in working a shingle machine, and involved both soft 
parts and bone. The wound of the medius, beginning about 
the middle of its second phalanx, on the radial border, passed 
upward to the head of the bone, at which point the finger was 
completely divided. The same course in the main was pursued 
in this instance as with the hand of General L. A portion of 
the splintered shaft of the bone was dissected away from its 
periosteum, and removed nearly as low down as the insertion of 
the dorsal interossei muscles. The sharpened eminence of bone 
still left was cut off smoothly with the pliers, and after cleansing 
the wound the redundant integument on the ulnar border of 
the finger was brought over to meet the short flap on the oppo- 
site side. The cicatrix extends from the radial around to the 
dorsal aspect, as may be seen in the picture.* Healing took 
* For this and other like favors I am much indebted to the skill and pa- 
tience of Mr. George E. Shaeffer, Photographer of Little Rock. SURGERY OF THE HAND. 
21 
place kindly and rapidly. The attachment of the flexor sub- 
limis tendon was only partially separated, and hence there is a 
considerable degree of motion in the stumps below the joint. 
The patient feels sure that he could write if the right were the 
maimed hand. The cicatrix of the index finger is placed well 
over on the dorsal surface, and the little stump affords a most 
useful opposition to the prehensile power of the thumb. 
In many wounds of the hands, particularly lacerated or shot 
injuries, where so much depends upon the amount of structure 
to be utilized and so much upon the ingenuity of the surgeon, 
it is not easy to indicate precise methods. If the operator is 
disposed to be an economist, his procedure may with advantage 
be varied to suit almost every case. The palmar surface of the 
hand, with its soft cushion of adipose and areolar tissue and its 
rich vascular and nervous supply, furnishes an ideal structure 
for fashioning the covering of stumps. It ought whenever 
practicable to be used for this purpose. Beside healing quickly, 
this skin has the additional advantage on the face of a stump 
of being less tender and liable to injury than that upon the 
other side, its normal situation and organization adapting it to 
the contact of all external objects. The different forms of am- 
putation in the hand, as in other parts, are but modifications of 
the leading general methods, flap and circular. If a mixed 
procedure be practiced, especially in disarticulation, the least 
important flap should be made first, and that containing the 
vessels or designed for the chief covering of the stumps be 
formed after the separation of the bones is completed. Of course 
when it can be done, healthy tissues should be selected for the 
formation of flaps; nevertheless they may be made from inflamed 
or infiltrated parts, as under drainage and suppuration the 
swelling will diminish, with little danger of gangrene, or inter- 
ruption to the reparative process. Both McLeod and Mr. Bry- 
ant have expressed themselves decidedly on this point, and the 
latter has not scrupled to assert that he has often had "brawny" 
flaps unite at least as rapidly and well as others not so affected. 
In the phalanges Ledran's amputation by two lateral flaps, as 
well as that by dorsal and palmar flaps of equal size, has been 
adandoned. If the conditions of the wound admit it, there can 22 
SURGERY OF THE HAND. 
be no better procedure than that known as Lisfranc's first 
method, the single flap operation. A curvilinear incision with 
its convexity looking downward is made over the joint (if the 
amputation be at a joint), disarticulation accomplished from the 
dorsal, and the principal flap cut from the palmar surface of the 
digit. Lisfranc's second method does not differ from this, ex- 
cept that the palmar flap is first fashioned by transfixion and 
disarticulation made from that surface. Amputation of all four 
fingers at once at the metacarpo-phalangeal joint, or amputa- 
tion at the carpo-metacarpal junction may be done by a modi- 
fication of the process for the removal of a single finger by 
Lisfranc's first method. The amputation through the radio- 
carpal articulation on the same principle, by single flap (method 
of Denouvillier), is a good one. The first incision is across the 
dorsal surface, between the styloid processes, its convexity look- 
ing downward, the joint is then opened, when a sufficient palmar 
covering for the stump may readily be secured. This latter, in 
its best shape, is really the mixed method first practiced by Mr. 
Carden in 1846 (described in " British Medical Journal," April, 
1864), and so applicable to the leg and forearm. It is doubtless 
best to remove the projecting styloid processes, but it is not 
essential, for it has been shown by the recent modifications of 
Pirogoff's operations in the foot that sawn bone as well as mus- 
cular and skin flaps grow firmly on incrustations of cartilage. 
While amputation at the elbow has for a good while constantly 
grown in favor, that at the wrist has received a late and hesi- 
tating encouragement. It is alleged that its statistics in com- 
parison with those of operation in the forearm are bad, that in 
146 cases tabulated by 8. W. Gross the mortality was 46 per 
cent., and that the Crimean surgeons lost nearly half their cases. 
These comparative estimates of the death rates are not borne 
out by the latest records. In Circular No. 6 from the Surgeon- 
General's office, of thirty-six cases of wrist amputation, at that 
time determined, the mortality was put down at 5.55 per cent., 
evidently much too low an estimate. In the extensive series of 
cases presented in the second surgical volume the fatality is 
given, as already mentioned in this paper, at 10.6. If we con- 
trast with this result the ablation in the forearm it is found that SURGERY OF THE HAND. 
23 
the aggregate percentage of death was of 491 in the upper 
third 13.4, of 676 in the middle third 11.1, of 452 in lower 
third 12.4, and of 128 at points not specified 37.8. Such fig- 
ures as these appear to decide the question definitely in favor of 
the less extensive mutilation. The more conservative measure 
recommends itself on general principles, and if the articular 
ends of the radius and ulnar are unharmed and a sufficiency of 
integument exists to cover them, any higher amputation is un- 
justifiable. 
So far as I can ascertain no excision of the entire carpus has 
ever given a satisfactory result, nor is it likely to do so. Yet it 
has often happened that a partial removal of these bones for 
caries, necrosis or injury was a highly advantageous expedient. 
The removal of diseased or injured metacarpal is sound prac- 
tice, and particularly in the thumb, as previously stated, does 
not absolutely necessitate amputation of the corresponding pha- 
langes. In such cases as little violence to contiguous structure 
is to be inflicted as is compatible with a thorough operation, and 
especially should the sheaths of the flexor and extensor tendons 
be guarded from harm. 
The surgeon is sometimes called upon to decide between am- 
putation and excision at the wrist. The question of precedence 
as to the two procedures is an interesting and important one. 
It may be said that the results of exsection have not been 
by any means gratifying, and hence many surgeons prefer am- 
putation in the first place to the pain, inconvenience and uncer- 
tainty of the former measure. Anything like a proper notice 
of the subject would require more space than is now at the 
command of the writer. 
We pass from a consideration of the principles upon which 
certain operations in the hand should be conducted to some ob- 
servations of a general character in relation to the treatment of 
its wounds. There are four great indications to be observed in 
the local management of incised and punctured wounds, and 
they are as applicable to those of the hand as to any others. 
Briefly they are: 1. The arrest of heemorrhage; 2. Removal 
of all foreign substances; 3. Coaptation of opposing surfaces; 
and 4. The treatment and dressing should be antiseptic and in- 24 
SURGERY OF THE HAND. 
stituted with a view to limit inflammation. Under the last 
head I declare my belief in an inflammation necessary for heal- 
ing in contradistinction to one that falls short of what is requi- 
site in that process, or that overreaches its demands. No re- 
finement of modern pathology can do away with the essential 
facts of a reparative inflammation as laid down by John Hunter; 
it stands out a towering landmark, and if his fertile genius 
had done no more, it alone confers immortality. Beside the 
general and specific treatment designed to limit inflammation 
or prevent the exhaustion and tissue waste of profuse suppura- 
tion, the local measures to be adopted readily suggest themselves, 
and are for the most part effective. If strangulation from ten- 
sion be imminent, the swollen structures are to be drained. 
For wasting suppuration, the remedies with which the materia 
medica is now so full are at hand, and I must beg to refer my 
reader to what I have already said (Transactions American 
Medical Association, 1876, p. 569) on that subject. The bene- 
fits derived from the antiseptic treatment of wounds are now 
so universally acknowledged that something should be done in 
that way, although we may not be prepared to carry out the 
plan perfectly. The common cotton wool, when carbolized, 
is an excellent, convenient and protective substance for dressing 
the hand. The ship caulker's oakum is an exceedingly useful 
material for the same purpose, absorbing foul discharges rap- 
idly, and acting as a potent disinfectant. I believe Dr. J. C. 
Nott, of Mobile, first brought it prominently into notice in the 
South, and I have heard his pupil, the late Dr. Gilmore, often 
speak of his partiality for it and commend its use. From its 
abundant lymphatic and blood supply it is manifest that septic 
infection may readily be propagated from disorganized dis- 
charges in the hand. Under circumstances of uncleanliness 
and neglect, absorption of putrid material is prone to occur, all 
the fluids are depraved, the nervous system deranged, in a word 
we are called on to encounter the dread culmination, constitu- 
tional toxaemia. We need not recount the events of its course; 
with its appalling history we are only too familiar. It is enough 
to say that every stage of that history teaches plainer than any 
language can teach that the prophylaxis is of the first import- 
ance. SURGERY OF THE HAND. 
25 
Few conditions are more disfiguring and intractable than the 
unyielding cicatrices in the palm from scalds, burns and other 
causes, and none perhaps tax more the ingenuity of the sur- 
geon. Permanent contraction and deformity are not infrequent. 
If the tendons are involved, tenotomy is a very questionable pro- 
cedure, and ought in most cases to be condemned. If, however, 
the injury is found to implicate only the skin and aponeuroses 
the knife may be used with much prospect of success. The 
inodular tissue may be divided at several points transversely, or 
the shortening of the palmar aponeurosis may be relieved by 
subcutaneous division. If the scar be cut, the object of course 
is to keep the hand fixed in a corrected position till healing 
takes place by granulation. But skin-grafting is the most 
rational, as it has proven itself the most successful means for 
the relief of the deformity. I have done the operation to good 
purpose; Dr. Truehart, of Galveston, and others have lately 
reported successful cases, and on the whole the little procedure 
is before the Profession well endorsed. The points in the opera- 
tion are that the entire cicatrix should be dissected out, and 
the transplantation effected on the principles indicated in the 
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