Translations from foreign Journals, etc.

8. LILIENTHAL, M. D., NEW YORK CITY, EDITOR.

PANARITIUM,

Its Consequences and Treatment, by C. Hueter, Prof. in Greifswald

FROM VOLKMANN S KLINISCHE VORTRÆGE.

Panaritium, (in the strict sense of the word), is an acute inflammation, quickly tending to suppuration, with tendency to necrosis in the connective tissue, always localized, on a narrow space, in the soft parts of the volar surface of the fingers and of the hand, but in unfavorable cases producing extensive suppuration, endangering, and even destroying by its results, the functions of the fingers and of the whole hand.

According to such a definition the severity, from its very outset, and the rapid progress of the inflammation to suppuration are the characteristics of the true panaritium. The next question for us to answer is: What are the causes of panaritium, and how do these causes explain the peculiar character of the inflammation ?

An essential factor in an ætiological examination of diseases is the results of statistical observation. According to such we know, that its sufferers are nearly exclusively found among the laboring classes, and among those again especially whose fingers are more frequently exposed to trifling lesions. Servants, cabinet-makers, carpenters, machinists, smiths, etc., are the trades which we find most frequently suffer from panaritia.

Youth is also more disposed to panaritia than people of more advanced age and experience has shown that the number of pan aritia sometimes accumulates in certain weeks, whereas at other times hardly any are observed. Such accumulations look sometimes like epidemics and the question has been raised if a peculiar virus may not be the cause of panaritia, which Pitha* answers affirmatively. I do not feel inclined just now to enter into a discussion about it, but confess that I cannot find any basis on which to put the infectious matter of panaritium. I do not deny that there are panaritia, caused by a specific poison, especially

* Billroth & Pitha, Handbuch der Chir., Vol. IV, p. 127.

from lesions during post mortem examinations. But how small is the number of such infected panaritia in comparison with the great number we yearly witness. A cook might, perchance, become infected by beef steaks or roast beef, but in artificers, working only in wood and metals, such an etiology must be put in the background.

Panaritium is a traumatic inflammation; its characteristics are based on the anatomical relations of the parts, on which the inflammation develops itself.

The sub-cutaneous connective tissue on the volar surface of the fingers and of the hand differs from the sub-cutaneous connective tissue of the dorsal surface and of the whole upper extremity by its considerable development in thickness, by its comро ition of short, stiff fibres of connective tissue, running, not as in all the other parts of the extremity parallel to the longitudinal axis of the extremity and connecting the skin with the fascia under very acute angles, but diving down perpendicularly in its short course from the papillary body. By such a course they nearly absolutely cause that the skin cannot move on the underlying parts, whereas on the dorsal surface of the hand and fingers, on the fore arm and upper arm we can move the skin without any difficulty for a few lines over the underlying parts. This peculiar construction of the sub-cutaneous connective tissue discloses thus the whole history of the panaritium.

According to the difference of the trauma, or the different manners by which the inflammatory irritation reaches the connective tissue, the primary origin of the inflammation will be different. A punctured wound may carry the inflammatory irritation in direct contact with the sub-cutaneous connective tissue, a contusion or a contused wound transfers the sub-cutaneous connective tissue immediately in a state of panaritial inflammation, or an acute or chronic traumatic irritation of the rete malpighi and of the papillary body, a fine fissure in the skin, or, exempli gratia, the formation of a callosity, or of a blister in the course of the finer lymph-ducts, may carry the inflammatory irritation down to the sub-cutaneous connective tissue. Thus we may have immediate inflammatory irritations of this tissue, or it may be brought about by the lymphatics, and the number of the latter exceeds in practice those of the former. But however it may have happened, we will always find the peculiar character of the inflammation. An essential characteristic is the limited localization of the initial focus of suppuration, easily explained by the stiff fibres of the sub-cutaneous connective tissue. Just as a sub-fascial suppuration penetrates only slowly through the fascia to the surface on account of the slight inclination of the firm fibres of the fascia to inflammation and ulceration, so also the short stiff fibres which surround the primary panaritial inflammatory focus offer the greatest resistance to the progress of the inflammation. We do not mean to say that the primary inflam

matory focus keeps from day to day its primary extension, for we will soon see how it spreads, but the panaritial inflammation stands in its primary development, and during its first stage, in direct opposition to the phlegmonous inflammation. The latter extends itself from hour to hour, yea in very bad cases from minute to minute as suppurative infiltration in the meshy connective tissue, (so plentiful in the sub-cutaneous connective tissue of the extremities with the exception of the volar surface of the hand and the plantar surface of the foot), and in the peri-muscular tissue, because the inflammatory irritation finds in these long and soft fibres a formation inclined to inflammation and to suppurative dissolution, every pus-infiltrated fibre of the connective tissue produces again new phlogogonous (inflammation producing) substances, and the contact with neighboring fibres incites these again to a similar production.

The contrary takes place in the panaritium. The fibres of the subcutaneous connective tissue surround the inflammatory focus from all sides and prevent effectually its spreading. The phlogogonous substances come here in contact with formations which respond only slowly to its irritation, to suppurative infiltration and dissolution. Thus a panaritial inflammation keeps up in the beginning its character of circumscription,and maybe compared on that account with a furuncular inflammation, which, mostly originating from a sebaceous gland, runs its course in a similarly constructed connective tissue, between the stiff fibres of the papillary body. In fact, a panaritium may be called a furuncle on the volar surface of the finger.

This apparently beneficial effect of the construction of the subcutaneous connective tissue on the volar surface of the fingers becomes reversed by another effect, deleterious in every directionThis is the squeezed-in condition of the primary inflammatory focus, showing itself by important obstructions in the circulation, by necrosis of the inflamed tissues, by severe pains and relatively high

fever.

If the suppuration be caused by the migration of white blood corpuscles or by a proliferation of cells, a swelling of the suppurating tissues will always go parallel with it, and such a swelling shows a marked effect on the blood-vessels and lymphatics surrounding the focus of suppuration. Its compression produces a collateral œdema, and when the compression has reached a certain height and has fully strangulated the blood-vessels, necrosis of the tissues must follow. But on account of the stiffness of the structures, surrounding the inflammatory focus, the compression of the blood-vessels will be so great, that the necrosis of the connective tissues, infiltrated with pus, will hardly ever be wanting. Only early and correct treatment may still save the structures from local death; a usual and not the most unfavorable issue of a panaritium is the exfoliation of a necrotic core of connective tissues impregnated with pus. The presence of necrotic tissue

is a further inflammatory irritation for the surrounding tissues, we see therefore extensive swelling, showing themselves mostly on such places which possess tissues, able to swell up. On the finger the soft parts of the dorsal surface swell up, although lying more distant from the inflammatory focus.

The intensity of panarital pains can be easily explained by the quantity of sensitive nerves and nerve-ends on the volar region of the fingers, by the strangulation of these nerves, taking place under the same condition as the strangulation of the blood-vessels, and finally by the gradual necrosis of the nerves, in so far as they belong to the connective tissue destroyed by necrosis.

Not every panaritium is accompanied by fever, but still we may frequently witness a febrile paroxysm in the initial state of panaritial inflammation. Even a slight chill, followed by heat and sweat may precede the panaritium. Such symptoms show us again the consequences of the compressed state, in which the inflammiation finds itself here from the very beginning. The quantity of fever-producing substance can only be trifling in the small inflammatory focus, and still resorption takes place in a relatively high degree, because the pyrogonous substances of the pus are under a high pressure from the moment of their formation. This pressure, exercised by the short stiff fibres of the volar sub-cutaneous connective tissue, forces the pyrogonous substance in the roots of the lymphatics, and after coming thus in the circulation they develop there these fever producing qualities. A teaspoonful of pus under the skin of the dorsal surface of the finger will hardly ever produce any fever, a few drops in the sub-cutaneous connective tissue of the volar surface suffice to raise the thermometer in the axillary pit up to 39-40 C. (104 R.)

Some rare cases of panaritium, especially when superficially situated, may stop here; the crowding forward of the suppuration, the demarcation of the inflammation, developing itself around the necrotic core, leads to the perforation of the papillary body. Some drops of pus flow in the rete malpighi and raise up the epidermis in vesicles. The small puriform vesicle breaks finally through the epidermis and a few drops of pus are evacuated. The pain now decreases and under it granulation-tissue forms, the opening in the papillary body increases on account of the continued puriform dissolution, and finally through the pressure of the granulations the necrotic core is expelled. This is the most favorable spontaneous course of a panaritial inflammation, and our exertions at the right time, on the right place, will not only shorten this normal course, but will also cause such cases, which might have run unfavorably, to change such a course; only there is among the people a prejudice against cutting and they allow especially panaritia to run their mischievous course. Finally there are some exceptionable cases which will turn out malignant, although the patient and his physician have tried their utmost to prevent it.