IN ANY TOWN where there are works of any kind one is constantly seeing accidents of various degrees of severity. Minor accidents are common. These generally affect the fingers and toes and vary from simple contusions and scrapes to complete amputations. I write from Earlestown, Lancashire, and being surrounded by several large works a great number of minor accidents are met with in practice. During the last two years I have personally attended over 250, the number in one month reaching as high as 27.

As it is of the first importance that a workman should have all his digits, it is of even greater importance that none of them should be stiff or useless, because then they are only in the way and had better be amputated. Consequently, if I have a case of badly crushed fingers, I generally remove them under a local anaesthetic, a procedure which is practically painless, if done soon after the accident and the local anaesthetic is properly injected. I always inject high up the injured fingers, entering the needle, which should be a Shimmel’s needle, on a syringe capable of standing pressure, close to the web on each lateral surface. I then massage the fluid round the finger and allow 5 to 6 minutes to elapse before commencing.

The amount of anaesthetic (cocaine) varies with the number of fingers requiring amputation, but I never exceed a drachm and a half, and often manage with less.

Efficient sterilisation of the wound area is impossible, because, as a rule, the patient’s hands are covered with grease and dirt at the time of the accident, and also the parts are too tender to be well scrubbed. The method I use is to bathe the parts with 1 per cent solution of Lysol, a great grease remover, and then paint over the affected parts with a 1 per cent solution of iodine made with spirits vini rect.

Asepsis also is impossible, because a general practitioner cannot find the necessary assistance to allow him to treat a case with sterilised hands and has to be constantly handling unsterilised objects, such as the box containing the dressings, etc. I therefore rely on antiseptics and use double cyanide gauze wrung out of the Lysol solution or a solution of 1-1,000 corrosive sublimate. All sutures are also placed in the iodine just before use.

The iodine solution should be freshly made and will keep about a month. I saw an account of the iodine method long ago in The Practitioner¹ and have used it ever since with remarkable results. Wounds, which were full of dirt and grease, healing by first intention by its use, after removing the dirt from the raw surfaces.

A point to be borne in mind is not to use too strong antiseptics, because this might kill the end, and also after dressing the part should be kept warm and not disturbed, if comfortable, for ten days.

Cotton-wool should always be dried before a fire before use, as it swells to three times its volume, and is much more absorbent and comfortable to the patients. Care should be taken not to hold it too near to the fire, as, of course, it is very flammable.

By following the above methods I have had remarkable success, only three cases going septic in two years.

Where the tip of a digit has been completely severed it is well worth while suturing it on to the raw stump, because if it lives the cosmetic effect is good and very often limited movement is possible, though in the case of a tip of a digit it does not really matter if there is no movement, provided there is good movement in the phalanx next to it, as both flexor and extensor tendons find fresh attachments to that bone.

A boy was brought to my surgery who had had the end of his thumb removed by a ticket-printing machine. I was just going to trim the stump when a message came to the effect that they had found the end of his thumb and were bringing it on. At the end of 20 minutes it arrived, very dirty, so I washed it in warm water. It contained a piece of bone, the line of separation evidently going through the middle of the last phalanx. I removed the nail and sutured the end of the thumb on to the stump with three sutures, two lateral and one palmar. The sutures were of silk, to prevent them from being absorbed. The dressings were removed in ten days and the part was dressed once a week. At the end of three weeks the sutures were removed and zinc ointment was applied. The extreme tip of the thumb became gangrenous and separated off, but the remainder grew on to the stump. In six weeks the boy was at work with a thumb slightly shorter than its fellow, and with a nail on it, and on looking at the hand one would think the thumb only rather short. Movement was perfect and bony union of the two pieces of phalanx was quite complete.