I g 1 Presented by Edythe F. Ashmore, D.o. COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA -'^,v,r '':-*:>> :^ l ^'fe^tA,:-r^-^teCi ^ : : t4^ (ji 07 ( w ^v_ 9 INFECTIONS OF THE HAND A GUIDE TO THE SURGICAL TREATMENT OF ACUTE AND CHRONIC SUPPURATIVE PROCESSES IN THE FINGERS, HAND, AND FOREARM BY ALLEN B. KANAVEL, M.D. ASSISTANT PROFESSOR OF SURGERY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL ATTENDING SURGEON, WESLEY AND COOK COUNTY HOSPITALS, CHICAGO SECOND EDITION, THOROUGHLY REVISED Illustrates witb 147 LEA & FEBIGER PHILADELPHIA AND NEW YORK 2 Entered according to the Act of Congress, in the year 1914, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. PREFACE TO SECOND EDITION IN the presentation of a contribution such as this, an author is at a loss to know just how much of the experimental and anatomical investigations upon which his surgical deductions are based should be included. Upon one hand is the fear that, if too much is intro- duced, the practical surgical deductions will be lost to the busy and hurried practitioner who first sees these cases; upon the other, if dogmatic statements are made as to diagnosis and therapy, although based on sound ^ reasoning and true for the great majority of cases, the - careful surgeon will lack the basal facts upon which he can diagnosticate and treat the atypical and hence more dreaded cases. The author has, therefore, attempted so to arrange the results of his experimental work that, although all of the facts are given upon which deductions can be made in the latter cases, the chapters are so grouped that the busy practitioner - can find the part dealing with his particular case quickly. Given a case in which the practitioner is in doubt, he should read the chapter upon "Diagnosis and Treatment in General." This will indicate the group into which his case falls, and will also direct him to the proper sections of the book where cases of that nature are treated more in detail. The present revision has given the author an oppor- tunity to make certain additions in regard to the chronic processes, which his experience in the last two years has suggested. It has also made it possible 4294 iv PREFACE TO SECOND EDITION for him to act upon the suggestions made by various reviewers particularly in relation to more complete descriptions under illustrations of cross-sections, and a clearer system of cross-references. It is a pleasure to say that further experience has justified the state- ments made in the first edition as to the value of the various incisions in the treatment of the individual types of infection. Following several of the chapters, resumes have been inserted which it is believed will aid the surgeon who is in haste for concrete knowledge concerning the contents of the chapters, but the author wishes emphatically to warn the student and surgeon that a comprehensive reading of the preliminary anatomical and experimental work will be necessary for an accurate knowledge of the diagnosis of the various types of infection and the position of the pus in each type. In conclusion it may not be out of place to emphasize again the necessity for careful study of the diagnosis of tendon-sheath infection, which, in the majority of cases, is overlooked until it is too late for satis- factory treatment. If each surgeon w r ould have in mind this possibility and be constantly on his guard, so that the proper operation might be performed promptly, the usefulness of many a hand that is now lost would be preserved. The author takes this opportunity to make acknowl- edgment of the many courtesies, in the way of per- mission to study cases, which have been received from members of the profession at large, including Dr. Van Hook, Dr. Martin, and his co-workers in the Surgical Department of the Northwestern University Medical School, Drs. Besley and Richter. He feels a particular obligation to the anatomical department, its various instructors and students, who have been of great assistance on many occasions. PREFACE TO SECOND EDITION v To his surgical assistants, Dr. Cushway, Dr. Eustace, and Dr. Wolfer, and to many others not so intimately associated with his work, he wishes to express his appreciation of their help in the care and study of the individual cases. He also wishes to express his appreciation of Miss Spencer's careful work in assisting in the preparation of the text, and to make acknowledgment to Miss Hamlin for her care and attention in the revision. Surgery, Gynecology, and Obstetrics has kindly given permission to use certain plates from the author's articles published in that journal. A. B. K. CHICAGO, 1914. CONTENTS CHAPTER I INTRODUCTION: SCOPE AND CLASSIFICATION OF TYPES OF INFECTIONS History 17 Scope and Classification of Types 20 PART I SIMPLE LOCALIZED INFECTIONS AND ALLIED MINOR CLINICAL ENTITIES CHAPTER II INFECTIONS OF THE DISTAL PHALANGES Felons 25 Treatment 29 Paronychia 31 Treatment 33 Subepithelial Abscesses 37 Anatomical Considerations and Pathogenesis 38 Treatment 42 Differential Diagnosis , 47 Oidiomycosis 47 Chronic Staphylococcus Processes 49 CHAPTER IV MISCELLANEOUS ABSCESSES Collar-button Abscess (Shirt-stud Abscess) (Frog-Felon) .... 52 Treatment 54 Localized Abscesses in the Thenar and Hypothenar Spaces .... 55 viii CONTENTS PART II GRAVE INFECTIONS: TENOSYNOVITIS, FASCIAL-SPACE ABSCESSES, LYMPHANGITIS, AND ALLIED CONDITIONS CHAPTER V DIAGNOSIS IN GENERAL Lymphangitis 58 Tenosynovitis 59 Fascial-space Infection 63 Diagnosis of Extensions from Various Sites 68 CHAPTER VI GENERAL PRINCIPLES OF TREATMENT Prophylaxis 70 Rest 70 Drugs 71 Passive Hyperemia 71 Hot, Moist Dressings 72 Prophylactic Incision 74 Drainage 76 Stimulation of Excretion 77 Massage 78 Baking in Dry, Hot Air 78 SECTION I THE ANATOMY OF THE HAND AND FOREARM, WITH ESPECIAL CONSIDERATION OF ITS RELATION TO INFECTIONS OF THE SYNOVIAL SHEATHS AND FASCIAL SPACES CHAPTER VII METHODS OF STUDY IN GENERAL: A STUDY OF SERIAL CROSS-SECTIONS OF THE HAND, WITH PARTICULAR RELATION TO THE FASCIAL SPACES Methods of Study 80 A study of Serial Cross-sections, with Particular Relation to the Fascial Spaces 83 Middle Palmar Space 90 Thenar Space . 91 Hypothenar Space 95 Discussion of the Relation of the Middle Palmar and Thenar Spaces 97 Rag with a sinus opening which frequently appears at one side near the nail. As a rule, the granulation tissue is not excessive, the sinus appearing more as a simple canal uniting the pus pocket with the exterior. Frag- ments of seminecrotic connective tissue often appear partially plugging the opening. TREATMENT. The treatment of felons consists in immediate incision into the infected area. Certain errors are seen at times. The first is an incision made into a phalanx in which there is a begin- ning lymphangitis and not a localization in the distal phalanx. Such infections cause pain and tenderness throughout the whole finger, although most marked in the distal phalanx. Again, the edema is more general, not having the excessive tenseness in the pulp of the finger characteristic of a beginning felon. In- cision here is not only unnecessary, but positively harmful, as will be brought out in discussing the sub- ject of lymphangitis as a whole. The second error consists in waiting until fluctuation has begun. If this is done, unnecessary pain is endured by the patient. Moreover, such destruction of the connective tissue, and even of the bone, has occurred as to cause not alone prolonged convalescence, but even permanent deformity. The incision should be made as soon as the edema restricted to the distal phalanx has proceeded to a degree causing a hardness, but not necessarily the board-like feeling characteristic of pus in other subcutaneous areas. In general, one may say that when there is present a painful, tender, 30 INFECTIONS OF THE DISTAL PHALANGES distal phalanx, with excessive edema limited to the phalanx, incision should be made. Generally the patient comes for treatment after the whole area is involved, but at times the finger will be seen early enough to decide, because of the localized tenderness, that the pus has not extended throughout the whole of the closed space, in which case the inci- sion should be made over the localized tender area. In those cases in which there is no localization, but the whole phalanx seems involved, the incision should be made somewhat to the side, and not in the median line, as is unfortunately frequently done. The median incision leaves a scar over the site of the tactile por- tion of the finger, so that the more delicate functions of that part may be impaired. By examining the cross- sections here shown it will be seen that this pocket can be opened by a lateral incision just as satisfactorily as by a median one, and, in fact, somewhat better, since the radiating columns of fat and connective tissue will be cut transversely, thus leading to more satisfactory drainage. If the incision is made early, one is often surprised at the rapidity of the recovery. In those cases in which incision has been delayed until necrosis has ensued, certain phenomena may be observed. The connective tissue of the pulp may be so destroyed that pus will continue to discharge until the slough of seminecrotic tissue is expelled. If the opening is small, recovery may be hastened by re- moving the detritus with tissue forceps. Its removal, however, must await the natural pathological processes incident to all separation of necrotic from living tissue. Again, when the bone is involved the question often arises as to what disposition to make of it. This will vary with the amount of involvement. If there is complete separation of the tissues from the diaphysis, so that it stands out free like a telegraph pole in PARONYCHIA 31 the pus, it should *be removed at once by the bone- cutting forceps, remembering that the epiphysis is not involved. In the case of a child the diaphysis is often separated at the time of incision or can be easily cut off with the scissors because of the lack of bony union between the epiphysis and diaphysis. If the bone is exposed upon only part of its circumference it will frequently heal without further trouble and should be treated conservatively. In those cases in which the diaphysis is removed no disability of the joint need be feared unless it has become involved, a complication occurring only in a few instances. The phalanx will be somewhat short and the ringer nail may be deformed, but movement will not be seriously impaired. The after-treatment is the same as that used after any incision in acutely infected areas, consisting essentially in procedures designed to relieve pain and favor walling-off of the process by round-celled infil- tration. Locally nothing is superior to the ordinary dressing saturated with hot boric acid solution until the acuteness of the inflammation subsides. The hand is elevated to lessen the throbbing pain. These meas- ures are supplemented by opiates if necessary. After the acute inflammation subsides the finger is dressed by gauze thoroughly saturated w r ith vaseline, which permits the free escape of pus and allows the removal of the dressings without pain to the patient. PARONYCHIA. Among the infections of the distal phalanx, is none apparently so simple as the paronychia, or "run- arounds, " and yet they frequently baffle treatment for some weeks, since the pathology may not be under- stood. They begin ordinarily at one side of the nail as a simple infection, frequently from a "hangnail." 32 INFECTIONS OF THE DISTAL PHALANGES This infection may be of two types: first, an acute infection, giving rise to a small wheat-grain-sized abscess in the subepithelial tissue at the side of the nail, which, if opened, makes an immediate recovery; if neglected, it spreads along the side of the nail and back to the base, becoming secondarily a typical "run-around. " More often, however, this chronic type develops from a chronic infection along the edge of a "hangnail." For a number of days a drop of pus or more will exude from the inflamed area about the nail edge. It will then be noticed that on the same side at the base there is a certain amount of swelling and redness, with little or no pain. As the days pass the swelling and redness gradually extend about the base of the nail until the opposite side is reached. At the end of two or three weeks drops of pus will be expressed from under various parts of the overlying epithelium (eponychium). A week or two later the entire nail may be lifted off the matrix and cast off, or at least detached along its entire base. Meanwhile, a chronic discharge of pus continues from the original nail sulcus from under the eponychium, since the swelling and edema do not favor satisfactory drainage. This continues for some time, during which the matrix begins to proliferate freely and an almost fungus-like elevation of granulation tissue appears growing from underneath the overhanging cuticle. This picture of the neglected case is not at all uncommon, owing to the habit of the patients to consider this infection as unimportant and consequently to treat it by poultices and salves. In this they are often abetted by the ill- informed physician. At times, it is true, spontaneous recovery may take place, but most often the nail is lost after a more or less prolonged course. Let us consider the pathology of these chronic inflammations when they spread to the base of the PARONYCHIA 33 nail. It will almost always be found that the pus is under the overhanging edge of the nail. Upon exten- sion the pus follows around the nail sulcus, still under the nail. The soft and delicate nail root, under the eponychium, is raised entirely off of the nail bed, although the distal exposed portion of the nail is still firmly attached to the matrix. TREATMENT. With a clear understanding of the above pathology, it is. manifest that the only proper procedure is to allow escape of this . imprisoned pus. This is done by making a longitudinal incision along the outer edge of the nail, going back to the base as far as the sulcus, with especial care, let me repeat, to cut to the outer side of the nail so as not to cut the nail bed or the overhanging cuticle, since if this is done it may result in a permanently split nail when it grows out anew r . The eponychium is now pushed back with a sponge and the point of a sharp scissors inserted under the detached edge of the nail and this is cut off, together with as much of the root of the nail as had become separated from the matrix by the pus. It is wise, generally, to be on the side of radicalism, since otherwise secondary operations may become necessary. After removing this portion of the nail the elevated flap of overhanging cuticle is packed up and out of the field by a small strip of gauze saturated with vaseline to favor drainage for a few days. A hot, moist dressing is applied to the entire finger for a couple of days, after which time a vaseline gauze dressing or dry dressing is applied as the case may demand. Concerning those cases in which more than half of the base has become involved in the swelling and redness, a w r ord further is required. Here a second incision should be made upon the other side of the nail, using the same precaution as in the first incision, not to cut the nail bed or the overhanging cuticle 3 34 INFECTIONS OF THE DISTAL PHALANGES (Fig. 3). The eponychium which is now entirely sepa- rated from the epithelium on its two sides is pressed FIG. 3 Lines of incision used in paronychia. FIG. 4 Photograph of steps of operation in paronychia. Flap has been raised and the point of the scissors inserted under the base of the nail. back and elevated as before, exposing the entire sulcus. The loosened portion of the nail in these cases will PARONYCHIA 35 often comprise the entire nail root. This is completely removed, leaving the distal portion of the nail still attached to the matrix. Gauze is packed in, as before, to raise the flap and secure drainage (Fig. 4). It is not necessary to remove the distal portion if it is not already detached. It does not interfere at all with recovery, and is still of some service after the FIG. 5 Untreated paronychia. acute inflammation at the base subsides. The new nail rapidly forms, and in growing out pushes the old nail in front of it (Figs. 5, 6, and 7). In those cases in which the condition has been neglected or in which the liberating incisions have not been made at the sides, a considerable cauliflower-like growth of granulations may appear, as has already been mentioned. This is, of course, due to the irritation 36 INFECTIONS OF THE DISTAL PHALANGES FIG. 6 All inflammation has subsided and new nail is growing out, forcing the old remnant off. FIG. 7. Complete recovery at the end of seven weeks. SUBEPITHELIAL ABSCESSES 37 incident to inadequate drainage. Hence we should see that the drainage is free. This will be followed by the formation of nail and the rapid disappearance of the granulations. I have never yet cauterized these. In one intractable case rapid relief was secured by placing a rubber band about the base of the finger, producing a Bier's hyperemia for some days. SUBEPITHELIAL ABSCESSES. It is not at all uncommon for subepithelial infections to take place either as local processes or associated with more extensive infections. The epithelium may be raised over a considerable area, both upon the flexor and the extensor surfaces. This kind of infection is frequently seen as a local process about the distal phalanx, the contents being generally a seropurulent fluid of low grade of virulency. The treatment consists in removing the elevated epithelial covering and applying some dry dressing or hot boric dressing as the virulency of the case demands. It is essential that every part of the detached epithe- lium be removed, otherwise the moist, warm pocket will favor the further development of the infection. CHAPTER III. CARBUNCULAR INFECTIONS. THE carbuncles which develop on the hand are typical of that condition elsewhere. Carbuncles, al- though seen frequently, are often not understood by the practitioner, who does not take the proper steps necessary to their immediate cure. They may develop in any portion of the dorsum containing hair follicles, their most common site, there- fore, being the dorsum of the proximal phalanges (Figs, ii and 12) and the back of the hand upon the ulnar side. The various types of staphylococci are most often the exciting organisms. The peculiar pathology characteristic of this condition is due to the nature of the skin and subcutaneous tissue with its sweat glands, hair follicles, and columns of fat extending up into the derma. ANATOMICAL CONSIDERATIONS AND PATHOGENESIS. In an attempt to determine the source of these infections and the cause of their persistence, I made serial sections of a portion of the skin and identified the various structures in the succeeding sections, with- out, however, being able to say definitely that the source could be attributed to either the sweat glands or hair follicles alone. Repeatedly on examination a hair follicle with its sebaceous gland could be found in the subjacent columnae adiposse; on the other hand, it almost as frequently occurred that the convoluted sweat gland would also be found (Figs. 8 and 9). One could only conclude, therefore, that it was possible for the carbuncle to begin from either, although it ANATOMICAL CONSIDERATIONS AND PATHOGEN ESI S 39 seemed more reasonable to attribute its source to the hair and its sebaceous gland. Garre, Budinger, and others have demonstrated upon themselves that it is very easy to produce such infections by rubbing into the skin virulent streptococcus cultures. Sit'eat Gland Sagittal section of the skin showing columna adiposa. At the upper part note the hair follicle with its sebaceous glands connecting this column of fat with the skin. In the lower portion of the column of fat a sweat gland is seen. In the accompanying microscopic illustration of a cross-section of the skin, the various columnae adiposse may be seen with the hair follicles, sebaceous glands, and sweat glands in various locations (Fig. 10). From a study of this, the course an infection will pursue can be seen readily. Beginning in one of the columnae, 40 CA RB UNC ULA R INFECTIONS the accumulation finds readier escape downward into the subjacent fat. From there it spreads laterally and gradually fills the loose mesh under the skin and ascend into the various columnar, from whence the infection extends to the surface from these many sources, strain- ing through a sieve, as it were. As the process persists the central part of the surface becomes necrotic, and FIG. 9 Section parallel to the skin. Note that here we have two columnae adi- posae cut transversely. In one a hair is seen and in the other a hair and a sweat gland. It is readily seen how pus would follow along these to the surface. through this is extruded pus and seminecrotic connec- tive tissue. Even this does not give free drainage, and the process still tends to extend around the periphery. Meanwhile, more and more of the overhanging skin becomes destroyed, until such time as enough sur- face is destroyed to give free exit to the pus and the surrounding inflammatory infiltration walls off the infection, which it does with difficulty, owing to the ANATOMICAL CONSIDERATIONS AND PATHOGEN ESI S 41 many interstices in the loose mesh of subcutaneous tissue through which the pus can extend. An exami- nation of a schematic cross-section of such an inflamed area shows these various facts. Clinically they are FIG. 10 A section of the skin, subcutaneous tissue, and muscle, showing the area in which the pus of a carbuncle develops and how it spreads beneath the skin and comes to the surface through the various dark lines in the skin which represent the hair follicles. Note several dark dots (H) in the fat under- neath the skin. These are cross-sections of hairs which have penetrated beneath the skin and lie in the fat. 42 CARBUNCULAR INFECTIONS observed on the surface as follows: First, the central necrotic area: about this the area of tissue shows punctate pus exudations, and beyond this a bluish circumference through which the pus has not pene- trated, although it is under the skin, and, finally, surrounding it all, an area of induration denoting inflammatory reaction. FIG. ii . v\,. Schematic drawing showing the areas of the carbuncle with the length of incisions upon the skin. TREATMENT. These cases are best treated by a crucial incision, the ends of which extend beyond the edge of infiltration, followed by incisions under the skin, so that this may be raised off of the underlying TREATMENT 43 tissue (Figs, n and 12). The base of the flaps should correspond with the ends of the crucial incisions. FIG. 12 Schematic drawing showing areas of infection in the carbuncle and the method by which, through a transverse incision parallel to the skin, the flaps are raised up. Note that this incision F goes to the limit of the area of induration A; B, area of round-celled infiltration and some pus; C, area of pus, most of the fat being destroyed; D, area of necrosis. Hot, moist gauze is now packed under the flaps to insure drainage. The patients are always anesthe- tized, nitrous oxide being preferable. The reasons 44 CARBUNCULAR INFECTIONS for carrying the incisions in the skin beyond the edge of inflammatory exudation, as indicated by the in- duration, are difficult to understand. The principle is directly opposed to the ordinary conception of this area as a protecting wall, which in other con- ditions we would use every possible precaution to preserve. Of the advisability of the length, however, I have no doubt, since I have had occasion to use this method in probably 30 cases, and whenever the tech- nique described has been faithfully carried out the result has always been satisfactory. If, however, through a conservatism I fell short, the extension always took place along that area, while the sides where I had made the long incisions would go on to satisfactory recovery. This same holds true for carbuncles of the neck and other areas. The cuts parallel to the skin designed to free the skin from the deep fascia should be made about mid- way between these two layers, going back through the area of induration also (Fig. 12). Any arterial bleeding is stopped, but the venous oozing is controlled by pack- ing, and this packing should be sufficient to raise the flaps well up. The packing is removed at the end of twenty-four hours, and the flaps allowed to fall back. If there is not much venous oozing, the gauze is thor- oughly saturated with vaseline, which allows drainage and permits removal without pain to the patient. If there is any free slough it is removed at the time of operation. It is not necessary to curette or cut away any tissue whatever. The removal of any of the skin, no matter how much damaged and fragmentary, should be condemned, since one is always surprised at the rejuvenation of apparently hopelessly injured skin. I have often found the flaps to fall into place and leave a granulating area no larger than a dime, where it had seemed the entire area must be lost. For TREATMENT 45 that reason also one should condemn most severely the procedure advocated by some of excising the entire area. On the other hand, the crucial incision alone, without raising the flaps, is futile in almost all cases, and certainly prolongs convalescence. CASE I. In this connection the history of a patient sent me for treatment is interesting. When the patient was first seen he had been suffering for three weeks with a carbuncle on the dorsum of the left hand. It had begun as a small pimple on the ulnar side, and incisions had been made on six different occasions at different points. The infection had spread to involve the entire dorsum, and had extended to the flexor surface around the thumb and the wrist at the ulnar side. The slough- ing connective tissue was being extruded from the in- cisions and small necrotic ostea which had appeared over its surface. In other places ii had the characteristic appearance of a carbuncle. The patient was anesthetized and a crucial incision made, not, however, carrying the incision the full length of the infected area, for fear of impairing the nutrition of the flaps. The entire area, however, was undermined and gauze saturated with hot boric acid solution carried to the edge. An immediate cessation of the process took place except at the wrist, where a subsequent incision had to be made, owing to the inadequacy of the early incision. When the flaps finally healed, it was found that no grafting was necessary. So much of the skin had retained its vitality that the denuded areas were soon covered by epithelium. At times I have been compelled to cover a small denudation by a Thiersch graft from the patient's body. This should be done as soon as a good granu- lating base has been assured. This, in my experience, is more often necessary on the dorsum of the finger than on the back of the hand. The illustrations show, in both cases, beginning carbuncles (Figs. 13 and 14). The one on the finger 4G CARBUNCULAR INFECTIONS had been treated a week before it came under my observation, and, after incision, was dressed only FIG. 13 Beginning carbuncle on the ulnar side of the dorsum of the hand. FIG. 14 Carbuncle on the dorsum of the proximal phalanx. twice and was entirely well in a week. The one on the dorsum of the hand had been treated for six days DIFFERENTIAL DIAGNOSIS 47 after a simple incision. After opening it properly and applying the Bier suction cup, which I have at times used with success, entire healing followed in a week. This picture of an apparently simple case is presented, since it is in such that the diagnosis is not made. They are considered simple abscesses. The more severe cases with the punctate areas of pus, if they are acute, are recognized by all. DIFFERENTIAL DIAGNOSIS. Oidiomy costs. There is a more chronic type of infection of this area which may be mistaken for oidiomycosis (blastomycosis), and, conversely, an oidiomycosis may be construed to be a subacute carbuncle. The appearance of these oidiomycotic areas is very characteristic, presenting a rather clean granulating surface, while the edge which is undermined appears as if moth-eaten, with pus drop- lets exuding through. In some parts the process will apparently have healed and be covered by a thin, shining sheet of epithelium. Over the granulating area the skin is not completely destroyed, since areas of epithelium remain which rapidly produce epidermiza- tion when the process is halted. The diagnosis can be made readily by securing pus from the abscess and examining the unstained smear diluted with 4 per cent. KOH, or with normal salt solution. This finding may be corroborated by micro- scopic examination of the skin, which will show the proliferating rete with miliary abscesses. One such case came under my care in which the condition had been held to be a chronic infection and had been treated with salves and applications until the entire dorsum was covered by the ulcerated area. The edges were curetted thoroughly and potassium iodide given in large doses (400 grains per day). The lesion finally healed after some weeks, during which it was necessary to remove the extending edge in 48 CARBUNCULAR INFECTIONS various parts several times. Unfortunately, I have not a photograph of the lesion, but it was practically identical with that shewn by the photograph (kindly loaned me by Dr. Ormsby) of the same condition in a patient of his (Fig. 15). FIG. 15 Oidiomycosis. (Photograph loaned by Dr. Ormsby.) Typical and practically identical with that seen in Case II. CASE II. Mr. G. C., of Gallion, Ohio, was referred to me with the history that seven months before he noticed a small pimple on the dorsum of the right hand. The patient opened the pimple with scissors, following which the sore began to spread by peripheral extension. A couple of weeks later a similar lesion began on the neck, as a result of the patient scratching a pimple there. These two lesions continued to spread until about three weeks before I saw the patient, when two small pustules appeared upon the right arm, and since that several small lesions had appeared on the trunk, all possibly implanted through self-contamination by scratching. The lesion on the hand was of approximately the size shown in the illustration. That upon the neck was about one and one-half inches in diameter. The characteristic appear- ance already described was present. The areas were DIFFERENTIAL DIAGNOSIS 49 excised, following which all the lesions disappeared except that upon the hand. This also finally disappeared under curettage and large doses of potassium iodide. The condition is essentially different from the picture presented by the foul sloughing syphilitic ulcer or the blue undermined tuberculous process. Chronic Staphylococcus Processes. We may have a chronic Staphylococcus process upon the dorsum, as FIG. i 6 Chronic Staphylococcus infection of the dorsum simulating oidiomycosis. (See Case III.) has already been said, which may be wrongfully diag- nosticated as oidiomycosis. Such a case came under my observation with an ulceration upon the dorsum which had involved during its course a greater part of the area, some parts, however, showing pinkish, glistening new epidermis, while others showed active process appearing as an ulcerating granulating surface, 4 50 CARBUNCULAR INFECTIONS or rather as a depressed verrucous process, while the edges of these areas showed the advancing border of infection. Repeated examinations, both by culture and microscopic tissue study, demonstrated a pure culture of staphylococcus. It is my belief that the process had become chronic in its nature, owing to the peculiar anatomy I have described as being found here, coupled with lowered resistance to the specific organism and the irritation of the various treatments to which it had been subjected. It healed rapidly under bland, slightly antiseptic applications. It is my opinion that a passive hyperemia produced by local suction cups would also have hastened recovery in this case. An autogenous vaccine might also have helped. The case history, written by the patient, who was a physician, is ap- pended. The photograph (Fig. 16) shows the condition inadequately. CASE III. "Family history negative; aged forty-four years; good health. On September 12, 1910, I noticed skin on middle knuckle of right hand, flecked up as if by a pin. On the morning of the I5th I noticed some reddening of the knuckle extending up into the back of the hand, with a slight burning pain. On the morn- ing of the 1 6th my hand was badly swollen. Pain very severe when hand hung down, and burning was intense. "I treated it vigorously with wet dressings of bichlo- ride, carbolic acid, and boric acid alternately. The swelling subsided in a few days. The pain was not so severe, but the burning sensation continued. The place where the infection started broke down, forming something like a small ulcer. The infection then seemed to extend up the back of my hand. Every hair follicle seemed to be a centre of infection, breaking down and forming a small opening from which exuded pus. I treated it with iodine, carbolic acid, ointments of every description, dry and wet dressings. With all the treatment the infection continued to spread over the back of the hand, with more or less pain all the LlGFf-F'f OF _ r r r ,, r r DIFFERENTIA L DlA GNOSTS ' ^ # time, but increasing at intervals, the burning being almost continuous. "On December 25, 1910, becoming disgusted with my own treatment, and upon advice of my neighboring doctors, I left for Chicago. There my hand was ex- amined by a number of prominent physicians. Each man had a diagnosis of his own. Dr. W. L. Baum's diagnosis was staphylococcus infection. His diagnosis was proved by both culture and the microscope. This was corroborated by Dr. Kanavel. "Was under treatment of these physicians, which consisted of a bland, slightly antiseptic ointment, two weeks before I noticed much change; but within three weeks from the time they started treatment my hand was thoroughly healed, leaving a red scar, which yet remains. The scar resembles that of a severe burn, extending over the entire back of the hand." 31KWIU 3T20 3D3JJOQ CHAPTER IV. MISCELLANEOUS ABSCESSES. COLLAR-BUTTON ABSCESS (SHIRT-STUD ABSCESS) (FROG FELON). AMONG the local infections of the hand none is more typical than the collar-button abscess, or, as the French describe it, en bouton de chemise. This is an abscess located at the distal edge of the palm under the dermal and epidermal tissues. Its peculiar character is due to the fact that at this site, in workingmen, the epithe- lium becomes markedly hypertrophied, making a dense sheet under which the pus spreads. An infection present under the derma passes through this to the epidermal tissue, where a second abscess forms, thus producing a dumb-bell-shaped accumulation of pus. The pus may locate primarily in the epidermic space and erode through the dermal tissue rather than through the dense epidermis to the surface, producing the same condition. It is possible that this latter course is more common than the former. These abscesses doubtless owe their origin to the lessened resistance due to trauma more than those developing elsewhere, for here the thickened area of superficial cornified epithelium is frequently opened by cracking, infection ensues in the deeper area by lymphatic extension, or, if the cracks are deep, by direct inoculation. Here it finds excellent food for development, since the repeated trauma has lowered the normal resistance found in healthy tissue. In this connection attention should be drawn to the COLLAR-BUTTON ABSCESS 53 fact that at the lower or distal end of the palmar aponeurosis the sheet may become very thin in spots, particularly between the processes which blend with the tendon sheaths and the superficial transverse liga- ment, and hence above the canal for the lumbrical muscles. Here, by noting one's hand, slight elevations of tissue may be seen, cushions of fatty tissue. When pus accumulates at this point it spreads very easily into the web of the finger, and in those anomalous FIG. 17 Schematic drawing, showing distal palmar abscess and its extension into the dorsal tissue between the fingers. cases where the fascia is lacking to any extent these shirt-button abscesses would enter the fat space and spread down into the cellular tissue of the web point- ing on the dorsum between the bases of the fingers. Then the dumb-bell abscess would have from its second chamber a connection with a still larger one on the dorsum, a sort of chain of lakes of pus (Fig. 17). In relation to this, two very interesting cases can be cited, showing how infection apparently in nearly the same site may occupy different spaces. 54 MISCELLANEOUS ABSCESSES CASE IV. From Northwestern University Medical School Dispensary. History: C. B., carpenter by trade, has been using a chisel several days in succession almost constantly. He hits the handle of the chisel with the palm of the hand to force it along. Two days ago the patient began to note tenderness at the distal portion of the palm between the base of the index and middle fingers, about 2 cm. from web. Upon examina- tion this was found to be tender to pressure, and had considerable local hardness. Slight edema of dorsum. Temperature, 99; pulse, 85. Treatment. Incision was made over the area and a small amount of pus evacuated. This was under the deeper layers of skin lying upon the transverse fascia in the pad of fat found in this region. CASE V. E. A. Applied to dispensary of North- western University Medical School November 5, 1904. The patient noticed pain and tenderness at base of ring and middle fingers, about 1.5 cm. from web. Swelling and redness had been increasing for four days. Tempera- ture, 99; pulse, 86. Local swelling and redness at site noted, involving web also, but most marked above. Tenderness noted as severe. Diagnosis. Abscess, subdermal, above aponeurosis. Operation: ethyl chloride spray, and incision made over site of greatest tenderness, down through deep layers of palmar skin. Moderate amount of pus escaped, and upon inserting probe the larger part of the pus was found to be in the cellular tissues of the dorsal web area, ]/2 inch back from web. Through-and- through drainage inserted. November 9, nearly well. Patient did not return. Here we see two abscesses to all appearances in the same place, yet in reality very different, being so near the distal edge of the transverse ligament that while one was confined to the subdermal tissue, the second had invaded the adjacent cellular tissue of the web, and spread, by continuity of spaces, into the loose tissue of the dorsum, where most of the pus was localized. A BSC ESSES IN THEN A R A ND H Y POT II EN A R SPA CES 55 TREATMENT. The treatment, therefore, consists in being certain that the second pocket is opened if it be present, and not being content when after incising free discharge of pus is noted. Always examine care- fully by inspection or a probe for the second pocket. If the pus has extended to the space in the web, it may be drained by a through-and-through incision from the palmar to the dorsal surface through the web. I have at times cut the web completely without noting any subsequent impairment of function. LOCALIZED ABSCESSES IN THE THENAR AND HYPOTHENAR SPACES. In the thenar region several minor and indefinite spaces lie beneath not only the skin, but also the fascia which covers the muscles. The areas are small, how- ever, and are generally opened through the adjacent skin before any serious damage occurs. It is in these areas more often than the thenar space proper that direct infection from puncture takes place, since the latter lies rather deeply, and to invade it the puncture should enter between the muscular body and the ad- duction crease, rather than upon the prominent part of the thenar eminence. It is well to bear this in mind in making a diagnosis as to whether the thenar space is involved or not, since a minor infection in the super- ficial tissues of the thenar area either upon the palmar or dorsal surface may be associated with great edema upon the dorsum, and thus confuse the surgeon and lead to a diagnosis of pus in the thenar space when it is uninvolved. This error occurred in one of my cases, and is of particular interest, since it demonstrates that treatment based upon this improper diagnosis may not produce serious results, for here it will be noted that no disastrous sequelae followed the opening of 56 MISCELLANEOUS ABSCESSES the uninfected space in conjunction with an abscess of the subcutaneous tissue. CASE VI. E. K. Injured December 12, 1904, at stock- yards, by running foreign body into thenar eminence at about middle of palmar surface. All signs of localized infection followed, and on December 16 patient applied to dispensary for treatment. Diagnosis of infection of the thenar space made and through-and-through drainage of thenar areas instituted, under gas anesthesia. It was seen that the dorsal subcutaneous tissue only contained pus; tube was withdrawn and dorsal opening enlarged. Patient made rapid recovery and was discharged in ten days, apparently fully recovered. The hypothenar area is a closed space, as will be shown later, infection practically always arising from direct implantation and localizing at that site. It does not spread out of the space. Therefore, there is nothing peculiar in its pathology and the treatment of its abscesses consists in simple incision. PART II. GRAVE INFECTIONS: TENOSYNOVITIS, FASCIAL-SPACE ABSCESSES, LYM- PHANGITIS, AND ALLIED CONDITIONS. CHAPTER V. DIAGNOSIS IN GENERAL. IT is the purpose of this chapter to give in general the diagnostic factors of the three severe types of infection, viz., lymphangitis, tenosynovitis, and fascial- space infection. It is not intended in any sense as a complete discussion of any, but is introduced with the idea that by reading it the beginner may be able in any given case to make his diagnosis in general, and thus be directed to the more extensive subsequent discussions for corroboration. Therefore, in various parts indication is made where these can be found. It is desirable to emphasize this, since the greatest diffi- culty to be met in these cases is the diagnosis. Unfor- tunately, a snap diagnosis is too often made and incisions hastily carried out which jeopardize the life of the patient and the use of a hand, when a little more care in the diagnosis would have led to an immediate cure. It should be emphasized, further, that if careful study is made it is possible in nearly every case to diagnosticate not alone the nature of the infection, but also the location of the pus if it be present. 58 DIAGNOSIS IN GENERAL There are certain facts which should be remembered : 1. The location of the greatest swelling does not indicate the position of the pus. The excessive swelling comes in those areas where there is the largest amount of loose cellular tissue, i. e., upon the dorsum, while in nine cases out of ten the pus is on the flexor surface. 2. The site of the greatest tenderness is of marked importance in the location of the pus. 3. The three types of infection, viz., lymphangitis, tenosynovitis, and fascial-space infection, in the majority of cases, are distinct processes, one type alone being present in a given case. At times the types may be combined. 4. The treatment of the three types is essentially different, and the gravest of errors will be made if they are not differentiated, since their treatment is diametrically opposed (see pp. 259 and 361). Let us now take up these three types in order. LYMPHANGITIS. Lymphangitis may be either superficial or deep. Deep lymphangitis may end in tenosynovitis or ab- scess formation in the deep tissues. Most often, how- ever, this does not take place. There is rapid increase of swelling of the whole hand and forearm, with the greatest redness, swelling, and tenderness upon the dorsum. Some red lines of lymphatic infection may be seen running up the arm, to the axilla or elbow. There is an absence of pain on extension of fingers and thumb. The fingers can be moved voluntarily without pain, and there is an absence of tenderness over the tendon sheaths and the middle palmar and thenar spaces. There is the absence of bulging of the palm, although the concavity may be lost. The patient often presents great prostration (see pp. 337 and 342). TENOSYNOVITIS 59 The superficial type lacks the great swelling of the entire hand and forearm. We receive a history of a slight abrasion or injury on the hand; within a short time the patient complains of all the symptoms of systemic absorption headache, thirst, sleeplessness, restlessness, and fever. On examination we see locally an area of suffused redness, with a swelling of the finger which is involved. The color seldom becomes of that violaceous tint seen in abscess formation or the pallor which succeeds it. In the most acute types there may be little or no edema, but most often one finds a considerable edema most marked upon the back of the hand. The swelling varies with the site of the invasion. A general rule may be enunciated. The lymphatics pursue the shortest course to the back of the hand. In other words, if the infection enters at the distal part of the palm the course will lie between the bases of the fingers. The lymphatics upon the dorsum will show up as bright red streaks running up the arm. Ordinarily one or two only will be seen upon the back of the forearm, although there are fifteen to twenty here. The lymphatics from the little finger and ring finger pass to the glands in the epitrochlear region, and except in the fulminating type these will be found enlarged. From here the infection, is carried to the axillary region and thence to the circulation. The lymphatics from the thumb and index finger will be found coursing upon the back and outer side of the forearm and wending their way to the axillary glands without the intervention of the epitrochlear glands (see p. 312). TENOSYNOVITIS. This type of infection is much more difficult to diagnosticate, and the surgeon is often in doubt as to whether he is dealing with a lymphangitis or tenosynovitis. 60 DIAGNOSIS IN GENERAL The disastrous consequences of delayed diagnosis are so well known that the surgeon should study his cases most carefully, since in nearly every case an early diagnosis can be made and the function of the hand saved. The three cardinal symptoms and signs are: 1. Exquisite tenderness over the course of the sheath, limited to the sheath. 2. Flexion of the finger. 3. Exquisite pain on extending the finger, most marked at the proximal end. These symptoms are seen to be only a difference in degree from those found in any infection of the hand, but when they are sought for in an intelligent manner there is not much difficulty in differentiating the con- ditions. The size of the primary wound is of no importance. The tendon sheath may become infected secondarily to a simple pin prick or an extensive wound. One finds only the cardinal symptoms I have mentioned, and in addition he may notice that the abutting sides of the adjacent fingers are swollen, as well as the back of the hand. The whole of the involved finger is uniformly swollen. The whole hand is slightly tender and the fingers are slightly flexed. The involuntary expression of pain which is noticed when the tendon sheath is touched by the examining finger leaves no doubt in the mind of the examiner as to the location of the infection. The greatest amount of tenderness is generally com- plained of at the proximal end of the finger sheath in the palm at the metacarpophalangeal articulation. A difference is readily seen between the rigidity in the infected finger and the simple flexion in the adjacent digits. So great is this difference that one is able to diagnosticate an extension into the palmar sheath, for instance, from the little finger sheath, since the TENOSYNOVITIS 61 character of the flexion changes to the more rigid noted in tendon-sheath infection. The spontaneous pain, which was at first severe, grows less as the edema develops, and may delude the surgeon into believing that the process is subsiding. The arm seems "to fall asleep," as the patient expresses it. Paresthesia with creeping and itching sensations may be present, and, especially after rupture of the sheath, the tenderness may subside to a considerable degree, leading the surgeon to an early erroneous conclusion. An infection of the sheath of the tendon in the little finger may be localized to the finger. Extensions to other areas are possible, however. The following are the most common: (i) The ulnar bursa; (2) the radial bursa; (3) the forearm; (4) fascial spaces in the hand: (a) middle palmar space, (b) lumbrical space; (5) osseous involvement, middle phalanx; (6) joints, proximal interphalangeal, wrist; (7) rupture to the surface. Extension to the ulnar bursa is often difficult to diagnosticate. It is marked by the development of edema in the hand, especially upon the dorsum. A general fulness in the palm is seen, but the palmar concavity is still to be found. On the flexor surface the greatest swelling is found just proximal to the annular ligament. This is not necessarily due to the rupture of the sheath here, but to the looseness of the tissues, which permits of distention. This swell- ing is accentuated by the non-distensible annular ligament distal to it. The swelling in the palm occurs at the same time, but is not so conspicuous, owing to the palmar fascia. This also diffuses the swelling so that it is not accurately limited by the outline of the ulnar bursa. Moreover, the surrounding edema tends to confuse the picture (see pp. 209 and 212). 62 DIAGNOSIS IN GENERAL The most conspicuous and valuable sign is the ex- tension of the exquisite tenderness to the area involved. It should be remembered that this is absent after a few days. The wrist becomes fixed, the thumb shows tenderness to pressure, and particularly on passive movements is the sensitiveness noted. It is seen readily of how much importance the latter symptom is in diagnosticating an extension to the ulnar bursa from the little finger. We note that while at first the symp- toms are limited to the little finger and slight changes in the ring finger, because of its juxtaposition, all at once the thumb begins to show the characteristic signs while the index and middle fingers remain unchanged except for the increase of pain on passive extension explained above. This sensitiveness of the thumb may be due either to the juxtaposition of the sacs, or to a real extension into its sheath. At first there may be a diffuse redness of the palm and dorsum, but it rapidly gives place to a whitish or even cyanotic hue. Above the wrist, however, the tissue generally takes on a marked red color, which later becomes violaceous. The temperature and pulse may not be of any diag- nostic importance. Ordinarily, after the infection has lasted a few days and the walling-off process has begun, the temperature is that of the local accumulations of pus and varies with the freedom of drainage. The first few days, however, the systemic absorption bears no relation to the abscess formation and cannot be relied upon for diagnostic purposes. From the bursa various extensions may take place into the fascial spaces of the hand and forearm. The symptoms and signs of this extension will be taken up under the head of "Fascial Space Infection" (vide infra; see also p. 212). Involvement of the index, middle, and ring fingers presents the same signs as the little finger. The only FASCIAL-SPACE INFECTION 63 difference is that here the paths of extension are different. Besides the extension to the surface at the proximal end, involvement of the middle phalanx and the proximal interphalangeal joint, the finger may show extension to the lumbrical space on either side, and from here involve the adjacent tendon (see p. 216). Extension to the radial bursa is diagnosticated as following an ulnar bursitis by the increased swelling and tenderness in the thenar eminence and along the sheath. The tumefaction "of the thenar area is not that of abscess in the thenar space (see p. 224). Diagnosis of extension from a tenosynovitis of the thumb into the radial bursa and then into the ulnar bursa is more difficult. We must depend upon the extension of the tenderness to the area over the radial bursa and the tenderness above the anterior annular ligament. When the extension has proceeded over into the ulnar bursa the diagnosis is easier, since all of the fingers become painful to passive extension, most markedly the little finger, with tenderness over the area of the ulnar bursa. The tenderness over the sheath is not always so marked in secondary involvement, however, due possibly to the previously developed edema (see p. 221). The pus from the radial bursa may rupture into the tissues of the forearm, and then the pus lies under the flexor profundus tendons just as in rupture of the ulnar bursa (see p. 155). FASCIAL-SPACE INFECTION. Pus may be found in various spaces in the hand and forearm, as I have already pointed out. This may occur as a primary infection or secondary to lymphatic or tendon-sheath infection, especially the latter. I have 64 DIAGNOSIS IN GENERAL demonstrated by injection and serial sections the spaces in which such accumulations can take place. These well-defined spaces are five in number: 1. Middle palmar space. 2. Thenar space. 3. Hypothenar space. 4. Dorsal subcutaneous space. 5. Dorsal subaponeurotic space. The thenar and middle palmar spaces are by far the most important in the hand. The forearm has certain spaces which are likely to become infected. Briefly, it can be stated that pus which has extended from the hand to the forearm always lies under the flexor profundus, upon the pronator quadratus and intermuscular septum. It passes upward, following the ulnar artery, going as high as the elbow (see p. 159). Now, how shall we diagnosticate an involvement of these various spaces? First, upon the possibility of extension from other foci. The middle palmar space would receive infection by extension from the middle finger, ring finger, little finger, also from the ulnar bursa and localized infections in the lumbrical canals between the heads of the metacarpals. Again, it may be involved by direct implantation or through osteo- myelitis of the middle and ring metacarpals. It is possible for a thenar space abscess to rupture into the middle palmar space (pp. 168 and 225). The thenar space might receive the infection from the index finger or thumb, or by direct implanta- tion, or by osteomyelitis of the index or thumb meta- carpals, and finally it would be possible for the space to become involved secondarily to the middle palmar space (see pp. 168 and 225). The forearm may be involved by extension along the connective-tissue spaces under the tendons or FASCIAL-SPACE INFECTION 65 by rupture from either the ulnar or radial bursa (see pp. 154 and 394). The source of the involvement of the other spaces can be readily surmised (see pp. 168 and 224). When the middle palmar space is involved we notice that whereas earlier there had been a fulness in the palm without loss of the concavity; now the concavity begins to be lost, and as the process becomes marked, a slight bulging of the palm is noticeable in spite of the palmar fascia. The correlation of this with tender- ness is of especial value. Early, before the swelling becomes marked, the tenderness is exquisite and limited by the outlines of the middle palmar space; but as the swelling increases, the tenderness and especially the spontaneous pain grow less. There is generally more or less extension along the lumbrical canals, so that the swelling of the area between the heads of the meta- carpals adds to the general picture. The area may be red, but generally it is pallid. With this there is found the flexion of the fingers due to the juxtaposition of the tendons to this area. They are held rigidly flexed, decreasing in rigidity from the little finger to the index finger. The latter may have considerable voluntary motion. If the pus has extended along the lumbrical canals to the base of the fingers, there may be swelling and induration in the loose tissue of the web, and an accumulation of pus may be found to have extended to the dorsum between the bases of the proximal pha- langes. The relation of the swelling in the palm to that in the thenar area is of great importance. In involve- ment of the middle palmar space there is an associated swelling of the thenar space of almost the same degree as that of the middle palmar space, but this is due to edema (see pp. 225 and 233). When the thenar space becomes involved the swelling is out of all proportion to that of the palm if it be involved. There is the 5 66 DIAGNOSIS IN GENERAL induration of infection rather than the softness of edema. The thenar space will look as if a balloon had been inserted into the area and blown up to its full capacity. I know of no clinical picture in surgery that is more characteristic than this of thenar-space infection, and having once seen it one cannot forget it. Besides the ballooning out of the thenar area, the metacarpal of the thumb is pushed away from the hand; the flexion of the distal phalanx becomes more marked, though lacking the rigidity found in involve- ment of the tendon sheath of the flexor longus pollicis. This infection of the thenar space may be primary and isolated or secondary to a middle palmar infection (see pp. 1 68 and 224). The edema upon the back of the hand is always present and the swelling much greater, of course, than in the palm, even though that be the site of the pus. It is extremely uncommon to find any pus upon the dorsum unless there has been a lymphatic infection or the pus has extended, as already described, between the metacarpals of the index finger and thumb from the thenar space, or between the heads of the proximal phalanges. We should bear in mind that edema gives rise to a soft pitting, while if pus be present induration can always be felt. If this fact is borne in mind many embarrassing mistakes will be avoided. I think that in three-fourths of the hands I see in which treatment has been instituted a number of unnecessary and improper incisions are found upon the dorsum (Fig. 84). The infection may spread from either space to the forearm, or this may be involved from a tenosynovitis of the ulnar or radial bursa. As has been pointed out, the pus in these cases passes between the pronator quadratus and the flexor profundus to the area between the latter and the interosseous membrane, and at about the middle of the area it passes more superficially and FASCIAL-SPACE INFECTION 67 to the ulnar side along the ulnar artery and nerve. This extension is characterized by a brawny induration that should not be confused with the softness of an edema. No fluctuation should be expected, since the accumulation lies too deeply. If the primary source is the ulnar or radial bursa, this extension is marked by the loss of the relative swelling immediately above the annular ligament, due to the distended upper end of the sheath. This swelling is not any less, but that of the arm is greater. The tenderness may become less, so it cannot be depended upon as a symptom. The redness is generally greater, and spontaneous pain, while at first marked, rapidly subsides. At this time some pus may accumulate subcutaneously above the wrist and lead to the supposition that there is no pus under the tendons. Thus valuable time is lost (see pp. 216 and 394). Involvement of the hypothenar space can often be prognosticated from the site of the primary injury, while the relative lack of swelling in the palm and fingers, with absence of involvement of the tendons, combined with the ordinary symptoms of abscess, leads us to an easy diagnosis. Fortunately, the hypo- thenar area is so separated from the remainder of the hand that it is not frequently involved secondarily to palmar infection (see pp. 147 and 183). An infection localized under the subaponeurotic fascia to the exclusion of the subcutaneous tissue may be difficult of differential diagnosis. However, we are aided materially if we remember the character of the primary injury, the methods of extension to this space already mentioned, and the local evidences of infection upon the dorsum, with the pitting edema of the subcutaneous tissue, yet lacking the brawny induration and localized tenderness of a subcutaneous abscess (see pp. 147 and 183). 68 DIAGNOSIS IN GENERAL We may be in doubt as to whether we are dealing with a tenosynovitis of the ulnar or radial bursa or a rheumatism of the wrist. I have seen several such cases, and in one case it was difficult to determine whether the patient was suffering from a gonorrheal rheumatism of the proximal interphalangeal joint of a finger or a gonorrheal tenosynovitis with secondary involvement of the joint. The latter assumption was later found to be the condition present. In those cases presenting an apparently spontaneous development of an inflammation at the wrist, the diagnosis may be most difficult in spite of the ease with which a theoretical differential diagnosis is made. Here again, however, the localized tenderness over the sheath and pain on extension of the finger are of the greatest importance. Moreover, these cases are always virulent and extend rapidly, so that if it be a tenosynovitis the hand grows rapidly worse. In a rheumatism there is as much pain on the dorsal as on the volar surface, the swelling involves the wrist more than the hand, fingers, or forearm, and other joints may be involved. The presence of a gonorrhea does not aid us materially since either condition may follow. DIAGNOSIS OF EXTENSIONS FROM VARIOUS SITES. The diagnosis of the extensions from various sites is of the greatest importance from a therapeutic stand- point. I have worked out these possibilities by both experimental and clinical observations. The present chapter is too brief to allow a full discussion. I shall, however, append a tabulation, with references attached, denoting where a complete discussion of each subject can be found. If the infection originates in the thumb, for possible extensions see p. 194. DIAGNOSIS OF EXTENSIONS FROM VARIOUS SITES 69 If the infection originates in the index finger, for possible extensions see p. 185. If the infection originates in the middle finger, for possible extensions see p. 195. If the infection originates in the ring finger, for possible extensions see p. 197. If the infection originates in the little ringer, for possible extensions see p. 198. If the palmar space is involved, for possible exten- sions see pp. 144 and 176. If the thenar space is involved, for possible exten- sions see pp. 145 and 181. If the forearm is involved, for possible extensions see pp. 159 and 396. If the ulnar bursa is involved, for possible exten- sions see pp. 121 and 212. If the radial bursa is involved, for possible extensions see pp. 126 and 221. CHAPTER VI. GENERAL PRINCIPLES OF TREATMENT. IT is not the intention here to discuss in detail the treatment of the various types of infections. Specific directions for dealing with individual cases will be discussed in the chapters devoted to the different types. It is proper, however, to deal with the general principles underlying the various procedures which might be scattered in the succeeding chapters. The early treatment in any case has for its pur- pose the walling off of the infection, or its removal by phagocytic action. PROPHYLAXIS. Great care should be used in the preliminary treatment of minor as well as major injuries, especially in factories. If the foremen were taught to insist upon each man taking proper pre- cautions, many hands would be saved. Every man injured should apply at once to the foreman, who should pour iodine into the wound and apply a light sterile bandage for 24 hours. There should be no preliminary scrubbing or washing. This system could be instituted in all factories with little difficulty. REST. Rest is one of the essential factors, at least in a negative sense. The extremity affected should always be so fixed that movement, either of the whole or muscular action of a part, is impossible, since it is well known that the lymphatic streams are aided materially in their return flow by muscular action. It will undoubtedly relieve the patient somewhat of the throbbing pain to have the hand elevated after the von Volkmann method, but beyond that I cannot feel that the procedure is of great therapeutic value. PASSIVE HYPEREMIA 71 Positive factors designed to increase phagocytic action are still subject to discussion, in spite of the extensive contributions in support of this or that pro- cedure. They may be classified as systemic and local. The local again are divided into the results of active hyperemia and of passive hyperemia. DRUGS. The systemic use of drugs, such as nucleic acid, etc., to increase leukocytosis, has never been followed by such marked and positive results as to prove beyond question the advisability of their use, and all, so far as known, may ultimately be dis- carded, as was turpentine, which preceded them. They have never given any results in my hands. We are not now discussing the applicability of drugs and sera in systemic infections. They will be taken up under that heading later (see pp. 366 and PASSIVE HYPEREMIA. Among the local procedures those producing passive hyperemia (Bier) have re- ceived the greatest attention in later years. While much of an enthusiastic nature has been written in favor of this method, it is probable that the American surgeons have not secured the results claimed for it by its German supporters. It is not the province of such a contribution as this to review the subject, with a discussion of the various theories as to the changes in the blood; the lessened resistance as claimed by some and the raised opsonic index as maintained by others. My personal opinion has become quite settled as to its value in acute infections. I have found its chief value in three conditions: i. In those conditions in which I wish to prevent the rapid absorption of toxins into the circulating blood, as, for instance, in an acute lymphangitis (see pp. 363 and 364), or immediately after incising viru- lent abscesses of the hand and arm where a marked 72 GENERAL PRINCIPLES OF TREATMENT constriction will reverse the lymph stream and tend to wash the toxins out into the wound, preventing absorption (see pp. 235 and 287). 2. In those cases in which the process has become semichronic with a low grade of infection (see pp. 236 and 446). 3. In the case of localized abscesses which do not drain freely. Here the suction cup is of especial value (see p. 446). Beyond these conditions I must say I look upon it as a possible adjuvant in the treatment, but never as the primary factor. It follows, therefore, that early in the course of an infection, if we suspect the process to be particularly virulent, a bandage may be applied to the arm after the method described on pp. 235 and 363. Any other method is painful and may even be harmful. In the ordinary cases I have contented myself with other means, namely, hot, moist dressings, the use of which it would appear rests upon a more rational basis. Klapp has emphasized the value of suction cups used over a localized infection. He has devised various types to fit various areas. Their value in certain conditions cannot be gainsaid, particularly in those cases which would be classified in the second and third groups above. HOT MOIST DRESSINGS. These are in common use by all, and have proved beneficial in many cases. The most common form in which they are applied is that of the saturated hot boric acid solution, although many other medicaments are employed, such as potassium permanganate, alcohol, bichloride, etc. The solution of hot boric acid, in my opinion, depends for its effi- ciency largely upon the moist heat, although scientific evidence is not wanting that its chemical action may be of some value. In this connection Dr. E. H. Ochsner reports that Professor Kakenberg, at the HOT MOIST DRESSINGS 73 University of Wisconsin, conducted a series of examina- tions demonstrating the presence of a small amount of boric acid o.oi to 0.03 per cent. in urine voided after hot applications of a saturated solution of boric acid in water, 3 parts, and 95 per cent, alcohol, I part. This is not the occasion to discuss the question as to the bactericidal effect of boric acid, especially in small percentages. Other investigators have maintained that a large percentage is found in the skin and sub- cutaneous tissue. The dressings may be applied as follows: The saturated solution is boiled and then set aside, and, as it is desired, it is heated to as great a heat as can be borne by the bare forearm of the attendant. Greater heat, as demanded by some, is not needful. The patient should not be left to decide "if he can stand it," since the infected hand is often very insensitive to superficial pain, and the inadvertent application of the excessive heat may lead to blisters which will be annoying and prolong convalescence. After the desired temperature is secured a sterile towel is unfolded, the dressings are dropped into it, and it is then immersed at its middle in the water. The dressings are wrung dry by turning the two dry ends in opposite directions, thus securing the dressings properly saturated and wrung out, but still sterile. The dressing is now applied widely, covering the entire infected area, going proximally some inches. Fear rather that your dressing may be too small than too voluminous. The whole is covered by some impervious material, such as paper saturated with paraffin or sheet gutta-percha. This should be covered by a layer of cotton followed by a bandage. Provision should be made at the time of dressing for subsequent applications of the solution by making a hole or two through the outside covering down to the dressing. Through these openings the boric acid 74 GENERAL PRINCIPLES OF TREATMENT solution should be poured every two hours, and the hand dressed as frequently as necessary. Too often we see the hot boric acid continued for several days. It is not only useless but harmful to continue this treatment after the process is once under control, since it tends to favor congestion and round- celled exudation, which if long continued produces a soggy, infiltrated hand, in which absorption is slow, and as a consequence the ravages of the disease are slowly repaired and fibrinous ankylosis of joints, adhesions of the tendons, shrinking of muscles, and fibrosis in all the various structures are favored. As soon as the process has subsided it may be treated in various ways, according to the condition. In the presence of congestion, a dressing saturated with a weak solution of alcohol or equal parts of alcohol and glycerin will aid in the dehydration. If there is a foul discharge, a i to 2000 potassium permanganate dressing is advisable. If there are many raw surfaces requiring dressing, the gauze may be saturated with vaseline, which permits of painless dressing and does not retard drainage. Against alcohol may be urged with justice its inflammability, so that it should always be used with care. One case came to my notice in which the patient was severely burned through its use. PROPHYLACTIC INCISION. One constantly meets cases in which the patient has been subjected to incision at some swollen or tender area, under the assump- tion that if there is not pus there the "drainage will do good anyway." Such incisions are always ill- advised, since they nearly always do more harm than good. A general rule should be laid down not to incise unless the surgeon has an accurate appreciation of the condition and an absolute diagnosis made. In general one may say that incision in lymphatic infections PROPHYLACTIC INCISION 75 should be made as a last resort or because of secondary complications (see pp. 364 and 372). Tenosynovitis should be treated by drainage as soon as the diagnosis is made (see pp. 257 and 259). Abscesses of the fascial spaces are never so urgent as to demand operation before one is sure of the diagnosis. These rules are urged most emphatically, since I see in consultation fully as many cases in which the incision made has been ill-advised or unnecessary as I do those in which further surgical work is indicated. When incision has been decided upon certain rules are imperative in the severe case. The operation should be done in a bloodless field. A Martin bandage is to be preferred which is applied from the elbow to the shoulder. After the operation is concluded the band- age is loosened slightly, just enough to allow circulation, but still tight enough to prevent rapid absorption. In fact, I attempt to produce a Bier's hyperemia. This is done with the hope of preventing the rapid absorption of toxins. In a patient who is severely ill such rapid absorption may take place as to over- whelm the system before it has an opportunity to develop antitoxins, while if the bandage is removed through the course of twenty-four hours the system may have an opportunity to develop antitoxins and ward off a systemic infection that might ultimately lead to death. Again, the patient should always be anesthetized. Nitrous oxide is the anesthetic of choice, owing to its non-toxic action. This gives time for carefully placed and adequate incisions. The surgeon should always convince himself before allowing the patient to awaken that he has done the work thor- oughly so that the operation will not have to be re- peated upon subsequent days. This cannot be done under local anesthesia. Moreover, the hypodermic injection of tissue about an infected area cannot be 70 GENERAL PRINCIPLES OF TREATMENT done without danger of causing a. spread either locally or systematically. DRAINAGE. Drainage of wounds . by means of gauze, tubes, etc., is not of the importance attributed to it by some. The essential factor is to make the incision at the right place and of adequate size. If this is done, drainage strips will be not only unnecessary after the first forty-eight hours, but often positively detrimental to recovery. After incision it is my custom to use either plain gauze, gauze saturated with vase- line, or gutta-percha strips. The former is used only when there is venous oozing and we desire to stop it by favoring coagulation. We must never expect it to do more than this, and keep the edges of the wound separated, for the plain gauze mesh is soon filled with pus and coagulated serum, which acts as an effectual bar to drainage. Where there is no bleeding, gauze strips thoroughly saturated with vaseline or gutta- percha strips are used. These secure adequate drain- age, and can be removed without pain. They are left in for twenty-four to forty-eight hours; if left in longer they prolong the suppuration. It has happened to every surgeon to see cases in which the wound has been kept open for weeks by ill-advised drainage material. Rubber tubes are never used, since they favor tissue necrosis and are not any more satisfactory for drainage than gutta-percha strips. It has been suggested by some that in order to prevent rapid absorption and danger of generalized infection, it would be advisable to open abscesses by the cautery, and again others have suggested painting the cut edges with some solution of iodine. The advisability of this procedure is open to discussion, since it surely should not be used unless the abscess is thoroughly walled off, in which case it is possible to conceive of this procedure being pathologically STIMULATION OF EXCRETION 77 sound. In a majority of cases, however, bacteria and toxins in the wall are thus sealed up and serum drain- age by the method I have suggested is prevented (see pp. 236 and 284). Thus the patient is in greater danger of systemic infection or prolonged local dis- turbance. It is my personal belief that any procedure which impairs the vitality of tissue cell life, thus reducing its resistance and reparative powers, will be discarded in the end. The common habit of pressing and squeezing wounds with the purpose of forcing out the contained pus cannot be too severely condemned. It is both un- necessary and harmful. If adequate incision is made, the pus free in the abscess will drain out, and if it is in the layers of fascia adjacent to the wound, pressure is just as likely to force it farther into the tissue as into the abscess cavity. If the opening is small and drainage inadequate because of the thickness of the pus the wound should be opened more widely, or the pus removed by the Klapp suction cup. If the open- ing is plugged by seminecrotic connective tissue, it may be removed by the forceps, never with a sharp curette. To repeat, the pressure and squeezing tend to disseminate the infection throughout the surround- ing tissue and even produce systemic infection or dislodge septic thrombi. After almost all incisions in virulent cases there is severe local reaction, causing more swelling in the first twenty-four to thirty-six hours. At the end of that time, if the process has been properly drained, the swelling, and temperature should begin to subside. STIMULATION OF EXCRETION. The excretions should be stimulated, particularly by the introduction of large amounts of water into the system. This may be done subcutaneously by rectum or by mouth, accord- ing to the conditions to be met. If introduced by 78 GENERAL PRINCIPLES OF TREATMENT rectum, ordinary tap water has been more satis- factory than normal salt solution, since it is better borne by the patient and relieves his thirst more quickly. In the severe toxemias I also use alcohol and peptonized foods for the reasons enumerated later (see p. 366). MASSAGE. The early use of massage and passive motion is one of the . essentials in the production of functionating hands. Its use is particularly urged in tendon-sheath infection (see p. 286). BAKING IN DRY, HOT AIR. Auchincloss, who has made an extensive study of infections of the hand, tells me that he has had most satisfactory results from the use of baking in dry, hot air. He is convinced that this gives the patient much comfort and adds to the recovery after hot fomentations in the acute as well as the chronic cases. The idea seems to be per- fectly rational and I believe will be a distinct addition to our therapy in these cases. SECTION I. THE ANATOMY OF THE HAND AND FOREARM, WITH ESPECIAL CONSIDERATION OF ITS RELATION TO INFECTIONS OF THE SYNOVIAL SHEATHS AND FASCIAL SPACES. CHAPTER VII. METHODS OF STUDY IN GENERAL: STUDY OF SERIAL CROSS-SECTIONS OF THE HAND, WITH PARTICULAR RELATION TO THE FASCIAL SPACES. UPON beginning the study of infections of the hand it was realized immediately that our general knowledge of the anatomy was entirely inadequate when we came to apply it to specific conditions. The first problem, therefore, with which we had to deal was a thorough study of the anatomy carried out entirely in relation to this question. As the work progressed, its immense value from a diagnostic and therapeutic standpoint began to be realized. The reasons for many failures in treatment were seen. The diagnosis was placed upon a firm basis. We are firmly convinced that any- one who wishes to master the proper steps in diagnosis and treatment must follow step by step the unfolding of the anatomical picture as we shall try to present it in the subsequent pages. It will be discussed in the following manner: 80 METHODS OF STUDY IN GENERAL Anatomy of the Hand and Forearm, with Surgical Deductions. A. Anatomy of the hand. I. Methods of study. II. Study of serial cross-sections, with particu- lar relation to fascial spaces. III. Study of the tendon sheaths in general. IV. Study of the fascial spaces and tendon sheaths by means of experimental injections. V. Study of x-ray pictures of injected hands. VI. Study of the embryology. B. Anatomy of forearm. I. Anatomy in general. II. Study of serial cross-sections. III. Study by means of injection of the con- nective-tissue spaces. METHODS OF STUDY. I. With the object of securing a tentative picture of the spaces and their relation to the tendon sheaths in particular and other structures in general, a freshly amputated cadaver hand was hardened in formalin and cross-sections made, beginning at the middle joints of the fingers, and cutting sections about one centimeter in width, going as high as the elbow. The fascial layers were then teased out and their relations to the muscles, bones, tendons, nerves, and blood- vessels determined. The prolongations of the various spaces were followed up, each space and each tendon sheath being followed from one section to another; thus, their limitations were determined and the rela- tion of the various adjacent structures noted. The specimen chosen was one with but little fat (Fig. 18). The same process was carried out in a fresh cadaver METHODS OF STUDY 81 hand in which the vessels were injected and the sections cut while the hand was frozen. Sections were made of a third hand at right angles to the metacarpal bone of the thumb, since it was found that the findings in the thenar area were somewhat confusing. This hand also was frozen, and, like the first and second, without much fat. By these sections a fairly definite idea of the spaces was secured. FIG. 1 8 ' Drawing made from specimen showing sites of the various sections taken through the hand. 2. To corroborate the findings above, as well as to determine their exact limitations, injections w r ere made into the various fascial spaces, by various channels, and with varying degrees of force. This determined not alone the positions and relations of the pockets, but also by what channel pus could reach them and where it would extend if it broke through the walls 82 METHODS OF STUDY IN GENERAL of the closed fascial spaces. By this we also deter- mined the course pus would pursue when it ruptured from the tendon sheaths, and thus fixed the relation of the tendon-sheath infections to fascial-space infections. The findings were very uniform and satisfactory, with the exception of three or four which did not reach the spaces intended. The material used was such as is ordinarily found in the dissecting room; hence, while the part was always well preserved, in some cases the material was more friable than in others, and, therefore, rupture from the space was more likely to occur. How- ever, this does not interfere with the deductions, since the changes present were, in a measure, comparable to those found in inflammatory processes. Moreover, no matter whether the tissue was fresh or preserved, the findings were the same, so we may feel sure that the results are to be depended upon. The fascial spaces of 56 hands and forearms were injected from various sites by plaster of Paris, which had been rubbed up with glycerin and diluted with water. It was injected by means of a hand pump through a cannula, which was inserted at various points, as will be noted later. As the hands were dissected, the location and paths of extension of the masses were noted. In those cases injected with moderate force a pressure of 4 to 8 pounds was used, and where forcible injection is noted, 25 to 35 pounds. 3. Several hands were injected as above, except that the injection mass was impregnated with red lead. X-ray pictures were taken. This showed the relation of the theoretical pus accumulations to the bones and bloodvessels, the latter having been injected with the same mass. Again, in other hands, injections of vari- ous spaces were made, concomitant with injections of the synovial sheaths, to show their relation and the A STUDY OF SERIAL CROSS-SECTIONS 83 proper site for operations designed to open the former without injury to the latter. 4. After this work had been done a study of the embryology was made, with a view of determining whether or not there was any relation between the anatomical peculiarities of the spaces and the embryo- logical development. 5. The clinical cases which came under observation were observed very carefully to see if the real pathology corresponded with the anatomical demonstration. Bac- teriological studies of all cases were made, that we might investigate the relation between the variety of germs present and the tendency to spread. A STUDY OF SERIAL CROSS-SECTIONS, WITH PARTICULAR RELATION TO THE FASCIAL SPACES. That we may follow the study of the serial cross- sections with more understanding, the following facts should be noted: It is known that five spaces may be found in the hand; the information about them, however, has been very indefinite. The result of our study shows that upon the palmar surface we have three distinct chambers, not communicating in any way with each other, and to these are given the names thenar, hypothenar, and middle palmar spaces re- spectively. Certain channels will be found which lead directly into them. Certain structures along which pus can pass will be noted lying in juxtaposition. Again, minor anatomical chambers will be noted; these, however, need little or no consideration from a surgical standpoint, since they are unimportant, not likely to become infected separately, and if they do, they will rupture into one of the larger pockets. Upon the dorsum two areas will be found, in each of which pus can accumulate to the exclusion of the other. 84 METHODS OF STUDY IN GENERAL To these are given the names dorsal subcutaneous space and dorsal subaponeurotic space. We shall find that while the pus may lie at various levels in the subcutaneous tissue, from an anatomical standpoint, yet for surgical purposes any subdivision of this space is unnecessary and confusing. Section I. Beginning with a cross-section which lies just distal to the web of the fingers, we note the following facts: The index finger is slightly different FIG. 19 SC5 FT Cross-section No. I. DSAS, dorsal subaponeurotic space; DV and N, digital vessels and nerves; ECT, extensor communis tendon; FT, flexor tendon; PP, proximal phalanx; SCS, subcutaneous space; SS, synovial sheath. The tendon sheaths are shown in red. from the middle and ring fingers in that the space which is most superficial, and which we will call "the subcutaneous space, " does not extend around the entire finger, as do the others, but at the radial side the peri- fascial space tissue is so dense as to obliterate it. It will be noted that this space is deep, and that between it and the skin is to be found considerable tissue which is rather dense and does not lend itself readily to the spread of pus, which in this area is more likely to come to the surface or infect the space above mentioned, A STUDY OF SERIAL CROSS-SECTIONS 85 where it will have little difficulty in spreading proxi- mally or distally (Fig. 19). The little ringer corresponds with the index finger in that the space is obliterated upon its ulnar side. Between the tendon and the bone in each of the four fingers there is a second space, and to this we will give the name of "dorsal subaponeurotic space of the finger," for upon each side of the tendon a dense sheet of tissue is given off, which unites firmly with the periosteum at each side. Upon the flexor surface are found the flexor tendons in their synovial sheaths, which sheaths are so closely united to the periosteum that no definite free spaces can be found. The importance of the close attachment of the tendon sheath to the bone will be brought out when discussing tendon-sheath infection in relation to the frequency of osteomyelitis secondary to this trouble. In my experience the "subcutaneous space" men- tioned above is frequently the seat of an abscess, and care should be taken not to mistake it for a tendon- sheath infection. The spaces above mentioned all pass through this serial section into the next, the second cross-cut being made through the epiphysis of the proximal phalanx. Section II. In this section the salient points may be pointed out briefly, so that we can retain a com- posite picture with that which has just been described (Fig. 20). The subcutaneous space is continuous with that in Section I ; at the volar side, however, we note a begin- ning division into two palmar and dorsal. The subaponeurotic space is also continuous and the interossei muscles (IM) begin to appear one part attached to the periosteum and one part to the dorsal aponeurotic sheet. More important still, we see the beginning of the lumbrical muscles (LM), and 86 note particularly the relation of this muscle to the sub- cutaneous space, especially in the third finger. The flexor tendons are still covered by their synovial sheaths. Ask yourself where pus would land if it followed down along the lumbrical muscle from the palm. As we follow these spaces into the next section, we will see that the subcutaneous spaces upon the abutting sides of the fingers merge into each other; that is to FIG. 20 Cross-section No. II. Through epiphysis of proximal phalanx. DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; DV and N, digital vessels and nerves; ECT, extensor communis tendon; EPP, epiphysis proximal phalanx; FT, flexor tendon; IM, interossei muscles; LM, lumbrical muscle; SS, synovial sheath. The tendon sheaths are shown in red. say, the subcutaneous spaces of the ulnar side of the index finger and the radial side of the middle finger join at the web, being in close relation to the lumbrical muscles; slightly proximal to this, as will be seen in the next serial section, the space is obliterated between the fingers, and only a small part remains upon the dorsum of each finger. It is in connection with the space about the lumbrical muscle in the palm, however, so that pus may spread from the palm downward into A STUDY OF SERIAL CROSS-SECTIONS 87 this space and thus point on the dorsum. (For sche- matic drawing showing this, see p. 437.) The dorsal subaponeurotic space is obliterated in this section, i. e., at the joint. Section III. The distal surface of the third serial section is seen upon a cut 0.5 cm. proximal to the joint (Fig. 21). Note here: FIG. 21 Cross-section No. III. Proximal to metacarpophalangeal joint. DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; DT, dense fibrous tissue; DV and N, digital vessels and nerves; ECT, extensor com- munis tendon; FT, fiexor tendon; IM, interossei muscles; LM, lumbrical muscle; MB, metacarpal bone; SB, sesamoid bone; 55, synovial sheath. Tendon sheaths are shown in red and the boundaries of the lumbrical spaces in blue. The absence of the subaponeurotic space, except for small diverticula lying between the two parts of the interossei muscle. The absence of the subcutaneous space between the fingers. It is continued, however, in the dorsal sub- cutaneous space (DSCS) and the space about the lumbrical muscle (LM). That the lumbrical muscle lies in a sheath of its 88 METHODS OF STUDY IN GENERAL own, as it were. This communicates with the subcu- taneous space of the fingers, and should be followed carefully into the palm. The dense layer of tissue that crosses the whole section lying around and over the tendon sheaths and under the lumbrical muscle. That the flexor tendons are surrounded by their sheaths. FIG. 22 Cross-section No. IV. Two cm, proximal to joint. ATP, adductor trans- versus pollicis; DB, digital branch, DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; DT, dense fibrous tissue; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; FT, flexor tendon; IM, interossei muscles; LM, lumbrical muscle; M, metacarpal bone; MFC, middle flexion crease; MPS, middle palmar space; RI, radialis indicis; SS, synovial sheath; TS, thenaj space. The tendon sheaths are shown in red and the lumbrical spaces in blue. Note the beginning of the middle palmar space. The spaces are all obliterated in passing either through this section or the previous one, except the synovial space about the flexor tendons, that about the lumbrical muscles, and the slight channel on the dorsum, above noted, passing between the subcu- taneous tissue of the finger and the hand. A STUDY OF SERIAL CROSS-SECTIONS 89 The surgical application of this will be brought out later. Section IV. The fourth cross-section lies two cen- timeters above the joint (Fig. 22). FIG. 23 L Cross-section No. V. 3$ cm. proximal to joint. A TP, adductor trans- versus pollicis; DIM, dorsal interosseous membrane; DSAS, dorsal sub- aponeurotic space; DSCS, dorsal subcutaneous space; ECT, extensor com- munis tendon; FLP, flexor longus pollicis in its synovial sheath; FT, flexor tendon; H M, hypothenar muscles with intermuscular spaces; IM, interossei muscles; 75, space between adductor transversus and first dorsal interosseous; IV, interosseous vessels and nerve; LM, lumbrical muscle; M, metacarpal bone; MPS, middle palmar space; PIM, palmar interosseous membrane; RI, radialis indicis; TS, thenar space; UB, ulnar bursa; UV and N, ulnar vessels and nerve; V, vein. The tendon sheaths are shown in red (ulnar bursa and radial bursa) . The outline of the middle palmar and thenar spaces are shown in blue. The dorsal subaponeurotic spaces, which were oblit- erated at the joint, are beginning again between each tendon and the corresponding bone. 90 METHODS OF STUDY IN GENERAL The dorsal subcutaneous spaces approximate each other. The palmar tissue is still dense, with no free passages except those about the lumbrical muscles and those along the sheaths of the tendons which are still present, but begin to be obliterated as they pass through this serial section. As yet no space has appeared into which pus would extend if it were to pass proximally along these syno- vial sheaths. We note, however, that a small space has appeared just above the small piece of adductor transversus muscle, which will become the thenar space (TS). Now let us imagine ourselves following through this serial section into the next. The free, open spaces of the hand appear suddenly, the synovial sheaths of the tendons become obliterated after entering them, the lumbrical muscles join the tendons, and the adduc- tor transversus, which is the keynote to the thenar space, begins to assume its characteristic relations. Section V. If we cut across about three centimeters above the joint, we find the following, which is well represented in Fig. 23. THE MIDDLE PALMAR SPACE. There is a large, free space with few fibrous septa extending from the middle metacarpal bone to the radial side of the metacarpal bone of the little finger. It is bounded dorsally by a thin fibrous sheet which overlies the anterior interosseous membrane and the interossei muscles; upon its palmar side is a second thin sheet separating it from the tendons and the lum- brical muscles of the little and ring fingers. The space is limited upon its ulnar side by dense, fibrous tissue, and upon its radial side by a dense, fibrous sheet THE THENAR SPACE 91 which lies over the adductor transversus. This space is probably the most important in the hand, and to it is given the name of "Middle Palmar Space." If we were to note the layers of tissue through the middle of the hand, going from the palm to the dorsum, they would be as follows: 1. Epidermis. 2. Dermis. 3. Firmly meshed subdermal connective tissue. 4. Palmar aponeurosis. 5. Loose mesh of connective tissue, in which lie (a) vessels; (&) tendons with lumbrical muscles, or endings of the synovial sheaths. 6. Anterior middle palmar sheet. 7. Middle Palmar Space. 8. Posterior middle palmar sheet. 9. Vessels. 10. Palmar interosseous membrane, extending from bone to bone. 11. Interossei muscles. 12. Posterior interosseous membrane. 13. Dorsal subaponeurotic space filled with thin meshed connective tissue and vessels. 14. Dorsal aponeurosis and tendons. 15. Dorsal subcutaneous space, with loose connec- tive tissue. 16. Dermis. 17. Epidermis. THE THENAR SPACE. Upon the radial side we note the large mass of the adductor transversus, and upon its palmar side is shown a large space extending from the metacarpal bone of the middle finger over the muscle to the radial side of the hand, stopping, however, at the middle of the radial side, at about the level of the palmar 92 METHODS OF STUDY IN GENERAL surface of the bones; or, in other words, being L-shaped in cross-section. It will be seen later that this limita- tion is of importance, since it prevents injection masses from passing freely to the dorsum of the hand, or vice versa. This space is known as the " Thenar Space. " Upon its palmar side there is a. strong layer of tissue, blending into the dense tissue of the palm, and between this dense palmar tissue and the space lie the tendon and lumbrical muscle of the index finger. Over the adductor muscle is a thin layer of tissue or perimuscular sheath. The middle palmar and thenar spaces are the two most important spaces in the hand, and it is well to note their relations to each other and to adjacent structures. They will be taken up later, and a com- posite picture made from the fragmentary description noted here and in the following serial sctions. Upon the dorsum the dorsal subcutaneous and sub- aponeurotic spaces are well shown. The synovial sheaths have entirely disappeared except for a small prolongation along the little finger tendon (UB) and that about the flexor longus pollicis (FLP). The tendon sheaths of the three tendons were obliterated while passing through this section. The ulnar bursa (UB), however, is seen to lie in juxtaposition to the middle palmar space as do the tendon sheaths of the middle and ring finger distal to this section. The tendon sheath of the index finger is in close connection with the thenar space (TS). Section VI (Fig. 24). This serial section is taken through the distal part of the thenar eminence, and thus shows the metacarpal bone of the thumb in cross- section. Here we note the great relative size of the thenar space (TS), and yet it is all upon the radial side of the middle metacarpal. The lumbrical muscle and index tendon are separated from it by a much THE THENAR SPACE 93 thinner septum than in the previous section. The tendon of the flexor longus pollicis appears here surrounded by its synovial sheath. FIG. 24 DSCS P1M 1M ( :!v - IT5 Cross-section No. VI. Through distal part of thenar area. A TP, adductor trans versus pollicis; DIA, dorsalis indicis artery; DP A, deep palmar arch digital branches beginning; DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; HM, hypothenar muscles with inter- muscular spaces; IM, interossei muscles; ITS, indefinite thenar spaces; IS, space between adductor transversus and first dorsal interosseous ; LM, lumbrical muscle; MA and N, median artery and nerve; M, metacarpal bone; MPS, middle palmar space; PF, palmar fascia; PIM, palmar interosseous membrane; TS, thenar space; TM, thenar muscles; TMF, tendon of middle finger; UB, ulnar bursa; UV and N, ulnar vessels and nerves. The ulnar bursa, radial bursa, and an intermediate tendon sheath are shown in red. The boundaries of the middle palmar and thenar spaces are shown in blue. The middle palmar space is much smaller and still lies under the group of tendons of the middle, ring, and little fingers. Upon the ulnar side of this group we see the ulnar synovial bursa in juxtaposition to the space, yet the septum between them must be strong since the injection masses in this bursa, noted later, 94 METHODS OF STUDY IN GENERAL have a greater tendency to rupture into the forearm than into this space. Upon the dorsum we still find our subaponeurotic and subcutaneous spaces, while over the thenar area the subcutaneous tissue is also lax, and either of the two former spaces can be made to communicate with it. The deep palmar arch (DP A) appears in this section, and its relation to the middle palmar space and the synovial sheath should be noted. We see that there is not much danger of injuring it if care is taken in operating. In the cases examined the flexor longus pollicis with its tendon sheath is separated from the thenar space by a considerable amount of tissue, and while rupture from it into the space is possible (particularly in those cases accompanied by inflammatory destruc- tion), yet it would be more likely to rupture at the upper end of the synovial sac into the cellular tissue of the forearm. Experimental evidence to support this will be brought forward later (see pp. 126 and 127). Section VII (Fig. 25). In the seventh section, taken through the base of the palm, the middle palmar space and the thenar space are seen to have shrunk into insignificance. They lie close together under the group of tendons, the middle palmar space being more superficial. They are still separated by a thin sheet, however, in those specimens examined. One or two indefinite spaces are present about the thenar region. They are of little importance, however, except to note that they are present between the groups of muscles, and localized infection can occur in them under exceptional circumstances. The dorsal spaces remain the same, except that the subaponeurotic is more constricted. The tendon sheaths are seen in four places the ulnar bursa (UB), the sheath about the flexor longus THE HYPOTHENAR SPACE 95 pollicis (FLP), and the two intermediate sheaths about the superficial tendons in juxtaposition to the ulnar bursa. These will be discussed later (see pp. 109 and no). M.N. FLP Cross-section No. VII. DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; FT, flexor tendon; HM, hypothenar muscles with intermuscular spaces; IS, space between adductor transversus and first dorsal interosseous; M, metacarpal bone; MN and V, median nerve and vessels; MPS, middle palmar space; RA, radial artery; SS, synovial sheath; TM, thenar muscles; TS, thenar space; UB, ulnar bursa; UV and N, ulnar vessels and nerve. The ulnar and radial bursas and the intermediate tendon sheaths are outlined in red and the middle palmar and thenar spaces in blue. THE HYPOTHENAR SPACE. Nothing as yet has been said of the hypothenar area, since it was desirable to avoid confusion. However, a glance at this section, and at those which have 96 METHODS OF STUDY IN GENERAL preceded, shows very clearly that while it is possible for pus to accumulate in the intermuscular septa of this space, yet it would be absolutely localized here, FIG. 26 EMfl ECU Cross-section No. VIII. DSCS, dorsal subcutaneous space; EC, extensor communis; ECRB, extensor carpi radialis brevior; ECRL, extensor carpi radialis longior; ECU, extensor carpi ulnaris; EMD, extensor minimi digiti; EPTP, extensor primi internodii pollicis; ESIP, extensor secundi internodii pollicis; FLP, flexor longus pollicis in its synovial sheath; HM, hypothenar muscles with intermuscular spaces; M N and V, median nerve and vessels; PL, palmaris longus; PMPS, prolongation of middle palmar space; RV and N, radial vessels and nerves; SS, synovial sheaths; TM, thenar muscles; UB, ulnar bursa; UV and N, ulnar vessels and nerve. The ulnar bursa, radial bursa, and intermediate sheaths are shown in red. The small prolongation of the middle palmar and thenar spaces in blue. and would spread to the surface. It would not enter either the middle palmar space or the ulnar synovial bursa. Such infections would be of little surgical interest, ow r ing to their localized nature. THE MIDDLE PALMAR AND THENAR SPACES 97 Section VIII (Fig. 26). In the eighth section, taken at the wrist, the middle palmar and thenar spaces can still be found, but they are so small as to be of little practical importance, since any inflammation in them would probably be followed by closure. Their behavior under forcible injection will be noted later. While it might be possible by forcible dissection to produce a dorsal subaponeurotic space, yet it should not be described as being present. The dorsal subcutaneous space can be demonstrated, but it is more difficult to do so here than in the previous sections, since more of the fibers tend to intermingle from layer to layer. The synovial sheaths about the dorsal tendons also appear in this section. DISCUSSION OF THE RELATIONS OF THE MlDDLE PALMAR AND THENAR SPACES. The inter-relation of the middle palmar and thenar spaces is of very great interest to the surgeon, and to understand it the roof and floor of the two spaces must be discussed together. They are separated from each other at the middle metacarpal bone by firm septa, so that neither one communicates with the other, nor does either overlap to the other side of this bone. The tendons of the third and fourth fingers, with their lumbrical muscles, lie just above the middle palmar space, separated from it by only a thin, indefinite membrane, while upon the palmar side of this group are a few indefinite spaces; but pus must pass around the tendons to their dorsal surface and rupture into the middle palmar space, since in every other direction firm tissue is found. Such a course might be followed in an infection passing upward along the lumbrical 7 98 METHODS OF STUDY IN GENERAL muscles. If it follows along the synovial sheath of the ring finger, and finally ruptures from the proximal blind end, it will pass ultimately into this space. The same holds true for the tendon sheath of the little finger in those cases in which it is separated from the ulnar bursa. To the ulnar side of the tendon of the little finger is seen the small synovial space repre- senting the continuation of the synovial sheath of the little finger into the synovial sheath of the tendons above, known as the ulnar bursa. It will be seen that the lumbrical muscle and tendon of the index finger occupy the same relative position to the thenar space that the third and fourth do to the middle palmar space, with this exception, that in those hands which have been examined the sheet of tissue separating it from the thenar space is somewhat firmer; still, it is not so dense as that upon the other three sides, and here also, then, it must communicate with the space below it. The lumbrical muscle and tendon of the middle finger in Section VI occupy an intermediary place between the two spaces, but in the previous section they will be seen to lie over the middle palmar space, at which site the enveloping fascia is much thinner, so that we would have reasons to believe, from an anatomical standpoint, that pus spreading along this tendon would communicate more easily with the middle palmar space, and experimental injections of the synovial sheath substantiate this reasoning. We have now discussed all of the relations of these spaces except the floor, or dorsal surface, and the proximal prolongation. The latter we will speak of in the chapter dealing with anatomy of the forearm. Concerning the floor, however, it is well to mention several things. Owing to the closed nature of these pockets, it is customary for clinicians to draw atten- THE MIDDLE PALMAR AND THENAR SPACES 99 tion to the frequency of rupture from them, through between the bones, to the dorsal surface. In the middle palmar space the floor is composed of a very thin fascial layer, through which pus could rupture easily, were it not for the support given it by the interossei muscles and the interosseous mem- brane, upon which it lies. Should inflammatory destruction of this sheet arise, however, or rupture ensue, the interossei muscles would still offer a slight resistance, for there is no distinct channel leading to the dorsum, although the intermuscular septa do tend in that direction. Having come through these, how- ever, the pus would then meet the septum passing from one bone to the other upon the dorsal surface of the interossei muscles. If the pus meets and over- comes the various obstructions, which it might do in chronic and exceptional cases, it would then lie beneath the tendons upon the dorsal surface, or in the dorsal subaponeurotic space. Now let us go back to the thenar space and its floor, or dorsal wall. This is slightly more complex, in that the muscular masses making up the floor confuse us. For the most part it is made up of the adductor transversus and the adductor obliquus, and in those cases where there is little tension upon the contents it would be limited dorsally by them and the thin sheet of fascia over the muscles. Upon the other hand, if the tension were increased, it would be very easy for the contents of the cavity to pass between these muscles and come to lie upon the dorsal surface of the adductor transversus. That is to say, it would come against the first dorsal interosseous upon the dorsum of the thenar region about on a level with the meta- carpophalangeal joint of the thumb, and thus, if there were any inflammatory action present, spread to the cutaneous tissue at the \veb; or, if the dorsal inter- 100 METHODS OF STUDY IN GENERAL osseous muscle were unimportant, in the dorsal sub- cutaneous tissue of the thenar region. Experimental evidence will be adduced later to prove this can occur. We note that we have six important fascial spaces with their tributaries in which pus can accumulate. 1. The dorsal subcutaneous, which is an extensive area of loose tissue, without definite boundaries, allowing pus to spread over the entire dorsum of the hand. 2. The dorsal subaponeurotic, limited upon its sub- cutaneous side by the dense tendinous aponeurosis of the extensor tendons, upon the deep side by the metacarpal bones, having the shape of a truncated cone, with the smaller end at the wrist and the broader at the knuckle. Laterally the aponeurotic sheet shades off into the subcutaneous tissue. 3. The hypothenar area, a distinctly localized space. 4. The thenar space, occupying, approximately, the area of the thenar eminence. Superficially its internal boundary is indicated by the adduction crease of the thumb. It lies entirely upon the radial side of the middle metacarpal. It should be remembered that this space lies deep in the palm, just above the adductor transversus. 5. The middle palmar space, with its three diver- ticula below along the lumbrical muscles, limited by the middle metacarpal bone upon the radial side, overlapped by the ulnar bursa upon the ulnar side, and separated from the thenar space by a partition which is very firm everywhere except at the proximal end, where it is rather thin. A small isthmus can be found leading from the proximal end of the space under the tendons and ulnar bursa at the wrist into the forearm. -, 101r J r ' 6. The web space, an area orioose connective tissue between the bases of the fingers, with prolongations distally into the subcutaneous tissue at the sides of the fingers, and proximally into the subcutaneous tissue of the dorsum on the dorsal surface and into the connective-tissue spaces around the lumbrical muscle on the palmar surface. The corroboration of our statement as to the outlines of these spaces will be brought out in the chapter upon experimental injec- tions (Chapter IX). TcO nO 3t?3JJOO c chAIOll-YI-i's CHAPTER VIII. THE TENDON SHEATHS: A DISCUSSION OF THEIR ANATOMICAL DISTRIBUTION AND RELATIONS, WITH SURGICAL DEDUCTIONS. FROM a consideration of the cross-sections we have described in the previous chapters it is possible to give a composite picture of the various tendon sheaths from an anatomical and surgical standpoint. In the following description the well-known anatomical points which have no bearing on the subject in hand will not be dealt with. It is my intention to emphasize those facts which will aid us in understanding the course an infection will pursue, and will point to the proper course of treatment. Therefore, before reading this one should have a clear conception of the anatomy of the six fascial spaces described in the previous chapter. The particular relation of the sheaths to the six fascial spaces will be emphasized in the chapter deal- ing with experimental injections (Chapter IX). These will also serve to corroborate the anatomical state- ments made here. 9 SHEATHS UPON THE FLEXOR SURFACE. From a surgical standpoint, the sheaths upon the flexor surface are the most important. The anatomy of these may be discussed under four heads: (i) The tendon sheaths for the index, middle, and ring fingers; (2) the tendon sheath for the thumb with its prolonga- tion in the hand (radial bursa); (3) the tendon sheath of the little finger and its prolongation in the palm (ulnar bursa) ; (4) the communications between these various sheaths. SHEATHS OF INDEX, MIDDLE, AND RING FINGERS 103 THE SHEATHS OF THE INDEX, MIDDLE, AND RING FINGERS. These begin just distal to the distal interphalangeal joint and extend into the palm, approximately a thumb's breadth proximal to the web; or the point of extension can be designated by drawing a line between the end of the proximal palmar crease at the base of the index finger and the end of the distal palmar crease at the base of the little finger. This line represents the approximate extension of these sheaths into the palm. It will be seen by noting Fig. 22 that at the distal portion of the palm there is a sheet of dense tissue enclosing the tendon sheaths and lumbrical muscles. The sheaths extend one-fourth inch proximal to this into the loose palmar tissue. This fact is of consider- able importance from a surgical standpoint (see pp. 118 and 168). While passing through the dense tissue mentioned above, these sheaths have on either side the space called the lumbrical canal, through which pass the lumbrical muscles and digital branches of the arteries and nerves (Fig. 21). This is also of surgical impor- tance (see pp. 183 and 216). As we pass distally, we find considerable tissue between the metacarpophalangeal joint and the sheath proper, while more distally, as we come to the base of the proximal phalanx, we note that the sheath approaches the bone and is in close relation with the loose connective tissue going entirely around the bone. The surgical importance of this will be brought out later. At the proximal interphalangeal joint (Fig. 132) we find considerable tissue between the sheath and the joint, while over the base of the middle phalanx, i. e., at the epiphyseal line (Fig. 27), there is little or no 104 THE TENDON SHEATHS tissue between the sheath and the bone. From this point distally the relation to the bone is not so inti- mate. At the distal end the relation of the structures can be seen by studying Fig. 2. (For surgical appli- cation, see p. 164 and Chapter XXVIII.) FIG. 27 Cross-section through the epiphysis of the middle phalanx. Notice the loose mesh and the small amount of connective tissue between the tendon and the bone. These sheaths bear almost the same relation to the respective fingers. They do differ slightly in their relation to the palm of the hand as pointed out in Chapter VII. The proximal end of the sheath for the index finger is in relation to the thenar space, while that of the middle finger is most often in relation to the middle palmar space, although at times it will allow of rupture into the thenar space, possibly through rupture into the lumbrical space between the index and middle finger and thence into the thenar space. However, this lumbrical space itself most often leads into the middle palmar space. The tendon sheaths of the ring finger and of the little finger are in relation to the middle palmar space. TENDON SHEATH OF THE FLEXOR LONGUS POLLICIS 105 THE RADIAL BURSA AND THE TENDON SHEATH OF THE FLEXOR LONGUS POLLICIS. This is of great importance from a surgical stand- point, owing to the fact that in youth and adult life the sheath nearly always communicates with the enlarged sac of the tendon sheath at the wrist (19 in 20 cases, Poirier). The entire sheath has been given the name of radial bursa, although technically speak- ing it should be applied only to the proximal part at the wrist. The sheath begins distally at the base of the distal phalanx and extends proximally a thumb's breadth proximal to the anterior annular ligament. It lies first in close proximity to the proximal phalanx, but at the distal end of the metacarpal bone becomes separated from the bone by the muscles of the thumb lying between the outer head of the flexor brevis pollicis and the adductor obliquus pollicis (Figs. 24 and 25). At times (i to 20, Poirier) there is a separa- tion of the sheath into two parts about the middle of the metacarpal bone. This is frequently only a thin diaphragm. The sheath is generally well sepa- rated by connective tissue from the metacarpo- phalangeal joint and an infection may spread from the joint to the sheath, or vice versa, but either is uncommon. It lies superficial to the proximal end of the thenar space, in juxtaposition to the flexor tendons in the carpal canal (Fig. 24) and passes upward to terminate about an inch above the annular ligament by a rounded cul-de-sac extending under the deep surface of the tendon, corresponding to the radio- carpal joint and the lower end of the radius, lying on the pronator quadratus. The communication between this and the ulnar bursa will be discussed later. The motor nerve to the thenar 106 THE TENDON SHEATHS muscle lies within a finger's breadth distal to the annular ligament and superficial to the sheath (see p. no). THE ULNAR BURSA AND THE SHEATH OF THE TENDON OF THE LITTLE FINGER. The tendon sheath of the flexor tendon of the little finger communicates freely with the ulnar bursa in FIG. 28 X-ray picture upon which are shown two types seen in the flexor tendon sheaths. Note that in the hand upon the left side there is a continuation between the little finger and the thumb and the ulnar bursa and radial bursa respectively. Note also the connecting sheaths between. In the hand upon the right side the sheaths are separated, not alone from their respec- tive fingers, but from each other. THE ULNAR BURS A AND THE LITTLE FINGER 107 about one-half of the cases according to Poirier, but statistics vary somewhat on this point. When the separation is present it is of any grade, from a simple narrowing to a complete occlusion some millimeters in length. In these cases the sheath corresponds in length to those of the other fingers. Also the relations to the joints and spaces are the same except that there is no lumbrical canal upon the ulnar side of the proximal end. The sheath extends into the middle palmar space, and the lumbrical canal upon its radial side FIG. 29 UB S S FLP Showing the relation of the tendons and synovial sheaths at the wrist. Note in this drawing the four pockets in the ulnar bursa instead of three as commonly described; also the tendon sheath of the flexor longus pollicis and the accessory synovial sheaths (55). See text for description of the difference between the relations of the tendons shown in Figs. 25 and 29. communicates with the same area. In this relation it should be remembered that these muscles do not lead into the thenar and middle palmar spaces directly, but lie just superficial to them, in a loft, as it were, from which pus easily extends into the space. The ulnar bursa proper (Fig. 28) begins at the proximal end of the finger sheath, spreads out rapidly, and becomes a good-sized sac overlapping the meta- carpal of the ring finger and the head of the middle metacarpal, passes under the anterior annular ligament and extends a thumb's breadth above this, lying in 108 THE TENDON SHEATHS FIG. 30 r relation to the lower end of the ulna and the ulnar side of the carpus and the radio-ulnar articulation, lying upon the pronator quadratus. It does not sur- round the tendons as a whole, but lies to the ulnar side of the group of super- ficial and deep flexors and only envelops them as if they were pushed in along the outside. It follows, then, that the ulnar side of the sac is free while the radial side envelops the ten- dons, forming three spaces or arches, as it were, the most superficial between the aponeurosis and the super- ficial tendons, the middle between the superficial and deep tendons, and the third between the deep tendons and the carpal canal (Figs. 25, 29, and 30). These all open upon the ulnar side into a common space. This arrangement, first drawn attention to by Leguey, I Photograph after Poiner, in which the ulnar bursa has been believe, is in general true, opened, showing its extension into b u t the arrangement varies the little finger and its closure *. rf , , . about the tendon of the ring at different levels and in finger. different individuals, as can be seen by examining Fig. 29, where there are four pockets, and none of them very deep. Moreover, the tendons upon the radial side frequently have sheaths separate from the ulnar bursa, as will be mentioned under our fourth caption, THE ULNAR BURSA AND THE LITTLE FINGER 109 "The Intercommunication of the Sheaths." Attention should also be drawn to the fact that the superficial palmar arch with some of the unimportant branches of the ulnar nerve lies superficial to the sheath. More important, however, is the fact that the sheath over- lies the middle palmar space, making part of its roof, as it were (Fig. 31). FIG. 31 Cross-section No. VI. Through distal part of thenar area. A TP, ad- ductor transversus pollicis; DIA, dorsalis indicis artery; DP A, deep palmar arch; DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; HM, hypothenar muscles with intermuscular spaces; ITS, indefinite thenar spaces; IM, interossei muscles; IS, space between adductor trans- versus and first dorsal interosseous; LM, lumbrical muscle; M, metacarpal bone; MA and N, median artery and nerve; MPS, middle palmar space; PF, palmar fascia; PIM, palmar interosseous membrane; TM, thenar muscles; TMF, tendon of middle finger; TS, thenar space; UV and N, ulnar vessels and nerves. The ulnar bursa, radial bursa, and an intermediate tendon sheath are shown in red. The boundaries of the middle palmar and thenar spaces are shown in blue. Above the anterior annular ligament it is well to note that the tendons of the palmaris longus and the flexor carpi radialis lie above the radial bursa, and that by drawing the tendon of the flexor carpi radialis to 110 THE TENDON SHEATHS the radial side one can come down directly upon the flexor longus pollicis and its sheath. Attention should likewise be drawn to the fact that the median nerve lies rather deeply between the two bursae. THE INTERCOMMUNICATION OF THE SHEATHS. Poirier 1 discusses the communication between the bursae as follows: "The synovial sheaths of the palm have no com- munication with each other, and the authors cite in proof of this the case of Gosselin, who had observed it only once. However, the result of my observation has been that this communication between the two important sheaths is very frequent in the adult. It is found in about half of the cases. The connection is made by a median synovial sheath which I will describe. "Accessory synovial sacs: The writers call atten- tion to the occasional existence of synovial sheaths in addition to the two large synovial sheaths, which they call accessory sheaths, and are found at times along the flexor tendons of the index finger. They lie be- tween the ulnar and radial bursae, being found especially along the deep tendon. My researches show that these synovial sheaths are two in number. They ought not to be called accessory, since one of these is almost always present. I have named them the intermediary anterior and posterior palmar synovial sheaths. "The intermediary posterior palmar sheath: This should be described as a normal sheath, since one finds it about eight times out of ten. It lies between the carpal canal and the flexor profundus of the index finger, and commences above the wrist at the edge of the radius. It spreads out at the level of the upper 1 P. Poirier et A. Charpy, Traite" d 'Anatomic Humaine, Tome ii. S. 189. THE INTERCOMMUNICATION OF THE SHEATHS 111 border of the semilunar bone and goes down more or less on the tendon of the flexor profundus, varying from 3 to 8 cm. To see it, it is necessary to cut trans- versely across the mass of muscles and tendons in the lower third of the forearm and turn the distal end down toward the fingers. It is by the intervention of this sheath that the ulnar and radial bursae communi- cate ordinarily. "The anterior intermediary palmar sheath: This is found in hardly half of the cases. Much smaller than the preceding, it is found placed between the super- ficial and deep tendons of the index finger. "Both of these appear later than the others, and it is very rare to find them as completely organized. In general, their walls lack the moist glassiness character- istic of complete development." It is said 1 also that the synovial sheaths of the ring, middle, and index fingers communicate exceptionally with the ulnar bursa, following their respective tendons, occurring in the order of frequency as the fingers are named above. Again, attention should be drawn to the fact that the intermediary sheaths may differ from that type mentioned by Poirier. I have dissected one case in which the profundus tendons of the index and middle fingers had separate sheaths. Communi- cating with the ulnar bursa (Fig. 25) at this level the anterior intermediary sheath was absent, but 2 cm. higher up the sheath of the middle finger profundus had disappeared, while the anterior and posterior interme- diary sheaths were present (Fig. 29). The communi- cation here, then, would have taken place as follows: Ulnar bursa, sheath about the middle finger profundus, sheath about the index finger profundus, or posterior intermediary sheath, and, in this case apparently, 1 Tilleau, Trait d 'Anatomie Topographique. 112 THE TENDON SHEATHS FIG. 32 An x-ray picture of a cadaver hand in which the tendon sheaths have been injected with red lead. The outline of the ulnar bursa and radial bursa with tendon prolongations is clearly shown. Note the distance of the radial bursa from the metacarpal bone of the thumb and the relation of the ulnar bursa to the metacarpal bone of the middle finger. THE INTERCOMMUNICATION OF THE SHEATHS 113 anterior intermediary sheath, to the radial bursa. It can be seen that in a fulminating type of infection, such as a streptococcus involvement, the process would FIG. 33 Photograph from Bardeleben, showing tendons upon the back of the hand passing under the posterior annular ligament. spread to the radial bursa, but in the more chronic types this devious course offers many chances for adhesive occlusion of the channel (Fig.- 32). This will be discussed later (see p. 215). 114 THE TENDON SHEATHS THE SHEATHS UPON THE DORSUM. The synovial sheaths of the hand upon the dorsum are six in number. These begin just above the pos- terior annular ligament and pass under and through it (Figs. 26 and 33). They are found as follows: 1. Lying upon the outer side of the styloid process of the radius, for the extensor ossis metacarpi pollicis and the extensor brevis pollicis. They may have separate sheaths and are 5 to 6 cm. in length. 2. Behind the styloid process, for the tendons of the extensor carpi radialis longior and brevior. These are 5 to 6 cm. in length and communicate with the sheath of the extensor longus pollicis through an oval opening by way of the longior (Poirier). 3. Overlapping the above tendons, and communica- ting with them as described, we have the sheath of the extensor longus pollicis. This is 6 to 7 cm. in length. 4. To the ulnar side of this we find the large sheath enclosing the tendons of the extensor communis digi- torum and the extensor indicis. It is 5 to 6 cm. in length and terminates below in three prolongations. The radial one encloses the communis tendon to the index finger and the extensor indicis; the middle, the communis tendon to the middle finger; the one on the ulnar side covers the tendons to the third and fourth fingers. 5. One opposite the interval between the radius and ulna, for the extensor minimi digiti. This is longer than the others, being 6 to 7 cm. in length. Covering the upper one-third of the length of the third inter- osseous space, it may bifurcate below, following the two branches of the tendon. 6. Upon the back of the ulna, the synovial sheath ofthe tendon of the extensor carpi ulnaris. This is 4 to 5 cm. in length. CHAPTER IX. THE RELATION BETWEEN THE SYNOVIAL SHEATHS AND THE FASCIAL SPACES. A STUDY BY EXPERIMENTAL INJECTION OF THE OUT- LINES, BOUNDARIES, AND DIVERTICULA OF THE FASCIAL SPACES AND THE RELATION OF THESE TO THE SYNOVIAL SHEATHS. IN my desire to corroborate the findings by dissec- tion in relation to the fascial spaces and tendon sheaths which have been detailed in the two preceding chapters, a large number of hands were injected after the manner described in Chapter VII. The results obtained were most satisfactory, since they were so uniform that they absolutely fixed the boundaries and relations of the spaces and sheaths. Moreover, these experiments gave results which, when applied clinically, were of inesti- mable value in determining the course the infections tended to pursue. Again, they determined not only the proper sites for opening any particular focus, but also indicated where secondary abscesses would be located, and thus favored early diagnosis and treatment of such processes. Furthermore, they demonstrated the relation between tendon-sheath abscesses and fascial-space abscesses. These studies have been of greater aid than any other in placing the treatment of infections of the hand upon a scientific basis. A brief outline of the various procedures will be of value in preserving a general picture. This will be followed by a discussion of the individual experiments. Our first group of experiments had for its object the determination of the relation of rupture of the synovial 116 SYNOVIAL SHEATHS AND FASCIAL SPACES sheaths to the secondary abscesses in the fascial spaces. In other words, if an infection began in a particular tendon and ruptured from it, where would the sec- ondary abscess lie? This was determined by an exten- sive series of experiments upon each sheath. Clinical evidence has accumulated in my hands sufficient to verify every one of the experimental deductions we have here made. The second problem dealt with determining the boundaries and diverticula of each of the definite spaces I have described. To do this injections of these spaces were made from every possible source of infec- tion the tendon sheaths, direct implantation, and extension from neighboring spaces. The results were uniform, as will be seen by a study of the experi- ments. Again, certain of these injections were made with great force to determine where pus would extend when it ruptured from these individual spaces. Therefore, by these experiments we have determined for the synovial sheaths, the sites of extension; and for each fascial space, (a) the source of involvement; (b) the normal limitations of that space; (c) the areas to which pus will extend from the space. Here again clinical evidence will be later adduced to show that all of these deductions are pathologically correct. For the sake of clearness a tabulation of these experiments is appended. I. The relation of rupture of the tendon sheaths to the fascial spaces. From the tendon sheath of the middle finger, Experi- ments i and 2. From the tendon sheath of the ring finger, Experi- ments 3, 4, 18, 19, and 20. .From the tendon sheath of the little finger, Experi- ments 5, 6, 7, and 47. OUTLINES AND DIVERTICULA OF FASCIAL SPACES 117 From the tendon sheath of the index finger, Experi- ments 8, 9, 27, and 35. From the tendon sheath of the thumb, Experiments 10 to 17. II. The boundaries and diverticula of the spaces. (a) Middle palmar space. Injection via ring finger sheath, Experiments 3, 4, 1 8 to 20. Injection via little finger sheath, Experiments I and 2. Injection via little finger sheath, Experiments 5, 6, 7, and 47. Injection via palmar fascia, Experiments 21 to 25. Injection via lumbrical muscle space, Experiments 26 A and 26 B. Of these, great force was used in 19, 20, and 3. From these and others, deductions were made as to the location of pus extensions from the middle palmar space. (b) Thenar space. Injection via index finger sheath, Experiments 27 to 35, 8 and 9. Injection via palmar fascia, Experiments 36, 37, and 38. Of these, great force was used in the experiments from 27 to 35 inclusive, and from the results deduc- tions were made as to the location of pus extensions from the thenar space. (c) Dorsal subcutaneous space. Injection between first and second metacarpals, Experiments 39 and 40. Injection between second and third metacarpals, Experiments 41 and 42. (d) Dorsal subaponeurotic space. Experiments 43, 44, and 45. (e) Hypothenar space. 118 General results of experiments quoted. (/) Forearm space. Injection via flexor longus pollicis sheath, Experi- ments 46, 10 to 17. Injection via ulnar bursa and little finger, Experi- ments 47 and 50. Injection via middle palmar space, Experiment 49. Injection along radial and ulnar vessels, grouped under composite experiment 51. THE RELATION OF THE TENDON-SHEATH RUPTURE TO THE FASCIAL SPACES. INJECTION VIA THE TENDON SHEATH OF THE MIDDLE FINGER. In inserting the cannula no effort was made to reach any particular spot, but it was allowed to rupture FIG. 34 Schematic drawing made from a dissection of a hand injected from the tendon sheath of the middle finger. The mass filled the middle palmar space and extended along the two lumbricals. INJECTION VIA TENDON SHEATH OF RING FINGER 119 through the weakest spot in its course. It will be noted that in each instance the mass entered and filled the middle palmar space. Experiment i. Left hand. Cannula inserted into tendon sheath of middle finger at the middle of the proximal phalanx, moderate force used in injection. The mass occupied the middle palmar space only, going up to about one-half inch below the annular ligament. Downward it had returned along the lumbrical muscles of the little and ring fingers nearly to the web of the fingers. It did not return to any extent along the lumbrical muscles of the middle finger. In every way this was a perfect representation of what is probably a typical collection in the middle palmar space. (See experimental injection drawing, Fig. 34.) Experiment 2. Left hand. Same as No. I in every particular. No mass to radial side of middle finger. Experiment 2A. Right hand. Same as No. I in every particular. INJECTION VIA THE TENDON SHEATH OF THE RING FINGER. The tendon sheath was opened at the base of the finger and the cannula inserted in the sheath and pushed through the proximal blind end into whatever space was at that site, thus trying to demonstrate where an infection would spread to if it extended from the tendon sheath. In one case, which is not included in the report, the tendon sheath did not end blindly, but extended up into the group of tendons at the wrist. In every case where the sheath ended normally the mass filled the middle palmar space. Experiment 3. Right hand. Moderate force used. In this case the mass occupied the middle palmar space as it has been described. No diverticula were noted except that the mass extended along the 120 SYNOVIAL SHEATHS AND FASCIAL SPACES lumbrical muscles of the ring finger for about one-half inch. (See experimental injection drawing, Fig. 35.) Experiment 4. Right hand. Moderate force used. In this case the cannula broke from the blind end, evidently superficial to the tendon, for there was a small mass only, lying superficial to the tendon, about a quarter of an inch wide and three-quarters of an inch long. It had not involved the middle palmar space, but it was seen that the thinnest wall was in relation to that space, and in case of infection the pus would have extended into it in all probability. (See experi- mental injection drawing, Fig. 36.) This is further supported by Experiments 18, 19, and 20 (q. v.). INJECTION VIA THE TENDON SHEATH OF THE LITTLE FINGER. The injections 5 and 6 demonstrate where the pus will lie in those cases in which the rupture takes place in the hand, namely, the middle palmar space. It may also rupture in the forearm. In fact, that is its most frequent site. The location of the pus in the latter case will be seen by studying Experiment 47. Experiment 5. During an attempt to inject the ulnar sheath in the right hand it was found to be obliterated at the phalangometacarpal articulation. The cannula broke out into a space which was injected with moderate force, and upon dissection the middle palmar space, as already described, was found filled with the mass. It had not gone up into the wrist, over into the thenar or hypothenar areas, but had returned along the lumbrical muscles of the little, ring, and middle fingers. (See experimental injection drawing, Fig. 37-) Experiment 6. In another attempt to inject the ulnar bursa with moderate force, the injection was arrested at the annular ligament owing to the rigidity of the tissue of the subject. Due to this fact and the INJECTION VIA TENDON SHEA TH OF LITTLE FINGER ] 21 FIG. 35 Schematic drawing made from a dissection of a hand injected along the tendon sheath of the ring finger. The mass filled the middle palmar space, with extension along the lumbrical muscle. FIG. 36 Schematic drawing made from a dissection of a hand in which the mass was injected from the tendon sheath of the middle finger and filled the loft over the middle palmar space, but did not rupture into it. 122 SYNOVIAL SHEATHS AND FASCIAL SPACES friability of the tissues incident to age, the ulnar bursa ruptured at about the middle of the palm, and the mass was found to occupy the middle palmar space only, in addition to the ulnar bursa sheath of the tendons. The mass returned along the ring finger lumbrical only. The surgical importance of this experiment is readily seen. (See experimental injection drawing, Fig. 38). Experiment 7. Here we have the result produced in those cases in which the rupture is in the forearm and not in the hand. The x-ray photograph here pre- sented, which is made from the hand injected in Experi- ment 7, presents a clear picture of the bones in their relation to the injected bloodvessels and ulnar bursa (Fig. 39). Upon this plate have been placed lines which represent the boundaries of the thenar and middle palmar spaces. The numerous parallel lines at the distal end of the palm represent the dense tissue here overlying the articulation, in which there are no spaces except those made by the lumbrical muscles with the vessels and the synovial sheaths. (See cross-section, Fig. 22.) Three curved lines show the position of the flexion creases of the palm of the hand, and in relation to these, note that the proximal end of the distal flexion crease corresponds with the beginning of the dense tissue noted. Again, note that the distal end of the middle flexion crease also begins at the dense tissue, and hence a line drawn between these two points limits the palmar spaces distally. Pay particular attention to the point at which this middle flexion crease crosses the space between the metacarpal bones of the middle and ring fingers, at the distal end of the middle palmar space, avoiding the thenar space upon the radial side, the ulnar bursa upon the ulnar side, the dense tissue distally, and the deep palmar arch which is seen crossing the upper INJECTION VIA TENDON SHEA TH OF LITTLE FINGER 123 FIG. 37 Schematic drawing made from a dissection of a hand injected from the tendon sheath of the little finger with which the ulnar bursa did not connect. The mass ruptured into the middle palmar space, filling it with prolonga- tions along three lumbrical muscles. ' FIG. 38 Schematic drawing made from a dissection of a hand in which the mass was injected along the tendon sheath of the little finger; closure at the upper end of the annular ligament of the ulnar bursa allowed rupture from the ulnar bursa, the mass filling the middle palmar space, with extension along one lumbrical muscle. 124 \SYNOVIAL SHEATHS AND FASCIAL SPACES part of the middle palmar space proximally. Note that although the injection mass has broken from the FIG. 39 -X"-ray Plate. Boundaries of the thenar (TS) and middle palmar spaces (MPS) marked and proper site for opening the latter indicated. Ulnar bursa and bloodvessels injected. ulnar sheath in the forearm, yet the spaces in the hand are uninvolved. INJECTION VIA TENDON SHEA TH OF INDEX FINGER 1 25 Experiments 54 to 58. In these as with many other experiments, the records of which are not here re- ported, the mass ruptured at the proximal end of the sheath under the flexor profundus tendons in the forearm. This is the most common site of extension. (See Experiment 50 for a complete description of these cases.) INJECTION VIA THE TENDON SHEATH OF THE INDEX FINGER. Here the findings are positive. In addition to the experiment here detailed, many others were performed FIG. 40 Schematic drawing made from a dissection of a hand injected along the tendon sheath of the index finger. Mass filled thenar space and extended around to the dorsum underneath adductor transversus and also along lum- brical muscle. which gave the definite information that when pus ruptures from this sheath it enters the thenar space. 126 SYNOVIAL SHEATHS AND FASCIAL SPACES Experiment 8. Injection was made through the tendon sheath of the index finger. The mass occupied the thenar space; did not go into the forearm or middle palmar space. Passed around the lower or distal edge of the adductor transversus, filled a space the size of a walnut between that muscle and the first dorsal interosseous, and abutted on the dorsal subcutaneous tissue at web. Followed index lumbrical only. (See experimental injection drawing, Fig. 40.) Experiment 9. Same findings as in Experiment 8. Experiments 24 to 30 and 29 to 35 corroborate these findings. INJECTION VIA THE TENDON SHEATH OF THE FLEXOR LONGUS POLLICIS. Here one would expect the mass to enter the thenar space in the hand, and we were therefore surprised to find that this was not generally the case. To deter- mine this point definitely, eight experiments were made. In each case great pressure was used in the injection. The cannula was inserted into the tendon sheath in the thumb and so bound that the mass could not escape around the needle. These experiments showed that in a majority of cases the rupture took place in the forearm under the flexor profundus digitorum. It did at times, however, rupture distal to the annular ligament and fill the thenar and even the middle palmar spaces. Experiment 10. A cannula was inserted into the sheath of the flexor longus pollicis at the thumb. The injection mass was found to have filled completely the radial bursa, including the part proximal to the annular ligament. The mass had ruptured from the proximal end and passed up into the forearm. No extravasation had taken place into the hand, either by direct rupture or retrograde extension. The attachment of the flexor longus pollicis at its origin had been torn in part from TENDON SHEATHS AND FASCIAL SPACES 127 the bone. The mass extended up along this muscle on the radial side of the forearm, having on its ulnar boundary and roof the flexor profundus digitorum and the flexor sublimis digitorum. The major portion of the mass was found under the flexor profundus digi- torum, going over even to the flexor carpi ulnaris. It filled an area extending from the wrist-joint to within three inches of the elbow-joint. Experiment n. The findings here were practically the same except that a small part of the mass passed downward under the annular ligament and the ulnar bursa to fill partially the middle palmar space. This, however, would probably not occur in an inflam- matory case owing to the small channel present. Experiment 12. In this case the mass ruptured from the upper third of the synovial sheath, just distal to the annular ligament. It extended downward to the thenar space and partially filled it. A small part had also entered the upper end of the palmar space, owing to the indefinite septum separating these spaces at the upper end. The large mass, however, was in the thenar space, but it demonstrated that extension into the middle palmar space would be pos- sible in neglected cases. Experiments 13, 14, 15, and 16. These were prac- tically duplicates of the above results. Experiment 17. In this case there was apparently a free anatomical communication between the ulnar and radial bursa, for the mass filled the ulnar bursa. There was also an extension into the forearm from a rupture of the proximal end at the radial bursa. GENERAL DEDUCTIONS AS TO RELATION OF TENDON SHEATHS TO FASCIAL SPACES. The injections through the synovial sheaths of the tendons of the ring and middle fingers passed into the 128 SYNOVIAL SHEATHS AND FASCIAL SPACES middle palmar space, while that space was reached also from the little finger in those cases where the synovial sheath was distinct from the ulnar bursa; and, indeed, the contents of the ulnar bursa itself, when it ruptured into the palm, entered the same space. Injection masses from the index synovial sheath passed into the thenar space. In those cases where the synovial sheath of either of these fingers communi- cated with the ulnar bursa, the mass passed into that, and followed the course of any bursal injection. The extreme rarity of communication between the index synovial sheath and the ulnar bursa robs that point of any surgical interest such an anomaly would have. A mass from the radial bursa or the synovial sheath of the flexor longus pollicis, if it ruptures into the hand, will lie in the indefinite spaces mentioned as lying directly over the muscles of the metacarpal bone of the thumb. It is possible for it to erode into the thenar space, but it is more likely to rupture into the fascial spaces of the forearm and lie under the flexor profundus digitorum. The ulnar bursa may rupture into the middle palmar space and it will almost surely rupture into the forearm under the flexor profundus digitorum. THE NORMAL BOUNDARIES OF THE FASCIAL SPACES AND THE POSITION OF SECONDARY ABSCESSES IN CASE OF EXTENSION FROM THE SPACES. THE MIDDLE PALMAR SPACE. INJECTION VIA THE TENDON SHEATH OF THE RING FINGER. Experiment 18. Left hand, along tendon sheath of ring finger; the mass was injected with con- siderable force. The middle palmar space as described was filled. Thenar and hypothenar area free, mass followed along little and ring finger lumbricals for three- fourths inch, none along other fingers, none through between bones to back, mass extended under tendons THE MIDDLE PALMAR SPACE 129 strictly, up into forearm, where a large mass was found lying under the deep muscles upon the pronator quadratus and the interosseous septum up to the pronator radii teres. The mass came to the surface late upon the radial side, about two inches above the wrist, but the mass was most marked upon the ulnar side from above downward, between the flexor carpi ulnaris and the deep tendons and muscles. The im- portance of the position of this mass from a clinical standpoint can be seen. Experiment 19. Same findings as in Experiment 18. Experiment 20. Wrist bound tightly above annular ligament; cannula inserted along ring finger synovial sheath, and mass injected with great force, the idea being to see where the mass would rupture in case that means of exit was closed. None of the mass went to the forearm or .dorsum, but did rupture into the thenar space at the upper or proximal end of the intervening septum and filled the thenar space, passed along all lumbrical muscles into canals for a consider- able distance, but not out into the web between the fingers. (See experimental injection drawing, Fig. 41.) Experiments 3 and 4 corroborate these findings. Experiments I, 2, and 3, in which the space was in- jected from the middle finger, and Experiments 5 and 6, in which the space was injected from the little finger, present the same findings as in Experiments 18, 19, and 20. INJECTION THROUGH THE PALMAR FASCIA. Injec- tion of the space by inserting a needle through the palm directly into the space gives the results uncomplicated by any other process. Experiment 21. Left hand. Cannula inserted through the palmar fascia where middle flexion crease crosses metacarpal space between ring and middle fingers. Moderate force used. 9 130 SYNOVIAL SHEATHS AND FASCIAL SPACES NOTE. Care must be taken that the cannula goes dorsal to the tendons, i. e., really into space, otherwise the mass will be confined to the imperfect spaces around the tendons, particularly superficial to them. Even if this should occur, if great force is used, it will rupture into the great space; not so readily, however, as would pus, since the erosive action of the latter is not present in simple injections. FIG. 41 Schematic drawing made from a dissection of a hand in which the injec- tion was made along the tendon sheath of the ring finger under great force. The mass filled the middle palmar and thenar spaces, with extension along all lumbrical muscles. Upon dissection the mass was found to be limited to what we have found in the middle palmar space. It was limited upon the radial side by the attachment of fascia to the middle metacarpal bone. This was the long leg of the right-angle triangle. The ulnar side represented the hypotenuse of the triangle lying to THE MIDDLE PALMAR SPACE 131 the radial side of the hypothenar space. The apex of the triangle, or the highest point to which the mass spread, was about one inch distal to the distal flexion crease of the wrist, or about a finger's breadth proximal to a line drawn transversely across the palm from the web of the extended thumb. At the lower part of the palm, i. e., toward the web of the fingers, the greater part of the mass was limited by a line drawn between the radial end of the middle flexion crease and the ulnar end of the distal flexion crease of the palm, or, roughly speaking, about a thumb's breadth above the web of the fingers; this is the short leg of our right-angle triangle. A prolonga- tion of the mass had taken place, however, along the lumbrical muscle between the middle and ring fingers, going almost to the web of the fingers. There was no appreciable mass along the other lumbrical muscles, although some of the stain from the methylene blue used in the injection mass had stained the space around the muscle leading to the little finger. No other prolongations were present. It did not break into the interossei muscles or superficially about the tendons. Superficial palmar vessels crossed upper part of mass. (See experimental injection drawing, Fig. 42.) Experiment 22. Left hand. Injection at the same point and in the same manner as No. 21. The mass here occupied exactly the same area of distribution as in Experiment 21, except the mass as a whole was not so large, being a little larger than an almond. The most prominent part of the mass was in the middle of the palm, over the middle metacarpal space. There were slight prolongations distally along the lumbrical muscle between ring and middle metacarpals as above. Experiment 23. Injection made same as in Experi- ment 21. Both .T-ray picture and dissection made of this right hand. Mass extended somewhat higher in 132 SYNOVIAL SHEATHS AND FASCIAL SPACES the hand than in Experiment 21, going to a point about a finger's breadth below, i. e., distal to the distal flexion crease of the wrist lying dorsal to the tendon group; laterally its boundaries were the same, while at the distal portion of the palm a prolongation of the mass occurred along the lumbrical muscles going to the FIG. 42 Schematic drawing made from a dissection of a hand in which the injec- tion was made through the palmar fascia into the middle palmar space. The mass filled middle palmar space, with extension along one lumbrical muscle. little, ring, and middle fingers. This is of considerable importance, since it is remembered that the relation .of the lumbrical muscle of the middle finger to the middle palmar space was discussed in the division devoted to cross-sections, and this experiment bears out the assumption hazarded there that this muscle space was really a diverticulum of the middle palmar space and not of the thenar space. (See cross-sections, Figs. 23 and 24.) THE MIDDLE PALMAR SPACE 133 Experiment 24. Injection left hand, same as in Experiment 21. Mass occupied same space as in Experiment 21, except that mass spread down along lumbrical muscle of little and ring fingers for a distance of one-third inch. FIG. 43 X-ray plate made from a hand in which the middle palmar space was injected with a mixture of red lead and plaster of Paris. Photograph repre- sents location of pus in typical middle palmar space infection. INJECTION THROUGH PALMAR FASCIA INTO MIDDLE PALMAR SPACE. Experiment 25 (see x-ray photograph, Fig. 43). This hand was also dissected. It represents how the mass extends down along the lumbrical muscles, and shows also what site should be opened to evacuate the contents of the space. Note that the hypothenar and thenar regions are uninvolved, the mass not extending to the radial side of the middle metacarpal. It is seen that the ulnar bursa would lie over the ulnar side of the mass. 134 SYNOVIAL SHEATHS AND FASCIAL SPACES INJECTION ALONG LUMBRICAL MUSCLE OF RING FINGER. Experiment 26A. Cannula inserted along lumbrical muscle, left hand. Some difficulty was experienced in the insertion, but when successful the mass occupied the middle palmar space. There was no return along the lumbrical muscles. Moderate force used in injection. (See experimental injection drawing Fig. 44.) FIG. 44 Schematic drawing made from a dissection of a hand in which the injec- tion was made along the lumbrical muscle space between middle and ring fingers. Middle palmar space filled. Experiment 26B. Right hand. Same technique, injection mass lies along lumbrical muscle. Middle palmar space only partly filled. THE THENAR SPACE. NOTE. The first injections' of this space were very unsatisfactory, owing to two errors in technique, which were corrected later. In the first place, the injections TENDON SHEATH OF THE INDEX FINGER 135 were not made deep enough; and secondly, they were too far to the radial side over the thumb. It is true that the results obtained by these injections were instructive in that they served to show indefinite limited spaces at these sites, but they did not reach the large space under consideration. FIG. 45 Schematic drawing made from a dissection of a hand in which the injec- tion was made along the tendon sheath of the index finger. Mass filled thenar space and extended to dorsum between adductor transversus and adductor obliquus. INJECTION VIA THE TENDON SHEATH OF THE INDEX FINGER. Experiment 27. Right hand. Cannula in- serted into tendon sheath about middle of proximal phalanx and ruptured from sheath at its proximal end. Moderate force used in injection. The mass when dissected out showed the limitations of the thenar space as described. The mass passed up dorsal to the tendon, to a thumb's breadth below the annular ligament. It 136 SYNOVIAL SHEATHS AND FASCIAL SPACES did not go to the ulnar side of the middle metacarpal. The mass laid directly upon the adductor transversus. It did not go along the lumbrical muscle to the side of the index finger. It did not spread around under the web of the thumb to the dorsum of the hand, but was limited at the distal border of the adductor trans- versus. It did spread to the back, however, at the upper or proximal edge of the adductor transversus, going between the adductor transversus and the adduc- tor obliquus, thus lying between the adductor trans- versus and the first dorsal interosseous, at the distal edge of which it came to lie in the subcutaneous tissue of the dorsum. (See experimental injection drawing, Fig. 45-) Experiment 28. Injection same as Experiment 27. Here the mass did not fill the space completely, but did return along the lumbrical muscle to the radial side of the index finger; condition well marked. For clinical purposes, Experiments 27 and 28 should be studied together. The probability is that the cannula did not rupture entirely into the space, but did get out of the synovial sheath into the indefinite spaces in the loose connective tissue about the tendon in the loft, as it were, of the thenar space. (See experimental injection drawing, Fig. 46.) INJECTION OF THE THENAR SPACE UNDER FORCIBLE PRESSURE. The index synovial sheath was opened and cannula forced out of the proximal end into the palm; forcible pressure with force pump was main- tained for from three to five minutes. Owing to the fact that the routes of extension from the thenar space were somewhat difficult to determine accurately, nine injections of the space were made, with the following results. In none of the cases did the mass go up into the forearm. In 3 cases only did it go into the middle palmar space. In 8 cases the mass passed dorsal to THE THENAR SPACE 137 the adductor transversus; of these, in 6 the mass went to the dorsum between the adductor transversus and the adductor obliquus, and in 4 passed below or distal to the adductor transversus to lie between the trans- versus and first dorsal interosseous. In no case did the mass pass to the dorsum between the second and third metacarpals. FIG. 46 Schematic drawing made from a dissection of a hand in which the injec- tion was made along the tendon sheath of the index finger. Mass filled the thenar space and extended along the lumbrical muscle. Experiment 29. Left hand. Tissues well preserved; mass here occupied thenar space, and spread between adductor transversus and adductor obliquus to fill space size of a walnut between them and first dorsal interosseous; also ruptured through tissues between thenar space and middle palmar space at the prox- imal end of the septum, passed over to fill the middle palmar space, and accompanied the four lumbricals into 138 SYNOVIAL SHEATHS AND FASCIAL SPACES their respective canals. Did not go under tendons to forearm. Experiments 30, 31, and 32 were the same as Ex- periment 29, except that the mass in 32 did not invade the middle palmar space. All went above the adductor transversus to dorsum, however. The mass in 31 passed along the middle finger lumbrical and came to lie in the tissue of the web immediately beneath the web. (See experimental injection drawing, Fig. 47.) FIG. 47 Schematic drawing made from a dissection of a hand in which the injec- tion was made along the tendon sheath of the index finger. Mass filled the thenar space and extended over to the middle palmar space, along all the lumbrical muscles, and went to the dorsum, first between the adductor transversus and obliquus, and secondly between the index and middle fingers. (See Fig. 136 for explanation of this latter extension.) Experiment 33. This mass extension was extremely interesting. It filled the thenar space and then passed to the space between the adductor transversus and the first dorsal interosseous, going both above and below THE THEN A R SPACE 139 the adductor, i. e., both proximal and distal, abutting on the dorsal subcutaneous tissue at web at distal edge of first dorsal interosseous, extending along index lumbrical canal, and did not go into middle palmar space or forearm. The most interesting extension, however, was that which occurred through the palmar aponeurosis at the distal edge of the bases of the index and middle FIG. 48 Schematic drawing made from a dissection of a hand in which the injec- tion was made along the tendon sheath of the index finger. The mass filled the thenar space, extended to the dorsum below the adductor transversus and to the palm through a defect of the palmar fascia. fingers into the soft pad of fatty tissue which lies here in the palm, thus giving corroboration to those clinical cases which are on record in which pus has pointed here, supposedly through an imperfect palmar fascia. This was the only experimental injection in which a mass appeared in the palm. (See experimental in- jection drawing, Fig. 48.) 140 SYNOVIAL SHEATHS AND FASCIAL SPACES Experiment 34. Result same as 33 except no sub- dermal palmar extension. Experiment 35. Mass filled thenar space; no ex- tensions except along index lumbrical canal. INJECTION THROUGH PALMAR FASCIA IN ATTEMPT TO REACH THENAR SPACE. To do this properly the cannula should be inserted about the middle line of the palm one centimeter to the thenar side of the adduction flexion crease of the thumb. FIG. 49 Schematic drawing made from a dissection of a hand in which the injection was made through the palmar fascia into the thenar space. Experiment 36. Left hand. Cannula inserted into middle thenaj space, moderate force used jn injection. Mass was found to have filled the space completely, but had not followed along the index lumbrical muscle to the finger, nor had it gone to the dorsum under the subcutaneous tissue. The space filled corresponded to the area comprised between the adduction crease of the thumb and the metacarpal bone of the thumb in adduction. (See experimental injection drawing, Fig. 49.) THE DORSAL SUBCUTANEOUS SPACE 141 Experiment 37. Attempt to inject thenar space. Right hand. Cannula was inserted too far to radial side over muscular group. Small mass was found in indefinite space adjacent to flexor brevis pollicis. (See experimental injection drawing, Fig. 50.) Experiment 38. Same as Experiment 37. FIG. 50 Schematic drawing made from a dissection of a hand in which an attempt was made to inject the thenar space but in which the cannula reached only one of the indefinite spaces near the metacarpal bone. THE DORSAL SUBCUTANEOUS SPACE. INJECTION OF SUBCUTANEOUS TISSUE OF THE DOR- SUM BETWEEN THE FlRST AND SECOND METACARPALS. NOTE. These injections were made to determine the relaticn of these spaces to the thenar space and the remainder of the subcutaneous tissue on the dorsum. Experiment 39. Injection right hand. Moderate force; insertion into subcutaneous tissue on dorsum, thenar region. Mass was found to be subcutaneous, and while there was evidently a tendency to limitation at the index metacarpal, yet it is doubtful if it was due to the attachment of fascia to the bone, being more 142 SYNOVIAL SHEATHS AND FASCIAL SPACES likely to be the natural tendency to limitation found in the meshes of any loose tissue. Moreover, in spite of the partial limitation at this point, it had spread into the subcutaneous tissue above the tendons, going from the wrist proximally to the metacarpophalangeal articulation distally and over to the level of the fourth metacarpal bone. It did not go through to the palm by any channel. Experiment 40. Injection of left hand same as above. Mass upon dissection found to occupy dorsal thenar subcutaneous tissue over to the index meta- carpal, beyond which it did not extend. It did not pass to the palmar surface nor into the thenar space. INJECTION OF THE SUBCUTANEOUS TISSUE OF THE DORSUM BETWEEN SECOND AND THIRD METACARPAL BONES. Experiment 41. Right hand. Cannula in- serted into subcutaneous tissue of dorsum of hand and the mass injected with considerable force. The tip of the needle was superficial to the tendons, but deeper than the superficial layers immediately beneath the skin. Upon dissection, mass was found to occupy a considerable space extending from the wrist above to the metacarpophalangeal articulation below and from the metacarpal bone of the index finger to the meta- carpal bone of the little finger; proximally and distally, at the wrist and fingers respectively, the tissue seemed to be bound more firmly to the underlying tissue than laterally. Experiment 42. Left hand. Technique and results same as Experiment 41. A study of these two show several layers of fascia between the skin and tendons, with no single space more distinct than another. THE DORSAL SUBAPONEUROTIC SPACE. INJECTION UNDER TENDONS OF DORSUM. The im- portance of this series is seen when we remember that THE DORSAL SUBAPONEUROTIC SPACE 143 it is in this space that pus would lie if it ruptured through between the metacarpals from the palmar surface. The results obtained were uniform. FIG. 51 Schematic drawing made from a dissection of a hand in which the injec- tion was made underneath the aponeurosis of the dorsum, the subaponeurotic space being filled. Experiment 43. Left hand. Cannula tip inserted under tendons between middle and ring fingers at lower third of dorsum. Considerable force was used in the injection. The mass was confined to the space under the tendons, i. e., was covered by the tendons and the aponeurosis between them. It passed up to the wrist, down to within one-half inch of the fingers, and later- ally to index metacarpal and little finger metacarpal; thus having the shape of a truncated cone flattened on one side. The mass appeared to be ready to break out upon the ulnar side, but none had done so. (See experimental injection drawing, Fig. 51.) Experiment 44. Left hand. Technique and results same as Experiment 43. Experiment 45. Right hand. Cannula inserted be- tween tendons of ring and little fingers, at the middle 144 SYNOVIAL SHEATHS AND FASCIAL SPACES of the dorsum of the hand; entire subaponeurotic space filled; no tendency to rupture between tendons, but evidence of beginning extension at two sides over index metacarpal and little finger. HYPOTHENAR SPACE. Many experiments were made to determine the limitations of this space. The injections spread from the site of injection only after considerable manipula- tion, and then the mass was limited to the hypothenar area, near the point of insertion. The details of the other injections are omitted, since they only corrobor- ate the findings already noted. RESUME OF PRECEDING EXPERIMENTS AS TO BOUNDARIES, DIVER- TICULA, AND EXTENSIONS FROM THE FASCIAL SPACES. 1 That we may have a clear understanding of the results obtained by experimental injection, let us 1 A study of the comparative embryology throws some light upon the natural divisions of the hand, but unfortunately this has as yet only been worked out in relation to the palmar fascia and tendon groups. Dr. McMurrich (Am. Jour, of Anat., No. 2, p. 202) described the relation of these in amblystoma. The muscular masses which here arise in the palmar fascia, and which cor- respond to the superficial tendons in the mammalia, divide longitudinally into three groups, the lateral parts destined for the second and fifth digits, sepa- rating from the median parts destined for the third and fourth digits. Here we see that thus early we have a suggestion of the ultimate relation of the parts, in that the tendons arising from the palmar fascia leave room below them for fascial spaces between them and the bones. And again, the early grouping of the tendons corresponds to the spaces, i. e., the radial lateral parts going to the index finger, and being entirely separated from the two ulnar parts corresponding to the middle, ring, and little fingers. The most ulnar part is not so distinctly separated from the median part as is the radial, that, in a way, being partly fused with the median, but still, both upon dissection and injection, we have noted a partial tendency to separation of the middle and ring finger area from the little finger area. How much the development of the muscular mass of the hypothenar area may have to do with this is, of course, undecided, since we as yet know little as to its embryological develop- ment, but it would seem reasonable to assume that it has little relation, owing to its extreme ulnar position; so that, reasoning a posteriori, we would Say that in case of the mammalian embryo there had been a persistence of the separation between the index mass and the others, while there had been either an incomplete fusion between the median and ulnar mass, or else they had partially fused as development proceeded. RESUME OF PRECEDING EXPERIMENTS 145 summarize them. The mass in the middle palmar space, in practically every case, filled the space we have outlined (Fig. 52). In no case did it extend into the hypothenar area or to the radial side of the middle metacarpal bone, except in the case noted, where a band was tied about the wrist in which the mass then ruptured into the thenar space. In every case there FIG. 52 M.P.S. Photograph of middle palmar space, tendons being raised. The end of the pencil lies in its deepest part. was some extension along the lumbrical muscles, almost always going down between the bases of the middle and ring fingers, and sometimes between the little and ring fingers, and, more uncommonly, the middle and index fingers. Unless great force was used, this was the limit of the extension. When great force was used, the masses in the lumbrical canals passed 10 146 SYNOVIAL SHEATHS AND FASCIAL SPACES out into the loose tissue of the web; also the mass filling the space proper passed upward under the tendons into the forearm, where it spread beneath the deep muscles nearly up to the elbow before it came to the surface at the lower part of the forearm on the ulnar side. (For the location of the mass in the forearm, see Chapters X and XXVI.) In no case did the mass go through between the bones to the back. FIG. 53 Photograph showing thenar space. The end of the pencil appears in its deepest part. The thenar space was found to be a large space, but lying very deep (Figs. 53 and 54). It was not continu- RESUME OF PRECEDING EXPERIMENTS 147 ous with the subcutaneous tissue of the dorsum, and the mass was limited at the free palmar edge of the radial side of the palm. The mass did pass, however, when force was used, into the perimuscular sheath on the dorsum, passing proximally and less frequently distally to the adductor transversus, lying between this muscle and the first dorsal interosseous. It also spread down along the lumbrical muscle of the index finger, making a diverticulum from one-quarter to one-half inch long. In no case did it spread up into FIG. 54 Photograph showing thenar space with the tendons drawn away so as to expose it widely. the forearm, even though anatomical dissection demon- strated that this would be possible, although im- probable, and if it did it would be in the same site as that described for masses coming from the middle palmar space. In no case did the mass lie to the ulnar side of the middle metacarpal bone, unless great force was used in the injection; then it passed through the upper part of the septum and filled the middle palmar space in one-third of the cases. Injections into the hypothenar area showed the spaces 148 SYNOVIAL SHEATHS AND FASCIAL SPACES to be localized and perimuscular for the most part, not communicating with any large space, and hence of no particular surgical importance. Injections of the subaponeurotic space demonstrated that the mass would not rupture through the aponeu- rosis unless anatomical exceptions were present. It would spread up to the wrist, down to the metacarpo- phalangeal joint, and laterally to the edge of the index or little finger tendon on the radial and ulnar sides respectively. If greater force were used, it tended to spread under the subcutaneous tissues, particularly on the ulnar side and at the knuckles. Injections of the dorsal subcutaneous space showed no particular pockets, but did show a tendency to localization at any site injected because of the obliquity of fibrous bands crossing from space to space. If the injections were given with great force, the mass spread equally in every direction, except that there seemed to be some particular factor at work limiting in a certain measure the spread of the mass over the index meta- carpal from the dorsum of the hand to the thenar dorsal region, and vice versa. Deep injections of the palm went into the spaces lying underneath, and since these spaces do not overlap, except at the wrist, only one space is affected by a given punctured wound. It must be remembered, however, that the lymphatic channels from the centre of the palm pass deeply into the tissue and come to lie immediately adjacent to the adductor transversus, so that a lymphatic abscess from a punctured wound might lie in the thenar area, although the puncture might appear to be at the radial side of the middle palmar space. When the masses spread up into the forearm they appeared under the flexor profundus digitorum. This subject is considered as a whole in the next chapter, devoted to a study of the various spaces in the forearm. CHAPTER X. ANATOMY OF THE FOREARM IN RELATION TO INFECTIONS. EARLY in my clinical work it was found that there was little knowledge as to the sites of predilection for pus in the forearm when it extended from the hand. Experience showed that incisions made at the sites suggested by Forssell and others were followed by a tedious convalescence owing to the necessity of main- taining satisfactory drainage through the muscular bodies. A study of the forearm after the same methods already pursued in the hand was begun, namely, by dissection of serial sections and injection of masses from various sites. As a result of this, I changed entirely the sites of my incisions, and had the great satisfaction of seeing cases, which under the old methods of incision required weeks of constant at- tention and multiple incisions, heal in a week to ten days, with two or at most three incisions made at one sitting. Parona, as quoted by Mauclaire, has suggested the advisability of one of these incisions that upon the ulnar side above the wrist. The anatomical and experimental data upon which these incisions were based are detailed in brief in this chapter. ANATOMY IN GENERAL. In general one should remember that the synovial sheaths, i. e., the ulnar and radial bursae, pass under the annular ligament and extend into the forearm for a distance varying from 'one to two inches. The greater 150 ANATOMY OF THE FOREARM part of the sac of each lies upon the dorsal surface of the tendons, i. e., between the tendons of the flexor profundus digitorum and the pronator quadratus (Fig. 91). Again, one should note that the bloodvessels and nerves are surrounded by fascial spaces and when pus once reaches them it can spread easily along these as channels. Before beginning this study one should be familiar with the general anatomy of the forearm; particularly the relations of the flexor carpi ulnaris, of the flexor profundus digitorum as a group, of the flexor sublimis digitorum as a group, of the course of the median and ulnar nerves, and of the ulnar and radial artery, espe- cially the former, the relation of the pronator quadratus and the ulna and radius with the interosseous mem- brane in one group to the flexor profundus digitorum. With these general facts in mind, let us now take up the study of the cross-sections. SERIAL CROSS-SECTIONS OF THE FOREARM. The cadaver arms were hardened in Kaiserling No. I . After being sectioned the pieces were preserved in Kaiserling No. 2, Sections were made at the following distances from the radial styloid: 3 cm., 7 cm., 9 cm., and 12 cm. The proximal surfaces of these sections were teased out with a needle and forceps. The large spaces found were packed with cotton or held open with small props and photographs taken to show their rela- tion to the other structures of the forearm. One par- ticularly large free space was found in the lower part of the forearm in direct contiguity with the tendon sheaths and in continuity with the middle palmar space in the hand. It is upon this that we will centre our attention. Section I (Fig. 55). Three centimeters above radial styloid. The space is rather small here, opening out from the narrow strait that connects it with the middle SERIAL CROSS-SECTIONS r QF THE FOREARM^ 151 palmar space in the hand. It extends well across the forearm, but is slightly larger upon the radial side. The vessels and nerves are separated from the space by well-defined layers of muscular and connective tissue. Upon the superficial surface it has the tendons of the flexor profundus digitorum, covered by their synovial sheath, and the flexor longus pollicis, covered by its synovial sheath. On the radial and ulnar sides there is nothing but the attachment of the muscular fascial sheath to the bones, and the subcutaneous tissue. On its deep surface is seen the pronator quadratus. FIG- 55 IM - Section 3 cm. above radial styloid: UA, ulnar artery; UN, ulnar nerve: MN, median nerve; RA, radial artery; S, space; IM, interosseous mem- brane; PQ, pronator quadratus. It is seen that if pus ruptured from the synovial sheaths or passed upward from the middle palmar space, it would enter this free area. It is manifest that a large accumulation could take place here. Its most superficial sites would be upon the sides. Section 2 (Figs. 56 and 57). Five centimeters above radial styloid. The relation of the structures has not changed materially. The body of the pronator quad- ratus is somewhat smaller. The space here goes well to the ulnar side. By comparing this with the other sections it will be seen how little tissue lies at the side, and it is at . _ OP i om t ct ana io 7 ^ rob Stri ~-d.i oJ J, 111 j-3 .o ^ d g-g rt 5^ S |-3f s-&fS ^ frt TO C ..-( g 2 a ^-^ O it: ! lll MHu ' 13 1 I . Cultures. GAS-BACILLUS INFECTION 387 The condition is characterized pathologically by a rapidly spreading inflammation associated with the formation of gas, the presence of which is denoted- by the crepitation found on palpation, characteristic of emphysema elsewhere. In the milder cases, locally, one finds a moderate degree of serum between the muscular bodies and in the subcutaneous tissue asso- ciated with gas. Systemically, one finds the changes of a moderate toxemia. In the severe cases we find a diffuse, watery, semibody edema of marked degree, going on even to necrosis of tissue with gas bubbles throughout. There is an absence of phagocytosis. Gas bubbles may be found disseminated in the blood- stream. An excessive amount of gas speaks for an infection by the Bacillus aerogenes capsulatus rather than one by the bacillus of malignant edema. The. finding of a mixed infection with streptococci and staphylococci is not uncommon. The infection may begin with the slightest wound, but more often it is found with severe injuries in which dirt has been ground into the tissues. It has been my fortune to see three cases in the arm, two of which began from very insignificant injuries, and the third followed a compound fracture of a finger. In the milder cases the systemic evidences of toxemia are not marked. The local swelling is frequently very great, however, and one elicits the sense of crepi- tation under the palpating finger. The history is that of a wound received twenty-four to forty-eight hours before. The arm is reddened and the swelling increases rapidly. Upon incision, free fluid, non- bloody, is seen, and from between the blanched mus- cles the gas-laden serum can be evacuated. Following free opening the extension stops. In the severer type the evidences of systemic intoxication are marked. The restless roving eye, 388 ERYSIPELAS, ERYSIPELOW, ANTHRAX the nervous movements of the body and hands, the parched tongue, cold, perspiring brow, scanty, high- colored urine, and running pulse are evident. Locally the evidences of severe infection are marked. While the gaseous crepitation may not be any more marked, and, indeed, it is often less so, yet to it is added the livid or blackish color suggestive of impend- ing gangrene; the epidermis may be raised in blebs filled with a dark, bloody fluid, the skin is hard, and incision evacuates a reddish or brownish fluid, foul- smelling, and, as a rule, containing gas. The muscles may begin to show the evidence of oncoming gangrene, while the subcutaneous and intermuscular tissue may already have become necrotic. The process con- tinues to spread rapidly in spite of the incisions. The arm becomes gangrenous and the patient rapidly succumbs to the toxemia, sometimes in from four to five days. The prognosis depends upon the type and the promptness of treatment. As our experience grows it is probable that we will be enabled to apply the proper treatment earlier, and in certain cases demand amputation more promptly, and thus reduce the mortality, which now varies from 30 to 55 per cent, according to various authorities. Personally, of my three cases one recovered and two died. One of these two was seen too late for any hope of relief. If we could but differentiate the types, clear indi- cations for treatment could be placed. Unfortunately, this is not the case. The milder type of infection due to the Bacillus aerogenes capsulatus can often be cured by wide incisions draining every focus. This includes separating the muscular masses if necessary, washing out the areas with peroxide of hydrogen or oxygenated water, and inserting gauze drainage to prevent the collapse of the openings and thus giving GAS-BACILLUS INFECTION 389 the anaerobic bacteria an opportunity for further development. The cutaneous incisions should be extensive and left unsutured. If under this treatment there is any tendency to spread in the next twelve hours, amputation should be advised. The same advice should be given in the more virulent type as shown by the local and systemic reaction. Here no time should be wasted in palliative measures, for the patient rapidly passes into the stage of systemic infec- tion or toxemia, from which he will not recover even with amputation. One may say, therefore, that amputation should be performed in case of doubt. It should be done well proximal to the infection, so as to make incisions in healthy tissue, and the stump should be left open for secondary suture after we are certain that the process is under control. My own experience in three cases bears out these statements. In the first case seen, amputation was performed at once and the patient recovered promptly. The gaseous infection had spread well into the arm. The amputation was performed at the upper third of the humerus. In the second case seen in consulta- tion, wide incisions were made which were further increased upon the next day. The patient was not seen by me subsequent to the first day. I am informed, however, that the gaseous infections subsided, and a secondary infection began from which the patient succumbed at the end of three weeks. The third case seen by me was one in which the patient had suffered a slight abrasion of the middle finger of the left hand. I saw him at the end of the fifth day, when the systemic condition show r ed the patient to be suffering from a marked toxemia. The whole arm has a bluish-black color, is swollen, and covered by blebs. The arm was amputated by an able surgeon at once, but the patient succumbed from his toxemia within a few hours. 390 ERYSIPELAS, ERYSIPELOID, ANTHRAX ANTHRAX. Anthrax is not common in the United States, although sporadically it may appear in various sections. The frequency of lesions upon the hand and arm is given by Koch in a series of 923 cases as 40 per cent. Keen has described a typical case in the Annals of Surgery of August, 1905. Personally, my experience is limited to one case seen during my interneship at the Cook County Hospital. The description of the condition which I append is modified from that given in Frazier's excellent description of the disease. No attention, of course, is here given to the pulmonary and intestinal types. When the disease is implanted upon the hand or forearm of those having to deal with hides and other sources of infection, we note an elevated pustule, 5 mm. to several centimeters in diameter, with a depressed central scab. The corium and papillary body become infiltrated with a sero- cellular exudate and with bacilli. The perivascular and connective-tissue spaces become filled with leukocytes, and the pressure of this serous and cellular infiltrate, together with the toxins of the bacteria, cause the central coagulation necrosis, though suppuration does not occur unless there is a mixed infection. When the serocellular exudate extends upward to the superficial epithelium, it elevates the latter and produces the typical vesiculation. In the edematous variety the swelling is due to the diffuse serocellular infiltrate and to the effect of the bacteria blocking or inducing coagulation in the capillary vessels. The lesion may be transferred to other parts of the arm or body, especially the face, by scratching the lesion and then the secondarily infected part. Wherever the lesion occurs we note that from a few hours to some days after the inoculation some itching ANTHRAX 391 and burning are felt, and upon inspection a small papule with a central bluish point is seen. A few hours later the papule becomes vesiculated, contains a brownish, sanguineous fluid, and may be scratched off by the patient. The surrounding tissues become red, indurated, and puffy, and later purplish and gangrenous in appearance, although there may be no indication of suppuration. Pain now ceases, and beyond malaise, nausea, slight fever, and muscular or joint pains, there may be no other constitutional effect. A vesicular areola limited in extent is soon observed about the pustule, containing serohemor- rhagic fluid; the pustule may undergo necrosis, the area of necrosis rarely exceeding 3 cm. in diameter. In about ten days, in favorable cases, a line of demar- cation forms about the eschar, which "floats off," leaving a defect to heal by granulation. In more severe cases the edematous swelling about the pustule may be very extensive and erysipelatous in appear- ance, associated with a lymphangitis and lymphade- nitis with hard and tender lymph nodes. The vesicles become bullae, contain a bloody fluid, and the ultimate suppurative and gangrenous process may involve areas as large as the entire half of the face. In these severe cases the constitutional symptoms are marked, resembling those of cholera, with great prostration and depression, a weak, rapid pulse, often icterus, diarrhea, delirium, and coma. In the parts where there is considerable loose areolar tissue, as the eyelids, neck, and forearm, great edema may be seen. Here, instead of the characteristic changes described above, the area may have a well- defined border without vesiculation, redness, or gan- grene. There may be little or no pain, even in those cases ending fatally. The diagnosis must be made from the furuncles 392 ERYSIPELAS, ERYSIPELOID, ANTHRAX and carbuncles. The careful surgeon will at once note that the lesion is essentially different from these, and will by smears and culture determine the presence of the anthrax bacillus. The statistics as to the mortality vary greatly^ being from 6 to 30 per cent. Koch collected 1413 published cases, with a mortality of 32 per cent. Frazier summarizes the treatment as follows: To judge from the experience of those who are most qualified to speak, the treatment of anthrax should consist essentially in the administration of Sclavo's serum, in the excision of the pustule, and in the appli- cation of certain bacteriological agents. The serum should be administered subcutaneously and the pus- tule should be excised only when the surrounding tissues are not very edematous, taking the precaution to cauterize the exposed surfaces with carbolic acid or the actual cautery. If the edema is marked, abso- lute rest of the part should be enjoined and local hot antiseptic fomentations, such as bichloride of mercury, applied. The serum has no deleterious effects, and in the hands of its originator and others, especially in Italy and England, the results substantiate the claims which have been made. It assists in the destruction of the bacilli, before they become so numerous that their destruction by the bodily defences increases the danger of fatal poisoning from the toxins set free by the disintegration of the bacilli. When the serum cannot be obtained, and when excision is impracti- cable, injections of carbolic acid (5 per cent.) should be tried, introducing the needle at several points along the margin of the pustule and infiltrating the base of the pustule and surrounding healthy tissue. These injections may be repeated frequently. The constitutional symptoms must be met by appropriate and supportive measures. ANTHRAX 393 It has been my fortune to meet with only one case of anthrax. That occurred in a man, aged thirty- five years, who worked in the Chicago stockyards. He applied at the Cook County Hospital for treat- ment, and I regret to say that the records of the case cannot be secured at the present time. The lesion was upon the left forearm and presented the charac- teristic gangrenous centre. He w r as treated by local antiseptics and made a prompt recovery. SECTION V. COMPLICATIONS AND SEQUELAE OF INFECTIONS OF THE HAND. CHAPTER XXVI. FOREARM INVOLVEMENT FROM INFEC- TIONS OF THE HAND PATHOLOGY AND DIAGNOSIS. FOREARM involvement occurs in two forms that associated with lymphangitis and that following ten- don-sheath infection of the flexor tendons and abscesses in the palm. These two forms have been touched upon in general in discussing these infections in the preceding chapters. The pathology and localization is essentially different, as it arises from the two sources. I refer, of course, to suppurative involvement, and have no reference to the edema which always occurs with any infection. At the risk of some repetition, I shall review the subject in general, so as to give a composite picture. SUBCUTANEOUS ABSCESSES. That form due to lymphatic involvement of super- ficial origin has been referred to on page 326. We may have a secondary involvement upon both the flexor and extensor surfaces. Upon the flexor surface we find a localization just above the annular ligament in many cases of deep infection of the hands, particu- 396 FOREARM INVOLVEMENT larly those cases showing an ulnar bursitis. They are characterized by redness and slight induration over an area two or three inches in length at the lower end of the forearm. The diagnosis is not difficult, the only thing to be borne in mind being that the surgeon should understand its origin and should not desist from dealing with the extension under the tendons from a rupture of its synovial sheath, since there is no connection between these pockets, and draining the superficial pocket does not drain the deeper and more important focus. Besides this well-differentiated localization, small foci may develop along the lines of any lymphatic, either on the flexor or dorsal surface. Care should be taken not to mistake these uncommon localizations for the acute non-suppurative inflammation of the lacunae (see p. 327). Again, localizations may take place about the glands of the epitrochlear region, as has been described in Chapter XX. The most important subcutaneous accumulation associated with lymphatic infection occurs upon the dorsum of the forearm. This condition, characterized by a brawny induration of the entire dorsum, with necrosis and sloughing of the subcutaneous tissue, is one of the gravest complications met with in hand infections. A full discussion may be found in Chapters XX and XXI. DEEP ABSCESSES. The deep involvement, no matter what the origin, almost always is found upon the flexor surface. This most commonly arises through extension by rupture of the proximal end of the ulnar or radial bursae or by extension from a palmar abscess. This is by all odds the most important question we have to deal with ABSCESS FORMATION WITHOUT COMPLICATIONS 397 when considering forearm involvement. It will be discussed under three heads: 1. Cases showing forearm abscesses without other complications. 2. Cases showing forearm involvement with carpal joint involvement. 3. Cases showing forearm involvement with second- ary hemorrhage. FOREARM INVOLVEMENT: ABSCESS FORMATION WITHOUT OTHER COMPLICATIONS. LOCATION OF THE ABSCESSES. It has been the habit of surgeons and writers dealing with this subject to speak of these abscesses in a general way only, and to suggest drainage through the volar surface between the tendons and muscles. In my earlier cases I was struck with the long convalescence, the repeated incisions, and the inadequate drainage owing to the rapid closure of the sinuses through the muscular bodies. There- fore a careful study of the anatomy of the forearm was undertaken both by dissection of serial sections and by experimental injections made through the various tendon sheaths and from other sites of predilec- tion of pus in the hand. By this I determined the probable site of these secondary abscesses in the fore- arm. These experimental and anatomical deductions were verified by a study of all my cases showing this complication, as well as an extensive review of cases reported in the literature. The result was beyond expectation. The study enables the surgeon to prog- nosticate before operation the exact location of pus in the forearm. It suggested new sites for drainage which cured cases in from one to two weeks by two, or at most three, primary incisions, which by the older procedures would have required from three to five weeks, with the probability of many complications. 398 FOREARM INVOLVEMENT The anatomical and experimental work I have detailed in Chapter X. It remains for me, therefore, to adduce the clinical proof of its correctness and sug- gest plans of treatment. It will be seen, by referring to Chapter X, that the final deduction made from the researches was that the important space in which pus would be found in those cases where the infection originated in the hand had the following boundaries: It lies under the flexor profundus digitorum tendons and muscle. About three inches up on the forearm the pus begins to invade the intermuscular septa, passing first to the area about the median nerve and later to the area about the ulnar artery and nerve. Here it lies between the flexor carpi ulnaris and the flexor profundus. This is about four inches up on the forearm. From here it may pass toward the elbow along the vessels and nerves, particularly the median nerve, or more commonly it may extend distally along the ulnar artery under the flexor carpi ulnaris and appear subcutaneously about three inches up on the ulnar side. It may extend downward along the radial artery, but this is certainly an uncommon termination. The largest part of the space is about two inches above the wrist. Its most superficial parts are on either side just volar to the ulna and radius. The floor of the space is made up by the pronator quadratus at the wrist and the interosseous septum above. The space may hold a half pint or more of fluid. No other well- defined space is present except that comprising the subcutaneous tissue. In corroboration of this state- ment, I shall make excerpts from some of the cases that have come under my observation, and shall add a few from the reports of Tornier and Forssell to show that my deductions are unbiased. That there may be no ques- tion as to the possibility of the infection having arisen sequentially from a carpal-joint involvement, those ABSCESS FORMATION WITHOUT COMPLICATIONS 399 cases will be excluded and only uncomplicated forearm involvement discussed. Altogether I have now had 37 cases showing this extension. The report of the post- mortem in Case XXII may also be noted in corrobo- ration. CASE XXV. The ulnar bursa was opened and inci- sion extended to the middle of the forearm, exposing an abscess lying mainly under the flexor profundus digitorum. CASE XXVI. The flexor side of the forearm was swollen and painful to the upper third, incision was continued from the ulnar bursa on the forearm toward the centre. In juxtaposition to the nerves and blood- vessels a pocket of pus was evacuated, which extended between the flexor sublimis digitorum and the flexor profundus digitorum, and lying on the interosseous mem- brane of the upper half of the forearm. CASE XXVII. The hand and forearm were swollen, incision was extended from the ulnar bursa in the fore- arm and the flexor muscles were separated by the handle of the scalpel. The abscess extended along the inter- osseous ligament to within a hand's breadth of the elbow. CASE XXVIII. Incision was made opening the sheath of the flexor longus pollicis and up to the annular liga- ment; a second incision was made into the same sheath above the annular ligament, and this was extended along the lower half of the forearm over the radial sources of the flexor sublimis digitorum. Pus was found along the flexor longus pollicis and behind the flexor profundus digitorum in the lower third of the forearm. CASE XXIX. A large amount of pus was shown in the lower two-thirds of the forearm lying between the flexor sublimis digitorum and the flexor carpi ulnaris, below the flexor profundus, which was entirely evacuated by a single incision upon the ulnar side above the wrist-joint. In the following case there was a neglected tendon- sheath infection on the dorsum. These cases are extremely uncommon, since they are generally only local abscesses without extension. 400 FOREARM INVOLVEMENT CASE XXX. An infection extended upon the back of the forearm; after two superficial abscesses had been opened, it was noted some days later that there was a painful swelling on the dorsal ulnar side of the forearm; this was incised as far as the fascia without freeing any pus. A pocket was found, however, under the dorsal annular ligament extending into the otherwise healthy muscle above. CASE XXXI (Forssell). A large incision was made on the middle of the forearm down to the palm, cutting the anterior annular ligament and part of the palmar aponeurosis, a large abscess was found in the palm and under the annular ligament and in the forearm lying between the ulnar muscles and the flexor profundus digitorum. The tendon sheaths were entirely intact. CASE XXXII (Forssell). About a week after the prim- ary injury there was an increase of pain in the arm, which became red, sensitive, and swollen. After four or five days pus was forced out by pressure on the forearm, a 7 cm. cut was made above the wrist through the skin, followed by a blunt dissection to the tendon sheaths, from which thin pus was evacuated ; a drain was inserted through this opening under the annular ligament out through the hand. On the ulnar side of the forearm an incision was made, 15 cm. long, carried down between the flexor profundus digitorum and the flexor carpi ulnaris; pus was met with here and the tendons of the flexor profundus digitorum were surrounded with pus in the lower three-fourths of the forearm. CASE XXXIII (Tornier). Two weeks after injury it was noticed that the entire arm was swollen, especially the forearm. On the same day the ulnar bursa was opened, a large amount of pus was found, much burrow- ing behind the muscles of the forearm, and wide incisions were made here. CASE XXXIV (Forssell). The lower third of the fore- arm was swollen and tender, but the patient had no spontaneous pain. The ulnar bursa was opened through- out its length and the incision continued over the lower third of the forearm. This exposed an abscess lying on the interosseous membrane under the muscles. Counter- incisions were made. Culture showed streptococcus. ABSCESS FORMATION WITHOUT COMPLICATIONS -401 FKY^tnr p CASE XXXV (Tornier). Incision was made into the radial bursa and on the forearm extending on the radial side, exposing an abscess lying between the pronator radii teres and the flexor carpi radialis, behind the deep flexors. CASE XXXVI (Tornier). Both bursae opened, anterior annular ligament incised, large amount of thick yellowish- green pus was found in the lower part along the inter- osseous membrane. FIG. 119 Photograph of cross-section, 7 cm. above the radial styloid, showing area filled with pus. Every case that has come under my observation has borne out these deductions and from these reports and my studies it is certainly justified to outline the position of these secondary abscesses as we have. The position of the pus at a point one and one-half inches up on the forearm is shown in cross-section (Fig. 119), and also the position of the pus when it reaches the middle of the arm is shown in a second cross-section (Fig. 120). SYMPTOMS, SIGNS, AND DIAGNOSIS. The diagnosis of a forearm involvement is based on the knowledge of an associated tendon-sheath infection of the ulnar or radial bursse or a middle palmar infection and the 26 10 N NfXhfel- 403. rjFQX&A'&M INVOLVEMENT tUYi^oTVoO - - - l .; \^^i.BJghs inci^erti TO the development of any deep abscess. Especially in an ulnar bursitis which has existed two or more days before drainage do we look for a beginning forearm involvement. In any case, we have the devel- opment of increased swelling of the forearm. The swollen part has not the soft feeling incident to edema, but a full, tense feeling as if the forearm were an over- distended bag. There may be but little increase in redness. The induration seen in subcutaneous abscesses will be absent. However, tenderness to deep pressure FIG. 120 Photograph of forearm just below the middle, showing position of pus in its relation to the ulnar artery and the median nerve. is increased. The wrist becomes more or less fixed and the careful observer has no difficulty in suggesting the diagnosis on the history of these findings. Of course, later, when the pus had infiltrated every part, even the novice can make the diagnosis. Early diagnosis is greatly to be desired, however. It should be urged that in case of doubt incision may be made after the manner already suggested, by lateral incisions, without in any way jeopardizing the patient's forearm. Whenever I open an ulnar or radial bursa, and there is INVOLVEMENT WITH WRIST-JOINT INVASION 403 any question in my mind as to forearm involvement, the forearm incisions are made. Indeed, these same incisions may be used to drain the upper end of the sheaths in the forearm. So that the incisions thus serve two purposes they drain the bursae, and if pus is already in the forearm or develops subsequently, they afford it an immediate outlet. DEEP FOREARM INVOLVEMENT ASSOCIATED WITH WRIST-JOINT INVASION. If operated upon early the involvement of the wrist- joint will be uncommon. In certain cases, however, it will be met with either early in the course or later as a complication. The wrist-joint involvement is a most serious complication, and it should be watched for, particularly in aged patients with involvement of the radial bursa (tendon sheath of the flexor longus pollicis). By reference to the cases it will be seen that of the 8 cases here reported, 7 were fifty-four years of age or older. It is to be noted particularly, however, that every case was one of involvement of the radial bursa, either alone or in conjunction with other foci. In 5, the primary process was in the thumb. One cannot help but feel that this is more than a coincidence; as yet, however, no definite anatomical reason can be adduced to explain it. In none of my injections of this synovial sheath has the mass ruptured or extended into the wrist-joint. EXAMINATION OF THE RADIAL BURSA IN CADAVERS. To determine whether or not there is at times a normal opening connecting the radial bursa and the wrist-joint, with the assistance of Prof. P. T. Burns and Dr. A. T. Horn, of the Anatomical Department of the Northwestern University Medical College, I have examined 30 cadavers, and in no one of them 404 FOREARM INVOLVEMENT have we found any normal* opening, although Prof. Burns states that he has at times noted such a com- munication. This is borne out by other observers, but it must be extremely rare. According to Schwartz, the parietal layer of the ulnar bursa is attached to the ligaments and periosteum of the carpal bones, par- ticularly the unciform and os magnum. Forssell states that in cases of carpal involvement he has noted that the os magnum suffers the greatest destruction (Fig. 121). FIG. 121 pscs IPMP5 Drawing showing intimate relation of the ulnar bursa to the os magnum and its early involvement. Notice the association of the radial bursa and the trapezium: DSCS, dorsal subcutaneous space; IPMPS, infected process leading from middle palmar space; IUB, infected ulnar bursa; O, ostium; OM, os magnum; RB, radial bursa; S, sinus; UV and A, ulnar vein and artery. PATHOLOGY FOUND IN SERIOUS WRIST-JOINT IN- VOLVEMENT. Since my own experience with this condi- tion is rare, I have been compelled to turn to the litera- ture for reports of postmortems. Of my personal cases, 5 in number, all recovered. One case (Case XLIX) INVOLVEMENT WITH WRIST-JOINT INVASION 405 is found in the chapter dealing with Osteomyelitis. Owing to the seriousness of this complication, one may be pardoned for making rather complete reports. In the first case the position of the sinus openings on either side above the annular ligament at the site of the two vessels emphasizes the tendency of these abscesses to follow the vessels (see Experiment 47, where the only place the mass became subcutaneous was on the ulnar side just above the annular ligament). The absence of tenderness and pain about the necrotic joint is also worthy of note. The involvement of the radio-ulnar joint, as here noted, is a frequent complication. CASE XXXVII (Bauchet). Deep phlegmon of the right thumb; deep phlegmon of the hand; phlegmon of the forearm; fistulous processes; abundant suppuration. Great scar over the sacrum; septic infection. Death. Postmortem. This man, between fifty-five and sixty years old, gives a history of an inflammation of the thumb two months before entrance. On the forearm there are two openings ; one is at the inside and the other at the outside of the anterior surface; both are about 4 cm. from the radio- carpal joint. These two openings are longitudinal, about 2 cm. long, with edges grayish and fungous. At the level of the first phalanx of the thumb one sees the scar of a former purulent focus. No redness; dorsal aspect of the hand shows no tumefaction; no sinuses. Tenderness to pressure is not very acute; the wrist is neither swollen nor painful. By pressing on tfie palm of the hand or on the lower part of the forearm, one causes a notable quantity of whitish, poorly mixed, fluid pus, without a bad odor, to flow out through the openings already mentioned. The probe introduced through these openings slides a considerable distance along the lower layers of the fore- arm, but meets no denuded portions of the bone. Aside from the two openings already mentioned, one notes still farther inward, at the level of the upper third of the anterior surface, a small opening from which pus 406 FOREARM INVOLVEMENT escapes, but in smaller quantity than from the other two openings. By pressing the ulna, the radius, and at the same time trying to make the patient move the wrist, one notes a grating between the ulna and the radius and between these bones and those of the wrist, which resembles nothing more than two nuts being rubbed together. Diagnosis. Deep whitlow of the thumb; extension of inflammation into the great common synovial sheath of the tendon of the little finger; rupture of the focus between the muscular layers of the forearm, but more especially of the deeper part; extension of the suppura- tion to the carpal joints; necrosis of the bones. Postmortem. The tendons are fixed in an invariable position, and to free them it is necessary to cut out the resisting fibrous adhesions. These changes are evident in the palm of the hand, under the annular ligament, and the lower part of the forearm, all along the synovial sac. These changes extend to the ends of the tendons of the thumb and little finger. They stop slightly above the metacarpophalangeal joints of the index, middle, and ring fingers. Along these fingers the synovial sheaths and the tendons are absolutely intact. The large focus, black and purulent, has an exit in the two openings before mentioned. At the upper and outer part it is closed, and the muscles of the forearm on this side are healthy. On the ulnar side, on the contrary, the fibrosynovial sac is frayed, and the pus has spread to the level of the upper part of the forearm, between the deep and superficial muscular layers. This purulent focus, formed by a rupture of the synovial sheath, has its exit in the smaller opening, which has already come under discussion. The joints, radiocarpal, radio-ulnar, and carpal, are open anteriorly and communicate extensively with the palmar purulent focus, through several openings. The bones are neither red nor spotted nor crumbling. They are rather of an ivory-gray color and, in spots, blackish; there is no false membrane or generative abscess in the joint; but the cartilage has been destroyed, almost entirely resorbed, and has disappeared; the bones bared of this cartilage resemble bones which have been soaked in water for some time. INVOLVEMENT WITH WRIST-JOINT INVASION 407 The following case, reported in the inaugural dis- sertation of Max Tornier, from the Griefswald Clinic (Prof. Helferich), emphasizes again the frequency of sinus openings in carpal involvement at the sites we have mentioned. CASE XXXVIII. Phlegmon of the forearm, involve- ment of carpal, and radiocarpal joints. Man, aged fifty-eight years. On the ulnar side of the wrist there is a sinus opening 4 cm. long, through which a probe reaches down into the wrist-joint. Under nar- cosis and anemia, Langenbeck's incision, the tendon of the long radial muscle, infiltrated with pus, was resected for about 8 cm. Resection of the proximal line of the carpal bones, between which small masses of pus were found. Drainage established. Very dilatory course ; the distal row of carpal bones sloughed through necrosis. An erysipelas with numerous abscesses on the forearm made further incisions necessary. When dismissed the incisions were healed; the wrist hung loose. The following case from the same report shows the beneficial results of early and radical operation in the case of wrist-joint involvement, and shows the inade- quacy of superficial incisions on the forearm. CASE XXXIX. Severe phlegmon of the hand and fore- arm; caries, of carpal and radiocarpal joints. Patient, aged sixty-three years. Two weeks after infec- tion, incision over abscess on flexor and extensor sides of forearm. Two weeks later, second incision through the intermuscular spaces to the ligamentum interosseum. lodoform drainage. No fever in evenings. The probe in the wound of the dorsal incision strikes carious bones of the wrist; it is pushed on in the direction of the dorsoradial incision to the wrist-joint. The latter is opened, and shows destruction of the cartilage and the bone. The joint is filled with pus. Resection of the navicular, semilunar, trapezium, and trapezoid. Good healing under Langenbeck's extension bandage. Good granulation. Daily massage. Patient dismissed for a few days and did not return. 408 FOREARM INVOLVEMENT Beside demonstrating the pathology of severe cases of carpal involvement and the extension of infection to this and the forearm, from the tendon sheaths, Case XL emphasizes the error that often occurs in mistaking for pus the enormous edema which is found upon the dorsum in these cases of palmar infections. CASE XL (Forssell). Suppuration of the radial and ulnar bursae with involvement of the radio-ulnar radio- carpal, and carpal joints and forearm. J. L., aged fifty-four years. Woman. Pain in the left hand from no known reason; three days later visited hospital. Seven days later, left hand (except for thumb and second and third phalanges of the other fingers) and to a certain extent the whole arm are swollen; pain over the whole back of hand, more in the palm, especially in the fourth interosseous space. Finger half bent; exten- sion very painful. Temperature, 100.5. Incision of the dorsum on the same day; little pus. Incision along the tendon sheaths of the first and fifth fingers; communica- tion established between this and incision above the liga- ment. Also incision over the flexor carpi ulnaris, with communication with the last-mentioned incision. Pus in large quantities from all the incisions. Four weeks after onset of infection the tendons removed so far as they appeared infected. All carpal bones removed with a curette except the trapezium and the upper part of the third metacarpal bone. Discharged after three months with ankylosis of the joint of the hand. CASE XLI (Forssell). Tenosynovitis of radial and ulnar bursae, with involvement of the carpus. G. K., aged sixty years, January 7, 1898. After a small wound at the end of the thumb, symptoms of tenosynovitis in the thumb and little finger. Same day, incision in the tendon sheath of the thumb. January 8. The ulnar bursa was completely cleft; incision into the upper part of the radial bursa. Aside from an insignificant necrosis of the thumb and little finger tendons, all went well until January 16, when symptoms of an infection of the wrist arose. These INVOLVEMENT WITH WRIST- JOINT INVASION 409 increased, and (January 18) necessitated an incision into the wrist-joint, a considerable serofibrinous secretion being found. Joint washed out with I per cent, sublimate solution. Gradually distinct formation of pus took place, which led to a partial resection of the wrist (February 5). In the following case the decreased sensitiveness in the area of the distribution of the median nerve serves to emphasize the tendency of infection to spread along that nerve, as demonstrated in Experiment 47 and shown in Fig. 120. CASE XLII (Forssell). Tenosynovitis of the thumb, little finger, and ulnar bursae. Phlegmon of the forearm and articulation between hand and forearm. S. T., aged thirty-three years, female. April 4, 1898. Distinct symptoms of suppuration of the carpal "tendon sheaths (tendon sheath of the little finger intact) and on the forearm. Only slight pain on passive movements of the finger; "the finger twinges;" the same is true of palpation of the palm and the flexor side of the forearm. Complete opening of the ulnar bursa; by mistake the sheath of the little finger was opened; no pus; incision into the thumb; pus within and without the sheath. April II. Incision into the lower part of the forearm down to the ulna (burrowing of pus). For three days there have been symptoms of infection of the wrist- joint; pus pours from a small hole in the capsule between the pisiform and cuneiform. Around the tendon of the flexor longus pollicis there is much pus, wherefore an incision of the same is made; it was especially necrotic in the region of the carpal ligament; here there is also necrosis of other tendons. April 12. Much pus in the wrist and upper arm. Several carpal bones removed under anesthetic. April 1 6. Temperature, 102 to 105. Amputation of the arm. Examination of the amputated arm; elbow- joint intact; all pus cavities opened except the suppurated tendon sheaths of the fourth and third fingers. Necrosis of all tendons at the anterior annular ligament; the con- dition of the median nerve was by mistake not investigated. April 17. Exitus 12 M. 410 FOREARM INVOLVEMENT Epicrisis. Worthy of notice was the decreased sensi- tiveness and pain in the median region, due probably to the compression of the nerve. The inflammation of the wrist was possibly due to the infection of the joint between the pisiform and the cuneiform; in the capsule of this joint a certain defect was noted, whether primary or secondary, still pointing to a certain weakness in the boundary of the canal toward the carpal canal. In the subjoined case the wrist did not become in- volved until fifteen days after the beginning of the infection. In this case, as in many of the others reported here, there may be some question as to whether or not the incisions were made early enough and at the proper sites. Throughout the literature it is evident that surgeons have paid too little attention to the fascial pockets in which pus lies, confining their attention almost entirely to the tendon sheaths. CASE XLIII. Compound dislocation of thumb. In- fection of radial and ulnar bursse, resection of necrotic carpal bones. C. E., aged fifty-eight years. A large quantity of grayish-yellow, thinly fluid pus was freed by opening the radial bursa. An incision which had been made on the volar side of the thumb lengthened, and the tendon cut out. May 20. Complete splitting of the ulnar bursa and the tendon sheath of the little finger; in the bursa and the tendon sheath a yellowish fluid pus. No burrowing toward the forearm could be discovered. The swelling on the hand went down. On May 24 it is especially noted that there is no swelling around the wrist-joint. The superficial tendons of the little finger had become necrotic just below the carpal ligament, and those of the fourth finger as well showed beginning of necrosis here. May 29. Temperature, 37.3 to 37.4. Slight pain in the hand near the wound in the carpal region. Several tendons showed signs of necrosis. On the anterior side of the wrist, exposed bone (radius, carpal bone?) can be felt. FOREARM INVOLVEMENT WITH HEMORRHAGE 411 June 7. Temperature, 37.4 to 38.2. Partial resec- tion of the wrist-joint. Removal of the carpal bones except the trapezium and pisiform; unciform necrotic. By these cases I have attempted to portray the pathology, symptomatology, and course of these fore- arm cases, complicated by wrist-joint involvement. The diagnosis of its occurrence depends upon the crepitation noted in the joint, associated with an increase of tenderness and swelling about the joint. It will be remembered that the original infection is upon the flexor surface. The swelling and tenderness are here. When the joint becomes involved the dorsum also partakes of this. Under normal conditions a depression is noted on the back of the wrist-joint to the radial side of the extensor communis tendons at the lower end of the radius. This marks the site of the radiocarpal articulation. When this fills with fluid the depression is replaced by a fluctuating swell- ing, and in case of doubt a needle can be inserted here and the contents of the joint aspirated for diag- nostic purposes. This site is particularly indicated in doubtful cases, since, the original infection being upon the palmar side, there is no great danger of infecting the joint if it is not already involved. FOREARM INVOLVEMENT WITH SECONDARY HEMORRHAGE. One of the most serious complications met with in the later stages of forearm involvement is that of hemorrhage. The onset of a sudden, profuse hemor- rhage in a patient who is unable to care for himself in the temporary absence of attendants may lead to an immediate lethal issue. The condition is especially dreaded, since the surgeon looks upon the condition as most difficult to handle, since he fears to undertake the dissection which he believes to be necessary to 412 FOREARM INVOLVEMENT find the point of hemorrhage and ligate. He therefore temporizes with a bandaging of the arm and tampor nade, only to be subjected to greater anxiety on account of a subsequent hemorrhage. It would seem that this complication may be successfully dealt with if the surgeon will only have in mind the following facts: 1. The vessel nearly always at fault is the ulnar. 2. The surgeon should not temporize, but cut down upon and ligate at once the bleeding vessel. The reason for the involvement of the ulnar vessel is seen by examining the cross-sections (Figs. 55 to 59, and 120), in which it is shown that the pus early involves this vessel. The line of extension is along this vessel, both up toward the elbow and downward to the ulnar side of the forearm. The radial is well separated from the space in a majority of cases. My statements do not depend alone upon my anatomical and experimental studies. Clinical proof in support of it can be adduced from my experience, and also from numerous cases reported in the literature. I will let two cases suffice for that: one that came under my observation, and one from the service of Prof. Velpeau in which a postmortem was performed. This latter is added for the further reason that the postmortem serves to give further corroboration to my statements as to the position of pus in these cases, a fact which cannot be definitely proved except by postmortem. My own case I shall report briefly. CASE XLIV. Mr. H. Referred to Dr. Richter at the Post-Graduate Hospital, with whom I saw the patient in consultation. Ten days previous to the onset of the first hemorrhage the patient had suffered from a tendon-sheath infection of the ulnar and radial bursae, with extension into the forearm. The infection had not been opened promptly, and even after the primary incisions the drainage from the forearm had not been satisfactory. Dr. Richter had FOREARM INVOLVEMENT WITH HEMORRHAGE 413 made free drainage, but by that time the vitality of the vessel had been impaired. A sudden profuse hemorrhage occurred, which jeopardized the patient's life before it was discovered by the nurse. A constrictor about the arm and tamponade completely controlled the hemorrhage, and it was felt that it would not recur. However, two days later a second profuse hemorrhage occurred, and the ulnar vessel was cut down upon as soon as the patient had recovered from the severe shock. The source was found to be the ulnar, as had been prognosticated. It was ligated with catgut, and the patient made an un- eventful recovery. Function in the hand, however, was impaired. The history of the following case, made the more interesting by the personal attention of the eminent Prof. Velpeau, serves further to emphasize the possi- bility of hemorrhage from ulceration of the ulnar vessel. The presence of the fistulous tracts near the annular ligament suggested the necrosis of the carpal bones which was present, and the deep position of the pus in the forearm is worthy of note. The whole clinical picture was one of extensive involvement of the wrist-joint, deep phlegmon of the arm, and the infection of synovial sheaths which at a later day would in all probability have been relieved by opera- tive procedure. CASE XLV (Bauchet). Whitlow of the left thumb caused by a prick of a needle; multiple abscesses pro- duced by the spread along the synovial sheath to the wrist and forearm. Hospital gangrene complicating the abscesses of the wrist and following the tissues along the ulnar artery, severe hemorrhage, tamponade, tourniquet; gangrene of hand and forearm; amputation; danger of hospital gangrene in stump. Recovery. Patient, aged fifty years, in the service of M. Velpeau, Charity Hospital; sick for two and one-half months; entered April 25, 1851; was dismissed August 13. About two and one-half months ago the patient pricked 414 FOREARM INVOLVEMENT the thumb of his left hand with a needle. There resulted a phlegmon of this finger which extended rapidly over the whole hand; abscesses formed on the palmar aspect of the finger and hand, some of which opened simulta- neously and some of which were opened by a bistoury; the swelling persisted, and even spread through the entire thickness of the wrist and forearm, along the synovial sheath. On the palmar face of the wrist one notes several sinus openings from which passes a purulent fluid, viscid, clear, and thready; by pressing the palmar surface from below upward, one causes this liquid to flow back. These openings seem to communicate freely with the synovial sheaths of the flexor tendons of the fingers at the level of the wrist. The inflammation spreading from the hand to the forearm along these channels is very intense, and pre- sents the characteristics of a diffuse phlegmon. During the next seven weeks the patient was treated in an expectant manner. June 20. Appearance of hospital gangrene. The open- ings on the palmar aspect of the wrist are larger, puffed up, mushroom-like, and forming a large projection show- ing a spongy, fungous, grayish aspect. June 28. Growth of the wound, which now covers the whole palmar face of the wrist. Sinking of the mush- room-like elevation of flesh. All the tissues between the skin and the bones of the wrist are in a state of putrilage, and the flexor tendons are floating in this decomposed matter. These tendons are stripped of their sheath, exfoliated, and have lost their silvery appearance. June 29. During the preceding night considerable hemorrhage from the ulnar artery. After several days hospital gangrene developed in the hand, and Prof. Velpeau amputated at the upper third of the forearm. The patient then made a rapid recovery. Pathological anatomy of the amputated member. A careful dissection permits one to ascertain that the ulcer- ation involves only the ulnar artery; the central end of this artery is stopped by a blood-clot. The radial artery in the gangrenous portion is filled with fibrinous clots. Upon examining the other tissues, one notes at the RESUME 415 level of the focus of the palmar abscess purulent trails which ascend the length of the forearm in the tendinous grooves, and the length of the aponeurotic sheaths of the muscles of the anterior aspect of the forearm, to the level at which the forearm was amputated. One notes, moreover, an infiltration of purulent fluid between these grooves and these aponeurotic sheaths. The connective tissue of the forearm is infiltrated like lard. The tissues of the hand are completely sphacelated, dead, and black. From all the evidence, therefore, one is justified in assuming that in the ordinary case the hemorrhage arises from the ulnar artery, and proceeding after the manner suggested below when dealing with this complication. RESUME. Subcutaneous abscesses ordinarily develop on the back of the forearm but may involve the subcutaneous tissue proximal to and above the anterior annular ligament. This especially accompanies ulnar bursitis. Deep abscesses of the forearm are practically always found upon the flexor surface and almost always come from a rupture of the proximal end of the ulnar or radial bursae. These abscesses practically always lie underneath the flexor profundus tendons and muscles and on the pronator quadratus and interosseous septum. The diagnosis is made upon an associated tendon-sheath infection with an increase of swelling and pain in the forearm. The wrist-joint may be involved particularly in aged patients with radial bursitis. It is evidenced by bony crepitus due to destruction of the bones, particularly the os magnum. Secondary hemorrhage occurring in the forearm follows long-continued sup- puration about the vessels, especially the ulnar artery. The surgeon should not temporize but cut down and ligate the bleeding vessels. CHAPTER XXVII.- TREATMENT OF INVOLVEMENT OF THE FOREARM SECONDARY TO HAND INFECTIONS. TREATMENT OF UNCOMPLICATED CASES. THE treatment of the subcutaneous abscesses sec- ondary to lymphangitis has been discussed in Chapter XXIII. In dealing with the deep forearm involvement, two methods may be used: (i) The older procedures by which the incision which opened the ulnar bursa may be continued upward into the forearm, cutting the anterior annular ligament (see p. 269 for full descrip- tion of this method). This procedure, however, I have abandoned except in rare cases. (2) Follow- ing the anatomical studies described in previous chap- ters, I have used lateral incisions upon either side above the wrist (Fig. 122). In many cases only one has been used, that upon the ulnar side. By referring to the cross-sections and Figs. 123 to 126, the site of these incisions may be seen. I begin my incision about an inch above the styloid process of the ulna and carry it upward for about three inches, cutting down to the ulna on a level with its volar surface. The attachment of the deep fascia to the bone is sep- arated and then the finger is inserted between the ten- dons and the pronator quadratus. A free opening is secured. If it is deemed wise to make a second incision upon the radial side, an artery forceps is passed across from the ulnar side (Fig. 123). The forceps should TREATMENT OF UNCOMPLICATED CASES 417 hug the radius closely, and when the point impinges upon the skin of the radial side an incision is made through the skin for a distance of a couple of inches. FIG. 122 Lines represent the various incisions made for drainage of the infected tendon sheaths and their possible extensions into the forearm. (See text for complete description.) FIG. 123 m.n. r.a. u.a. u.n. Cross-section 7 cm. above radial styloid. Artery forceps inserted trans- versely in juxtaposition to ulna and radius through the anterior interosseous space, showing that incision can be made here and not injure important vessels and nerves. Notice tissue between radial artery and the forceps. r. a., radial artery; u. a., ulnar artery; u. n., ulnar nerve; m. n., median nerve. The opening is enlarged by separating the fascial attachment with the fingers. Any pockets between the tendons or muscles are widely opened by the pal- pating finger. 27 418 INVOLVEMENT OF THE FOREARM FIG. 124 Cross-section of forearm at about its middle. The knife is seen to make an incision beyond the flexor carpi ulnaris and the flexor profundus, which incision should be made for pus in the middle of the forearm. (See Fig. 125.) Cotton packed in the opposing surface shows the position of pus. FIG 125 Photographs showing the proper incisions for draining abscesses in fore- arm. The photograph above is made of a cadaver arm in which serial sections were made and the proper sites for striking large cavities determined, the artery forceps being thrust through immediately above the wrist, and an ulnar incision being made at the middle of the forearm. The photograph below shows the sites of these two ulnar incisions. TREATMENT OF UNCOMPLICATED CASES 419 If the case has been opened late and the pus has infiltrated the forearm extensively, I commonly add an incision at a second site higher up, about the middle of the forearm. Here one will see by examining the cross-section (Figs. 120 and 124) the pus tends to lie between the flexor carpi ulnaris and the flexor sublimis around the ulnar artery and nerve. Therefore an inci- FIG. 126 Photograph of a hand of a patient showing proper incisions for opening tendon-sheath infections of- the thumb and -little finger, with ulnar bursal extensions of pus in the forearm. This patient made a complete recovery with function and left the hospital at the end of one month. Function was complete at the end of three months. sion is made about one inch from the ulna on the flexor surface of the forearm, attempting to strike the area between these two muscular bodies (Figs. 124, 125, and 126). The opening is separated widely by the forceps and fingers after the skin incision is made. Instead of this, one may cut down directly upon the flexor surface of the ulna and separate the fibrous 420 INVOLVEMENT OF THE FOREARM attachment of the flexor carpi ulnaris from this bone, and in this manner separate the muscle from the flexor sublimis and profundus and thus drain the pockets. FIG. 127 Photograph of baby G.'s hand and forearm three days after incision was made for the drainage of an ulnar bursal infection with extension into the forearm. (See Case XLVI.) FIG. 128 Result three months after (baby G.), showing extension and flexion of fingers. Perfect function restored except for two distal phalanges of the little finger. These are all the incisions that in my experience have been necessary to produce rapid cure in these cases. TREATMENT OF WRIST-JOINT INVOLVEMENT 421 One should use care not to cut through any muscular body, since drainage will be unsatisfactory. The incisions should be free and may be kept open from twenty-four to forty-eight hours by gutta-percha strips or vaseline, saturated gauze. Even in very young individuals this treatment is most satisfactory. My youngest case of ulnar bursitis and forearm in- volvement was in a child (Case XLVI, Figs. 127 and 128), whose photographs I here present. CASE XLVI. Wesley Hospital. The child was three months old when it was treated and six months old when the second photographs were taken. There was abso- lutely no impairment of function in any of the joints or muscles except the little finger, in which it lost the power of flexion, as will be seen by examining the photographs. Owing to the age of the patient and the severity of the infection, the life of the patient was despaired of by the family physician. The child left the hospital at the end of the eighth day after the above-described incision had been made. TREATMENT IN CASES WHERE THE WRIST-JOINT IS INVOLVED. Besides the incisions suggested above for drainage of the forearm, special considerations must be borne in mind when dealing with involvement of the carpal, carpometacarpal, or carporadial articulations. Owing to the frequently associated involvement of the radial bursa, this will generally have been opened, and in serious cases the necrotic tendon will have been removed. The fact that when this occurs the patient is generally of advanced age will emphasize the necessity of radical treatment rather than temporizing measures which might be justifiable in younger individuals. This holds true not alone for the resection of the tendon, but also as regards removal of the carpal bones. In 422 INVOLVEMENT OF THE FOREARM every one of the several cases reported above, in which the joint became involved, a resection of some or all of the carpal bones was indicated. Even in younger individuals, unless prompt and radical incisions are made, associated with careful after-treatment, unfor- tunate sequelae are likely to result. That it does not always ensue I am convinced by two cases which came under my observation, in which the joint made a recovery without necrosis of the bones, but here prompt drainage had been instituted. However, I cannot speak with authority upon this point, since, fortunately, my own experience with this serious sequela has been limited. In three cases it became necessary to remove necrotic bone, and in these cases a complete removal of all carpal bones was found advisable. A study of the anatomy suggests the cause of the tenacity of this infection and the rapidity with which it involves the entire joint. We note that, as described by Gray, 1 while there are four separate synovial sheaths, yet in reality the joint proper has only two, and, moreover, these two are so intimately associated that the least erosive action on the part of an infection lying in one would cause an extension to the other. Moreover, 1 Although all the authors agree in describing the radiocarpal synovial sac as isolated from the carpal, there is great variation in the description of the carpal sacs. Cunningham and Quain follow Allen Thompson, and, in addition to the radiocarpal and cuneiform-pisiform, describe one sac between the semi- lunar and cuneiform above and the os magnum and unciform below, another between the scaphoid above the trapezium and trapezoid below, these being separated from the carpometacarpal sac below, with a single sac between the trapezium and thumb metacarpal. Gerrish follows Testut, giving the same description with the exception that he divides the carpometacarpal between the middle and ring metacarpals into two. Joessel, on the other hand, shows a communication between the carpal and the metacarpocarpal on the radial side, with a separate sac for the metacarpocarpal of the ring and little finger metacarpals. Gray shows a general communication between the carpal and metacarpocarpal. This difference of opinion simply demonstrates that the communications vary in different individuals. In a surgical consideration we should expect a more or less free communication, consequently in this discussion I have followed Gray's classification. TREATMENT OF WRIST-JOINT INVOLVEMENT 423 the removal of any of the more important carpal bones in the radiocarpal articulation will permit of immediate extension in the synovial spaces about the distal bones, as, for instance, in Case XXX we read: "Re- sected proximal line pf carpal bones, later distal row of carpal bones sloughed." Consequently, in those cases where the infection is confined to the radiocarpal articulation we should attempt to remove the carious bone by the curette and give perfect drainage to the joint, with the hope of preventing extension to the carpal synovial sac. The probable involvement of the radio-ulnar synovial sac should be borne in mind, since it seems to be a frequent complication. The intimate relation of the ulnar sheath, as already pointed out, results in early and extensive involvement of the os magnum (Fig. 119). While these deductions theoretically are true and in certain cases will be found applicable, in the majority of cases it will be found upon operation that it will be necessary to remove all of the bones of the carpus. The ultimate results following this procedure are much better than one would think. When the carpal synovial sheath is involved, how- ever, we may remove any of the carpal bones with the exception of the cuneiform, semilunar, or scaphoid without danger of causing a spread to the radiocarpal joint. The infection of the synovial sheath between the pisiform and cuneiform may spread to the carpal articulation, as in Case XLII. In relation to which Forssell quotes from Henle to the effect that anatomic- ally there is frequently a communication between the two sheaths. In no case of involvement of the wrist-joint, in which the diagnosis was delayed three weeks, did the patient escape without the removal of some of the bones of 424 INVOLVEMENT OF THE FOREARM the joint. In other words, there was considerable erosion of the bones before the diagnosis was made. We are urged, therefore, to watch with special care aged patients with involvement of the radial bursa and to open the joint at the first evidence of infection. I am convinced, however, that this complication should be a rare one in those cases submitted to early and radical treatment for infections of tendon sheaths and soft parts. In each of the five cases coming under my observation the sheath had not been opened until long after the infection had begun. .Early in the course of joint involvement free incision will give great possibility of a cure without the necessity for resection. But should the indication arise for curettage or removal of the carpal bones, it should be done thoroughly and completely along the lines suggested above. TREATMENT IN CASES OF SECONDARY HEMORRHAGE. As has already been hinted in dealing with this sub- ject, those cases showing hemorrhage should not be temporized with. As soon as the patient has recovered from the primary shock and before the temporary tamponade and constriction have been removed, the surgeon should make an incision over the ulnar vessel. To do this an incision should be made about the middle of the forearm on the ulnar side, as described above. The flexor carpi ulnaris is then drawn to the ulnar side and the artery searched for (see Fig. 122). The site of the hemorrhage should be sought and the vessel double ligated proximally and distally. Tam- ponade and clotting cannot be depended upon. Further hemorrhages are almost sure to occur and leave the patient in such serious condition that he may not survive the combined hemorrhage and infection. RESUME 425 Subcutaneous abscesses should be opened by free incision. Deep abscesses in the forearm are best treated by making incisions directly down upon the ulna an inch and a half up on the forearm cutting the fascial attach- ments of the bone and freely opening up the inter- osseous space with the finger inserted between the tendons and the pronator quadratus. Counter drain- age may be made upon the radial side just superficial to the radius. The ulnar incision particularly should be from two to three inches in length. In complicated cases involving the whole forearm where incision has been long delayed, it may be necessary to make an incision two-thirds of the way up on the forearm on the ulnar side between the flexor carpi ulnaris and the flexor profundis. This incision, however, will seldom be required. When the wrist- joint is involved, prompt drainage of the tendon sheaths may end in recovery ; but when treatment has been delayed, it may be necessary to remove all of the carpal bone. In cases of secondary hemorrhage the vessels should be ligated as soon as the patient has recovered from the primary shock. CHAPTER XXVIII. SEQUELS OF INFECTIONS OF THE HAND. CHRONIC PROCESSES, OSTEOMYELITIS, ARTHRITIS, CONTRACTURES, AND ATROPHY. IN cases showing a long-continued suppuration, we ask ourselves what structures are involved which pro- long the trouble, or why we have inefficient drainage. Frequently both factors are at work. By far the most frequent causes are osteomyelitis, arthritis, and necrosis of tendons. Areas which were primarily poorly drained cavities are soon complicated by one of these factors. Suppu- rative arthritis seldom exists without concomitant osteomyelitis. Such cases frequently give a history of primary tenosynovitis, followed by osteomyelitis, ending in arthritis. Involvement of the wrist-joint has been discussed in the previous chapter. The pathology of these cases naturally varies with the tendency of the tissues to react to the particular germ which is the exciting cause, the length of time the process has existed, and the structure involved. Grossly the most important findings are the sinuses, which are an almost constant accompaniment of chronic disease. Here we note several types, and while there is a distinct difference between them, any system of classification is inadequate. We might say the osseous and connective-tissue types, or the acute, sub- acute and chronic. While the pathology presents some justification for either system, yet the reactive resist- INVOLVEMENT OF THE FINGER PROPER 427 ance of the individual and the kind of germ enter into the subject as varying factors; consequently only generalized statements can be made. The chronic osseous type presents three pictures, varying with the bones involved: (i) Those cases where the terminal phalanx is the seat of osseous de- struction; (2) where the finger proper is involved; (3) where the metacarpal and carpal bones are involved. INVOLVEMENT OF THE FINGER PROPER. Those cases (first group) showing chronic processes in the terminal phalanx have already been discussed in the chapter on Felons (Chapter II). The second group of cases noted in the chronic osseous type is that which comprises suppurative pro- cesses of the proximal and middle phalanges. We all have had opportunity to observe that the proximal interphalangeal joint particularly may become involved early, either primarily or secondarily. In the case of the metacarpophalangeal- joint, however, there is more fibrous tissue intervening between the tendon sheath and the joint and the adjoining bone; therefore, the sheath erodes through at some less resistant point, as, for instance, at the proximal interphalangeal joint, in the course of the tendon over the proximal phalanx, or at its proximal end in the palm of the hand. Fre- quently I have seen a sinus lead from the proximal end of the sheath of a tendon through the palmar fascia, and the metacarpophalangeal joint still remain intact (Fig. 119). Again, the metacarpophalangeal joint is likely to escape in cases of palmar abscesses where the diaphysis of the metacarpal has become involved, or even when the process has been so severe as to extend under the annular ligament and invade the carpal articulation. It has been my experience in these cases 428 SEQUELA OF INFECTIONS OF THE HAND that the distal articulation frequently escapes even in long-continued synovial disease and extensive osteo- myelitis. In the ordinary case of chronic suppuration in the finger it is the proximal interphalangeal joint that is at fault, and the pathological condition noted in Fig. 130 is fairly typical. The constant irritating discharge coming from the necrosing bone, passing through the connective tissue rich in lymphatics, produces an excessive deposit of granulation tissue, building up a FIG. 129 In this case the metacarpophalangeal joint was intact, although the tendon sheath was involved and a sinus had opened at its proximal end through the palmar fascia, all of the distal and part of the middle phalanx had been lost and the proximal interphalangeal joint was extensively destroyed. small volcano-like structure, from which oozes forth a constant stream of pus, and through which winds a tortuous canal leading down to the necrotic bone. Where bone alone is involved, I have seen this crater clearly defined, occupying no greater extent than the length of one phalanx and raised above the surface for a distance half the diameter of the finger. This characteristic picture, however, is seldom seen, owing to the very frequent involvement of the tendon or the joint in the same process. Here, while the devel- INVOLVEMENT OF THE FINGER PROPER 429 opment of granulation tissue is still excessive, the mouth of the crater is generally much wider, owing to FIG. 130 Drawing from pathological section, showing sinus leading down to carious bone. An associated tenosynovitis has increased the extent of the granula- tion tissue and destroyed in part the typical volcano-like picture of an uncomplicated palmar bcne sinus. A, ostium; B, intact bone; MP, middle phalanx; PP, proximal phalanx. FIG. 131 Uncomplicated bone sinus on dorsum of phalanx. the excessive discharge from the tendon sheath. The granulation tissue is not so circumscribed, although very abundant. Moreover, the picture loses some of 430 SEQUELAE OF INFECTIONS OF THE HAND its force, owing to the associated swelling of the finger along the tendon sheath, the absence of which in the first case serves to accentuate the local tumor forma- tion. Again, if the sinus be upon the dorsum there is less granulation formation, owing both to the smaller amount of connective tissue and probably also to the great reduction in the number of lymphatics (Fig. 131). FIG. 132 Cross-section through the joint, showing head of the proximal phalanx. Notice the large amount of tissue between the tendon and the joint cavity as compared to Fig. 133. It is not necessary to go into the minute pathology of osseous necrosis, since that process is well known and described in the ordinary text-books. However, a few details peculiar to these two phalanges should be mentioned. We so often see three processes in con- junction, so that it is difficult to say in what sequence they developed namely, tenosynovitis, arthritis of the proximal interphalangeal joint, and necrosis of the middle phalanx. The cross-sections here presented (Figs. 132 and 133) demonstrate the close proximity of the tendon sheath to the bone and joint respectively. INVOLVEMENT OF THE FINGER PROPER 431 From the character of the tissue it would seem reason- able to assume that first the joint is involved, and the phalanx sequentially. In the few early cases that I have been able to observe discriminatingly, the joint seemed to have the more extensive involvement of the two. However, if that be true, why does the middle phalanx suffer so much more than the proximal one, a fact which I have had the opportunity to verify frequently. Is it that the point of invasion is the FIG. 133 Cross-section through the epiphysis of the middle phalanx. Notice the loose mesh and the small amount of connective tissue between the tendon and the bone. epiphysis of the middle phalanx? Does the fact that that phalanx only has an epiphysis articulating with the joint have any bearing on the subject? This question must be left for further study. Again, destruction of the epiphysis is frequently noted, while the diaphysis- is only partly involved (Fig. 130). The anatomical relation of the sheath of the tendon to the joint capsule and the epiphysis may help to explain this, but it is possible that the vascular nature of the epiphyseal tissue may have considerable 432 SEQUELAE OF INFECTIONS OF THE HAND bearing, since the involvement may have its origin through the blood supply rather than by direct erosion. That isolated destruction of a diaphysis of a phalanx may occur at times cannot be questioned, and a study of the cross-sections demonstrates how easily this can occur if the tendon sheath be eroded. What we most often find upcn operation in these cases is a suppurative arthritis with extensive destruc- tion of both the epiphysis and shaft of the middle phalanx, while the proximal surface of the joint, that is, the head of the proximal phalanx, may be only FIG. 134 Drawing from a pathological specimen, showing destruction of the epi- physis of the middle phalanx, with pinhead-sized areas of the necrosis on the head of the proximal phalanx. MP, middle phalanx; PP, proximal phalanx slightly or not at all eroded (Fig. 134); at least, the articular surface is still clear and shining, with possibly one or two minute foci of destruction. Frequently it has shown a larger area of necrosis upon the shaft just at the point where the ligaments of the joint are attached. Indeed, at times, either upon the volar or dorsal surface, varying with the site of the original infection, I have scooped out at this site an area the size of a small pea, the articular surface apparently being free, while the epiphysis of the middle phalanx was almost entirely destroyed. INVOLVEMENT OF THE FINGER PROPER 433 TREATMENT. In the chronic processes involving the finger proper, the diagnosis must be made first as to the structure involved. If the tendon sheath, it must be opened throughout its extent to give perfect drainage. Frequently it will be necessary to remove the tendon in these chronic cases. The possibility of localized in- volvement must always be borne in mind. In these cases a plastic exudate forms and prevents extension along a sheath; here only so much of the sheath as has been involved should be exposed. If the joint be invaded, some judgment is called for, since in the very earliest stages it may recover with partial restoration of function if the infection is a mild one, the joint surfaces not destroyed, and other structures which might prolong the suppuration are uninvolved. In a great majority of the cases, however, considerable destruction of the proximal phalanx will have taken place when the case comes to operation, and the ques- tion arises whether an amputation should be advised. Certain sociological factors come into consideration. If the patient be a laboring man, with a family depend- ent upon him, and at examination we find an extensive destruction of the joint with a tenosynovitis, amputa- tion offers the quickest method of giving a serviceable hand. If, however, the patient desires to preserve the finger, in a majority of the cases one can be assured that the finger may be preserved, but that it will be somewhat shortened. Exceptionally the finger may be preserved with considerable function. In certain cases it becomes imperative to make the attempt, as, for instance, in infections of the thumb. This member is so valuable that some sacrifice is justifiable in the attempt to preserve it. In Case XLVII, quoted below, the articular surfaces and a considerable portion of the shaft of the proximal phalanx were removed. There was no involvement of the tendon sheath. A fairly 28 434 SEQUELA OF INFECTIONS OF THE HAND serviceable opposing member was thus saved to the hand. CASE XLVII. Primary paronychia of thumb, sec- ondary suppurative arthritis of interphalangeal joint, resection, ultimate recovery, with preservation of the thumb. C. H., treated in the Northwestern University Medical School Dispensary, May, 1902. Infection began on the thumb under the nail at the side and developed into a typical "run-around." When he applied at the dispensary, four weeks after the beginning of the infection, a chronic suppurative arthritis had developed, involving the inter- FIG. 135 Photograph showing thumb in which joint has been resected. Notice the opposing ability of the member. (Case XLVII.) phalangeal joint. Under narcosis the epiphysis of the distal phalanx and about half of the distal portion of the proximal phalanx were found partially destroyed. All this involved bone was removed with a curette, the nail was removed, silkworm-gut drain inserted, hot boric dressings applied. The tendon sheath of the flexor longus pollicis was not involved. The patient returned repeatedly for dressings, and after four weeks all discharge ceased. The patient was discharged with the thumb shortened half an inch, with ability to flex the distal phalanx 20 degrees, complete function in the metacarpophalangeal joint. There was little strength to the flexion of the distal phalanx, but it served admirably as an opposing member when using the fingers (Fig. 135). INVOLVEMENT OF THE FINGER PROPER 435 The procedure when the proximal interphalangeal joint of the fingers is involved is as follows: Owing to the frequent destruction of the proximal end of the middle phalanx, this is chosen for attack, and the entire epiphysis and generally about half of the shaft is removed. If the articular surface of the proximal phalanx is intact, it is not disturbed, otherwise this may be removed also, my desire being in the first place to remove all necrotic bone, and secondly, to separate the ends of the bone so far that only a fibrous union will take place, thus allowing some motion at this joint if the tendon is intact. Otherwise no motion can be promised. These fingers are dressed in slight flexion, so that if no function results they will not be in the way and will still be of some use, at least for cosmetic purposes. In some cases I have tried, with moderate success, a variety of extension on a straight splint. The proximal end is fastened at the wrist, and at the distal end, adhesive straps are fastened to the end of the splint and the distal portion of the finger, so that the ends of the necrotic bones are separated. The details of this mechanical contrivance may be seen by examin- ing Figs. 136 and 137. This aids in preserving the functionating joint, although it is somewhat difficult to retain in position. Not much can be promised in the way of function in a majority of cases. That in excep- tional cases these fingers can be saved with a moderate amount of function, even in some cases of combined suppurative arthritis and tenosynovitis, is demon- strated by Case XLVIII. CASE XLVIII. Limited tenosynovitis of index finger, arthritis of proximal interphalangeal joint, osteomyelitis of middle phalanx, resection of phalanx, recovery, with preservation of the finger and slight motion at the joint. Miss C. W. Seen in consultation with Dr. C. E. Boddinger. Infection had begun in the index finger by 436 SEQUELA OF INFECTIONS OF THE HAND a prick of a needle while sewing two weeks previously, and the soft parts had been opened over the middle phalanx. FIG. 136 A photograph of a finger with a chronic suppurative arthritis of the middle metacarpophalangeal joint, dressed in extension produced by an ordinary rubber band attached to the end of the finger by means of a string tied to it and the ends fastened through the eyes of a button, the latter being attached to the finger by narrow adhesive strips running around the finger up to the middle metacarpophalangeal joint a gauze roller around the adhesive strips. Extension is secured by fastening the rubber band on the back by a piece of adhesive plaster, as shown in Fig. 137. The board splint on the palmar surface is prevented from being displaced up the arm or laterally by adhesive strips as shown in the figures. It is a modified Buck's extension. The relief from discomfort and rapid recovery under its use is often remarkable. Condition upon Examination. Suppurative tenosyno- vitis of the index tendon extending to the metacarpo- phalangeal articulation, but no farther. Tendon exposed. FIG. 137 See FIG. 136. Suppurative arthritis of the proximal interphalangeal joint with destruction of the proximal end of the middle phalanx, Distal phalanx not involved, articular surface slightly clouded, but not eroded. INVOLVEMENT OF THE HAND PROPER 437 Operation. Tendon sheath opened throughout extent of infected area. Middle phalanx resected to one-half its extent. Dorsal counterincision made at side for thorough drainage, and hot boric dressings applied. Course. After three weeks, the finger had entirely healed; flexion at metacarpophalangeal and distal pha- langeal joints perfect; flexion at proximal interphalangeal joint 15 degrees. Six months after operation atrophy of soft tissues of distal and middle phalanges. The patient states that the finger is not of great service, but, on the other hand, is not in the way, and she is very glad, for cosmetic reasons, that it was saved. Where there is only a destruction of the synovial covering of the joint, resection is not indicated. It is probable that a functionating joint can be restored in case of ankylosis if the tendon sheath is not involved, although I have not had the opportunity to demon- strate it. If the destruction of the adhesions by repeated flexion of the finger by passive motion, which I have used with more or less success at various times, does not succeed, the implantation of periosteum from the tibia, as suggested by Hoffman, 1 is worthy of consideration, or the transplantation of a pad of tissue and fat such as I have used in the wrist-joint may be used with satisfaction. Suppuration is uncommon in the metacarpophalan- geal joint, but here also resection may be resorted to if the tendon is intact. If this be involved, in a majority of cases, I, at the present time, would ampu- tate the finger. INVOLVEMENT OF THE HAND PROPER AND THE META- CARPALS AND CARPALS. PATHOLOGY. The third type of chronic osseous lesion is that in which the bones of the hand proper 1 Arch. f. klin. Chir., vol. Ixxx, No. 2, p. 31 1 ; Zur Behandlung der knachernen Ankylose in Elbogengelenk. 438 SEQUELAE OF INFECTIONS OF THE HAND are involved. Here, unless modified by an original wound or operative procedure, the picture is again different, owing to the dense aponeurosis upon the palmar side and the sheet of dense tissue upon the dorsum uniting the tendons of the extensor communis digitorum. These dense sheets, particularly upon the FIG. 138 Skin. Lumbrical muscle in middle palmar space. Palmar arch. - Blood vessel. Lumbrical muscle and tendon. Median nerve and vessels. Flexor lonyus pollicis. Thmiar muscles. Blood vessels. Point of exit of pus. nterosseons muxcle spread over bone. Epiphysis of bone. Subcutaneous space. Subaponeurotic space. Bone. Interoasei separated by fancinl septum. Extensor communis tendon. Middle palmar space ' filled with pus. Skin. Metacarpals. Radial artery. Drawing showing the relation of pus in the middle palmar space to the tendons. Also showing course pus pursues in its course along the lumbrical muscle to point on the dorsum near the web. Serial sections of the hand were made as shown, the tissues teased out, and middle palmar space filled with plaster of Paris. Sections restored to normal position and sagittal section made between ring and middle metacarpal of all sections except the proximal. Heavy dotted area shows position pus would occupy. palm, prevent the free egress of pus, and, as a conse- quence, it is more likely to burrow a considerable dis- tance from the site of origin before exit (Fig. 138). This diffuses the reactive inflammation, and even if the exit is found near the site, the dense sheet prevents the crater-like elevation of granulation tissue noted in the second or phalangeal type. Hence, we are more INVOLVEMENT OP THE HAND PROPER 439 likely to find a diffuse swelling of the whole palm or dorsum with multiple ostia, any of which may be open FIG. 139 DSCS IDSAS 15 PF ITS FLP T5 Schematic drawing, showing pus under dorsal aponeurosis with ostium at the side: C, site of discharge of pus; DP A, deep palmar arch; DSCS, dorsal subcutaneous space; FLP, flexor longus pollicis; IDS AS, infected dorsal subaponeurotic space; IS, indefinite spate; ITS, indefinite thenar space; LM, lumbrical muscle; MPS, middle palmar space; OM, osteitis of the meta- carpal; PF, palmar fascia; TS, thenar space. for a time and discharge, while another may be closed. There is often only a small amount of granulation FIG. 140 Drawing of fragments of metacarpal removed by Dr. W. E. Schroeder. tissue about the openings. In these cases of early osseous involvement often no sinus will appear upon 440 SEQUELM OF INFECTIONS OF THE HAND the palmar surface, unless the soft tissues of the palm have been seriously involved primarily, or the infection has spread into the wrist-joint, and this is generally preceded by palmar phlegmon or tenosynovitis. There- fore, in these cases of osteomyelitis of the metacarpal bones, dorsal sinuses are most common. They may appear at any point on the dorsum, but have a pre- dilection for the sides and distal part near the knuckles (Fig. 139), owing to the dense sheet of tissue before mentioned. It is a well-known fact, however, that fre- quently this sheet has areas where it is not complete, particularly in the lower third between the tendons; and through these pus may discharge. But it is not at all an uncommon thing to see a sinus ostium at either side over the index and little finger metacarpal, and one or two at the distal end between the knuckles, from a single focus of infection in either the middle or ring metacarpal (Fig. 64), as will be shown clearly by x-ray picture. Again, these ostia on the dorsum at the knuckles may be due to a chronic process in the palm discharging through the lumbrical canals (see Fig. 138). So fas as I have observed, there is no peculiar pathological destruction of the metacarpal bones in these cases (Fig. 140). There is one clinical fact, how- ever, worth remembering from a therapeutic stand- point, and that is the relative immunity from involve- ment of the metacarpophalangeal joint; this is possibly owing to the dense ligaments surrounding the joint, which protect it from invasion by way of the synovial sheath and adjacent phlegmons. As a consequence of this we are often able to preserve a functionating finger, although a considerable destruction of the metacarpal may be present; isolated necrosis of a metacarpal is uncommon except in tuberculosis or syphilis. PIG. 141 X-ray photograph of hand (Case XLIX). Necrotic bone was removed from the wrist and the three metacarpals. (See photograph of hand shewing present function, Fig. 142.) 442 SEQUELA OF INFECTIONS OF THE HAND Involvement of the wrist-joint in chronic processes is characterized by multiple foci on both the dorsal and palmar surface. CASE XLIX. S., Post-Graduate Hospital, December, 1910. The patient suffered from a previous tendon- sheath infection of the ulnar and radial sheaths. I saw him after three months of chronic infection, when there were multiple sinuses both on the dorsum and flexor FIG. 142 Hand of patient described in Case XLIX two years after operation. surface of the wrist from the joint, with lateral and distal sinuses upon the dorsum of the hand from osteomyelitis of the metacarpals of the index, middle, and little fingers. There was no involvement of the metacarpophalangeal articulations, in spite of the long-continued infection and extensive osteomyelitis. The x-ray picture clearly showed the location of the foci. All of the carpal bones were removed and the necrotic part of the metacarpals. The INVOLVEMENT OF THE HAND PROPER 443 hand rapidly recovered. All discharge ceased within four weeks. Almost all function was lost. (Fig. 141.) I have been surprised to find that now after two years he has developed considerable function of the fingers and hand, so that he can now hold a glass and perform other gross functions with the hand as well as write, hold a knife and fork, and similar actions (Fig. 142). I have had a similar experience in two other cases. The following history of a patient in the practice of Dr. H. B. Baumgarth, with whom I saw the case in consultation, illustrates the course of these chronic cases when untreated. CASE L. Mrs. G. received infection September 5, 1904, at web between the middle and ring fingers. The patient consulted a magnetic healer and remained under his care for seven weeks, when she applied to Dr. Baum- garth, who obtained the following history and drained the hand properly: Twenty-one days after the receipt of the infection, point 2, noticed on the dorsum, opened up; a few days later, points 3 and 4 opened, slightly more on the dorsal surface than on the palmar. Points 5, 6, 7, and 8 appeared successively in the next few days. After an interval of a few days, points 9 and 10 appeared, followed in succession by 12 and 13, and after an interval of several days, 14, 15, and 16, at which time the patient applied to Dr. Baumgarth, who thoroughly drained the pockets, and the patient made a tardy recovery. The atrophy of the distal phalanx of the index finger is due to a previous felon. The atrophy of the other fingers followed as a sequence of the present infection. On February 25 adhesions were broken up under nitrous oxide, which benefited the movement of the finger and wrist to a slight extent only. A careful study of this case serves to point out the pathological sequence which occurred as a result of the infection (Fig. 143). Points I and 2 were the original 444 SEQUELA OF INFECTIONS OF THE HAND site of the infection, which spread from there, without doubt by lymphatic extension or continuity of tissue, along the lumbrical canal into the mid palmar space; from here in turn it retraced its course through the lumbrical canals to the base of the index finger, point 4, and the base of the little finger, point 6. The ulnar bursa evidently became involved, and points 9 arid 10 FIG. 143 Photograph of Dr. Baumgarth's case. Figure numbers on the photograph represent the various sinuses and their approximate order of development by which the course of the infection can be traced. (See Case L.) show the site of rupture from the sheath, the other areas at the base of the palm developing as a rupture of the proximal end of this bursa. This point was corroborated by Dr. Baumgarth at the time of opera- tion, since pus was found above the annular ligament in this synovial sac. It is to be noted that all the primary points of rupture from I to 8 appeared upon the dorsal surface of the base of the webs of the fingers. INVOLVEMENT OF THE HAND PROPER *445 The characteristic claw-hand seen in neglected tendon- sheath infection is shown in Fig. 144. In those exceptional cases in which the pus has extended to the dorsum between the metacarpal bones, there is generally some destruction of bone requiring attention. It is at times seen in advanced cases accompanying wrist-joint invasion. FIG. 144 Photograph showing claw-hand in neglected tendon-sheath infection. TREATMENT OF CASES INVOLVING THE HAND PROPER. The treatment in those cases in which the chronic process lies in- the palm may be confusing. We should determine first the location of the pus. Does it lie in the synovial sheaths or in the fascial space? Are the bones or the wrist-joint involved? While theoretically difficult to determine, it is not so confusing as in the acute cases, since there are generally sinuses which can be followed down to the hidden pockets. X-ray photo- graphs may show necrotic bone. Complete anesthesia is essential. No operation upon infected hands should be undertaken without it. The ramifications should 446 SEQUELAE OF INFECTIONS OF THE HAND be followed up carefully and with patience. I shall not speak in detail of the factors which lead us to diag- nosticate the presence of pus in the various sites, since this has already been discussed exhaustively in the previous chapters. Various sinuses leading from the tendons to the sur- face will be followed down to the respective synovial sheaths. The sinuses found at the most proximal point of the finger sheaths designate the corresponding sheath, and this should be cut down upon and followed distally along the finger until every part of the tendon bathed in pus is exposed. Where the little finger tendon is involved, the extension of the sheath in the palm should be borne in mind, and the opening con- tinued proximally over this when the grooved director inserted into the infected sheath on the little finger passes up into this without obstruction. Here the sheath should be opened throughout its extent up to the annular ligament, the incision lying to the ulnar side of the tendons. The incision should be limited to the annular ligament until the decision has been made as to whether the infection has extended under this into the proximal end of the sheath above the annular ligament. If this is diagnosticated, the ligament should be cut and the incision be continued into the forearm as far as the upper end of the sheath. Instead of this last incision the upper end of the sheath may be drained by incisions upon the ulnar and radial side of the forearm as described in the chapter on Forearm In- volvement. It is not wise to open the sheath above and below the ligament and leave this latter intact. Having thoroughly opened this, the question thus arises: Has the radial bursa, i. e., the sheath cf the flexor longus pollicis, become involved? If so, this must be opened throughout its extent down to a thumb's breadth, distal to the annular ligament. The INVOLVEMENT OF THE HAND PROPER 447 incision should stop here for fear of injuring the motor nerve to the thenar area. If the tendons have become necrotic, removal is indicated; on the other hand, one is often surprised at the amount of vitality present in the tendons which have lost their synovial covering, therefore after open- ing a sheath considerable conservatism is justifiable when it comes to a question of preserving or removing a tendon. Some of the chronic sluggish processes in the fingers have seemed to be benefited by the Klapp suction cup (Fig. 145). FIG. 145 Showing Klapp 's aspiration cup used in some old chronic infections of the fingers. If the fascial spaces are involved, they should be drained after the methods described in Chapter XVII. In considering the treatment of those cases in which the suppurating ostia appear upon the dorsum, par- ticularly between the knuckles, I have already pointed out that in a majority of cases these are really sinuses leading from the palm along the lumbrical canals (Fig. 138), and the perfect drainage of the palm along the lumbrical canals, as already mentioned, will end in rapid recovery if uncomplicated by tendon or bone involvement. 448 SEQUELA OF INFECTIONS OF THE HAND If the bones of the hand or wrist are involved, they should be removed or the necrotic part curetted out. In treating the wrist-joint the general principles as to the removal of bones, which have been enunciated in Chapter XXVII, when dealing with carpal involve- ment, should be borne in mind. These should not, however, interfere with the paramount rule that all dead bone should be removed. ATROPHY AND CONTRACTURE. The anatomical and clinical evidence already adduced shows the tendency for the infection to extend in juxtaposition to the bloodvessels and nerves. The former leads to contracture about the veins and lym- phatics, and consequently a persisting distal edema. The most serious sequelae, however, ensue because of the extension along the nerves metacarpal, ulnar, and median leading secondarily to trophic changes in the part. This secondary change follows probably upon contraction of the scar tissue about the nerves, since they are not likely to be destroyed by the process. At times we see the median nerve persisting, partly isolated from the surrounding tissue, although in con- junction with the tendons it may be destroyed at the wrist-joint from pressure necrosis by the non-distensible annular ligament. This secondary change is particularly noticeable in the claw-hand and the atrophy of the distal phalanges, and even of the whole hand (Fig. 143 and 144). This sequela of nutritive and trophic disturbance yields slowly or not at all to the restorative processes of nature. Massage, passive motion, and constant use of the hand carried out systematically under the careful personal supervision of the surgeon will aid nature. Adhesions between the joints, when they are not the result of ATROPHY AND CONTRACTURE 449 the destruction of the synovial coverings, may be treated by repeated non-violent passive movements under nitrous oxide anesthesia, or by the various appliances designed to produce passive motion, par- ticularly those which act by exhausting the air, and hence, in addition to producing mobility, favor active congestion of the parts (Figs. 96 and 97). The amount of function secured by these hands, apparently irretrievably injured by scar tissue and destruction of nerves and tendons, is above expecta- tion if treatment such as suggested above is persist- ently carried out. Unfortunately very few patients will continue their treatment day after day for two or three years. But even under the best circum- stances the most delicate functions of the hand are frequently lost. The claw-hand is likely to persist and ankylosed joints add materially to the impair- ment of function. I have constantly sought for some surgical procedure which might offer some hope of restoring function in these cases. In several instances I have dissected out the tendons on the flexor and extensor surfaces and tried various procedures, and while I am not ready, as yet, to offer much encour- agement, my best results have been obtained by the transplantation of pads of fat around the tendons. At a subsequent period, after further observation of cases already operated upon and others that may come under my care, it is possible that a technique may be developed that will offer some hope, at least, in these most lamentable cases. Where the tendon is involved in the synovial sheath of the finger, I have so far been able to do little. Where the involvement is upon the dorsum or in the palm, some results have been obtained. The involvement of the wrist-joint with ankylosis has been successfully treated by the removal of the 29 450 SEQUELA OF INFECTIONS OF THE HAND carpal bones and the transplantation of free flaps of fat or fat and fascia into the joint, although these cases also have not been observed long enough to present the maximum of benefit or develop an absolute technique. Whether the incision is made upon the radial or ulnar side, or both, of the dorsum, the bones are chiseled or curetted away, the contour of the joint is restored, and free flaps of fat from the leg with fascia are transplanted into the joint. In no case has the transplant been lost by infection or necrosis, and in every case a considerable degree of function has been restored. In addition to this the function of the fingers has been improved by the shortening of the forearm. I herewith present the photograph of one case recently operated upon. CASE LI. Mr. E. History: The patient's arm was crushed between the couplings of a railroad train. Fol- lowing this a severe infection ensued in the hand and fore- arm in which apparently both the ulnar and radial bursae were involved and there was a destruction of nerves and tissue at the time of injury which was subsequently followed by sloughing of the ulnar nerve. The ultimate result presented at the time he came under my observa- tion, two years after the injury, was that of a claw-hand with sharp flexion at the wrist and ankylosis of the wrist- joint with adhesions about the tendons and scar tissue and contracture on the flexor surface of the forearm. Operation. The scar tissue along the flexor surface was dissected out, the ulnar nerve was sought for and could not be found, owing to its loss from previous destruc- tion. The median nerve was isolated from the scar tissue of the forearm, and as far as possible the tendons were removed from the scar tissue. Incision was made on the dorsal surface on the radial side and the carpal bones removed. A flap of fat was transplanted from the leg into the joint and the wound closed. Owing to scar tissue on the back and buttocks, it was deemed advisable to secure skin and fat for the restoration of the flexor surface from the upper portion of the abdomen. Here ATROPHY AND 'CONTRACTURE 451 ur FIG. 146 Case LI, before operation, showing full amount of flexion and extension. Note that the thumb cannot be adducted to meet any of the fingers. PIG. 147 Case LI, two months after operation. 452 SEOUEfcE^QP, A&KECTIONS OF THE HAND a semi lunar flap of skin and subcutaneous tissue was dissected out with its base downward. The fat was dis- sected off from the flap for a considerable portion of its surface. The skin was then attached to the forearm on its ulnar side and the flap of fat, still attached to the skin at its base, was wrapped around the median nerve and sutured in position. By repeated incisions and suturing the skin flap was completely attached at the end of twelve days and the hand made an immediate recovery. Ultimate function cannot as yet be determined, but the immediate result is shown by the picture. The patient now has a functionating hand with which he can feed himself, can write, adjust his tie, drive a horse, and do other gross func- tions. The patient is entirely satisfied with the result, but I am sure as the months go by much greater function will be secured, both by the wrist, which now has 45 degrees of flexion and on the part of the fingers which though much improved still contract. We cannot expect complete restoration of function owing to the scar tissue in the sheaths. This is but one of several cases now under observa- tion. A later contribution will detail in full the final results. Experimental investigations as to the restoration of destroyed tendons have been carried out, but as yet nothing definite can be recommended in cases of loss of finger tendons, although something may be hoped for in the future. Where the tendon is outside of its bursal sheath it can be restored by the transplantation of free fascial flap, as has been shown by Lewis and Davis and others. Experience has taught me that scientifically made incisions based upon the anatomy herein pointed out will provide complete drainage of all the pockets, and in the end will give a much more serviceable hand than we have had the fortune to secure in the past. It cannot be urged too strongly that we should make careful study as to the possible position of pus RESUME CHRONIC INFECTIONS 453 in the hand, to the end that we may make early and radical incisions and thus prevent these cases of atrophy and contracture. RESUME CHRONIC INFECTIONS. Necrosis of the distal phalanx ordinarily ends in sloughing of the diaphysis alone. Joint function should be preserved. Incision should be made laterally in- stead of upon the volar surface. (See Chapter I.) The proximal interphalangeal joint is most commonly involved. The proximal phalanx excapes while the epiphysis and part of the diaphysis of the middle phalanx are destroyed. Conservative operations may be done with some success. Isolated involvement of the tendon sheaths may be present. Incision of the sheath should expose all involved parts. Chronic palmar abscesses frequently point on the dorsum, passing along the lumbrical canals. Palmar abscesses may be opened along these canals. Chronic dorsal abscesses may point at a distance from the focus, owing to the dorsal aponeurotic sheet. The carpal joints are frequently invaded from the radial bursa; abscesses and sinuses appear upon the dorsum, as well as upon the flexor surface. It will generally be necessary in these cases to remove all of the carpal bones. (See Chapter XXVII.) Serious forearm abscesses lie dorsal to the flexor profundus digitorum, and should be opened by lateral drainage. Trophic changes result from the tendency of the pus to extend along the nerves and bloodvessels. 454 SEQUELM OF INFECTIONS OF THE HAND Complete function can be promised patients suffer- ing with palmar abscesses uncomplicated by tendon- sheath or osseous infection. Tendon-sheath infections operated upon early give good function, except that flexion of the two distal phalanges may be lost. In ankylosis of the joints, considerable improvement may be secured by a transplant of fat and fascia into the joint. INDEX ABSCESS, collar-button, 52 treatment of, 55 in course of lymphatic vessel, 327 deep, of forearm, 396 distal palmar, 52 of fascial spaces, after-treatment of, 304 treatment of, 289 of forearm, treatment of, 416 localized, 55 hypothenar space, 55 thenar space, 55 location of, in forearm, 397 of middle palmar space, treat- ment of, 290 periglandular, treatment of, 373 of radial lymphatics, 175 shirt-stud, 52 subaponeurotic space, treatment of, 303 subclavicular and shoulder, treat- ment of, 373 subcutaneous, in forearm, 395 treatment of, in lymphan- gitis, 372 subepithelial, 37 thenar space, treatment of, 301 Absorption of virulent toxins, preven- tion of, 259 Adhesions, prevention of, 303 in tenosynovitis, 206 prevention of, 286 treatment of, Bier's, 288 Alcohol dressings, 257 Anatomy, cross-section, distal to web, 84 one-half centimeter proximal to the joint, 87 taken at wrist, 97 three centimeters above joint, 90 through base of palm, 94 distal part of thenar emi- nence, 92 epiphysis of proximal phalanx, 85 Anatomy, cross-section, two centi- meters above joint, 89 of forearm, 150 five centimeters above radial styloid, 151 nine centimeters above radial styloid, 153 in relation to infections, 149 seven centimeters above radial styloid, 153 three centimeters above radial styloid, 150 of hand and forearm, 80 of hypothenar space, 95 of lymphatics, 310 of middle palmar space, 90 of thenar space, 91 Anesthesia in operations, 259 Annular ligament cut in hand infec- tions, 260, 269, 277 extensions of pus matter, 176 Anthrax, 390 Arthritis, 202, 426, 432 metacarpophalangeal, 186 Atrophy, 426, 448 Axillary glands, source of involve- ment, 328 B BACILLUS aerogenes capsulatus infec- tion, treatment of, 389 of malignant edema, differentia- tion of, 386 Bacteria of gas-bacillus infections, differentiation of, 386 influence of types of, in lymph- angitis, 324 Baking in dry, hot air, 78 Bier's hyperemic treatment, 71, 242, 259. 285, 363 treatment of adhesions, 288 Bloodless field in operations, 259 Bone involvement, 430 Bones of finger, treatment of, when involved, 436 of wrist-joint, necrosis of, 422 Bursitis, radial, diagnosis of, 222 456 INDEX CARBOLIC acid gangrene, 257 Carbuncles, 38 anatomical considerations of, 38 pathogenesis of, 38 pathology of, 38 site of, 38 treatment of, 42 Carpals, involvement and treatment of, 436 Cautery to open abscesses, 76 Claw-hand, 211 Collar-button abscess, treatment of, 55 Contractures, 426, 448 Cross-sections of hand and forearm. See Anatomy. DISTAL palmar abscess, 52 Diverticula of each of definite spaces, 116 Dorsal abscess, diagnosis of, 231 as extension from thenar space infection, 181 from middle palmar abscess, 180 subaponeurotic space, 100 experimental study of boundaries and posi- tion of secondary abscesses in case of rupture from, 143 subcutaneous spaces, 100 boundaries, diverticula, and position of sec- ondary abscess in case of rupture from, 148 experimental study of boundaries and posi- tion of secondary abscess in case of rupture from, 141 Dorsum of hand and forearm, lymph- angitis and, 329 infections beginning in, 200 tendon sheaths of, 1 14 infection of, treatment of, 283 Drainage in incisions in forearm, 270 in infections, 75 in palmar abscess, 291 in tenosynovitis, 259, 284 at wrist, 270 Dressing, alcohol, 257 dry, in tenosynovitis, 285 hot, moist, in lymphangitis, 361 in tenosynovitis, 256, 285 Drugs, antagonistic, in lymphangitis, 366 Durillon force", 322 E EDEMA of dorsum, differentiated from erysipelas, 328, mistaken for pus, 180 malignant, 388 in tenosynovitis, 211 Embryology of hand, comparative, 1.43 Epitrochlear glands, source of involve- ment, 328 Erysipelas, 383 differentiated from edema of dorsum, 328 from lymphangitis, 362 gangrenous, 383 treatment of, 383 Erysipeloid, 384 Esmarch bandage, 329 Excretion, stimulation of, in infec- tions, 77 Extensor carpi radials longior and brevior, tendon sheath of, 113 ulnaris, tendon sheath of, 113 communis digitorum, tendon sheath of, 1 13 indicis, tendon sheath of, 113 longus pollicis, tendon sheath of, minimi digiti, tendon sheath of, H3 ossis metacarpi pollicis, tendon sheath of, 1 13 F FACTORY prophylaxis, 70 Fascia palmaris, isolated necrosis of, 243 abscess of, acute, prognosis and resume of, 305 after-treatment in, 304 diagnosis of, 223 pathogenesis of, 163 pathology of, 204, 206 surgical considerations of, 163 symptoms, signs, and diagnosis of, 209, 223 treatment of, 289 immobilization in, 304 experiments as to boundaries, diverticula, and extensions from, 143 INDEX 457 Fascial spaces, extension of, from one to another, 175 of forearm, experimental in- jection of, 154 infection of, 63 direct implantation of infection in spaces, 169 etiology of, 163 relation to lymphangitis, 173. 309 involvement of, 168 recapitulation as to source of, 183 normal boundaries of, 128 position of secondary abscess in, 128 relation of, to synovial sheaths, 115 to tendon sheaths, 127 study of, by serial cross- sections, 83 Felons, 25 after-treatment of, 31 etiology of, 25 pathogenesis of, 26 pathology of, 26 treatment of, 29 Filleaux, 245, 246 Fillmans, 249 Finger, index, diagnosis of extension from infections beginning in, 217 experimental study of exten- sion after rupture from tendon sheath of, 125 infection involving, 185 tendon sheath of, 103 extensions from in- fections in, 189 relation of, to the- nar space, 104 tenosynovitis of, treatment of, 261 infectious processes of, 427 course of lymphatic from each, 328 extensions from primary foci on, 185 involving sides of, 175 involvement of, 433 little, diagnosis of extensions from infections beginning in, 198, 212 experimental study of exten- sion after rupture from tendon sheath of, 120 infection of, incision in, 264 tendon sheath of, 106 relation of, to mid- dle palmar space, 104, Finger, little, tenosynovitis of, treat- ment of, 263 and ulnar bursa, extensions from, treatment of, 270 middle, diagnosis of extension from infections beginning in, 195, 217 experimental study of exten- sion after rupture from tendon sheath of, 118 extensions from tenosyno- vitis of, treatment of, 263 tendon sheath of, 105 relation of, to mid- dle palmar space, 1 06 ring, diagnosis of extensions from infections beginning in, 197, 217 experimental study of exten- sion after rupture from tendon sheath of, 119 extensions from tenosyno- vitis of, treatment of, 263 tendon sheath of, 105 extensions of, 199 relation of, to middle palmar space, 1 06 Flexor longus pollicis, tendon sheath of, 107 tenosynovitis of, 221 Forearm, abscess of, deep, 396 diagnosis of, 232 subcutaneous, 395 treatment of, 416 anatomy of, 79 in relation to infections, 149 dissection and experimental in- jections of, 159 incisions in, -drainage in, 270 infections of, treatment of, 271 injections of fascial spaces of, 154 involvement of, abscess forma- tion without complica- tions, 397 associated with wrist-joint invasion, 403 following tenosynovitis of thumb, treatment of, 273 incision in, 268 from infections of hand, pathology and diagnosis of, 395 from middle palmar space, 175 secondary hemorrhage and, 411 treatment of, 416 to little finger infection, 212, 215 458 INDEX Forearm, involvement of, from ulnar bursitis, treatment of, 266 lymphatics of, 318 serial cross-sections of, 150 Forssell, 234, 238 Friedrich, 249 Frog-felon, 52 GANGRENE, carbolic acid, 257 Gangrenous erysipelas, 383 Gas-bacillus infection, 385 Gauze in treatment of infections, 76 Gonorrheal tenosynovitis, 234 Gutta-percha in treatment of infec- tions, 76 HAND, anatomy of, 79 chronic processes in palm of, treatment of, 437 and forearm, lymphatic vessels of, 312 infections, diagnosis of differ- ential, 233 Heineke, 244 Helferich, 250 Hemolysis in streptococcus infections, 325 Hemorrhage in forearm involvement, 412 secondary, treatment of, 272, 414 Hot air, baking in dry, 78 Hyperemic treatment, Bier's, 71, 242, 259. 285, 363 Hypothenar space, 96, 100, 242 abscess of, treatment of, 289 anatomy of, 96 boundaries, diverticula, and position of secondary ab- scess in case of rupture from, 147 experimental study of bound- aries, diverticula, and posi- tion of secondary abscesses in cases of rupture from, 144 infection of, diagnosis of, 241 relation of, to infection in middle palmar space, 1 80 involvement of, source of, 183 ICE-BAG in axilla in treatment of in- fections, 257 Immobilization in fascial-space ab- scesses, 304 in tenosynovitis, 285 Incision in forearm involvement, 268 errors in making, 269 in infections, prophylactic, 74 in little finger infections, 264 in lymphangitis, 364 in tenosynovitis, 259 in ulnar bursal infections, 264 Index finger. See Finger, index. Infections. See also Tenosynovitis, Lymphangitis, Fascial-space infection, carbuncular, 38 chronic, repeated, 374 staphylococcus, 49 classification of, 17 diagnosis of, general, 57 drainage "in, 76 grave, 57 passive hyperemia in, 71 simple localized, 25 spread of, from any given pri- mary focus, 185 from one fascia! space to another, 176 from sides of fingers, 175 subepithelial, 37 treatment of, Bier's, 71 boric acid solution in, 72 cautery to open abscesses in, A 7 ' 5 drainage in, 75 drugs in, 70 gauze in, 75 general principles of, 70 gutta-percha in, 75, hot, moist dressings in, 72 Klapp suction cup in, 77 massage in, 78 passive hyperemia in, 71 prophylactic incision in, 74 rest in, 170 rubber tubes in, 76 types of, 17 Intermediary palmar sheath, anterior, in posterior, no Interosseous artery, anterior, lymph- atic abscesses and, 175 Interphalangeal joint, proximal, rela- tion of, to tendon sheath, 103 Iodine in prophylaxis, 70 JOINTS, interphalangeal, 218 proximal, treatment of, when involved, 435 involved secondary to little finger infection, 212 INDEX 459 Joints, metacarpophalangeal, involve- ment and treatment of, 437 preserving function of, in teno- synovitis, 286 KARENSKI, 238 Kausch, 237 Klapp, 72, 236, 237, 447 Konig, 247 LACUNAE of lymphatics, relation of, to subcutaneous abscess, 328, 365 Lejars, 250 Leukocytosis, increase of, in lymph- angitis, 368 Lexer, 248 Little finger. See Finger, little. Lumbrical muscles, extension to thenar space from middle palmar space, 181 involved from infection of middle finger, 195, 218 of tendon sheath, 169, 190, 218 in web, 197 from middle palmar space, 176 from ring finger tendon sheath, 197, 218 secondary to index teno- synovitis, treat- ment of, 261, 262 to little finger infec- tion, 216 involvement of, source of, 176 relations of, to infections of middle palmar space, 103, 172, 262 tenpsynovitis and, 260 Lymphangitis, 58 acute, simple, 338 with minor local complica- tions, 338 with serious local complica- tions, 339 with systemic involvement, .342 bacteria and, 324 in central part of palm, 200 complications of, treatment of, 370 deep, 343 differentiated from erysipelas, 362 dressing in, 361 drugs in, antagonistic, 366 Lymphangitis, etiology of, 322, 333 extension of, in infection of middle finger, 195 of thumb, 194 frequency of localization in, 342 hot, moist dressings in, 372 incisions in, 364 leukocytosis in, increases of, 368 pathogenesis of, 322, 333 pathology of, 322, 333 phlegmpnous, 341 prognosis of, 357 relation of, to fascial-space infec- tion, 309 to other types of infection, 309 to tenosynovitis, 309 septicemia and, 310 symptoms and signs of, 337 systemic involvement from, 346 treatment of, 361 normal salt solution in, 366 peptonized food in, 366 types of, 309, 338 Lymphatic abscess along arteries, 175 experimental injections and, 331 dilatations, sacciform, 312 infections, treatment of, 361 rest in, 363 Lymphatics, anatomy of, 310, 312 influence of, on course of infection, 326 course of, 174 deep, 320, 330 fascial-space infection and, 173 history of, 18 relation of, tendon sheaths, 329 superficial, 312 termination of, 319 M MALIGNANT edema, 388 Mascagni, 310 Massage in treatment of infections, 77 Mauclaire, 249 Median nerve, relation of, to bursae, 108 Metacarpal bones, extension of infec- tion of, to dorsum, 180 fifth, relation of, to infection of hypothenar space, 172 involvement and treatment of, 437 of middle finger, 195 osteomyelitis of, 198, 199, 200 relation of, to infections of middle palmar space, 172 Metacarpophalangeal arthritis, 187 460 INDEX Metacarpophalangeal joint and the tendon sheath, 103 Middle finger. See Finger, middle, palmar space. See Palmar space, middle. N NECROSIS of bones of wrist, 422 of tendons, 205, 274 Nerves to thenar muscles, relation of, to tendon sheath, 273 Nicaise, 241, 255 Normal salt solution in lymphangitis, 366 OIDIOMYCOSIS, 45 diagnosis of, 47 Osteomyelitis, 426 metacarpal bones, 198, 199, 200 PALM, infections beginning in, 200 lymphatics of, 317 relation of, to infections, 326 wound of, punctured, 135 Palmar abscess, drainage in, 291 fascia, relation of, to abscesses, 200 sheath, intermediary, anterior, in posterior, no space, middle, 90, 100 abscess of, treatment of, 290 anatomy of, 90, 97 boundaries, diverticula, and position of second- ary abscesses in case of rupture from, 145 experimental study of boundaries and position of secondary abscess in case of ex- tension from 128 of site of rup- ture and ex- tensions into forearm, 157 infections of, after results of, 206 diagnosis of, 224 by direct implanta- tion, 169 Palmar space, middle, infections of, extension from, 176 to thenar space, 179 to ulnar bursae, 181 relation of, to hypo- thenar space, 180 involved from infection spreading from sides of fingers, 175 secondary to fascial space infec- tion, 181 to little finger infect i on, 216 to middle and ring finger tenosyno- vitis, 168, 198, 219 to ring finger inf e ct i on, 197 to tenosyno- vitis, treat- ment of, 262, 271 involvement of, source of, 183 and subaponeurotic spaces, combined in- volvement of, treat- ment of, 297 and thenar space, com- bined in- volv e m e n t of, treat- ment of, 293 interrelation of, 97 Parona, 250 Paronychia, 31 pathology of, 32 treatment of, 33 types of, 32 Peptonized food in lymphangitis, 366 Periglandular abscess, treatment of, 373 Phalanges, distal, 25 infection of, 25 involvement of joints of, treatment of, 261 Phalanx, 436 involved secondary to little finger infection, 212 middle, 218 Phlegmon of dorsum, treatment of, 372 Phlegmonous lymphangitis, 341 INDEX 461 Poirier, 310 Poulsen, 253 Punctured wound of palm, 200 RADIAL artery, abscesses along, 175 bursa, 105 anatomy peculiar to infec- tions, 403 communication of, with ulnar bursa, no diagnosis of extensions from infections beginning in, 221 experimental study of site of rupture and extension into forearm from, 155 infections of, extension of, to ulnar bursa, 166 treatment of, 273 involved secondary to little finger infection, 212, 215 to tenosynovitis of throat, 222 bursitis, diagnosis of, 222 lymphatics, abscesses of, 175 Rheumatism of wrist, 233 Ring finger. See Finger, ring. Rubber tubes in treatment of infec- tions, 76 "Run-around" paronychia, 31 S SACCIFORM lymphatic dilatations, 312 Sappey, 310 Scneide, 244 Schleich, 252 Schuller, 245, 255 Septicemia, 346 Serum and vaccine treatment in lymphangitis, 367 Shirt-stud abscess, 52 Sinuses in chronic processes, 438 treatment of, 446 Sporotrichosis, 330 Staphylococcic tenosynovitis, 211 Strep tococcic tenosynovitis, 211 Streptococcus infections, hemolysis in, 325 Subaponeurotic space, abscess of, treatment of, 303 Subaponeurotic space, boundaries, diverticula, and position of secondary abscesses in case of rupture from, 146 infection from, extension of, 181 Subaponeurotic space, infection from, secondary changes fol- lowing, 208 source of, 173, 181 treatment of, 297, 303 Subcutaneous abscess following radial bursal inflammation, treatment of, 274 tenosynovitis, treatment of, 272 tissue, source of infection, 173 Subepithelial abscess, 37 Symbiosis, effect of, on course of infec- tion, 325 Synovial sacs, accessory, no sheaths of dorsum, infections of, treatment of, 283 fascial spaces and, relation between, 115 of wrist-joint, 422 TENDONS, necrosis of, 205, 274 treatment of, 447 prevention of adhesions of, in tenosynovitis, 286 prolapse at wrist prevented after incision, 285 sheaths, anatomical distribution and relations of, 102 upon dorsum, 113 extension to fascial spaces from, 1 68 from little finger, 198 extensor carpi radialis longior and brevior, 113 ulnaris, 113 communis digitorum, 113 * indicis, 113 longus pollicis, 113 minimi digiti, 113 ossis metacarpi pollicis, of to fascial spaces, relations of, 127 of flexor longus pollicis, 105 e x p e r imental study of ex- tension after rupture from, 126 surface, 102 tendon of little finger, 1 06 of index finger, experimental study of extension after rupture from, 125 intercommunication of, no 462 INDEX Tendon sheaths of little finger, 106 experimental study of extension after rupture from, 120 of middle finger, experimen- tal study of ex- tension after rupture from, 118 infection involv- * ing> I95 ' t i of ring nnger, experimental study of extension after rupture from, 119 rupture of, relation of, to fascial spaces, 118 of thumb, anatomical study of, relation of, to motor nerves of the- nar muscles, 273 spread of infection in- volving, 194 of thumb, removal of, 275 Tenosynovitis, 59 acute suppurative, treatment of, 256 adhesions in, 211 prevention of, 286 after-treatment of, 284 position of hand in, 286 by aspiration, diagnosis of, 261 diagnosis of, 209 drainage in, 259, 284 dressing in, dry, 285 hot, moist, 256, 285 edema in, 211 etiology of, 163 extension of, from one sheath to another, 165 of flexor longus pollicis, 221 extension from, 221 following lymphangitis, treat- ment of, 370 gonorrhe.al, 234 incision in, 259 of index finger, treatment of, 259 261 involvement of various sheaths in, 164 of little finger, treatment of, 263 lumbrical space and, 260 of middle finger, treatment of, 259 pathogenesis of, 163 pathology of, 204 preserving function of joints in, 286 prognosis of, 305 relation of, to lymphangitis, 309 of ring finger, treatment of, 259 staphylococcic, 211 streptococcic, 211 Tenosynovitis, subcutaneous abscess following, treatment of, 272 surgical considerations of, 163 symptoms and signs of, 209 tenderness in, 210 of thumb, treatment of, 256 treatment of, 235, 256 elevation of part in, 257 immobilization in, 285 passive and active move- ments in, 286 rest in, 257 Thenar area, involved secondary to index tenosynovitis, treatment of, 261, 262 space, 91 abscess of treatment of, 301 anatomy of, 91, 96 boundaries, diverticula, and position of secondary ab- scesses in case of rupture from, 146 experimental study of boundaries and position of secondary abscess in case of rupture from, 134 infection of, diagnosis of, 224 extension of, to middle palmar space, 1 80 to other spaces, 180 from tendon sheath, 190 involved from infection from sides of fingers, 175 from metacarpophalan- geal arthritis, 187 from middle palmar space, 179 secondary to index finger tenosyno- vitis, 219 to tendon-sheath in fection, 169 involvement of, source of, 1 83 middle palmar abscess and, treatment of, 297 space and, inter- relation of, 97 Thiersch graft after carbuncles, 45 Thrombophlebitis, 353 Thumb, infection involving, 194 tendon sheath of, 105 extension of rupture from, 126 tenosynovitis of, treatment of, 273 Toxins, virulent, prevention of ab- sorption of, 259 U ULNAR artery, abscesses along, 175 hemorrhage and, 415 INDEX 463 Ulnar bursa, 106 communication of, with radial bursa, 1 1 1 with tendon sheath of ring, middle, and index finger, 1 1 1 experimental study of site of rupture and extension into forearm, 156 extensions from, treatment of, 270 infection of, extension of, to radial bursa, 166 incision in, 265 involved from middle palmar space infection, 181 secondary to little finger infection, 212 to radial bursal in- fection, diagnosis of, 222 tenosynovitis of, treatment of, 263 Ulnar sheath infection, secondary to radial bursal inflammation, treat- ment of, 275 VON VOLKMANN treatment of teno- synovitis, 285 W WEB of finger, infection from, 199 involved, secondary to tenosyno- vitis, treatment of, 262 space, 101 Wound of palm, punctured, 200 Wrist rheumatism of, 263 Wrist-joint, bones of, necrosis of, 422 infection of, preservation of func- tion in, 423 secondary to little finger involvement, 212 involvement of, 403 treatment of, 421 resection of, 436 Date Due CAT. NO ?3 233 PRINTED IN U.S.A. WE832 Kl6i Kanavel . Infections of the hand WE832 KL6i Kanavel . Infections of the hand PRINTED IH U A