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 Presented by 
 Edythe F. Ashmore, D.o. 
 
 COLLEGE OF OSTEOPATHIC PHYSICIANS 
 AND SURGEONS LOS ANGELES, CALIFORNIA 
 
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 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 
 
 R<sum6 100
 
 CONTENTS ix 
 
 CHAPTER VIII 
 
 THE TENDON SHEATHS: A DISCUSSION OF THEIR 
 
 ANATOMICAL DISTRIBUTION AND RELATIONS, 
 
 WITH SURGICAL DEDUCTIONS 
 
 Sheaths upon the Flexor Surface 102 
 
 The Sheaths of the Index, Middle, and Ring Fingers . . . 103 
 The Radial Bursa and the Tendon Sheath of the Flexor Longus 
 
 Pollicis 105 
 
 The Ulnar Bursa and the Sheath of the Tendon of the Little 
 
 Finger 106 
 
 The Intercommunication of the Sheaths no 
 
 Sheaths upon the Dorsum .114 
 
 CHAPTER IX 
 
 THE RELATION BETWEEN THE SYNOVIAL SHEATHS AND 
 
 THE FASCIAL SPACES A STUDY BY EXPERIMENTAL 
 
 INJECTION OF THE OUTLINES, BOUNDARIES, AND 
 
 DIVERTICULA OF THE FASCIAL SPACES AND 
 
 THE RELATION OF THESE TO THE 
 
 SYNOVIAL SHEATHS 
 
 The Relation of the Tendon-sheath Rupture to the Fascial Spaces . 1 1 8 
 
 Injection via the Tendon Sheath of the Middle Finger . . . 118 
 Injection via the Tendon Sheath of the Ring Finger ... .119 
 Injection via the Tendon Sheath of the Little Finger ... .120 
 
 Injection via the Tendon Sheath of the Index Finger .... 125 
 
 Injection via the Tendon Sheath of the Flexor Longus Pollicis . 126 
 General Deductions as to Relation of Tendon Sheaths to Facial 
 
 Spaces 127 
 
 The Normal Boundaries of the Fascial Spaces and the Position of 
 
 Secondary Abscesses in Case of Extension from the Spaces . . 128 
 
 The Middle Palmar Space 128 
 
 Injection via the Tendon Sheath of the Ring Finger . . . 128 
 
 Injection through Palmar Fascia into Middle Palmar Space . 133 
 
 Injection along Lumbrical Muscle of the Ring Finger . . . 134 
 
 Thenar Space 134 
 
 Injection via the Tendon Sheath of the Index Finger . . . 135 
 
 Injection of the Thenar Space under Forcible Presure . . . 136 
 Injection Through Palmar Fascia in Attempt to Reach the 
 
 Thenar Space 140 
 
 Dorsal Subcutaneous Space 141 
 
 Injection between the First and Second Metacarpals . . ". 141 
 
 Injection between the Second and Third Metacarpals . . . 142 
 
 Dorsal Subaponeurotic Space 142 
 
 Injection under Tendons of Dorsum 142 
 
 Hypothenar Space 144 
 
 Re'sume' of Preceding Experiments as to Boundaries, Diverticula, 
 
 and Extensions from the Fascial Spaces 144
 
 CONTENTS 
 
 Anatomy in General 149 
 
 Serial Cross-sections of the Forearm 150 
 
 Experimental Injections of the Fascial Spaces of the Forearm . . . 154 
 
 Injection of the Radial Bursa 155 
 
 Injection of the Ulnar Bursa 156 
 
 Injection from the Mid-palmar Space 157 
 
 Resume of Findings by Dissection and Experimental Injection . . . 159 
 
 SECTION II 
 
 THE SURGICAL CONSIDERATIONS OF TENDON-SHEATH 
 
 INFECTIONS AND FASCIAL-SPACE ABSCESSES OF 
 
 THE HAND AND FOREARM 
 
 CHAPTER XI 
 
 PATHOGENESIS SOURCE OF INVOLVEMENT OF THE 
 TENDON SHEATHS AND FASCIAL SPACES 
 
 Etiology in General 163 
 
 Source of Involvement of the Various Sheaths 164 
 
 Extension from One Sheath to Another 166 
 
 Source of Involvement of the Important Fascial Spaces in the Hand . 168 
 
 Involvement from the Tendon Sheaths . * . 168 
 
 Direct Implantation of the Infection in the* Spaces 169 
 
 Involvement by Lymphatic. Ex tension 173 
 
 Extension from One Fascial Space to Another 175 
 
 Recapitulation as to Source of Involvement of the Fascial Spaces 183 
 
 CHAPTER XII 
 
 THE SPREAD OF INFECTION FROM ANY GIVEN PRIMARY 
 
 FOCUS 
 
 The Probable Extensions from Primary Foci on the Fingers . . . 185 
 
 The Spread of Infection Involving the Index Finger .... 185 
 
 The Spread of Infection Involving the Thumb 195 
 
 The Spread of Infection Involving the Middle Finger .... 196 
 
 The Spread of Infection Involving the Ring Finger 197 
 
 Infection Spreading from the Little Finger 199 
 
 Infections Beginning in the Palm and Dorsum 200 
 
 Re'sume' 201
 
 CONTENTS xi 
 
 CHAPTER XIII 
 
 THE PATHOLOGY OF TENDON SHEATH AND FASCIAL-SPACE 
 
 ABSCESSES 
 
 The Tendon Sheath Proper 204 
 
 The Fascial-space Abscesses ......... .- 206 
 
 CHAPTER XIV 
 
 THE SYMPTOMS, SIGNS, AND DIAGNOSIS OF TENOSYNOVITIS 
 AND FASCIAL-SPACE ABSCESSES 
 
 The Symptoms, Signs, and Diagnosis of Acute Tenosynovitis . . . 209 
 Symptoms, Signs, and Diagnosis of Extensions from Infections 
 
 Beginning in the Little Finger 212 
 
 Extension to Ulner Bursa 212 
 
 Extension to Radial Bursa . . ^ 215 
 
 Extension to Forearm 215 
 
 Extension to Lumbrical and Palmar Spaces 216 
 
 Symptoms, Signs, and Diagnosis of Extensions from Infections 
 
 beginning in the Index, Middle, and Ring Fingers . . . . 218 
 Symptoms, Signs, and Diagnosis of Extensions from Infections 
 
 Beginning in the Radial Bursa 221 
 
 The Symptoms, Signs, and Diagnosis of Fascial-space Abscesses . . 223 
 
 The Middle Palmar and Thenar Spaces 224 
 
 The Hypothenar Space 231 
 
 The Dorsal Abscesses 231 
 
 Forearm Abscesses 232 
 
 Differential Diagnosis 233 
 
 CHAPTER XV 
 
 THE TREATMENT OF ACUTE SUPPURATIVE TENOSYNOVITIS 
 
 GENERAL CONSIDERATIONS A REVIEW OF THE 
 
 LITERATURE 
 
 Excerpts from the Literature 236 
 
 CHAPTER XVI 
 
 THE TREATMENT OF ACUTE SUPPURATIVE TENOSYNOVITIS 
 DISCUSSION OF TECHNIQUE 
 
 Treatment While the Diagnosis May Be in Doubt 256 
 
 Technique of Treatment after Diagnosis is Made 257 
 
 Treatment of Tenosynovitis of the Index, Middle, and Ring 
 
 Fingers 259 
 
 When the Involvement of Adjacent Areas has Begun . . . 261 
 
 The Index Finger 261 
 
 The Middle Finger 263 
 
 The Ring Finger 263
 
 xii CONTENTS 
 
 Technique of Treatment after Diagnosis is Made 
 
 Treatment of Tenosynovitis of the Little Finger and Ulnar 
 
 Bursa 263 
 
 Treatment of Extensions from the Little Finger and the Ulner 
 
 Bursa 270 
 
 Treatment of Inflammation of the Tendon Sheath of the Long 
 
 Flexor of the Thumb 273 
 
 Treatment of Inflammation of the Synovial Sheaths upon the 
 
 Dorsum 283 
 
 After-treatment 284 
 
 CHAPTER XVII 
 
 THE TREATMENT OF FASCIAL-SPACE ABSCESSES 
 
 Technique of Treatment of Abscesses in the Middle Palmar Space . . 290 
 The Treatment of Combined Involvement of the Middle Palmar 
 
 and Thenar Spaces 293 
 
 The Treatment of Combined Involvement of the Middle Palmar 
 
 and Subaponeurotic Spaces 297 
 
 Technique of Treatment of Abscesses in the Thenar Space . . . .301 
 
 Technique of Treatment of Abscesses of the Subaponeurotic Space . 303 
 
 After-treatment in Fascial-space Abscesses 304 
 
 CHAPTER XVIII 
 
 RESUME OF ACUTE SUPPURATIVE TENOSYNOVITIS AND 
 FASCIAL-SPACE ABSCESSES PROGNOSIS 
 
 Resume 305 
 
 Prognosis 307 
 
 SECTION III 
 
 LYMPHATIC INFECTIONS 
 CHAPTER XIX 
 
 THE RELATION OF LYMPHANGITIS TO OTHER TYPES OF 
 INFECTION DISCUSSION OF THE ANATOMY 
 
 The Relation of Lymphangitis to Other Types of Infection . . . 309 
 
 Anatomy 310 
 
 The Lymphatic Vessels of the Hand and Forearm 312 
 
 Superficial Lymphatics 312 
 
 Deep Lymphatics 320
 
 CONTENTS xiii 
 
 CHAPTER XX 
 
 LYMPHANGITIS ETIOLOGY, PATHOGENESIS, AND 
 PATHOLOGY 
 
 Predisposing and Active Factors in the Production of Lymphangitis . 322 
 
 Influence of the Type of Germ 324 
 
 Influence of the Anatomy on the Course 326 
 
 Sporotrichosis 330 
 
 Relations of Lymphatic Abscesses Studied by Experimental Injections . 331 
 
 Report of Injections of Forearm Near the Radial and Ulnar 
 
 Vessels 331 
 
 Experiments by Injection along Ulnar Artery 333 
 
 Pathology of Lymphangitis 333 
 
 Resume -. 335 
 
 CHAPTER XXI 
 
 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 Symptoms and Signs in General 337 
 
 Types 338 
 
 Type I. Simple Acute Lymphangitis 338 
 
 Type II. Acute Lymphangitis with Minor Local Complications . 338 
 Type III. Acute Lymphangitis with Serious Local Complica- 
 tions 338 
 
 Type IV. Acute Lymphangitis with Systemic Involvement . . 338 
 
 Acute Lymphangitis with Serious Local Complications . . . . . 339 
 
 Phlegmonous Lymphangitis .341 
 
 Frequency of Localization in Lymphatic Infections 342 
 
 Acute Lymphangitis with Systemic Involvement 342 
 
 Deep Lymphangitis 343 
 
 Systemic Involvement 346 
 
 Postmortem Statistics 352 
 
 Thrombophlebitis 353 
 
 Resume" 355 
 
 CHAPTER XXII 
 
 PROGNOSIS IN LYMPHATIC INFECTIONS 
 
 CHAPTER XXIII 
 
 THE TREATMENT OF LYMPHATIC INFECTIONS GENERAL 
 DISCUSSION 
 
 Discussion of Various Procedures 361 
 
 Local 361 
 
 Hot, Moist Dressings 361
 
 xiv CONTENTS 
 
 Discussion of Various Procedures: Local 
 
 Rest 363 
 
 The Bier Treatment 263 
 
 Incisions 364 
 
 Systemic Treatment 366 
 
 Antagonistic Drugs 366 
 
 Serum and Vaccine Treatment 367 
 
 Supportive Measures 368 
 
 Resume 369 
 
 CHAPTER XXIV 
 
 THE TREATMENT OF THE COMPLICATIONS OF 
 LYMPHANGITIS 
 
 Tenosynovitis 370 
 
 Subcutaneous Abscesses 372 
 
 Periglandular Abscesses 373 
 
 Subclavicular and Shoulder Abscesses 373 
 
 Systemic Complications 374 
 
 Chronic Infections Repeated Infections 374 
 
 Resume" 382 
 
 SECTION IV 
 
 ALLIED INFECTIONS 
 
 CHAPTER XXV 
 
 ERYSIPELAS, ERYSIPELOID, GAS-BACILLUS INFECTION, 
 ANTHRAX 
 
 Erysipelas 383 
 
 Erysipeloid 384 
 
 Gas-bacillus Infection 385 
 
 Anthrax 390 
 
 SECTION V 
 
 COMPLICATIONS AND SEQUELS OF INFECTIONS OF THE HAND 
 
 CHAPTER XXVI 
 
 FOREARM INVOLVEMENT FROM INFECTIONS OF THE 
 HAND PATHOLOGY AND DIAGNOSIS 
 
 Subcutaneous Abscesses 395 
 
 Deep Abscesses 396
 
 CONTENTS xv 
 
 Forearm Involvement Abscess Formation without Other Complica- 
 tion 397 
 
 Location of the Abscesses . . . . . 397 
 
 Symptoms, Signs, and Diagnosis 401 
 
 Deep Forearm Involvement Associated with Wrist-joint Invasion . . 403 
 
 Examination of the Radial Bursa in Cadavers 403 
 
 Pathology Found in Serious Wrist-joint Involvement .... 404 
 
 Forearm Involvement with Secondary Hemorrhage 411 
 
 Resume 415 
 
 CHAPTER XXVII 
 
 TREATMENT OF INVOLVEMENT OF THE FOREARM 
 SECONDARY TO HAND INFECTIONS 
 
 Treatment of Uncomplicated Cases 416 
 
 Treatment in Cases Where the Wrist- joint is Involved 421 
 
 Treatment in Cases of Secondary Hemorrhage 424 
 
 Resume 425 
 
 CHAPTER XXVIII 
 
 SEQUELS OF INFECTIONS OF THE HAND CHRONIC PRO- 
 CESSES, OSTEOMYELITIS, ARTHRITIS, CONTRACTURES, 
 AND ATROPHY 
 
 Involvement of the Finger Proper 427 
 
 Pathology . . . . 427 
 
 Treatment 433 
 
 Involvement of the Hand Proper and the Metacarpals and Carpals . 437 
 
 Pathology 445 
 
 Treatment 445 
 
 Atrophy and Contracture ....'.. 448 
 
 Resume Chronic Infections ...... . 453
 
 INFECTIONS OF THE HAND. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 SCOPE AND CLASSIFICATION OF TYPES OF INFECTIONS. 
 
 THE accompanying contribution to our knowledge 
 of infections of the hand is the result of several years' 
 study, comprising experimental and anatomical inves- 
 tigations carried on in conjunction with careful clinical 
 observation of an extensive number of cases. In the 
 following pages the diagnostic factors and incisions 
 which this work has suggested will be described. By 
 their use it has been possible even in neglected cases 
 to insure a restoration to complete function in 95 per 
 cent, of the abscesses of the fascial spaces; while in 
 tendon-sheath infections the morbidity has been 
 reduced by fully one-half, and a greater reduction is 
 possible if the profession as a whole will learn to make 
 an early diagnosis in this most lamentable compli- 
 cation. 
 
 HISTORY. 
 
 Professor Albert 1 says that while the word pana- 
 ritium was not used by Celsus, it is found in the 
 Arabian and other ancient writings, and appears to 
 be a corruption of the Greek Tra^oupd (jiapd ovuc). 
 Paracelsus, Dorneus, and others have used the words 
 
 'Chir., 1885, ii.
 
 18 INTRODUCTION 
 
 pandalitium, passa, panaris, and panarium, and it 
 cannot be said whether these refer to different types 
 or are corruptions of the same word. Concerning the 
 elemental meaning of panaritium, Forestus 1 states: 
 "Panaritium s. Paronychia tumor edicitur, calidus, 
 ulcer osus, summe dolor osus, accidens in summit ate 
 digitorum, in later e unguis et quandoque tarn vehementer 
 afficiens, ut vigilias et inquietudinem excitet." 
 
 Our anatomical knowledge of the lymphatic vessels 
 dates back to the time of Aristotle, but it is to 
 Herophilus (300 B. c.) and Herasistratus (280 B.C.) 
 to whom, according to Galenic writings, we ought to 
 attribute the discovery of the chyliferous vessels. 
 These observations fell into obscurity, and it was not 
 until 1532, when Nicolas Massa discovered renal 
 lymphatics, that the knowledge of the subject began 
 to grow. Following Eustachius, Aselli, and others, 
 Vessling and Rudbeck in the seventeenth century 
 described lymphatics in the liver, pancreas, lungs, 
 and pelvis. Mascagni, Lippi, and Lauth followed 
 with admirable work, while Sappey, in 1876, published 
 his large atlas after twenty years of work, when the 
 subject can be said to have been put upon a scientific 
 basis. 
 
 It was shortly before this time, however, that the 
 study of lymphatic abscesses was begun. Bauchet's 2 
 treatise, in 1859, upon infections of the hand lacked 
 this knowledge to make it a masterpiece. From this 
 time until the culmination of Sappey 's work an acri- 
 monious discussion was maintained over the subject 
 of lymphatic versus synovial sheath extension of infec- 
 tion. Gosselin, following dissections, adduced proof 
 that extension nearly always progressed along synovial 
 sheaths. Dolbeau meanwhile presented a masterly 
 
 1 Chir., lib. v, Observat. 16. 
 
 2 Du Panaris, Paris, 1859.
 
 HISTORY 19 
 
 discussion, supported by clinical evidence, in support 
 of the possibility of lymphatic extension with the 
 formation of deep abscesses. Chevalet, 1 a pupil of 
 Dolbeau, chose for his doctorate thesis, in 1875, to 
 make a further contribution to the literature in sup- 
 port of his master's assumptions, bringing to his aid the 
 brilliant investigations of Sappey and others. Later, 
 Polaillon and Le Dentu supported the theories of 
 Gosselin, although the latter was led to admit that the 
 theories of Dolbeau might have some justification in 
 a few cases. Since that time the subject has received 
 little attention, but we have gradually come to assume 
 that each party was too radical in its claims and that 
 infection can spread by either channel, an assumption 
 that every clinician has had occasion to verify. 
 
 In later years a carefully observed series of cases 
 has been reported from the Griefswald Clinic by Max 
 Tornier, 2 who brought prominently before the pro- 
 fession Helferich's method of opening widely the 
 sheaths, which was later substantiated and discussed 
 with carefully observed cases by Forssell. 3 
 
 I wish to make acknowledgment of abstracts w r hich 
 I have taken freely from these authors. Forssell par- 
 ticularly has written a most masterly article upon 
 tenosynovitis. I am forced, however, to take issue 
 with him as to certain methods of treatment. Con- 
 cerning these and the various modern ideas as to the 
 treatment of tenosynovitis, full reference will be found 
 in the chapter dealing with that subject. 
 
 In spite of the fact that from earliest times the 
 importance of the subject has been recognized, neither 
 
 1 These pour le doctorat en Medecine, Paris, 1875. 
 
 2 Beitrag zur Kenntnis schwerer Phlegmonen, Inaugural Dissertation, 
 Griefswald, 1891. 
 
 3 Klinische Beitrage zur Kenntnis der akut septischen Eiterungen der 
 Sehnenscheiden der Hohlhand besonders mit Rucksicht auf die Therapie, 
 Xordisches medizinisches Archiv, 1903, Abt. i, Heft 3.
 
 20 INTRODUCTION 
 
 in text-books nor in special articles can the student 
 find clear descriptions of the various types of acute 
 infections, with the methods of their diagnosis and 
 treatment. This I shall here attempt to give. 
 
 SCOPE AND CLASSIFICATION OF TYPES. 
 
 It is manifest that if we are to have a clear idea of 
 the various phases of infections of the hand, it will be 
 necessary to divide the subject into various types, 
 depending upon the nature of the infection and the 
 results it produces. It should be understood that we 
 are dealing with acute infective processes, and not 
 those associated with syphilis, tuberculosis, and other 
 chronic infections, although the general principles laid 
 down by the anatomical and experimental researches 
 will be found to be applicable there also. 
 
 I have divided the subject in general as follows: 
 
 1. Simple localized infections and allied minor 
 clinical entities. 
 
 2. Grave infections. 
 
 (a) Discussion of diagnosis and treatment in 
 
 general. 
 
 (b) Tenosynovitis and fascial space abscesses. 
 (c} Acute lymphangitis and allied infections. 
 (d) Complications and sequelae of acute infec- 
 tions. 
 
 It is true that in certain cases we shall find all three 
 of the graver types present i. e., a lymphangitis, a 
 tenosynovitis, and a fascial space abscess yet in a 
 majority of cases only one type will be found. If 
 they are combined, the symptoms and signs of each 
 are present, and each will demand a separate and 
 distinct form of treatment, for in opening a synovial 
 sheath infection w r e do not by any means drain the 
 fascial spaces, nor vice versa. Again, unless we have 
 a clear picture in our minds of fascial-space infection,
 
 SCOPE AND CLASSIFICATION OF TYPES 21 
 
 and in a given case do not determine whether or not 
 it is present in an acute tenosynovitis and the diag- 
 nosis is by no means easy we might so make our 
 incision in the synovial sheath that the fascial spaces 
 would become infected unnecessarily; and in a patient 
 who depends upon his hands for his livelihood, such 
 an error becomes criminal carelessness. 
 
 Again, while a lymphangitis may become a teno- 
 synovitis or fascial-space infection, in a great majority 
 of cases it remains a clinical and pathological entity, 
 and the mistake frequently made of assuming this 
 relationship and treating it accordingly has been 
 responsible for the gravest errors and most serious 
 consequences, both as to morbidity and mortality, 
 that I have met in my experience. 
 
 In a great majority of cases the differentiation of 
 these types can be made, but I know of no single rule 
 by which it can be done. The requisite knowledge 
 comes only with a clear understanding of the basic 
 principles of inflammation produced by the various 
 bacteria, coupled with a knowledge of the anatomical 
 relations peculiar to the hand and a study of the 
 course any given infection will normally pursue. It 
 has, therefore, seemed necessary to give in some detail 
 the anatomical and experimental investigations upon 
 which my deductions are based, rather than to state 
 dogmatically the rules upon which a diagnosis should 
 be made and the various incisions which I have found 
 to lead to the most rapid recovery. If one will take 
 the time to fix in mind the fundamental facts which 
 are here discussed, he will have no difficulty in apply- 
 ing them to any given case. The technical procedures 
 incident to the operations are easily learned and 
 applied. In almost all cases the difficulty has been 
 an improper diagnosis, both as to the nature of the 
 infection and the position of the pus.
 
 22 INTRODUCTION 
 
 Therefore, I wish to emphasize that while for the 
 sake of clearness a brief resume of the contents has been 
 introduced into certain chapters, the careful surgeon 
 will find it necessary to read the context for the 
 coordination of the various data. 
 
 It will be found that lymphatic infections follow a 
 distinct anatomical and clinical course, having at all 
 times the possibility of producing certain definite com- 
 plications which may be prognosticated and -antici- 
 pated. We shall see that the tendon-sheath infections 
 pursue definite lines of invasion, and the position of 
 the pockets of pus when rupture occurs can be prog- 
 nosticated, so that incisions can be made early at 
 these sites and further extensions prevented. 
 
 Concerning the fascial spaces it will be shown 
 that: 
 
 (a) There are certain well-defined, uniform spaces 
 upon the fingers, palm, and dorsum of the hand in 
 which pus can accumulate. 
 
 (&) There are definite anatomical channels by which 
 infection arising in a given spot will extend to certain 
 of these spaces, while certain other spaces will remain 
 uninvolved; hence the diagnosis of the position of the 
 pus is simplified and the proper site for the incision 
 determined. 
 
 (c) There are definite anatomical channels by which 
 pus can spread from the uniform spaces mentioned, 
 and when this occurs, the position of the pus can be 
 prognosticated. 
 
 (d) The boundaries of the fascial spaces having been 
 determined, it is easily seen that in the case of some 
 of these the incisions for evacuation must be made at 
 definite spots; otherwise important structures may be 
 injured, or by ill-advised incisions adjacent spaces 
 may be opened at the same time and a spread of the 
 infection favored to parts of the hand that would not
 
 SCOPE AND CLASSIFICATION OF TYPES 23 
 
 have become involved without this unfortunate surgical 
 procedure. 
 
 (e) It can be understood readily why, in certain cases, 
 the infection has persisted for weeks and months after 
 apparently opening the pus pocket, since diverticula 
 and intermediary chambers have not been taken into 
 consideration. 
 
 The interrelation of these various facts wi41 be 
 emphasized by case reports, each of which has been 
 introduced to illustrate or clarify some important 
 clinical fact. The number could have been multi- 
 plied many times, but I have tried not to duplicate 
 these illustrations. 
 
 We will return now to the slighter infections, such 
 as felons, carbuncles, paronychia, etc., which bear 
 little or no relation to these more serious types just 
 considered. It must be remembered that they are 
 clinical entities, each having a pathology peculiar to 
 itself. Owing to their frequency they are of especial 
 interest to the practitioner. While the diagnosis is 
 easily made, the course is often unnecessarily pro- 
 longed, owing to a lack of appreciation of the patho- 
 logical anatomy and the proper means of treatment. 
 These types will be discussed in the immediately 
 succeeding chapters, so that they may not be left to 
 confuse the student later while studying the graver 
 and more important forms.
 
 PART I. 
 
 SIMPLE LOCALIZED INFECTIONS AND 
 ALLIED MINOR CLINICAL ENTITIES. 
 
 CHAPTER II. 
 INFECTIONS OF THE DISTAL PHALANGES. 
 
 FELONS, PARONYCHIA, SUBEPITHELIAL ABSCESSES. 
 
 FELONS, 
 
 FELONS are among the most common infections of 
 the distal phalanx. The source may be a small pin 
 prick or unnoticed injury, and occasionally no history 
 of injury may be elicited. The patient first notices 
 a sticking pain in the distal phalanx, which rapidly 
 becomes throbbing in character and most severe. He 
 cannot rest or sleep. The distal portion of the finger 
 becomes red and swollen. Early it is tender to the 
 touch and this tenderness is most marked over the 
 site of the infection. In the later stages, after pus 
 formation and tissue destruction, the sensitiveness dis- 
 appears. The phalanx is at first tense from the edema ; 
 more tense, in fact, than is ordinarily observed with 
 edema, owing to the peculiar anatomical structure, 
 which will be discussed later. Soon the tenseness is 
 replaced by an induration and later by a fluctuating, 
 boggy mass. 
 
 The reason for the peculiar pathological condition 
 which is present here in localized infection and
 
 26 INFECTIONS OF THE DISTAL PHALANGES 
 
 nowhere else in the body is worthy of consideration. 
 The ordinary conception of the pathogenesis is that 
 which has been attributed to Roux, whether justly or 
 not I cannot say. By this the lymphatic vessels are 
 supposed to run perpendicularly from the skin to the 
 periosteum; infection thus takes place under the peri- 
 osteum, which is lifted off, and necrosis of the bone 
 ensues. Against this assumption w r e have the very 
 firm attachment of the periosteum to the bone, 
 Sharpey's fibers going down into the osseous tissue 
 in such a way that it is practically impossible for the 
 periosteum to be separated and differentiated as it is 
 elsewhere. Moreover, there are certain anatomical 
 peculiarities which seem to point to another explana- 
 tion of this frequent change, so essentially different 
 from that noted elsewhere in the body. The con- 
 nective-tissue framework is such as to produce a 
 closed sac comprising the distal part of the phalanx, 
 thus differing from the remainder of the finger, while 
 the glands lying in the columns of fat present a portal 
 for the entrance of pathogenic bacteria. This will be 
 seen- by examining the accompanying cross and longi- 
 tudinal sections of the phalanx. Some of the glands 
 may be seen lying near the periosteum. Of especial 
 interest is the presence of the bloodvessels which may 
 be seen in the cross-section, one lying upon either side 
 in the closed space and running parallel with the 
 phalanx (Figs. I and 2}. Should pus, or edema the 
 result of infection, develop to an undue degree in 
 this closed space, it would have no means of free 
 egress as in the other connective-tissue space. Hence 
 it would have a tendency to shut off the blood supply 
 and cause necrosis of the bone. It will be seen by 
 examining the longitudinal section that the portion 
 of the bone involved is the diaphysis, since the epiphy- 
 sis receives its blood supply before the vessel enters
 
 FELONS 
 
 27 
 
 the closed space. Anatomically, then, we expect the 
 epiphysis to escape necrosis in these cases, and clinical 
 
 FIG. i 
 
 Bloodvessel. 
 
 Transverse section of distal phalanx, showing the closed pocket with columns 
 of fat radiating from the bone. The glands are well shown and demonstrate 
 how easy it would be for pathogenic organisms to invade this space through 
 these glands.
 
 28 INFECTIONS OF THE DISTAL PHALANGES 
 
 observation corroborates this view, since the diaphysis 
 is the part of the bone which is lost. This finds its most 
 perfect example in children and those whose epiphyses 
 and diaphyses have not progressed to perfect bony 
 union. It has been my experience frequently to open 
 these old felons in children and have the diaphysis 
 fall out of the sac, where it has been floating, a free 
 body, in a sea of pus. In adults, where osseous union 
 
 FIG. 2 
 
 Longitudinal section of the distal phalanx and articulation. Note the 
 closed pocket of the pulp of the finger and the columns of fat, with glands 
 shown as dark dots spread throughout. Note that the epiphysis is well 
 separated from this pocket. 
 
 has taken place, an examination will show the necrotic 
 diaphysis standing out free from the surrounding 
 tissue, with the epiphysis and joint, in the early 
 stages at least, practically untouched by the destruc- 
 tive process. 
 
 This explanation of the pathological sequence would 
 seem to be more reasonable than that of Roux, and 
 also explains the rapid recession of the process after 
 an early opening, and the slow recovery when delay
 
 FELONS 29 
 
 has permitted the disease to destroy the connec- 
 tive tissue which must ultimately be expelled as a 
 slough. 
 
 When the incision has been delayed or the process 
 permitted to go on to spontaneous expulsion of the 
 necrotic matter, we find a bluish insensitive pus >ag 
 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
 
 <i' V' O /\ O J2 ) ] ^ 
 
 152 "ANATOMY.OF THE FOREARM 
 
 nmT/^03TcO nO HDaJJO^ 
 
 Section 5 cm, above radial styloid. ZL4, ulnar artery; UN, ulnar nerve; 
 MN, median nerve; RA, radial artery; S, space; PQ, pronator quadratus. 
 
 FIG. 57 
 
 Drawing from teased cross-section, Fig. 56: a, extensor secundi internodii 
 pollicis; b, extensor communis digitorum; c, extensor indicis; d, extensor 
 minimi digiti; e, extensor carpi ulnaris; /, interosseous membrane; g, ulna; 
 h, pronator quadratus; i, i, flexor carpi ulnaris; j, ulnar nerve; k, ulnar 
 artery; /, flexor profundus digitorum; m, m, flexor sublimis digitorum; n, 
 palmaris longus; o, median nerve; p, flexor carpi radialis; q, flexor longus 
 pollicis; r, radial artery; s, space propped open by pegs of wood; t, supinator 
 longus; u, extensor carpi radialis longior; v, extensor carpi radialis brevior; 
 w, radius; x, extensor primi internodii pollicis.
 
 SERIAL CROSS-SECTIONS OF THE FOREARM 153 
 
 this site that drainage is instituted. The blocks of 
 wood holding open the space are about a centimeter 
 and a half in length. 
 
 Section 3 (Fig. 58). Seven centimeters above radial 
 styloid. In this section the pronator quadratus has 
 almost entirely disappeared. The space is bounded 
 below by the interosseous membrane with the artery 
 exposed. The radial and ulnar arteries and the median 
 and ulnar nerves are still well separated from the space. 
 Attention will be drawn to this fact later in discussing 
 treatment. 
 
 FIG. 58 
 
 Section 7 cm. above radial styloid. Pronator quadratus has almost dis- 
 appeared. Notice that the vessels and nerves with the exception of the 
 interosseous (I A) are well separated from the space. 
 
 Section 4 (Fig. 59). Nine centimeters above radial 
 styloid. In this section the space is leaving the inter- 
 osseous membrane and passing toward the flexor sur- 
 face on the radial side of the deep flexors. It extends 
 to the median nerve and over to the ulnar artery and 
 nerve along the ulnar side. 
 
 This relation of the space to the bloodvessels and 
 nerves explains why the injection masses go up the 
 forearm and then pass in a retrograde manner toward 
 the hand along these structures. It also explains those 
 cases in which the injection mass passes up along
 
 154 
 
 the median above the elbow. It helps to explain the 
 trophic sequelae and cases of ulcerative hemorrhage 
 that have been reported. In the upper part of the fore- 
 arm the space follows the nerves and bloodvessels and 
 becomes indefinite. It is seen that the ulnar nerve 
 
 FIG. 59 
 
 IA 
 
 Section 9 cm. above radial styloid. Note the relation of the space to the 
 median nerve and the ulnar artery: IA, interosseous artery. 
 
 and artery along which the secondary mass extends 
 lie immediately under the junction of the flexor carpi 
 ulnaris with the flexor profundus digitorum. This 
 so indicates then a second site for incision (Figs. 122 
 and 123). 
 
 EXPERIMENTAL INJECTIONS OP THE FASCIAL SPACES OF 
 THE FOREARM. 
 
 To verify the findings here, experimental injections 
 were made with plaster of Paris from various sites 
 that might be the origin of spreading abscesses. These 
 will show the intimate relation which exists between 
 the fascial spaces of the hand and the forearm and those 
 about the bloodvessels. 
 
 It should be remembered that we are only selecting 
 illustrative experiments which bear upon the subject
 
 INJECTION OF THE RADIAL BURSA 155 
 
 in hand, and that they do not by any means represent 
 a complete report of the results obtained from injec- 
 tions at these various sites. 
 
 INJECTION OF THE RADIAL BURSA. 
 
 Out of the eight injections made into the radial 
 bursa under high pressure to produce rupture and 
 extravasation of the mass, six showed extension from 
 a rupture at the proximal end into the forearm (see 
 p. 126). The following may be taken as an example of 
 the condition found upon dissection of the arm. 
 
 Experiment 46. Injection under great pressure of 
 synovial sheath of flexor longus pollicis by plaster of 
 Paris. 
 
 Upon dissection the mass was found to have filled 
 the synovial sheath completely and ruptured from the 
 proximal end into the tissue of the forearm. No ex- 
 tension has taken place into the hand either by rup- 
 ture of the sheath in continuity or by retrograde move- 
 ment from the forearm under the annular ligament, 
 although the mass had extended down to the annular 
 ligament and lay under the superior border. The 
 attachment of the flexor longus pollicis to the bone 
 was partially destroyed, owing possibly to the friability 
 of the muscle in this particular cadaver, but the mass 
 showed a tendency to follow this muscle and a pre- 
 dilection for the radial side of the forearm. A portion 
 of the mass lay between the flexor longus pollicis and 
 the flexor sublimis digitorum. The larger part, how- 
 ever, extended underneath the flexor profundus digi- 
 torum to fill a space bounded on the ulnar side by the 
 flexor carpi ulnaris, on the radial side by the flexor 
 longus pollicis, dorsally by the bones with the inter- 
 osseous membrane and pronator quadratus. This ex- 
 tended up to within three inches of the elbow-joint 
 and distally to the wrist-joint. A great amount of
 
 156 
 
 ANATOMY OF THE FOREARM 
 
 material was present. The area filled was practically 
 that described in the cross-sections, except that the 
 mass did not extend between the flexor carpi ulnaris 
 and the flexor profundus. 
 
 FIG. 60 
 
 X-ray Plate. Injection via tendon sheaths of both thenar and middle 
 palmar spaces with considerable force. Note extension into forearm from 
 middle palmar space. Showing where pus would lie in neglected cases, as 
 in Cases 25 and 45. 
 
 INJECTION OF THE ULNAR BURSA. 
 
 Injection of the ulnar bursa resulted frequently in 
 rupture at the proximal end. The mass showed a
 
 INJECTIONS FROM THE MID-PALMAR SPACE 157 
 
 greater predilection for the ulnar side, and had a ten- 
 dency to return along the course of the ulnar artery. 
 This extension along the vessel explains the presence 
 of the ulceration of the vessel and profuse hemorrhage 
 which occurs at times. 
 
 Experiment 47. Injection of the ulnar bursa, rup- 
 ture from proximal end, filling deep space in the fore- 
 arm (Fig. 39). 
 
 The ulnar bursa was injected with great force. 
 Rupture occurred at the proximal end; the mass was 
 found to fill space described above, being dorsal to the 
 flexor profundus tendons and muscles. It showed a 
 primary predilection for the ulnar side, but returned 
 along both the ulnar and radial vessels. There was 
 also an extension along the median nerve, this tongue 
 of plaster following the nerve to two inches proximal 
 to the elbow-joint. 
 
 INJECTIONS FROM THE MID-PALMAR SPACE. 
 
 What is the result when the mass extends from the 
 mid-palmar space of the hand? 
 
 Experiment 48 (Fig. 60). In this case the result 
 is shown by an x-ray picture. Both the thenar and 
 middle palmar spaces were injected with force from the 
 index and ring fingers respectively. The thenar mass 
 remained in its usual compartment, while the middle 
 palmar mass passed up under the group of flexor ten- 
 dons into the forearm. Note the prolongations along 
 the lumbrical muscles, and the thinness of the mass 
 under the site of the annular ligament. 
 
 This graphically represents what has been suggested 
 in the preceding pages, that extension to the forearm 
 may occur from middle palmar space infections, but 
 is not likely to from the thenar space. 
 
 This tendency for pus to extend along the vessels 
 and nerves helps to explain the frequency of trophic
 
 158 ANATOMY OF THE FOREARM 
 
 changes which so often occur as a sequence of infections 
 of the hand. 
 
 Experiment 49. Injection with great force through 
 synovial sheath of the ring finger, filling mid-palmar 
 space and extending under anterior annular ligament 
 into forearm. (See experimental injection drawing, 
 Fig. 61.) 
 
 FIG. 61 
 
 Schematic drawing made from a dissection of a hand in which the injec- 
 tion was made along the tendon sheath of the ring finger. The mass filled 
 the middle palmar space and extended along two of the lumbrical muscles 
 and under the annular ligament into the forearm. 
 
 The mass was injected with considerable force. The 
 middle palmar space as described was filled. Thenar 
 and hypothenar areas free, mass along little and ring 
 finger lumbricals for three-fourths inch, none along 
 other fingers, none through between bones to back, 
 mass extended under tendons strictly, up into forearm, 
 where a large mass was found lying under the deep 
 muscles upon the pronator quadratus and interosseous
 
 FINDINGS BY DISSECTION AND INJECTIONS 159 
 
 septum. It extended into the intermuscular fascial 
 spaces up to the pronator radii teres, it came to the 
 surface late upon the radial side at about two inches 
 above 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, so 
 that this upper mass was most easily reached by sepa- 
 rating the flexor carpi ulnaris along its volar edge 
 from the adjacent muscular body. This also exposed 
 the ulnar artery and nerve which were surrounded by 
 the mass. 
 
 This is further exemplified by an x-ray picture taken 
 of an arm injected as shown by the legend (Fig. 60), 
 the mass being impregnated with red lead. 
 
 RESUME OF FINDINGS BY DISSECTION AND EXPERIMENTAL 
 
 INJECTIONS. 
 
 By these experiments we have demonstrated that in 
 neglected cases, no matter whether the pus extends up 
 from the ulnar bursa, radial bursa, or the mid-palmar 
 space, the same area of the forearm is involved, thus 
 indicating the position pus would occupy in neglected 
 cases, or in those cases in which early rupture of the 
 synovial sheaths (ulnar and radial bursa) occurs. This 
 space lies under the flexor profundus digitorum ten- 
 dons and muscle (Fig. 62). 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 (Fig. 63). 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
 
 160 
 
 ANATOMY OF THE FOREARM 
 
 ulnaris, and appear subcutaneously about three inches 
 up on the ulnar side. It may extend downward along 
 
 FIG. 62 
 
 UA 
 
 Photograph of cross-section, 7 cm. above the radial styloid, showing area 
 
 filled with pus. 
 
 FIG. 63 
 
 Photograph of forearm just below the middle, showing position of pus in 
 its relation to the ulnar artery and nerve and the median nerve. 
 
 the radial artery, but this is certainly an uncommon 
 termination. The larger part of the space is about 
 two inches above the wrist. Its most superficial parts
 
 FINDINGS BY DISSECTION AND INJECTIONS 161 
 
 are on either side, just volar to the ulnar 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. 
 
 The only other distinctfy separated space is that 
 comprising the subcutaneous tissue. 
 
 (For the surgical application of these facts see 
 Chapters XXVI and XXVII.) 
 
 11
 
 SECTION II. 
 
 THE SURGICAL CONSIDERATION OF TENDON 
 
 SHEATH INFECTIONS AND FASCIAL- 
 
 SPACE ABSCESSES OF THE 
 
 HAND AND FOREARM. 
 
 CHAPTER XI. 
 
 PATHOGENESIS SOURCE OF INVOLVEMENT 
 OF THE TENDON SHEATHS AND 
 FASCIAL SPACES. 
 
 CONCERNING the surgical application of the anatomi- 
 cal and experimental data we have discussed in the 
 previous chapters, it should be borne in mind that our 
 remarks are strictly confined to a discussion of these 
 facts in relation to the subject of tendon sheath and 
 fascial abscesses in the hand. Lymphatic infection 
 will be considered only insofar as it has a distinct 
 bearing upon these conditions, a full discussion being 
 reserved for a subsequent chapter. 
 
 ETIOLOGY IN GENERAL. 
 
 In all of the cases coming under observation, the 
 accumulations of pus have been submitted to bacterio- 
 logical examination, and the results differed in nowise 
 from the findings elsewhere ; nearly all the slow-growing 
 abscesses showing the staphylococcus in pure culture, 
 while those originating in the tendon sheaths, if of a 
 fulminating nature, showed the streptococcus unless
 
 1 64 PA THOGENESIS 
 
 there was a secondary infection. The severity of the 
 course was often in inverse relation to the extent of 
 the primary wounds. Again, the general health and 
 resistance of the patient were often below normal. 
 The latter factor has been particularly conspicuous. 
 On the other hand, cases of localized infection (from 
 deep lacerated wounds) have followed in very robust 
 individuals, where doubtless the infection has been 
 carried directly to the space infected. Again, it has 
 been noted that local trauma, without apparent 
 abrasion of the skin, has acted by lessening the local 
 resistance, hence favoring infection. We soon learned 
 also that the older the patient the greater would be 
 the danger of a serious course and complications. The 
 gonococcus may be found in some cases, almost always 
 of hematogenous origin. 
 
 SOURCE OF INVOLVEMENT OF THE VARIOUS SHEATHS. 
 
 Attention has been drawn above to the theories 
 advanced by the earlier authors as to the source of 
 infection of the sheaths. It is probable that they may 
 be involved either by lymphatic extension or direct 
 continuity. The latter, of course, needs no discussion. 
 That wounds involving the sheath may be an atrium 
 and that abscesses lying in continuity may cause 
 necrosis and involvement will be admitted by all. 
 It is rather uncommon for a felon to give rise to 
 tenosynovitis. The same may be said of suppurative 
 arthritis of the distal interphalangeal joint, and the 
 metacarpophalangeal joint. This is explained by the 
 anatomical relations, which also probably explain 
 the frequent involvement from the proximal inter- 
 phalangeal joint (see pp. 103 and 104). I have seen 
 extension to a sheath from abscesses in a lumbrical 
 canal. Here, however, the involvement is likely to
 
 SOURCE OF INVOLVEMENT OF VARIOUS SHEATHS 165 
 
 be localized to the proximal end of the finger sheaths. 
 Indeed, this holds true for all of these cases which 
 develop as a result of abscesses in continuity. One 
 explanation of this can be found in the fact that the 
 contiguous inflammation has probably given rise to 
 plastic adhesions in the sheath before the actual 
 involvement has taken place, and, again, these local 
 accumulations have generally been produced by the 
 staphylococcus or some like germ of moderate viru- 
 lence. This is also true of involvement of the ulnar 
 or radial sheaths secondary to abscesses in the palm, 
 as was exemplified by the case of Henderson (see 
 Case XVI). 
 
 The question of lymphatic involvement is one that 
 is not so easily demonstrable, but any surgeon can 
 recall numerous histories of patients who developed an 
 infection of a sheath within twenty-four to thirty-six 
 hours after a simple needle prick of a finger upon the 
 volar surface. This is most commonly met with in 
 the distal or middle phalanx (see Case XI), and is 
 almost always strep tococcic in origin. Why it does 
 not occur in dorsal wounds is understood when we 
 remember that the course of the lymphatic vessels is 
 from the palmar to the dorsal surface. 1 It is this type 
 of infection which presages the most disastrous results, 
 since localization to any part of the sheath is un- 
 common, and unless early incision is instituted, necrosis 
 of the sheath takes place with serious local and con- 
 stitutional sequelae. The possibility of gonococcus 
 tenosynovitis of hematogenous origin must always be 
 borne in mind in cases with an obscure origin. Two 
 such cases have come under my observation. 
 
 1 Frequently we see cases of tenosynovitis in which the patient cannot give 
 any history of injury, the abrasion or injury having been so slight as to escape 
 notice.
 
 166 PATHOGEN ESI S 
 
 EXTENSION FROM ONE SHEATH TO ANOTHER. 
 
 The extension from one sheath to another follows 
 strictly on anatomical lines. Apparent exception to 
 this is found in simultaneous involvement of the thumb 
 and ulnar bursa without involvement of the radial 
 bursa, the thumb being primary, as was found in four 
 of Forssell '.s cases. He did not note any cases of little 
 finger infection and radial bursitis without associated 
 ulnar bursitis. Before this exception is admitted 
 further observations must be made. In two of my 
 cases I was led to the same conclusion on first open- 
 ing the sheath of the flexor longus pollicis, but further 
 search revealed pus at both ends of the sheath. 
 
 The anatomical relations of the finger sheaths of 
 the little finger and thumb to the ulnar and radial 
 bursae respectively, as well as the intercommunication 
 of these latter, have already been discussed (see pp. 
 1 06 and no). When we are dealing with an infection 
 of little virulence, such as one due to the staphylo- 
 coccus, we frequently find a plastic exudate or adhesions 
 closing the narrowed opening between these parts and 
 the infection located in any section; as, for instance, 
 the finger sheath, ulnar bursa, radial bursa, or the 
 intermediary sheaths at the wrist. Indeed, I have 
 at times seen an infection of an ulnar bursa limited to 
 that part of the sheath between the base of the finger 
 and the annular ligament, the part of the sheath in the 
 forearm being uninvolved, protected by adhesions at 
 the annular ligament. My experience here agrees with 
 the earlier observations of Schwartz and Gosselin, 
 and differs from that of Forssell, who says that "out 
 of 34 cases of ulnar bursitis, an extension of the infec- 
 tion to the tendon sheath of the litle finger was found 
 in 30 cases on their entrance into the hospital, and if 
 we assume with Poirier that the ulnar bursa is com-
 
 EXTENSION FROM ONE SHEATH TO ANOTHER 167 
 
 pletely separated in 33 per cent, of the cases, it is very 
 improbable that a secondary boundary should in a 
 single one of the aforementioned cases have developed 
 through an adhesive inflammation. ... I have 
 never, in operating upon a suppurative bursitis, found 
 within the bursa proper a fibrinous or plastic synovitis 
 in such a mass as to notably affect the operation." 
 
 In general, however, it may be said that in the 
 virulent types of infection beginning in the little 
 finger sheath, we will almost always have an involve- 
 ment of the ulnar bursa and in a majority of cases the 
 radial bursa and sheath of the flexor longus pollicis 
 will be involved from it (see p. no). The converse 
 is also true. 
 
 Besides spreading by direct continuity these infec- 
 tions may, of course, involve one or more sheaths 
 secondarily by a rupture from a previously infected 
 sheath. 
 
 I report the case of Mr. P., who had an infection of 
 the middle finger tendon sheath which extended by 
 way of the lumbrical canal over to the tendon sheath 
 of the ring finger, since it demonstrates the possibility 
 of such infection spreading to contiguous tendon 
 sheaths, a point that has not been brought out in 
 previous contributions. 
 
 CASE VII. Mr. P., referred by Dr. A. T. Horn. 
 
 History: Patient received slightly lacerated wound on 
 the flexor surface of the middle finger. Inside of two days 
 the finger was markedly swollen and tender, and when 
 seen in consultation on the third day tenderness was 
 marked throughout the course of the tendon sheath, the 
 finger was flexed and on extension presented the greatest 
 amount of pain at the proximal end of the sheath. 
 
 A diagnosis of tenosynovitis was made and the tendon 
 
 , incised throughout its length. The lumbrical spaces on 
 
 either side were involved and were drained. The infection 
 
 apparently subsided, but on the seventh day it was noted
 
 1 68 PA THOGENESIS 
 
 that the ring finger was markedly flexed, tender through- 
 out the course of the sheath, and that on extension pain 
 was present at its proximal end. The diagnosis of infec- 
 tion of this sheath due to contiguity of the lumbrical space 
 was made, and the tendon sheath was incised and drained 
 by an incision upon its flexor surface. From this time 
 on there was an uninterrupted recovery as to the infection, 
 but the ultimate result showed the patient with moderate 
 flexion of the ring finger at its proximal interphalangeal 
 joint, no motion at its distal joint, and complete motion 
 at the metacarpal phalangeal joint. The middle finger 
 was held semiflexed with complete flexion at the meta- 
 carpophalangeal joint; other joints of the finger could 
 not be moved. 
 
 The extension from the sheaths by rupture has been 
 discussed in the chapter on experimental injections 
 (Chapter IX), and will be considered in the subsequent 
 section upon the course of involvement of the fascial 
 spaces. 
 
 SOURCE OF INVOLVEMENT OF THE IMPORTANT FASCIAL 
 SPACES IN THE HAND. GENERAL DISCUSSION. 
 
 INVOLVEMENT FROM THE TENDON SHEATHS. This 
 source is certainly one of the most common, and the 
 experimental and anatomical discussions in Chapters 
 VII, VIII, and IX had for one of their purposes the 
 determination of these facts. Accepting the results 
 of these investigations as probabilities only, I have 
 been able to verify nearly every statement by clinical 
 observation. In the less virulent cases inflammatory 
 barriers may be thrown out that will close the normal 
 anatomical canals. If the process continues any time, 
 however, or the process is acute, the result follows 
 absolutely along anatomical lines. 
 
 The middle palmar space becomes involved second- 
 arily to a tendon-sheath infection of the middle, ring,
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 169 
 
 and little finger. At times the middle finger may rup- 
 ture into the lumbrical space between the index and 
 middle finger, and by secondary rupture may involve 
 the thenar spaces. But even in cases of such a lumbri- 
 cal rupture, it generally involves the middle palmar 
 space. 
 
 The thenar space is involved as a result of rupture 
 from the tendon sheath of the index finger and excep- 
 tionally from the middle finger. It also occurs at 
 times that a rupture of the flexor longus pollicis sheath 
 may involve this space, but here the pus is more 
 likely to come to the surface at the web. 
 
 The lumbrical spaces are most commonly the site 
 of the primary focus after rupture from the proximal 
 end of the various sheaths. The middle and ring 
 fingers may rupture on either or both sides. The index 
 finger most commonly ruptures to the ulnar side, but 
 may rupture upon the radial side, while the little 
 finger sheath ruptures only upon its radial side. 
 
 Infection of the dorsal tendon sheaths is so uncom- 
 mon that prognostic data here would not be of any 
 value. 
 
 DIRECT IMPLANTATION OF THE INFECTION IN THE 
 SPACES. The middle palmar space is more often in- 
 fected by implantation, both through direct puncture 
 and extensive crushing injuries and lacerated wounds. 
 
 CASE VIII. Crushing injury of hand; fracture of ring 
 finger metacarpal, with infection involving the middle 
 palmar space. 
 
 Mr. B. P., aged twenty-five years, Chicago Charity 
 Hospital. 
 
 Patient 's Statement : Patient states that he was thrown 
 in front of a moving car and the wheel ran on his hand, 
 but evidently did not cross it. Condition found upon 
 entrance to hospital on following day: Lacerated wounds 
 across dorsum of right hand, midway, two and one-half
 
 170 PATHOGENESIS 
 
 inches long, rather deep, into subcutaneous tissue; lacer- 
 ated wound of palmar surface two inches long and irreg- 
 ular, so that there was a flap raised up consisting of tissue 
 superficial to palmar aponeurosis; wounds infected; frac- 
 ture of metacarpal of middle finger; tendons intact; 
 fingers extended; not particularly tender to flexion and 
 extension, although thumb was more tender than others. 
 (This was later found to be due to a fracture of the proxi- 
 mal phalanx). Whole hand swollen, no particular areas. 
 Flaps opened to allow drainage. Hot boric dressingsapplied. 
 
 Patient's temperature and pulse demonstrated a con- 
 tinuation of the severe infection, and two weeks after 
 entrance, owing to the site of the injury and the greater 
 rigidity of the middle, ring, and little fingers, a diagnosis 
 of pus in the middle palmar space was made. Proximal 
 phalanx extended, two distal phalanges flexed 45 degrees 
 from the same line. Incision into middle palmar space 
 disclosed abscess there in communication with the frac- 
 tured metacarpal. Through-and- through drainage from 
 palm to dorsum instituted. Rapid fall of temperature and 
 pulse followed. Drainage was free. Edema and swelling 
 continued for some time, beginning to decrease, however, 
 at the end of the first week. 
 
 January 29 (second day). Temperature 101.5 to 
 102^; pulse, 70 to 104. 
 
 January 30. Temperature, 101 to 103.25; pulse, 80 
 to 108. 
 
 February I. Temperature, 101.5 to 101.25; pulse, 
 100 to 1 08. 
 
 February 3. Temperature, 99 to 99^; pulse, 92 to 
 104. 
 
 February 4. Temperature, 98^ to 99.5; pulse, 80 to 
 92. 
 
 February 6. Temperature, 99.5 to 102.5; pulse, 88 
 to 92. 
 
 Here the infection evidently extended. 
 
 February 9. Temperature, 100.5 to 101^; pulse, 84 
 to 90. 
 
 February n. Temperature, 99.25 to 104!; pulse, 84 
 to 92. 
 
 February 13. Temperature, 100 to 103.25; pulse, 96 
 to 124.
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 171 
 
 February 15. Temperature, 100.25 to ioi; pulse, 
 76 to 90. 
 
 Operation: Middle palmar space drained. 
 
 February 17. Temperature, 99.25 to 100.5; pulse, 
 96 to 100. 
 
 Temperature curve begins to fall and septic symptoms 
 decrease. Sleeps well and begins to eat. 
 
 February 19. Temperature, 99.5 to 101.25; pulse, 
 92 to 96. 
 
 February 22. Temperature, 99^ to 101; pulse, 94 
 to 96. 
 
 Drain removed. 
 
 Gradual fall until March 3, when the temperature fell 
 to normal and remained there. 
 
 March 20. Temperature and pulse normal; hand still 
 swollen and little movement in fingers; position of digits 
 same as upon extrance; can move all slightly without 
 pain, index most of all; thumb slightly tender to passive 
 movements (fractured). Other fingers: little pain pro- 
 duced by manipulation. 
 
 April 20. Hand improved much; much greater range 
 of movement of fingers; evident that nearly full functions 
 will be restored. 
 
 In deciding, however, whether or not the middle 
 palmar space has been invaded by injury, it is well to 
 bear in mind that the space lies dorsal to the tendons 
 and superficial vessels; hence these can be uncovered 
 by a lacerated wound, and the space not necessarily 
 become involved, although it is probably true that 
 unless scrupulous care be taken to give perfect drain- 
 age superficially, the space will later become involved, 
 since the fascial sheet separating the tendons from the 
 space is very thin, as has already been pointed out. 
 This same fact is to be remembered in case of a 
 punctured wound, since while the loose cellular tissue 
 surrounding the tendons, superficial vessels, and the 
 lumbrical muscles would harbor pus for a short time, 
 if properly drained it need not extend to the space.
 
 172 PATHOGEN ESI S 
 
 If intervention is withheld for any length of time it 
 must extend either down along the lumbrical muscles, 
 through the fibrous canal at the distal part of the palm 
 already noted, and thence into the cellular tissue dor- 
 sal to the web, or break into the palmar space, and in 
 nearly every case the latter result will be found to 
 have occurred long before the former. 
 
 Owing to the juxtaposition of the metacarpal bones, 
 particularly of the middle and ring fingers, any crush- 
 ing injury of the hand, with consequent compound 
 fracture of these bones, will frequently lead to infec- 
 tion through this dorsal wound, as I myself have seen 
 (Case VIII). The metacarpal bone of the little finger, 
 being somewhat distant from the space, is not so likely 
 to open the space, while the metacarpal bone of the 
 index finger (and in exceptional conditions the middle 
 finger) will open the thenar space. Compound frac- 
 ture of the thumb metacarpal would more likely lead 
 to dorsal subcutaneous accumulations of pus, or even 
 synovial infection of the sheath of the flexor longus 
 pollicis, than thenar-space infection. It is well to bear 
 these predisposing etiological factors in mind when we 
 come to discuss the diagnosis of the position of the 
 pus. 
 
 Since few lymphatics lead into the hypothenar space, 
 and it is isolated from adjacent areas by densely 
 circumscribed tissue, infection here is due most often 
 to direct implantation. For instance, a palmar in- 
 fection will rupture into the ulnar bursa or extend, 
 in preference, under the annular ligament, and then 
 rupture into the cellular spaces of the forearm, before 
 it will overcome the resistant tissue intervening be- 
 tween it and the hypothenar space (see cross-sections, 
 Figs. 24 and 25). The space can be infected, however, 
 from the dorsum, through a compound fracture of 
 the fifth metacarpal, but even there the pus would
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 173 
 
 be more likely to accumulate upon the dorsum, owing 
 to the intimate relation of the hypothenar muscles to 
 the bone, than in the space, unless the injury of the 
 muscles is extensive. 
 
 Direct infection of the subaponeurotic space can occur 
 by punctured or incised wounds, or by crushing in- 
 juries compounded particularly upon the dorsum. The 
 incised wounds, lying transverse to the tendons, would 
 be less likely to lead to subaponeurotic accumulations 
 of pus, owing to the retraction of the aponeurosis by 
 the extensor muscles, thus opening the gap widely 
 so that free drainage would ensue into the subcutaneous 
 tissue or externally. Longitudinal cuts, on the con- 
 trary, would tend to close, and thus prevent free 
 drainage. 
 
 The subcutaneous tissue is infected in the same man- 
 ner. It also can be invaded in the pileous infections 
 occurring upon the dorsum, which at times become 
 carbuncular in their nature, thus extending from the 
 skin proper into the subcutaneous tissue. 
 
 INVOLVEMENT BY LYMPHATIC EXTENSION. Besides 
 the direct infection of these spaces, they may become 
 involved by an extension from adjacent injuries, either 
 through the lymphatics, or by continuity of fascial 
 spaces. There is abundant clinical proof that infection 
 by the less virulent germs can spread by lymphatic 
 channels, and abscesses develop at distant spots. Upon 
 the other hand, it is often impossible to say whether 
 an extension has occurred by means of the lymphatic 
 vessels, or by means of the spaces, and fortunately in 
 these cases it is not necessary to decide the question, 
 since the two courses are generally side by side. Thus, 
 the deep lymphatics pass from the fingers along with 
 the vessels in the same space in which the lumbrical 
 muscle lies, and in a given case, for instance, an infec- 
 tion at the base of the ring finger which spreads into
 
 174 PATHOGEN ESIS 
 
 the middle palmar space, who can say whether it 
 extends by means of the lymph vessel or along the 
 lumbrical muscle, going to the radial side of that 
 finger? Moreover, we do not need to know. What is 
 of importance is to know where the pus lies after it 
 has extended, and certainly a study of the course of 
 the lymphatic channels is of importance in relation 
 to this. It is not our purpose to discuss the subject 
 of lymphatic infection as a whole, nor do more than 
 draw attention to the monumental work of Sappey, 
 Leaf, Malgaine, and others, by which we can, in some 
 measure, prognosticate the position of a metastatic 
 abscess when the point of primary infection is known. 
 The subject as a whole will be discussed in a subsequent 
 chapter. 
 
 The superficial lymphatics upon the palmar surface 
 pursue the shortest course to the dorsum. Thus, for 
 instance, an infection starting upon the distal part 
 of the palm would go between the web of the fingers 
 to the subcutaneous tissue of the dorsum. Hence, 
 should an abscess develop as a result of this, it would 
 be found in the dorsal subcutaneous area. Should a 
 lymphangitis be present, however, without localized 
 abscess formation, the swelling in this region would 
 be just as great, owing to the edema which develops 
 in the loose tissue found here. This will be brought 
 out later in discussing the diagnosis. Should the deep 
 lymphatics be involved, the infection will follow the 
 deeper vessels, hence passing into the palm. Theo- 
 retically speaking, then, an infection spreading from 
 the adjacent sides of the little and ring finger, and the 
 ring and middle fingers, would lead to an accumulation 
 of pus in the middle palmar space, while an infection 
 of the adjacent sides of the middle and index fingers 
 and index and thumb would infect the thenar space. 
 Other infections upon these fingers more dorsal would
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 175 
 
 follow the deep vessels under the aponeurosis upon the 
 back of the hand, thus producing a subaponeurotic 
 abscess. Unfortunately, sufficient clinical evidence 
 has not accumulated to prove these assumptions, 
 although some cases have been reported which tend 
 to support them. Chevalet and Dolbeau, particularly, 
 have presented cases showing this complication, espe- 
 cially those showing extension and development of 
 abscesses under the dorsal aponeurosis. The proof 
 of an extension to the palmar and thenar spaces is 
 much harder to demonstrate, for the reasons that 
 have already been pointed out. But with the accurate 
 outlines of the spaces that we have shown in mind, 
 it is to be hoped that the future will enable us to be 
 more definite upon this point. 
 
 Dolbeau has drawn attention to the frequency of 
 infection along the course of the radial in the forearm, 
 due to extension from the thenar region, by means of 
 the radial lymphatics. He also notes the presence of 
 abscesses along the ulnar artery and in the deep tissues 
 in the forearm, originating, he believes, by a lymphatic 
 extension along the anterior interosseous. That these 
 all occur is not only possible, but probable; but in this 
 connection the reader will remember the experimental 
 injections of the palmar space, and the ulnar and radial 
 bursae where the mass spread by continuity of tissue, 
 under the tendons into this middle foyer, and then 
 involved, secondarily, both the radial and ulnar areas 
 mentioned (Experiments 46 to 49), demonstrating that 
 the same clinical signs and pathological condition can 
 be produced by fascial space or synovial sheath exten- 
 sion as by the lymphatic course, except those cases in 
 which the radial and ulnar foyers are the primary 
 source, or are alone involved. 
 
 EXTENSION FROM ONE FASCIAL SPACE TO ANOTHER. 
 In the preceding section we have answered the ques-
 
 176 PATHOGEN ESIS 
 
 tion as to the source of involvement of the various 
 spaces. We now arrive at the next question which 
 confronts the surgeon. With a given space already 
 involved, to what other spaces could the infection ex- 
 tend, and by what course? The question now becomes 
 one more of pathology than anatomy, and while the 
 infection still retains its full relation to the anatomical 
 peculiarities of a part, yet the destruction of tissue 
 incident to long inflammation must be taken into 
 consideration. The longer one studies the question 
 the more prone he is to ask whether many of the com- 
 plicating extensions are not due either to inadequate 
 treatment, or an improper idea as to the position of 
 the pus, and consequently the institution of incisions 
 which tend to favor the extension of the infection as 
 much as to give proper drainage. 
 
 Let us take the palmar space. Here the question 
 of extension has been studied by injection. The pus 
 would have a natural tendency to spread in two ways: 
 First, along the lumbrical muscles of the little, ring, 
 and middle fingers, and thus point, in time, in the con- 
 nective tissue of the web upon the dorsum. This we 
 know has occurred in long-standing cases, in spite of 
 the pseudoclosure of the canal at the lower end and 
 its narrowness, which would thus favor closure by 
 inflammatory exudate (see x-ray plate, Fig. 41, and 
 schematic drawings, Figs. 39 and 45). Secondly, the 
 pus would tend to pass under the annular ligament 
 behind the tendons, immediately over the wrist-joint, 
 thence into the forearm, lying upon the radius, ulna, 
 interosseous membrane, and its attached muscles, and 
 the pronator quadratus, covered by the flexor pro- 
 fundus digitorum, thus filling the entire space from the 
 elbow to the wrist before it comes to the surface later- 
 ally two to three inches above the wrist-joint (Experi- 
 ment 49). This extension would take place in at least
 
 two-thirds of the injections of the palmar space if 
 force were used. But now enters the question of 
 destruction of tissue at the wrist-joint, swelling of the 
 tissues under the annular ligament, and the plastic 
 exudate, which would tend to close this natural exit. 
 That this occurs in a majority of the cases we have 
 abundant clinical evidence. I have not had a single 
 case in which pus extended from the middle palmar 
 space to the forearm, but in corroboration of the experi- 
 mental data we find the report of a postmortem done 
 by Professor Dolbeau, and reported by Chevalet in his 
 Paris thesis of 1875. The extension under the syno- 
 vial sheath, without invading it, and the involvement 
 of the forearm, with its diverticulum along the radial, 
 all make a picture the duplicate of Experiment 49. It 
 will be noted that the pus occupies the exact outlines 
 of the middle palmar space, bathes the free portions 
 of the tendons in juxtaposition to the palmar aponeu- 
 rosis, and yet it is specifically stated that the abscess 
 cavity lay dorsal to the tendons. 
 
 CASE IX. "At the hand the lesion is limited to the 
 middle palmar region; the two eminences, thenar and 
 hypothenar, are intact. In the middle palmar region the 
 aponeurosis is raised with some difficulty, the tissues, 
 infiltrated with plastic matter, form a thick layer as if 
 lardaceous, in the deep part of which are plunged the 
 superficial palmar arch and the terminal ramifications 
 of the median nerve. 
 
 "These organs being dissected and raised, one begins 
 to uncover the tendons in their palmar portion, and in 
 order to be able to examine them in their whole length, 
 the annular ligament of the carpus is incised. 
 
 "The sheath of the tendon of the long flexor of the 
 thumb is intact in all its length, at the thumb, at the 
 palm of the hand, under the annular ligament, and above 
 this ligament the cul-de-sac by which it terminates. Let 
 us recall that it is upon the thumb that the initial wound 
 
 12
 
 178 PATHOGEN ESIS 
 
 is found, the point of departure of all the trouble. But 
 the sheath of the flexor longus pollicis is absolutely intact. 
 
 "In examining the ulnar sheath one finds the follow- 
 ing: The portion of this sheath destined to cover the 
 tendons of the superficial flexor is little altered, and these 
 tendons, save that of the little finger, are relatively intact. 
 The portion of the sheath destined to the tendons of the 
 deep flexor is much more diseased, especially at the level of 
 the tendon of the little finger. In examining the sheath 
 of this tendon, one finds it intact in its digital portion. 
 The tendon presents there its mother-of-pearl appearance, 
 and is absolutely sound. But if one follows it to the palm 
 of the hand, one sees it penetrate into a purulent foyer, 
 which occupies the deep part of the hand. The tissue 
 about bathed in pus is diseased. Likewise the tendons 
 which it envelops for a stretch of about 4 cm. of the tendon 
 of the little finger, of 2.5 cm. to 3 cm. of the other tendons, 
 index, middle, and ring. Above this point the sheath and 
 the tendons take again their character of integrity and 
 keep it in the carpal canal, even to the terminal cul-de-sac 
 of the sheath. 
 
 "In raising the tendons of the deep flexor, one begins to 
 uncover a purulent foyer occupying the profound palmar 
 region, situated exactly upon a median line (par rapport) 
 in relation to the axis of the hand, and corresponding 
 exactly to the deep palmar arch that one sees placed 
 against its posterior wall. Its anterior wall is formed by 
 the sheath of the deep flexor tendons that it flooded over. 
 It is prolonged the length of the sheath of the tendon of 
 the little finger, had opened it and pus had penetrated 
 and traversed it in such a manner as to come to show itself 
 beneath the palmar aponeurosis; but a thing to notice, 
 it had not spread into this sheath, neither at the lower 
 part, toward the little finger, nor in the upper part in 
 the carpal canal. 
 
 "The radiocarpal articulation is filled with pus; its 
 cartilages are destroyed, the osseous surfaces which sup- 
 ported them are eroded. The triangular ligament partly 
 destroyed allows the radiocarpal articulation to com- 
 municate freely with the inferior radiocubital articulation. 
 
 "The articulation of the first row of the carpal with 
 the second is in the same condition; likewise the articu-
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 179 
 
 lation of the bones of each row between them, especially 
 of the first. What is the origin, what has been the mode 
 of production of this suppurative arthritis of the wrist? 
 It is a question not easy to decide, but that which can be 
 affirmed is that the lesion so limited by the sheath has 
 not been there for nothing, since this sheath is intact at 
 the level of the articulation. 
 
 "In dissecting the forearm, one is struck, first of all, 
 by the apparent integrity of its anterior region. The 
 lesions are, in fact, very deep. Alone, the sheath of the 
 radial vessels appears diseased from the first inspection. 
 It is, in the interior half of the forearm region, infiltrated 
 with a plastic matter which gives to it the appearance of 
 a whitened cord with granulated surface. The artery, 
 plunged in the middle of this plastic matter, is detached 
 from it only with difficulty, and by dissecting it with care. 
 The sheath of the ulnar is intact; the median nerve 
 presents nothing at all particular; the muscles are intact 
 also, at least those of the superficial layers, because in 
 dissecting the deep flexor one finds beneath it, or rather 
 in its thickness, in front of and inside of the ulnar bone, a 
 purulent foyer of about the volume of a small egg. This 
 foyer, situated at the middle part of the forearm, well 
 limited below, at least upon the anterior region of the 
 forearm, is without communication with the lesion of the 
 palm of the hand, and, with that which we shall see 
 presently, exists at the level of the pronator quadratus. 
 In seeking what has been its point of departure, one finds 
 it at the side of the ulnar bone. This latter has been the 
 seat, in its inferior half, of the suppurative periostitis, 
 and is almost totally denuded, even to the middle of its 
 length. The foyer that we have just indicated is a tributary 
 of the subperiosteal foyer, which bathes the bone from the 
 back and the inside. The origin of this periostitis appears 
 to have been the rupture of the articulation full of pus, 
 which was opened from the back. 
 
 "In raising, at the wrist, all the tendons, the flexors, 
 one begins to uncover a second foyer situated between 
 these tendons and the pronator quadratus. This muscle 
 altered but not destroyed, separates this foyer from the 
 ulnar bone, so that there exists no relation between it 
 and the osseous lesion. On the contrary, this foyer com-
 
 180 PATHOGEN ESI S 
 
 municates by the proper canal, behind the sheaths of the 
 tendon, with the palmar foyer." 
 
 We now ask ourselves, What are the probabilities 
 for extension when these normal exits are closed? In 
 what way will the inflammatory destruction of barriers 
 show itself? The pus cannot break through the firm 
 palmar aponeurosis. We first turn our attention to 
 the adjacent thenar space. We remember that the 
 lower, or distal portion of the intervening wall is very 
 firm, but that at the proximal end, the dividing tissue 
 is rather thin, and it is very easy to suppose that 
 the infection may destroy this and thus invade the 
 radial side. Experimentally, this can be seen to occur. 
 (See Experiment 20, Fig. 41.) This, however, would not 
 occur until late, since most of the pus is at the distal 
 part of the hand. But that it does occur frequently 
 in neglected cases I have abundant clinical evidence. 
 It is one of the most common of the extensions. 
 
 Again, the pus might extend along the lumbrical 
 muscle of the middle finger, and rupture from here 
 into the thenar area. 
 
 Upon the hypothenar side there is so much tissue 
 intervening between the middle palmar space and the 
 hypothenar that we would expect this to become 
 involved only in exceptional cases. 
 
 Text-books all tell us that the pus in these cases 
 finds exits between the metacarpal bones, and thus 
 escapes to the dorsum. When one studies the dense 
 layer of fascia spreading from bone to bone, upon both 
 the volar and dorsal surfaces, being really an anterior 
 and posterior interosseous membrane, with the inter- 
 osseous muscles between, and a division between them 
 being often difficult to find, we are led to wonder if 
 this complication really occurs as early in the course 
 of the disease as we are led to believe. Whether often
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 181 
 
 the edema upon the dorsum may not have been mis- 
 taken for pus, and the spurious corroboration obtained 
 by through-and- through drainage misinterpreted. By 
 no means can it be denied that at times, later in the 
 course, the pus does find this means of exit. When 
 it does, it first comes to lie in the subaponeurotic, 
 and then in the subcutaneous tissue. I personally 
 have never seen such a case unless there was an osteo- 
 myelitis of the metacarpals or carpal bones, and I 
 believe it to be uncommon. 
 
 Another cause of extension is sometimes seen in 
 which the ulnar bursal sheath is destroyed, and pus 
 thus enters the sac, spreads along the tendons, and 
 ruptures into the forearm in the same space we have 
 already described as lying under the flexor profundus. 
 
 Suppose our thenar space to be primarily involved; 
 the pus here does not so readily extend into the fore- 
 arm. (See experiments forcible, Nos. 29 to 33.) Here 
 probably the weakest place lies toward the dorsum, 
 either above or below the adductor transversus, thus 
 invading the tissue between the thumb and index 
 metacarpal, and between the adductor transversus and 
 first dorsal interosseous, where there is a large, cone- 
 shaped cavity. (See Experiments Nos. 29 to 32.) It 
 should be borne in mind, however, that this result is 
 not obtained easily, since the pus will often remain 
 for days confined to the thenar space (Case X). In 
 long-continued or anomalous cases it can spread up 
 along the lumbrical muscles of the index finger, infect 
 the loose connective tissue about the palmar tendons, 
 and thus infect the palmar space, or can rupture 
 through at the upper end. (See Experiments 29 to 35.) 
 This complication should be rare, however, in properly 
 treated cases. 
 
 In case the subaponeurotic space is infected by 
 extension from the palmar space or otherwise, there
 
 182 
 
 PATHOGEN ESI S 
 
 might be considerable variation in the course the pus 
 would pursue; if the sheet is dense, as it is in a majority 
 of cases, the suppurative process would tend to extend 
 under the aponeurosis and point laterally, upon either 
 side, at the thinner tissue there, thus becoming subcu- 
 taneous, or at the distal margin between the metacar- 
 
 FIG. 64 
 
 ^^^Ki^^MHi^^^^^^^^^^H^^^^B^M^H^B^H^^HK^BH^M^H^HBKH^H^^M^BH 
 
 Scars showing where subaponeurotic abscess has pointed. Note four 
 openings at the edge of the aponeurotic sheet. Note prominence of tendons, 
 i. e., suppuration beneath. 
 
 pophalangeal joints, as I myself have seen. However, 
 at times there are thin places between the tendons, 
 and then the purulent matter would become sub- 
 cutaneous through this small opening. In all prob- 
 ability, however, before any of these things happen, 
 operative interference will have opened the abscess 
 (Fig. 64).
 
 INVOLVEMENT OF FASCIAL SPACES IN HAND 183 
 
 
 
 RECAPITULATION AS TO SOURCE OF INVOLVEMENT 
 OF THE FASCIAL SPACES. Given a distinct space, from 
 what source, in a majority of cases, is it likely to become 
 involved, leaving out of consideration direct implanta- 
 tion of infection? 
 
 The middle palmar space would receive infection 
 from the middle finger, ring finger, and radial side of 
 the little finger, with their synovial sheaths and the 
 corresponding lumbrical muscle spaces. Osteomyelitis 
 of the middle or ring metacarpals would also extend 
 to this space. 
 
 The thenar space would become involved by infec- 
 tion from the index finger and the ulnar side of the 
 thumb and their synovial sheaths, especially that of 
 the index finger and the index lumbrical space. Osteo- 
 myelitis of the index and thumb metacarpals could also 
 involve this space, although it would be possible for 
 either of them to be the seat of disease and not involve 
 the space. 
 
 The hypothenar space would become involved in an 
 osteomyelitis of the fifth metacarpal. 
 
 The subaponeurotic space would become involved by 
 an osteomyelitis of the middle and ring finger meta- 
 carpals particularly, and at times from the little and 
 index metacarpals. Lymphatic abscesses along the 
 deep dorsal vessels would also lie under this sheet of 
 tissue. 
 
 The dorsal subcutaneous space communicates freely 
 with the fingers and the thumb. 
 
 The lumbrical spaces would be involved by extension 
 from a tendon sheath infection from either side and 
 from an infection at the web between the fingers or 
 a "collar-button" abscess.
 
 184 PATHOGEN ESI S 
 
 The tendon sheaths may be involved by direct injury 
 or by lymphatic extension from slight injuries upon the 
 volar surface of the fingers or thumb. 
 
 Extensions may occur from one sheath to another 
 by extension through a lumbrical space or other 
 fascial space abscess. 
 
 The extension from the little finger to the ulnar 
 bursa and then to the radial bursa, or the sheath of 
 the flexor longus pollicis, is well known and frequently 
 met with by the surgeon. 
 
 Extension from one fascial space to another may 
 be seen. Extension from the lumbrical spaces to the 
 middle palmar and vice versa occurs very easily, while 
 extension between the middle palmar and thenar 
 occurs only in neglected cases. Extension from the 
 lumbrical space to the loose tissue of the web on the 
 dorsum is also common, but extension from the palmar 
 spaces to the dorsum between the metacarpal bones is 
 very uncommon. Extension can occur from the middle 
 palmar space to the deep spaces of the forearm, but 
 this is also uncommon. This extension is nearly always 
 due to a rupture from an ulnar or radial bursitis.
 
 CHAPTER XII. 
 
 THE SPREAD OF INFECTION FROM ANY 
 GIVEN PRIMARY FOCUS. 
 
 THIS will be discussed under three heads the pos- 
 sible spread from primary foci on the fingers, from 
 foci on the palm, from foci on the dorsum. 
 
 THE PROBABLE EXTENSIONS FROM PRIMARY FOCI ON THE 
 
 FINGERS. 
 
 THE SPREAD OF INFECTION INVOLVING THE INDEX FINGER. 
 
 The index finger having received a severe injury, 
 causing a deep infection, we admit that the infection 
 can spread by three methods: (a) Lymphatic; (b) 
 fascial; (c) through the synovial sheath. The subject of 
 lymphatic extension is discussed in Chapter XXI. 
 
 FASCIAL SPACE EXTENSION. The extension by the 
 fascial spaces is easy to follow when we study the 
 series of cross-sections (Figs. 65 to 72). By studying 
 these we see there is loose connective tissue surround- 
 ing the phalanges in which it could spread with ease. 
 Upon the dorsum it might go up into the subcutaneous 
 tissue in the back of the hand, internally, it would 
 come to lie in the cellular spaces at the web between 
 the index and middle fingers, and could even spread 
 along the lumbrical muscle of the middle finger into 
 the palm, and thus invade the middle palmar space. 
 This latter extension, however, would be more likely 
 to occur in a deep inflammation involving the proximal 
 phalanx of the middle finger, if at all ; since, as a general 
 rule, the pus would come to the surface before extending 
 along the lumbrical canal.
 
 186 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 Upon the radial side of the index finger there would 
 be still less likelihood of the pus entering the lumbri- 
 
 FIG. 65 
 
 IDSA5 
 
 SCS 
 
 . 
 
 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; 55, synovial 
 sheath. The tendon sheaths are shown in red. 
 
 FIG. 66 
 
 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. 
 
 cal canal in preference to coming to the surface, since 
 this canal is not so well marked. Of course, it could
 
 INFECTION INVOLVING THE INDEX FINGER 187 
 
 not extend upon the volar side into the palm, because 
 there is no connecting space (see cross-sections 66 and 
 68). Again, we note that if the pus were under the 
 dorsal aponeurosis of the proximal phalanx, it would be 
 limited to this area, since it is a closed space and does 
 not communicate with the subaponeurotic foyer upon 
 the dorsum of the hand. Thus, we see that while it is 
 possible for the thenar space to become infected by 
 fascial-space extension from the index finger, it is not 
 probable. However, a metacarpophalangeal arthritis 
 
 FIG. 67 
 
 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, flexor tendon; IM, interossei muscles; LM, lumbrical 
 muscle; MB, metacarpal bone; SB, sesamoid bone; SS, synovial sheath. 
 Tendon sheaths are shown in red and the boundaries of the lumbrical spaces 
 in blue. 
 
 may develop with destruction of the bone and liga- 
 ments. This extension then becomes not only possible 
 but probable, since the metacarpal bone of the index 
 finger lies in juxtaposition to the thenar space, sep- 
 arated, however, in part, by the adductor transversus. 
 Pus would probably first enter the space between the
 
 188 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 adductor transversus and the first dorsal interosseous, 
 then pass into the thenar space. 
 
 The question now arises, however, should the pus 
 lie either primarily or secondarily in the subcutaneous 
 tissue upon the dorsum of the hand in the region of 
 the index metacarpal, could it spread around the radial 
 border of the index metacarpal into the thenar space? 
 
 FIG. 68 
 
 Cross-section No. IV. Two cm. proximal to joint. APT, abductor trans- 
 versus pollicis; DSAS, dorsal subaponeurotic space; DSCS, dorsal subcu- 
 taneous 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, thenar space. The tendon sheaths are shown 
 in red and the lumbrical spaces in blue. Note the beginning of the middle 
 palmar space. 
 
 Again, should it lie in the subcutaneous tissue between 
 the index and thumb metacarpals, could it pass under 
 the web into that space? The study of the cross- 
 sections (Figs. 69 and 70) as well as the experimental 
 injections (Nos. 39 and 40) seem to show that this 
 is not probable. Clinical evidence can be adduced 
 to corroborate this. The pus would rather come to
 
 INFECTION INVOLVING THE INDEX FINGER 189 
 
 the surface upon the dorsum. The subaponeurotic 
 accumulations, unless complicated by an osteomyelitis, 
 would also follow the same course. (See experiments. 
 Figs. 43 to 45.) 
 
 FIG. 69 
 
 D5C5 V IM 
 
 DIM M 
 
 D5A5 ECT 
 
 Cross-section No. V. 3^ cm. proximal to joint. A TP, adductor trans- 
 versus pollicis; BV, bloodvessels; DIM, dorsal interosseous membrane; 
 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; IM, interossei muscles; IS, space between adductor transversus 
 and first dorsal interosseous; IV, interosseous vessels and nerve; LM, 
 lumbrical muscle; M, metacarpal bone; MPS, middle palmar space; N, 
 nerves; PIM, palmar interosseous membrane; 55, synovial sheath; TS, 
 thenar space; UB, ulnar bursa; 77 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. 
 
 SYNOVIAL SHEATH EXTENSION. We now come to 
 the third method of extension by the index synovial 
 sheath. Let us suppose that the synovial sheath 
 has become filled with pus and an "extension taken
 
 190 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 place into the hand along this sheath. Here the 
 anatomical, experimental, and clinical evidence is 
 clear. (See cross-sections, Figs. 69 and 70; Experiments 
 8, 9, 27, and 35; Case X.) Having ruptured from the 
 proximal end of the sheath, where it is very thin 
 
 FIG. 70 
 
 Cross-section No. VI. Through distal part of thenar area. A TP, adductor 
 transversus pollicis; DIA, dorsalis indicis artery; DP A, deep palmar arch; 
 DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; 
 ECT, extensor flexor tendon; HM, hypothenar muscles with intermuscular 
 spaces; ITS, indefinite thenar spaces; IM, interossei muscles; LM, lum- 
 brical 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 
 the middle palmar and thenar spaces are shown in blue. 
 
 generally, the pus would lie in the loose connective 
 tissue which surrounds this tendon and the lumbrical 
 muscle. After a short time, as the infection persisted, 
 or the accumulation of pus grew, it would follow the 
 lines of least resistance, and run along the lumbrical 
 muscle toward . the radial side of the index finger 
 (Experiment 8, Fig. 73), and, being limited here,
 
 INFECTION INVOLVING THE INDEX FINGER 191 
 
 would then rupture through the thin sheet of fascia, 
 separating this tissue from the thenar space (cross- 
 
 FIG. 71 
 
 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; 75, 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 bursae and the intermediate 
 tendon sheaths are outlined in red and the middle palmar and thenar spaces 
 in blue. 
 
 sections, Figs. 69 and 70), and thus become a thenar 
 space infection. (For tendon sheath extensions see 
 also Chapters IX and XI.) 
 
 The following case corroborates these deductions: 
 
 CASE X. Seen in the service of Prof. F. A. Besley at 
 the Post-Graduate Hospital.
 
 192 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 Diagnosis: Infected wound of index finger, tenosyno- 
 vitis of index tendon, infection of thenar space, ultimate 
 amputation of finger. 
 
 FIG. 72 
 
 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; MN and V, median nerve and vessels; 
 PL, palmaris longus ; PMPS, prolongation of middle palmar space ; R V and 
 N, radial vessels and nerves; 55, 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. 
 
 September 2, 1904. T. W. Ten days before coming 
 to the hospital the patient cut his finger just above the 
 knuckle-joint on a tin can; wound slightly to radial side 
 of dorsum. This became infected, and the patient con- 
 sulted a physician, who opened the wound and passed a
 
 INFECTION INVOLVING THE INDEX FINGER 193 
 
 drainage tube through and across the dorsum, coming out 
 between the index and middle fingers. Upon examination 
 the finger was seen to be much swollen, as was the entire 
 hand, particularly the dorsum. Several openings appeared 
 about the proximal phalanx. A probe into one of these 
 found rough bone and easily entered the knuckle-joint. 
 The entire finger and hand were slightly tender, but 
 marked and conspicuous tenderness was elicited over the 
 
 FIG. 73 
 
 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 
 lumbrical muscle. 
 
 site of the tendon sheath, and sharply limited by it, being 
 most acute at the proximal end, over the metacarpophalan- 
 geal articulation. Flexion of finger did not increase pain; 
 extension of index finger caused marked pain through 
 finger, but most sharply noted by patient at proximal 
 end of sheath. Extension of other fingers caused little 
 increase of pain; no particular pain on dorsum of finger 
 where cuts were found. Temperature, 101; pulse, 92. 
 13
 
 194 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 Infection of foot present also, as well as small boil on 
 opposite shoulder. Epitrochlear and axillary glands 
 swollen out of proportion to those in left arm. (Patient's 
 resistance is evidently far below par). Systemic symptoms 
 marked. Neutrophilia, 94 per cent. 
 
 Clinical Diagnosis : Infected wound of hand ; probably 
 staphylococcus ; infected index tendon sheath ; extension to 
 glands of axilla and elbow and, in addition, infection of 
 skin on shoulder and in foot. Etiology of latter unknown 
 possibly pyemic from hand; infected knuckle-joint. 
 
 Prognosis: Will probably lose finger. 
 
 Operation: Tendon sheath opened from end to end. 
 Pus in moderate amount evacuated. Dorsal openings 
 previously present enlarged. Hot boric dressings. Foot 
 opened and drained. Temperature ran 99? to 101 every 
 day. 
 
 September 9. Finger shows fluctuation on dorsum of 
 hand just proximal to index finger and ulnarly. Incision 
 and drainage. Finger not so painful; flexion about same. 
 Not so tender; no special swelling in palm of hand. 
 
 September 12. Infection has extended to thenar emi- 
 nence ; tenderness localized to this area. Swelling marked ; 
 palm not involved. 
 
 Operation: Inserted forceps into cut on dorsum made 
 September 9; forceps fell into direct communication with 
 volar surface of thenar eminence; opened here; pushed 
 forceps then from volar surface through to dorsum be- 
 tween first and second metacarpals ; forceps passed through 
 dorsal skin with little or no resistance; drainage inserted. 
 
 September 15. Subcutaneous abscess has developed 
 in radial region of forearm above wrist and above elbow, 
 and over brachial vessels; incised and drained. White 
 blood cells, 18,000. 
 
 September 24. Temperature, 99 to 101. 
 
 October 14. Temperature has been running 99 to 
 1 00 for last two weeks; index finger swollen to four times 
 its normal size; blue, and evidently there is an osteo- 
 myelitis of the proximal phalanx, and a suppurative 
 arthritis of the metacarpophalangeal joint. 
 
 Operation: Index finger and head of metacarpal bone 
 amputated ; drainage. 
 
 October 20. Condition of hand much better.
 
 INFECTION INVOLVING THE THUMB 195 
 
 Following this the patient improved rapidly; dis- 
 charged. 
 
 November 3, 1904. Small area of granulation tissue 
 over amputated area; moves thumb and three fingers 
 three-fourths of normal; wrist-joint same; function of all 
 will ultimately be restored. 
 
 THE SPREAD OF INFECTION INVOLVING THE THUMB. 
 
 Infection of the thumb would at first glance seem to 
 offer the most favorable course for pus to extend into 
 the thenar space. But let us consider for a moment. 
 Lymphatic extension does offer some chance, if the 
 infection be deep and upon the ulnar side, as will be 
 pointed out (Chapter XX, and Fig. no). Upon the 
 other parts, however, the tendency would be for the 
 pus to be carried away from the space. 
 
 The synovial sheath of the flexor longus pollicis lies 
 some distance from the space, and hence pus would 
 tend to come to the surface if the sheath ruptured in 
 its course. It can be seen, however, that if the sheath 
 ruptured in its distal part, and the infection thus 
 became an infection of the connective-tissue spaces, 
 it could spread along the ulnar side of the thumb, and 
 by considerable destruction of connective tissue come 
 to lie upon the origin of the adductor transversus, 
 and thus invade the space. In the majority of cases, 
 however, the pus would rupture from the sheath into 
 the forearm. (For further discussion of tendon-sheath 
 extensions, see Chapters IX and XIV.) 
 
 Should the infection be upon the back of the thumb, 
 the pus would extend more easily into the dorsal sub- 
 cutaneous tissue of the thenar area, while, in all 
 probability, upon its radial side it would point upon 
 the surface.
 
 196 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 THE SPREAD OF INFECTION INVOLVING THE MIDDLE FINGER. 
 
 Here the finger, lying as it does in the dividing line 
 between the thenar and middle palmar spaces, becomes 
 an extremely interesting subject of study. The lym- 
 phatic extension has already been touched upon and 
 will be discussed further in Chapters XX to XXIV. 
 
 Extension from the synovial sheath at its proximal 
 end gives positive results experimentally (Experiments 
 
 FIG. 74 
 
 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. 
 
 I and 2), since in every case the mass extended into 
 the middle palmar space after rupturing through the 
 indefinite connective tissue, separating it from the 
 space, as already described under the index finger 
 discussion. It is to be borne in mind, however, that 
 the lumbrical muscle joining this tendon comes back 
 to pass under the transverse ligament, between the
 
 INFECTION INVOLVING THE RING FINGER 197 
 
 index and middle fingers, and that while the tissue 
 intervening between this muscle and the thenar space 
 is firm, and experimental injections have failed to 
 rupture through, yet, anatomically, it would seem 
 to be possible in some cases. Clinical evidence shows 
 that while it does occur this extension is rare. For a 
 complete discussion of the extensions from the tendon 
 sheaths, see Chapters IX and XIV. Should the in- 
 fection be a deep-seated accumulation of pus in the 
 cellular tissue upon the dorsum it could spread sub- 
 cutaneously upon the back of the hand ; upon the radial 
 side it would pass exceptionally along the lumbrical 
 muscle into the middle palmar space, with the pos- 
 sibility of invading the thenar space, as above noted; 
 upon the ulnar side, if it should spread along the 
 lumbrical muscle, it would go into the middle palmar 
 space (Experiments 26 A, and 26 B}. 
 
 Subaponeurotic infection would be limited to the 
 phalanx, while osteomyelitis, involving the metacarpal 
 bone, would tend to invade the middle palmar space 
 in front and the subaponeurotic on the back. 
 
 THE SPREAD OF INFECTION INVOLVING THE RING FINGER. 
 
 Here there is little doubt about the relatioa between 
 this finger and the middle palmar space. The exten- 
 sion by the dorsal subcutaneous tissue may be in any 
 direction. The connective-tissue spaces at either 
 side of the finger and in the web of the infected hand 
 allow the pus to spread through the fibrous canal sur- 
 rounding the lumbrical muscles and lead into the 
 palmar space. (See Experiments 26 A and 26 B, and Fig. 
 21.) In making this deduction it should be emphasized 
 again that in a majority of cases pus would be evacu- 
 ated on the surface before it would burrow through 
 this canal. Hence it is only in neglected cases that
 
 198 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 this complication would ensue, unless extension had 
 taken place by the lymphatic channels which pass 
 through these same canals. 
 
 Suppuration extending from the synovial sheath 
 would enter the middle palmar space. (See Experiments 
 3, 4, 1 8, 19, and 20; cross-sections, Figs. 69 and 70.) 
 Primarily, of course, it would lie in the loose connective- 
 tissue superficial to the space, spread down along the 
 
 FIG. 75 
 
 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. 
 
 lumbrical muscles (Fig. 36), especially of the little, 
 ring, and middle fingers, and then, destroying the thin 
 roof of the space, would involve the entire middle 
 palmar space (Fig. 75). (For a complete discussion of 
 tendon-sheath extensions, see Chapters IX and XIV.) 
 Arthritis of the metacarpophalangeal joint, with 
 osteomyelitis of the diaphysis of the metacarpal,
 
 INFECTION SPREADING FROM LITTLE FINGER 199 
 
 could also infect this space as well as the subaponeu- 
 rotic on the dorsum (Case VIII). 
 
 (The lymphatic extension will be discussed in 
 Chapters XX and XXI.) 
 
 FIG. 76 
 
 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. 
 
 INFECTION SPREADING FROM THE LITTLE FINGER. 
 
 Here the lymphatic channels and connective-tissue 
 spaces upon the inner side of the finger could lead into 
 the middle palmar space, although such extension is 
 uncommon. On the outer and dorsal side they would 
 tend to lead into the subcutaneous tissue externally. 
 
 The synovial sheath, if continuous with the ulnar 
 bursa, would probably rupture earliest in the forearm. 
 (See x-ray plate, Fig. 39.) (For a discussion of this, see 
 Chapters IX and XIV.) If it did rupture in the hand,
 
 200 INFECTION FROM ANY GIVEN PRIMARY FOCUS 
 
 or if the synovial sheath of the finger were shut off 
 from the ulnar bursa, and the finger sheath ruptured, 
 it would tend to involve the middle palmar space 
 (See Experiments 5 and 6, Fig. 76.) It might be men- 
 tioned here that Chevalet and Dolbeau maintain that 
 a rupture of the sheath is not necessary to extension 
 but that this can take place from the sheath by lym- 
 phatic extension, and they adduce a postmortem 
 examination in support of their contention. This, 
 however, is an academic question, since the same space 
 would be involved by the extension, and the clinical 
 findings would be identical. (For a complete discus- 
 sion of the tendon-sheath extensions, see Chapters 
 IX and XIV.) 
 
 If an osteomyelitis of the fifth metacarpal be present, 
 the hypothenar space would be involved upon the 
 volar surface and the subcutaneous tissue dorsally. 
 (See cross-sections, Figs. 69 and 70.) 
 
 INFECTIONS BEGINNING IN THE PALM AND DORSUM. 
 
 When a primary focus appears upon the palm, if it 
 is a punctured wound, the abscess may develop in any 
 of the pockets I have described, if implanted there 
 under the palmar fascia. If in the superficial thenar 
 or hypothenar area, they may develop local abscesses 
 without entering the palmar or thenar spaces. If the 
 infection develops at the distal part of the palm in the 
 subcutaneous tissue or in the lumbrical space, i. e., 
 a "frog felon," "collar-button" abscess (see Chapter 
 IV), and if extension occurs it will generally be to the 
 dorsum between the bases of the fingers, although 
 occasionally proximally along the lumbrical canals into 
 the middle palmar space, if between the little and 
 ring fingers or into the thenar space if between the 
 middle and index fingers. In the central part of the
 
 L 
 
 palm it is not possible for large abscesses to develop 
 between the skin and the palmar fascia, owing to 
 their intimate association. 
 
 Lymphatic infections in the central part of the 
 palm may involve the deeper part of the hand (Fig. 
 i \2). At the sides the infection pursues the shortest 
 course to the back of the hand, where abscesses may 
 develop subcutaneously. At the proximal end of the 
 palm secondary lymphatic abscesses may develop 
 subcutaneously above the anterior annular ligament. 
 (See Chapter XIV.) 
 
 Middle palmar and thenar-space abscesses are 
 generally secondary and are discussed elsewhere in 
 detail. 
 
 When the primary focus develops upon the dorsum, 
 if it be a localized abscess it will be either in the sub- 
 cutaneous or subaponeurotic spaces. If extension takes 
 place by contiguity or lymphatic channels, the second- 
 ary abscesses lie upon the dorsum of the forearm or the 
 glandular areas at the elbow and axilla. 
 
 Infection may spread in one of three ways; by 
 a lymphatic canal, by a fascial space, or through a 
 synovial sheath. 
 
 If the infection in the index finger spreads by the 
 fascial spaces, the pus will lie in the connective tissue 
 at the web of the index and middle finger, whence it 
 may spread along the lumbrical muscle into the palm. 
 
 In any other part, the pus will lie underneath the 
 skin and will soon come to the surface. 
 
 The proximal interphalangeal joint will be involved 
 more often than the metacarpophalangeal joint. 
 
 When the pus extends by way of the synovial sheath 
 it may spread to the thenar space; either by direct
 
 202 INFECTION FROM KflFF GIVEN PRIMARY FOCUS 
 
 -iT/^lOr; I cVJ T^ 
 
 ^upture into the space or 'by an intermediate involve- 
 ment that embraces the space on either side; less often 
 it will involve the proximal interphalangeal joint or 
 come to the surface. 
 
 Infection involving the thumb, if it spreads by the 
 fascial space, will readily come to the surface. If by 
 the synovial sheath, it will rupture into the forearm 
 or possibly into the thenar space. 
 
 If the middle finger be involved and the pus spreads 
 by the fascial space, it will come to the surface or lie 
 in the connective-tissue space at the web, whence it may 
 involve the middle palmar or thenar space by way of 
 the lumbrical canal. It will not generally come to the 
 surface, however. If it spreads by way of the tendon 
 sheath, it will ordinarily involve the middle palmar 
 space but may involve the thenar space. In the 
 latter instance, the course is by the intermediate 
 channels along the lumbrical space between the index 
 and middle fingers. In the former case it is by way 
 of the lumbrical canal between the middle and ring 
 finger. The proximal interphalangeal joint will at 
 times become involved. 
 
 If the pus spreads along the ring finger by way of 
 the fascial space, it will be liable to come to the surface 
 or involve the connective-tissue space on either side of 
 the web, where it will ordinarily rupture externally but 
 may pass along either lumbrical canal into the middle 
 palmar space. 
 
 If the tendon sheath be involved, pus will invade 
 the middle palmar space either directly or by rupture 
 and extension along the lumbrical canal on either side. 
 It may involve the interphalangeal joint or come to 
 the surface. 
 
 If infection spreads along the little finger by way of 
 the fascial space, the pus will either come to the sur- 
 face or lie in the connective- tissue space of the web
 
 RESUME 203 
 
 between the ring and little finger, from whence it will 
 probably come to the surface but may spread along 
 the lumbrical canal into the middle palmar space. 
 
 If the pus spreads by the tendon sheath it will 
 ordinarily extend into the ulnar bursa and from thence 
 may involve the tissue in the forearm underneath the 
 flexor profundus or rupture into the middle palmar 
 space. It generally involves the radial bursa after a 
 day or two. It may be confined in the tendon sheath 
 of the little finger and rupture into the lumbrical 
 space between the little finger and ring finger and 
 thence involve the middle palmar space. 
 
 If pus spreads from the palm and is superficial to 
 the palmar fascia, it will develop small abscesses which 
 will rupture quickly. If in the distal part of the palm 
 in the connective tissue at the web or in the lumbrical 
 space, it will either come to the surface at the web or 
 enter the lumbrical canal and pass into either the 
 middle palmar or thenar space varying with the area 
 involved. 
 
 If in the middle palmar space, the pus will extend 
 into the lumbrical canal to the web and possibly rupture 
 through the intervening tissue into the thenar space. 
 
 Thenar space abscesses will ordinarily come to the 
 surface on the dorsum, between the thumb and index 
 finger, or may rupture into the middle palmar space. 
 
 If in the hypothenar space, the pus will ordinarily 
 come to the surface upon the dorsum. If under- 
 neath the skin of the dorsum it will readily rupture 
 externally, and if in the subaponeurotic space, it will 
 point laterally or distally at the edge of the fascial 
 sheath.
 
 CHAPTER XIII. 
 
 PATHOLOGY OF TENDON SHEATH AND 
 FASCIAL-SPACE ABSCESSES. 
 
 THE discussion is here limited to changes in the 
 tendons, tendon sheaths, and fascial spaces. The 
 pathology of bone changes, arthritis, and secondary 
 sequelae in the hand and forearm will be taken up 
 later. 
 
 A classification of the changes incident to teno- 
 synovitis may be made as follows: 
 
 Primary: A. Changes while the infection is limited 
 to the sac: (i) Contents of sac, serum, tendon. (2) 
 Wall of sac. (3) Circulation, lymphatics with edema. 
 
 B. When rupture of the sac occurs: (i) Involve- 
 ment of the fascial spaces, (a) hand, (b) forearm. (2) 
 Involvement of the nerves. (3) Involvement of joints. 
 (4) Involvement of bones. 
 
 Secondary: (i) Tendon adhesions. (2) Ankylosis of 
 joints. (3) Persistent edema and hyperplasia of cellular 
 tissue; scar contraction with subsequent atrophy. (4) 
 Chronic osteomyelitis. 
 
 The changes occurring in the section under "primary 
 B" will be discussed under fascial-space abscesses 
 following, and the "secondary" changes will be dis- 
 cussed in detail in later chapters, dealing with the 
 complications and sequelae of infections (see Chapter 
 XXVIII). 
 
 THE TENDON SHEATH PROPER. 
 
 Anyone who has had occasion to open the acutely 
 inflamed tendon sheath has been surprised at the rapid
 
 THE TENDON SHEATH PROPER 205 
 
 change which has taken place. The changes are com- 
 parable to a pressure necrosis, but whether due to the 
 great toxicity of the streptococcus infection or the 
 great edema about and the effusion into the sheath, 
 shutting off the blood supply, may be a question. 
 
 The serum in the sac in the more acute cases is nor- 
 mally scanty in amount and only slightly tinted. The 
 consistency varies from a slightly slimy fluid to a thick 
 pus. While in the more acute varieties the amount may 
 at times be very great, it soon ruptures, and on oper- 
 ation we may find little or much in the sac ; in the more 
 chronic type we frequently find a large amount of 
 thick, creamy pus, even though rupture has ensued. 
 
 The wall of the sac is congested and edematous with 
 the exception of the part under the anterior annular 
 ligament where the pressure is great. Here necrosis, 
 not alone of the sheath, but also of the tendons, is 
 prone to occur. While we may find the synovial wall 
 clear and unchanged, we generally find it cloudy with 
 whitish-yellow spots of beginning necrosis, or we may 
 find even early the entire wall seminecrotic. Even in 
 these cases we are often surprised at the reparative 
 possibilities after drainage is instituted. 
 
 The tendons themselves are swollen, but retain their 
 glistening synovial covering for some time. At the 
 wrist, however, the tendons show the result of com- 
 pression by the non-distensible anterior annular liga- 
 ment being pale and compressed; this is accentuated 
 by the swelling which has occurred both above and 
 below the ligament. If the case has been left un- 
 treated for too long a time, the tendons lose their 
 glossy covering and, becoming necrotic, are extruded, 
 looking like grayish strings of connective tissue. 
 
 While the entire hand partakes of the edema, it is 
 in the finger involved that the most extensive and 
 persistent changes occur. Especially in the neglected
 
 206 TENDON SHEA TH A ND FA SCI A L-SPA CE A BSC ESSES 
 
 cases do we see a most extensive exudation of inflam- 
 matory elements which persist for weeks after the 
 acute process has subsided; this is followed by an 
 atrophy of the entire finger, ankylosis of joints and 
 impaired nerve function, which aids materially in pre- 
 venting a proper use of the finger even if the tendon 
 is not destroyed. The adhesions between the sheath 
 and the tendon combined with these serious sequelae 
 make an almost hopeless prognosis as to function in 
 the neglected cases. 
 
 If the ulnar bursa has been involved, the ultimate 
 result is the characteristic claw-hand. 
 
 THE FASCIAL-SPACE ABSCESSES. 
 
 In discussing the essential pathology it should be 
 remembered that we are restricting ourselves strictly 
 to that phase of the subject having a relation to the 
 anatomical and experimental studies preceding. The 
 pathology of acute abscess formation in connective 
 tissue is too well known to merit discussion here. 
 Moreover, to do more than mention the arthritis in 
 the wrist, the osteomyelitis of the metacarpals, and the 
 destruction of tissue and fistulous sequelae would be 
 out of place, since these will be discussed in the chap- 
 ters dealing especially with these subjects. We should, 
 however, draw attention to certain consequences of 
 suppuration in the individual spaces. 
 
 Let us ask ourselves what would be the after-results 
 of infection of the middle palmar space alone, the 
 tendon sheath not being opened. We shall divide 
 them into primary and secondary; and under the 
 caption of primary, attention should be drawn to the 
 fact that the scar tissue following such a process would 
 involve particularly the tendons of the middle and ring 
 fingers, with the lumbrical muscles of the middle, ring, 
 and little fingers. Consequently, it is in these fingers
 
 THE F ASCI AL-SP ACE ABSCESSES 207 
 
 that we would expect to find the most persistent 
 adhesions and contraction; and it is in consequence 
 of the disturbed circulation in the bloodvessels going 
 to these fingers that long persisting edema and nutri- 
 tional changes occur, augmented somewhat, probably, 
 by impaired nerve supply. 
 
 Secondary sequelae are noted in the associated 
 edema and changes in the index finger and the thumb, 
 and while these are severe, they are not of such high 
 grade as in others. These changes are most marked 
 in the index finger, and are due to the juxtaposition 
 of the tendons and the intimate relation of the circu- 
 lation. Moreover, the ulnar bursa, with its contained 
 tendons, is adjacent to the area of infection; conse- 
 quently, there is the probability of a low grade of 
 inflammation within. Again, the correlation of move- 
 ment between the tendons determines approximately 
 the same position for the index finger as the others. 
 This constant position, associated with an effusion 
 into the joints, leads to adhesions of the articular 
 surfaces in all the fingers, the thumb least of all, since 
 the tendon of the thumb is well separated from the 
 site of infection. Should the process extend to the 
 thenar area, the index finger would then be in the same 
 condition as the other fingers. On the other hand, if 
 the infection were primary in the thenar space, the 
 most disastrous changes would ensue in that finger, 
 while the other three fingers would suffer only the 
 secondary changes, but fortunately not so severe 
 as the secondary changes were in the thenar space 
 when associated with palmar infection. This is owing 
 not alone to the comparative size and complexity of 
 the areas, but also to the fact that thenar abscesses 
 are sooner recognized and drained more perfectly; 
 consequently the process is not so disastrous. 
 
 Should the subaponeurotic space be involved
 
 208 TENDON SHEA TH A ND FA SCI A L-SPA CE A BSC ESSES 
 
 primarily, or by an extension from the palmar space, 
 secondary adhesions take place, and the whole sheet 
 becomes more or less immobile as a consequence of 
 the involvement of all the extensor communis tendons. 
 Should proper treatment be resorted to even after a 
 number of days, all of these changes will disappear 
 and a perfectly functionating hand be assured.
 
 CHAPTER XIV. 
 
 THE SYMPTOMS, SIGNS, AND DIAGNOSIS 
 
 OF TENOSYNOVITIS AND FASCIAL- 
 
 SPACE ABSCESSES. 
 
 THE SYMPTOMS, SIGNS, AND DIAGNOSIS OF ACUTE 
 TENOSYNOVITIS. 
 
 To diagnosticate the onset of involvement of the 
 tendon sheaths is one of the most difficult problems 
 in surgery; and yet withal one of the most important. 
 I know of no place where calm judgment is more re- 
 quired, since the symptoms and signs are all of degree. 
 It must be said, however, that more extensive expe- 
 rience has taught me that it is generally better to 
 err by making an unnecessary incision than by failing 
 to operate where it is needed. 
 
 The three cardinal symptoms and signs are: 
 
 1. Excessive tenderness over the course of the sheath, 
 limited to the sheath. This symptom is by all odds the 
 most important. 
 
 2. Flexion of the finger. 
 
 3. Excruciating 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 sought for in an intelligent manner there is 
 not much difficulty in differentiating the conditions. 
 
 A patient applies to the physician with what is 
 
 evidently a serious infection. If there has been a 
 
 crushing injury, the probability of an infected tendon 
 
 sheath is great; on the other hand, it frequently arises 
 
 14
 
 210 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 from simple cuts, as, for instance, a slight laceration 
 from a tin can or from the prick of a needle, or there 
 may be no history of injury. The pain has increased 
 in severity after a day or two. The systemic symptoms 
 of infection may be present. The finger and the cor- 
 responding side of the hand at least are edematous. 
 In addition to the tumefaction in the infected finger 
 the adjacent digits are swollen. The back of the hand 
 particularly is edematous. The whole hand is slightly 
 tender to superficial palpation. The fingers are all 
 slightly flexed. Now, how shall the differential diag- 
 nosis be made? Press deeply and firmly in all parts 
 of the hand and fingers; the patient will volunteer the 
 information that all points hurt; but if the tendon 
 sheath is involved, pressure upon it throughout its 
 course causes an immediate and involuntary expression 
 of pain, and while before the patient has allowed his 
 hand to remain passive in yours, he will now attempt 
 to withdraw it voluntarily, and there is no doubt in 
 your mind of the exquisite tenderness over this area. 
 If this tenderness is outlined by the extent of the sheath, 
 your diagnosis is nearly made. As a matter of fact, the 
 greatest tenderness is generally complained of on 
 deep pressure at the proximal end of the finger sheaths 
 in the palm of the hand, just over the metacarpo- 
 phalangeal articulation. I have seen a lacerated wound 
 on the back of the finger, which was inflamed and 
 naturally tender, show much less sensitiveness than 
 the infected sheath on the opposite side- of the finger 
 where there was no injury. Now make passive ex- 
 tension of the finger, and the patient immediately 
 complains of severe pain along the tendon sheath, 
 very often again most marked at the site of the meta- 
 carpophalangeal articulation. This is a valuable 
 symptom. The flexion of the fingers is of less impor- 
 tance and is probably due to several factors the
 
 ACUTE TENOSYNOVITIS 211 
 
 arthritis in the finger-joints, possibly irritation of the 
 adjacent filaments of the median or ulnar nerve, and 
 again, possibly because it lessens the tension upon the 
 tendon. The finger is generally held rigid in that 
 position and a difference is readily seen between the 
 simple flexion occurring in the adjacent swollen 
 fingers and the rigid flexion of the infected finger. So 
 marked is this that often one is able to diagnosticate 
 an extension into the palmar sheath, for instance, 
 from the little finger sheath, since the character of the 
 flexion changes in that case at once in the fingers 
 supplied by these tendons which pass through this 
 common sheath. Mauclaire has described a claw-hand 
 position, but I have not found it to be characteristic of 
 acute inflammation, but to be rather the evidence of an 
 old chronic untreated tenosynovitis. 
 
 There are two clinical types to be differentiated: 
 First, that variety in which the infection is a local one, 
 generally of staphylococcic origin, commonly following 
 lacerated wounds. Here we have a local infection 
 beginning slowly; plastic adhesions may be present, 
 limiting the infection to a particular part. There is a 
 little general reaction, but the local evidences of inflam- 
 mation are marked. A second type is that in which 
 the injury is generally a slight one, a pin prick or an 
 insignificant cut. It is generally of streptococcic origin. 
 The infection is carried to the sheath by lymphatics. 
 The pain is severe, and within a few hours the finger 
 is greatly swollen, red, and exquisitely tender. The 
 evidences of toxemia are present early, but the red 
 lines running up the arm, indicative of a lymphangitis, 
 are absent, although they may have been present early. 
 (See Case XVIII.) This type, not having a tendency 
 to plastic adhesions, spreads rapidly throughout the 
 entire communicating system of sheaths. This is dis- 
 tended with a fluid, at first only cloudy, but rapidly
 
 212 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 becoming purulent, and on examination we find thick 
 pus with fragmented nuclei, due probably to the 
 virulent toxins, and here and there streptococci. This 
 type is prone to produce early rupture and extension 
 into the connective-tissue spaces. 
 
 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 ex- 
 presses 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. 
 
 SYMPTOMS, SIGNS, AND DIAGNOSIS OF EXTENSIONS FROM INFECTIONS 
 BEGINNING IN THE LITTLE FINGER. 
 
 An infection of the sheath of the tendon in the little 
 finger may be localized to the finger. Extensions to 
 other areas are probable, however (Fig. 77). The fol- 
 lowing 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. In the fulmina- 
 ting type, where the opening between the ulnar bursa 
 and the sheath in the little finger is present, the infec- 
 tion extends rapidly throughout the hand. It should 
 be noted here that the frequency of extension from the 
 one to the other is greater than the anatomical opening 
 would explain ; we are therefore led to conclude that the 
 opening is present much more frequently than is stated, 
 or there is some other method of extension, possibly 
 by the lymphatics.
 
 INFECTIONS BEGINNING IN THE LITTLE FINGER 213 
 
 This extension 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 
 
 FIG. 77 
 
 To epiphyseal line and joint. 
 
 To connective-tissue space in web 
 and around lumbrical muscle. 
 
 To surface through palmar fascia. 
 To middle palmar space. 
 
 Exceptionally to wrist joint. 
 
 Under flexor profundus. 
 
 Schematic drawing showing the various probable extensions from an infection 
 of the tendon sheath of the little finger. 
 
 palm is found, but the palmar concavity is still present. 
 On the flexor surface the greatest swelling is just 
 proximal to the annular ligament. This is not neces- 
 sarily due to the rupture of the sheath here, but to the
 
 214 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 looseness of the tissues which permits of distention. 
 This swelling is accentuated by contrast with the non- 
 distensible annular ligament distal to it. The swelling 
 in the palm occurs at the same time, but is not so con- 
 spicuous, 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. In relation to 
 this Forssell states: 
 
 "One very seldom finds in acute infections of the 
 bursae so great a collection of pus within the latter 
 as to cause a purely mechancial swelling of such extent 
 that one can easily see it from the outside. The wall 
 of the bursa, before an extensive formation of exudate, 
 is necrotic and has usually permitted the accumulation 
 to escape into the surrounding connective-tissue 
 spaces." 
 
 As to fluctuation, Mauclaire says: "Fluctuation is 
 almost the rule. One can easily notice it by placing 
 the fingers above and below the annular ligament." 
 While I agree that a sense of fluctuation can be noted 
 by this maneuver, yet the edema and swelling are of 
 such a character that I cannot attach the significance 
 to it that is given by Mauclaire. One should never 
 wait for this symptom before operating. In chronic 
 tenosynovitis, such as tuberculous infection, the symp- 
 tom is of undoubted value. 
 
 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 
 movement is the sensitiveness noted. It is seen readily 
 of how much importance this latter symptom is in 
 diagnosticating an extension to the ulnar bursa from the 
 little finger. We note that while at first the symptoms
 
 INFECTIONS BEGINNING IN THE LITTLE FINGER 215 
 
 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 of con- 
 tracture and tenderness, while the index and middle 
 fingers remain unchanged except for the increase of 
 pain on passive extension explained above. This sen- 
 sitiveness of the thumb may be due to either 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 diagnostic importance. Ordinarily, 
 after the infection has lasted a few days and the 
 walling-off process has begun, the temperature is 
 that of the local accumulation of pus and varies 
 with the freedom of drainage. In the first few days, 
 however, the systemic absorption bears no relation 
 to the abscess formation and cannot be relied upon 
 for diagnostic purposes. 
 
 EXTENSION TO THE RADIAL BURSA. This is diag- 
 nosticated as following an ulnar bursitis by the in- 
 creased swelling and tenderness in the thenar eminence 
 and along the sheath with the associated symptoms 
 described above. The tumefaction of the thenar area 
 is not that of abscess in the thenar space. Forssell 
 states that this extension occurred in 6 out of 29 cases 
 coming under his observation average age, fifty to 
 fifty-eight years; 23 cases remained confined to the 
 ulnar bursa average age, thirty-six to thirty-nine 
 years. In my own experience the percentage of ex- 
 tension is greater. 
 
 EXTENSION TO THE FOREARM. By this we mean a 
 rupture from the proximal end of the sheath and an
 
 216 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 extension along the connective-tissue spaces, or rather 
 the intermuscular spaces. As I have already pointed 
 out, the pus 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 to 
 the ulnar side along the ulnar artery and nerve. I 
 have had opportunity to verify this area of extension 
 many times in cases I have operated upon, and have 
 also seen it in one fatal case I had an opportunity to 
 dissect (Case XXII). 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. 
 This extension is marked also by the loss of the rela- 
 tive 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 (see Chapter XXVI). 
 
 At this time some pus may accumulate subcu- 
 taneously above the wrist, due to lymphangitis, and 
 lead to the supposition that there is no pus under the 
 tendons, so that valuable time is lost. 
 
 EXTENSION TO THE LUMBRICAL AND PALMAR SPACES. 
 One of the commonest sites of extension is into the 
 lumbrical and palmar spaces. The involvement of 
 the adjacent lumbrical space occurs so frequently as 
 to keep one continually on his guard, since from this 
 involvement of the tendon of the adjacent finger or 
 palm occurs very easily. It is characterized by ten- 
 derness, swelling, and pain at the site. The tissue 
 between the fingers on the dorsum of the corresponding 
 web is generally swollen and red ; the side of the finger
 
 INFECTIONS BEGINNING IN THE LITTLE FINGER 217 
 
 adjacent to the infected finger is often red and tender. 
 It begins to swell slightly, and by extension the tendon 
 sheath of that finger often becomes involved with the 
 characteristic symptoms and signs. In involvement 
 of the lumbrical space alone, the swelling of the area 
 involved is marked. The middle palmar space is most 
 commonly involved, either by extension along the 
 lumbrical space or from rupture of the ulnar bursa 
 which lies in juxtaposition. The thenar space is never 
 
 FIG. 78 
 
 f To epiphyseal line 
 < of middle phalanx 
 ( and joint. 
 
 To fascial spaces about 
 web and around the 
 lumbrical muscles. 
 i ( Through palmar fascia 
 
 to surface. 
 To thenar space. 
 
 Schematic drawing showing probable extensions from an infection of the 
 tendon sheath of the index finger. 
 
 primarily involved in the little finger infections. In- 
 volvement of the middle palmar space is characterized 
 by a slight bulging of the palm replacing the normal 
 concavity. The symptoms and signs of this complica- 
 tion, as well as those observed in osseous and joint 
 involvement, will be discussed in the subsequent pages. 
 (See Chapters XVII and XXVIII.) Mention should 
 also be made of the frequency of rupture of the sheath 
 through the palm to the surface at the proximal end of 
 the finger sheath in neglected cases.
 
 218 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 SYMPTOMS, SIGNS, AND DIAGNOSIS OF EXTENSIONS FROM INFECTIONS 
 BEGINNING IN THE INDEX, MIDDLE, AND RING FINGER. 
 
 Involvement of the index, middle, and ring fingers 
 presents the same signs as the little finger. The only 
 
 FIG. 79 
 
 To epiphyseal line 
 of middle phalanx, 
 and to joint. 
 
 To fascial spaces about 
 
 web and around the 
 
 lumbrical muscles. 
 Through palmar fascia 
 
 to surface. 
 
 To middle palmar space; 
 exceptionally, the thenar space. 
 
 Schematic drawing showing probable extensions from infection of the tendon 
 sheath of the middle finger. 
 
 FIG. 80 
 
 To epiphyseal line 
 of middle phalanx, 
 and to joint. 
 
 To fascial spaces about 
 web and around the 
 lumbrical muscles. 
 , f Through palmar fascia 
 \ to surface. 
 
 To middle palmar space. 
 
 Schematic drawing showing probable extensions from the infection of the 
 tendon sheath of the ring finger. 
 
 difference is that here the paths of extension are 
 different. The most common extension is into the 
 lumbrical space on either side; from here the pus
 
 EXTENSIONS FROM INFECTIONS IN THE FINGERS 219 
 
 extends into either the palm as noted below, or to the 
 dorsum in the web or at times to the adjacent tendon 
 sheath. (See Case VII.) The fingers differ somewhat 
 in the method of their extension into the palm, as 
 will be seen by noting the accompanying drawings 
 (Figs. 78, 79, and 80). The middle and ring fingers 
 
 FIG. 81 
 
 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. 
 
 drain into the middle palmar space, and the index 
 finger into the thenar space. 
 
 In common with the little finger these also present 
 less often involvement of the middle phalanx, the 
 proximal interphalangeal joint, and rupture to the 
 surface most infrequently of all. 
 
 As illustrating the extension from the index finger 
 into the thenar space, with no involvement of the
 
 220 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 middle palmar space, I record the case of Miss M., 
 seen with Dr. Besley at the Post-Graduate Hospital. 
 The probability of this extension was pointed out by 
 myself experimentally some, time previous to the 
 opportunity to observe a clinical case proving the 
 assumption. Fig. 81 shows such a condition. 
 
 CASE XL Seen in consultation with Dr. F. A. Besley 
 at the Post-Graduate Hospital, October, 1906. 
 
 History. Patient stated that twenty-four hours before 
 she had run a needle in the distal phalanx of the index 
 finger of the right hand. Inside of seven or eight hours 
 the pain became severe and she arrived at the hospital 
 complaining of excessive pain and tenderness. 
 
 Examination. Patient's temperature, 102.5; pulse, 100. 
 Index finger seemed to be slightly swollen. Tenderness 
 was present over the entire finger and the lower portion 
 of the hand on the radial side without localization at 
 any point. The glands in the axilla were swollen, those 
 in the elbow not involved. No lymphatic lines seen. 
 
 Treatment. A diagnosis of lymphatic infection, possibly 
 tenosynovitis, was made and hot boric dressings applied. 
 
 The next morning the temperature had fallen markedly 
 and the patient insisted on leaving the hospital. She 
 returned in two days with all the evidences of acute 
 systemic infection temperature, 102; headache and 
 sleeplessness. Locally the finger presented about the 
 same appearance as when seen two days before, except 
 that there was a slight increase in swelling and the thenar 
 space from the adduction crease in the thumb seemed to 
 be ballooned out from the remainder of the hand. The 
 concavity of the palm was still present. 
 
 Diagnosis of previous tenosynovitis in the index tendon 
 sheath, with rupture at its proximal end and involvement 
 of the thenar space was made. 
 
 On operation pus was found to be present; there was a 
 very large accumulation in the thenar space, which was 
 drained by through-and-through drainage from the palm 
 to the dorsum between the metacarpal bones of the index 
 finger and thumb. The tendon sheath of the index finger 
 was opened throughout its extent.
 
 EXTENSIONS FROM INFECTIONS IN THE FINGERS 221 
 
 Course. Patient's temperature rapidly subsided and 
 in two or three days was normal or 99. Infection of 
 the thenar space had entirely subsided at the end of seven 
 days, and the wounds healed promptly. The opening in 
 the tendon sheath of the index finger, however, was 
 present for four weeks, necessitating repeated dressings. 
 
 Result. Recovery with all functions except flexion of 
 the distal phalanges of the index finger. 
 
 FIG. 82 
 
 To joint. 
 
 To surface. 
 To thenar space. .. 
 
 Under flexor profundus. 
 
 Schematic drawing showing probable extensions from infection of the tendon 
 sheath of the thumb. (Flexor longus pollicis.) 
 
 SYMPTOMS, SIGNS, AND DIAGNOSIS OF EXTENSIONS FROM INFECTION 
 BEGINNING IN THE RADIAL BURSA. 
 
 The gravity of tenosynovitis of the flexor longus 
 pollicis of the thumb has long been recognized. The 
 symptoms and signs common to the other fingers are
 
 222 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 found here. To diagnosticate the extension into the 
 radial bursa and then to the ulnar bursa is more 
 difficult (Fig. 82). Let us suppose the thumb has been 
 the seat of the primary infection. This member is 
 very painful, the index finger slightly sensitive, and the 
 other three fingers hardly at all. After a time, if the 
 infection spreads throughout the sheath, all the fingers 
 become more painful to passive extension, and should 
 the infection pass over into the ulnar sheath all the 
 fingers become flexed and the pain severe upon exten- 
 sion of the tendons, most marked, however, in the 
 little finger. In other words, it assumes the character 
 of an ulnar sheath infection. The tenderness over the 
 sheath is not always so marked in secondary involve- 
 ment, however, due possibly to the previously de- 
 veloped edema. I recall one case where the only 
 marked tenderness was at the base of the little finger. 
 Here, however, owing to this tenderness, which was not 
 present at the base of the other fingers, a diagnosis of 
 involvement of the ulnar bursa was correctly made. 
 Forssell's statistics show that 23 out of 27 cases of 
 radial bursitis extended to the ulnar bursa average 
 age, forty- three years; the 4 that remained confined to 
 the radial bursa averaged thirty-seven and one-half 
 years of age. It cannot be emphasized too strongly 
 that in the early state of secondary involvement of 
 the ulnar bursa there is no marked swelling upon the 
 palmar surface and that there is no special tumefaction 
 over the ulnar bursa. 
 
 One fact may confuse the surgeon in that the ten- 
 derness over the radial bursa may be absent. Not 
 only that, but upon operation no macroscopic pus may 
 be found in the middle part of the sheath. By careful 
 extension of the incision and pressure upon the two 
 ends pus may be brought into the wound. 
 
 The extension of the infection into radial bursa is
 
 F ASCI AL-SP ACE ABSCESSES 223 
 
 generally accompanied by a swelling above the anterior 
 annular ligament, just as in ulnar bursa infection. It 
 may rupture from here into the tissues of the forearm, 
 and then the pus lies under the flexor profundus tendons 
 as previously described in discussing rupture of the 
 ulnar bursa. (See p. 149 and Chapter XXVI for com- 
 plete discussion of forearm extensions.) 
 
 The diagnosis of involvement of the wrist-joint will 
 be discussed in Chapter XXVI. 
 
 THE SYMPTOMS, SIGNS, AND DIAGNOSIS OF FASCIAL- 
 SPACE ABSCESSES. 
 
 The well-defined spaces I have described as being 
 present in the hand may be infected primarily, or sec- 
 ondarily to a tendon-sheath infection. In either case 
 the symptoms and signs are the same except that the 
 diagnosis of the location of the pus is simplified when 
 we have had a certain finger sheath involved, as has 
 already been pointed out. Let us discuss the question, 
 however, as if we were dealing with one or more of the 
 spaces without relation to tenosynovitis. The student 
 will have no difficulty in combining or differentiating 
 the two pictures if they are present in an individual 
 case, and the differentiation must be made, since in 
 draining a tendon sheath we do not drain a fascial 
 space, nor vice versa. Each must be treated separately, 
 even if in a given case the two infections are combined. 
 
 The symptoms and signs may be divided into local 
 and general. The general evidences of this variety of 
 infection do not differ at all from those seen elsewhere. 
 The temperature often reaches 103 to 104, and the 
 restless tossing of the patient, the sleepless nights, the 
 wandering eye, the sweaty brow, and the flushed 
 cheek all demonstrate the absorption of the toxins, 
 bound in closed spaces, with no means of exit.
 
 224 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 Locally, one elicits particular pain limited to the 
 area involved. This localization of the pain is not so 
 definite, however, as that noted in the synovial sheath 
 infection, particularly in those patients in whom the 
 mental equilibrium is disturbed as a result of suffering 
 and septic intoxication. After a number of days the 
 tenderness and pain grow less severe, owing to the 
 edema with pressure on the nerves. Unfortunately, 
 the brawny induration so helpful in diagnosticating 
 subcutaneous accumulations of pus cannot be definitely 
 elicited upon the palmar surface, owing to the palmar 
 fascia and its general rigidity. Upon the dorsal surface, 
 however, the induration and localized tenderness will 
 aid us materially in distinguishing between the doughy, 
 pitting edema which is always present and an accumu- 
 lation of pus, long before fluctuation gives its tardy 
 evidence. The position of the fingers is worth noting. 
 Incident to any inflammatory process about the palm of 
 the hand, with its consequent edema, the fingers tend 
 to become flexed; here, however, the flexion of the 
 fingers is neither so marked nor so rigid as in synovial- 
 sheath infection. 
 
 THE MIDDLE PALMAR AND THENAR SPACES. 
 
 If the middle palmar space be involved, we are often 
 aided in making the diagnosis by the site of the primary 
 injury. Since in the chapter upon pathogenesis 
 (Chapter XI) the routes of extension from various 
 fingers and parts of the hand were pointed out, it is 
 not necessary to go into detail upon this subject again, 
 although an example may be given. For instance, 
 in Case VIII the palmar surface was evidently in- 
 volved. The fistulous tract on the dorsum opened 
 over the metacarpal bone of the hypothenar area 
 dorsally; but with the facts in mind that the meta-
 
 THE MIDDLE PALMAR AND THENAR SPACES 225 
 
 carpal bone of the middle finger was fractured and 
 infected, and also that pus in the subaponeurotic space 
 would tend to point at the side, a diagnosis of pus in 
 the middle palmar space rather than the hypothenar 
 was made. Drainage of this space was instituted, and 
 the immediate fall of the temperature, with rapid 
 convalescence, substantiated the diagnosis. Tender- 
 ness most marked over this area, swelling of the whole 
 hand, marked upon the ulnar side (or it is better to say 
 without the excessive swelling of the thenar area which 
 
 FIG. 83 
 
 Photograph showing the ballooning of the thenar space when filled with pus. 
 Note that the concavity of the palm still remains. 
 
 characterizes infection of that space), aid us in making 
 the differential diagnosis. The obliteration of the con- 
 cavity of the palm and the presence of a slight bulging 
 is almost pathognomonic, since while edema may pro- 
 duce an obliteration of the concavity, I have never 
 seen it produce a bulging or convexity a condition 
 which I have seen in all large abscesses of the middle 
 palmar space. Attention is drawn to the relative 
 swelling of the thenar and palmar areas, since in palmar 
 infections the swelling of the two might be almost the 
 same, owing to the rigidity of the palmar fascia over 
 15
 
 226 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 the one and its absence over the other, the swelling 
 of the thenar space being due to associated edema. 
 On the contrary, however, infection of the thenar area 
 is characterized by a much greater swelling in the thenar 
 than the more resistant palmar tissue; and, moreover, 
 the swelling of the thenar region is greater than that 
 due to the collateral edema of midpalmar infection 
 (Fig. 83). ^ 
 
 The position of the fingers does not aid much, though 
 we expect the middle, ring, and little fingers to be 
 held in their characteristic positions more markedly 
 than the index when the middle palmar space is in- 
 volved, while the converse is true in thenar-space 
 involvement. The slight rigidity of the thumb, in 
 contradistinction to its involvement in thenar infection, 
 also aids one in making the differential diagnosis be- 
 tween the two spaces. It is well to remember that the 
 fingers can be moved from their positions with much less 
 pain than is elicited when the fingers are involved in a 
 tenosynovitis. 
 
 The great difficulty in making the diagnosis, however, 
 is not in those cases in which the question is only 
 which space is involved; it is when we ask ourselves, 
 Are they both involved? or when we wish to know 
 whether a midpalmar-space infection has spread over 
 into the thenar space, or vice versa. Fortunately, 
 however, the thenar-space infection does have, to a 
 certain extent, that induration which has been spoken 
 of as being absent in infections under the palmar 
 fascia, and this aids us, slightly at least, to differentiate 
 between collateral edema and pus in this space. More- 
 over, the history helps us some. Given a primary 
 palmar-space infection for several days, we note a 
 rapid increase of the size of the thenar area ; the edema 
 upon the dorsum, which has not been so great as that 
 upon the ulnar side of the hand, becomes greater; the
 
 THE MIDDLE PALMAR AND THENAR SPACES 227 
 
 palmar surface swelling becomes very marked, the 
 tissues of the thenar area seeming to balloon out, as 
 it were, from the adduction crease of the thumb; the 
 thumb metacarpal is pushed away as far as possible 
 from the hand, and the flexion of the distal phalanx 
 becomes more marked, although lacking the rigidity 
 of synovial infection of the flexor longus pollicis. 
 In such a case we now fear an extension into that 
 space. 
 
 The extension of an infection from the thenar to 
 the palmar space is not so common, fortunately, since 
 diagnosis is made earlier and the proper treatment 
 instituted. 
 
 The immense size to which these infected hands may 
 grow can hardly be believed unless they are seen. I 
 recall particularly a patient who presented himself 
 with such a hand which had been treated for four 
 weeks without the surgeon having diagnosticated and 
 opened a typical middle palmar abscess. It is that of 
 the patient whose photograph is present in Case XII. 
 In the photograph the two hands are upon the same 
 level, and the size of the infected hand is not exagger- 
 ated in the picture. It could be compared to nothing 
 except the appearance of a large turtle. The patient 
 had had ten to fifteen incisions upon the fingers and 
 dorsum of the hand when I saw him. Only one incision, 
 that of the middle palmar space, was necessary for 
 drainage. A cupful of pus was evacuated, and the 
 patient ultimately recovered complete function of his 
 hand, as will be seen by examining the photographs. 
 He had been advised by several surgeons to have his 
 hand amputated. There might be some excuse for 
 the failure to diagnosticate the position of pus, since 
 the long-continued infection had so obtunded the 
 nerves that he complained of no pain or tenderness. 
 This is only one of the several cases that have been
 
 228 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 seen some weeks after the beginning of the infection in 
 which the diagnosis as to the position of pus had not 
 been made, and in consequence of the apparently 
 desperate condition of the hand the advice to amputate 
 had been given, and yet upon proper drainage the 
 patient secured serviceable hands. (See Case XVI.) 
 
 FIG. 84 
 
 Photograph of dorsum of infected hand. (See Case XII.) Note multiple 
 ill-advised incisions upon the dorsum. 
 
 CASE XII. Geo. S., Streator, Illinois. History in 
 Brief. Four weeks ago patient cut his hand on a piece 
 of steel. He was in the hospital four days, and it appar- 
 ently recovered. Following this, numerous small pockets 
 of pus developed upon the fingers, which were opened 
 by a surgeon. The hand began to swell enormously,
 
 THE MIDDLE PALMAR AND THENAR SPACES 229 
 
 and incisions were made upon the dorsum of the hand 
 without evacuating much pus. The patient began to 
 suffer from systemic intoxication. 
 
 FIG. 85 
 
 Photograph of palmar surface of the same patient. Note wound leading 
 along lumbrical muscle through which the middle palmar space was drained. 
 This is the largest hand I have ever seen. The pictures show the right 
 and left hands respectively of the same patient. They are on the same level 
 and the same distance from the camera. (Case XII.) 
 
 Examination on Entrance. General condition: tem- 
 perature, 101; pulse, 120; respirations, 26. Marked 
 headache and emaciation; general evidence of systemic 
 intoxication. Locally, right hand swollen to two and 
 one-half times normal size. The fingers are from one to 
 one and one-half inches in diameter. The hand is at least
 
 230 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 three inches thick, swollen both upon the flexor and 
 extensor surfaces. Forearm slightly swollen. Numerous 
 incisions upon fingers and dorsum, from which exude a 
 moderate amount of pus. There is little or no tenderness 
 about the hand. 
 
 Upon the bulging of the palm and the lack of evidences 
 of tendon-sheath involvement, a diagnosis of an abscess 
 in the middle palmar space was made. Incision along 
 ring finger lumbrical. A cupful of pus was evacuated. 
 
 FIG. 86 
 
 Result (Case XII, Figs. 84 and 85) six months after treatment. 
 Note perfect function of all fingers and all joints. 
 
 After-history. Following the operation the tempera- 
 ture rose to 103, and fell the next day to 99.8. It 
 rose to 102 the second day, and then fell to 99.4, 
 from which time it gradually reached normal. The 
 swelling slowly subsided under hot baths and active 
 and passive movements, so that the patient left the 
 hospital at the end of five weeks, with three-fourths 
 function in the hand, and at the end of four months,
 
 DORSAL ABSCESSES 231 
 
 when I had an opportunity to examine 'the patient, the 
 function was perfect in every respect, as will be seen 
 by examining the photographs (Figs. 84, 85, and 86.) 
 
 THE HYPOTHENAR SPACE. 
 
 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, lead 
 us to an easy diagnosis. Fortunately, the hypothenar 
 area is so separated from the remainder of the hand 
 that it is seldom involved, secondarily, to palmar 
 infection. 
 
 DORSAL ABSCESSES. 
 
 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 sub- 
 cutaneous tissue, yet lacking the brawny induration 
 and localized tenderness of a subcutaneous abscess. 
 
 Reference has already been made to the edema upon 
 the dorsum, due to the fact that there we find a large 
 area of loose subcutaneous tissue in which serum can 
 accumulate, and secondly, to the anatomical distri- 
 bution of the superficial lymphatics, which, as we 
 have pointed out, all seek the shortest course from the 
 palmar surface to the dorsum. Consequently, one often 
 finds much greater swelling upon the latter than the 
 former, even though the abscess be upon the palm. 
 If, however, we bear in mind the soft pitting of edema, 
 with its generalized moderate tenderness, as opposed
 
 232 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 to the induration with slight pitting and localized 
 tenderness of the abscess in this tissue, the diagnosis 
 is easy. One should never wait for fluctuation to 
 make a diagnosis of abscess formation; it should be 
 made from the induration. 
 
 FOREARM ABSCESSES. 
 
 It is well at this time to speak briefly of those cases 
 which extend into the forearm. We remember that 
 this is much more likely to occur in the palmar space 
 infections than in the thenar infections (see experi- 
 ments), although cases are reported in which it has 
 extended from either (Chevalet). Personally, I have 
 not seen a single case in which an extension occurred 
 from an uncomplicated midpalmar or thenar-space 
 abscess. It most commonly arises from a radial or 
 ulnar bursitis. Here we would note the sudden in- 
 crease of evidences of inflammation in the forearm; 
 the temperature would rise, the tenderness over the 
 forearm in front grow greater, and the swelling become 
 more marked; but owing to the fact that the pus is 
 deep under the muscles, induration would be absent 
 until later, when the whole area became involved, and 
 it would tend to come to the surface probably a few 
 inches above the wrist, along the vessels. (See Chapters 
 X and XXVI for a full discussion of this subject.) 
 
 Exception must be made of those cases already 
 noted where the infection develops about the radial 
 and ulnar arteries, probably of lymphatic origin. Here 
 the abscess is not so deep, yet is considerably below 
 the skin in the area of those vessels. 
 
 Osteomyelitis, arthritis, and other complications and 
 sequelae have no peculiar relation to fascial-space 
 infection, and hence will not be considered in the 
 symptoms, diagnosis, and treatment. They will be 
 reserved for a subsequent chapter.
 
 DIFFERENTIAL DIAGNOSIS 233 
 
 DIFFERENTIAL DIAGNOSIS. 
 
 One may mistake a lymphatic infection for a teno- 
 synovitis. Here, however, the red lines of lymphatic 
 involvement running up the arm without the localized 
 tenderness over the tendon sheaths, the slight pain 
 on moving the fingers, the generalized edema of hand 
 and arm in contradistinction to the localized swelling 
 found in the early stage of tenosynovitis aid us in the 
 diagnosis. Again, 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. In one case it was difficult to 
 determine whether the patient was suffering from a 
 gonorrheal rheumatism of the proximal interpha- 
 langeal joint of a finger or a gonorrheal tenosynovitis 
 with secondary involvement of that joint. The latter 
 assumption was later found to be the condition present. 
 In those cases where there is a lack of traumatic his- 
 tory and an apparently spontaneous development of 
 an inflammation, especially 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. Subcutaneous in- 
 fections are seldom difficult to differentiate. One case 
 of gonorrheal tenosynovitis of the tendon sheaths of the 
 dorsum of the wrist came under my notice in which
 
 234 SYMPTOMS, SIGNS, DIAGNOSIS OF TENOSYNOVITIS 
 
 the diagnosis of rheumatism had been made. Here the 
 absence of any tenderness or swelling on the flexor sur- 
 face combined with swelling and tenderness localized 
 to the sheaths confirmed the diagnosis. 
 
 Forssell, in a personal communication, has drawn my 
 attention to three cases which came under his observa- 
 tion in which there was a palmar infection represented 
 by necrosis of a part of the palmar fascia. This con- 
 dition, he states, was extremely difficult to diagnosti- 
 cate from an ulnar bursitis. Personally, I have not 
 met with such a case and can offer no suggestion as 
 to its pathogenesis.
 
 CHAPTER XV. 
 
 THE TREATMENT OF ACUTE SUPPURATIVE 
 TENOSYNOVITIS. 
 
 GENERAL CONSIDERATIONS AND REVIEW OF THE 
 LITERATURE. 
 
 BEFORE discussing my own views as to the site and 
 course of the incisions for the various fingers when the 
 diagnosis of tenosynovitis has been made, let us study 
 the suggestions of those who have previously made 
 contributions to this subject. 
 
 Professor Bier (Berlin), with his assistants, has been 
 an active advocate of the production of passive hyper- 
 emia in these cases of infection of the hand. His 
 method consists in applying a constrictor to the arm 
 so as to produce a moderate passive hyperemia with- 
 out causing pain and without restricting the arterial 
 flow of blood. The constrictor should be a broad band, 
 and to prevent pain should extend from two to four 
 inches up and down the arm. It should be so applied 
 that the full amount of edema does not appear at 
 once, but accumulates gradually for from three to 
 four hours. The constrictor is left on from sixteen 
 to twenty-four hours. After an interval of from two to 
 four hours it is reapplied. Small incisions are made 
 into the tendon sheaths or other sites of pus. 
 
 Klapp has added to this by suggesting the use of 
 suction cups, these being applied so as to produce 
 moderate hyperemia without pain. Cups from which 
 the air can be exhausted are used over localized accumu- 
 lations of pus. Long glasses with rubbers at the end,
 
 236 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 which can be applied over the finger, as shown by the 
 illustrations, have also been devised. 
 
 In involvement of the connective-tissue spaces, it 
 is my personal opinion that these appliances may be 
 of slight value. In other conditions the benefit to be 
 derived, it would seem, is so slight as hardly to justify 
 their use. Many German surgeons have maintained 
 that Bier's methods are of value in tendon-sheath 
 infections, but personally I have never been able to 
 secure good results with them, except possibly in a 
 few cases where there has been a sinus, leading down 
 to a tendon sheath. The sinus seemed to close more 
 rapidly under the suction cup of Klapp than by other 
 means. 
 
 In order to prevent rapid absorption of toxins, it 
 is my habit, after operation upon exceptionally virulent 
 cases, to leave on an Esmarch constrictor for from 
 twelve to twenty-four hours after operation, except 
 that a constrictor is loosened to produce only a slight 
 hyperemia. 
 
 I cannot but feel that while slight benefit may occur 
 in some cases, the so-called Bier treatment of infections 
 of the hand cannot be looked upon as a marked aid. 
 
 EXCERPTS FROM THE LITERATURE. 
 
 Klapp and other surgeons have discussed the Bier 
 method of treatment in these cases at the German 
 Surgical Congress. 1 
 
 Klapp has begun to make free incisions in the tendon 
 sheaths at the lateral surface of the fingers and cut the 
 ulnar bursa throughout its length with the exception 
 of the anterior annular ligament, using alcohol dress- 
 ings, and active movements the first day. His results 
 have apparently been as satisfactory as those obtained 
 
 1 Berliner klinische Wochenschrift, April 13, 1908, No. 25.
 
 EXCERPTS FROM THE LITERATURE 237 
 
 by Bier and Klapp previously where they made small 
 incisions into the tendon sheaths and applied the Bier 
 constrictor. By this method he had treated 19 cases. 
 
 1. Ten cases of pure tendon-sheath infection; 9 
 healed with necrosis. 
 
 2. Two cases' of subcutaneous abscess under the 
 tendon with necrosis of the skin: I healed and I 
 recovered completely. 
 
 3. Six cases of tendon-sheath infection complicated 
 with infected phalangeal fractures: 2 of these healed, 
 and 4 became necrotic. 
 
 4. One case developed sepsis and died on the twelfth 
 day. 
 
 Klapp therefore concludes that he has thus answered 
 the question as to whether Bier's good results came 
 from hyperemia or from the physiological treatment. 
 He maintains that he has proved that it came from 
 the latter. He now proposes to study whether good 
 opening, physiological treatment, and Bier's hyperemia 
 will not produce still better results. 
 
 Klapp's paper was discussed by Joseph, who sug- 
 gested that there are two types of the infection which 
 must be differentiated: (i) where it is localized to the 
 sheath, not showing a tendency to spread; (2) a type 
 which shows a tendency to spread beyond, due to 
 the great virulence of the infection. 
 
 He maintained that we should use care not to go 
 beyond the zone of protection which Nature has thrown 
 out. to wall off the infection, whether it be within the 
 sheath or without. In these cases we should use the 
 smallest possible incisions and Bier's hyperemia. 
 
 Kausch stated that he had treated a large number 
 of tendon-sheath infections after Bier's method, and 
 must say he was generally well satisfied with the 
 result. He has not been so well satisfied with the very 
 severe cases. In the beginning he used small incisions,
 
 238 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 then medium-sized, and drained with passive hyper- 
 emia, but in his severe cases he has now gone back 
 to large incisions, although not as large as formerly. 
 
 Karewski stated that he could not attribute his bad 
 results to the Bier method, but rather to the fact that 
 his material was ambulatory and could not be correctly 
 handled. He had used the older method for twenty- 
 five years. He now makes a moderate-sized incision, 
 packs lightly, and keeps the arm at rest as long as 
 there is fever. Of 57 cases, 4 had to have amputation 
 of the fingers at once. Of the 53 cases remaining, 9 
 were treated by lateral incisions. Of the 53 cases, 42 
 showed good results: that is, 79.25 per cent.; bad 
 results, 5 cases, or 9.5 per cent. This result is better 
 than that given by Dr. Klapp. 
 
 Forssell, in his monograph previously referred to, 
 has collected the opinions of various surgeons, and I 
 shall quote and abstract extensively from him. He 
 gives the results of his own experience as follows: 1 
 
 "Even if one makes smaller incisions into the sheath, 
 at least according to the experience met with in the 
 Seraphimer-Lazarett, one rarely succeeds in saving the 
 sheath (Poulsen's experience was the opposite). I 
 have often attempted to treat such an infection with 
 incision at each end of the tendon sheath and with 
 complete exposure of the surrounding folds of the 
 synovialis (and subsequent washing of the sheath 
 with water, normal salt solution, boric acid solution, 
 iodoform-glycerin, weak carbolic or sublimate solu- 
 tions), but only on three occasions was this treatment 
 successful. 
 
 "The treatment which in my judgment should be 
 used in most cases is a complete splitting of the sheath 
 from one end to the other. Thus, one often succeeds 
 in saving at least the inner tendon from complete 
 necrosis. 
 
 1 Nordisches Med. Archiv, 1903, Abt. i, Heft 3.
 
 EXCERPTS FROM THE LITERATURE 239 
 
 "For the opening of the ulnar sheath on the forearm, 
 if for some reason one prefers to begin the incision 
 here, several starting points are at his command. If 
 one can determine the ulnar pulse, the skin incision 
 is made one centimeter to the radial side thereof, and 
 after cutting through the fascia meets the collected 
 muscular bundle of flexors of the fingers, at whose 
 ulnar and posterior circumference the sheath extends 
 farthest upward; by passive movement of the ulnar 
 finger it is now a simple matter to know the lay of the 
 land. If one does not feel the ulnar pulse, nor the os 
 pisiforme, which lies close to the ulnar side of the 
 ulnar artery, nor the unciform, on whose radial boun- 
 dary the incision must fall, one can make the skin in- 
 cision on the border of the middle and inner third of 
 the wrist-joint and then dissect layer for layer down to 
 the tendon sheath. 
 
 "If it is a case of inflammation of the ulnar sheath 
 of the palm and the tendon sheath of the little finger 
 it is often preferable to begin with the fissure of the 
 latter. Only in exceptional cases it might be worth 
 while to use a more conservative treatment, and that 
 especially in such cases of fresh tenovaginitis, where 
 this is secondary after an ulnar bursitis; in such cases 
 one can occasionally make an attempt to conquer the 
 inflammatory process by washing out the tendon 
 sheath through incisions made in either end; there is 
 little danger in this method, and if successful, it insures 
 complete movability of the little finger. 
 
 "The skin incision must then be laid from the upper 
 end of the opened little finger sheath, up toward the 
 hook of the unciform (i. e., must follow the radial 
 boundary of the hypothenar), and then continued in 
 the length of the forearm to a point three or four 
 centimeters or more above the wrist. After cutting 
 through the skin and the subcutaneous fat, usually
 
 240 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 especially developed here, the palmar aponeurosis, the 
 strong anterior annular ligament, and the forearm 
 fascia are cleft, the superficial vessels cut through and 
 ligated (the ligatures being left long because the vessels 
 usually draw back deep into the tissue and with their 
 infected ligatures give rise to collections of pus which 
 might easily be overlooked), after which the sheath 
 is opened. Even when the infection is confined to the 
 tendon sheath, the incision should be continued in the 
 skin and soft parts until it gives a good opening into 
 the sheath, through which this can be easily and com- 
 pletely packed with gauze. 
 
 "In continuing the incision, it must not be allowed 
 to deviate too far to the ulnar side, as the ulnar nerve 
 and artery might thus be injured; the cut can and 
 should be so laid that neither of them is exposed. The 
 anterior annular ligament is best cut some distance 
 from the hook of the unciform. 
 
 "If, however, it is a question of suppuration of the 
 radial bursa, I believe that a complete cutting of the 
 anterior wall of the bursa should not be attempted- 
 If the incision is made in the early stages of the in- 
 fection, one may have the satisfaction of seeing the 
 tendon of the thumb saved and the infection restricted ; 
 the tendon cannot, however, be saved in all these 
 cases, and sometimes, moreover, it is rendered useless 
 by adhesions to neighboring regions. An incision of 
 the whole length of the sheath is to be regarded as 
 even more than useless when it is attempted in more 
 advanced cases where there is no chance of saving the 
 tendon since the suppuration is kept up by the necrotic 
 tendon; moreover, such an operation lames an im- 
 portant group of muscles and so makes the thumb 
 practically useless. 
 
 "How then should one proceed in suppurations of 
 this order? I believe there are three ways at our 
 command :
 
 EXCERPTS FROM THE LITERATURE 241 
 
 "i. Incision in the radial bursa above and below 
 the ligamentum carpi, sparing the nerve of the thenar 
 group. The first mention of this method which I 
 have found in the literature I found in an article by 
 Nicaise (Gazette medicate de Paris, 1870, s. 615), who, 
 however, opens only the tendon sheath of the thumb 
 under the carpal ligament and not the radial bursa; 
 the case ended in necrosis of the distal part of the 
 tendon Surely, then, if a decided improvement has 
 not been shown within the first twenty-four hours, 
 one should proceed more radically, in which case the 
 choice is between the two following methods. 
 
 "2. Incision as in I, and excision of the long flexor 
 tendon of the thumb. Through removal of the tendon, 
 which is usually the principal reason for persistent 
 suppuration, one also gains a lessened pressure in the 
 radial bursa and better drainage with less danger of 
 a spreading of the inflammation. Primary excision 
 of the tendon is to be considered: (i) When the tendon 
 is already necrotic or its continuity broken, or if it 
 is so injured that its restitution seems hopeless; (2) 
 if the synovialis is infiltrated with pus and is necrotic; 
 (3) in case of inflammation of the joint or fracture 
 of the thumb, whereby the functions of either the 
 interphalangeal joint or of the tendon are completely 
 interrupted; (4) in people of age or poor general con- 
 dition. 
 
 "3. A more or less complete cutting of the liga- 
 mentum carpi beginning at the upper edge is added 
 to the above-mentioned incision. Complete fissure of 
 the ligamentum carpi can be carried out without any 
 direct injury to the motor medianus branch to the 
 thenar muscles; nevertheless, this nerve branch in 
 case of an infection of the edges of the wound might 
 possibly be exposed to the dangers of necrosis." 
 
 I am in receipt of a letter from Dr. Forssell, under 
 
 16
 
 242 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 date of September 10, 1908, in which he reiterates his 
 belief in free incision. It is abbreviated as follows: 
 
 "With regard to your query, whether I have modi- 
 fied my opinion of the complete splitting of the tendon 
 sheath from the end of the finger up into the forearm, 
 I must answer that I still adhere to it with the excep- 
 tion mentioned on pages 37 and 63 of my paper, i. e., 
 I still make attempts sometimes with smaller incisions 
 and irrigations through the tendon sheaths of the thumb 
 and little finger when a tendon sheath has there given 
 rise to an infection of the radial or ulnar bursa and split 
 the tendon sheath of the finger only when the smaller 
 incisions do not lead to the desired results. 
 
 "Prof. Bier's hyperemic treatment has been used 
 by me for a few cases of infection, but without any 
 appreciable benefit, this being also my experience with 
 cases of tendon-sheath infection. The material at my 
 disposal may, however, have been too slight for my 
 forming an opinion of my own concerning the value 
 of the Bier method for tendon-sheath infections. At 
 the surgical department of the Karolinska Institute 
 (The Royal Seraphim Hospital), where I worked out 
 my paper, and where the principles I advocated gained 
 general approbation, and caused a considerable im- 
 provement in the results obtained, there was later on 
 a good deal of enthusiasm felt for the method invented 
 by Bier; but I was told that some time ago the method 
 was discontinued, since it had given several very un- 
 favorable running cases, and in the main the former 
 old method of treatment has been taken up again. 
 
 "Whatever method may be used, I feel sure that 
 fatal cases will have to be deplored. As the prophyl- 
 axis, therefore, is invariably of the very greatest 
 importance, I have lately come to the conclusion that 
 one way of trying to prevent infections of the fingers 
 from attacking the tendon sheaths is by previously
 
 EXCERPTS FROM THE LITERATURE 243 
 
 exposing the tendon and tamponing it around, to the 
 extent of a couple of centimeters. This proceeding 
 should be of special use in necrosis of the end phalanx 
 of the thumb that so often occurs and which greatly 
 endangers the tendon sheath of the thumb and thus 
 also the bursa of the hand. 
 
 "The method has been proved by me as yet in but 
 one single case, though with success. I then proceeded 
 as follows: The tendon sheath of the thumb was split 
 to the extent of a couple of centimeters, the tendon 
 was cut near its attachment on the end phalanx, and 
 was flexed by a suture in the vicinity to its surround- 
 ings, a tampon being placed around it. After this the 
 necrotic phalanx with the tendon attachments was 
 removed. 
 
 "Seeing the interest you have for the infections of 
 the hand in general, I must call your attention to the 
 small contribution I have given in pages 32 and 33 of 
 my paper. So far as I am aware, the isolated necrosis 
 of the fascia palmaris has not previously been men- 
 tioned in literature, which is singular, since both from 
 a diagnostic and therapeutic point of view it is of 
 great interest. I have recently had a similar case 
 under treatment. An English sailor a fortnight pre- 
 vious to being admitted to the hospital had punctured 
 his hand with a nail. Besides the mark of the injury, 
 there was great soreness in the palm, accompanied by 
 considerable swelling of both palm and back of the 
 hand, with a very observable crooking of the fingers, 
 together with pain when moved, but no tenderness 
 when the fingers themselves were subjected to palpa- 
 tion. The diagnosis was made of a probable abscess 
 in or around one of the aforesaid fascia, which was 
 found to be necrotic in the great part of its extent, 
 this without any appreciable accumulation of pus in 
 the vicinity. It w^ould be interesting to hear whether
 
 244 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 you have had any occasion of observing a case of this 
 localizing of the infection." 
 
 W. Heineke, in his Anatomic und Pathologic der 
 Schleimbeutel und Sehnenscheiden, Erlangen, 1868, p. 
 79, speaks of the acute inflammations of the tendon 
 sheaths of the hand: 
 
 "The only cure in these malignant inflammations is 
 to be found in an early and extensive incision ; thus, one 
 can sometimes prevent a necrosis of the tendon, but 
 one must not expect too much in this direction. After 
 cutting several openings, one can, by use of the drain, 
 help the outflow of pus and the cleaning of the wound." 
 
 An article by Scheide 1 shows what a lack of even 
 elemental knowledge there has been in the past in 
 regard to the position of the pus in these cases. He 
 warns against hot cataplasm treatment of these diseases 
 and recommends that introduced by von Volkmann, the 
 so-called vertical suspension of the arm together with 
 continuous ice applications, and even painting with 
 iodine. 
 
 "In very great swellings, and excessive overfilling 
 of the veins, numerous stabs with a very sharp knife 
 often do good service. When the period of progressive 
 inflammation has passed and with it the danger of 
 death, when the healing has begun, then the question 
 will again be, What operations are necessary? Many 
 a necrotic phalanx, many a finger whose tendon sheath 
 has become purulent, will have to be removed ; and now 
 another question becomes of primary importance, the 
 greatest possible functional activity of the remaining 
 parts. 
 
 "This latter is most frequently hindered through 
 the necessary fixation of the hand for weeks and 
 months, thus causing the fingers to lose a great part 
 
 1 Ueber Hand und Fingerverletzungen, Volkmann 's Sammlung klinischer 
 Vortrage, 1871, No. 29, Note i.
 
 EXCERPTS FROM THE LITERATURE 245 
 
 of their power of motion. The well-known changes to 
 which joints are subject when kept stiff for a long 
 while seem to take place especially quickly in these 
 small joints under the influence of rest and the inflam- 
 mation of the surrounding tissue. One distinctly feels 
 then how in bending pseudoligaments snap or the 
 capsule tears. With the necessary patience and endur- 
 ance one can master these disturbances without a 
 doubt. But a great deal of trouble to the physician 
 and pain to the patient would be avoided if immedi- 
 ately after the first period of reaction simple passive 
 exercises were given whenever the dressing was changed 
 and so prevent any severe stiffening of the joint." 
 
 Schiller 1 shows the same lack of anatomical knowl- 
 edge. His remarks are typical in that they show a 
 lack of tendency to make an early diagnosis. His 
 drainage under the anterior annular ligament should 
 also be condemned The same may be said concerning 
 the remarks of Tilleaux, which follow: 
 
 "If after a tendonal panaritium of the thumb a 
 doughy swelling along the arterioradialis of the fore- 
 arm is noticeable, pressure there and on either side of 
 the ligamentum carpi volare is very painful, while the 
 fingers are crooked, it is advisable to make a few in- 
 cisions immediately, if possible, along the line of the 
 flexor longus pollicis, into the tendon sheath as far as 
 the muscle, in order to prevent further changes, 
 especially the occurrence of pyemia or septicemia. The 
 incisions are made to the best advantage on the fore- 
 arm outward (radially) from the arterioradialis and 
 along it. In some cases this is sufficient, as evidently 
 the whole of the great tendon sheath is not always 
 affected from the very beginning, but only its radial 
 half. In other cases, further incisions in the great 
 
 1 Chirurgisch-Anatomische Studien uber die Sehnenscheiden der Hand, 
 Deutsche med. Wochenschrift, 1878.
 
 246 TREATMENT OP SVPPURATIVE TENOSYNOVITIS 
 
 tendon sheath, in the ulnar side, are necessary. Here 
 an incision is made to the best advantage close above 
 the anterior annular ligament and at that, not exactly 
 in the centre, but to avoid injuring the median, more 
 toward the ulnar side and in the direction of the long 
 axis of the forearm. That one should put drains in 
 all incisions (best under the ligamentum carpi volare), 
 wash out the pockets with an antiseptic fluid, and band- 
 age the wound antiseptically, I will only mention in 
 passing. Sometimes even these incisions are not suffi- 
 cient; then one must add similar ones in the palm and 
 in the forearm." 
 
 P. Tilleaux 1 speaks of the so-called subaponeurotic 
 abscess : 
 
 "One must hasten to make two incisions, one in the 
 palm of the hand, the other in the forearm, connecting 
 them by a drainage tube which passes behind the 
 anterior annular ligament of the wrist." 
 
 Concerning operation when a diagnosis of extension 
 into the forearm is made, he continues as follows: 2 
 
 "It is now well to delay no longer in opening the 
 focus extensively without waiting for the fluctuation 
 to become more superficial. In reaching the skin the 
 pus must "invade the lower layers of the forearm and 
 also the radiocarpal articulation. 
 
 "In making this opening one must cut through the 
 entire thickness of the antibrachial region and ' manage ' 
 the important organs there enclosed, especially the 
 median nerve. Remember that this nerve is placed 
 slightly without the axis of the forearm; consequently 
 the place to choose for the opening of deep abscesses 
 of the wrist-joint is located just inside the median line. 
 
 "At this level make an incision about 4 to 5 cm. 
 long, and successively, layer for layer, as if for a liga- 
 
 1 Trait6 d 'Anatomic topographique, 1887, p. 572. 
 2 Traite de Chir. clinique, 1897, tome i, p. 674.
 
 V 
 
 EXCERPTS FROM THE LITERATURE 247 
 
 ture of the artery, cut through all the soft parts of the 
 forearm until you reach the focus. 
 
 " If in the hand there be a focus communicating with 
 that of the wrist below the anterior annular ligament 
 of the wrist, it would be necessary to drain it, and it 
 might be even necessary to make another opening." 
 
 Farther on (pages 684 and 685) he not only continues 
 to show a lack of knowledge of the anatomical and 
 pathological condition present, but advises procedures 
 which should be condemned. 
 
 " Subaponeurotic abscess. The abscess must be 
 opened from the palmar face, always remembering that 
 the superficial palmar arch lies in a transverse line, 
 beginning at the root of the thumb. One should, at 
 the same time, open the abscess from the dorsal side 
 and establish thorough drainage. 
 
 "If necessary, pass another drain, joining the hand 
 and wrist through the radiocarpal canal. Long car- 
 bolic baths should be given." 
 
 Konig 1 speaks for early and large incisions, strong 
 antiseptics (5 per cent, carbolic acid), drainage, suit- 
 able position of the hand and finger inside the bandage, 
 vertical suspension of the arm, excision of the arm, 
 excision of the necrotic tendon, but only after a true 
 loosening has taken place. 
 
 "But even when the tenovaginitis has persisted for 
 a long time, if the abscesses have formed along the 
 forearm with suppuration, much may be accomplished 
 with antiseptic treatment. Here, too, it is a question, 
 after one or two days of suspension, to stop the swell- 
 ing, of extensive opening of the abscesses and drainage, 
 to introduce a number of small pieces of a drain into 
 the abscess openings. Then all the abscesses are dis- 
 infected in the manner described above and an anti- 
 septic bandage applied (iodoform). If one succeeds 
 
 1 Speciale Chirurgie, vol. iii, pp. 369, 370.
 
 248 TREATMENT OF SVPPVRATIVE TENOSYNOVITIS 
 
 in this wise in mastering the progress of the disease, 
 then usually permanent irrigation with salicylic acid 
 will work admirably. 
 
 "Large, widespread incisions are to be recommended 
 under such circumstances, and one should not hesitate 
 to do as Helferich has already suggested, under special 
 conditions to cut through the transverse ligament. 
 Helferich recommended that after so extensive an 
 incision the ligament and the wound should soon be 
 closed with a secondary suture, if the phlegmon is 
 receding." 
 
 The use of strong antiseptics, particularly 5 per cent, 
 carbolic acid, as suggested by Konig, has been almost 
 entirely abandoned. It is recognized now that these 
 antiseptics certainly impair the physiological function 
 of the cells and probably do as much harm as good. 
 
 E. Lexer 1 says: 
 
 "Good results may be obtained only by as early 
 and as long an incision as possible." 
 
 B. Tillmans 2 says: 
 
 "In light cases one treats an acute non-suppurative 
 carpal bursitis by a high vertical position on a splint, 
 and ice. If improvement does not follow, if suppura- 
 tion threatens, or if it has already started, one should 
 open the synovial sac by extensive incisions above and 
 below the anterior annular ligament, drain it and apply 
 an aseptic bandage, preferably with a higher vertical 
 position on the suspension splint, according to von 
 Volkmann. Strict precautions should be taken against 
 an extension of the suppuration, for example, to the 
 forearm." 
 
 P. L. Friedrich 3 expresses himself as follows: 
 
 "If the inflammatory process finally extends up- 
 
 1 Speciale Chirurgie, 1902, s. 726. 
 
 2 Lehrbuch der speciellen Chirurgie, 1901. 
 
 3 Von Bergmann, v. Bruns, v. Mikulicz, Handbuch der praktischen Chirur- 
 gie, 1901, vol. iv, p. 420.
 
 EXCERPTS FROM THE LITERATURE 249 
 
 ward under the carpal ligament and in the manner 
 just described reaches the subfascial muscular inter- 
 stices of the arm, the only advice one can give is to go 
 down with knife and dressing forceps into each sus- 
 pected focus of infection, with careful consideration of 
 the nerves and vessels, and to drain effectually with 
 a not too thin drainage material which will not be 
 pasted together by taut portions of the tissue. If it 
 is not possible to guarantee the outflow of the pus in 
 a short time to such an extent in the region of the 
 transverse ligament, consideration of the danger to 
 the carpal joints demands the cutting of the transverse 
 ligament (Helferich, Konig)." 
 
 Friedrich's article demonstrates that even at the 
 present time there is a tendency to blind dissection 
 in these cases. The same may be said of the articles 
 appearing in the later symptoms of surgery emanating 
 from American authors. 
 
 P. Mauclaire, 1 in a similar French system of surgery 
 (we find a very similar description by Lyot), gives the 
 following description of treatment: 
 
 "As for the subaponeurotic abscess, if it is a ques- 
 tion of deep lymphangitis, or of suppurative synovitis, 
 the incision should be made where there is fluctua- 
 tion, and the region drained, it being possible for the 
 same drain to go from the palmar region to the anti- 
 brachial region. In making this incision one should 
 guard the bloodvessels, the nerves, and the tendons. 
 One often finds a focus of suppuration in the forearm, 
 in the median line in front of the pronator quadratus, 
 or sometimes between this muscle and the inter- 
 osseous membrane. 
 
 "To open this focus, one should make an incision 
 either on the centre of the anterior face of the wrist 
 along the inner edge of the palmaris longus, or longi- 
 
 1 Dentu et Delbert, Trait de Chirurgie, 1901, tome x, and tome iii, p. 850.
 
 250 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 tudinally along the internal border of the wrist; by 
 approximately following the anterior face of the ulna, 
 one makes a path between the deep flexor and the 
 pronator quadratus (Parona)." 
 
 F. Lejars 1 gives the following advice for the treat- 
 ment of deep phlegmon of the hand : 
 
 "One must open the palm, the great palmar sheath 
 then above the wrist, incise the superior extension, the 
 antibrachial cul-de-sac of the abscess; and last from 
 one opening to the other pass a drain. An operation, 
 indeed, a difficult operation in such a position, yet 
 an operation of immediate urgency, if one wants to 
 save this hand. This done, place the member in a con- 
 tinuous bath, leave it for hours in the liquid, which 
 one renews from time to time to keep the temperature 
 the same. This will be the best after-treatment of 
 the operation which you have just made." 
 
 Lejars' procedure is one that can be carried too 
 far, since the development of granulation tissue may 
 be excessive, and in my opinion the treatment should 
 be abandoned after twenty-four to forty-eight hours, 
 when the process is found to have come to a standstill. 
 After that the hot bath may be used at the time of 
 dressing only. 
 
 In a treatise on the treatment of serious phlegmons, 
 delivered in the Naturforscherversammlung in Halle, 2 
 1891, Helferich, of Griefswald, explains his methods as 
 follows: As example, he takes a phlegmon of the hand 
 and forearm, resulting from a penetrating injury to 
 the little finger, and emphasizes that such a case, as 
 well as a crushed fracture, should be opened as quickly 
 as possible to prevent the spreading and further 
 resorption of the poisonous matter and the inflam- 
 matory disturbances of tendons and connective tissue. 
 
 1 Traite de chirurgie d'urgence, Paris, 1901. 
 
 2 Berliner klinischen Wochenschrift, 1892, No. 4.
 
 EXCERPTS FROM THE LITERATURE 251 
 
 'GO- ifeE ' OGTEGFA-THr 
 
 "After the usual preparations for the operation 
 (bath, deep narcosis, cleaning of the operative field, 
 application of Esmarch's bandage), he makes an ex- 
 tensive incision at the point of infection, that is, for 
 example, on the little finger, which runs to the side of 
 the flexor tendon longitudinally. An assistant care- 
 fully draws apart the edges of the wound, which are at 
 first only slightly gaping, with two little hooks. If 
 the suppurative channel is opened either beside or 
 within the tendon sheath, the careful introduction of 
 a sound serves to control the direction of the knife 
 and scissors. And so the preparations having been 
 made, one continues the incision further into the palm 
 of the hand, sparing only the tendons, nerves, and 
 large vessles, through the anterior annular ligament 
 over the volar side of the forearm. Here, in case of a 
 phlegmon extending from the little finger, one keeps 
 to the ulnar side of the common flexors, continuing 
 upward, the region having been prepared below. If 
 it is a question of a phlegmon on the thumb side of 
 the hand and the radial side of the forearm, one would 
 proceed accordingly, but following the same principles. 
 The object is complete exposure of the suppurative 
 foci and the prevention of the infiltration of pus into 
 the intermuscular layers of connective tissue. Often 
 enough a focus somewhat encapsulated by the sticking 
 together of the edges is found between the muscles, 
 and even under the flexor profundus digitorum, so 
 that the interosseous membrane is widely laid open. 
 Upward the incision first comes to an end when a 
 thorough examination of the tissue and the palpation 
 of the adjoining region leads one to expect healthy 
 conditions. 
 
 "So far as necessary, other incisions are added to 
 this large one, either on the other side of the palm or 
 on the dorsal side."
 
 252 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 He is decidedly ; against any other treatment of this 
 process, and has never seen any good results from 
 small punctures; small incisions and drainage cannot 
 effect nearly as much. Disinfection of the wound is 
 dispensed with, and he confines himself to a careful 
 washing out with a 6 per cent, salt solution, empha- 
 sizing the local injuries, irritating effect of antiseptics 
 and the very unfavorable effect of the same on the 
 kidneys. 
 
 In the after-treatment he emphasizes passive move- 
 ments, baths, active movements in water-baths, mas- 
 sage, electricity, occasional compression, and nightly 
 fixation in various positions. 
 
 Helferich then recommends an apparatus invented 
 by Dr. Krukenberg for the development of passive 
 movements. 
 
 C. L. Schleich 1 says in speaking of the treatment of 
 phlegmons of the palm of the hand : 
 
 "If we cut through the ligament we can prepare for 
 the most serious functional disturbances ; if, on the other 
 hand, we do not follow up the channel of suppuration 
 we leave a great mortal danger. To decide this matter 
 we press firmly on the tendinous convolutions above 
 the ligament of the forearm and pressing out the con- 
 tents toward the periphery; we will suppose that no 
 drop of pus flows from the tendon pocket below the 
 ligament. We are then obliged to make a counter- 
 opening above the ligament, which would have been 
 absolutely necessary in the presence of pus above the 
 same. I depend on the appearance of this super- 
 ligamentary flexor swelling to decide whether, through 
 a counter-opening, I shall pass a drain of gauze strip 
 under the ligament, or whether I shall cut through the 
 ligament to further lay bare the avenues of infection. 
 In case of dry opacity and scarring, I usually let gauze 
 
 1 Neue Methoden der Wundheilung, Berlin, 1899.
 
 EXCERPTS FROM THE LITERATURE 253 
 
 drainage suffice ; if, however, fluid pus is found between 
 the tendons, I stand for unconditional severing of 
 the ligament and further following up the avenues of 
 infection. " 
 
 K. Poulsen (quoted from Forssell) gives the follow- 
 ing description of the opening of the ulnar tendon 
 sheaths : 
 
 "If the sheath is swollen, or the skin edematous, 
 it is not so easy to see what one is about or to say 
 exactly what flexor tendon lies before him while he 
 is making the incision; yet in these cases it is of no 
 great importance if one should happen to get in between 
 the deep flexor tendons of the second and third fingers ; 
 the sheath when it is stretched is always opened, if 
 one only gets in between the tendons of the deep 
 flexor muscles. The incision is then made in the follow- 
 ing manner: The arm is rendered bloodless, and then 
 one determines the position of the M. flexor ulnaris 
 with the help of the os pisiforme, its point of insertion, 
 and of the tendon of the M. flexor carpi radialis by 
 drawing a line upward from the second metacarpal 
 joint, to whose base it is attached. Half-way between 
 these two tendons an incision is made to the liga- 
 mentum carpi volare proper; hooks are used to widen 
 the wound, with the radial (side) one must be very 
 careful on account of the median nerve. Next, he 
 proceeds into the depth between the tendons, first 
 the superficial ones, then the deep-lying ones; when 
 the connective tissue which binds together the deep 
 tendons has been passed, the sheath is opened, the pus 
 streams out, while with a Lister 's forceps the opening 
 of the sac is dilated upward and downward ; after this 
 iodoform gauze is laid in, the bandage removed, and 
 the bleeding stopped by compression. 
 
 "As a bandage I usually use a boric acid applica- 
 tion which is changed daily. The gauze remains undis-
 
 254 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 turbed until it loosens of itself; and as a support for 
 the hand, a volar splint is used. Some prefer to make 
 an opening upon a bulb-headed probe previously in- 
 troduced in the vola manus on the lower border of the 
 ligamentum carpi volare proper, and to draw a drain 
 in between the two openings. Yet I must say that I 
 have no particular fondness for using drains in this 
 place, as they easily compress the tendons in this 
 comparatively narrow canal and thereby give rise 
 to necrosis. If the incision has been made above the 
 ligament, and along the tendon to the little finger, 
 there will be an upper and lower opening of the bursa, 
 which, without danger to the tendons, can be held 
 open by gauze drainage, and offers sufficient outlet 
 for the pus, at least so long as the pus confines itself to 
 the sheath alone. If the suppuration lasts I prefer 
 to split the ligamentum carpi volare proper and lay 
 open the canals; it is not rare to succeed in this way 
 in rescuing the tendons which at this point have a 
 fairly large vessel lying in mesotendon. " 
 
 K. Poulsen has also discussed the therapeutics of 
 tendovaginitis of the thumb and radial bursa. He 
 opens the finger tendon sheath to the lower edge of 
 the M. adductor pollicis and the radial bursa above 
 the ligament, avoids drainage tubes, and in their place 
 uses gauze drainage. 
 
 "In cases of persistent suppuration the ligament is 
 cut and a peritendinous phlegmon is mastered by 
 continuing the incision on the thumb along the lower 
 border of the abductor, and laying in drains when it 
 is seen that the tendon will be lost; the cutting through 
 of the muscular system of the thenar, used by some, 
 should be resorted to only in desperate cases, because 
 it destroys in large measure the function of the ab- 
 ductor. " 
 
 It would seem from this that Poulsen, at least in
 
 EXCERPTS FROM THE LITERATURE 255 
 
 coincident infections of the tendon sheath of the thumb 
 and the radial bursa, opens the latter only above the 
 ligament, and exposes that part of the bursa which 
 lies within the thenar, only when the suppuration has 
 spread beyond the bursa. In cases of persistent sup- 
 puration the ligament is cut; but he does not state 
 whether, after this tardy fissure of the ligament, he has 
 found the flexor tendon of the thumb and the thenar 
 nerves capable of carrying on. their work or not. 
 
 "Why it should ever be necessary to split the thenar 
 muscles after cleaving the ligament I cannot see, as 
 only a small upper point covers the radial bursa below 
 the ligament. Nor is it clear why such a fissure of 
 the muscles in question should destroy a great part 
 of their functional activity; but the incision, continued 
 through the ligaments and all the soft parts, including 
 the tendon sheath, cuts through the nerves, not only 
 of the M. adductor, but also of the M. opponens and 
 of the superficial part of the M. flexor brevis, and thus 
 causes a very troublesome crippling of the thumb. 
 
 "Finally, to use this method of operation in 'des- 
 perate' cases will not save the tendon of the thumb; 
 it is undoubtedly better to remove the tendon, which 
 in such a case would undoubtedly be destroyed or 
 rendered useless at this late date." 
 
 To open the upper end of the radial bursa, Max 
 Schiiller proceeds as follows: The incisions are best 
 made outward (toward the radial side) on the forearm, 
 beginning at the radial artery and extending along it. 
 
 Nicaise, on the other hand, places the incision 
 between the arterioradialis and the tendon of the 
 M. flexor carpi radialis, and between the latter and 
 the tendon of the M. palmaris longus.
 
 CHAPTER XVI. 
 
 THE TREATMENT OF ACUTE SUPPURATIVE 
 
 TENOSYNOVITIS DISCUSSION OF 
 
 TECHNIQUE. 
 
 FOLLOWING the anatomical investigations detailed 
 in the previous chapters and a careful study of all 
 clinical cases coming under observation, certain pro- 
 cedures were instituted, which in my hands have given 
 most satisfactory results. The technique which I 
 have used in these serious cases is herewith described. 
 This may be classified under three heads. 
 
 1. In the early hours while the diagnosis may be 
 in doubt. 
 
 2. When the symptoms and signs of tenosynovitis 
 are marked. 
 
 3. After-treatment. 
 
 TREATMENT WHILE THE DIAGNOSIS MAY BE IN DOUBT. 
 
 Very commonly, when a finger is infected, it is some 
 days before the tendon sheath becomes involved; 
 again, it may be early, and when it is invaded the 
 symptoms develop rapidly because, as was mentioned 
 above, there is so little resistance that the infection 
 spreads throughout the sheath in a short time. How- 
 ever, during the preliminary stage, much may be done 
 to prevent a spread into the sheath. The best sort 
 of application is undoubtedly some form of moist, hot 
 dressing. Boric acid solution in saturated strength is 
 most commonly used, but any of the other solutions 
 in common use are probably just as efficient. Carbolic 
 acid dressing in any form should be avoided because of
 
 TECHNIQUE OF TREATMENT AFTER DIAGNOSIS 257 
 
 the danger of gangrene. Local painting with ichthyol, 
 iodine, and such irritating solutions is absolutely use- 
 less. German surgeons speak highly of 95 per cent, 
 alcohol dressings left on twenty-four hours. They 
 probably are no more efficient than the hot boric 
 solution, and are always a source of some anxiety, 
 owing to the possible danger of their catching fire, as 
 I have personal knowledge of in one case. Probably 
 the next most essential procedure is to keep the part 
 at rest; this, of course, is indicated in any infection, 
 since the muscular action tends to disseminate the 
 germs, thus extending the area to be walled off by the 
 leukocytes carried in by the dilatation of the vessels 
 incident to the hot dressings. Elevation of the parts 
 is recommended by many, but personally I could never 
 see any advantage in it except to make the arm com- 
 fortable, and it is true the elevation of the hand is 
 sometimes necessary for this. If the infection is severe, 
 put the patient in bed. An ice-bag in the axilla may 
 help some. Keep the bowels open and the kidneys 
 active. Preserve the nutrition of the patient. The 
 methods of Bier and Klapp are discussed above. 
 
 TECHNIQUE OF TREATMENT AFTER DIAGNOSIS IS MADE. 
 
 The diversity of opinions as to the proper methods 
 of treatment held by various surgeons, as noted above, 
 is sufficient proof of the severity of this condition and 
 the difficulty of its treatment. It emphasizes the fre- 
 quency of bad functional results and should stimulate 
 us to most careful study of our cases. 
 
 The diagnostic acumen of the operator cannot but 
 be a vital factor in the treatment. It is probable that 
 too many will err on the side of conservatism in the 
 treatment of the first cases that are met. It will be 
 reasoned that since some damage already will have 
 17
 
 occurred to the tendons, if they are involved, a few 
 hours' delay will not add seriously to the condition. 
 This possibility will be preferred to that of opening and 
 infecting an uninvolved sheath. However, these few 
 hours are of great importance in the fulminating type, 
 and operation should be most prompt. 
 
 I do not intend this as advocacy of operation regard- 
 less of accurate diagnosis, but as a stimulus to careful 
 study to the end that the surgeon, being better qualified, 
 may neither, by ill-advised conservatism, delay neces- 
 sary operation, nor by thoughtless, audacious incisions 
 jeopardize the usefulness of a healthy hand. 
 
 My own opinions as to the best methods are based 
 upon my anatomical researches and upon observation 
 of the patients presenting themselves at the dispensary 
 and hospital of the Post-Graduate Medical School and 
 Hospital, at Wesley Hospital, and the Northwestern 
 University Medical School. To Professors Besley and 
 Richter, and others of my friends at these hospitals 
 and at the Cook County Hospital, I wish to acknowl- 
 edge my appreciation of the opportunity for the study 
 of their cases in addition to my own. Concerning the 
 technique of treatment, I cannot help but feel that 
 the future has much in store for us that we cannot 
 know at the present time. The subject is one not only 
 of local condition, but of the resistance of the individual 
 and his reaction to various toxins. In other words, 
 the newer problems in serum pathology must first be 
 worked out before we can attain the best results. I 
 cannot but feel, however, that even the local conditions 
 are not so well understood by the average surgeon as 
 is possible, and that our bad results would be reduced 
 at least by half if more study were given to careful 
 diagnosis. 
 
 I have secured the best results by the following 
 procedures. Operation should always be done under
 
 TREATMENT OF TENOSYNOVITIS OF FINGERS 259 
 
 general anesthesia and in a bloodless field. Where the 
 process is especially virulent and acute, I leave on the 
 Esmarch bandage for twelve to eighteen hours after 
 the operation. Care is taken, however, to loosen it so 
 as to produce a passive hyperemia. In other words, a 
 Bier's hyperemia is secured for this time. This is 
 done not so much for the therapeutic effect as to prevent 
 the rapid absorption of virulent toxins. I hope in this 
 manner to give the patient time to react and develop 
 antitoxins to overcome the poison rather than allow 
 him to be overwhelmed by a large amount of virulent 
 toxin absorbed at one time. 
 
 TREATMENT OF TENOSYNOVITIS OF THE INDEX, MIDDLE, AND 
 
 RING FINGERS. 
 / 
 
 The procedure will vary according to the form of 
 infection and the amount of destruction present. The 
 first incision is made at the site of known infection, 
 opening the sheath at the side and not in the median 
 line, cutting the length of the shaft of the proximal or 
 middle phalanx, and leaving the part over the articula- 
 tion uncut so that the tendon does not prolapse, unless 
 there is doubt as to the freedom of drainage. I wish 
 to insist that the first requisite is adequacy of the open- 
 ing for drainage, since a small incision soon becomes 
 closed by prolapsing tissue. Make the incision too 
 free rather than too small. In those cases where it has 
 seemed advisable to incise the length of the sheath, 
 which I do in case of doubt, I have bound the finger 
 in an extended position to prevent prolapse of the 
 tendons. After having opened the sheath at this one 
 point, pressure upon its various parts will give one 
 some idea of the extent of the invasion. If it is com- 
 plete, as is generally the case, a similar incision is made 
 over the uncut proximal or middle phalanx. No 
 incision is necessary, as a rule, over the distal phalanx,
 
 260 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 and in making this I feel that Klapp is in error if his 
 drawing represents his technique correctly. Over the 
 proximal end of the sheath, at the base of the palm, 
 the technique will vary according to the extent of the 
 invasion. If early, the incision is made over the middle 
 of the sheath at its end in the palm, carrying it from 
 the flexion crease at the base of the proximal phalanx 
 for about three-fourths of an inch into the palm. If, 
 however, there is some question whether the lumbrical 
 spaces at the sides have begun to become involved 
 
 FIG. 87 
 
 Lines show area of possible incisions for infections of the various tendon 
 sheaths. (See text for full description.) 
 
 (vide supra), the incision is made upon the side most 
 affected, opening the space and the tendon sheath 
 at the same time. If both sides are involved, two 
 incisions are made. The finger is now cleansed and 
 examined. If the amount of pus is great, a second line 
 of incisions is made upon the opposite side of the 
 finger over the two proximal phalanges by inserting 
 the knife blade through from the incision already made 
 on the one side (Fig. 87). If there is much involve- 
 ment of the synovial surfaces, or if there is much
 
 TREATMENT OF TENOSYNOVITIS OF FINGERS 261 
 
 edema of the finger, which would tend to close the 
 incisions, I connect the two first incisions made, thus 
 making one incision the length of the finger rather than 
 multiple incisions on both sides of the finger. 
 
 I have tried cutting down to the sac in doubtful 
 cases, 1 then inserting an aspirating needle and attempt- 
 ing to draw off some pus for diagnostic purposes, 
 hoping by this procedure to avoid the possibility of 
 infecting an uninvolved sheath through opening it with 
 a scalpel. While, theoretically, the procedure would 
 appear to be advisable, practically it is of little aid. 
 The bulging of the sheath, proving the presence of 
 fluid under tension, is generally easily seen, while a 
 failure to secure pus is not sufficient evidence of its 
 absence. 
 
 WHEN THE INVOLVEMENT OF ADJACENT AREAS HAS 
 BEGUN. The involvement of the articulation between 
 the middle and proximal phalanges, which occurs in 
 late cases, will be discussed in the chapter dealing with 
 complications and sequelae (Chapter XXVIII). The 
 method of treatment will be outlined there. I shall 
 only add to what I have already said, that if early 
 incision of the sheath is made this involvement is 
 generally prevented: another reason for early incision. 
 As has been pointed out, the paths of extension in 
 the involvement of the lumbrical spaces vary in the 
 individual fingers. 
 
 The Index Finger. When the infection passes to 
 the lumbrical space on the outer side, it may extend 
 into the thenar space, and the incision which opens the 
 lumbrical space can extend up into the thenar. Press- 
 ure upon the thenar area will force pus out along the 
 line of incision. This is then extended along the radial 
 side of the metacarpal bone, the incision lying dorsal 
 to the web which extends from the thumb to .the base 
 
 1 White, Whitlow and its Treatment, Brit. Med. Jour., February 24, 1906.
 
 262 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 of the index finger. The artery forceps is then carried 
 across the palmar surface of metacarpal bone and the 
 blades opened, thus draining the thenar space without 
 an incision upon the palmar surface (Figs. 100 and 106). 
 Care should be used not to force the point of the for- 
 ceps beyond the middle metacarpal bone; otherwise the 
 middle palmar space will be entered and an extension 
 to this space favored. 
 
 When the extension has entered the lumbrical space 
 between the index and middle finger, the incision should 
 be made into the sheath at its ulnar side, thus opening 
 both the sheath and the lumbrical canal through the 
 same skin incision. If the lumbrical canal is badly 
 involved, the pus may have extended distally into the 
 loose mesh of tissue at the web or proximally. If 
 distally, it may be necessary to add a second incision 
 upon the dorsum between the bases of the index and 
 middle fingers, and procure through-and-through drain- 
 age of the web, or at times I have split the web com- 
 pletely and have not as yet observed any serious 
 impairment of function following (Fig. 106). 
 
 If the infection extends proximally, some care 
 should be used in the incision, since it may extend 
 either into the thenar or middle palmar spaces. After 
 the lumbrical canal is opened, pressure over these 
 areas will demonstrate which is involved, since pus will 
 exude into the incision. The incision is then extended 
 upon a grooved director along the line of invasion, cut- 
 ting about one-fourth of an inch proximal to the line 
 joining the ends of the flexion creases at the distal 
 part of the palm ; an artery forceps is thrust under the 
 tendon into the space, which, by separating the blades, 
 is effectually opened. We frequently find invasion of 
 the thenar area either directly from the sheath or 
 secondarily by way of the lumbrical canals; when this 
 occurs I supplement this palmar incision by one upon
 
 TENOSYNOVITIS OF FINGER AND ULNAR BURSA 263 
 
 the dorsal surface between the metacarpal bones of 
 the thumb and index finger, i. e., drainage of the 
 thenar space as described in Chapter XVII. 
 
 The Middle Finger. When extension occurs into the 
 lumbrical canal upon the radial side, or the web on 
 either side, the technique of treatment is that just 
 described. When the extension is along the lum- 
 brical canal between the middle and ring fingers 
 toward the palm, early the pus may be between the 
 palmar fascia and the tendon in the "loft," as already 
 described, but it very soon involves the middle palmar 
 space. Here the incision is carried one-quarter inch 
 into the palm, i. e., proximal to the transverse line 
 joining the ends of the flexion creases. If pus is ex- 
 pressed through this from the palm, an artery forceps 
 is inserted under the tendons going to the ulnar side 
 and the blades opened. No drainage is inserted, al- 
 though in a few instances I have placed in the pocket 
 small strips of gutta-percha or gauze thoroughly im- 
 pregnated with vaseline. Ordinary gauze acts simply 
 as a plug, and I never use it. 
 
 The Ring Finger. Here the extension to the web 
 or into the palmar space from either side is treated by 
 the same technique as described above. 
 
 TREATMENT OF TENOSYNOVITIS OF THE LITTLE FINGER AND 
 ULNAR BURSA. 
 
 If the finger alone is involved, the treatment is the 
 same as that noted above for the other fingers, except 
 that almost always it will be found advisable to make 
 a single incision on the lateral surface the length 
 of the two proximal phalanges, since we wish to 
 procure perfect drainage, and thus avoid possible 
 extensions. In about half of the cases there is a 
 congenital separation of the proximal from the distal 
 portion at approximately the metacarpophalangeal
 
 264 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 articulation, and in a certain proportion of these cases 
 in which there is no separation the opening is so nar- 
 rowed that there is a temporary dam produced by 
 serous adhesions if the inflammation is not too ful- 
 minating in character, which unfortunately it generally 
 is. In the former condition there is little likelihood 
 of a spread to the ulnar sheath, so that we should be 
 extremely careful not to open this sheath unless we are 
 certain that it has become infected, since we are ex- 
 posing the patient to grave danger. On the other hand, 
 if the occlusion is of temporary inflammatory origin, 
 we can readily see how important it is that an early 
 diagnosis of the condition should be made and proper 
 treatment of the distal portion instituted to prevent a 
 spread to the ulnar sheath. As to just what the proper 
 procedure should be, in case we are fairly certain that 
 there is an infection of the distal portion of the sheath 
 and we are still in doubt as to whether it has extended 
 to the proximal or palmar portion or not, there is room 
 for discussion. 
 
 Forssell advises that we should begin at the point 
 where we are least sure of infection, while Helferich 
 suggests that we begin at the point of infection where we 
 are sure and make our way along with care. Naturally, 
 we would admit the former to be the proper method 
 if certain unknown equations did not enter into the 
 discussion. In the first place, what proportion of aseptic 
 ulnar sheaths can be opened and not infect the sheath 
 from the lymphatics which are constantly carrying 
 germs from the point of infection through the subcu- 
 taneous tissue in which our so-called aseptic incision 
 is made? Upon the answer to this question depends in 
 all probability the proper solution of the question, and 
 it will take a large number of carefully observed cases 
 to arrive at a decision. Increasing experience, however, 
 has confirmed me in the opinion that it is wiser to
 
 TENOSYNOVITIS OF FINGER AND ULNAR BURSA 265 
 
 incise at a known point of involvement. This pocket 
 being opened, pressure is exerted over the sites of pre- 
 dilection in continuity. If they are involved, pus will 
 be seen to enter the previously opened site. A grooved 
 director is now inserted along the canal and the incision 
 continued or the focus opened by the proper methods. 
 
 FIG. 88 
 
 Lines represent the various incisions made for infections of the tendon 
 sheaths and their possible extensions into the forearm. (See text for com- 
 plete description.) 
 
 When the continuation of this sheath in the hand is 
 involved, the palmar portion is opened by an incision 
 extending from the base of the finger at the distal 
 flexion crease of the palm and passing toward the base 
 of the palm (Fig. 88). It is my custom to insert a 
 grooved director in the sheath at this point and follow 
 along this, cutting the tissues between the sheath and 
 the surface, having the thought in mind to avoid the 
 tendon and cut as far to the ulnar side of the sheath as 
 possible, since there will be better drainage, particu- 
 larly at the wrist, if this is done (Fig. 89). After the 
 anterior annular ligament is reached, pressure above 
 over the prolongation of the sheath in the forearm will 
 force pus downward into the sheath below the ligament 
 if the infection has extended here, as it generally has. 
 
 If an involvement of the prolongation of the sheaths 
 above the annular ligament or a forearm involvement 
 is diagnosticated, I proceed as follows. At a point
 
 266 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 about one and one-half inches above the tip of the ulna 
 an incision is made directly down on this bone at its 
 flexor surface, an artery forceps is now thrust across 
 the flexor surface of this bone and the radius until 
 
 FIG. 89 
 
 ECU 
 
 Cross-section No. VIII. DSCS, dorsal subcutaneous space; EL, 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; MN and V, median nerve and vessels; 
 PL, palmaris longus; PMPS, prolongation middle palmar space; RV and N, 
 radial vessels and nerves; SS, synovial sheath; TM, thenar muscles; UB, 
 ulnar bursa; UV and N, ulnar vessels and nerves. The ulnar bursa, radial 
 bursa, and intermediate sheaths are shown in red. The small prolongation 
 of the middle palmar and thenar spaces in blue. 
 
 it impinges on the skin at the radial side, where the 
 knife cuts down upon it. The incisions in the skin are 
 now enlarged to the length of an inch and one-half or 
 more and the artery forceps opens the subtendinous
 
 TENOSYNOVITIS OF FINGER AND ULNAR BURSA 267 
 
 area to the same extent. Make the incision too long 
 rather than too short, since a large incision with free 
 drainage will heal more rapidly than a small incision 
 with inadequate drainage. Especial care should be used 
 here to make the incision neither too far upon the flexor 
 surface nor dorsally, since in the first instance, especially 
 upon the radial side, the artery may be injured either 
 by the primary incision or subsequent necrosis; and 
 in the second instance, if the incision is too far 
 dorsal it will not drain easily. If the primary incision 
 is made low down and on the radial side the danger 
 of injuring the radial is greater. With the proper 
 
 FIG. 90 
 
 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 interos- 
 seous 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. ., median nerve. 
 
 precaution, no anxiety need be felt (Fig. 90). Having 
 opened this area, the finger is now inserted under the 
 flexor profundus tendons, and if there is any infection 
 of the sheath, it is bulging and can be opened easily. 
 In case it is not found easily, flexion and extension of 
 the fingers will locate the tendons involved and the pal- 
 pating finger can be pushed up among them, or an 
 artery forceps can be pushed under the annular liga- 
 ment through the bursa which has been opened in the 
 palm in front (Fig. 91). Its point is felt plainly by 
 the finger under the tendons, and the opening dilated
 
 268 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 freely. As a matter of fact, the infection will be found 
 to have ruptured into this space in practically every 
 case, except in the very earliest stages. / wish to 
 emphasize that it is upon this incision that I depend for 
 drainage of the upper end of the bursa, since it extends 
 upward on the tendons on their posterior surface (Fig. 
 91). In other words, this site is used for entering and 
 draining the sheath before rupture, as well as for 
 incision for draining the extension into the forearm. 
 At times when the ulnar bursa alone is involved the 
 
 FIG. 91 
 
 Drawing showing extension of the ulnar bursa underneath dorsal surface 
 of the flexor tendons, and probe inserted from a palmar incision, passing 
 under the anterior annular ligament with end showing in the ulnar bursa 
 above. 
 
 incision upon the ulnar side has been found sufficient, 
 and I shall be inclined to use that alone in the future 
 in the uncomplicated cases. It will be remembered 
 that attention has already been drawn to the fact that 
 when extension takes place this area between the 
 flexor profundus tendons and the interosseous septum 
 and the pronator quadratus is always first involved. 
 In the early stages of rupture, after having cut through 
 the skin and subcutaneous tissue, the operator will be 
 inclined to desist, since no evidence of pus will be found. 
 It is not until the area under the profundus is reached
 
 TENOSYNOVITIS OF FINGER AND ULNAR BURSA 269 
 
 that one finds the pus. Again, a second fallacious 
 reason for stopping the incision at this stage may be 
 found. There may be a subcutaneous accumulation of 
 pus on the flexor surface of the wrist, in all probability 
 of lymphatic origin; this having been opened, the 
 operator feels that he has drained a pocket in direct 
 communication with the tendon sheath or may fear 
 that his diagnosis of tendon-sheath infection has been 
 incorrect. 
 
 Because of necrosis of tendons or superficial involve- 
 ment of the tendons above the wrist, it may be deemed 
 advisable to make drainage upon the flexor surface. 
 The anterior annular ligament may or may not be cut 
 as is indicated in the given case. If we wish to open 
 the tendon sheath above the ligament without cutting 
 it, the line of incision lies about one-half inch to the 
 radial side of the ulnar artery. Generally, however, 
 the swelling is such that the pulsation of this vessel 
 cannot be felt. It is then necessary to proceed by 
 choosing a point at the junction of the middle and ulnar 
 thirds .of the flexor surface and incising carefully, 
 layer by layer, until the group of flexor tendons is 
 reached. These can be identified by moving the fingers. 
 The dissection is now carried down along the ulnar 
 border of these tendons in juxtaposition to them and 
 immediately above the anterior annular ligament, 
 since the sheath lies to the ulnar side and posterior to 
 the tendons. If infected, it should be freely opened, 
 since the swelling due to edema and inflammatory 
 infiltration tends to close a small opening. If the 
 infection is now seen to be at all severe, the anterior 
 annular ligament is split as far to the ulnar side as 
 possible. The hook of the unciform interferes some- 
 what with the incision. If it is determined when 
 the palmar part is first incised that the anterior 
 annular ligament shall be cut, one proceeds differently.
 
 270 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 The incision is continued from below upward, carrying 
 the incision about an inch up on the forearm. This 
 latter is made as much to drain the subcutaneous 
 area above the wrist, which commonly becomes in- 
 fected, as to open the sheath. This method of drainage 
 of the upper part of the sheath and the forearm was 
 used exclusively in my early cases before I began to 
 use the transverse drainage under the tendons, and, 
 while fairly satisfactory, it in no way compares with 
 the transverse drainage in ordinary cases. Its use 
 should be restricted to exceptional cases. 
 
 Concerning drainage in these wounds, it has been 
 my experience that when incision has been made in 
 this manner no drainage material is necessary in the 
 majority of cases. If it is desired and there is no 
 hemorrhage, I insert strips of gutta-percha tissue, 
 while if there is hemorrhage small strips of gauze 
 thoroughly saturated with vaseline are packed into 
 the wound. 
 
 It seems especially unsurgical to draw rubber tubes 
 or gauze under the anterior annular ligament, and I 
 never use them. The drainage is not improved and 
 pressure necrosis is favored. Moreover, where drain- 
 age at the wrist is unsatisfactory, I have had little 
 cause to be displeased with the splitting of the anterior 
 annular ligament. No case has been seen in which I 
 felt that that procedure per se had resulted in loss of 
 function, and I have frequently seen entire restoration 
 of function after it had been cut. 
 
 TREATMENT OF EXTENSIONS FROM THE LITTLE 
 FINGER AND THE ULNAR BURSA. The treatment of the 
 various extensions in the finger proper is the same as 
 that outlined while discussing the index finger. When 
 we come to the base we may have extension either 
 into the ulnar bursa, the lumbrical space, or both. 
 In the more acute cases the former alone is more
 
 TENOSYNOVITIS OF FINGER AND ULNAR BURSA 271 
 
 common, while in the more chronic type it is often 
 both. Here the incision opening the tendon sheath 
 can be made to drain the lumbrical space. 
 
 Extensions into the middle palmar space are opened 
 by following along the lumbrical space as in the other 
 fingers if the ulnar bursa is uninvolved. If this latter 
 is invaded, the same incision which opens the ulnar 
 bursa may be utilized by inserting the forceps through 
 the synovial wall of the bursa under the tendons into 
 this space. If the pus has extended over to the thenar 
 space it should be drained by making the incision upon 
 the dorsum between the metacarpal bones of the 
 thumb and index finger and opening it by the forceps, 
 as was described above when discussing the extensions 
 from the index finger. 
 
 The treatment of involvement of the wrist-joint 
 will be discussed in detail in Chapters XXVII and 
 XXVIII, dealing with chronic processes and compli- 
 cations. 
 
 Beginning invasion of the forearm has already been 
 touched upon. Those cases presenting marked in- 
 volvement of the forearm are best treated by incisions 
 as follows (Figs. 122 and 125): 
 
 First, incision upon either side just above the wrist, 
 allowing drainage of the subtendinous space under 
 the profundus digitorum, as described above. These 
 incisions should be increased to two or three inches 
 in length if the accumulation of pus is large. This 
 is especially true of the ulnar side, where even longer 
 incisions can be made with advantage. If the pus has 
 involved the intermuscular septa higher up, the incision 
 should be made about half-way up the forearm upon 
 the ulnar side, either just above the level of the ulnar 
 bone or about an inch farther up on the flexor surface, 
 the desire being in the first instance to go between the 
 flexor carpi ulnaris and the ulna. Here the muscle
 
 272 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 must be separated from the bone. In the second in- 
 stance we attempt to go between the muscular body 
 of the flexor carpi ulnaris and the inner border of the 
 flexor sublimis digitorum. This latter incision gives 
 better drainage, but there is some danger of injuring 
 the ulnar artery either primarily or secondarily. The 
 incision between the ulna and the flexor carpi ulnaris 
 is safer and is sufficiently satisfactory to give good 
 results in a majority of cases. This one incision may 
 be extended three to four inches and generally is 
 all that is necessary in these cases. The incisions 
 through the flexor surface upon the middle or radial 
 side should be condemned. Particularly in those 
 lying upon the middle, i. e., going through the flexor 
 sublimis digitorum, the inflammatory swelling of the 
 muscular mass acts as an effective barrier to free 
 drainage. I have yet to see the case in which the ulnar 
 incision supplemented by the incisions above the 
 wrist, as described, failed to give free and satisfactory 
 drainage. (For a complete discussion of forearm in- 
 volvement and treatment see Chapters XXVI and 
 XXVII.) 
 
 At times it may be necessary to make some incisions 
 through the skin for the liberation of subcutaneous 
 accumulations of pus, probably lymphatic in origin. 
 The most common site for this is immediately above 
 the wrist on the flexor surface. 
 
 Secondary hemorrhage is nearly always from the 
 ulnar artery. It will generally be advisable to ligate 
 this after verifying the fact that it is the vessel at 
 fault, since repeated hemorrhages are likely to occur 
 if tamponade is depended upon, and the patients are 
 generally not in condition to withstand many hemor- 
 rhages. (For a complete discussion of this subject see 
 Chapters XXVI and XXVII.) 
 
 When the radial bursa becomes involved secondarily
 
 INFLAMMATION OF TENDON SHEATH OF THUMB 273 
 
 to the ulnar bursa, it should be treated as a primary 
 radial bursa infection, which we will discuss below. 
 Primary dressing and after-treatment are discussed 
 later. 
 
 TREATMENT OF INFLAMMATION OF THE TENDON SHEATH OF THE LONG 
 FLEXOR OF THE THUMB. 
 
 Here it is my habit to dissect down to the tendon 
 upon the flexor surface of the proximal phalanx; after 
 entering the sheath, the incision is enlarged along the 
 sac through the thenar eminence, separating the mus- 
 cular mass (heads of the flexor brevis pollicis). It 
 should be remembered that the tendon lies nearer the 
 palm than one would be inclined to think, and that the 
 mass of the thenar muscles lies to the radial side of 
 the incision. This is only carried up to within a thumb's 
 breadth of the lower border of the anterior annular liga- 
 ment. I limit the incision at this point, since with the 
 assistance of Professor P. T. Burns and Dr. A. T. Horn, 
 at the Anatomical Laboratory of the Northwestern 
 University Medical School, I made a careful examina- 
 tion of 85 cadaver hands, with the result that it was 
 shown that the motor nerve to the thenar muscles 
 passes across the sheath between this point and the 
 lower edge of the anterior annular ligament, and in 
 my opinion loss of the flexor longus pollicis tendon is 
 to be preferred to destroying this nerve and thus bring- 
 ing about a loss of the muscles which it supplies. 
 Drainage of the upper end of the radial bursa is best 
 carried out by the methods described above when 
 discussing drainage of the upper end of the ulnar 
 bursa. Incisions are made laterally at the flexor sur- 
 face of the ulna and radius and through-and-through 
 drainage secured under the flexor profundus tendons. 
 At times incision upon the radial side alone will be 
 sufficient if the sheath has not already ruptured. If 
 
 18
 
 it has not ruptured, two fingers are thrust into the 
 radial incision under the tendons and a grooved director 
 or forceps is pushed up from the palmar incision along 
 the sheath. The end of the forceps is easily felt in the 
 forearm under the tendons. The sheath is opened and 
 gauze saturated with vaseline or gutta-percha strips 
 inserted into the wound for drainage. (For a further 
 study of the basis upon which this method is advised 
 see Chapters XXVI and XXVII.) 
 
 At times an accumulation of pus will be found on 
 the forearm subcutaneously just above the wrist upon 
 the radial side. When this is opened the surgeon may 
 be of the opinion that the sheath has ruptured and is 
 thus draining anteriorly; hence, he will desist from 
 drainage of the deeper tissue. Such an accumulation 
 is of lymphatic origin and has no connection with the 
 sheath, so that the lateral incisions described above 
 should always be made in addition to this skin incision 
 in front. 
 
 At times, owing to necrosis of tendons or extensive 
 suppuration among them, it may be advisable to drain 
 the sheath from the front, in which case an incision 
 is made going a quarter of an inch to the radial side 
 of the median line of the flexor surface of the forearm. 
 The dissection is carried down to the radial side of the 
 flexor sublimis tendons, avoiding the median nerve 
 which lies in the floor and to the ulnar side. The ten- 
 don sheath has generally ruptured by this time, or can 
 be identified by a grooved director or fine probe passed 
 from the opened sheath below. It is entirely safe to 
 cut the upper part of the anterior annular ligament 
 (Fig. 88). 
 
 In almost every case, however, I feel that this anterior 
 incision should be limited to opening the subcutaneous 
 accumulation if there be any, and the tendon sheath 
 should be opened by the lateral incisions described
 
 INFLAMMATION OF TENDON SHEATH OF THUMB 275 
 
 above for entering the space between the flexor pro- 
 fundus tendons and the pronator quadratus. Good- 
 sized incisions should be made, so that drainage may 
 be free. 
 
 If many cases where the infection has been severe 
 or the tendon impaired primary removal of the tendon 
 should be favored. This is particularly liable to die 
 and remain for many weeks,, causing the infection to 
 persist and jeopardize other structures, so that if the 
 tendon is at all destroyed or the infection shows a 
 slow recovery it should be removed at once. I 
 am also especially inclined to do this if the ulnar 
 bursa has so far escaped involvement, since the preser- 
 vation of this is particularly to be sought. 
 
 The principles of treatment of involvement of the 
 thenar space and the ulnar bursa have already been 
 discussed. In relation to secondary ulnar sheath in- 
 fection, it may be noted that there is doubt frequently 
 as to the diagnosis in these cases. In such cases it is 
 advisable to dissect down carefully upon the sheath in 
 the lower third of the palm just to the radial side of 
 the hypothenar space. After the palmar fascia is cut 
 a pad of edematous fat will be seen to bulge into the 
 wound as if there were great tension in the subaponeu- 
 rotic palmar space. This fat having been dissected 
 away, the tense bursa will be seen to bulge into the 
 field. This is opened and the operation proceeds as 
 described above while discussing the technique of 
 treatment of the ulnar bursa. There is always a grave 
 decision to make as to whether or not the sheath of 
 the little finger tendon has become involved, and 
 therefore should also be opened. Involvement of the 
 carpal joints is discussed in Chapter XXVI. 
 
 When the forearm becomes involved, the treatment 
 is the same as when the involvement has originated 
 from the ulnar bursa, since the foci of extension are 
 the same.
 
 276 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 The case of Mr. W. is reported, since it is probably 
 the most virulent case of tenosynovitis beginning in 
 the thumb and extending over by way of the tendon 
 sheath of the flexor longus pollicis to the ulnar bursa 
 that I have had an opportunity to observe. The 
 infection was virulent and the toxic symptoms so 
 severe as to threaten the patient's life. The result 
 was very satisfactory considering the fact that the 
 case did not come under observation until after the 
 sheath had been involved for at least thirty-six hours. 
 In this case there was a complete restoration of func- 
 tion of the entire hand and fingers, with the possible 
 exception of slight loss of flexion of the distal phalanx 
 of the little finger. This result is a marked contrast 
 to those cases of similar nature which I have seen 
 several days after the sheath had become involved, 
 when such destruction of the tendons and their cover- 
 ings had taken place as to preclude the possibility of 
 a favorable outcome no matter what the surgical 
 procedure might be. The history of the case is prac- 
 tically identical with one seen two months previously, 
 which had remained eight days without opening. The 
 general health and resistance of the individuals were 
 much the same. The outcome in the first case which 
 had been treated conservatively was most disastrous, 
 the patient barely escaping with his life and ending 
 with a functionless hand. After observing these two 
 cases, so close together and with such similar condi- 
 tions, I cannot but feel that under these conditions 
 conservatism is most inadvisable, and that the earliest 
 possible opening of the sheath is indicated. 
 
 CASE XIII. Mr. W., referred by Dr. Colleran, Post- 
 Graduate Hospital, July, 1908 (Fig. 92). 
 
 Patient gave a history of having run a splinter of wood 
 into the distal phalanx of the thumb seven days previous 
 to coming to the clinic. This had been removed with a
 
 INFLAMMATION OF TENDON SHEATH OF THUMB 277 
 
 penknife, and later, at the end of five days, another 
 splinter had been removed. Three days before, he began 
 to complain of pain over the course of the thumb and 
 radial side of the hand. The whole hand now became 
 tender and swollen. 
 
 FIG. 92 
 
 Photograph showing the incision in the case of Mr. W., splitting of the 
 ulnar bursa and radial bursa and incisions above the wrist. Accompanying 
 photographs show result two and one-half months after treatment. (See 
 Case XIII.) 
 
 On examination, temperature was 101; pulse, 96. 
 The whole hand was found to be swollen on both the 
 flexor and dorsal surfaces, as was also the forearm. Con- 
 cavity of the palm was still present. Tenderness was 
 most marked at the wrist-joint and slightly above on both 
 the radial and ulnar sides. There was tenderness also 
 along the course of the ulnar bursa in the palm of the hand 
 and over the tendon sheath of the little finger. There was 
 only slight tenderness in the palm of the hand. Tenderness 
 is also found over the course of the flexor longus pollicis. 
 There is no tenderness over the index, middle, or ring 
 fingers, and none on the dorsum. On extension of the 
 fingers, extension of the little finger and thumb caused
 
 278 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 marked pain, the ring finger slight pain, and the middle 
 and index fingers very little pain. 
 
 Diagnosis of tenosynovitis of the flexor longus pollicis, 
 the intermediary sheaths at the wrist, and the ulnar bursa 
 was made. 
 
 Operation. General anesthesia; Esmarch's bandage 
 applied. Incision was made through the skin and sub- 
 cutaneous tissue over the ulnar bursa in the lower third 
 of the palm. After cutting through the palmar fascia the 
 fat bulged into the wound. This was split and the bulging 
 sheath was seen beneath. This was opened and pus found. 
 The sheath was then opened throughout its length from 
 the base of the middle finger up to and through the anterior 
 annular ligament (Fig. 92). Pus was found throughout. 
 An incision was then made in the forearm on either side 
 at the level of the flexor surfaces of the ulna and radius, 
 one inch above the anterior annular ligament; an artery 
 forceps was passed underneath the tendons of the flexor 
 profundus digitorum. A slight amount of pus was found 
 here. An artery forceps now opened the sheath of the 
 ulnar bursa at its upper end, passing into the space under- 
 neath the flexor tendons, and a finger enlarged the opening. 
 
 An incision was made over the proximal end of the 
 proximal phalanx of the thumb into the sheath of the 
 flexor longus pollicis. A small amount of slightly turbid 
 fluid was present that was not clearly pus. The opening 
 was extended, however, to the distal end, where consider- 
 able pus was evacuated. The incision was then extended 
 upward along the sheath to within a thumb's breadth of 
 the lower border of the anterior annular ligment. Free 
 pus was found here also. An artery forceps was then 
 passed along the sheath up into the forearm underneath 
 the flexor profundus tendons, communicating with the 
 opening previously made. 
 
 After washing the sheath out thoroughly with normal 
 salt solution, strips of gauze saturated with vaseline were 
 laid between the cut edges of the skin and also drawn 
 underneath the flexor profundus. Hot boric dressings 
 were applied. 
 
 Subsequent Course. Pain was immediately relieved, 
 temperature fell to 99, around which it remained, at no 
 time going higher than 100, and the patient made a
 
 INFLAMMATION OF TENDON SHEATH OF THUMB 279 
 
 gradual and satisfactory recovery. At the end of twenty- 
 four hours the hot boric dressings were changed for dry 
 dressings, the inner layer of which was saturated with 
 vaseline. The strips of gauze between the edges of the 
 wound were removed, the hand was dressed in dorsal 
 extension on a right-angled dorsal splint (Fig. 93). 
 
 FIG. 93 
 
 Photograph showing the dorsal right-angled splint used after splitting the 
 annular ligament in infection of the ulnar bursa. In the photograph the hand 
 has been loosened from the dressing so as to show the right angled splint. 
 
 Subsequent Treatment. Each day the hand was dressed, 
 each of the articulations was moved, including the finger-
 
 280 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 joints and wrist, and the hand dressed in dorsal extension. 
 On the fifteenth day it was deemed advisable to open 
 the tendon sheath of the little finger, which had not 
 been opened at the time of operation. A small amount of 
 pus was evacuated, and I believe it would have been 
 advisable to have opened this sheath at the time of the 
 primary operation. The incisions over the flexor longus 
 pollicis were completely healed at the end of three and 
 one-half weeks. Those above the wrist closed at the 
 end of five days. That over the tendons of the ulnar bursa 
 was completely closed at the end of four and one-half 
 weeks. At that time the patient could move slightly all 
 the fingers of the hand, and flex voluntarily, with the 
 exception of the little finger, every joint, including the 
 wrist. He was urged to use his hand repeatedly and to 
 return for passive motions. In this respect he was some- 
 what dilatory. At the beginning of the sixth week his 
 hand was treated daily in the Klapp apparatus for break- 
 ing up adhesions, and at the end of the ninth week he 
 began to work with his hand, and at the end of the twelfth 
 week he had practically complete function of all joints 
 and fingers, with the exception of the little finger, where 
 there was only 25 per cent, of function. This will improve, 
 but will never be perfect (Fig. 92). 
 
 The following case of acute streptococcic infection 
 of the flexor longus pollicis is reported in some detail, 
 since it is one in which the patient narrowly escaped 
 with her life, and shows the course in these cases; and 
 because the sheath ruptured permitting involvement 
 of the subprofundus space without involvement of the 
 ulnar bursa. 
 
 The complete restoration of the tendon function in 
 this case is most encouraging. I believe that with an 
 early incision, carefully followed by conservative treat- 
 ment, we can hope for much better results in the future 
 than in the past. 
 
 CASE XIV. Dr. S., seen in consultation with Dr. 
 Besley, gave the following history which is abbreviated 
 from the history sheets of the hospital.
 
 INFLAMMATION OF TENDON SHEATH OF THUMB 281 
 
 January 23. Pulse, 100; temperature, 101.8 ; respira- 
 tions, 26. Hot dressings applied to right arm; under 
 nitrous oxide anesthesia, Dr. M. L. Harris incised the 
 flexor surface of the thumb. Condition good. 
 
 January 24. Pulse, 80; temperature, 98.6; respira- 
 tions, 20. Slept fairly well. Condition seems very much 
 improved. 
 
 January 26. Leukocytosis, 11,000. 
 
 January 27. Pulse, 64; temperature, 98; respirations, 
 20. Entire thumb swollen and pus oozes from incisions. 
 Thumb again incised by Dr. Charles Davison; drainage 
 inserted. Normal salt enemas given every four hours; hot 
 boric acid solution to part; 5 P.M., pulse, 80; temperature, 
 101 ; respirations, 20. 
 
 January 29, 4 A.M. Pulse, 108; temperature, 102.8; 
 respirations, 26; 8 A.M., pulse, 80; temperature, 103.4; 
 respirations, 22; leukocytosis, 21,000. Thumb irrigated 
 with hot boric and peroxide; dry dressings applied; 9 P.M., 
 temperature, 102.2; palm of hand greatly swollen and 
 angry red extending into wrist. Vomited small amount 
 of fluid. 
 
 January 30, 9 A.M. Temperature, 101.6; nauseated 
 and vomited greenish fluid; face flushed; slept very 
 little. 
 
 January 31, 9 A.M. Temperature, 101.4; pulse, 96; 
 respirations, 20. Swelling on hand increasing and extend- 
 ing; under gas-ether anesthesia Dr. F. A. Besley made 
 an incision into the radial bursa, liberating yellowish pus. 
 Rubber drain inserted, allowing free drainage between 
 first and second metacarpals. Small incision made above 
 wrist, but no pus found in arm, although there was con- 
 siderable redness and swelling. 
 
 February I. Pulse, 84; temperature, 102; respira- 
 tions, 20. Slept some since 10 P.M. Pain in hand. Hot 
 dressings. Smears from pus show short chains of strepto- 
 cocci. 
 
 February 2. Temperature, 101.6; leukocytosis, 24,000. 
 Feels rather drowsy. Does not have much pain. Slept 
 at intervals. 
 
 February 3. Pulse, 84; temperature, 100.2; respira- 
 tions, 20. Cultures on agar and in bouillon show only 
 streptococci; leukocytosis, 32,000. Under gas anesthesia
 
 282 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 incisions enlarged and opened wide by forceps by Drs. 
 Besley and Kanavel. 
 
 February 4, I A.M. Pulse, 80; temperature, 102; 
 9 P. M., temperature, 101. Slept most of forenoon. 
 
 February 5, 10 A.M. Temperature, 102. Hand 
 dressed. Swelling, hyperemia, and tenderness along flexor 
 surface of arm, radial side. Pus oozes from wounds. Good 
 night's rest; 4 P.M., pulse, 112; temperature, 103; respir- 
 ations, 24. Another incision made in forearm by Dr. 
 Besley. The incision was made on radial surface of arm, 
 and liberated a large quantity of yellow pus. Gauze pack- 
 ing inserted. Gas anesthesia. 7.30 P.M., gauze packing 
 removed. Patient rather restless. 
 
 February 6. Pulse, 92; temperature, 102; respira- 
 tions, 20. 
 
 February 7. Pulse, 90; temperature, 99.4; respirations, 
 20. Patient very comfortable. Small superficial pocket 
 of pus on anterior surface of wrist opened by Dr. Besley. 
 
 February 8. Pulse, 80; temperature, 98; respirations, 
 
 20. 
 
 FIG. 94 
 
 Photograph showing the function present in Case XIV; infection of the 
 radial bursa, three months after treatment. 
 
 From this time on the temperature remained normal. 
 Patient gradually improved, and was discharged February 
 24. The wound in the thenar space closed about two 
 weeks later.
 
 SYNOVIAL SHEATHS ON THE DORSUM 
 
 283 
 
 Subsequent History. At the end of five months the case 
 presents a complete restoration of function of the muscles 
 of the thumb and the tendon of the flexor longus pollicis, 
 and the tendons of the hand upon flexion (Fig. 94). 
 
 SYNOVIAL SHEATHS ON THE DORSUM. 
 
 When the synovial sheaths upon the dorsum are 
 infected, a simple splitting of the sheath throughout 
 
 FIG. 95 
 
 Acute suppurative dorsal tenosynovitis. Note the area of surrounding 
 edema. The tendon sheath is only about one-half the length of the tume- 
 faction. 
 
 its length apparently gives the best results. I have had 
 only four of these cases due to acute infection, and they 
 all recovered with good function after a short time,
 
 284 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 with the exception of the case in which this involve- 
 ment was associated with a palmar infection, when 
 a fatal issue followed (Case XXII, Fig. 95). 
 
 AFTER-TREATMENT. 
 
 DRAINAGE. The use of drainage has been discussed 
 by every surgeon, and the principles underlying it here 
 are the same as elsewhere. Those who after much 
 experience and thought have decided upon its use will 
 probably use it here. My own results have led me 
 to abandon it almost extirely. I never use a rubber 
 tube, owing to my fear of pressure necrosis. Gauze, if 
 left in many hours, begins to act as a plug. Unless 
 there is bleeding, it is not used. If, however, one fears 
 that the skin will close down at once and prevent the 
 escape of pus, gauze saturated with vaseline is inserted. 
 I have found this to give good drainage and not to 
 act so much as a plug, yet giving tampon pressure 
 in cases of oozing. Strips may be inserted from the 
 sides above the wrist under the flexor profundus, and 
 also above into the ulnar incision on the forearm. I 
 have also used gutta-percha strips with satisfaction. 
 In my earlier cases drainage tubes were inserted 
 through from the palm to the dorsum, after the older 
 methods of palmar drainage, but since introducing 
 palmar drainage along the lumbrical spaces this pro- 
 cedure has been abandoned entirely. 
 
 In the virulent cases, every attempt is made not to 
 manipulate the arm and hand any more than is neces- 
 sary, so as to protect the patient against absorption 
 of toxins as much as possible. The application of the 
 Bier method of constriction of the arm to prevent the 
 rapid absorption of bacteria and toxins during and 
 immediately after incision has already been touched 
 upon. During the after-treatment the same pre-
 
 AFTER-TREATMENT 285 
 
 cautions are taken so long as the process is acute. The 
 area is kept immobilized and slightly elevated. This 
 latter is done to secure comfort as much as to aid in 
 recovery. The von Volkmann treatment, i. e., vertical 
 elevation of the hand, has not seemed to me to be 
 of great therapeutic value, although apparently it is 
 a valuable procedure in that it prevents excessive 
 edema in the later stages. 
 
 For the first few days after incision it would appear 
 that hot, moist dressings are of value to relieve the 
 pain and promote walling off of the infection. After 
 this stage they should be abandoned in favor of dry 
 dressings, since they seem to produce excessive granu- 
 lation. In several cases I have been able to apply dry 
 dressings at the end of twenty-four hours. The hot, 
 moist dressings are generally made from a saturated 
 solution of boric acid. However, it is probable that 
 the moist heat is the essential factor. Strong anti- 
 septic solutions, such as bichloride and carbolic acid, 
 are never used. The inner layer of the dry gauze may 
 be saturated with vaseline to prevent it adhering to the 
 wound. 
 
 The hand is dressed from once to twice daily. If 
 gauze has been inserted and has adhered to the wound, 
 there is less shock produced by anesthetizing the patient 
 with a small amount of nitrous oxide than is given by 
 the pain incident to withdrawal without such an aid. 
 
 The hand is dressed with the fingers in extension 
 upon a dorsal splint. This is done to prevent prolapse 
 of the tendons. In the fingers this procedure is of 
 special importance, not only to avoid the prolapse of 
 the tendons, but also to prevent all of the fingers 
 tending to become flexed in one position. In the first 
 few dressings the hand may be flexed and normal salt 
 irrigation used to wash out about the tendons. 
 
 The prolapse of the tendons at the wrist is prevented
 
 286 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 by dressing the hand with the wrist sharply bent 
 backward. I ordinarily mould a plaster of Paris 
 splint to fit the back of the forearm up to the wrist; 
 here the plaster splint is bent back at a right angle. 
 The hardened splint is applied to the forearm and 
 held in place by a bandage. A second bandage now 
 attempts to bring the hand back to the horizontal 
 prolongation. At times I have used light elastic 
 pressure. The tension and position are varied from day 
 to day after danger of prolapse has ended, so as to 
 prevent ankylosis of the tendons and joint in one 
 position. The primary splint is applied immediately 
 after the operation (Fig. 93). 
 
 The prevention of adhesions in the joints, preserva- 
 tion of the vitality of the muscles, and the use of the 
 tendons is most important, and at times the results 
 are discouraging. Unfortunately the surgeon so often 
 sees these cases after primary incisions have been made 
 and the case treated for several days. In the severe 
 fulminating types this has permitted such destruction 
 of the tendons and synovial coverings as to make any 
 after-treatment of little avail. It seems to me advisable 
 to begin passive and active movements within a few 
 days after primary incisions; in other words, as soon 
 as the danger of systemic infection is over. I do not 
 believe that the local condition is made materially 
 worse, and we do aid in the prevention of firm adhesions. 
 It is better to do this in baths of very hot water, which 
 relieves the pain to some extent and helps to cleanse 
 the discharging wound. The patient's hand and fore- 
 arm being immersed in hot sterile water, the surgeon 
 with glove-covered hands gently flexes and extends 
 each finger, as well as the hand at the wrist, several 
 times. Violent movements are not indulged in. The 
 bath is not kept up any length of time, since we 
 wish to prevent rather than to favor the development
 
 AFTER-TREA TMENT 
 
 287 
 
 of granulation tissue at this stage. The patient is 
 encouraged to make active movements himself. If a 
 dry, hot chamber is at hand, this may be used to 
 advantage. I cannot emphasize too strongly the impor- 
 tance of this early, gentle, and intelligent manipulation. 
 I do not refer to massage, but to the intelligent use 
 of the various joints, muscles, and tendons. 
 
 FIG. 96 
 
 Showing the Bier apparatus for production of mobility in stiffened 
 tendons and joints. 
 
 Bier (Fig. 96) and others (Fig. 97) have used mechani- 
 cal appliances to produce the same effect. The force 
 may be exerted by exhausting the air in a chamber 
 in which the hand has been placed, the hand or the
 
 288 TREATMENT OF SUPPURATIVE TENOSYNOVITIS 
 
 individual fingers being applied to the fixed end so 
 that when the air is exhausted the joints are flexed 
 or extended. He attributes some of his good results 
 to the therapeutic effect of exhausting the air and 
 producing a hyperemia. The apparatus also has the 
 advantage that the patient will be more persistent 
 
 FIG. 97 
 
 Showing the Klapp apparatus for producing mobility in stiffened wrist-ioint. 
 
 and regular in the application of the treatment than 
 he will be if he depends on treatment by the surgeon 
 alone. The results of treatment may be materially 
 bettered by such an apparatus, as I have had oppor- 
 tunity to verify in my late cases. The surgeon must 
 not expect that it will cure old, contracted cases or 
 those with great destruction of tissue.
 
 CHAPTER XVII. 
 
 THE TREATMENT OF FASCIAL-SPACE 
 ABSCESSES. 
 
 WE shall here consider the treatment of fascial 
 space abscesses uncomplicated by tenosynovitis, or in 
 case of complications presenting only those of minor 
 importance, so that the fascial-space abscess is still 
 the predominant picture. 
 
 The treatment naturally divides itself into prophyl- 
 actic and active. In the first instance all wounds 
 should be given aseptic care, and any localized infec- 
 tion should be attended to, thorough drainage being 
 instituted before the infection has a chance to spread. 
 In those cases in which we are waiting to decide 
 whether or not a localized abscess is present, immobili- 
 zation and the local use of the well-known hot, moist 
 dressing is probably more efficient than any other 
 application. The usual general tonic and excretory 
 procedures should be instituted. 
 
 Should the diagnosis of a localized accumulation of 
 pus in any of the various tissues be made, our first 
 question is, What is the best site for incision? for we 
 need not discuss the fact that such a condition 
 as that demands early and efficient drainage. Should 
 the subcutaneous tissue of the dorsum or the areas 
 under the epidermis or dermis of the palm be involved, 
 or minor infections of the thenar and hypothenar areas 
 be present, a wide opening by simple incision is gen- 
 erally sufficient. Should the middle palmar, thenar, 
 lumbrical, or subaponeurotic spaces be involved, 
 however, some special consideration is necessary. 
 19
 
 290 TREATMENT OF FASCIAL-SPACE ABSCESSES 
 THE MIDDLE PALMAR SPACE. 
 
 TECHNIQUE OF TREATMENT. It is probably better 
 to err upon the side of radicalism, than conservatism, 
 when confronted with a possible middle palmar-space 
 abscess, owing to the liability of complications in the 
 ulnar synovial sheath, the bones, and the joints, if 
 the abscess is neglected. 
 
 Any method of opening the space exposes certain 
 tissues to injury, and it is a question of choosing the 
 least dangerous route. It cannot be opened upon the 
 ulnar side, owing to the fear of infecting the ulnar 
 bursal sheath; a flap of the palmar fascia should not 
 be dissected up from below, as has been suggested, 
 making a sort of trap-door, as it were, since the in- 
 fection lies below the tendons, and to make such an 
 opening and then drain anteriorly between the tendons 
 would result in unnecessary adhesions. 
 
 The least injury and the most efficient drainage of 
 the middle palmar space can be secured by an incision 
 along one of the three lumbrical canals leading into 
 this space, i. e., the little finger, ring finger, or the 
 middle finger canals (Fig. 98). That canal will be 
 chosen which is already markedly infected, either be- 
 cause it has been the atrium of the infection or because 
 it has been secondarily involved. If the surgeon has 
 any choice in the matter, that between the ring and 
 middle finger gives the most satisfactory drainage. An 
 incision is made into the canal and carried one-half 
 inch above its end up into the palmar space, i. e., 
 one-half inch proximal to a line joining the proximal 
 end of the distal flexion crease with the distal end 
 of the middle flexion crease, or, grossly speaking, a 
 thumb's breadth and a half up into the palm. This 
 brings the incision between the tendons. An artery 
 forceps is thrust under the group of palmar tendons
 
 THE MIDDLE PALMAR SPACE 
 
 291 
 
 and the blades opened, satisfactory drainage ensuing. 
 A small strip of gutta-percha or gauze saturated with 
 vaseline will keep the opening from closing for a day, 
 after which time it will not be needed. I think that I 
 
 FIG. 98 
 
 Showing incisions for opening the lumbrical space and for opening the 
 lumbrical space in conjunction with the middle palmar space. 
 
 am indebted to Dr. F. A. Besley for the suggestion as 
 to this method of incision. It is remarkable how 
 rapidly cases will recover under this treatment. 
 
 Herewith is reported the first case in which I used 
 this method. I have used it many times since with 
 absolute satisfaction.
 
 292 TREATMENT OF F ASCI AL-SP ACE ABSCESSES 
 
 CASE XV. Infection base of palm spreading along 
 lumbrical canal into palm; incision along canal. Recovery 
 with perfect function. 
 
 M. R., treated at the Post-Graduate Hospital, July, 
 1906. Service of Prof. F. A. Besley. Five days before 
 entrance patient developed an infection from the crack 
 of a callus at the base of the palm of the right hand between 
 the ring and little fingers. An abscess had formed in the 
 fascial space at the base of these fingers and extended along 
 the lumbrical canal. Upon investigation it was found to 
 have involved the middle palmar space. This was diag- 
 nosticated by the tenderness localized over the lumbrical 
 canal, and the bulging of the palm associated with local- 
 ized tenderness. The incision was made at the original 
 
 FIG. 99 
 
 Photograph of incision in a case of infection in the middle palmar space 
 originating in web at end of lumbrical canal. Recovery with complete func- 
 tion in ten days. (See Case XV.) 
 
 site of the infection, passing from the palm through the 
 fascial tissue to the dorsum between the proximal phalanges 
 of the fingers. A grooved director was then inserted along 
 the lumbrical canal, which was opened throughout its 
 extent, the incision being carried up to the middle flexion 
 crease of the palm ; in other words, one-half inch above the 
 lumbrical canal. Forceps were now inserted underneath 
 the tendons, opening the palmar space widely; about one 
 ounce of pus escaped ; no drain was inserted ; hot boric 
 dressings applied. 
 
 Course. At the end of ten days all discharge of pus had 
 ceased and wound had healed. At the end of three weeks 
 complete function was present in all the fingers and hand 
 (Fig. 99).
 
 TREATMENT OF PALMAR AND THENAR SPACES 293 
 
 THE TREATMENT OF COMBINED INVOLVEMENT OF THE MIDDLE PALMAR 
 AND THENAR SPACES. 
 
 The treatment here can be best illustrated by quot- 
 ing a typical case. Here the middle palmar and the 
 thenar spaces having been simultaneously involved, 
 
 FIG. 100 
 
 Drawing showing the drainage under tendons. AT, adductor transversus; 
 LS, lumbrical space; MPS, middle palmar space; TS, thenar space; UB, 
 ulnar bursa. 
 
 the forceps was passed from the incision into the middle 
 palmar space under the palmar tendons, as already 
 described, and pushed through the thin septum sepa- 
 rating the palmar and thenar spaces at the proximal
 
 294 TREATMENT' OF F ASCI AL-SP ACE ABSCESSES 
 
 end, the point thus passing through the thenar space 
 superficial to the adductor transversus and coming out 
 on the dorsum between the metacarpal bones of the 
 thumb and index finger (Fig. 100). A gutta-percha 
 drainage strip was then drawn through and left 
 eighteen hours. 
 
 CASE XVI. Primary infection, cracks from callus on 
 palm, extension into palm of hand, drainage of middle 
 palmar space, thenar space, ulnar bursa, and forearm. 
 Recovery with perfect function. 
 
 H., Post-Graduate Hospital. Two weeks before com- 
 ing to the hospital patient had developed an infection 
 in the palm of the hand, evidently in the callus produced 
 by tongs handling ice. Two or three inadequate incisions 
 had been made when the patient entered the hospital, 
 with a temperature of 102 and an enormous swelling of 
 the entire hand and forearm, involving the palmar and 
 dorsal surfaces. The palmar fascia bulged up instead of 
 presenting its normal concavity, while the thenar area was 
 ballooned out as if inflated to its complete capacity. 
 There was redness and swelling upon the flexor surface of 
 the forearm involving particularly the lower third. The 
 swelling upon the back of the hand was ascribed to edema. 
 The fingers were flexed at an angle of 45 degrees, while the 
 metacarpal bone of the thumb set back from the hand and 
 the distal phalanx of the thumb was sharply flexed. The 
 diagnosis of pus in the middle palmar space, thenar space, 
 the forearm under the profundus tendons, and the probable 
 involvement of the common synovial sheath in the palm 
 was made. Owing to the inadequate incision already made 
 in the palm, this was chosen as the proper site for explor- 
 ation. The incision having been carried through the 
 palmar fascia, pus was found in the position designated, 
 with an involvement of the ulnar bursa from the base of the 
 little finger to the forearm. The bursa was opened through- 
 out its length, cutting through the anterior annular liga- 
 ment. The major portion of the pus, however, lay outside 
 the sheath. An artery forceps was inserted under the 
 tendons of the palm below the sheath and a large ostium 
 made. An artery forceps was then thrust through the
 
 TREATMENT OF PALMAR AND THENAR SPACES 295 
 
 FIG. 101 
 
 Case XVI before and after incision, 
 from the dorsum into the thenar space, 
 ligament was cut. 
 
 Note the artery forceps through 
 In this case the anterior annular
 
 296 TREATMENT OF F ASCI AL-SP ACE ABSCESSES 
 
 partition between the thenar and middle palmar spaces 
 at the base of the hand lying on the volar side of the trans- 
 versus pollicis, coming out between the metacarpal bones 
 
 FIG. 102 
 
 Case XVI, showing result three months after treatment. Note perfect 
 
 function. 
 
 of the thumb and index finger. A drainage strip was then 
 drawn through this space of the palm and left in eighteen 
 hours. The incision, which was carried through the 
 anterior annular ligament to the forearm, exposed a large
 
 THE PALMAR AND SUBAPONEUROTIC SPACES 297 
 
 abscess lying underneath the tendons of the flexor pro- 
 fundus digitorum upon the pronator quadratus and 
 interosseous membrane. The incision was extended for 
 three inches up on the forearm to open this space com- 
 pletely. Hot boric dressings were applied. 
 
 Course. Immediate subsidence of temperature and 
 septic symptoms. In ten days complete cessation of 
 discharge, and in two weeks all wounds were healed. In 
 three weeks the patient was using his hand with 75 per 
 cent, of function, and in five weeks complete function was 
 present, as demonstrated by accompanying photographs 
 (Figs. 101 and 102). 
 
 This case was one of the worst that ever came to 
 my notice. We were fortunate, however, in that no 
 necrosis of the tendons had taken place. The rapid 
 and complete recovery can be ascribed only to the 
 thorough opening of every pocket of pus by incisions 
 that did not endanger previously uninvolved areas. We 
 should also note that the annular ligament was cut. 
 
 THE TREATMENT OF COMBINED INVOLVEMENT OF THE MIDDLE PALMAR 
 AND SUBAPONEUROTIC SPACES. 
 
 At times we will have crushing injuries of the hand 
 in which the metacarpal bones are fractured. Here the 
 subaponeurotic space on the dorsum is involved in con- 
 junction with the middle palmar space (Case VIII). In 
 such cases the through-and-through drainage so much 
 in vogue among the older surgeons is indicated. Let 
 us study where such drainage can be safely instituted 
 if it is indicated. Such a point should be chosen as 
 will give the most satisfactory outlet to all the diver- 
 ticula, and at the same time injure the fewest structures. 
 Here the value of our x-ray plates, with the cross- 
 sections and injections, is invaluable. We see that the 
 mass always lies over the interosseous space between
 
 298 TREATMENT OF F ASCI AL-SP ACE ABSCESSES 
 
 the ring and middle fingers, and that an opening here 
 will drain all the pockets (Fig. 103). Our incision, 
 however, must lie proximal to the superficial trans- 
 verse ligament. (See cross-section, Fig. 68; x-ray, 
 Fig. 105.) Secondly, it must lie to the radial side of 
 the ulnar bursa (x-ray plate, Fig. 104), and must be to 
 
 FIG. 103 
 
 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. 
 
 the ulnar side of the middle metacarpal, or it will 
 enter the thenar space. This again throws the incision 
 into the metacarpal space, between the middle and 
 ring fingers. Thus we see that not only are the fewest 
 structures injuced at this site, but also the most perfect 
 drainage is instituted.
 
 THE PALMAR AND SUBAPONEUROTIC SPACES 299 
 
 Now let us consider where an incision should lie 
 in this space. An examination of the x-ray picture 
 (Fig. 105) shows the deep palmar arch running across 
 this area, at the upper end; the fine lines drawn trans- 
 versely represent the dense transverse ligament while 
 the curved lines represent the palmar creases. It is thus 
 
 FIG. 104 
 
 X-ray plates, representing the location of pus in the thenar space, with its 
 relation to the ulnar bursa. 
 
 seen that at the point where the middle palmar crease 
 crosses the metacarpal space should be the indicated 
 site for drainage. Making a cut here through the palmar 
 aponeurosis, and then forcing a pointed artery forceps 
 through to the dorsum, being careful to rupture the 
 dorsal aponeurosis freely, we draw through a large 
 twisted gutta-percha strip. At this site there is little
 
 300 TREATMENT OF F ASCI AL-SP ACE ABSCESSES 
 
 danger of a pressure necrosis of the ulnar bursa or the 
 palmar arches. 
 
 FIG. 105 
 
 X -ray Plate. Boundaries of the thenar and middle palmar spaces marked, 
 and proper site for opening the latter indicated. Ulnar bursa and blood- 
 vessels injected. Photograph made for me by Miss Brindley 's Surgical X-ray 
 Laboratory. MPS, middle palmar space; A, deep palmar arch; B, thenar 
 space.
 
 v rr 
 
 , 
 
 TREATMENT OF ABSCESSES IK TffENAR SPACE 301 
 
 -"Fttrjijr 
 
 TECHNIQUE OF TREATMENT OF ABSCESSES IN THE 
 THENAR SPACE. 
 
 Should the thenar area be involved, the indications 
 for radical operation are absolute, even upon less 
 evidence than in the case of palmar infection, since 
 here the dangers of delay are greater, and the conse- 
 quences of opening the space, even though uninfected, 
 are not serious (see Case VI, in which space was 
 opened when uninfected, under mistaken diagnosis). 
 Here the pus lies either anterior to the adductor 
 transversus, or upon both its dorsal and palmar 
 surface. Theoretically, the most available place to 
 open would lie to the radial side of the index meta- 
 carpal, where a free incision would drain both in front 
 of and behind the adductor. We therefore make an 
 incision through the dorsum, on the radial side of the 
 index metacarpal and opposite its middle, and on a 
 level with its flexor surface. An artery forceps is then 
 thrust into the thenar space across the flexor surface 
 of the index metacarpal. This gives perfect drainage 
 and leaves no scar upon the flexor surface of the hand. 
 Care should be taken not to pass the artery forceps 
 beyond the middle metacarpal bone, for fear of spread- 
 ing the infection to the middle palmar space (Fig. 
 106). 
 
 Illustrating these facts, the following case may be 
 cited : 
 
 CASE XVII. K., injured September 3, 1904. The 
 sharp point of a meat tongs ran into the thenar area upon 
 the level of the extended thumb about 2 cm. from the thenar 
 adductor crease. Pain and swelling ensued the following 
 day. On September 5, he consulted a physician, who 
 found much redness and swelling upon the dorsal thenar 
 area and made an incision there, but evidently failed to 
 evacuate pus. Hot dressings were applied, and two days
 
 ^F ASCI AL-SP ACE ABSCESSES 
 
 ,UMQIS 
 
 slater patient presented himself at the Northwestern Uni- 
 versity Surgical Dispensary for treatment. There was 
 considerable swelling of the whole hand, but distinctly 
 greater upon the radial side. Dorsal thenar area had 
 slightly greater swelling present than palmar thenar area. 
 Upon inspection it was not difficult to see that the thenar 
 
 FIG. 106 
 
 Showing incisions made upon the dorsum of the hand. That upon the 
 thenar space is made to drain the thenar space in the palm. Those upon 
 the distal part are made to drain extensions from the palmar space to the 
 dorsum and the so-called collar-button abscesses when they extend to the 
 dorsum. 
 
 area, as a whole, was much more swollen than the re- 
 mainder of the hand. Adduction thenar crease was the 
 dividing line. Thumb metacarpal fully abducted, proximal 
 phalanx semiflexed, distal phalanx fully flexed, giving an 
 almost spastic look to the hand. The finger phalanges 
 were all semiflexed. The flexion of the index finger,
 
 ABSCESSES IN SUBAPONEUROTIC SPACE 303 
 
 however, was more rigid than that of the other three, and 
 movement of it and the thumb caused more pain than 
 the three ulnar fingers. Both epitrochlear and axillary 
 glands slightly enlarged and tender. Old incision upon 
 dorsal thenar region, from which small amount of pus 
 was exuding. Temperature, 101 ; pulse, 90. Tenderness 
 marked over palmar thenar area. 
 
 Diagnosis. Abscess, thenar space. Operation: Under 
 nitrous oxide anesthesia incision made into thenar area 
 at about the same site as the wound; much pus evacuated. 
 Gutta-percha drainage established; hot, moist boric dress- 
 ings applied. September 7, swelling almost subsided, still 
 discharge of much pus. Temperature, 99; pulse, 84. 
 Treatment continued. Cultures taken; typical staphy- 
 lococcus aureus colonies, methylene blue and Gram's 
 stains; staphylococcus aureus. September 9, hand much 
 better, drainage removed, hot dressings reapplied. Sep- 
 tember II, hand in good condition; dry dressings applied. 
 Following this, patient made a rapid recovery. Seen July, 
 1905. No contraction; function perfect. 
 
 TECHNIQUE OF TREATMENT OF ABSCESSES IN SUB- 
 APONEUROTIC SPACE. 
 
 If the subaponeurotic space be involved, we should 
 remember that the tendons proper in the lower part 
 of the dorsum overlie the metacarpal bones, except the 
 tendon going to the little finger; consequently our 
 incision should lie over the interosseous space. More- 
 over, any deep transverse incision, if too long, would 
 cut the tendon, while a simple longitudinal incision 
 would tend to close. Therefore, in making our incision 
 and drainage, these two factors should be taken into 
 consideration and an adequate opening provided, which 
 does not injure the tendon. Those cases complicated 
 with middle palmar-space infection have already been 
 discussed (p. 297). 
 
 // the infection has spread up under the annular 
 ligament into the forearm, the pus will lie beneath the
 
 304 TREATMENT OF FASCIAL-SPACE ABSCESSES 
 
 tendons of the flexor profundus and upon the pronator 
 quadratus. The best method of emptying this abscess 
 would be to go laterally, just anterior to the radius and 
 ulna about three inches from the wrist. A complete 
 description of the method of treating these cases will 
 be found in Chapter XXVII. 
 
 AFTER-TREATMENT IN FASCIAI^SPACE ABSCESSES. 
 
 After any of these procedures the usual hot, moist 
 dressings are applied until we feel that extension of the 
 process has ceased, when they should be abandoned, 
 since the continuation of the enlargement of the vessels 
 incident to their use results in increasing edema and 
 ultimately lessening resistance, owing to improper cir- 
 culation; hence they become a menace to the part 
 rather than a help. At this stage elevation of the part 
 will be found to be of material aid. Immobilization 
 should be kept up as long as there is any danger of 
 muscular action disseminating the infection. As soon 
 as this stage has passed, however, active and passive 
 movements should be encouraged at once, with the 
 idea of assisting in the absorption of the excessive 
 edema, as well as assisting in the prevention of tendon 
 and joint adhesions. I frequently begin these on the 
 third day.
 
 CHAPTER XVIII. 
 
 RESUME OF ACUTE SUPPURATIVE TENO- 
 
 SYNOVITIS AND FASCIAL-SPACE 
 
 ABSCESSES PROGNOSIS. 
 
 RESUME. 
 
 SUCCESS in the treatment of tendon-sheath infections 
 of the hand depends upon early accurate diagnosis 
 upon incisions so made as to drain the proper sites 
 without involving uninfected areas, and upon careful 
 after-treatment. 
 
 Two types must be recognized, the fulminating and 
 the subacute. The treatment will vary with the type. 
 The most marked symptoms and signs are : Localized 
 excruciating tenderness over the course of the sheath, 
 pain on extension, especially at the proximal end of the 
 sheath, and the characteristic position of the finger. 
 
 Infection from the tendon sheath of the index finger 
 will most often extend to the lumbrical spaces and the 
 thenar space and less often to the proximal interpha- 
 langeal joint, and the surface at the proximal end of 
 the sheath. 
 
 From the middle finger it most often extends to the 
 lumbrical spaces and middle palmar spaces or at times 
 the thenar space and less often to the proximal inter- 
 phalangeal joint, and the surface at the proximal end. 
 
 From the ring finger the extensions are the same, 
 except that they always involve the middle palmar space 
 if extension takes place into the palm. 
 
 From the little finger, the most common sites of exten- 
 sion are the lumbrical space, the middle palmar space, 
 and the ulnar bursa, less commonly to the proximal inter- 
 phalangeal joint and the surface at the proximal end 
 
 20
 
 306 TENOSYNOVITIS AND FASCIAL-SPACE ABSCESSES 
 
 of the sheath. From the ulnar bursa it may extend 
 to the middle palmar space, radial bursa, interosseous 
 space below the flexor profundus, and the wrist-joint. 
 From the sheath of the flexor longus pollicis to the 
 thenar space, ulnar bursa, wrist-joint, and inter- 
 osseous space above described. 
 
 Incisions should be too radical rather than too 
 conservative. Incisions are best made in the fingers, 
 either upon one or both sides of the tendon sheath 
 over the length of the shaft of the middle and proximal 
 phalanx, avoiding the joints, and into the proximal end 
 of the sheaths or the lumbrical spaces to provide drain- 
 age there. Complete splitting along one side should be 
 done in case of doubt, since the adequacy of drainage 
 should be the first requisite. 
 
 The ulnar bursa is best treated by splitting it 
 throughout its length, cutting upon the ulnar side. 
 The anterior annular ligament may be cut if necessary. 
 This is commonly supplemented by incisions upon the 
 radial and ulnar sides of the forearm above the wrist- 
 joint, and. on a level with the flexor surface of the bones; 
 through-and-through drainage is then carried out 
 under the flexor profundus tendons. An ulnar incision 
 may be sufficient. If the pus has invaded the forearm, 
 an ulnar incision is made at the middle of the forearm 
 between the flexor carpi ulnaris and the flexor sub- 
 limis, or between the flexor carpi ulnaris and the ulna. 
 
 Incision of the flexor longus pollicis sheath is made 
 from a finger-breadth below the anterior annular liga- 
 ment to the end of the sheath. Opening may be made 
 above the anterior annular ligament, the upper half 
 of which may be cut. However, drainage may be 
 better instituted above the wrist by the lateral incision 
 mentioned under ulnar bursal infections. 
 
 In the after-treatment the Bier constrictor may be 
 used for a few hours, hot, moist dressings for from two
 
 PROGNOSIS 307 
 
 to four days, followed by dry dressings, the hand being 
 held in overextension by splint and daily manipulation of 
 joints and muscles after immediate danger of systemic 
 infection has ended. 
 
 There may be accumulations of pus in any of the 
 six fascial spaces I have described, to the exclusion of 
 any or all the others, namely, the middle palmar, 
 thenar, lumbrical, hypothenar, dorsal subaponeurotic, 
 dorsal subcutaneous. These may be involved separ- 
 ately or in conjunction with the tendon sheaths. The 
 middle palmar space with its diverticula along the three 
 lumbrical muscles is best drained by an incision along 
 a lumbrical canal carried up to the space. The thenar 
 space is best drained by an incision on the dorsum to 
 the radial side of the index metacarpal. Hypothenar 
 abscesses are localized and can be drained by simple 
 incision. All forearm extensions may be drained by 
 lateral incisions above the wrist, the drainage being 
 inserted under the tendons of the flexor profundus 
 
 digitorum. 
 
 PROGNOSIS. 
 
 The life of the individual is frequently jeopardized 
 in either of these types of infections. Undoubtedly if 
 proper treatment is instituted the danger will be 
 reduced to a minimum. The lymphatic infections 
 which will be discussed in the subsequent chapters are 
 the most frequent source of death. The fulminating 
 type of tendon-sheath infections may cause death, but 
 the more chronic type, as also the fascial space abscesses, 
 should have few fatalities except in neglected cases. 
 Especial caution should be exercised in giving a favor- 
 able prognosis in the aged, since the prognosis grows 
 rapidly worse after forty. The presence of a nephritis 
 is also of serious import. 
 
 It is very nearly impossible to state from a study of 
 the literature what proportion of cases may hope for 
 a satisfactory local outcome. The authors base their
 
 308 TENOSYNOVITIS AND FASCIAL-SPACE ABSCESSES 
 
 statistics upon different classifications. "Good result" 
 is used by some to designate a recovery without loss 
 of any part of the hand, with function at the wrist and 
 in the uninvolved fingers, while others insist upon a 
 complete restoration of the function in the finger as 
 well. It is to be hoped that in the future the statistics 
 may be more accurate. From my personal experience, 
 however, I feel that the following statements may be 
 made. A complete functionating hand can always be 
 promised in acute infections of the hand, not involving 
 the tendon sheaths, unless necrosis of tissue has taken 
 place or joint involvement has occurred. That is to say, 
 abscesses of the middle palmar space, thenar space, and 
 forearm, as well as simpler conditions, can be treated 
 with a perfect functionating result. This has occurred 
 in my experience even after four or five weeks of in- 
 adequate treatment. In tendon-sheath infection, how- 
 ever, the results are not nearly so good. By proper 
 and early treatment a perfect result can generally be 
 assured as to function of the wrist-joint, hand and 
 fingers not involved. Where the tendon sheath of a 
 finger is involved, unless early treatment is instituted, 
 flexion of the phalanges of that finger is likely to be 
 lost, while flexion at the metacarpophalangeal articu- 
 lation may generally be preserved. In early cases or 
 under exceptional circumstances complete function may 
 be secured. In the thumb, even though the function 
 of the flexor longus pollicis is lost, the hand will not 
 be seriously impaired, since the smaller muscles of the 
 thumb will give it such function that the impairment 
 will not be as serious by any means as in the fingers. 
 Extension from tendon sheaths to the forearm should 
 be looked upon with anxiety, and if serious complica- 
 tions or sequelae are present, the patient must be 
 warned that the course may be long and the ultimate 
 restoration of function depend much upon continued 
 and faithful application of after-treatment.
 
 SECTION III. 
 LYMPHATIC INFECTIONS. 
 
 CHAPTER XIX. 
 
 THE RELATION OF LYMPHANGITIS TO 
 OTHER TYPES OF INFECTION DIS- 
 CUSSION OF THE ANATOMY. 
 
 THE RELATION OF LYMPHANGITIS TO OTHER TYPES OF 
 INFECTION. - 
 
 LYMPHANGITIS may be of two types, superficial and 
 deep. Of these, the superficial is most common, owing 
 to the fact that slight abrasions, superficial fissures, and 
 small punctures, disregarded by the patient because 
 they are considered of no importance, are generally 
 the source. These lie in the superficial tissues and 
 lead to a superficial or subcutaneous infection. The 
 rarer type, deep lymphangitis, undoubtedly may occur. 
 When it does, however, it develops as a complication 
 of superficial lymphangitis or as a sequence of deep 
 injury, and when such deep injury occurs the wound is 
 generally considerable, so that the lymphangitis is of 
 secondary importance to the local condition. 
 
 For the sake of study, lymphangitis must be sharply 
 differentiated from tenosynovitis and fascial space in- 
 fection. It is true that in a large number of cases a 
 tenosynovitis or fascial-space infection may develop 
 from a lymphangitis, but it is also true that in a 
 majority of cases neither complication ensues unless 
 ill-advised surgery produces them. Under patho-
 
 genesis I shall discuss these complications in full, and 
 under symptomatology shall try to suggest the various 
 points which may serve to differentiate them when 
 they are separate conditions or may serve to diag- 
 nosticate their development when they arise in the 
 course of a pure lymphatic infection. Owing to the 
 intimate relation of lymphangitis to septicemia, it has 
 seemed wise to associate the discussion of the former 
 with that of the latter, and, for the sake of the clinical 
 picture, to consider in relation to them the various 
 severe infections jeopardizing life, such as gas bacillus 
 infections and anthrax. A complete discussion of teno- 
 synovitis and fascial-space abscesses may be found in 
 the preceding chapters. 
 
 ANATOMY. 
 
 In order to understand the pathogeny of lymphatic 
 abscesses, an accurate knowledge of the position and 
 course of the lymphatic vessels is absolutely essential. 
 The masterful work of Mascagni and the later work 
 by Sappey have been fully reviewed and verified by 
 Poirier, with the assistance of his pupil Cuneo, making 
 use of Gerota's process of injection, and the following 
 is largely quoted from their treatise upon that subject. 
 We so often see the superficial lymphatics in the course 
 of surgical practice that we are inclined to forget that 
 there are deep lymphatics which follow the deeper 
 vessels. Sappey believed that these two systems were 
 absolutely independent. Poirier, however, maintains 
 that communication is fairly common, especially in 
 the articular regions. It is important to remember 
 that the principal vessels and glands lie superficial to 
 the large veins and seldom deep. The clinical signifi- 
 cance of this is apparent to the surgeon. Another 
 general point of importance is that the texture of the
 
 ANATOMY 
 
 311 
 
 surrounding connective tissue influences their shape and 
 number. If the connective tissue is lax, their tendency 
 is to run together and become sinuous and sacciform 
 (Fig. 107). Consequently the infection is likely to 
 
 FIG. 107 
 
 -CK 
 
 
 m 
 
 V^V^Hp'- 
 
 Drawing showing lymphatics grouped about a hair follicle on the dorsum. 
 Character of lymphatic tissue commonly seen in loose connective-tissue spaces. 
 (After Sappey.)
 
 312 LYMPHANGITIS AND OTHER TYPES OF INFECTION 
 
 localize in the looser connective-tissue areas. This 
 probability is accentuated by the fact that glands, 
 either microscopic or macroscopic, show a predilection 
 for these areas. The fact that sacciform dilatations 
 and microscopic glands do occur explains the produc- 
 tion of abscesses in the course of an apparently un- 
 interrupted lymphatic. Moreover, the variability both 
 in the number and the position of these glands renders 
 absolute statements as to their position impossible. 
 Not alone are microscopic glands present in the course 
 of the vessels; Gulland has demonstrated them in 
 the axilla, and Stiles has seen axillary glands appear 
 during lactation and disappear on its cessation. How- 
 ever, this may be stated: In a given animal and a 
 given region the quantity of glandular tissue is always 
 practically identical. Thus if the glands are small 
 they are numerous, and if large they are likely to be 
 scarce. In any case, however, they are generally 
 paravascular. 
 
 THE LYMPHATIC VESSELS OF THE HAND AND FOREARM. 
 
 These may be divided into two groups the super- 
 ficial lymphatics, which arise from the integument 
 and whose collecting trunks run in the subcutaneous 
 cellular tissue, and the deep lymphatics, arising in the 
 deeper tissues and in vessels following the deep blood- 
 vessels. 
 
 SUPERFICIAL LYMPHATICS. 
 
 These, being easily demonstrated experimentally and 
 seen so often clinically, are well known. 
 
 "The superficial lymphatics come from all parts of 
 the cutaneous covering of the limb, but it is in the 
 fingers (Fig. 108) and the palm of the hand that the 
 net-work of origin is the richest. It is, therefore, at
 
 SUPERFICIAL LYMPHATICS 313 
 
 these points, and more particularly on the palmar 
 surface of the fingers, that punctures must be made 
 for the injection of the lymphatics of the upper limb. 
 "The collecting trunks of the superficial net-work 
 appear at the roots of the fingers and at the base of 
 the palm of the hand (Fig. 109). They then run up- 
 ward on the forearm and arm, receiving as they ascend 
 the lymph from other parts of the cutaneous covering. 
 They terminate in the glands of the axilla. We will 
 study first their digital and palmar origin, and then 
 their course and termination. 
 
 FIG. 108 
 
 Net-work of lymphatics on the side of the finger. The accompanying 
 drawing represents the trunklets which carry the lymphatic stream to the 
 base of the finger. (After Sappey.) 
 
 "Origins: (A) In the fingers, the net- work of origin 
 presents its maximum of development on the palmar 
 surface (Fig. no). Here the meshes are so closely 
 set that it is only by a careful examination with a 
 lens that they can be distinguished. The dorsal net- 
 work is much less rich than the preceding (Fig. in). 
 From these two net-works arise a considerable number 
 of collectors, which converge toward the sides of the 
 fingers and unite to form two or three trunks on each 
 of these surfaces (Fig. 108). These trunks at first
 
 314 LYMPHANGITIS AND OTHER TYPES OF INFECTION 
 
 FIG. 109 
 
 Showing lymphatics of a hand and arm, the areas of origin and distribution. 
 
 (After Sappey.)
 
 SUPERFICIAL LYMPHATICS 
 
 315 
 
 FIG. no 
 
 Showing extensive net-work of lymphatic channels on the palm and fingers, 
 with their extensions to the dorsum and to the forearm through the collecting 
 trunklets. (After Sappey.)
 
 316 LYMPHANGITIS AND OTHER TYPES OF INFECTION 
 
 follow the corresponding collateral artery, but, having 
 arrived at the base of the finger, they incline backward 
 
 FIG. in 
 
 Showing lymphatics upon the dorsum. Note how few there are in com- 
 parison with those upon the palmar surface. (After Sappey.) 
 
 and run toward the interdigital space. They then pass 
 to the posterior surface of the hand, and are directed 
 toward the wrist, where we shall trace them again
 
 SUPERFICIAL LYMPHATICS 317 
 
 shortly. In their course on the dorsal surface of the 
 hand they effect numerous anastomoses. They cross 
 one another frequently, and it is no unusual thing to 
 see a collecting trunk, which has arisen, for example, 
 in the fourth interdigital space, uniting with trunks 
 which run along the external part of the dorsal surface 
 of the hand. 
 
 FIG. 1 1-2 
 
 Lymphatic vessels of the palm, showing their extensions from all the 
 borders to the dorsum and the extension from the central portion into the 
 deep lymphatic along the palmar arch. (After Sappey.) 
 
 " (B) In the palm of the hand the net- work of origin 
 is also extremely rich. From this net- work run 
 numerous trunklets, which we may divide into exter- 
 nal, internal, inferior, superior, and central (Fig. 112). 
 
 'The external trunklets, four to six in number, run 
 obliquely upward and outward, and, crossing the sur- 
 face of the thenar eminence in a slanting direction, 
 terminate in the lymphatics coming from the integu- 
 ments of the thumb. 
 
 "The internal trunklets, more numerous than the 
 preceding (eight or ten), run almost transversely 
 inward, and, crossing the ulnar border of the hand,
 
 318 LYMPHANGITIS AND OTHER TYPES OF INFECTION 
 
 reach the dorsal surface and empty themselves into 
 the collecting trunks which arise from the integument 
 of the little finger. 
 
 "The inferior trunklets, which vary from twelve to 
 fifteen in number, are directed toward the interdigital 
 spaces; they then reach the dorsal surface of the hand 
 and terminate in the digital collecting trunks. 
 
 'The superior trunklets reach the anterior surface 
 of the wrist, and unite to form three or four trunks, 
 which ascend on the anterior surface of the forearm. 
 
 'The central trunklets run toward the deep portion. 
 They traverse the subcutaneous fatty layer and the 
 superficial palmar fascia, and they usually unite into 
 a single trunk. The latter, which has been well 
 described by Sappey, takes the following course: It 
 is directed immediately outward, running underneath 
 the fascia, in front of the flexor tendons. It thus comes 
 to the adductor transversus pollicis, crosses the inferior 
 border of this muscle, and then crosses the outer border 
 of the first dorsal interosseous, on the posterior surface 
 of which it ascends. It there joins collectors coming 
 from the index finger, and in company with the latter 
 reaches the dorsal surface of the wrist. 
 
 "Course: All these collecting trunks, which arise 
 from the integuments of the fingers and hand, run in 
 the subcutaneous cellular tissue toward the root of 
 the limb. They are usually more superficial than the 
 veins whose trunks they cover. They diminish in 
 number as they are traced upward. In the forearm 
 there are about thirty, but in the middle of the arm 
 not more than fifteen to eighteen. (Sappey.) 
 
 "In the wrist they are divided into two groups, of 
 which one runs on the dorsal, the other on the palmar 
 surface of this part of the limb. 
 
 "In the forearm they tend to divide themselves 
 into three groups an external group, which ascends
 
 SUPERFICIAL LYMPHATICS 319 
 
 along the radial border of the forearm; an internal 
 group, which follows the ulnar border; a middle group, 
 which is a satellite of the median vein and runs between 
 the two preceding. 
 
 "A little below the bend of the elbow the two lateral 
 groups come more and more to the anterior surface 
 of the limb and unite with the median group; on the 
 dorsal surface we find nothing but some rather small 
 collecting trunks, which incline obliquely, some out- 
 ward, others inward, and reach the anterior surface of 
 the arm (Fig. 109). At the level of the olecranon these 
 collecting trunks present remarkable sinuosities. 
 
 "In the arm the different collecting trunks, hence- 
 forth united into a single bundle, show a tendency to 
 arrange themselves on the external surface of the arm, 
 parallel to each other. 
 
 "Termination: The majority of these collectors run 
 as far as the neighborhood of the base of the axilla. 
 Here, they perforate the deep fascia and terminate 
 in the humeral chain of axillary glands. The collectors 
 from the outermost and innermost parts have quite a 
 different termination; thus, two or three of the most 
 internal end in the supra-epitrochlear gland. We have 
 already seen that the efferents of this gland perforated 
 .the deep fascia in the middle part of the arm and end 
 in the deep vessels. When this gland is absent, we may 
 nevertheless see the internal collectors perforating the 
 fascia at the same point to reach the deep absorbents. 
 The most external trunk is also remarkable for the 
 special course it pursues. It separates itself from the 
 other collectors in the region of the humeral insertion 
 of the deltoid, then ascends in the deltopectoral groove, 
 where it may traverse one or several glands which we 
 have indicated above. This trunk usually passes into 
 a subclavian gland, placed at the spot where the 
 cephalic joins the axillary vein. It may also be seen
 
 320 LYMPHANGITIS AND OTHER TYPES OF INFECTION 
 
 to pass above the clavicle, and to empty itself into a 
 supraclavicular gland. This arrangement, though 
 somewhat infrequent (Grossmann says 38 out of 100 
 cases), has been figured by Mascagni. This delto- 
 pectoral trunk is sometimes double and even triple." 
 
 DEEP LYMPHATICS. 
 
 "The deep lymphatics follow the brachial artery and 
 its chief branches. There are usually two lymphatic 
 trunks for each artery. With Sappey, we will divide 
 these deep lymphatics into radial, cubital, posterior 
 interosseous, anterior interosseous, and brachial. 
 
 "The radial trunks arise from the subfascial portions 
 of the palm of the hand. 'One accompanies the deep 
 palmar arch, turns around the head of the first meta- 
 carpal bone, and runs on the outer side of the carpus, 
 and reaches the forearm, where it is situated on the 
 external side of the radial artery; the other, whose 
 origin is not so deep, follows, according to the sketch 
 left us by Mascagni, the course of the radiopalmar 
 artery, and also joins the forearm, where it is placed 
 on the inner side of the radial. Both then ascend as 
 far as the bend of the elbow, where they anastomose. 
 In their antibrachial course they traverse one or two 
 small glands, the existence of which is not constant.' 
 (Sappey.) 
 
 "The ulnar trunks are also two in number. They 
 have a separate origin. One, in fact, appears by the 
 side of the superficial palmar, while the other is a 
 satellite of the deep palmar arch. They unite at the 
 wrist, just above which they receive a large affluent 
 which is a satellite of the dorsal branch of the ulnar. 
 They then run parallel to the ulnar vessels as far as 
 the bend of the elbow. During their course they 
 sometimes present one or more small glands. 
 
 "The posterior interosseous trunks, which arise from
 
 DEEP LYMPHATICS 
 
 321 
 
 the deep muscles of the forearm, perforate the inter- 
 osseous membrane and then unite at the bend of the 
 elbow with the preceding vessels. 
 
 "The anterior interosseous trunks follow the vessels 
 of this name, and, after presenting in their course one 
 or two small glands, also end in the lymphatic meeting- 
 place at the bend of the elbow. 
 
 FIG. 113 
 
 Showing lymphatics about a hair follicle. (After Sappey.) 
 
 'The humeral trunks comprise all the above-men- 
 tioned antibrachial collecting trunks. They vary from 
 two to three in number. They run by the side of the 
 humeral vessels, and terminate in the humeral group 
 of the axillary glands. As we have already seen, they 
 present in their course some small glands which appear 
 to be nearly always present. In the middle part of 
 the arm they collect the efferent vessels from the 
 supra-epitrochlear gland. They also receive some small 
 trunks from the muscles of the arm," 
 
 21
 
 CHAPTER XX. 
 
 LYMPHANGITIS ETIOLOGY, PATHOGENESIS, 
 AND PATHOLOGY. 
 
 PREDISPOSING AND ACTIVE FACTORS IN THE PRODUCTION 
 OF LYMPHANGITIS. 
 
 WHILE a lymphangitis may develop at any time of 
 the year, it is most frequently observed in the fall and 
 winter, an observation that is concurred in by all 
 authors. This may find its cause in the unnatural 
 conditions under which workingmen live during the 
 colder months, at which time they are closely housed, 
 with the result that they breathe impure air, and be- 
 cause of this and the lack of outdoor exercise their 
 power of resistance is reduced. It is possible that the 
 colder air which contracts the superficial vessels may 
 have some bearing on the development of the infections 
 by lessening the natural protection against superficial 
 injuries. 
 
 The source is most often some slight puncture, carry- 
 ing bacteria beneath the surface, or the small cracks 
 so often found in workingmen's hands, especially in 
 winter, about the calloused areas, the so-called durillon 
 force of the French authors. These are particularly 
 noted at the distal part of the palm, where dirt incident 
 to the occupation is rubbed into the fissures. The 
 slight punctures often come from needles or pins, and 
 are thus frequently found on the distal phalanx, gen- 
 erally being so slight as to have been forgotten when 
 the patient applies for treatment. Again, we note its 
 frequency after trauma of the nail. The patient gives a 
 history of running a splinter under the nail, or of some
 
 FACTORS IN THE PRODUCTION OF LYMPHANGITIS 323 
 
 injury which has caused a separation of the nail from 
 its bed, with a small subonychial hemorrhage, which 
 has become infected. 
 
 Why it is that similar injuries may be followed 
 in one case by severe lymphangitis and in another by 
 no results is still an unanswered question. We are 
 
 FIG. 114 
 
 Showing lymphatics in the palm of the hand. (After Sappey.) 
 
 accustomed to say that the resistance of the patients 
 varies, and this is undoubtedly true. On the other hand, 
 every surgeon has seen many cases of severe lym- 
 phangitis in patients of apparently normal resistance. 
 We cannot attribute the cause entirely to lessened 
 resistance. It is possible that some bacteria contain
 
 324 LYMPHANGITIS 
 
 inherent cytolytic attributes which lessen the possi- 
 bility of the walling-off process and favor extension. 
 Many investigators have studied the question and 
 added individual facts to our knowledge, which is 
 inadequate, however, for a complete understanding of 
 the subject. Canon showed that ligation of the small 
 intestine favored bacterial growth in the blood stream, 
 thus showing the importance of proper intestinal action. 
 He also thought that he had demonstrated that an 
 excessive acidity of the blood is more favorable to 
 bacterial growth than any alkalinity. This, however, 
 has not been verified. 
 
 THE INFLUENCE OF THE TYPE OF GERM. 
 
 It is probable that almost any of the various patho- 
 genic bacteria may give rise to lymphatic infection. 
 In a great majority of the cases, however, the strepto- 
 coccus will be found to be the etiological factor. The 
 virulence of both streptococci and staphylococci varies 
 within wide limits, and even the same organism may in 
 successive cultures or various media change its viru- 
 lence. Many attempts have been made to classify 
 the bacteria according to their virulence, but without 
 success. On the other hand, certain physiological 
 processes of bacteria have been studied which may 
 in time lend some aid, and meanwhile they serve to 
 explain some of the phenomena noted in infections. 
 Among the most marked characteristics of severe 
 infections we have the cytolytic and hemolytic func- 
 tions. The semijaundiced appearance of the severe 
 cases due to the hemolysis is a well-known picture, and 
 while most often seen with streptococcus infections, 
 it may also appear in the staphylococcus forms to a 
 marked degree, especially in the aureus infections and 
 to a lesser degree in the albus. This staphylohemolysin
 
 THE INFLUENCE OF THE TYPE OF GERM 325 
 
 must, however, be present in considerable amounts 
 before its effects become apparent in man, since his 
 serum contains normally small amounts of antista- 
 phylolysin, as was shown by Neisser, and, moreover, if 
 the inoculation or infection begins slowly, the system 
 will develop larger amounts. 
 
 This hemolysis is particularly marked in the strep- 
 tococcus infections, where the pasty, semi-yellow ap- 
 pearance in the fatal cases is almost constant. This 
 observation was discussed by Marmorek in 1895, 
 but attempts to classify the virulence of the types 
 in relation to it have failed, since many avirulent 
 forms possess the same property as shown by Schott- 
 muller. Fromme thought he could differentiate these 
 by attempting a culture on a media of lecithin and 
 bouillon, in that the lecithin would inhibit the growth 
 of the more pathogenic forms, and that through this 
 he could prognosticate the severity of any infection 
 and thus take proper steps for its cure. Unfortunately, 
 subsequent investigations of Sachs and others have 
 dispelled these hopes, and we are no further in our 
 knowledge than we were. Attempts have also been 
 made to classify the virulence of the streptococci by 
 reference to the length of the chains. Lingelsheim, in 
 1899, first employed the terms streptococcus "longus" 
 and "brevis." The more virulent types in man are 
 most likely to be found in the long chains. No absolute 
 dependence, however, can be placed upon this finding. 
 Many of the other types of bacteria may be found in 
 the systemic infections; even the Bacillus pyocyaneus 
 has been found in a number of cases, as instanced by 
 Roberts, Finkelstein, and Brill and Libman. 
 
 A careful study of the effects of combined bacterial 
 infections is to be desired. The effect of symbiosis is 
 not fully known, although it has been hinted at by 
 various authors. The effect of combined streptococcus
 
 326 LYMPHANGITIS 
 
 and staphylococcus involvement is of special interest, 
 since we so often see this combination. Fisher and 
 Levy suggest that the streptococus through its rapid 
 spread prepares the soil for the staphylococcus. When 
 this occurs the prognosis is more grave, since the com- 
 bination seems to increase the virulence of the strepto- 
 cocci. I personally have observed" that such cases have 
 a convalescence prolonged much beyond the ordinary 
 course seen in patients infected with either separately. 
 
 THE INFLUENCE OF THE ANATOMY ON THE COURSE. 
 
 A general rule which the anatomy emphasizes is that 
 from any given point the superficial lymphatics pursue 
 the shortest course to the dorsum. An exception is 
 made of the centre of the palm, from which, as has 
 been shown, an infection would tend to go down to 
 the superficial palmar arch. These are rare, however. 
 The general rule of the dorsal extension explains the 
 frequency of great edema on the back of the hand in 
 all cases. As specific examples of the importance of 
 this observation, those infections arising at the distal 
 part of the palm should be noted. Here the lymphatics 
 first go distally, then pass around the web and on to 
 the dorsum, at which site the swelling and redness are 
 seen, giving rise to the assumption on the part of the 
 thoughtless that the infection is primarily there. This 
 is then followed by unnecessary and harmful incisions. 
 A little care would have shown that the starting-point 
 was a slight fissure in the callus on the flexor surface, 
 and that the dorsal redness was lymphatic in nature, 
 accompanied by an inflammatory edema which would 
 be harmed rather than helped by an incision. The 
 same is true of infections upon the ulnar and radial 
 sides of the palm. Where there is localized redness on 
 the dorsum of the hand we less often see the dorsal
 
 THE INFLUENCE OF ANATOMY ON THE COURSE 327 
 
 lines of redness running up the arm. These are gener- 
 ally the accompaniment of an absence of local reaction. 
 Along the course of the lymph vessels, particularly 
 on the dorsum of the hand, will be found areas of 
 redness and edema about twice the width of the red- 
 ness accompanying the vessels, appearing as if the 
 
 FIG. 115 
 
 Showing lymphatics in the skin and around the nail in a child, aged four 
 years. (After Sappey.) 
 
 infection were localizing there or as if small abscesses 
 were forming. These may be incised under that 
 assumption. It is doubtless true that in the semi- 
 acute cases, or those going on to abscess formation, the 
 localizing processes may start from these foci, but great 
 care should be exercised before making this deduction,
 
 328 LYMPHANGITIS 
 
 since these are but the evidences of the lacunae men- 
 tioned in the anatomical discussion, and generally sub- 
 side at the same time the inflammation disappears from 
 the vessel proper. 
 
 Attention should also be drawn to the normal course 
 of the vessels, and it should be emphasized that lym- 
 phatic extension from the little and ring finger takes 
 place through the epitrochlear glands, then to the 
 axillary, while infections beginning in the thumb and 
 forefinger go to the axillary glands without the inter- 
 position of the epitrochlear; hence systemic infection is 
 more easily engendered, and, moreover, if the observer 
 were searching for glandular enlargement he would not 
 expect to find it at the elbow in these cases. Infec- 
 tions beginning in the middle finger . are of special 
 interest in that either the axilla or the epitrochlear 
 glands may be first involved, and in some cases neither 
 of these areas may receive the lymphatic vessels, since 
 they may pass up over the clavicle and into the sub- 
 clavian glands and thus directly into the circulation. 
 The clinical importance of this lies in the fact that 
 these infections may reach the circulation very early 
 and because of the rapidity of involvement lead to 
 severe and even fatal systemic infection. I have had 
 one case that lends support to this assmption. There- 
 fore, one would look with great anxiety upon severe 
 infections arising from the middle and index fingers. 
 
 In some of the patients the lymphatic infection 
 rapidly spreads from the lymphatic vessel and extends 
 over the entire dorsum of the hand and forearm with 
 the appearance of an erysipelas without the raised 
 border. The swelling is considerable, the skin takes 
 on a board-like hardness, and vesicles may appear on 
 the surface. This may subside without further trouble, 
 but very often subcutaneous tissue soon becomes 
 involved and diffuse abscess formation takes place.
 
 THE INFLUENCE OF ANATOMY ON THE COURSE 329 
 
 These are ordinarily virulent cases and should be care- 
 fully watched and the abscesses opened. 
 
 There is an intimate relation between the lymphatics 
 of the distal extremity and the tendon sheaths. Of 
 this I have no anatomical proof, but such clinical 
 evidence that there can be no doubt of the association. 
 
 FIG. 116 
 
 Lymphatics about one of the palmar flexion creases. (After Sappey.) 
 
 It has been my experience frequently to meet with 
 cases in patients with pin pricks, especially of the distal 
 phalanx, which lead to a typical lymphangitis with a 
 red line running up the arm, and after a couple of days 
 these would show the typical evidences of tendon- 
 sheath infection of the finger involved. The distal
 
 330 . LYMPHANGITIS 
 
 phalanx itself, the site of the primary injury, would 
 show little or no serious consequences. This will be 
 discussed more fully under symptomatology. 
 
 If the deep lymphatics are involved, the course 
 naturally follows the course of the veins, as has been 
 pointed out above. If localized abscesses develop, they 
 appear along the line of these vessels. If it be the 
 interosseous, the abscesses will naturally lie under 
 the flexor profundus, thus occupying the site I have 
 already pointed out as that in which the deep abscesses 
 spreading from the tendon sheaths are always found. 
 In these cases doubtless the tendon sheaths would be 
 involved early, and then we would have a typical 
 tendon-sheath infection. 
 
 If the lymphatic vessels along the radial and ulnar 
 vessels are the source, the abscess will naturally lie 
 along these vessels. It has not been my experience to 
 meet with any such cases, and I am inclined to believe 
 that their occurrence is uncommon. I have seen 
 abscesses along the brachial vessels, however. In one 
 case it developed as an extension from a deep infection 
 of the forearm, and in another as the sequel of a typical 
 superficial lymphangitis of the forearm. It seemed 
 to me reasonable in this latter case to ascribe its 
 development to suppuration in a lymphatic gland lying 
 in juxtaposition to the vessel, since we know that, while 
 these glands ordinarily lie at the elbow and axilla, 
 they may occur at any part of the lymphatic stream. 
 From the very nature of the cases we would expect 
 deep lymphatic abscesses to be uncommon. 
 
 SPOROTRICHOSIS. 
 
 Certain cases in which nodules develop along the 
 lines of the lymphatics, giving rise to small abscess 
 formation, may cause confusion in that it is possible
 
 LYMPHATIC ABSCESSES 331 
 
 for us to have in traumatic injuries of the hand an 
 infection by sporotrichosis. Practically all of these 
 infections follow open wounds. It is first described 
 by Schenck. 
 
 The disease seems fairly prevalent in rural districts. 
 It is possible that some of the cases have been diag- 
 nosticated as tuberculous lymphangitis. The organism 
 consists of a branching septate, coarse mycelium from 
 which ovoid bodies develop by budding, either from 
 lateral or terminal filaments or from the sides of the 
 threads. These ovoid bodies are spores. 
 
 The condition is characterized by the history of a 
 traumatic injury, and is accompanied by the develop- 
 ment of one or more sharply circumscribed, painless 
 or subcutaneous abscesses along the course of the 
 lymphatic. Inflammatory manifestations are generally 
 absent. The course is extremely chronic, lasting for 
 a number of weeks. 
 
 The treatment consists in thoroughly opening the 
 abscesses, cleansing them, and giving large doses of 
 potassium iodide internally. 
 
 RELATIONS OF LYMPHATIC ABSCESSES STUDIED BY 
 EXPERIMENTAL INJECTIONS. 
 
 In order to study the subject, attempts were made 
 to inject masses from given sites along the vessels in 
 cadaver hands. The results did not add much to our 
 knowledge, but I will summarize them here. 
 
 REPORT OF INJECTIONS OF FOREARM NEAR THE 
 RADIAL AND ULNAR VESSELS. Experiment i. Can- 
 nula passed through small incision superficial to. the 
 radial vessels just above the wrist. The mass was 
 injected with considerable force, and on examination 
 a superficial area three inches in length and one inch 
 in diameter was found filled with the injected mass.
 
 332 LYMPHANGITIS 
 
 (NOTE. It is extremely difficult in injecting the 
 cannula to know just exactly the position it occupies.) 
 
 Experiment 2. Injected posteriorly, i. e., dorsal to 
 the radial vessels. The mass spread upward, and in the 
 section was found to lie on the radial side of the flexor 
 longus pollicis, tearing the muscle to a great extent 
 up to its origin. The mass had extended to the ulnar 
 side of this vessel, a small part of it lying on the radial 
 side between the bodies of the flexor profundus digi- 
 torum and flexor sublimis digitorum. The greater 
 portion had passed underneath the flexor profundus 
 digitorum and filled up the area between this muscle 
 and the bones with the interosseous membrane. It 
 had extended to the ulnar side, lying in juxtaposition 
 to the flexor carpi ulnaris, and at its distal end came to 
 lie near the surface, i. e., near the ulnar vessels. It 
 had extended distally between the tendons of the flexor 
 profundus digitorum and the pronator quadratus. It 
 did not pass into the hand. It has extended en masse 
 approximately to about three inches below the elbow- 
 joint, and a small prolongation or isthmus extended 
 along the median nerve above the elbow-joint for three 
 or four inches into the arm, still lying close to the 
 median nerve and consequently near the brachial 
 vessels and accompanying nerves. (NOTE. Out of six 
 injections more or less satisfactory, this extension oc- 
 curred in two cases, suggesting why it is that in deep 
 infections of the forearm, loss of function of the muscles 
 is so uncommon, since both the blood supply and the 
 nerve supply are impaired.) 
 
 Experiment 3.- Results practically the same as 
 Experiment 2. 
 
 Experiment 4. Results practically the same as 
 Experiment I. 
 
 Experiment 5. Mass lay to the radial side of the 
 arm above the flexor longus pollicis and to the radial 
 side of the flexor profundus digitorum.
 
 THE PATHOLOGY OF LYMPHANGITIS 333 
 
 GENERAL CONCLUSIONS IN THIS SERIES OF EXPERI- 
 MENTS UPON THE RADIAL VESSELS. We have demon- 
 strated that if an abscess should develop along the 
 course of the lymphatic vessels, lying in juxtaposition 
 to the radial artery, it may be a superficial abscess 
 which would point on the radial side of the arm. If 
 it follows the vessels farther it may spread to the deep 
 tissues of the arm. In other words, it may produce 
 the same result as an extension along the interosseous 
 vessels or a rupture from the ulnar or the radial syno- 
 vial sheaths. It may extend to the ulnar side and lie 
 immediately under the skin. 
 
 EXPERIMENTS BY INJECTION ALONG THE ULNAR 
 ARTERY. As in the injections along the radial artery, 
 these experiments are more or less unsatisfactory owing 
 to the fact that there was always considerable doubt 
 as to the exact position the tip of the cannula occupied, 
 although the intention was to inject as close to the 
 ulnar artery as possible, i. e., to simulate the origin 
 of a large abscess coming from the lymphatics and 
 lying in juxtaposition to this vessel. 
 
 In this series five injections were made at various 
 sites, and demonstrated the tendency of such accumula- 
 tions to come to the surface on the ulnar side early in 
 the course. If the injection was persisted in, the area 
 of the forearm involved was first that between the 
 flexor carpi ulnaris and the flexor prof undus digitorum ; 
 then between the superficial and deep flexors, and then 
 the area between the deep flexor and the bone, i. e., 
 the typical deep abscess of the forearm. 
 
 THE PATHOLOGY OF LYMPHANGITIS. 
 
 The pathology of these cases concern's itself particu- 
 larly with the changes in the lymph vessels and glands, 
 and need not be discussed in completeness, since the 
 general facts are well known. A picture of the condi- 
 tion found in a typical case will be as follows:
 
 334 LYMPHANGITIS 
 
 The local changes at the site of injury may be so in- 
 significant as to escape notice. The local reaction, even 
 in a case that threatens lethal issue, may be nothing 
 more than a slight redness indicative of a hyperemia. 
 There is no hardness suggestive of the outpouring of 
 the protective leukocytes with the coagulation of the 
 lymph and blood elements about a site of injury and 
 infection, as is seen in the localized staphylococcus 
 infection, although great pain may be present. This 
 is particularly seen in the distal phalanx, where the 
 differential diagnosis between this condition and a 
 beginning felon must be made. 
 
 The lymphatic vessels show grossly by their redness 
 the hyperemia surrounding them, and a microscopic 
 examination shows the destruction of the endothelium, 
 suggesting a virulent poison or great activity in over- 
 coming the bacteria. Adami has emphasized the im- 
 portant part the endothelial cells play in inflammations, 
 in that they may act as phagocytes and may undergo 
 changes to giant cells or other forms more fitted to 
 combat the process. A cross-section will show these 
 changes, and in addition may show the vessels filled 
 by a thrombus made up of cells and bacteria, and in 
 those cases where the thrombus lies close to the wall 
 the bacteria may be seen in that also. If the vessel 
 is injured or cut, the bacteria spread beyond the wall, 
 but in the ordinary simple case they will be found 
 confined to the wall and the lumen. The bacteria do 
 not seem to be in the leukocytes to any great extent, 
 but they are so mixed together in the thrombus as to 
 leave some doubt in my mind on this point. At some 
 points I have found the thrombus entirely free from 
 bacteria, in which case it may be reasoned that the 
 toxin has produced the thrombus in advance of bac- 
 terial extension. In some instances, in spite of the 
 changes in the lumen, the vessel wall showed little
 
 RESUME 335 
 
 change. The endothelium was not changed. There 
 were no endothelium giant cells. The connective tissue 
 about showed the evidences of inflammation with 
 moderate round-celled infiltration, although this did 
 not extend far into the adjacent areas. The capillaries 
 were engorged with blood for some distance, and the 
 connective-tissue fibers were separated by the serous 
 exudate. If the inflammation is a chronic one, all of 
 the changes incident to such infection are seen. If 
 the vessel is cut, there is a rapid extension to the sur- 
 rounding tissue, which macroscopically takes on the 
 appearance of an erysipelas and pathologically shows 
 the inflammatory changes associated with it. About 
 the lacunae the changes I have just described are most 
 marked, a much wider area about them being involved. 
 
 The lymph glands show nothing different from the 
 ordinary picture seen in varying inflammations of their 
 structure. Systemically in severe cases marked changes 
 in the blood and various organs are found which will 
 be discussed when speaking of the fatal cases. 
 
 In the severe cases locally we may find that the 
 subcutaneous tissue and even the skin may become 
 gangrenous. Of course, the former is most common. 
 Here the abscess will form, and when opened large 
 sloughs of connective tissue may be removed from 
 which the streptococcus may be secured in pure 
 culture. 
 
 RESUME. 
 
 The source of lymphangitis is frequently an injury 
 so slight as not to be recognized or remembered by the 
 patient. It is probable that in the majority of cases 
 the organism at fault is the streptococcus, but various 
 pathological organisms may be found. 
 
 Gonorrheal lymphangitis occurs as a result of 
 systemic infection. 
 
 While hemolysis is often a marked accompaniment
 
 336 LYMPHANGITIS 
 
 of streptococcous lymphangitis, it is not necessarily 
 present. In very severe types of infection the effect 
 of symbiosis is not definitely determined. 
 
 The lymphatics pursue the shortest course to the 
 back of the hand, consequently infection at the distal 
 portion of the palm will spread around the web into 
 the dorsum. In case of local infection in the palm the 
 swelling of the dorsum, due to edema, may be very 
 great, even greater than on the palm. Care should be 
 exercised not to incise on the dorsum but in the palm 
 in such cases. 
 
 Small areas along the inflamed lymphatic, the size 
 of a small pea, which appear red and swollen, indicate 
 lacunae in the course of the vessels and are not an 
 evidence of localized infection and should not be incised. 
 
 The little finger and ring finger drain into the 
 epitrochlear glands and then to the axillary. A small 
 percentage of infections beginning in the middle finger 
 pass directly up over the clavicle and into the sub- 
 clavian glands without passing through either the 
 epitrochlear or axillary glands. The thumb and index 
 finger drain into the axillary glands. 
 
 Deep lymphatic abscesses are uncommon. 
 
 Sporotrichosis may be seen and should be differ- 
 entiated from tuberculous and other chronic processes. 
 
 Abscesses following the deep lymphatics will lie 
 along the vessels. If one develops along the radial 
 artery it will appear on the radial side of the arm in 
 the lower third. If the abscess extends upward, it will 
 enter the deeper portion of the arm and will become 
 a submuscular abscess. If along the ulnar vessel the 
 pus will readily come to the surface between the flexor 
 carpi ulnaris and the flexor sublimis digitorum. 
 
 The pathological change in the lymphatic vessels 
 is that observed in any inflammation. 
 
 In an exceptionally severe case, marked sloughing 
 of the entire subcutaneous tissue may occur.
 
 CHAPTER XXI. 
 SYMPTOMS AND SIGNS OF LYMPHANGITIS. 
 
 SYMPTOMS AND SIGNS IN GENERAL. 
 
 A PATIENT with a lymphangitis ordinarily gives a 
 history of a slight abrasion or pin prick, which had been 
 considered of no importance. Frequently no history 
 of injury can be secured. The patient has noticed a 
 slight malaise or chilly sensations, possibly a severe 
 chill may be noted. There may be no local pain in the 
 hand or arm and no swelling. Generally, however, 
 there is slight swelling accompanied by a dull pain, and 
 at times the edema on the dorsum may become marked 
 and the pain very severe. The symptoms and signs 
 bring the patient to the physician, who finds in addition 
 to the local condition a red line running up the forearm 
 and arm corresponding to the anatomical distribution 
 of the lymphatic vessels draining the area of primary 
 infection. There may or may not be tenderness or 
 swelling in the region of the epitrochlear or axillary 
 glands. Generally, however, after the infection has 
 lasted twenty-four hours some tenderness and swelling 
 are found. The arm as a whole may show some slight 
 swelling, although this is generally absent. 
 
 The degree of systemic involvement varies in the 
 widest limits. In some cases, even early in the course, 
 the patient will present the evidences of severe toxemia 
 with a chill and high or low temperature, headache, 
 anorexia, and prostration. In a majority of cases, 
 however, these severe symptoms are delayed two or 
 three days, even though there may be a severe onset 
 with a chill, temperature, and headache. 
 
 22
 
 338 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 TYPES. 
 
 Four types may be seen. 
 
 TYPE I. SIMPLE ACUTE LYMPHANGITIS. If the 
 process subsides, the physician may be surprised at 
 the rapid disappearance of all evidences of the infec- 
 tion both systemic and local. All objective evidences 
 may entirely disappear in from twenty-four to forty- 
 eight hours. The red line of lymphatic inflammation 
 may disappear over night with slight tenderness over 
 the gland area persisting for a few hours longer. 
 
 TYPE II. ACUTE LYMPHANGITIS WITH MINOR LOCAL 
 COMPLICATIONS. In a second group the symptoms 
 may subside more slowly and end in a delayed reso- 
 lution or even abscess at the site of inoculation or in 
 the gland area accompanied by mild systemic symp- 
 toms. 
 
 TYPE III. ACUTE LYMPHANGITIS WITH SERIOUS 
 LOCAL COMPLICATIONS. In a third group of cases 
 complications arise ending in tenosynovitis or sub- 
 cutaneous abscesses. These cases are accompanied 
 by severe pain early in the course and symptoms 
 more or less grave which arouse the anxiety of the 
 physician, first, as to the possibility of early death 
 from systemic infection, and later, on account of the 
 toxemia associated with the local process, which heals 
 slowly and threatens the life of the patient or raises 
 the question as to the necessity for amputation. 
 
 TYPE IV. ACUTE LYMPHANGITIS WITH SYSTEMIC 
 INVOLVEMENT. In a fourth group the process may 
 give rise at once to most alarming systemic symptoms 
 and with or without local difficulty end fatally in a 
 few days. 
 
 The first and second groups are easily classified and 
 understood.
 
 LYMPHANGITIS WITH LOCAL COMPLICATIONS 339 
 
 ACUTE LYMPHANGITIS WITH SERIOUS LOCAL 
 COMPLICATIONS. 
 
 The third type may be a constant source of anxiety, 
 and the surgeon is often in doubt as to the ability of 
 the patient's resistance to cope with the infection, and 
 he is constantly questioning the correctness ot his 
 diagnosis as to the position of pockets of pus and 
 the adequacy of his treatment. It may clear up the 
 picture somewhat to illustrate this by one or two 
 examples. 
 
 CASE XVIII. A patient, Mr. L. W., was seen by 
 me on the second day of his infection. He had injured 
 the forefinger of his left hand with a piece of fine, rusty 
 wire which had penetrated the distal phalanx upon the 
 volar surface. He was complaining of severe pain in 
 the entire finger, but most marked in the distal phalanx. 
 An examination showed that the entire finger partook 
 of a pinkish hue, and was somewhat swollen throughout. 
 The distal phalanx, while the most painful and tender, 
 lacked the induration characteristic of localized infection. 
 A red line ran up the back of the hand and forearm and 
 could be traced to the axilla, where slightly tender glands 
 could be palpated. He was profoundly ill, with a tem- 
 perature of 104 to 1 06. 
 
 The proper procedure was considered to be that of 
 applying a hot boric solution dressing, rest both local 
 and general, eliminatives, and sedatives. The ques- 
 tion immediately arises as to the advisability of 
 incising the distal phalanx. It seemed to me that 
 lacking the induration, suggestive of localized pus, 
 the incision would do little good, and might open new 
 avenues for absorption. There could have been no 
 question as to making incisions at other points. Upon 
 the third day our conservatism was rewarded by 
 seeing the pain disappear from the distal phalanx
 
 340 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 as well as the red line of lymphatic involvement in 
 the arm. The patient now located and limited the 
 tenderness to an area over the tendon sheath of the 
 index finger. There was no increase of the swell- 
 ing of the distal phalanx, although the finger as a 
 whole had taken on the full appearance characteristic 
 of distention of the sheath with pus. The tendon 
 sheath was opened and the pus evacuated, following 
 which the patient ultimately recovered with a pre- 
 servation of the finger. It should be noted that no 
 incision was made into the distal phalanx, although 
 that was the site of the original pain and tenderness. 
 Moreover, upon the second day it was certainly 
 impossible to make the diagnosis of tenosynovitis. 
 
 CASE XIX. Mr. Geo. W. applied to the dispensary 
 of the Post-Graduate Hospital with a history of having 
 had a small cut upon the ulnar side of the palm. Sud- 
 denly, after three days, he suffered from a chill and felt 
 feverish. The hand began to swell, especially upon the 
 dorsum. Upon examination the remains of a small 
 cut could be seen upon the palm, but there was no evi- 
 dence of inflammation about it. No localized tenderness 
 or swelling. The dorsum of the hand, especially upon the 
 ulnar side, was greatly swollen and reddish. The skin 
 of the entire dorsum was red. There was no subcutaneous 
 induration, and the skin itself, while red, did not have 
 the brawny induration found in erysipelas. A red line 
 of lymphatic involvement ran up on the dorsum of the 
 forearm, and could be traced to the epitrochlear region 
 and then along the inner side of the arm to the axilla. 
 Tender glands could be palpated in both regions. Tem- 
 perature, 103; pulse, 100. 
 
 The question arose whether or not an incision 
 should be made over the tender swollen dorsum. It 
 was reasoned that this was not indicated, since 
 there was no evidence of a localized abscess here or 
 of a diffuse phlegmon, which at times accompanies
 
 PHLEGMONOUS LYMPHANGITIS 341 
 
 erysipelatous infection in this region. Conservative 
 treatment was therefore instituted with a rapid 
 cessation of all symptoms in the hand and lymphatic 
 vessels. However, the tenderness gradually increased 
 in the epitrochlear region, and a redness which had 
 not been present before now appeared. At the end 
 of seven days a suppuration which had had its origin 
 in the gland here was diagnosticated. Drainage was 
 instituted, with complete recovery in a short time. 
 
 PHLEGMONOUS LYMPHANGITIS. One of the most 
 serious types is that in which the infection seems 
 to involve the skin of the back of the hand and fore- 
 arm like an erysipelas. The toxemia is great, the 
 forearm greatly swollen, and the board-like skin 
 shows small blebs or blisters upon its surface. The 
 bacteria soon invade the subcutaneous tissue and 
 lead to a destruction of areas of the subcutaneous 
 tissue en masse, thus leaving the infected skin without 
 proper blood supply. Consequently, large pockets 
 filled with pus and seminecrotic tissue underlie the 
 skin of the dorsum, which itself soon becomes gan- 
 grenous in spots. Meanwhile, the patient is suffering 
 from a severe toxemia or sepsis. The superficial 
 veins may become thrombosed and threaten death 
 by acting as the source of infection, even though the 
 lymphatic absorption may have ceased. The greatest 
 care should be exercised in differentiating this type 
 from the swollen, reddened, edematous form seen in 
 ordinary lymphangitis, in which there is no induration 
 either of the skin or subcutaneous tissue. 
 
 Examples of these types could be multiplied many 
 times in my experience. The early signs and symp- 
 toms very commonly point to an entirely different 
 area as the probable site of abscesses than the one in 
 which it ultimately develops, and I wish to emphasize, 
 therefore, that the diagnosis of the accumulation of
 
 342 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 pus should be made only upon positive signs. After 
 once localizing, the abscesses follow the definite lines 
 laid down in the chapters upon tenosynovitis and 
 fascial space infection. 
 
 THE FREQUENCY OF LOCALIZATION IN LYMPHATIC 
 INFECTION. The frequency with which localization 
 takes place in lymphangitis is hard to state accu- 
 rately. In my experience 10 to 15 per cent, of the cases 
 would probably be nearly correct, and if anything it 
 would be less rather than more than that. The sites 
 of such involvement are ordinarily the tendon sheaths 
 of the respective finger, the dorsum of the hand, the 
 dorsum of the forearm, the axilla, and the epitroch- 
 lear region. Secondary to tendon-sheath infections 
 and deep infections of the hand, it is common to find 
 a subcutaneous accumulation of pus of lymphatic 
 origin on the flexor surface of the wrist. From these 
 observations it is very evident that a great majority 
 of the cases of lymphangitis subside without second- 
 ary abscesses unless they are engendered by ill-advised 
 incisions. 
 
 ACUTE LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT. 
 
 In our classification we have included in this group 
 those severe infections which through systemic absorp- 
 tion or infection threaten or destroy the life of the 
 individual. They may arise from any source or in 
 any individual. They are more likely to occur in 
 individuals over thirty-five years of age, and, if fatal, 
 within a short time are more inclined to follow infec- 
 tions of the thumb, index or middle finger. The little 
 finger is the origin of many fatal cases, but here the 
 lethal issue is often due to infection through involve- 
 ment of the tendon sheaths with improper drainage. 
 In other words, death is the outcome of two types of
 
 LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT 343 
 
 infections: (i) An acute type without localization 
 in the hand, and (2) a severe type with localization, 
 subsequent toxemia from inadequate drainage, and 
 the inability of the patient's system to wall off the 
 infection, ending in death from exhaustion and sepsis. 
 These types will be discussed when dealing with 
 systemic infection, and we shall mention them only 
 briefly here for the sake of completeness. The onset 
 is generally brusque. The patient suffers a chill, 
 followed by a high temperature, which later becomes 
 lower as the toxemia increases. There is little local 
 reaction along the line of the lymphatic or other gland- 
 ular region. The prostration is profound, the head- 
 ache severe. The face becomes pinched, the eyes 
 roving, the pulse running, and the patient is restless 
 and cannot sleep. The prostration becomes greater, 
 the pulse more running, the temperature normal, 
 subnormal, or high, the skin clammy and the nose 
 cold; in other words, the typical picture of a virulent 
 toxemia. Meanwhile the physician looks on helplessly, 
 since there is no localization which he may attack. 
 
 DEEP LYMPHANGITIS. The diagnosis of deep lym- 
 phangitis must often remain in doubt, since it is 
 generally associated with a superficial inflammation, 
 at times showing red lymphatic lines, but generally 
 appearing as of the erysipelatous type. The whole 
 arm and forearm are swollen as if the extremity were 
 a sac and the whole filled with fluid. It will be noted 
 that this is different from the appearance in superficial 
 lymphangitis, in which the back of the forearm is 
 swollen out of proportion to the front. There is ten- 
 derness early throughout, but most marked on the 
 dorsum, where the superficial lymphatics are acutely 
 inflamed. The patient is generally profoundly ill 
 with all the evidences of toxemia. In no case that I 
 have had has there been any localization of pus about
 
 344 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 the deeper portion of the arm. In one patient an 
 abscess localized itself along the radial artery about 
 two inches above the wrist. This was subsequently 
 drained, with recovery of the patient. I have not 
 seen any cases with abscesses under the flexor pro- 
 fundus tendons which could not be explained on the 
 assumption of an extension from a ruptured tendon 
 sheath, although it is certain they are possible. 
 
 A fatal case of deep lymphangitis came under my 
 notice a short time ago, in which the patient made 
 a primary recovery, but died after four weeks from a 
 pneumonia, probably directly dependent upon the 
 primary infection. Indeed, these serious 'cases of 
 infection frequently come to a fatal issue because 
 of some intercurrent complication, and such should 
 always be looked for and guarded against. A brief 
 resume of the case will emphasize the clinical picture. 
 
 CASE XX. Mr. J. R. D. (Fig. 117), an employee of 
 the customs house, bruised the thumb of his left hand 
 in getting off a street car. As he expressed it, he thought 
 that he had dislocated the thumb. There was some 
 primary swelling. At the end of the third day there was 
 a considerable increase of the swelling, so that the whole 
 thenar area was involved, and the forearm also began 
 to increase in size. He now consulted Dr. J. J. Cole, 
 with whom I saw the patient in consultation. The swell- 
 ing of the thenar area was so great as to suggest the bal- 
 looning out seen in the abscess of the thenar space. The 
 swelling was distinctly an edema, however, there being 
 no hardness present. It was treated by hot boric dressings. 
 Within a few hours the whole arm was swollen and edema- 
 tous, as much upon its flexor as its dorsal surface, although 
 the dorsum showed some redness which was not present 
 on the flexor surface. Deep tenderness could be elicited 
 on both surfaces, especially over the radial side. By 
 the end of the third day the swelling of the arm had 
 subsided to a considerable extent, and the swelling of 
 the flexor surface of the forearm was distinctly less.
 
 LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT 345 
 
 The dorsum, however, was still swollen, having the 
 appearance and giving the same sense of hardness on 
 palpation as noted in erysipelas. Incisions made upon 
 the dorsum showed that the subcutaneous connective 
 tissue was necrotic en masse and could be removed with 
 the forceps. The whole dorsum of the forearm was under- 
 mined. Several incisions were made which drained 
 satisfactorily. Owing to the large flaps of skin left with- 
 out blood supply, in which the vitality was impaired by 
 the infection, some areas of this also sloughed. As the 
 
 FIG. 117 
 
 Photograph of the hand of a patient with a deep lymphangitis (phlegmo- 
 nous erysipelas). (See Case XX). 
 
 process subsided the thrombosed superficial veins could 
 be seen on the surface of the deep fascia. The patient 
 made a rapid primary recovery, so that he left the hospital 
 at the end of eight days. The local process, however, 
 had not entirely healed. Some slight toxemia was present, 
 from which the patient was slowly recovering, when he 
 was suddenly overtaken by a pneumonia at the end of 
 four weeks, and died after three days. . A culture taken 
 from a bleb which had formed upon the skin showed a 
 staphylococcus infection. In the subcutaneous pus, how- 
 ever, a pure culture of Streptococcus pyogenes was found,
 
 346 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 and I believe that to have been the source of the infection. 
 Unfortunately, no postmortem could be secured. 
 
 Incidentally this finding of the staphylococcus under 
 the epidermis when the real cause was a streptococcus 
 emphasizes the error which is common of mistaking 
 the local subepidermal infection for the primary cause 
 when it may be really secondary. 
 
 SYSTEMIC INVOLVEMENT. As a sequence of lym- 
 phangitis proper or associated with other types of 
 infection of the hand, systemic involvement may be 
 seen. It occurs more frequently as the age increases. 
 While deaths may occur at any age, by far the greatest 
 number occur after forty-five years, and after fifty 
 years a severe infection of the hand should be looked 
 upon with anxiety. It occurs most often associated 
 with a streptococcus infection. In one case, however, 
 that died under my care, a staphylococcus was 
 present in the pus of the primary abscess (Case XXI). 
 Every case showing evidence of septicemia should be 
 regarded as extremely grave. Early in the course it 
 may be impossible to differentiate a septicemia from a 
 toxemia, since they will present the same picture 
 at the onset. The temperature is often 103 to 106; 
 the pulse, 120 to 130. The dry tongue and skin; the 
 restless, roving eyes; the constantly moving limbs; 
 the thirst; scanty urine; headache; sleeplessness; 
 flushed cheek; damp brow; and the quivering nostril, 
 with the history of chilly feelings or a chill, present 
 a picture known to all, and early may be present 
 in either a toxemia or a septicemia. In a toxemia, 
 however, all these symptoms should subside within 
 three days if due to a primary unopened lymphangitis 
 or if it follows the opening of an abscess or a teno- 
 synovitis. If, instead of subsiding, the symptoms 
 grow more severe, it is probable a systemic infection
 
 LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT 347 
 
 is present if the local pockets of infection have been 
 drained. The temperature generally continues high 
 until death, but may become remittent, showing 
 chills from time to time or symptoms and signs inci- 
 dent to complications, such as bronchitis, pneumonia, 
 pleurisy, lung abscess, metastatic abscesses, and teno- 
 synovitis, especially of the extensor tendon of the great 
 toe, in my experience. The eye muscles may become 
 paralyzed (Tornier). Almost all cases die when these 
 severe symptoms develop. Death comes on with 
 the patient in coma or delirium. Should the patient 
 recover, the evidences of toxemia gradually subside 
 and the local wound begins to show evidences of repair. 
 The condition of the local wound as to repair is of 
 considerable prognostic importance. When a wound 
 does not heal as rapidly as it should after opening, 
 exceptional care as to the systemic treatment should 
 be used. 
 
 A fatal case following a simple middle palmar 
 abscess which had been undiagnosticated was referred 
 to me and is worth reporting, since it illustrates the 
 picture in the septic cases. 
 
 CASE XXI. Mr. R. K., aged sixty-five years, admitted 
 to the hospital January 23, 1909. Died, February I, 
 1909. 
 
 The history as recorded is very meager. He stated 
 that he hurt his hand rubbing meat and getting some 
 brine in the scratches about a month previous to entrance, 
 December 22, 1908. Following this his hand was swollen 
 and painful. Several incisions had been made on the 
 dorsum. On examination the right hand was found to be 
 swollen, with the palm bulging. The fingers were slightly 
 restricted in motion. Little restriction of motion at the 
 wrist and little swelling of the forearm. Systemically 
 the patient showed the results of toxemia, being pale, 
 weak, and emaciated, with the hunted look characteristic 
 of these cases. The urine showed a specific gravity of
 
 348 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 1020, was scanty in amount, but contained no albumin. 
 There were, however, many hyaline and granular casts, 
 both broad and narrow. A diagnosis of a middle palmar 
 abscess was made, associated with a toxemia of a high 
 grade, or asepsis, and in addition a nephritis. 
 
 In view of these findings and the man's age, a poor 
 prognosis was given. Operation: Under nitrous oxide 
 anesthesia, a Bier constrictor was applied and about a 
 half-pint of thick, creamy pus was evacuated from the 
 middle palmar space. There was no pus in the thenar 
 space or the tendon sheaths. 
 
 Following the operation the temperature varied from 
 99 to 101; pulse, 84 to 100. During the second day 
 it is noted on the history sheet: "Patient removed Bier 
 constrictor during night, has involuntary urination. Hand 
 and forearm violently inflamed, arm not involved. Am 
 not sure whether mental symptoms are due to kidneys 
 or hand." 
 
 That night the temperature rose to 102, but varied 
 from this to normal during the next day. The pulse 
 averaged 100. During the fourth day the temperature 
 varied from normal to 100. The pulse was still not 
 rapid, although the patient was delirious and there was 
 evidently a metastatic infection in the tendon sheath 
 of the extensor hallucis of right leg. Operation, January 
 29, 1909. Incision in palm enlarged and incision on 
 lateral surface of forearm to secure drainage. Consider- 
 able pus evacuated. Incision over right fibula near ankle 
 and into tendon sheath of extensor hallucis. Watery 
 pus evacuated. 
 
 The pulse and temperature ran about the same as 
 before. The highest pulse recorded is 120, and the highest 
 temperature, 101.4. The mental condition grew worse, 
 and the patient died two days later. 
 
 Another fatal case, which I saw in consultation 
 with Dr. A. B. Eustace, to whom I am indebted for 
 the history and report of the findings at postmortem, 
 at which I was permitted to be present through the 
 courtesy of Dr. W. H. Hunter and Dr. Eustace, is 
 a very valuable one, since the positions of pus shown
 
 LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT 349 
 
 at the postmortem fully corroborate the findings 
 which I have noted clinically in the cases which 
 recovered, as well as verify the results which I obtained 
 experimentally by injections of the forearm. It 
 emphasizes also the difficulty of differentiating these 
 cases at times from rheumatism. Unfortunately, 
 I have not the exact age, but the patient was in the 
 neighborhood of fifty years, which again draws atten- 
 tion to the influence of age in these fatalities. 
 
 Here the primary focus was in the ulnar bursa. 
 Owing to the difficulty of diagnosis, the diagnosis 
 and, consequently, the proper treatment were held 
 in abeyance several days. 
 
 CASE XXII. Miss E. J., Cook County Hospital. 
 Patient entered on June I, 1908. Attending surgeon, 
 Dr. E. Wyllys Andrews; house physicians, Drs. Eusta'ce 
 and Courtenay. 
 
 History of Present Trouble: Patient enters hospital 
 complaining of pain and swelling in right wrist and hand. 
 Upon questioning she says she awoke last Friday night 
 with pain in this joint. There was a sense of heat and 
 the joint was particularly painful on motion. Her sleep 
 was disturbed, and by the next morning she says her 
 wrist was notably swollen and red. Tenderness was 
 pronounced over the end of the ulna posteriorly, and 
 also anteriorly over both bones of the forearm at their 
 carpal articulation. 
 
 A history of any previous injury, fall, infection, or 
 arthritis of any sort is denied. Accompanying this the 
 patient denies other symptoms of any sort, but since 
 Friday the joint has become swollen and progressively 
 worse, the pain is agonizing, and there is an indefinite 
 history of chills and fever. 
 
 Previous Illnesses: For the past ten years she has 
 suffered intermittently from articular rheumatism, and 
 three weeks ago she was a patient in this institution 
 for otitis media and discharged after a period of two 
 weeks' treatment. 
 
 Physical Examination: Negative except as follows:
 
 350 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 The right wrist and hand are greatly swollen and inflamed, 
 the wrist on both surfaces, the hand on the posterior 
 surface only. The swelling is localized to the wrist-joint 
 and extends up the forearm for about three inches. The 
 fingers are in semiflexion, and the slightest movement 
 causes extreme pain. There is also extreme tenderness 
 around the wrist-joint, which is also very painful upon 
 motion. Lymphatic involvement is lacking, and appar- 
 ently there is no tendon-sheath involvement. No atrium 
 of infection can be found, and shoulder and elbow-joints 
 are not involved. The left arm is not involved, though 
 some pain is elicited on motion of shoulder. Fingers 
 give evidence of a rheumatic diathesis (G. T. Courtenay). 
 
 Pulse. Temperature. Respirations. 
 
 June 2, 1908 .... 94 102 24 
 
 June 2, 1908 .... 103 102 24 
 
 June 2, 1908 104 101 22 
 
 White blood count on entrance, 8200. Patient given 
 large doses of sodium salicylate. 
 
 Operation, June 4, 1908. Incision down to ulnar 
 bursa and one above the anterior annular ligament on 
 ulnar side. A hemostat was forced through to the radial 
 side and pus evacuated. Gauze drainage and hot boric 
 dressings. Bier's constrictor applied to arm (A. B. 
 Eustace) . 
 
 Operation, June 7, 1908. Two incisions on the flexor 
 surface of the forearm just above the wrist-joint and 
 another three inches above this. These were each one 
 inch long and penetrated to the flexor tendons; openings 
 connected with gauze drainage (G. T. Courtenay). 
 
 Operation, June 15, 1908. Incision along ulnar bursa 
 enlarged and a large amount of pus evacuated. Knee- 
 joint aspirated and pus obtained. Two per cent, solu- 
 tion of formalin in glycerin injected. Died June 16, 
 1908. Autopsy by Dr. A. B. Eustace and Dr. Allen B. 
 Kanavel. 
 
 Hand and Arm: Extensor surface: On opening back 
 of forearm a small focus of pus is found at junction of 
 lower quarters of forearm. This communicates with 
 incision in skin on side. There was no pus between 
 extensor communis and deeper tissues, except at point
 
 LYMPHANGITIS WITH SYSTEilKi ^INVOLVEMENT 351 
 
 pjjv r/ . r 1J " ' ^ r jFf. 77-f 
 
 indicated, and this pus extended down underneath this 
 
 muscle. 
 
 No pus found subcutaneously on the dorsum of the 
 hand except at the wrist-joint, and this could be traced 
 into the tendon sheath of the extensor communis digi- 
 torum. The tendon sheaths of the extensor radialis 
 longior and brevior also showed pus. The tendon of the 
 extensor carpi ulnaris was free from pus. 
 
 Back of the sheath of the extensor communis digi- 
 torum is seen an opening extending down to the carpal 
 bones. Articulation between the carpal bones and the 
 radius found to contain a slight amount of pus. Articu- 
 lation between proximal and distal row of bones also 
 contains a slight amount of pus. No pus found under 
 tendons on the back of the hand, communicating with 
 joint. 
 
 Flexor Surface: Incision found in median line, at 
 junction of lower and middle thirds through skin imme- 
 diately above annular ligament, and on either side at 
 and above articular surface. 
 
 Incision on ulnar side extended upward for a distance 
 of two and one-half inches. Incision also in palm of 
 hand on ulnar side lengthwise along inner edge of hypo- 
 thenar eminence. The hand as a whole does not appear 
 to be greatly swollen, and some concavity appears in the 
 middle of the palm. 
 
 Upon opening the palm of the hand, ulnar bursa found 
 to be filled with pus and tendon sheath of little finger 
 also filled with pus. Rupture had occurred into the fore- 
 arm at a point one and one-half inches above the articular 
 surface of the wrist-joint. Middle palmar space opened 
 and found to be filled with pus. Thenar space free from 
 pus. Tendon sheath of flexor longus pollicis free from 
 pus. Radial bursa, no pus found at any point. Above 
 the wrist-joint, pus is found in sheath passing up under- 
 neath tendons from midpalmar space. 
 
 Forearm: Pus is found underneath the flexor pro- 
 fundus digitorum. Pus extended up the forearm in 
 juxtaposition to ulna up to the elbow lying immediately 
 on the ulna. 
 
 Pus also found along ulnar artery for a distance of 
 about one and one-half inches at middle of forearm,
 
 352^ SYPOM^ : v4^ $IGNS OF LYMPHANGITIS 
 
 put <^id x {iqt \ Kte\i<3 Vp ^to the elbow. A small opening 
 L" \ i ^ 1s^ tliscernible at lower end of ulna connecting joint with 
 ulnar bursa. It could not be determined definitely 
 whether this opening was made by dissection or was 
 present before. 
 
 No opening was demonstrable between wrist-joint 
 and radial bursa. 
 
 No necrosis of bones of wrist- joint; tendon sheath of 
 ring finger intact; tendon sheath of middle finger intact; 
 tendon sheath of index finger intact. Pus extended out 
 in little finger to proximal interphalangeal joint. Peri- 
 osteum of radius and ulna not destroyed. No pus in 
 elbow-joint. 'Axillary glands barely palpable. 
 
 Heart: No evidence of pericarditis or adhesions. 
 
 Pleural Cavities: Left, no adhesions; right, few adhe- 
 sions at apex. 
 
 Lungs: Left, crepitates, no consideration, frothy red 
 serum exudes, apparently normal; right, answers above 
 description. 
 
 Liver: Gall-bladder distended and filled with fluid. 
 Liver is mottled on cut sections, the interlobular mark- 
 ings faint, no evidence of miliary abscesses. Tissues 
 very soft and friable and color is paler than normal. 
 
 Spleen: Enlarged in size, is soft and friable. Cuts 
 like butter. Miliary abscesses found. 
 
 Kidneys: Soft and friable. Capsules strip with some 
 difficulty and leave parts of the cortex. Cortex is almost 
 obliterated, as are also the pyramids, but here and there 
 a distinct outline of a pyramid may be found. 
 
 Right Knee-joint: Filled with thick yellow pus, small 
 ecchymotic areas in periosteum. 
 
 Cultures before and after death showed Staphylococcus 
 albus. 
 
 Microscopic examination of the various organs showed 
 acute parenchymatous degeneration. 
 
 POSTMORTEM STATISTICS. Tornier reports ten fatal 
 cases upon which postmortem had been made. The 
 findings were as follows:
 
 LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT 353 
 
 Cases. 
 
 Acute hyperplasia of spleen 9 
 
 Parenchymatous nephritis 7 
 
 Bronchopneumonia 5 
 
 Lung abscesses 2 
 
 Empyema 2 
 
 Acute pericarditis I 
 
 Hemorrhagic pleuritis I 
 
 Subpericardial, subpleural, and cecal hemorrhages ... 4 
 
 Abscess of kidney 2 
 
 Abscess of liver 2 
 
 Thrombosis of veins 2 
 
 Icterus 3 
 
 The age of the fatal cases averaged forty-three and 
 eight-tenths years. 
 
 THROMBOPHLEBITIS. Either associated with lym- 
 phangitis or as a distinct process we may have throm- 
 bophlebitis. The symptoms and signs here would 
 be the same as those occurring with thrombophlebitis 
 of the leg, where it is more common. Generally begin- 
 ning with a localized infection, the process extends 
 into a vein. The severity of the symptoms depends 
 upon the extent of the process, varying from those 
 of a mild septicemia with localized evidences to most 
 severe toxemia, metastatic abscesses, and death. This 
 can best be illustrated by a case which came under 
 my care at the Post-Graduate Hospital. 
 
 CASE XXIII. Mr. L., aged twenty-five years. Post- 
 Graduate Hospital, March 5, 1909 (Fig. 118). 
 
 Diagnosis. Suppurative phlebitis of veins of dorsum 
 of hand. 
 
 The patient applied to the hospital with a small infection 
 upon the, dorsum of the hand, apparently carbuncular 
 in nature. The infection had been present for four days, 
 and was gradually increasing in size. The hand was con- 
 siderably swollen, and there was an area of swelling 
 and induration extending up the dorsum of the forearm 
 for three inches. Temperature, 101; pulse, 94; urine 
 negative. 
 23
 
 354 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 Operation. Gas anesthesia. A crucial incision was 
 made over the area and an accumulation of thick pus 
 and seminecrotic tissue evacuated. The indurated area 
 extending up the dorsum of the forearm was found to be 
 a large vein which was filled with a septic thrombus. 
 This was opened for four inches up on the area, when a 
 free regurgitation of venous blood was secured. The 
 vessel was tied and the wound left open (Fig. 118). A 
 Bier constrictor was applied. 
 
 FIG. 118 
 
 Photograph of a hand of a patient with thrombophlebitis. Wound is left 
 open, as is seen in photograph. (Case XXIII.) 
 
 Following the operation the local area granulated 
 freely, and rapidly went on to complete repair. Over 
 a period of four weeks, however, the patient developed 
 three metastatic abscesses in various parts of the body, 
 which were opened. Fortunately, none developed 
 in the bones or viscera, at least, so far as was discovered. 
 The temperature and pulse were never high, but still 
 fluctuated with the development of the foci. The 
 patient ultimately made a complete recovery.
 
 LYMPHANGITIS WITH SYSTEMIC INVOLVEMENT 355 
 
 The symptoms and signs appear as follows: A 
 red line running up the forearm corresponding to 
 the anatomical distribution of the lymphatic vessels 
 draining the area of primary infection. There may 
 be no local reaction and little swelling; generally, 
 however, there is slight swelling accompanied by dull 
 pain. In the less severe cases considerable edema 
 will develop on the dorsum and the pain will be very 
 severe. Early there is little tenderness. Generally, 
 after twenty-four hours, tenderness may develop in 
 the extremity over the glands involved, i. e., the 
 epitrochlear or axillary. 
 
 Systemic symptoms vary in the widest limits. In 
 some cases very early the patient presents evidences 
 of severe toxemia, with a chill, high or low tempera- 
 ture, headache, anorexia, and prostration. Four 
 types are seen: A, simple acute lymphangitis: This 
 is a type with few systemic symptoms and a rapid 
 disappearance of lymphatic inflammation. B, acute 
 lymphangitis with minor local complications: Here 
 the symptoms subside slowly ending in an abscess 
 at the site of inoculation or in the gland area. C, 
 acute lymphangitis with serious local complications: 
 Here we have such complications as tenosynovitis 
 and subcutaneous phlegmons. D, acute lymphangitis 
 with systemic involvement: In this group we have 
 the most alarming systemic symptoms with little 
 local evidence of disease and a rapidly fatal issue. 
 
 Phlegmonous lymphangitis is one of the most 
 serious types of infection seen. Here we have profound 
 toxemia, a greatly swollen forearm, board-like indura- 
 tions and blisters on the skin. The subcutaneous 
 tissue sloughs en masse. The superficial veins become 
 thrombosed and the patient dies from toxemia or some
 
 356 SYMPTOMS AND SIGNS OF LYMPHANGITIS 
 
 of the severer complications of infection, such as sepsis, 
 meningitis, pneumonia, etc. 
 
 Localization takes place in lymphangitis in from 
 10 to 15 per cent, of the cases. The sites are ordinarily 
 the tendon sheaths, dorsum of the hand, the dorsum 
 of the forearm, the epitrochlear region, and the axilla. 
 
 Systemic infection is more likely to occur in indi- 
 viduals over thirty-five years of age and is more 
 likely to follow infections of the thumb, index or little 
 finger, especially the middle finger. In these cases 
 the onset is brusque, there is little local reaction 
 along the lymphatic or glandular region, prostration 
 becomes profound, and death rapidly ensues. 
 
 Deep lymphangitis is on the whole rather a rare 
 complication. If present, the pus is found in the 
 deeper portions in the pockets already enumerated. 
 
 Thrombophlebitis may occur associated with lym- 
 phangitis or as a distinct process.
 
 CHAPTER XXII. 
 
 PROGNOSIS IN LYMPHATIC INFECTIONS. 
 
 THE prognosis as to life in lymphatic infections is 
 dependent upon so many factors over which we have 
 no control that it is extremely difficult to arrive at 
 any satisfactory statement concerning it. In Hel- 
 ferich's clinic, in a series of nearly 200 severe infections 
 of the hand, a fatal issue followed in 22 per cent. 
 These statistics comprise all types of infection of the 
 hand, and are limited to extensive abscesses, teno- 
 synovitis, and severe lymphangitis. This percentage 
 is certainly high for patients in the ordinary walks 
 of life. In my own experience the mortality in these 
 severe cases will average about 3 or 4 per cent. 
 
 Of the factors concerned, of chief importance is the 
 age of the individual. The average age of fatal cases 
 is in the neighborhood of forty-five years. The general 
 state of the patient's resistance is of importance. 
 For instance, in Cook County Hospital, where the 
 social derelicts are found, the mortality is much higher 
 than in private hospitals. The presence of nephritis 
 in the various forms or of any of the chronic system 
 diseases has a marked influence upon the prognosis. 
 
 If the symptoms of toxemia do not subside within 
 three days, if no local process has developed, or within 
 two days after opening such foci, anxiety should be 
 felt for the patient. Either there is a local extension, 
 or the patient is not reacting. The part affected has 
 some influence upon the prognosis. The presence of 
 an infection beginning in the little finger or the thumb 
 causes fear of tenosynovitis with a prolonged con- 
 valescence, while an involvement of the index or middle 
 finger may early lead to severe systemic symptoms. 
 The type of germ in a given patient is also of great
 
 358 PROGNOSIS IN LYMPHATIC INFECTIONS 
 
 importance from a prognostic standpoint, since it 
 is well known that the gravest infections arise from 
 the streptococcus and certain of the gas bacilli. 
 Again, a brusque onset with high temperature and 
 chills speaks for a serious infection. 
 
 To my mind the prognosis is influenced somewhat 
 by the character of treatment. If ill-advised and 
 premature incisions are made, what might have been 
 a moderate infection may be turned into a severe 
 type. Many attempts have been made to secure 
 data upon which prognosis may be made by an exami- 
 nation of the blood, and this is of some general value. 
 One of the latest and most complete researches is 
 that of Zangmeister. 1 
 
 The first conclusion which the author derived 
 from a large series of blood counts was that the numeric 
 fluctuations of the single leukocyte forms per cubic 
 centimeter of blood show the real condition of the 
 patient, but not the numerical ratio of the variety 
 of forms to each other. To make a prognosis in strep- 
 tococcus infections from the blood picture it is impor- 
 tant to know that the conditions change completely 
 after the first twenty-four hours after the infection, 
 and that the findings during the first twenty-four 
 hours do not apply later on. 
 
 In monkeys he found the following after the first 
 twenty-four hours after infection: 
 
 1. In infections rapidly fatal, all forms of leuko- 
 cytes decline quickly in number. 
 
 2. In infections fatal after a few days he found 
 a tardy and small increase of the mononuclear neu- 
 trophilic cells and a decrease of the polynuclear 
 neutrophilic and eosinophilic cells and lymphocytes 
 in the first eighteen hours. 
 
 3. In infections not fatal he found an increase 
 of the mononuclear neutrophilic cells during the first 
 
 1 Monatsschrift f. Geb. und Gynak., Band xxxi, Heft i.
 
 PROGNOSIS IN LYMPHATIC INFECTIONS 359 
 
 six hours after the infection; from then a decrease. 
 The polynuclear and eosinophilic cells and lympho- 
 cytes increase in number after the first six hours. 
 Therefore good prognostic symptoms are: 
 
 (a) An immediate increase of the mononuclear 
 neutrophilic cells for the first six or eight hours, 
 with a following decline. 
 
 (b) An increase of the polynuclear cells after six 
 hours, after a short decline. 
 
 (c) An increase of the eosinophilic cells inside the 
 first twenty-four hours. 
 
 (d) An increase of the lymphocytes in the first 
 twenty-four hours. 
 
 The prognosis is bad (i) if the mononuclear cells 
 show no increase or a decrease in the first eight hours; 
 (2) if there is a continuous decrease of the polynuclear 
 cells and lymphocytes. 
 
 In a large series of the blood countings before and 
 immediately after operations the author found that 
 these findings in monkeys are parallel to those in 
 man. 
 
 After the first twenty-four hours conditions are 
 changed, and the curve of the eosinophilic cells, of 
 the lymphocytes, and of the mononuclear neutro- 
 philic cells is of no importance. A continuous decrease 
 of the polynuclear cells or their remaining stationary 
 is a bad prognostic sign. In less severe infections they 
 will rapidly or at least slowly increase. 
 
 His final conclusions are: 
 
 "We are allowed to make a good prognosis inside 
 the first twenty-four hours after the infection if we 
 find (a) an immediate increase of the mononuclear 
 neutrophilic cells with a slow decrease after eight 
 hours; (b) an increase of the polynuclear ce'lls after 
 eight hours after a small decrease. 
 
 "We have to deal with a fatal infection (a) if the 
 mononuclear cells increase after the first twenty
 
 360 PROGNOSIS IN LYMPHATIC INFECTIONS 
 
 hours; (&) if the mononuclear cells do not increase 
 at all or decrease immediately after infection; (c) 
 if the polynuclear cells decrease constantly. 
 
 He made one blood count before, one six to eight 
 hours, and one twenty to twenty-four hours after 
 the operation respectively. 
 
 After twenty-four hours, the number of polynu- 
 clear cells only is of importance; if they are below 
 normal and keep on decreasing the prognosis is bad, 
 and vice versa. 
 
 By injecting a person with dead streptococci, 
 Zangmeister was able to test the resisting power of 
 the person against streptococcus infection "Resisteur 
 probe." If the resisting power is reduced, the mono- 
 nuclear cells after the injection will show no increase or 
 the increase comes late ; the polynuclear cells will show 
 no increase soon after the infection, or a decrease. 
 
 What may be said regarding the probability of 
 local complications? It is impossible to arrive at any 
 just estimation as to the probability of the develop- 
 ment of tenosynovitis and fascial-space abscesses. 
 In my experience those patients showing a brusque 
 onset with great pain are more likely to have such 
 complications. The tenosynovitis is more likely to 
 develop from infection implanted on the volar sur- 
 face of the distal or middle phalanx. Local accumula- 
 tions on the dorsum of the web between the fingers 
 are apt to develop from the callus cracks at the distal 
 portion of the palm. Dorsal subcutaneous thenar 
 abscesses appear in infections of the thenar palmar 
 surface. Subcutaneous abscesses above the anterior 
 annular ligament often occur in connection with 
 tenosynovitis. Ill-advised incision may determine the 
 localization of infection in various spaces. In several 
 patients whom I have seen in consultation, I feel 
 sure that the tenosynovitis which developed was 
 directly due to the primary incision.
 
 CHAPTER XXIII. 
 
 THE TREATMENT OF LYMPHATIC INFEC- 
 TIONSGENERAL DISCUSSION. 
 
 THE treatment of lymphatic infections is based 
 Upon two principles conservatism and conservation. 
 In no type can more harm be done by ill-advised 
 incisions than in this. The position of masterful 
 inactivity is most difficult to maintain, and yet the 
 surgeon is constantly aware that his tendency to incise 
 is due to his desire "to do something" rather than 
 an exact knowledge as to what to do. We therefore 
 use local measures designed to wall off and overcome 
 the infection, combined with procedures designed to 
 support the system and increase its resisting powers. 
 In the ordinary case, until some localization is present, 
 we apply hot, moist dressings, insist upon local and 
 systemic rest, combined with cathartics and sedatives, 
 as the case may demand. 
 
 DISCUSSION OF VARIOUS PROCEDURES. 
 
 LOCAL. Hot, Moist Dressings. Many forms of 
 such applications are in use and have a vogue for a 
 time. It is my personal opinion that such applications 
 owe their value more to the moist heat than to the 
 drug with which they are combined. It is my custom 
 to use boric acid in saturated solution. I am aware 
 that many studies have been made from which con- 
 clusions were drawn as to its antiseptic property 
 when absorbed by the blood stream. It is probable 
 that it would be unjust to say that such minute 
 quantities as have been demonstrated in the blood,
 
 and consequently in the urine, can have no effect, 
 since no one knows the effect of combining small 
 proportions of any chemical solution with blood serum 
 in vivo, although in the test-tube such combinations 
 may be shown to be without value. It would seem 
 more reasonable to ascribe the beneficial value of 
 such applications to the dilatation of the capillaries 
 and the bringing of more blood to the part, favoring 
 the walling off of the infection. 
 
 Peculiar value has been ascribed by various sur- 
 geons to bichloride solution, creolin, almost all of the 
 various antiseptics, ichthyol, alcohol, etc. Unless 
 they are used for a particular purpose, however, it 
 would seem that hot boric solution will be as efficient 
 as any. 
 
 Certain special purposes may be secured by special 
 solutions. In those cases in which there is a foul odor, 
 a I to 2000 or i to 4000 potassium permanganate 
 solution will be found of value. We may secure some 
 slight local antiseptic property in the use of alcohol 
 dressings, using a 30 to 50 per cent, solution. This 
 should not be kept up any length of time. It is cer- 
 tainly not necessary to warn the profession against 
 the use of carbolic acid solution in any strength. The 
 frequency with which carbolic acid gangrene is seen, 
 however, leads me to urge upon physicians the necessity 
 of informing patients of the danger of this remedy, 
 which is so often the home application for all cuts and 
 injuries. 
 
 The method of applying hot boric dressings has been 
 discussed on p. 72. They are so applied as to cover 
 the entire forearm and arm in the severe cases. It 
 is a good rule to make the dressing much larger than 
 the condition would seem to call for. These hot, 
 moist dressings are to be used until the red line of 
 lymphatic involvement has entirely disappeared and
 
 DISCUSSION OF VARIOUS PROCEDURES 363 
 
 any acute edema has begun to subside, at which time 
 a change should be made to a dry dressing of some 
 kind. 
 
 Rest. Both local and systemic rest should be 
 insisted upon, especially in severe infections. The 
 local rest is of special value in a prophylactic sense, 
 since every movement of the fingers or hand tends 
 to favor lymphatic circulation and hence to favor 
 dissemination of the infection. Von Volkmann and 
 others have advised suspending the arm so that the 
 hand is elevated. It does not seem that this would 
 be of value except to relieve the pain of a congestion, 
 and it has not seemed to me to influence the course 
 favorably. 
 
 The Bier Treatment. The place of the Bier treat- 
 ment in infections of the hand has already been 
 touched upon (p. 71). In these lymphatic infections 
 I have used it only in the same sense that we would use 
 a ligature to prevent the rapid absorption of any 
 poison, as, for instance, in the slow absorption per- 
 mitted in snake bites. It, therefore, would find a 
 place in the early hours of a virulent lymphatic 
 infection in which the system may be receiving large 
 doses of virulent toxins without seeming to have the 
 reactive power necessary to wall off the infection. 
 Here the constrictor is applied for from twelve to 
 eighteen hours, tight enough to secure a marked edema. 
 This is done with the hope that the lack of reaction 
 upon the part of the system is due in part to the fact 
 that it is overwhelmed, and that if small doses are 
 allowed to enter the system a marked antitoxin will 
 be developed which will be able to withstand the toxin 
 if its entrance into the system is spread over some 
 time. Whether or not diapedesis of leukocytes in 
 these infections is favored by passive congestion is 
 a moot question.
 
 364 THE TREATMENT OF LYMPHATIC INFECTIONS 
 
 The method of applying the bandage is as follows: 
 A Martin bandage two inches wide is used. The 
 bandage is begun at a point slightly above the elbow 
 and carried to a point slightly below the axilla. Sev- 
 eral turns are carried about the arm, so made as to 
 preserve an equable pressure throughout. The pres- 
 sure should be sufficient to produce a moderate edema 
 in an hour, and should not be sufficient to produce 
 pain. The method used by some of wrapping a towel 
 about the arm and securing constriction by a rubber 
 tube or narrow rubber band is unwise, since it will 
 cause considerable pain and is more likely to produce 
 nerve injury. After the bandage has been in place 
 twelve to eighteen hours it is removed and replaced 
 in a couple of hours if the toxemia is still high. Ordi- 
 narily, one or two eighteen-hour periods is all I have 
 found of advantage in these cases. 
 
 Incisions. There may be some difference in opinion 
 as to the advisability of these under certain conditions. 
 
 There are those who teach that an incision made 
 at the point of great pain and tenderness when it is 
 the site of the primary infection will be of value. 
 They maintain that such an incision if it does not 
 evacuate pus favors drainage about the site of the in- 
 fection, and that the escaping serum carries off the 
 bacteria. It is my own belief that this hope is seldom 
 justified, and that the incision simply opens new 
 lymphatics for infection and fails to reach the bacteria 
 which have already entered the lymphatic stream 
 and are multiplying some distance from the site of 
 entrance. Therefore, the prophylactic incision fails 
 of its purpose and may do much harm by producing 
 complications. 
 
 Shall incisions be made along the line of lymphatics? 
 In those cases in which there is one or possibly two 
 red lines of lymphatic involvement running up the
 
 DISCUSSION OF VARIOUS PROCEDURES 365 
 
 arm the advice to make a transverse incision through 
 the skin and subcutaneous tissue, so as to prevent 
 the channel from carrying more toxin, seems logical, 
 and I have carried it out in a few cases. I am con- 
 vinced, however, that the procedure is likely to do 
 more harm than good, since it pours out into the wound 
 the virulent bacteria and toxins which at the end of a 
 few hours begin to be absorbed in greater amount 
 than before. The picture presented by this procedure 
 is very characteristic. Within an hour after the cut 
 is made the part proximal to the incision becomes 
 pale, the red lymphatic disappears, and the surgeon 
 feels that his procedure has been justified by the 
 results. At the end of a few hours, however, it is 
 seen that the portion distal to the incision has begun 
 to assume a reddish tinge, and shortly a consider- 
 able area takes on the characteristic appearance of 
 an erysipelas, with an aggravation of the symptoms. 
 
 In other instances the little lacunae found in the 
 course of the lymphatic vessels (see p. 327) show small 
 areas the size of a bean in the course of the lymphatics, 
 at which sites there is a local swelling and edema. 
 These are most common on the dorsum of the hand. 
 The thoughtless are inclined to incise these under the 
 impression that localization will be found there and 
 that drainage is indicated. If incision is made, how- 
 ever, only a small amount of serum will exude, and in 
 the severe cases the procedure is generally followed 
 by a chill and rise of fever within an hour or two, 
 sometimes to an alarming degree, while the procedure 
 is detrimental rather than beneficial to the ultimate 
 course. 
 
 If incision is made in these cases for any cause, 
 the possibility of spreading the infection must be borne 
 in mind and one should seek at least to prevent 
 rapid absorption. This is done by keeping the arm
 
 366 THE TREATMENT OF LYMPHATIC INFECTIONS 
 
 absolutely at rest and applying a Bier constrictor 
 to the arm. This should be left on for from twelve 
 to eighteen hours. These incisions will be called for 
 in those cases in which localization in the tendon 
 sheaths or in the subcutaneous tissues has taken place, 
 as, for instance, on the back of the forearm or about 
 the glands. (For a discussion of these, see p. 370.) 
 
 SYSTEMIC TREATMENT. Antagonistic Drugs. Vari- 
 ous drugs have been vaunted from time to time as 
 of exceptional value in septic conditions. They may 
 be classified as those designed to destroy bacteria 
 and those to neutralize the toxin. The value of any 
 of them is questionable. Quinine has been used for 
 many years, and if it were of marked value sufficient 
 positive evidence should have accumulated by this 
 time to leave no doubt, and this cannot be said to 
 be true. The same may be said of urotropin and 
 the various silver salts which have been vaunted so 
 highly. Upon none of these can the surgeon depend 
 with any distinct hope that they will be of value. 
 The use of whisky is in a different class. Any value 
 it may have depends upon the fact that its elements 
 are less stable than normal cell protoplasm, and con- 
 sequently there is some hope that the toxin may unite 
 with these rather than cause destruction of the living 
 cells. There may be some truth in this. The trouble 
 is that to be of much value in this regard there should 
 be a considerable amount in the blood, and the excre- 
 tion of any considerable amount would be injurious 
 to the kidneys. 
 
 In this connection it has been my habit to give these 
 patients who are seriously ill fully peptonized food 
 per rectum if they cannot take it by mouth, so as 
 to introduce into the blood peptones, less stable than 
 normal albumin of the living cells, with the hope that 
 the toxins will unite with the less stable combinations
 
 DISCUSSION OF VARIOUS PROCEDURES 367 
 
 and thus protect the system. This can do no harm, 
 and may do good. 
 
 Related to this we have the use of normal salt 
 solution or plain water introduced into the system 
 per rectum, as well as large amounts of water and 
 fluids by mouth. In serious cases the normal salt 
 may be given subcutaneously. It is my belief that the 
 introduction of large amounts of fluid with the idea 
 of diluting and eliminating the toxins is of great 
 value. 
 
 Serum and Vaccine Treatment. We have not as yet 
 developed any serum or vaccine that can be said to 
 be of definite value in these acute cases. The field 
 is a most engaging one, and many attempts have 
 been made to produce an antitoxin. The difficulties 
 seem to be almost insuperable. If given very early 
 it might have some effect, since some of the sera, 
 such as that of Aronsen, have some bactericidal in 
 addition to its antitoxic and opsonizing effect. Often 
 the toxemia is well advanced, and such an immense 
 amount of antitoxin would be necessary to neutralize 
 the toxins that we cannot hope to inject it, and the 
 opsonizing and bactericidal effects are insufficient. 
 Moreover, it has been shown many times that the 
 antitoxin prepared for one type of streptococcus 
 will have no effect upon the toxins generated by a 
 second type of streptococci. 1 
 
 Van de Velde showed that the leukocidin produced 
 by one staphylococcus pyogenes aureus might be 
 almost innocuous, while another might be most 
 virulent. Denys, Van de Velde, Neisser, and Wech- 
 berg have produced antileukocidin, but it must be 
 for the specific organism. 
 
 Therefore, to secure the best results a serum must 
 
 1 Meakins, Phagocytic Immunity in Streptococcus Infection, Jour, of 
 Exper. Med., xi, 815.
 
 368 THE TREATMENT OF LYMPHATIC INFECTIONS 
 
 be made from the germ producing the disease, and 
 this is manifestly impossible, since the time is too 
 short. In attempts to obviate this difficulty some 
 have made their antistreptococcus serum from a 
 combination of several strains of streptococci, i. e., 
 the so-called polyvalent antistreptococcus sera, such 
 as those of Tavel, Moser, Menzer, and others, while 
 the sera of Marmorek and others is monovalent, 
 i. e,, made from one strain. Whether these sera act 
 in a bactericidal or antitoxic manner or by stimulating 
 cellular activity is a subject for discussion, but at 
 least the effect is inadequate. It is possible that in 
 the more chronic types vaccines may be produced that 
 will aid somewhat. In this connection a perusal of 
 Case XXIV should be of interest. In this case almost 
 all of these methods were tried without avail. 
 
 The injection and use of elements designed to in- 
 crease leukocytosis is another favorite method of treat- 
 ment. For this purpose several drugs have been used, 
 as, for instance, protonuclein and nucleic acid, but 
 without definite results. His has recently suggested 
 the injection of sterile exudate, secured incident to 
 aseptic injections of the pleural cavities of lower 
 animals with aleuronat. As yet this has not secured 
 a trial. 
 
 In spite of the lack of definite results by any of 
 these methods, one cannot but hope that the future 
 holds some promise of aid from these studies. The 
 surgeon should always have in mind the possibility 
 of value from the sera, watching his cases closely 
 for a favorable opportunity; but as the case now 
 stands it is my personal opinion that he is not in 
 position to promise his patients any distinct curative 
 action in the more acute cases. 
 
 Supportive Measures. Supportive measures in the 
 way of stimulants, fresh air, good food, attention to
 
 RESUME 369 
 
 the bowels, and proper rest should not be neglected. 
 The fresh air and sunlight, especially in the more 
 chronic cases, is of distinct value. One patient suffer- 
 ing from such a chronic infection, which defied all 
 manner of treatment, was transferred to an open air 
 sun room where he lived and slept. The benefit of the 
 change was evident to everyone. (See Case XXIV.) 
 
 Treatment of lymphatic infection is based upon two 
 principles conservatism and conservation. In general 
 we use local means tending to wall off and overcome 
 infection, combined with procedures designed to sup- 
 port the system and increase its resisting power. 
 
 Local Procedures: Hot, moist dressings applied 
 voluminously should be used until the infection is 
 walled off. Boric acid, potassium, permanganate, 
 and other solutions may be used. Both local and sys- 
 temic rest should be insisted upon. The Bier treat- 
 ment is of some value in preventing rapid extension 
 of the infection. Incisions should not be made unless 
 there is an absolute surety that there is an accumula- 
 tion of pus. 
 
 Systemic treatment such as quinine, whisky, uro- 
 tropin, and silver salts all have advocates and in 
 certain instances may be of value, although probably 
 in the majority of cases they will be found to be of 
 no use. 
 
 Peptonized food by rectum may be of value. Large 
 amounts of normal salt or water is probably a great 
 aid in diluting and eliminating the toxin. 
 
 Serum and vaccine treatment have not given dis- 
 tinct aid in these cases. 
 
 Supportive measures in critical cases are always a 
 great benefit.
 
 CHAPTER XXIV. 
 
 THE TREATMENT OF THE COMPLICATIONS 
 OF LYMPHANGITIS. 
 
 TENOSYNOVITIS. 
 
 ATTENTION has been drawn to the frequency of 
 tenosynovitis in lymphatic infections beginning in 
 the distal phalanges on the volar surface. In the 
 chapter dealing with the subject of tendon-sheath 
 infections (Chapter XI), a complete discussion has 
 been given which should enable the student to diag- 
 nosticate the presence of such a complication, and 
 rules have been laid down for the treatment that has 
 been most successful in my hands. There only 
 remains, therefore, a discussion of such general prin- 
 ciples as pertain to lymphangitis in particular. 
 
 If the patient complains of great pain over the ten- 
 don sheath when the primary puncture has been upon 
 the volar surface of the finger, even though the pain 
 has not extended to the entire finger, one should be 
 especially on his guard, and the moment that the 
 tenderness has extended from the site of the infec- 
 tion to involve the distribution of the subjacent 
 tendon sheath, the incision should be made exposing 
 the sheath. If one delays longer, destruction of the 
 synovial covering will have occurred, in which case the 
 prognosis for function is much more grave. It is my 
 habit to make lateral incision on one of the middle 
 and proximal phalanges, and thus secure drainage, 
 being careful not to produce a secondary infection, 
 and also using care to cut far enough toward the volar
 
 TENOSYNOVITIS 371 
 
 surface to avoid the lateral vessels and nerve which 
 run up the sides of each finger. If there is much 
 destruction of the synovial covering, parietal and 
 tendinous, it will be advisable to lengthen the incision 
 upon one side so as to connect the two phalangeal 
 cuts, thus giving free drainage but preventing 
 prolapse of the tendon because of the lateral site of 
 the incision. This is further prevented by placing a 
 dorsal splint upon the finger and hand, which tends 
 to keep the finger in extension and thus favor reten- 
 tion of the tendon in its proper place. If one is very 
 prompt in the incision, so that no destruction has 
 taken place, he is gratified and surprised at the rapid 
 recovery he secures. Sometimes it is entirely well 
 by the end of ten days or two weeks. If the process 
 has lasted some time, it is frequently necessary to 
 incise at the side of the finger over the lumbrical 
 space to secure drainage of the loose tissue here and 
 in the web. Care should be taken here not to cut 
 the blood supply. If there is doubt as to the side 
 involved, it may be best to cut down upon the median 
 surface over the proximal end of the sheath in the 
 palm and then secure drainage from either side through 
 this incision by inserting an artery forceps into the 
 loose tissue at the side and separating the blades so 
 as to give free exit to the pus (see p. 260, and Figs. 
 98 and 100). If vaseline gauze or gutta-percha drain- 
 age is inserted in the early cases, it can be removed 
 the next day. If the thumb or little finger is the source 
 of the infection, the radial or ulnar bursae are opened 
 after the method described in Chapter XVI. If there 
 is no tenderness above the wrist it may not be neces- 
 sary to make the lateral incision above the flexor 
 surface of the ulna and radius. If there is any tender- 
 ness, however, or swelling, incisions should be made 
 at once and drainage instituted (see p. 265). Before
 
 372 TREA TMENT OF COM PLICA TIONS OF LYMPH A NGITIS 
 
 any incisions are made the Martin elastic bandage 
 should be applied to the arm, and following the opera- 
 tion it should be loosened only to the degree neces- 
 sary to produce a marked Bier's hyperemia. This 
 helps to wash the toxins out of the tissue adjacent to 
 the wound, and also prevents the rapid absorption 
 of toxins, a fact which I have already discussed. 
 All the various locations of pus secondary to tendon- 
 sheath infections and the proper procedures indicated 
 in their treatment have been discussed in Chapter 
 XVI. 
 
 SUBCUTANEOUS ABSCESSES. 
 
 Subcutaneous abscesses frequently appear upon the 
 dorsum. As soon as a definite redness and hardness 
 have appeared, indicating pus, free incisions should 
 be made. Simple redness and edema is not suffi- 
 cient to indicate incision, but when the hardness has 
 been added free incisions under the same precautions 
 as mentioned above should be made. The presence 
 of extensive subcutaneous destruction of the connec- 
 tive tissue with the formation of a slough with strepto- 
 coccus pus is one of the most serious complications. 
 Incision should be made early, in several places upon 
 the dorsum, so as to give perfect drainage. At the 
 risk of useless repetition, let me say again that I am 
 speaking of the indurated, brawny, dark red dorsum, 
 characteristic of the spreading virulent phlegmon, not 
 of the pinkish, edematous, pitting dorsum. Neither 
 am I speaking of the simple staphylococcus abscess. 
 The gravity of this severe type has long been 
 recognized. 1 
 
 1 Bauchet thus describes how they were considered and treated by Velpeau: 
 
 "An unconfined phlegmon is one of the most serious complications of a 
 
 whitlow. It is heralded by a series of serious symptoms here as in all other 
 
 parts, by a considerable swelling, and a characteristic dull, yellowish redness. 
 
 "The diffuse phlegmon' is undoubtedly a serious matter when it appears
 
 SUBCLAVICULAR AND SHOULDER ABSCESSES 373 
 PERIGLANDULAR ABSCESSES. 
 
 Periglandular abscesses occur especially on the 
 epitrochlear and axillary regions. These are not so 
 virulent as the type just described, and a more con- 
 servative course may be pursued. Since they start 
 from glandular suppuration, some days will elapse 
 before they become evident. The surgeon will often 
 be in doubt for a day or two as to whether the infec- 
 tion may not be a simple glandular hyperplasia. 
 The waiting period is not without advantage to the 
 patient, since it offers an opportunity for the abscess 
 to become walled off, and thus favors the prevention 
 of extension when it is opened. 
 
 SUBCLAVICULAR AND SHOULDER ABSCESSES. 
 
 The occurrence of such an abscess will of course 
 be rare, since they arise in the course of the lymphan- 
 gitis extending along the lymphatics lying in the pec- 
 terodeltoid groove, having its origin most commonly 
 in the middle finger. It has been my fortune to meet 
 with only one such case, and this began in the index 
 finger. Dr. J. M. Neff, of Spokane, has seen and 
 
 on the back of the hand, but it is even more dangerous when it invades the 
 forearm and arm. 
 
 "The first symptoms of this awful complication once recognized, one must 
 not hesitate to have recourse to the most drastic therapeutic measures; anti- 
 phlogistics, local and general baths, purgatives, opiates, and the arm placed 
 in an elevated position. If at the end of twenty-four or thirty-six hours the 
 symptoms do not mend, and if the disease seems stationary, one must insist 
 upon the compresses, if the patient has been able to stand them, after generous 
 applications of ointments of mercury. If the compresses increase the pain, 
 one may profitably resort to the application of a large volatile vesicatory, 
 covering all the diseased parts. This means, so extolled by M. Velpeau, has 
 and always will render good service. 
 
 "However, if the general symptoms continue to grow worse, if the swelling 
 increases, the moment to proceed with the bistoury has come, and three or 
 four long deep incisions must be made. This is the only road to recovery left 
 to the patient."
 
 374 TREA TMENT OF COM PLICA TIONS OF L YMPHA NGITIS 
 
 operated upon another one, in which the origin was 
 in the middle finger, followed in three days by a 
 subclavicular abscess, which was opened, and this in 
 turn was followed or accompanied by a synovitis of 
 a knee-joint of a serious nature, but from which the 
 patient ultimately recovered. This case then is most 
 interesting, since it emphasizes the origin of these 
 abscesses and also serves to emphasize what I have 
 previously called attention to, and that is the seri- 
 ousness and frequency of systemic involvement from 
 lymphangitis originating in the middle finger. 
 
 SYSTEMIC COMPLICATIONS. 
 
 These must be met as they arise and the treat- 
 ment based upon the general surgical principles 
 governing septicema and pyemia. The metastatic 
 abscesses should be opened, empyemas drained, pneu- 
 monia, etc., guarded against with every possible pre- 
 caution. 
 
 The question of amputation of the arm in these 
 severe cases will be a constant one, but no definite 
 rules can be laid down. One will constantly feel in 
 the early cases that amputation is too severe for the 
 condition, and when systemic infection has begun 
 it will be considered that amputation will be futile, 
 so that the indications for amputation will be drawn 
 between narrow lines. In exceptional cases some 
 hope may be offered by this procedure, as, for instance, 
 in a spreading phlegmon or in a malignant edema. 
 
 CHRONIC INFECTIONS; REPEATED INFECTIONS. 
 
 It is an unfortunate fact that one infection with 
 a streptococcus does not immunize the patient; at 
 least, if it does, it is only for a short time. Not only
 
 CHRONIC INFECTIONS; REPEATED INFECTIONS 375 
 
 are repeated infections possible, but one infection 
 seems almost to favor a second at a later date. This 
 is not true to the same degree with the staphylococcus, 
 by which a mild degree of immunization may be 
 secured. This is demonstrated by the raising of the 
 opsonic index as determined by the Wright method. 
 The streptococcus particularly not only may not 
 develop immunization, but also lacks to a marked 
 degree the power in many cases to produce antitoxins 
 in a degree sufficient to overcome itself, so that we 
 often see cases of chronic long-continued infection 
 which undoubtedly had their origin in a streptococcus 
 infection. No better example of this type of infection 
 could be cited than that of a case I saw with Dr. 
 Oleson, of Lombard, 111. It is true that another 
 factor came into this case, namely, that the infection 
 had possibly come from organisms which had passed 
 through a lower animal which we know may change 
 the virulence in many ways. The case, however, 
 is worth a careful perusal, since it was so carefully 
 and conscientiously treated by Dr. Oleson by every 
 known scientific method, and yet it resisted treat- 
 ment for over two years, the patient apparently not 
 having the slightest ability to develop antitoxins. 
 He has now completely recovered. 
 
 Dr. Oleson has already reported the case, and I 
 herewith abbreviate his report: 
 
 CASE XXIV. "On June 15, 1906, over three years 
 ago, the patient removed a wart from the index finger 
 of his right hand, leaving an opening in the subcutaneous 
 tissue which did not readily close. While this condition 
 existed he received orders to care for some sick calves, 
 afflicted with a disease which caused dyspnea, with 
 considerable salivation. In giving them medicine it 
 was necessary for him to introduce his right hand into 
 their mouths, with the natural consequence that it became 
 covered with their slobbery saliva. In a few days he
 
 376 TREA TMENT OF COM PLICA TIONS OF LYMPHANGITIS 
 
 sickened and called in Dr. William Dillon, of Urbana, 
 who reports under date of August 18, 1906, substantially 
 as follows: 
 
 "'In regard to Mr. J.'s illness, I was called to his room 
 about 9 P.M., June 27 (1906). I found him lying down, 
 with perspiration in large drops over his face, pulse full 
 and rapid, temperature about 103 F. Pain about axilla. 
 Axillary glands indurated and enlarged. There was a 
 small unhealed place in the centre of a spot on one of his 
 right fingers, from which I could press out a little serum, 
 but which had no soreness. I ordered fomentations 
 during the night, with magnesia sulphate internally. The 
 following morning there was less pain, but more fever, 
 and I had him removed to a hospital, where the treatment 
 was continued. The glands returned to their normal 
 size so far as could be detected, but fever and sweating 
 continued. About the third day in the hospital painful 
 tympanites developed, also swelling along the general 
 direction of the pectoralis tendon from a little below the 
 arm-pit to near the eleventh rib. This was the first appearance 
 of localization. I called in Dr. Newcomb, who aseptically 
 incised the tissues down through the deep fascia. A 
 little serum escaped. About July 22 the second incision 
 was made and the entire cavity washed out with bichloride 
 and dressed with dry dressings. Now the patient rapidly 
 improved and the abscess walls united so that when 
 irrigated the fluid would extend but a short distance in 
 any direction. The pus by July 30 had almost ceased. 
 Temperature normal, pulse normal, patient bright, no 
 sweating." 
 
 Dr. Oleson here continues: 
 
 "I first saw the patient on August 10, 1906. On enter- 
 ing my office a limitation of motion in the right shoulder 
 and a marked cervical scoliosis was evident. He was 
 pale, anemic; pulse, 106; temperature, 98 F. At the 
 anterior margin of the right axilla, along the border of 
 the pectoralis major, appeared a long scar, presenting 
 at its upper end a small orifice discharging a thin blue- 
 green serum. A second opening existed to the axillary 
 side of the scar, about an inch below the first sinus. No 
 swelling, some redness, tenderness slight, shoulder-joint 
 motion limited, evidently from scar contraction. A
 
 CHRONIC INFECTIONS; REPEATED INFECTIONS 377 
 
 flexible sterilized probe introduced into the sinus with 
 strict asepsis passed under the clavicle for some distance 
 toward the vertebrae, so that the general clinical picture 
 simulated a cervical Pott's. But a few days' study sat- 
 isfied me that there was no vertebral disease, nor could 
 I find evidence of any shoulder- joint trouble. 
 
 "He passed into the hands of a neighboring sectarian 
 practitioner, and after some weeks of unimprovement 
 entered a homeopathic hospital in this city. Here the 
 gradually enlarging ulcer, which appeared at the site of 
 the sinus and slowly spread downward along the thoracic 
 wall in the direction of the original incision, was curetted, 
 and the patient received considerable x-ray treatment, 
 with a steady failure of his vital forces until the latter 
 part of March, 1907, some nine months after the oirginal 
 infection, when, on the suggestion of the hospital author- 
 ities, he was taken from the institution to end his days 
 among his friends. Here I saw him on March 28, 1907, 
 since which time he has been continuously under my care. 
 He presented then the typical picture of advanced chronic 
 sepsis. He was thin, haggard, with a marked Hippo- 
 cratic facies, scoliosis more evident, temperature running 
 a classical hectic curve (morning remissions to 98 F., 
 evening readings varying around 102 F.), then con- 
 stantly between 120 and 130, having the appearance 
 of impending death. Locally the margins of the sinus 
 had broken down to form along the thoracic wall a deep 
 ragged ulcer as large as the palm of one's hand with 
 sinuses radiating upward, forward, and downward, honey- 
 combing the tissues in the pectoral region, while over 
 the third and fourth right costochondral junctions ap- 
 peared bluish-red depressed areas, evidently marking 
 points at which pus was about to appear. The former 
 bluish-green discharge was now almost colorless, very 
 profuse, and of a thin serous nature, soaking large gauze 
 dressings daily. 
 
 "On April 6, 1907, under chloroform anesthesia by 
 Dr. Pickard, with Dr. W. F. Scott assisting me, I removed 
 inflamed periosteum and perichondrium, with subjacent 
 necrotic tissue at the points indicated by the discolored 
 skin, curetting from all accessible places the various 
 sinuses, scraping out large quantities of soft, pale, pulpy,
 
 378 TREA TMENT OF COM PLICA TIONS OF LYMPHANGITIS 
 
 friable granulations, with free hemorrhage easily checked 
 by pressure. The patient was put to bed in an exhausted 
 condition, while my consultants cheerfully foretold an 
 early lethal termination. 
 
 "On May 6, 1907, I performed a second similar opera- 
 tion, attacking new fresh necrotic areas over the second 
 and fifth costochondral junctions. The result of these 
 two operations was a considerable improvement in the 
 pulse curve, which now rarely went over no, while the 
 temperature did not pass above 101, with no loca change 
 except the healing of one sinus which had invaded the 
 tissues from the lower margin of the ulcer. 
 
 "On July 6, 1907, I performed what was intended for 
 a radical operation, by making a deep curved incision 
 from the lower border of the ulcer, anteriorly to the 
 sternum, separating the entire pectoral flap of muscles, 
 reflecting them back over the shoulder and exposing this 
 region for general curettage. 
 
 "After thorough scraping of all other lesions the flap 
 of muscle was sutured back into place. The patient did 
 not react well, it being several days before he ceased 
 vomiting, and the general immediate result of this inter- 
 vention was the actual spread of the infection, as it fol- 
 lowed each suture and needle puncture into new regions, 
 reaching around alsointo the intermuscular septaand subcu- 
 taneous tissue of the back, a region previously uninvaded. 
 Various abscesses were opened during the next month. 
 
 "During all this time the wound had been dressed by 
 daily irrigation through drainage tubes or along the 
 sinus tracts. All sorts of fluids had been used normal 
 saline, plain sterilized water, iodine water, hydrogen 
 peroxide, pure and in solutions of varying strengths, 
 bichloride and phenol dilutions, with no appreciable 
 improvement. On September 2, 1907, I made a radical 
 change; permanently abandoning all forms of irrigations, 
 and substituting plain, dry, sterile dressings, with immedi- 
 ate marked improvement in the general condition. The 
 temperature fell to 99 and remained there, while the pulse 
 varied between 90 and 100. There had been nervous 
 digestive disturbances, so that any unwelcome suggestion, 
 e. g., the discussion of an anesthetic or the odor of ether, 
 etc., would cause a prompt and thorough emesis. Yet
 
 CHRONIC INFECTIONS; REPEATED INFECTIONS 379 
 
 he had gained 10 pounds in bodily weight in five months, 
 but with the cessation of irrigation, the digestive derange- 
 ment ceased, he took and retained large amounts of food, 
 with cod-liver oil, sevetol, etc., so that in the next five 
 months he gained 26 pounds, with corresponding physical 
 improvement. By the middle of January, 1908, he was 
 strong, robust, healthy appearing, but with absolutely 
 no improvement whatever in the local lesion, which 
 remained stationary, discharging daily large quantities 
 of seropus, necessitating copious aseptic dressings. 
 
 "At about this time Dr. Emil Beck announced the 
 result of his work in the treatment of certain unhealed 
 sinuses by the bismuth paste method. Injections were 
 given January 22 and 28, 1908, with no special result 
 except that the patient's weight fell off a little. In order 
 to give the paste a little better chance, I decided to 
 curette the granulations from the sinuses again, and then 
 to make a third injection. This I did on February 10, 
 1908, and on the morning of February n, I found my 
 patient with a pulse of 140; temperature, 102; rusty 
 sputum and consolidation of the left lower lobe. 
 A typical crisis occurred on the seventh day, with uncom- 
 plicated convalescence. One peculiar phenomenon pre- 
 sented itself on the third morning of the seizure, when 
 the patient suddenly expectorated a single mouthful 
 of pure pus, of which the anatomical origin was never 
 satisfactorily located. 
 
 "On February 26, 1908, he returned to his home, 
 having lost 17 pounds, which he proceeded to regain. 
 At this time, through the courtesy of Prof. Ormsby, I 
 secured from the research laboratory of Parke, Davis 
 & Co., a supply of staphylococcus vaccine, varying doses 
 being injected on March 14, and for a month afterward, 
 without effect. Thorough search was now made by Prof. 
 Ormsby for evidences of blastomycosis, actinomycosis, 
 and tuberculosis, with negative results. Prof. Hektoen 
 now generously placed at my disposal his laboratory 
 facilities, and his assistant, Dr. D. J. Davis, readily iso- 
 lated from the pus a streptococcus which grew abund- 
 antly in almost pure cultures, but presented no identifying 
 morphological characteristics. The patient's opsonic index 
 to this organism was subnormal.
 
 380 TREA TMENT OF COM PLICA TIONS OF LYMPHANGITIS 
 
 "On April 16, 1908, I injected the dead bodies of 
 500,000,000 autogenous cocci obliquely into the subcuta- 
 neous tissue of the right thigh. In two days an indura- 
 tion appeared at the site of injection. Twelve days from 
 date of puncture fluctuation was evident at this point. 
 On May 6, twenty days from the injection, the skin here 
 grew purplish. Two days afterward, on May 8, under 
 aseptic precautions, I aspirated some of the contents of the 
 swelling, which, on examination by Dr. Davis, proved to 
 be sterile, chemical pus. On May 15, twenty-nine days 
 after injection, the skin finally broke down and the con- 
 tents escaped, leaving a superficial ulcerated area, which 
 slowly cicatrized across from the margins, ultimately heal- 
 ing on July 3, 1908, seventy-eight days after the date 
 of injection. 
 
 "The history is that of each inoculation made obliquely, 
 leaving the vaccine in the subcutaneous tissue. As time 
 went on I lessened the dose to 250,000,000, 60,000,000, 
 10,000,000, and each one caused the breaking down of 
 connective tissue, the formation of sterile chemical pus, 
 the death of the overlying skin from starvation an 
 open ulcer slow healing, so that we finally had an 
 absolute clinical demonstration of the method of local 
 spread of this coccus, namely, by the secretion of toxins, 
 which by their chemical action on the connective tissue 
 not skin, not muscles, but subcutaneous tissue, fasciae, 
 septa, etc. cause this to gradually die and melt away, 
 destroying the bloodvessels which run in its meshes, and 
 so bringing about the death of overlying skin or under- 
 lying bone, not by attacking these structures themselves, 
 but by cutting off their nourishment. 
 
 "To prove this I then proceeded to inject the same 
 doses of dead cocci deeply in the muscles themselves, 
 beginning with 10,000,000 and steadily increasing the 
 quantity until, on August 29, 1908, I gave him 300,000,000 
 and not once was there the least reaction, local or 
 general, to a single intramuscular injection, while every 
 one of the oblique subcutaneous injections of the same 
 cultures, with identical aseptic precautions, produced local 
 necrosis. 
 
 "During this period, while we were endeavoring to 
 do something to help the patient by means of specific
 
 CHRONIC INFECTIONS; REPEATED INFECTIONS 381 
 
 vaccine, his general condition failed slightly. He lost 
 about 8 pounds in weight, and there was a slow spread- 
 ing by undermining the skin around the affected area, 
 so that at the end of this time, when this method was 
 abandoned, the area involved reached its maximum, 
 covering the right side of the body from the sternum 
 into the middle of the right half of the back and extend- 
 ing from a point above the clavicle down beyond the 
 costal margin a stretch of 29 cm. in each diameter. 
 I now decided to expose the affected region thoroughly, 
 and on September 15, 1908, I curetted again all sinuses 
 and completely excised all undermined skin. At last this 
 was followed by actual healing. 
 
 "For some time I had been anxious to give my patient 
 the benefit of sunshine in direct application to the wound 
 surfaces, but no practicable method presented itself to me 
 on account of the large area to be covered and the very 
 free discharge. Fortunately, on November 28, 1908, 
 Dr. Allen B. Kanavel saw him and suggested a home- 
 made wire cage. This crude appliance was applied on 
 December 3, and proved to be the one missing link in 
 the chain to drag the patient back to health. The wire 
 cage was enveloped with sterile gauze, and so enfolded 
 and protected, my patient has spent the last ten months 
 basking in the sunlight, with slow but steady healing of 
 the local lesions in all spots the sun's direct rays could 
 reach. The range of pulse is in the sixties, the tempera- 
 ture normal, and the general condition most excellent." 
 
 The history of this patient serves to emphasize 
 that in such cases the general hygienic rules are of 
 more value than any special procedures. This would 
 include outdoor life and nourishing food, combined 
 with the least possible local treatment of the infected 
 areas. The -futility of vaccine treatment was also 
 emphasized.
 
 382 TREA TMENT OF COM PLICA TIONS OF LYMPHANGITIS 
 
 Tenosynovitis should be treated here, when it ap- 
 pears, as elsewhere. Description of the technique will 
 be found in the chapters dealing with that subject. 
 
 Subcutaneous abscesses which appear upon the 
 dorsum should be opened freely but simple redness 
 and edema do not indicate pus and an incision should 
 not be made. 
 
 In phlegmonous lymphangitis extensive incision 
 should be made upon the dorsum. 
 
 Periglandular abscesses should be opened when 
 they appear. One should be conservative and not 
 make incision too early. 
 
 Systemic infection should be treated upon the same 
 general principles as septicemia and pyemia. 
 
 Chronic infections and repeated infections are prob- 
 ably better treated by general supportive treatment, 
 such as outdoor life, nourishing foods, etc., although 
 in certain cases vaccines have been found to be of 
 value.
 
 SECTION IV. 
 ALLIED INFECTIONS. 
 
 CHAPTER XXV. 
 
 ERYSIPELAS, ERYSIPELOID, GAS-BACILLUS 
 INFECTION, ANTHRAX. 
 
 ERYSIPELAS. 
 
 ERYSIPELAS may appear in two types : first an uncom- 
 plicated cutaneous lymphangitis corresponding to the 
 picture seen upon the face, and second, as a cutaneous 
 lymphangitis, complicated with a subcutaneous lym- 
 phangitis. This latter type is more common in the 
 hand. The former, the rarer type, is that of the 
 typical erysipelas as seen upon the face with the 
 brawny induration confined to the skin and outlined 
 by a distinct border. The deep purple-red skin may 
 have blebs upon it. The second type is the accom- 
 paniment of the severe subcutaneous lymphangitis, 
 and has been discussed on pages 341 and 372. 
 
 The treatment of erysipelas proper is clearly that 
 of a lymphangitis which also has been discussed (see 
 pp. 361 and 366). No special applications, such as 
 carbolic acid, ichthyol, salicylic acid, can be considered 
 to be of special value. In the superficial type the 
 usual hot, moist dressings may be used; the treatment 
 of the severer types referred to, which are often called 
 gangrenous erysipelas or gangrenous cellulitis by 
 surgeons, has been discussed on page 372.
 
 384 ERYSIPELAS, ERYSIPELOID, ANTHRAX 
 
 ERYSIPELOID. 
 
 This is a condition seen most commonly upon the 
 fingers and which may be mistaken for true erysipelas. 
 The earlier writers have described it under the title 
 of chronic erysipelas, or erythema migrans. Rosen- 
 bach designated the condition erysipeloid, a name 
 which has been accepted by the profession. 
 
 It commonly has its origin in some slight wound, 
 and is most often seen in those handling fish and 
 oysters or cheese and herring. Therefore, it is found 
 among fishermen, butchers, cooks, etc. Gilchrist 
 has described his findings in over 300 cases which 
 originated in crab bites. He thought the condition 
 was due to a ferment injected by the crab bite, and 
 not to a special organism. Rosenbach described a 
 cladothrix-like organism as the cause, and this finding 
 was later confirmed by Ohlemann. It is an irregular 
 round organism, developing into threads in old cul- 
 tures. Pathologically one finds an invasion of the 
 corium with polynuclear leukocytes and a massing 
 of lymphoid cells about the bloodvessels. 
 
 SYMPTOMS. Following a slight injury, generally upon 
 the fingers, the skin becomes swollen, painful, and 
 of a deep bluish color. There is some local burning 
 and itching, but no fever or any general reaction. 
 The infection extends gradually with a sharp line of 
 demarcation up the finger into the hand rarely as 
 high as the middle, but it may involve the adjacent 
 fingers. As it extends, the older area becomes pale. 
 A lymphangitis of a very resistant type may develop. 
 There are no papules, vesicles, or suppuration. The 
 disease lasts from one to four weeks, varying with 
 the treatment. 
 
 TREATMENT. Lexer advises immobilization by a 
 splint for from two to four days, accompanied by
 
 GAS-BACILLUS INFECTION 385 
 
 applications of vaseline. If movement begins too 
 early, the trouble will reappear. Others recommend 
 25 per cent, salicylic acid ointment followed by a 
 bland oil. 
 
 GAS-BACILLUS INFECTION. 
 
 Under this title many conditions are included which 
 have in past years been described by many titles, 
 such as gaseous phlegmon, emphysematous gangrene, 
 malignant edema, etc. It is probable that there are 
 at least two distinct types here included, if not more: 
 namely, infection by the. bacillus of malignant edema 
 and that by the Bacillus aerogenes capsulatus. Other 
 bacteria may produce gas, and thus come under this 
 classification. 
 
 While we may thus separate them etiologically, 
 clinically we must consider them as one, since we can- 
 not be certain when making smears at the operation 
 with which type we are dealing. We are wont to say 
 that the more serious type is probably due to the 
 bacillus of malignant edema, and the milder type to 
 the Bacillus aerogenes capsulatus. We cannot be 
 certain of this, however, and for the purpose of treat- 
 ment must divide them into fulminating and subacute, 
 and base our treatment upon this without regard to 
 the organism present. 
 
 The accompanying table, which may be found of aid 
 in differentiating the various organisms obtained by 
 smear or culture in these cases, was prepared for me 
 by Dr. W. H. Buhlig. It is designed to differentiate 
 not alone the virulent organisms, but also to separate 
 these from the non-pathogenic organisms with which 
 they may be confused.
 
 386 
 
 ERYSIPELAS, ERYSIPELOID, ANTHRAX 
 
 
 g 
 
 
 o 
 
 fl 
 
 co 
 
 
 
 w 
 
 * 
 
 o 
 
 PH d 
 
 s 
 
 flll^ 
 
 X'~% 
 
 CM 
 
 
 Stri 
 
 
 I-'S >. 
 
 _ 
 
 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