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Infections of the hand
INFECTIONS CYRIL A.
OF THE HAND*
RAISON, MB.,
CH.B., P.R.C.S.
BIRMINGHAM, ENGLAND
T
are more intimate than in the hand, and yet this is often quite overIooked in both diagnosis and treatment; in fact surgery of the infected hand is “anatomy pIus common sense.” It is impossibIe in a short paper to go into much detai1, but I wiI1 first attempt to emphasize a few anatomica points which have particuIar bearing upon treatment. The hand and fingers are divided into a number of fascia1 compartments and synovia1 spaces so distinct from one another that pus may not, at any rate in the earIy stages, pass easiIy from one to the other. There is a right and wrong method of opening these spaces and a cIear understanding of them is essentia1 so that we know exactIy where to incise. The superficia1 fascia of the dorsum of the hand is Ioose and thin, but in the paIm it is generaIIy we11 furnished with fat, forming a pad for the protection of vesseIs and nerves. It is cIoseIy adherent to both paImar fascia and skin. The deep fascia of the arm becomes thickened at the wrist to become the anterior annuIar Iigament, which forms a strong membrane binding down the flexor tendons and the median nerve in the carpa tunne1, which is subdivided into two compartments, one occupied by the Aexor carpi radiaIis tendon and the other by the nerve and flexor tendons to the thumb and fingers. As one wouId expect, the Aexor carpi radiaIis tendon has a separate synovia1 sheath, as has aIso the ffexor Iongus poIIicis tendon, aIthough it Iies in the same fascia1 compartment as the remainder of the flexor tendons to the fingers, which are themseIves encIosed in a common sheath. The paImar fascia is a thick trianguIar membrane, with its apex continuous with ANATOMICALRELATIONS the anterior annuIar Iigament and ending beIow by dividing into four sIips, each of There is, probabIy, no part of the human which ends at the base of the finger by frame in which the anatomica reIations * Submitted for pubIication March 5, 1929. 530 HIS paper is based upon experiences of eight years spent in charge of the CasuaIty Department of the Birmingham Genera1 HospitaI, where about fifty thousand patients are treated annuahy, a Iarge proportion being cases of infections of the hand. During this same period I had the advantage of carrying out very many examinations under the Workmen’s Compensation Act, and so have seen many typica exampIes of what one may caI1 the end resuIt, and I cannot heIp being impressed by the very Iarge part pIayed by hand infections in damaging the effrciency of industria1 workers in our big cities. Indeed so often does a sIight cut or prick Iead to a permanentIy crippIed hand that it is surprising what IittIe attention is often paid to these seemingIy unimportant injuries by the medica profession on ‘the one hand and those responsibIe for the working of the Factories Act on the other. Even in some of the Iarger teaching hospitaIs, the casuaIty department is under the charge of a senior house surgeon, who, as a student, was never taught to regard his out-patient dressing as one of the most vaIuabIe parts of his training, and, in fact, has often been given but scanty instruction upon what is reaIIy an extremeIy intricate matter. The student, time after time, is impressed with the necessity of earIy treatment in acute appendicitis, but faiIs to reaIize the great advantage of prompt and efficient treatment in the very earIy stages of a simpIe infected wound of the hand, and yet the Ioss of earning capacity to the manua1 worker may be manifoIdIy greater in the Iatter than in the former.
NEW SERIES VOL. VI, No.
4
Raison-Infections
dividing into two further sIips, which become continuous with the IateraI sides of the digita sheaths, which are tubuIar envelopes encIosing the flexor tendons in the fingers. They consist of strong fibrous sheaths attached on either side to the phalanges, and are Iined by synovia1 membrane, which aIso covers the tendons. The sheaths encIosing the flexor Iongus poIIicis tendon and the ffexor tendon to the IittIe finger are usualIy continuous with the Iarger sheaths beneath the anterior annuIar Iigament, but those encIosing the flexor tendons of the first, second and third fingers extend into the paIm for onIy a short distance. This anatomy of the synovia1 sheaths is so eIementary that I must ask forgiveness for mentioning it, but it is surprising how often it is forgotten by students. There are, however, other spaces in the hand which are aImost of equa1 importance, and which have been so carefuIIy worked out by KanaveI. Surgeons accustomed to deaIing with Iarge numbers of cases of infected hand have, of course, reaIized that a coIIection of pus can remain IocaIized in certain parts of the hand for a considerabIe period without spreading to other parts, but without reaIizing exactIy why this is the case. And yet how accepted is the fact of spread of suppuration along other fascia1 spaces of the body, as for instance in the case of a psoas abscess! The structures of the paIm are divided into three spaces by the fascia and the key to the situation Iies in the origin of the adductor obIiquus poIIicis and the adductor transversus poIIicis. These muscIes Iie deep in the paIm, the former taking its origin from the OS magnum and bases of the first and second metacarpa1 bones and the Iatter from the shaft of the second metacarpa1 bone, that is, in both cases deep in the paIm beneath the flexor tendons. These muscIes are covered by fascia extending deep into the paIm, and this forms what is known as the thenar space. The muscIes of the hypothenar eminence are aIso encIosed in an
of Hand
American
Journal
of Surgery
53’
enveIope of fascia, and this space takes the name of the hypothenar space. Between these two spaces Iies the paImar space, roofed in by the dense paImar fascia, separated by quite dense fascia on the one side from the thenar space and on the other from the hypothenar space. Above, this space is continuous beneath the annuIar Iigament with the fascia1 spaces containing the ffexor tendons in the forearm, whiIe beIow there are further openings to give exit to the flexor tendons, the Iumbrical muscIes and the digita vesseIs and nerves. It was pointed out that the synovia1 sheaths in the fingers extend into the paIm for onIy a short distance, but it is the proxima1 ends of these sheaths that are intimateIy reIated to the paImar space. Before we Ieave the fascia1 spaces in the hand it is worth remembering that the subcutaneous tissue of the dorsum of the hand, unIike that of the paIm, is Iax, but beneath this the extensor tendons are encIosed in a Iayer of fascia, and it is into these tendons that the IumbricaI muscIes are inserted. The density of the paImar fascia is so commonIy given as the expIanation of the edema of the dorsum of the hand in the presence of a paImar abscess that the other fact that the Iymphatics of the paIm run backwards to join the main trunks on the back of the hand is often forgotten. I cannot but think that if these few eIementary anatomical facts were more wideIy appreciated by those caIIed upon to treat the infected hand one wouId see far Iess crippIed hands and far fewer amputations of stiff fingers, because the uItimate resuIt must depend upon earIy and accurate diagnosis of the site of the pus, and that a11 one has to do is to appIy the ordinary principIes of surgery, respecting anatomica detaiIs and foreseeing the probabIe paths in the spread of the infection. One can recaI1 case after case where iII-conceived and inadequate incisions, often without finding pus, have been made, and in spite of such the sepsis has continued to spread.
532
American JournaI of Surgery
GENERAL
Raison-Infections
TREATMENT
I wiII now pass on to a few remarks regarding the general principIes of treatment. It wiII be easiIy appreciated that the first essentia1 in treating infected conditions of the hand is an accurate diagnosis of the situation of the pus. In the majority of cases this is cIear when one first sees the case, but when in doubt I do not hesitate to wait for twenty-four or forty-eight hours. It is important to remember that the position of the pus does not necessariIy coincide with the maximum degree of swelling, but the point of maximum tenderness is a vaIuabIe guide. Edema of the tissues shouId be carefuIIy distinguished from induration secondary to inffammation. The incision shouId be a free and adequate one; the majority of primary incisions are, in my experience, far too smaI1 and easiIy become cIosed. Every pocket shouId be carefuIIy opened up and any arteria1 bIeeding secured by Iigature. Local anesthesia (ethyl chloride), the frequent request of the patient so often acceded to by the practitioner, cannot be too strongIy deprecated, except in quite smalI superficia1 IocaIized subcuticular infections, for one never knows the extent of the incision with certainty unti1 the pus is found. Novocaine, or any other form of injection anesthesia, must not be used in the presence of infection, there being a rea1 danger of spreading the infection and further devitaIizing the aIready damaged tissues. The wound shouId be Ieft freeIy open, and personaIIy I prefer to pack fairIy firmIy with gauze soaked in fIavine, and this should be Ieft in unti1 the next day. The packing wiI1 stop a11 venous bIeeding, but even more important, convert the incision into an open cavity and so avoid the tendency for it to cIose up. Drainage tubes are seIdom necessary, and indeed seIdom indicated. OccasionaIIy gIove drainage combined with packing is useful when through-and-through incisions are indicated, as for instance when the
of Hand
APRIL. IVZ~
paImar space and IumbricaI spaces have to be opened up. It is the practice of certain surgeons, in addition to opening up the coIIection of pus, to incise freeIy into the edematous tissue in order, according to them, to reIieve the tension. It is a common experience to see the results of such incisions having been made into the dorsum of the hand at the time when no actua1 pus was present. In a few days suppuration has resuited, which eventuaIIy heaIs, fixing the extensor tendons firmIy in scar tissue and Ieaving the patient’s hand crippIed perperhaps in manentIy for Iife. Except ceIIuIitis of the hand (and even then it is a dubious matter) it is unwise to make incisions other than to give free drainage to pus. Next in importance to efficient drainage is absoIute rest in an optimum position of function. I fee1 very strongIy that a11 infected hands and fingers shouId be put on a splint, and kept there unti1 active inflammation has subsided. Rest, and in many cases elevation, add much to the comfort of the patient, but in addition have a definite therapeutic vaIue. He whose Iot it has been to attempt to get fmgers, which are stiff in the fuIIy extended position, into a more usefu1 one, nearIy aIways with disappointing resuIts, wiI1 not hesitate to condemn the proIonged use of the straight spIint for hand and fingers. It must aIso be remembered that the thumb must never be aIIowed to become contracted in towards the paIm. After the first twenty-four hours foIIowing operation, the IocaI treatment shouId consist mainly of frequent hot moist dressings and periodic baths in the more serious cases. I have tried many forms of dressings, but have come to the concIusion that, at any rate during the stage of active it is the action of the inff ammation, heat that does most, rather than that of the chemica1 reagents. I beIieve that for baths hot steriIe water is just as vaIuabIe as saIine soIutions, hypertonic or ordinary, euso1, iodine or anything eIse. FrequentIy
NEW SERIESVOL. VI, No. 4
Kaison-Infections
I have seen skin eruption which subsequentIy became infected foIIowing the use of iodine baths of quite Iow strength. In actua1 practice I use ordinary boracic acid fomentations or gamgee tissue, wrung out in boracic Iotion, covered by some form of mackintosh and wooI. One shouId be carefu1 not to aIIow the skin to become too sodden, discarding the waterproof covering for a dressing or two, or a spirit dressing as a variant is usefu1. I remember Jordan LIoyd deprecating, nearIy twenty years ago, the squeezing of and around infected wounds, and stiI1 how often we see it done, often with resuIts quite the reverse of that desired. When once active inffammation is under contro1 the hot dressing shouId be discontinued, as we11 as the baths, and ordinary wet dressings (personaIIy I Iike eusol) commenced. FIavine and potassium permanganate are useful in clearing up very septic wounds, but Aavine I think deIays heaIing. When we are quite satisfied that active inflammation has settIed down, gradua1 active movements shouId be commenced with caution. I have not been suffrcientIy impressed by Bier’s hyperemic treatment to fee1 that its use is to be commended. PoIyvaIent antiscarIatina1 serum (and I have recentIy been toId that the antitoxin is better, aIthough I have no experience with it myseIf) shouId aIways be tried in the acute streptococca1 infections. It appears to have IittIe effect upon the IocaI Iesion, but frequentIy affects the genera1 condition very beneficiaIIy, the temperature often faIIing in a most dramatic fashion. On occasions I have thought that the intravenous or intramuscular injection of some coIIoids, such as manganese and iodine, have heIped to cIear up sepsis, especiaIIy when there has been a tendency for it to become chronic, The patient’s genera1 condition shouId not be forgotten. The boweIs must be kept freeIy open and plenty of fluid given during the active stage, and I am particuIarIy attracted by the interna administration of Iiquor ferri perchIoridi.
of Hand
American
SPECIAL
JWMI
of surgery
533
INFECTIONS
I wiI1 now briefly describe a few of the specia1 types of infection of the hand and fingers. The simpIe cuticuIar whitIow, resuIting from a prick or an infected blister, is easily deaIt with by cutting away the whoIe of the raised epitheIium. It must not be forgotten that an abscess of this type, of the finger tip, may quite easiIy Iead to bone necrosis as a resuIt of Iymphatic infection. Subcutaneous whitIows of the dista1 section of the finger are very prone to resuIt in necrosis of the phaIanx, quite apart from those actuaIIy starting as subperiostea1 whitIows. The prick may be so superficia1 as not to be remembered by the patient. It is interesting to note how nearIy aIways an epiphysea1 end of the termina1 phalanx remains when “apparentIy ” the whoIe phaIanx is discharged or removed. EspeciaIIy important in conservative treatment is the case of the thumb, where Iength is of great importance. I frequentIy see a Iarge portion of bone, which has appeared to be the whole of the dista1 phaIanx, discharged, yet the patient has finished up with quite a usefu1 portion of the dista1 phaIanx and a movabIe interincapacity is phaIangea1 joint. ProIonged often spared by the earIy treatment of a paronychia. It wiI1 be recaIIed that the greater part of each IateraI border of the nail is overIapped by a foId of skin, and it is beneath this that suppuration commences. It soon traveIs around the nai1 and before very Iong gets under the edge of the nail, separating it from the matrix. The nai1 root covered by the eponychium easiIy becomes detached from the nai1 bed. Surgeons are, with increasing frequency, deaIing with these cases by making a IongitudinaI incision aIong the edge of the pushing back the overnai1, carefuIIy hanging cuticIe, cutting away the portion of the nai1 raised from its bed and Ieaving the distal portion intact. This may scientifically be a better operation than the oIder one of remova of the whole nai1, but there is a danger of being too conservative and
534
American Journal of Surgery
Raison-Infections
it is not an uncommon thing, even in expert hands, to have repeated operations for remova of further portions of the naiI under which suppuration has spread. PersonaIIy, I am not at a11 sure that the radica1 remova of the whoIe nai1 is not the safest and surest procedure. It is equaIIy important after remova of the whoIe of a nai1 to keep the eponychium packed back for a few days. This Iatter operation has, I think, a more genera1 appIication, and I doubt if incapacity is any more prolonged. ProbabIy the most disabIing infection of the hand is due to invoIvement of the tendon sheaths. Sufficient has aIready been said to appreciate that aIthough the synovia1 sheaths of the thumb and IittIe fmger are usuaIIy aIone in their direct communication with the Iarger bursae under the annuIar Iigament Ieading into the forearm, the bIind proxima1 ends of the sheaths of the remaining fingers butt into the paImar space and so pus, by bursting into this space, may not onIy infect other sheaths but pass aIong the IumbricaI spaces and give rise to widespread infection. It is therefore important to diagnose and treat infections of the thecae earIy, and again it cannot be too strongIy emphasized how possibIe it is to get a whitIow of this type without a penetrating wound to the sheath. The pus which spreads aIong the sheath as far as it extends is under considerabIe tension, giving rise to considerabIe pain and often marked constitutiona1 disturbances. The finger is edematous and tenderness is present aIong the course of the tendon, whiIe the finger is heId rigid in the semiflexed position. Active movements are absent, and any passive attempt gives rise to severe pain. The sheath shouId be opened up freeIy aIong the IateraI side of the finger and in front of the digita vesseIs and nerves.
+El3+
of Hand
APRIL, 1929
When possibIe, however, the sheath just over the joints is preserved, but even this must be sacrificed if one is not certain that it in any way interferes with free. drainage. If it has aIready extended into the paImar space the incision shouId be carried freeIy into the paIm. It may aIso have extended aIong the IumbricaI spaces of the dorsum of the hand, when an incision just between the cIeft of the fingers of the back of the hand is essentia1. I have often seen infection in a bIister at the base of a finger spreading to the underIying tendon and quickIy passing aIong the IumbricaI space to the back of the hand. An incision into the sheath and another into the back, opening up the cIears up the IumbricaI space, rapidIy troubIe. It is important to remember that both the thenar and paImar spaces may be secondariIy infected from the index finger, whiIe the paImar space may foIIow suppuration of the sheaths of the second or third, and Iess frequentIy the IittIe finger. It is not usua1 to find the hypothenar space invoIved except by direct infection through the skin, and then it remains IocaIized. I have thus attempted in a very brief way to emphasize some of the more important principIes in treatment of a subject which does not, I venture to say, receive in the ordinary way the consideration that it deserves. Just as the ordinary coId in the head damages most sensibIy the ef%ciency of thousands of working peopIe every day and often opens up the way to further indisposition, so does the simpIe injury to the hand, if negIected, often bring serious troubIe into industria1 Iife. A smaI1 infection, if not effIcientIy treated, may resuIt in the Ioss of many working hours, maybe in permanent disabiIity and proIonged and costIy Iitigation, for it is a truism to remark that to the manua1 worker a perfect hand is as important as a perfect brain.
OF THE HAND*
RAISON, MB.,
CH.B., P.R.C.S.
BIRMINGHAM, ENGLAND
T
are more intimate than in the hand, and yet this is often quite overIooked in both diagnosis and treatment; in fact surgery of the infected hand is “anatomy pIus common sense.” It is impossibIe in a short paper to go into much detai1, but I wiI1 first attempt to emphasize a few anatomica points which have particuIar bearing upon treatment. The hand and fingers are divided into a number of fascia1 compartments and synovia1 spaces so distinct from one another that pus may not, at any rate in the earIy stages, pass easiIy from one to the other. There is a right and wrong method of opening these spaces and a cIear understanding of them is essentia1 so that we know exactIy where to incise. The superficia1 fascia of the dorsum of the hand is Ioose and thin, but in the paIm it is generaIIy we11 furnished with fat, forming a pad for the protection of vesseIs and nerves. It is cIoseIy adherent to both paImar fascia and skin. The deep fascia of the arm becomes thickened at the wrist to become the anterior annuIar Iigament, which forms a strong membrane binding down the flexor tendons and the median nerve in the carpa tunne1, which is subdivided into two compartments, one occupied by the Aexor carpi radiaIis tendon and the other by the nerve and flexor tendons to the thumb and fingers. As one wouId expect, the Aexor carpi radiaIis tendon has a separate synovia1 sheath, as has aIso the ffexor Iongus poIIicis tendon, aIthough it Iies in the same fascia1 compartment as the remainder of the flexor tendons to the fingers, which are themseIves encIosed in a common sheath. The paImar fascia is a thick trianguIar membrane, with its apex continuous with ANATOMICALRELATIONS the anterior annuIar Iigament and ending beIow by dividing into four sIips, each of There is, probabIy, no part of the human which ends at the base of the finger by frame in which the anatomica reIations * Submitted for pubIication March 5, 1929. 530 HIS paper is based upon experiences of eight years spent in charge of the CasuaIty Department of the Birmingham Genera1 HospitaI, where about fifty thousand patients are treated annuahy, a Iarge proportion being cases of infections of the hand. During this same period I had the advantage of carrying out very many examinations under the Workmen’s Compensation Act, and so have seen many typica exampIes of what one may caI1 the end resuIt, and I cannot heIp being impressed by the very Iarge part pIayed by hand infections in damaging the effrciency of industria1 workers in our big cities. Indeed so often does a sIight cut or prick Iead to a permanentIy crippIed hand that it is surprising what IittIe attention is often paid to these seemingIy unimportant injuries by the medica profession on ‘the one hand and those responsibIe for the working of the Factories Act on the other. Even in some of the Iarger teaching hospitaIs, the casuaIty department is under the charge of a senior house surgeon, who, as a student, was never taught to regard his out-patient dressing as one of the most vaIuabIe parts of his training, and, in fact, has often been given but scanty instruction upon what is reaIIy an extremeIy intricate matter. The student, time after time, is impressed with the necessity of earIy treatment in acute appendicitis, but faiIs to reaIize the great advantage of prompt and efficient treatment in the very earIy stages of a simpIe infected wound of the hand, and yet the Ioss of earning capacity to the manua1 worker may be manifoIdIy greater in the Iatter than in the former.
NEW SERIES VOL. VI, No.
4
Raison-Infections
dividing into two further sIips, which become continuous with the IateraI sides of the digita sheaths, which are tubuIar envelopes encIosing the flexor tendons in the fingers. They consist of strong fibrous sheaths attached on either side to the phalanges, and are Iined by synovia1 membrane, which aIso covers the tendons. The sheaths encIosing the flexor Iongus poIIicis tendon and the ffexor tendon to the IittIe finger are usualIy continuous with the Iarger sheaths beneath the anterior annuIar Iigament, but those encIosing the flexor tendons of the first, second and third fingers extend into the paIm for onIy a short distance. This anatomy of the synovia1 sheaths is so eIementary that I must ask forgiveness for mentioning it, but it is surprising how often it is forgotten by students. There are, however, other spaces in the hand which are aImost of equa1 importance, and which have been so carefuIIy worked out by KanaveI. Surgeons accustomed to deaIing with Iarge numbers of cases of infected hand have, of course, reaIized that a coIIection of pus can remain IocaIized in certain parts of the hand for a considerabIe period without spreading to other parts, but without reaIizing exactIy why this is the case. And yet how accepted is the fact of spread of suppuration along other fascia1 spaces of the body, as for instance in the case of a psoas abscess! The structures of the paIm are divided into three spaces by the fascia and the key to the situation Iies in the origin of the adductor obIiquus poIIicis and the adductor transversus poIIicis. These muscIes Iie deep in the paIm, the former taking its origin from the OS magnum and bases of the first and second metacarpa1 bones and the Iatter from the shaft of the second metacarpa1 bone, that is, in both cases deep in the paIm beneath the flexor tendons. These muscIes are covered by fascia extending deep into the paIm, and this forms what is known as the thenar space. The muscIes of the hypothenar eminence are aIso encIosed in an
of Hand
American
Journal
of Surgery
53’
enveIope of fascia, and this space takes the name of the hypothenar space. Between these two spaces Iies the paImar space, roofed in by the dense paImar fascia, separated by quite dense fascia on the one side from the thenar space and on the other from the hypothenar space. Above, this space is continuous beneath the annuIar Iigament with the fascia1 spaces containing the ffexor tendons in the forearm, whiIe beIow there are further openings to give exit to the flexor tendons, the Iumbrical muscIes and the digita vesseIs and nerves. It was pointed out that the synovia1 sheaths in the fingers extend into the paIm for onIy a short distance, but it is the proxima1 ends of these sheaths that are intimateIy reIated to the paImar space. Before we Ieave the fascia1 spaces in the hand it is worth remembering that the subcutaneous tissue of the dorsum of the hand, unIike that of the paIm, is Iax, but beneath this the extensor tendons are encIosed in a Iayer of fascia, and it is into these tendons that the IumbricaI muscIes are inserted. The density of the paImar fascia is so commonIy given as the expIanation of the edema of the dorsum of the hand in the presence of a paImar abscess that the other fact that the Iymphatics of the paIm run backwards to join the main trunks on the back of the hand is often forgotten. I cannot but think that if these few eIementary anatomical facts were more wideIy appreciated by those caIIed upon to treat the infected hand one wouId see far Iess crippIed hands and far fewer amputations of stiff fingers, because the uItimate resuIt must depend upon earIy and accurate diagnosis of the site of the pus, and that a11 one has to do is to appIy the ordinary principIes of surgery, respecting anatomica detaiIs and foreseeing the probabIe paths in the spread of the infection. One can recaI1 case after case where iII-conceived and inadequate incisions, often without finding pus, have been made, and in spite of such the sepsis has continued to spread.
532
American JournaI of Surgery
GENERAL
Raison-Infections
TREATMENT
I wiII now pass on to a few remarks regarding the general principIes of treatment. It wiII be easiIy appreciated that the first essentia1 in treating infected conditions of the hand is an accurate diagnosis of the situation of the pus. In the majority of cases this is cIear when one first sees the case, but when in doubt I do not hesitate to wait for twenty-four or forty-eight hours. It is important to remember that the position of the pus does not necessariIy coincide with the maximum degree of swelling, but the point of maximum tenderness is a vaIuabIe guide. Edema of the tissues shouId be carefuIIy distinguished from induration secondary to inffammation. The incision shouId be a free and adequate one; the majority of primary incisions are, in my experience, far too smaI1 and easiIy become cIosed. Every pocket shouId be carefuIIy opened up and any arteria1 bIeeding secured by Iigature. Local anesthesia (ethyl chloride), the frequent request of the patient so often acceded to by the practitioner, cannot be too strongIy deprecated, except in quite smalI superficia1 IocaIized subcuticular infections, for one never knows the extent of the incision with certainty unti1 the pus is found. Novocaine, or any other form of injection anesthesia, must not be used in the presence of infection, there being a rea1 danger of spreading the infection and further devitaIizing the aIready damaged tissues. The wound shouId be Ieft freeIy open, and personaIIy I prefer to pack fairIy firmIy with gauze soaked in fIavine, and this should be Ieft in unti1 the next day. The packing wiI1 stop a11 venous bIeeding, but even more important, convert the incision into an open cavity and so avoid the tendency for it to cIose up. Drainage tubes are seIdom necessary, and indeed seIdom indicated. OccasionaIIy gIove drainage combined with packing is useful when through-and-through incisions are indicated, as for instance when the
of Hand
APRIL. IVZ~
paImar space and IumbricaI spaces have to be opened up. It is the practice of certain surgeons, in addition to opening up the coIIection of pus, to incise freeIy into the edematous tissue in order, according to them, to reIieve the tension. It is a common experience to see the results of such incisions having been made into the dorsum of the hand at the time when no actua1 pus was present. In a few days suppuration has resuited, which eventuaIIy heaIs, fixing the extensor tendons firmIy in scar tissue and Ieaving the patient’s hand crippIed perperhaps in manentIy for Iife. Except ceIIuIitis of the hand (and even then it is a dubious matter) it is unwise to make incisions other than to give free drainage to pus. Next in importance to efficient drainage is absoIute rest in an optimum position of function. I fee1 very strongIy that a11 infected hands and fingers shouId be put on a splint, and kept there unti1 active inflammation has subsided. Rest, and in many cases elevation, add much to the comfort of the patient, but in addition have a definite therapeutic vaIue. He whose Iot it has been to attempt to get fmgers, which are stiff in the fuIIy extended position, into a more usefu1 one, nearIy aIways with disappointing resuIts, wiI1 not hesitate to condemn the proIonged use of the straight spIint for hand and fingers. It must aIso be remembered that the thumb must never be aIIowed to become contracted in towards the paIm. After the first twenty-four hours foIIowing operation, the IocaI treatment shouId consist mainly of frequent hot moist dressings and periodic baths in the more serious cases. I have tried many forms of dressings, but have come to the concIusion that, at any rate during the stage of active it is the action of the inff ammation, heat that does most, rather than that of the chemica1 reagents. I beIieve that for baths hot steriIe water is just as vaIuabIe as saIine soIutions, hypertonic or ordinary, euso1, iodine or anything eIse. FrequentIy
NEW SERIESVOL. VI, No. 4
Kaison-Infections
I have seen skin eruption which subsequentIy became infected foIIowing the use of iodine baths of quite Iow strength. In actua1 practice I use ordinary boracic acid fomentations or gamgee tissue, wrung out in boracic Iotion, covered by some form of mackintosh and wooI. One shouId be carefu1 not to aIIow the skin to become too sodden, discarding the waterproof covering for a dressing or two, or a spirit dressing as a variant is usefu1. I remember Jordan LIoyd deprecating, nearIy twenty years ago, the squeezing of and around infected wounds, and stiI1 how often we see it done, often with resuIts quite the reverse of that desired. When once active inffammation is under contro1 the hot dressing shouId be discontinued, as we11 as the baths, and ordinary wet dressings (personaIIy I Iike eusol) commenced. FIavine and potassium permanganate are useful in clearing up very septic wounds, but Aavine I think deIays heaIing. When we are quite satisfied that active inflammation has settIed down, gradua1 active movements shouId be commenced with caution. I have not been suffrcientIy impressed by Bier’s hyperemic treatment to fee1 that its use is to be commended. PoIyvaIent antiscarIatina1 serum (and I have recentIy been toId that the antitoxin is better, aIthough I have no experience with it myseIf) shouId aIways be tried in the acute streptococca1 infections. It appears to have IittIe effect upon the IocaI Iesion, but frequentIy affects the genera1 condition very beneficiaIIy, the temperature often faIIing in a most dramatic fashion. On occasions I have thought that the intravenous or intramuscular injection of some coIIoids, such as manganese and iodine, have heIped to cIear up sepsis, especiaIIy when there has been a tendency for it to become chronic, The patient’s genera1 condition shouId not be forgotten. The boweIs must be kept freeIy open and plenty of fluid given during the active stage, and I am particuIarIy attracted by the interna administration of Iiquor ferri perchIoridi.
of Hand
American
SPECIAL
JWMI
of surgery
533
INFECTIONS
I wiI1 now briefly describe a few of the specia1 types of infection of the hand and fingers. The simpIe cuticuIar whitIow, resuIting from a prick or an infected blister, is easily deaIt with by cutting away the whoIe of the raised epitheIium. It must not be forgotten that an abscess of this type, of the finger tip, may quite easiIy Iead to bone necrosis as a resuIt of Iymphatic infection. Subcutaneous whitIows of the dista1 section of the finger are very prone to resuIt in necrosis of the phaIanx, quite apart from those actuaIIy starting as subperiostea1 whitIows. The prick may be so superficia1 as not to be remembered by the patient. It is interesting to note how nearIy aIways an epiphysea1 end of the termina1 phalanx remains when “apparentIy ” the whoIe phaIanx is discharged or removed. EspeciaIIy important in conservative treatment is the case of the thumb, where Iength is of great importance. I frequentIy see a Iarge portion of bone, which has appeared to be the whole of the dista1 phaIanx, discharged, yet the patient has finished up with quite a usefu1 portion of the dista1 phaIanx and a movabIe interincapacity is phaIangea1 joint. ProIonged often spared by the earIy treatment of a paronychia. It wiI1 be recaIIed that the greater part of each IateraI border of the nail is overIapped by a foId of skin, and it is beneath this that suppuration commences. It soon traveIs around the nai1 and before very Iong gets under the edge of the nail, separating it from the matrix. The nai1 root covered by the eponychium easiIy becomes detached from the nai1 bed. Surgeons are, with increasing frequency, deaIing with these cases by making a IongitudinaI incision aIong the edge of the pushing back the overnai1, carefuIIy hanging cuticIe, cutting away the portion of the nai1 raised from its bed and Ieaving the distal portion intact. This may scientifically be a better operation than the oIder one of remova of the whole nai1, but there is a danger of being too conservative and
534
American Journal of Surgery
Raison-Infections
it is not an uncommon thing, even in expert hands, to have repeated operations for remova of further portions of the naiI under which suppuration has spread. PersonaIIy, I am not at a11 sure that the radica1 remova of the whoIe nai1 is not the safest and surest procedure. It is equaIIy important after remova of the whoIe of a nai1 to keep the eponychium packed back for a few days. This Iatter operation has, I think, a more genera1 appIication, and I doubt if incapacity is any more prolonged. ProbabIy the most disabIing infection of the hand is due to invoIvement of the tendon sheaths. Sufficient has aIready been said to appreciate that aIthough the synovia1 sheaths of the thumb and IittIe fmger are usuaIIy aIone in their direct communication with the Iarger bursae under the annuIar Iigament Ieading into the forearm, the bIind proxima1 ends of the sheaths of the remaining fingers butt into the paImar space and so pus, by bursting into this space, may not onIy infect other sheaths but pass aIong the IumbricaI spaces and give rise to widespread infection. It is therefore important to diagnose and treat infections of the thecae earIy, and again it cannot be too strongIy emphasized how possibIe it is to get a whitIow of this type without a penetrating wound to the sheath. The pus which spreads aIong the sheath as far as it extends is under considerabIe tension, giving rise to considerabIe pain and often marked constitutiona1 disturbances. The finger is edematous and tenderness is present aIong the course of the tendon, whiIe the finger is heId rigid in the semiflexed position. Active movements are absent, and any passive attempt gives rise to severe pain. The sheath shouId be opened up freeIy aIong the IateraI side of the finger and in front of the digita vesseIs and nerves.
+El3+
of Hand
APRIL, 1929
When possibIe, however, the sheath just over the joints is preserved, but even this must be sacrificed if one is not certain that it in any way interferes with free. drainage. If it has aIready extended into the paImar space the incision shouId be carried freeIy into the paIm. It may aIso have extended aIong the IumbricaI spaces of the dorsum of the hand, when an incision just between the cIeft of the fingers of the back of the hand is essentia1. I have often seen infection in a bIister at the base of a finger spreading to the underIying tendon and quickIy passing aIong the IumbricaI space to the back of the hand. An incision into the sheath and another into the back, opening up the cIears up the IumbricaI space, rapidIy troubIe. It is important to remember that both the thenar and paImar spaces may be secondariIy infected from the index finger, whiIe the paImar space may foIIow suppuration of the sheaths of the second or third, and Iess frequentIy the IittIe finger. It is not usua1 to find the hypothenar space invoIved except by direct infection through the skin, and then it remains IocaIized. I have thus attempted in a very brief way to emphasize some of the more important principIes in treatment of a subject which does not, I venture to say, receive in the ordinary way the consideration that it deserves. Just as the ordinary coId in the head damages most sensibIy the ef%ciency of thousands of working peopIe every day and often opens up the way to further indisposition, so does the simpIe injury to the hand, if negIected, often bring serious troubIe into industria1 Iife. A smaI1 infection, if not effIcientIy treated, may resuIt in the Ioss of many working hours, maybe in permanent disabiIity and proIonged and costIy Iitigation, for it is a truism to remark that to the manua1 worker a perfect hand is as important as a perfect brain.