Infections of the hand; a guide to the surgical treatment of acute and chronic suppurative processes in the fingers, hand and forearm

Front matter

Hibrarp

Open Knowledge Commons

Deep ami superficial flexors

Preface To Fourth Edition

The present revision has given the' author the opportunity of supplementing the text with the knowledge gained during the great war upon gas bacillus and streptococcus infections as well as permitting the addition of a chapter upon the restoration of function in infected hands.

The sequence of subjects has not been altered. Beginning with the experimental and anatomical studies upon which our deductions are founded, an attempt is made to give the reader a clear understanding of the basis for proper surgical procedures. While dogmatic statements as to the proper sites for incisions might be made, yet they could hold true only for the usual case, and it is only by a proper appreciation of the underlying pathogenesis that the surgeon will be equipped to care for the unusual and more dreaded cases.

In a given infection the surgeon should first read the chapter upon "Diagnosis and Treatment in General." This will indicate into which group the particular case will fall and will direct the student to the proper sections of the book where cases of that nature are discussed more in detail.

Warning should still be given as to care in the diagnosis and treatment of tenosynovitis. An increasing experience has demonstrated that with careful and intelligently directed treatment, hands suffering even from this dreaded complication may be restored to complete function.

It is a pleasure to acknowledge my indebtedness to

Drs. Koch, Woolston, Davis and Day for aid in the

present revision.

A. B. K.

Chicago, 1921.

(iii)

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 n.

INFECTIONS OF THE DISTAL PHALANGES.

Subepithelial Abscesses 39

Herpes 40

CHAPTER HI.

CARBUNCULAR INFECTIONS.

Anatomical Considerations and Pathogenesis . 41

Oidiomycosis 49

Chronic Stapliylococcus Processes 51

CHAPTER IV.

MISCELLANEOUS ABSCESSES.

Collar-button Abscess (Shirt-stud Abscess) (Frog Felon) 55

Localized Abscesses in the Thenar and Hypothenar Spaces 57 vi CONTENTS

Part II. Grave Infections: Tenosynovitis, Fascial-space

ABSCESSES, LYMPHANGITIS AND ALLIED

CONDITIONS.

CHAPTER V.

DIAGNOSIS IN GENERAL,

Lymphangitis 60

Fascial-space Infection 55

Diagnosis of Extensions from Various Sites ■ . . . . 70

CHAPTER VI.

GENERAL PRINCIPLES OF TREATMENT.

Prophylaxis 71

Rest 71

Drugs 72

Passive Hyperemia 72

Hot Moist Dressings 73

Hypertonic Salt Solution 75

Prophylactic Incision 76

Drainage 77

Stimulation of Excretion 79

Massage 79

Baking in Dry, Hot Air 79

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 81

A Study of Serial Cross-sections, with Particular Relation to the Fascial

Hypothenar Space 94

Discussion of the Relations of the Middle Palmar and Thenar Spaces 96

CONTENTS vii

CHAPTER VIII.

THE TENDON SHEATHS: A DISCUSSION OF THEIR ANATOMICAL

DISTRIBUTION AND RELATIONS, WITH SURGICAL

DEDUCTIONS.

Sheaths upon the Flexor Surface 100

The Sheaths of the Index, Middle and Ring Fingers 101

The Radial Bursa and the Tendon Sheath of the Flexor Longus PoUicis 102

The Ulnar Bursa and the Sheath of the Tendon of the Little Finger . 103

The Intercommunication of the Sheaths 107

Sheaths upon the Dorsum 110

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 SYNOVL^L SHEATHS.

The Relation of Tendon-sheath Rupture to the Fascial Spaces

116 116 117 119 122 123

Injection via the Tendon Sheath of the Middle Finger .

Injection via the Tendon Sheath of the Ring Finger

Injection via the Tendon Sheath of the Little Finger

Injection via the Tendon Sheath of the Index Finge'r

Injection via the Tendon Sheath of the Flexor Longus Pollicis

General Deductions as to Relation of Tendon Sheaths to Fascial Spaces 125 The Normal Boundaries of the Fascial Spaces and the Position of Secondary

Abscesses in Case of Extension from the Spaces 126

Injection via the Tendon Sheath of the Ring Finger .... 126

Injection through the Palmar Fascia 127

Injection through Palmar Fascia into Middle Palmar Space . . 131

Injection along Lumbrical Muscle of Ring Finger 131

Injection via the Tendon Sheath of the Index Finger .... 132

Injection of the Thenar Space under Forcible Pressure . . . 134 Injection through Palmar Fascia in Attempt to Reach Thenar

Space 137

Injection between the First and Second Metacarpals .... 138

Injection between the Second and Third ^letacarpals .... 139

Dorsal Subaponeurotic Space 139

Injection under Tendons of Dorsum 139

Hypothenar Space 1-10

Resume of Preceding Experiments as to Boundaries, Diverticula and

Extension from the Fascial Spaces 141 viii CONTENTS

CHAPTER X.

ANATOMY OF THE FOREARM IN RELATION TO INFECTIONS.

Anatomy in General 147

Serial Cross-sections of the I'orearm 148

Experimental Injections of the Fascial Spaces of the Forearm .... 152

Injection of the Radial Bursa 152

Injection of the Ulnar Bursa 153

Injection from the Mid-palmar Space 154

Resume of Findings by Dissection and Experimental Injections . . 157

Section II. The Surgical Consideration Of Tendon-sheath

INFECTIONS AND FASCIAL-SPACE ABSCESSES OF

HAND AND FOREARM.

CHAPTER XI.

PATHOGENESIS— SOURCE OF INVOLVEMENT OF THE TENDON SHEATHS AND FASCIAL SPACES.

Etiology in General 159

Source of Involvement of the Various Sheaths 160

Extension from One Sheath to Another 161

Source of Involvement of the Important Fascial Spaces in the Hand . . 164

Involvement from the Tendon Sheaths 164

Direct Implantation of the Infection in the Spaces 165

Involvement by Lymphatic Extension ... 169

Extension from One Fascial Space to Another 171

Recapitulation as to Source of Involvement of the Fascial Spaces . . 178

CHAPTER XII.

THE SPREAD OF INFECTION FROM ANY GIVEN PRIMARY FOCUS.

The Probable Extensions from Primary Foci on the Fingers . . . . 180

The Spread of Infection Involving the Index Finger 180

Fascial-space Extension 180

Synovial Sheath Extension 183

The Spread of Infection Involving the Thumb 188

The Spread of Infection Involving the Middle Finger 189

The Spread of Infection Involving the Ring Finger 191

Infection Spreading from the Little Finger 192

Infections Beginning in the Palm and Dorsum 193

CONTENTS ix

CHAPTER XIII.

THE PATHOLOGY OF TENDON SHEATH AND FASCIAL-SPACE

ABSCESSES.

The Tendon Sheath Proper 197

The Fascial-space Abscesses 199

CHAPTER XIV.

THE SYMPTOMS, SIGNS AND DIAGNOSIS OF TENOSYNOVITIS AND FASCIAL-SPACE ABSCESSES.

The Symptoms, Signs and Diagnosis of Acute Tenosynovitis . .201 Symptoms, Signs and Diagnosis of Extensions from Infections Beginning in the Little Finger 204

Extension to Ulnar Bursa 204

Extension to Radial Bursa . . 207

Extension to Forearm 208

Extension to Lumbrical and Palmar Spaces 208

Symptoms, Signs and Diagnosis of Extensions from Infections Beginning in the Index, Middle an*d Ring Fingers 209

Symptoms, Signs and Diagnosis of Extensions from Infections Beginning in the Radial Bursa 213

The Symptoms, Signs and Diagnosis of Fascial-space Abscesses . . . 215

The Middle Palmar and Thenar Spaces 216

Dorsal Abscesses 222

Forearm Abscesses 223

CHAPTER XV.

THE TREATMENT OF ACUTE SUPPURATIVE TENOSYNOVITIS

—GENERAL CONSIDERATIONS— A REVIEW OF THE

LITERATURE.

Excerpts from the Literature 227

CHAPTER XVI.

THE TREATMENT OF ACUTE SUPPURATIVE TENOSYNOVITIS . —DISCUSSION OF TECHNIQUE.

Treatment while the Diagnosis may be in Doubt 245

Technique of Treatment after Diagnosis is Made 246

Treatment of Tenosynovitis of the Index, Middle and Ring Fingers . 248

When the Involvement of Adjacent Areas has Begun .... 250

TKe Index Finger 250

The Middle Finger 251

The Ring Finger 252

X CONTENTS

Technique of Treatment after Diagnosis is Made —

Treatment of Tenosynovitis of the Little Finger and Ulnar Bursa . 252

Treatment of Extensions from the Little Finger and the Ulnar Bursa 259 Treatment of Inflammation of the Tendon Sheath of the I-ong Flexor

of the Thumb 261

Synovial Sheaths on the Dorsum 271

After-treatment 272

CHAPTER XVII.

THE TREATMENT OF FASCL^L-SPACE ABSCESS.

Technique of Treament 277

The Treatment of Combined Involvement of the Middle Palmar and

Thenar Spaces 280

The Treatment of Combined Involvement of the Middle Palmar and

Subaponeurotic Spaces 284

Technique of Treatment of Abscesses in the Thenar Space 287

Technique of Treatment of Abscesses in Subaponeurotic Space .... 289

After-treatment in Fascial-space Abscesses 290

CHAPTER XVIII.

RESUME OF ACUTE SUPPURATIVE TENOSYNOVITIS AND FASCIAL-SPACE ABSCESSES— PROGNOSIS.

Prognosis 293

Section III. Lymphatic Infections

CHAPTER XIX.

THE RELATION OF LYMPHANGITIS TO OTHER TYPES OF INFECTION— DISCUSSION OF THE ANATOMY.

The Relation of Lymphangitis to Otber Types of Infection 295

Anatomy 296

The Lymphatic Vessels of the Hand and Forearm 298

Superficial Lymphatics 298

Deep Lymphatics ... 305

CONTENTS xi

CHAPTER XX.

LYMPHANGITIS— ETIOLOGY, PATHOGENESIS AND PATHOLOGY.

Predisposing and Active Factors in the Production of Lymphangitis . . 308

Influence of the Type of Germ 310

Influence of the Anatomy on the Course 313

Sporotrichosis 317

Relations of Lymphatic Abscesses Studied by Experimental Injections . 318

Report of Injections of Forearm Near the Radial and Ulnar Vessels . 318

General Conclusions in this Series of Experiments upon the Radial

Vessels 319

Experiments by Injection along Ulnar i\rtery 320

Pathology of Lymphangitis 320

CHAPTER XXI.

SYMPTOMS AND SIGNS OF LYMPHANGITIS.

Symptoms and Signs in. General 324

Types 325

Type I. Simple Acute Lymphangitis 325

Type II. Acute Lymphangitis with Minor Local Complications . . 325

Type III. Acute Lymphangitis with Serious Local Complications . 325

Type IV. Acute Lymphangitis with Systemic Involvement -. . . 325

Acute Lymphangitis with Serious Local Complications 326

Phlegmonous Lymphangitis 328

Frequency of Localization in Lymphatic Infection 328

Acute Lymphangitis with Systemic Involvement 329

Deep Lymphangitis • , 330

Systemic Involvement . 332

Postmortem Statistics 338

Thrombophlebitis 339

CHAPTER XXn. .

PROGNOSIS IN LYMPHATIC INFECTIONS.

Prognosis in Lymphatic Infections 342

CHAPTER XXni.

THE TREATMENT OF LYMPHATIC INFECTIONS— GENERAL DISCUSSION.

Local 346

Hot, Moist Dressings 346

Rest 348

The Bier Treatment • • • 348

Incisions . . , 349 xu

CONTENTS

Systemic Treatment 351

Antagonistic Drugs 351

Serum and Vaccine Treatment ' . . . . 352

Supportive Measures 353

CHAPTER XXIV.

THE TREATMENT OF THE COMPLICATIONS OF LYMPHANGITIS.

Subcutaneous Abscesses 355

Periglandular Abscesses 356

Subclavicular and Shoulder Abscesses 356

Systemic Complications ... 357

CHAPTER XXV.

HAND INFECTIONS AMONG EMPLOYES.

A Consideration of Methods of Prevention and an Economic Plan of Treatment 365

Prevalence of Hand Infections 366

Etiology of Infections among Employes 368

Prevention of Hand Infections 371

Active Treatment of Hand Infections among Employes 374

Ambulatory Versus Hospital Treatment of Serious Hand Infections . 379 Serious Complicated Cases Treated at Home and Taken to Hospital as

Final Resort 380

Economic Value of Proper Diagnosis of Location of Pus and Proper Surgical

Interference in Hand Infections 381

Conclusions . 38?

Section IV. Allied Infections

CHAPTER XXVI.

ERYSIPELAS, ERYSIPELOID, GAS-BACILLUS INFECTION, ANTHRAX.

Erysipelas 384

Erysipeloid 385

Gas-bacillus Infection 386

Classic Gaseous Gangrene 387

Toxic Gaseous Gangrene 388

Mixed Gaseous Gangrene 388

Anthrax 392

CONTENTS xiii

Section V. Complications And Sequels Of Infections Of The Hand

CHAPTER XXVII.

FOREARM INVOLVEMENT FROM INFECTIONS OF THE HAND —PATHOLOGY AND DIAGNOSIS.

Subcutaneous Abscesses 396

Deep Abscesses 397

Forearm Involvement — Abscess Formation without Other Complications 398

Location of the Abscesses 398

Symptoms, Signs and Diagnosis 402

Deep Forearm Involvement Associated with Wrist-joint Invasion . 404

Examination of the Radial Bursa in Cadavers 404

Pathology Found in Serious Wrist-joint Involvement 405

Forearm Involvement with Secondary Hemorrhage 412

CHAPTER XXVIII.

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

CHAPTER XXIX.

SEQUEL/E OF INFECTIONS OF THE HAND.

Chronic Processes, Osteomyelitis, Arthritis, Contractures and Atrophy 426

I a v'C' .ement of the Finger Proper 427

Involvement of the Hand Proper and the Metacarpals and Carpals . . 437

Pathology 437

CHAPTER XXX.

RESTORATION OF FUNCTION IN INFECTIONS OF THE HANDS.

Hydrotherapy ; .... 477

The Use of Splints 480

Occupational Therapy • 489

Psychotherapy 492

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 investigations carried on in conjunction with careful clinical observation of a considerable number of cases. In the following pages the diagnostic factors and incisions which this work has suggested will be described. Experience has shown that with careful diagnosis and properly placed incisions we may expect a restoration to complete function in 95 per cent, of the abscesses of the fascial spaces; while in tendon-sheath infections the morbidity will be reduced by full}^ 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 complication.

HISTORY.

Professor -Albert^ says that while the word panaritium was not used by Celsus, it is found in the Arabian and other ancient writings, and appears to be a corruption of the Greek 7raf>ouycd {Trayd ouu^) Paracelsus, Dorneus, and others have used the words pandalitium, passa, panaris, and panarium, and it cannot be said whether these refer

18 INTRODUCTION

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 Masse discovered renal lymphatics, that the knowledge of the subject began to grow. Following Eustachius, Asselli, 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^ 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 acrimonious discussion was maintained over the subject of lymphatic versus synovial sheath extension of infection. Gosselin, following dissections, adduced proof that extension nearly always progressed along synovial sheaths. Dolbeau meanwhile presented a masterly discussion, supported by clinical evidence, in support of the possibility of lymphatic extension with the formation of deep abscesses. Chevalet,3 a pupil of Dolbeau, chose for his doctorate thesis, in

2 Du Panaris, Paris, 1859.

^ These pour le doctorat en medecine, Paris, 1875.

HISTORY 19

1875, make a further contribution to the literature in suppoi of his master's assumptions, lirin^ini^; to his aid the brih.ant investigations of Siippey and others. Later, Polaillon a id Le Dentu supported the theories of GosseHn, 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,^ who brought prominently before the profession Helferich's method of opening widely the sheaths, which was later substantiated and discussed with carefully observed cases by Forssell.^

I wish to make, acknowledgment of abstracts which I have taken freely from these authors. Forssell particularly has written a most masterly article upon tenosynovitis. I am forced, however, to take issue with him as to certain methods of treatment. Concerning 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 in text-books nor in special articles can the student find clear descriptions of the various types of acute infections, with the methods Df their diagnosis and treatment. This I shall here attempt to give.

20 INTRODUCTION

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 ex,..rimental 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.

(6) Tenosynovitis and fascial-space abscesses.

(c) Acute lymphangitis and allied infections.

{d) Complications and sequelae of acute infections. 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 we 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, and in a given case do not determine whether or not it is present in an acute tenosynovitis — and the diagnosis 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-

SCOPE AXD CLASSIF/CATfOX OF TYPES 21

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 is responsible for the gra\'est errors and most serious consequences, both as to morbidity and mortality.

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 recover}'. If one will take the time to fix in mind the fundamental facts which are here discussed, he will have no difficulty in applying 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.

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 necessar\' 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 complications which may be prognosticated and anticipated. We shall see that the tendon-sheath infections pursue

22 INTRODUCTION

definite lines of invasion, and the position of the pocket of pus when rupture occurs can l^e prognosticated, 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.

(b) There are definite anatomical channels by which infection arising in a given site 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 incisions for evacuation of pus in the various spaces must be made at definite sites; 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 have become involved without this unfortunate surgical procedure.

{e) The infection may persist for weeks and months after apparently opening the pus pocket, if diverticula and intermediary chambers are not taken into consideration.

The interrelation of these various facts will be emphasized by case reports, each of which has been introduced to illustrate or clarify some important clinical fact. The number could have been multiplied many times, but I have tried not to duplicate these illustrations.

We will discuss first the slighter infections, such as felons, carbuncles, paronychia, etc., which bear little or

SCOPE AND CLASSIFICATION OF TYPES 23

no relation to the more vserious 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 prolonged, owing to a lack of appreciation of the pathological 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 can 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 disappears. 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 he 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 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 periosteum, which is lifted off, and necrosis of the bone ensues. Against this assumption we 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 w^hich seem to point to another explanation of this frequent change, so essentially different from that noted elsewhere ^in the body. |The connective-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 longitudinal 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 spaces. Hence it would have a tendency to shut off the blood supply and cause necrosis of the bone. It w^ill be seen by examining the longitudinal section that the portion of the bone involved is the diaphysis, since the epiphysis receives its blood supply before the vessels enter the closed space. Anatomically, then, we expect the epiphysis to escape necrosis in these cases, and clinical observation corroborates this view, since the diaphysis is the part of the bone which is lost. I This finds its most perfect example in children and those whose epiphyses and diaphyses ha\-e not progressed to perfect Ijony union. It has been my experience frequently to open these old felons in children and have the diaphysis fall

Bloodvessel.

I

Fig. 1. — 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.

out of the sac, where it has been floating, a free body, in a sea of pus (Fig. 3). 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.

PlG_ 3. — V. D., aged nine years. Osteomyelitis of distal phalanx following felon. Note separation of the epiphysis and diaphysis.

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 b\- the destructive 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 has permitted the disease to destroy the connective tissue which must ultimately be expelled as a slough.

When the incision has been delayed or the process permitted to go on to spontaneous explusion of the necrotic matter, we find a bluish insensitive pus bag 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. Fragments 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 in treatment are seen at times. The first is an incision made into a phalanx in which there is a beginning 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. Incision here is not only unnecessary, but positively harmful, as will be brought out in discussing the subject 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 only prolonged convalescence but also 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 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 incision 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 portion 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. This incision should be long enough to open the pocket freely. If the incision is made early, one is often surprised at the rapidity of the recovery. It has been recommended by some that the incision should extend in a circular direction around the end of the finger. While this gives perfect drainage it leaves a scar upon the end that interferes with function. Attention should also be drawn to the fact that if a median flexor incision be made it should not extend beyond the base of the phalanx but rather fall short of it since otherwise the development of a tenosynovitis is favored. I have met this unfortunate result several times in consultations.