FIB. 24, 19o6.] WHITLOW AND ITS TREATMENT. [TaLrJRAL 423 2. Oral Sepsis in Relation to the Oceurrence of, the subsequent occurrence !ofl- tonsillitis, of., adenitis, and Secondary An?yina.-In 60 per cenit. of. -tlle eases having especially has undo,ubtedly', ,itflueneed the, severity. qf this oral sepsis ill whichl complicationss occurird, the oral the complications afterwards.- sepsis was noted to be very severe. The last ease I 'have The.practical outcome,.irrespective of imere etatistical lescribed to you illustrates that very wel Here is imy. considerations as to, whetler oral. sepsis, .:d,oes or niote of it. Rashi, moderate; aniginia, moderate:; adenitis, does not influence scarlet fever, is. tbat it. is absolutely moderate. Yet the one fact noted in connexion with' that necessary -to remove ;even, the -chance of it doing so. is that there was the severest degree of oral sepsis, witlh Therefore it is .to me a; very impiortant duty, in all cases an ab§cess rounid onle of her teethl. Tle 'subsequeint' course of fever coming under mny care, to ,endeavour to,eliminate of thi§ case was the severest angina, thek sevlerest adentitis, this factor as far ;as possible. So,L;ddilnot wait to find out and the severest cellulitis. She also 'iad' vomiting, and wlhat it is goinig to do, but. I remo.ve it,., as I .should she had diarrhloea, denoting " septic gastritis " and " septic remove any other possible source of.. trouble, just as I enteritis," anld afterwards lhyperpyrexia occurred and should give the patient fresh air, good food, or see that he deatlh. was kept properly clean. That is the general ou,tcome of 3. The -Relation of Oral Sepsis to the' Seeieeity of the Cown- this work, and I thinik you will find that in.the, cas,es pli6ations.-This is very striking. I have here notes of which come under your care you will derive the greatest 7 cases. The 7 cases in whichl oral sepsis was noted to be' possible satisfaction yourself anid you will confer the severe were nearly all severe. Two had severe adenitis, greatest possible benefit on your patieits by dealing,with severe septic enteritis, anid septic rash; the' third had this as you would with any other possible element of angina of severe degree, rheumatism very severe, albuinin- danger in connexion with the ease. The prima facie uria lasting thirty-four days, gangrenous stomatitis, which ease for dealing with it seriously in searlet fever is,2I gave the greatest trouble, septic gastritis, eniteritis, and think, greater than in any other fever with whichwle have finally pyaemic abscesses in the hip, from which strepto- to deal. coccus was isolated. These were all in one case which As I showed in a previous communication,' it is no less eventually recovered. The fourth ease had adenitis twice; important in enteric fever, in which disease, according to tlle fi.fth case had rlheumatism and albuminuria lasting my observations, the septic factor is an important eause nine days; the sixthl case had severe angina, and the of the chief intestinal complications-perforation and severest form of otitis lasting six weeks. In"other words, haemorrhage. 6 'out of the 7 cases in whiclh this eonAditiion of severe The sepsis associated with these two fevers and respon- tonsillitis was nioticed were actually very severe cases, sible for the chief complications is. thus, in my experience both as regards the degree anid the variety of the com- and judgement, largely a preventable condition, and the plications. question I now leave with you is: If preventable, why not Now let iiie note aniother fact in connexion with oral prevented ? sepsis in relationl to complicationis as a whole. The actual I drew attention to the subject at the Oxford meeting frequency of the occurrenice of complications of some kind of the British Medical Association,2 and this lecture is or another is but little affected by the presence or absence ani addition to the facts then brought forward. of oral sepsis, but the number of complications met witl in cases of oral sepsis is much higlher than in those with- out it. And still more, the severity of 'the complications met with is mliuclh greater. In cases of oral sepsis, 66 per cent. had complications of moderate or severest degree, whereas only 35 per cent. had such complieations in cases ON in which there was no oral sepsis. This is well brought WHITLOW AND ITS TREATMENT. out by taking any one complication, such as tonsillitis, to which the figures I have given you refer. With regard By G. B. MOWER WHITE, M.B., B.S., F.R.C.S., to the relationi of oral sepsis to albuminuria, 30 per cent. SURGEON, GREAT NORTHERN CENTRAL HOSPITAL. of the cases had albuminuria. In the' cases without oral sepsis the average durationi of the albuminuria was 5.8 THE subject I have chosen for this lecture may appear to days. In cases with oral sepsis the average duration was be a very everyday one, but that is really the reason 15.1 days. In eases with oral sepsis and cellulitis the which led me to choose it. The subject of whitlow, as I figures are equally divided. Of rlhinitis we had 13 cases. shall deal with it to-day, is one whiCh appeals to every- No oral sepsis in 7, and those 7 eases were of mild body who is in practice; every one who sees cases of all degree. Oral sepsis was presenit in 6, 2 of them of kinds will see many cases of whitlow in the course of mild degree, 2 of moderate degree, 2 of severest degree. twelve months, and if we can arrive at some understanding Next witli regar(d to oral sepsis and otitis. There were as to what is the best way of treating the several cases of 12 cases. No oral sepsis in 6 cases; 5 of them were of whitlow as they appear I shall be satisfied with the results mildest degree. Oral sepsis in 6 cases, 2 of these were of this hour's lecture. of mildest degree, 1 of moderate degree, and 3 of severest I do not think I can do better than start by reminding degree. Oral sepsis and rlheumatism we will take next you of the customary classification of whitlow, and then -20 cases. Witlhout oral sepsis, 10 cases, all of them I shall pass in review fairly rapidly what is considered to of mildest degree; with oral sepsis, 10 cases, the slightest be the best treatment for each variety of the disease. cdegree in 7, severe or moderate in 3. Then I shall describe the extensions of the disease, which Time will not permit me to go further, but I hiope are very important, into the palm of the hand and so enough has been said to bring out the fact that this class forth, and shall state, as far as it can be stated, what is the of work is of interest. We cannot deal directly witlh the best method of treating cases whiCh we will suppose have searlatinal factor, but with the septic factor we can deal ; come before us. and these figures bring out the fact that there is a definite relation, as one would expect, between the actual exist- THE VARIETIES OF WHITLOW AND THEIR TREATMENT. ence of oral sepsis in a patient with scarlet fever and the The four varieties of whitlow are the subeuticular, severest complications. It must be remembered that in all subcutaneous, thecal abscess, and subperiosteal abscess. these cases I removed tile oral sepsis immediately, and did The subcuticular variety is that in which the inflamma- not'leave them to, as it were, soak in their oral sepsis; and tion is found underneath the cuticle, between the cuticle yet that is what has been done hitherto. Usually no care and the cutis vera; it is probably due to the poison having lhas been taken to remove this source of infection. So been introduced by inoculation through the cuticle. The these figures do Iiot bring out the true relation. To do second variety, which is perhaps the commonest, is the that it would be neeessary to compare this series of cases subcutaneous form, in which the inflammation occurs in with a parallel series in which the oral sepsis had been the fibro-fatty pad, and this is the variety which one sees observed and yet nothinlg done for it. Of this class I so often at the top of the finger. The third variety is not have no cases; for in all cases which have come under usually a primary one, but occurs secondarily as an exten- mny care the condition has been immediately treated sion from the last mentioned form, that is to say antiseptically by swabbing out, and carefully removring thecal abscess, or an inflammation which has extended the sepsis from the mouth. Despite these precautions, i Oxford Meeting, British Medical Association, BRITISH MEDICAL the existence of oral sepsis at the time of contraction JOURNAL, November, 1904. of thie dlisease lla.S influenced the primary angina, the 2 BRITISH MEDICAL JOURNAL, November, 1904. 424 mXDmsL J.A3 WHITLOW AND ITS TREATMENT. [FEB. 24, I906. into the tendon sheath on the flexor aspect of the finiger fibres which run obliquely in various direction-s, so as to and involves that more or less rapidly from one enid to the admit of its being crumpled up when the fingers are other. The fourth variety is comparatively uncommiioni; acutely bent, The terminiation of this fibrous sheathl we do not so often see it, but any one may see 3 or 4 forminlg the front wall of our canal oCCurs on the front cases in the course of a year; it is the subperiosteal form, aspect of the terminal phalanix of the finiger, just beyond in whliC}l the inflammation has either started there origini- the insertion of the flexor profundus tendon. The fibro- ally, or has extended from a more superficial position osseous canal thus formed is lined by a serous membrane, under the periosteum of the phalanx. That is the most which is likewise reflected on to the surfaces of the deep-seated form of all, and although fairly simple as tendons occupyiing the canial. The serous membrane regards treatment, it is nevertheless a form in whichl the forms a closed sae, whichl is of equal extenit with the affection lasts a considerable time before one is able to fibro-osseous canal itself. get a healed wound. You will remember there are two flexor tenidonis in eaclh I will now mention a few points with regard to wlvitlow finger, one only in the thumb, anid that each of these ha& whieh may be taken to apply generally to all the forms. almost, but not quite, a complete covering from this The inflammation in this condition is an acute inflamma- serous membrane. It is the introductioni inlto this serous tion. In the majority of instances it is started by tlle sac, in this fibro-osseous canal, of some sepsis, or micro- introduction of micro-organisms, generally a strepto- organisms, we will say, which produces the thecal abscess, coceus, and it hat a great tendency to spread rapidly to anid it is in these conditionis, wheni the iniflammiiationi has the deeper parts. If the infection is beneath the skinl, been started and has been increasing for some little time, the teindency for this inflammation to spread is greater that we mostly see it, for it is then that the patient comes than if the inflammation begins superficial to the eutis for treatment. The treatment to be applied is undoubtedly vera. very early incision. I think it is a mistake to wait even. Now, I propose to discuss the treatment of eaclh of tlhe unitil we can be sure that there is pus present in the finger varieties of whitlow. The subcuticular form of whitlow The incision shoiild be made before the pus forms, because is not so often seen, I imagine, because the patienit does that gives us the best clhanice of preventing the formationl not consult a surgeon soon enough. If you had a typical of pus at all. And the next poinit wlhichl I would like to case of this kind you would see some redness at the top of insist upon is, that nio one should attempt to open the the finger; and if you looked at it very closely, and, better thecal abscess without givinig a general anaestlhetic, and still, withl a magnifying glass, you would be able to recog- that no one shourd attempt to openi a tlhecal canal without nize that the inflammation was exceedingly near the having previously re,,ndered the part bloodless, because surface. There is very little general hardness of the pad you want to do this operation withl tlle greatest care. If at the top of the finger. And a little later you would you do too much it is sometimes wor'se tlhani not doinig notice that there was a drop of pus forming in the centre anytlhing at all. of the reddened area of skin and euticle. The treatment The kind of operation I recommend is tlhis. (Usually to apply lhere is to avoid making a deep incision for fear there is not muelh time to prepare the patient for opera- you should introduce the inflammation or the sepsis into tion.) He shoul(l be (ompletely anaestlhestized by a general the fatty pad under the skin. That should be avoided at anaesthletic, ain(l the limb should be raise(d above the all costs. The proper treatment is to soften the cuticle as trunk for a short time, the surgeon or hiis assistanit hold- far as possible by immersing the finiger in lhot water or inig the arm by the wrist in such a way as not to compress any hot lotion, and, keeping the blade of the knife flat on the vessels, lholding it by the bones betwieen tlle finger- the surface, thus to shave off the cuticle until onie lhas and thumb, so that no pressure is exerted upoIn the vessels opened the centre of the inflammation and let out the of the limb. For if the han-d encircles the wrist, niaturally drop of pus which lies there. Following this plan of a good deal of blood riemainis in the patient's hand. treatment, this variety of whitlow can be ofteni brought to Having held the hand like that for thlree or four minutes, an end very quickly indeed. the surgeon applies an elastic bandage, that which wce The next variety is the commonest of all, the sub- call Esmarch's bandage, round the upper arm, and it is cutaneous, and the treatment is early incision thlrough tlle generally sufficient to place six turns, oIne over the other, top of the finger, through the fibro-fatty pad, sufficien-tly anywhere on the lengtlh of the arimi below the deltoid tco deep to expose or incise the whole thiekn-ess of this pad, render the limb comparatively bloodless. And I think it but not so deep as to run any risk either of inlcising would be a mistake if one put on the Esmarch bandage in- periosteum of the bone or of opening the tenidoni sheath the way that Esmarcl hiimself advised it should be put on- whichl ends over the front aspect of the terminal plhalanx for otlher conditions; I mean by beginning at tlle fingers of the finger. With these two reservations, a free inciision, and winding it spirally up the arm, and thlen placing six whieh can be done without giving an anaesthetic, slhould turns round the arm, and subsequently unirolling a piece be made in the middle line, directly througlh the fibro- of the bandage from tlhe fingers up to the top. That fatty pad of the finger. would be wrong, because there would be some risk The next variety we come to is the theeal abscess, anid I of forcinig material in the lymphatics of the limb, ask you to follow me for a minute or two as I pass in and septic material probably, higher up in tlhe review the anatomy of the parts wlich are concernied in limb than it had already reaclhedI in the course of this particular kind of whitlow. There is, you will the disease. No one slhould start suchi an operation witl remember, on the front aspect of the finger, a fibro-osseous the determination of openinig the theca at all, because it canal. This canal extends from the nieck of the meta- is impossible to say wlhethler or not it is niecessary in any carpal bone to the base of the terminal phalanix of each given case. One first makes an inlcisionltlhrouglh the ski]} finger, and it is formed over the head of the metacarpal aind subcutaneous tissues, and theni discovers wlhether it bone by the special arrangement which the palmar fascia is necessary to open the tendon slheatlh. You may find lhas with that fibrous plate or ligament wlhiell is called that the inflammation which is causinlg a vely large the anterior metacarpo-phalangeal ligament. It is the swollen and oedematous finger is superficial to thme theca, ligament wlich covers the front aspect of the lhead of the a fact which you cannot determine until you lhave exposed mnetacarpal bone, and forms the anterior ligamenit anid the surface of the theca and viewed it directly with the capsule of the metacarpo - phalangeal joinlt. This, part free from blood. One often embarks uponi an opera- together with the palmar fascia in front, forms tion of this sort with a fixed idea in one's hlead of what the commencement of the fibro-osseous canal along one has to do, and then it is difficult to alter one's course the front of the finger. Further down in relation with the of actioni at a moment's niotice. So it slhould be an opera- phalanges we have special ligameints which belong to the tioIn of exploration, not having determined beforehand phalanges themselves. That is to say, at the front of each what you will do be-cause you do not know wlhat has taken phalanx, meaning now the first and middle phalanx in the place, kinowing only that the theca lhas to be exposed aniT case of the fingers, there is a ligament whicll arehes from dealt with as occasion requires. I advise that amongst the one border to the other of the shaft of the phalanix; the instruments prepared for this operationi slhould be a this is the ligament commonly spoken of as the vaginial lhypodermic syringe, so that if there is any doubt as tor ligament, because it forms a large part of the sheatlh of the what the contents of time theca are, one can easily draw of tendons. Opposite the joints, you will remember, the some of the contents in tIme syringe and view them in the fibrous wall of this fibro-osseous canal is conisiderably glass barrel. If they are turbid I recoimimend you to open thinner. Instead of being formed of fibres whichl archi the theca; and if they are clear I recommenid that, at any from one border of the phalanx to the other, it consists of rate on that occasion, it should niot be openied freely, but FEB. 24, Igo6.] WVHITLOW AND ITS TREATMENT. MNDICALML]L Bu=JOVAAL 42v42 that a small opening be made, sufficient to give drainiage some importance, and may serve as guides to certaini for the clear fluid. operations which I have to speak of presently. Of the The next question which arises is, WVhere should the two large sacs beneath the annular ligamenit one is conl- incisions be made ? I think there are undoubtedly two siderably larger than the other. This onie extends up incisions which should be made; one should be an inito the forearm for l in. above the level of the upper incision which traverses the site of infection, and since border of the annular the site of infection is nearly always at the top of the ligamenit, and is in re- finger, it follows that this incision traverses the fibro- lationiwitlh the tenidons fatty pad in that situation. It should be prolonged a of the flexores sub- little further up thani the usual incision there whiclh I limis and profundus have recommended for treating the subcutaneous form of digitorum. It is thell whitlow, so as to open the termination of the theca if somewhat constricted necessary. One would then see within the theca the in its passage througlh insertion of the tendon of the flexor profundus digitorum. the narrower space be- The other incision is also generally necessary, and it ineatlh the anterior should be made at the other end of the tendon sheath. l1 annular ligament. I have already said that this fibro-osseous canal in which (There is a fibro- the tendons lie begins at the neck of the metacarpal bone. osseous canal formed The positioni of the upper incision should be therefore here by the annular over the head of the metacarpal bone, and it will then \/'\.\J/ ligament in fronit and divide practically nothing of any importance, so long as 'I the carpus bent it is kept in a line with the axial line of the finger. '.'. J/ / lI Jbyupon itself so as to The incision divides skin and subcutaneous fat, and form a deeply concave underneath the fat you will see the strip of the \/. / groove on this aspect palmar fascia, and if you divide this you open the \(''s'./ j / bellind.) But at the thecal space. I recommend that -when you have :.# '> , | lower border of the reached the theca the surface should be sponged clean, \ *^ ^^/1 s annular ligament the so that you can see what its colour is. If it obvi- sac expanids againi, an(d ously contains pus, an incision should be made freely in on its ulnar side is it about 1 in. long. But if there is any doubt as to what continuous with the it contains, though you can demonstrate by the feeling ____=___ / serous sac whichl lines which you get by touching it with your fingers that it the tendoni sheath of contains fluid, some of the latter should be drawn off with )_ the little finger. The( the hypodermic syringe, and theni, according to the smaller sac beneatlh character of the fluid, so you either make a long incision, the annular ligament say 1 in. long, or a short incision just sufficient to give is in relation witlh the exit to the clear fluid which you have found to be present flexor longus pollicis, in the sac. There are other positions which have been and does niot extend(l recommended for opening a thecal abscess, but I am so hligh above the liga- bound to say I do not know of any two which are so Fig. 1.-Slhowing tlhc five distinct ment by about iin. useful as the one at the termination and the other at the serous sacs usually found in the For all practical pur- commencement of the thecal sac. Sometimes if you can lhand in relation with the ten- poses there is nio dif- dons of the flexor longus pollicis show that the suppuration within the theca is local, you and of the flexor sublimis and.Tesciference. The sac i can deal with it where you know it to be. If, for instance, flexor profundus digitorum. constrieted benieatlh there were no in the the The position of the anterior the annular ligament swelling palm, and swelling were aninular ligament is indicated found to extend along a certain length of the finger, you by lines representing its upper and in the palm shows miglht deal with it locally by making your incision and lower borders respectively. an expansion which I through the thickest part of the swelling. The tendon (After von Rosthorn.) hlave indicated in my sheath should never be laid open from end to end, for then diagram. This expansion lies in the inner part of the the tendons stand out from the finger and invariably thenar eminence, and is overlapped by the outer lhead of slouglh. the flexor brevis pollicis muscle. Afterwards the'sac is prolonged without a break down the course of the thumb, TREATMENT OF EXTENSIONS OF THE INFLAMMATION. where it is continuous with the serous sac which lines Now we come to another considerationi, niamely, that if we the tendon sheath of that digit. I have indicated in"-my are dealing withl a whitlow wlhich has started at the top of sketch the position of the serous sacs of the otlherdigits either the index, middle, or ring fingers, the probability is so as to make the picture complete. that the suppuration within tlle tendoni sheath will not extend, provided that the pus be not left unduly long in the finger. It will not extendl beyonid the level of the li neck of the metacarpal bone, because that is the limit of F.r m.1 the thecal space, and of the serous membranie in which the pus lies. But in the case of the thumb, and in the case of the little finger, one should look out for extension much further than that extension, in fact, up to the wrist, and even above the level of the wrist, into the lower part of the forearm. I will make a few remarks with reference to these statements. It was shown some years ago by Dr. Alfons von Rosthorn that in the majority of inistances there was direct extension of the serous sacs within the tendon sheathls of the little finger and thumb upwards through the palm, so as to communicate respectively with two large serous sacs lying beneath the anterior annular Fig.'2.-Showing a section of thewrist through the upper row of ligament of the wrist, and the following diagram (Fig. 1) carpal bones. It indicates in particular the relation of the represents what he described as the typical arrangement serous sacs to the tendons as they pass beneath the anterior of these sacs. annular ligament. S, scaphloid: C, cuneiform; Py, pyramidal; Pi, pisiform; f.c.r.. flexor carpi radialis; f.I.p., flexor longus You will remember the upper border of the anterior pollicis; m.n., median nerve: u.a., ulnar artery: u.n., ulnar annular ligament of the wrist corresponds almost exactly nerve. The tendons of the flexor sublimis and flexor pro- with the lower of the two creases across the front of the fundus digitorum are easily recognized. (After von Rosthorn.) wrist. The upper crease is a slighlt one, while the lower We have now to consider what steps are necessary if is quite a deep crease, and if you follow inwards the suppuration has started in the thumb or in the little course which it takes the upper end of the pisiform bone finger, and has spread beyond the digit into the large sac is reached, while following it outwards leads to the in the case of the thumb, or into the still larger sac in tuberosity of the scaphoid. These bony points are of the case of the little finger. There is usually a small Tzn BiLrnm 426 KzDxc&L Jomm'A AVHITLOWWHITLOW AND ITS TREATMENT. rFEB.frFEB. 24,24,) 'qo61906.

communication between thiose two at the upper eind, wlhich the severity of the haemolrrlage which' resulted, and ih is effective for practical purposes; that is to say, you may the otlher case the bleeding was arrested onily by ligatuting easily get an extension of suppuration- in one *r othler the braclhial artery at the middle of the arm. Whllen the direction. We now wai-nt to know wlhat relationl these sacs incision is made on tlle inner side of the flexor carpi have to the several tendons underneatlh tIe anterior radialis tendon that brings you very near the median annular ligamenit. If we know tllis, it follows tllat we nerve, and if you are goinlg to use a tube for drainage, and have the exact relation of the sacs to the tendons above or sometimes wvithout it, you may create a nieuritis of the below tIme anterior annular ligament. I can slhow this median n-erve whicll will damage the hand either per- relation best by means of a diagram (Fig. 2), wlich is also manenltly, or at any rate for a great lenlgth of tinme. after von l{ostlior mi. My owin preference is to make an incision on the We will imaginie we have cut aeross the earpus tran-s- outer side of the flexor carpi radialis, but I shoul-d versely, so as to show in front the anterior aninular liga- protect the radial artery, either by covering it witlh ment. There are nine tendons in the fibro-osseous canal gauze, or, if I felt that that was not sufficient, I shoul(d so formed. On the outer side the flexor longus pollicis remove a piece of the vessel, that is to say, I should cuxt tendon, a tendoni wlhieh is in relation witlh the smaller of out about 11 in. of it, and wipie over tlie surface of thme the two sacs. There are placed upoIn the floor of the wound with some strong antiseptic solution, such as space four tendons, those of the flexor profundus digi- chloride of zinc lotion (40 gr. to thme oZ), anid: then pack a torum. In front there are the four tendonls of tlle flexor piece of gauze into each end of the wouVd so as to shut off sublimis; and of these the middle and ring finger tendons lie completely the ligatured ends before evacuatinig the pus. a little in advanee of those of the index and little finger. Having thus disposed of thie radial artery you stand very The relatioii of the serous sacs canInow be shown to the little chance of getting any troubl-e from it. That, I believe, several tenidons underneath the anterior annular ligament. is a better course than placing the nerve in jeopardy, and Their position is mainly wlhat we should expect. Eacl it is certainly a better course thani running the risk of sac shows two layers: tlle parietal and the visceral layers, secondary haemorrhage from the radial artery by leaving if we may so term them. Tlle parietal layer linies the it in its normal position. Only the other day I sawv a case space in which the tendons lie, and the visceral layer is irn whieh the incision had been made on the inniier side of reflected oni to the tendons. And time way in whliel it is the flexor carpi radialis tendon, and tlIe median nerve had reflected is peculiar. A series of pouclhes are formed suffered terribly; the patient had absolutely no tactile which pass between the several tendons, anid so give to sensation over the flexor aspects of the thumb, inidex, eaeh tendon either a complete covering or almost a middle, and radial side of ring fiingers, and this was some complete covering. It is a closed sac whichl surrouInds or six months after the operation lhad been performed. nearly surrounds the space in which the tendonis are, and There had been not only neuritis, but tIme nerve was is so arranged witlh reference to each tendon that it gives included in the scar that had formed, and was certainly almost a complete eoverinig to eaclh. In the case of the very considerably damaged. smaller sac of the twvo the same arrangemen-t lholds. The There is one other point, and that is tliat to complete parietal layer lines the outer portion of tIme space under- the treatment of this serous sac of the flexor longus neath the anterior annular ligament, and the visceral pollicis, one should have an incision in such a positioin layer is reflected on to the tendon. It is a closed sac in the palm as to open the dilatationi of the sac of whlich again whicli eitlher completely or almost completely I spoke. This incision is best made along the inner surrounds the tendon of the flexor longus pollicis. border of the outer head of the flexor brevis pollicis. We now pass on to describe tlhe opera.tions that become By making the incision lhere you avoid injuring thme necessary wlhen suppuratio'n has extenided into either of digital branches of the median nerve which go to the these sics. Let us take the case of the thumb first, as thumb, and the incision is in the best position1 for that is tIme simpler, because we are there dealing with one reaching the serous sac, and in a position in whlich tendon oinly. Wlhen a whitlow starts at the top of the nothing of importance is likely to be divided-except, thumb, becomes secondarily.a thecal abscess and spreads perhaps, one thing. If you carry the incision too far up upwards under the annular ligament into that portioii you will divide the braneh of the median nerve which of the serous sac which lies above that ligament, it goes to the small muscles of the thtumb. But since you becomes necessary to deal with it somewhat energetically. are doing the operation bloodlessly, you are viewing the One has to institute as complete drainage as possible for parts almost as in the dead subject; you can see the the whole of the length of serous sac involved. It is nerves distinctly, and you will be on the look-out for the probable that one would make, if not quite at the begin- motor branch of the median nerve which goes to the ning of the operationi, quite early, an incision through the three outer muscles of the theniar eminienee. So by fibro-fatty pdl of tlme thumb, because that is the site in looking out for it you can avoid dividinig it. In that which the infeetion w%as first inoculated. One would then case which I referred to just niow, in which the Imedialn make an inCisioni into the -upper end of the serous sac; neive was involved in the scar on the front of the wrist, that is to say, an incision would be made in tIme lower the branch of the nerve to the three thenar muscles had part of the forearm above the wrist, so as to evacuate the been cut right througlh also by an inicision whiel had pus which lies there, and so as to give us an opening at been placed too far out, over the prominent part of the the upper limit of the sac for the purpose of free drainage. thenar eminence. One should make the incision on the Opinions differ as to where exactly this incision should be inner side of the eminencee so as to reaclh the inner made. The question is as to whether you should make border of thle flexor brevis pollicis. the inceisionl on the outer side or on the inner side of the With regard to the bigger of the two saes a few more flexor carpi radialis. One can demonstrate on one's own remarks must be made. Here, againi, we will imagine wrist tlhe positioni of the flexor carpi radialis. It lies one- that we have a case in which the disease started origi- third of an inichi internial to the radial artery, and about nally as a subcutaneous infection at the top of the little the same distaiice external to the palmaris longus tendoni. finger. It has become a tliecal abscess, and since the Should the incision be made on the outer or the inner side serous lining of the tendon sheath is continuous with the of it? Each position is equally good as regards the larger sac beneath the annular ligament, which is in 'facility of reachinig the tendon of the flexor longus relation withl the two sets of four tendons, of the flexor pollicis, whliich lies underneath the flexor carpi radialis sublimis and the flexor profundus digitorum muscles, tendon. suppuration lhas spread through the palm and is involvinig Now oni the outer side of 'this tendon is the radial those portions of the sac which lie above the ianntilar artery; and since you will probably. be putting a tube ligament in the lower part of the forearm.. into the wound anid because the wounid will become For practical purposes you will find that what is intensely septic from the character of the material which necessary in order to evacuate the pus when it occupies you will evacuate, you are exposing the artery to very this big sac is to open up the space between the two sets unfavourable conditions, in that, if you use a drainage of tendons, though that would appear to be rather con- tube, and sometimes even if you are able to do without a trary to what I have shown (Fig. 2) with regard to the tube, youi may get ulceration of the vessel where the tube r'elation of the sac to the several tendons, but not nieces- or dressing lies upon it. I know of two instances in sarily so. Probably by the time that you have got the which thiis occurred, inl which the radial artery ulcerated, case for treatment, or are making your incision, this sac and in both instanices a tube was being used. In one has given way, and has done so in one pr more of those case, though tIme patieint was in hospital, she died from processes which project between tile adjoillilg te`iidoims, LTx BamrX. FEB. 24, I906.] WHITLOW AND ITS TREATMENT. L1BDICAL JOU3NAL 427I . either of the superficial or of the deep set, as the case mercury, beginning with a solution of 1 in 5,000 or of may be. So when you make your incision, the position 1 in 4,000, and, if necessary, gradually increasing the in which you will probably find the pus is between the strength. I am of opinion that more good will be done tendons, those of the flexor sublimis in front and those of by using large quantities of weak solution than by using the flexor profundus behind. The incision should be one of greater strength in flushing out the suppurating made along the broad ridge which indicates the inner tracks, and thus bringing about the removal of the septic border of the flexor sublimis digitorum. This is i in. material. If the suppuration extends higher into the external to the tendon of the flexor carpi ulnaris, forearm than we have yet mentioned, you will always find and the incision should be carried from the upper border the pus between the flexor sublimis and the flexor pro- of the ann-ular ligament 1J in. to 2 in. or more along the fundus digitorum, and I would reminld you of the kinid of forearm. You make tlhe incision with the limb bloodless, case one sees. A patient comes to you witlh suppuration as before, and then you see what you are doing. Divide in his hand, and you find that he has developed an oval the skin, the subcutaneous fat, and the deep fascia, and swelling over the upper two-thirds of the front of the then see the border of the flexor sublimis tendon. You forearm. The latter is prominent, hot, red, extremely will probably see the border of the ring finger tendon tender, and oedematous, and tlle summit of the first, and looking further inwards you will see the surface swelling is in the middle line of the forearm. of the little finger tendon. Pull both these tendons It may require some little restraint to preven-t oneself outwards, and you now look into the space between the making an incision into the middle of it, though two sets of tendons, the flexor sublimis and the flexor in reality that is the worst possible thiing to do. If you profundus digitorum, and it is there that you will make an incision into the middle of the swelling you have probably find the pus. You may find pus before you to traverse the superficial layer of muscles; you have to reach this level; you may find pus superfieial to the traverse at least the whole thiikiness of the flexor flexor sublimis tendons. If so, it does not mean that you sublimis digitorum, and you will remember that on the must stop; you must go deeper and look underneath the deep surface of that muscle is the median nerve. It sublimis tendons, because there may be a larger collection sticks there, either because it lhas passed througlh the of pus in the more usual situation between the sublimis upper part of the muscle, or because it is lheld there by and the profundus tendons; and it is usually wise to the median artery; and it will be a matter of sheer good look deeper still, namely, between the flexor profundus luck if you make this incision into the big swelling in the digitorum and the surface of the pronator quadratus; middle line of the limb and do not divide, split, or other- because it occasionally happens that pus is found there wise injure the median nerve. As a matter of fact, the also-that is to say, pus may be found in either of these incision should not be made there at all. The proper situations whieh I have indicated. If you find pus in the position for the incision is along the ulniar border of the last situation mentioned I should recommend that forearm, as if you were going to tie the ulniar artery at the another openinig should be maade in addition to the one junction of the upper and middle thirds of its course. whichl you lhave made in fronit, because you can then You can make an incision in a line placing a string on make a very direct drainage of the space underneatlh the the forearm for the purpose if necessary- from the outer flexor profundus tendons by an incision along the ulnar border of the pisiform bone to the back of the internal border of the wrist just behind the tendon of the flexor hiimeral condyle. After dividing skin anid subcutaneous carpi ulnaris. It may be a long incision, but it need not fat you look for two white lines in tflec (leep fascia; come down lower than the pisiform bone. Nothing can you choose that one of these tNwo w-ich is niearest to be harmed there, unless, perhaps, it is the dorsal branch the guiding line of the incision. Make an incision in that of the ulnar nerve at the upper end of the wound. You line in the deep fascia and so open the interval between will see this nerve, and then you pass deep to the flexor the flexor carpi ulnaris and the flexor sublimis digitorum; carpi ulnaris, deep to the ulnar nerve, and deep to the and you find almost at once you are in the cavity of the ulnar artery, inlto the space (now full of pus) beneath the abscess which lies deep to the last-named muscle. The flexor profundus digitorum. You should place the fore- only thing which interferes with this operation is the arm midway between the prone and the supine position, ulnar artery. You will remember the ulnar artery comes so as to obtain the best position of the wound for from the middle line of the limb, and only reaches the drainage. line of the ulnar nerve at the junction of the upper and There are two other things I want to say. When middle thirds of the length of the limb, and if you are making the incision above the annular ligament to using a drainage tube it may lie across the ulnar artery. deal witlh the larger sac, one should make another The nerve is under cover of the flexor carpi ulnaris, and is incision below the annular ligament also, and likewise protected, but the ulnar artery may be injured; and a a third incision through the top of the little finger. similar accident may happen to it as the one which I The incision below the annular ligament so as to open described as likely to happen to the radial artery in the the large dilatation of the sac there, is not very easy outer incision at the wrist. I should be disposed to deal to place; the reason being that you have to place it with the ulnar artery in the same way as I suggested witl in such a positioni that you shall not injure the nerves. regard to the radial at the wrist, and before opening the I take it that it does not matter what you do with the abscess, to cut a piece out of the ulnar artery sufficiently arteries; you are doing the operation bloodlessly. You long to give you plenty of room to place your tube com- will see the superficial palmar areh, you will tie it on fortably, and then proceed to open an abscess and to give either side of the wound and cut out as much as there is it perfect drainage. between the two ligatures. You want to place your One other poinit is, that besides tlhis last extension which incision so as to injure the nerves as little as possible. I have mentioned, the commonest is an extension of the The best place for the incision from that point of view is suppuration into the wrist joint. When the suppuration distinctly between the digital branehes of the median and has involved either of the sacs beneath the anterior ulnar nerves-that is to say, to the inner side of the fifth aninular ligament the distanice into the articulations of the digital branch of the median nerve and to the radial side of wrist joint is no greater than the thickness of the liga- the outer of the ulnar branches. The only nerve which you ments on the anterior surface of the carpus, and the will find here is a little cross-Communication from the extension now spoken of is not therefore a imatter for median to the ulnar nerve, or a twig in the opposite direc- surprise. It is perhaps commoner than extension into tion; but it is very small, and if all the damage which you the forearm; and, of course, it is a state of affairs wlhicl do to nerves is confined to injury to that cross branch you is about as bad as it can be. The case is, however, not will have done very little. This incision should be made hopeless, but you will need to make onie or more incisions in the palm in the line of the axis of the ring finger begini- on the back of the carpus, and perlhaps to remove the ning at the lower border of thle aniterior annular liga- carpal bones. Sometimes these bones are lyinig loose, just. ment. In both these instances, (a) where the infection as if they had been macerated ready for an anatomical is from the thumb, and (b) where it is from the demonstration. They can then be scraped out through little finger, lhaving made your three openings into the one or more incisions on the dorsum of the wrist, and, by serous sac you can use your openings from either end for puttinlg the limb on a suitable splint-Lister's wrist irrigation of the abscess cavities. You should pass splint, for instance-you may obtain a lhanid which is through the abscess daily, or twice a day if you like, a moderately useful. considerable quantity of an antiseptic fluid, say a weak The after-treatment of all these cases is manipulation solution of biniodide of) mercury or of perchloride of and massage; passive and active moveme.nts of the joints 428 Tjo.jjZ LEAD AS AN ABORTIFACIENT. [FEB. 24, 1906. slhould be begun as sooni as possible, before the wounds are easily be ventilated in the public press, or by the circula- healed. You should try and induce the patienit to help in lation of warning notices. Moreover, there is the fear -every possible way and in particular in movements of the that publication might tend to spread the evil, instead of fingers. Of course there will be sure to be many consider- redueing it. able adlhesiols, and the sacs may be to a large extent History and Extent of Spread.-Tlie first cases were obliterated. Still, evenl theii, some small parts will observed at Leicester and were reported in 1893 by remain, and you may obtain a very large degree of move- Dr. Pope. ment if tllese atteinpts at movement are beguni sooIn After that thle practice seems to have been less prevalent enough, before the parts are fixed by firm cicatrization. for a wlhile, or at least to have spread but very slowly, for One knows this because one sees the good results whicl I can find no further record of cases until 1898, that is, five occur in those cases of tuberculous disease of these serous years later, whlen cases were reported in the neighbouring sacs after one lIas removed by dissection every bit of city of Birmingham. In 1899 it had reached Nottingham >:synovial sac wlichl can be found. In such cases, if tlle in considerable vigour, where it lhas remained ever since. dissection be done carefully, you can obtain a remarkably At that time it lhad certainly not reachled as far north as good result with free movements of finigers and of the Sheffield, nor did it do so to any exten-t until some two or w%rist, if you will begin the movements early-passive first, three years later, sinice when the number of cases has anid tlhein active movements-and continue them for a very steadily increased in the locality. Inquiries which I have long time indeed. I do not think that one can put any limit made from all the neighbourinig centres show that it has to the lenigth of time during which such movements are reached various smaller or larger towns still furtlher nortlh, likely to prove beneficial in these cases. suclh as Barnsley and Doncaster, and that a few cases have The treatmenit of the fourth or subperiosteal variety of occurred in Leeds, includinig one deatlh, but this seems wlhitlow is comparatively simple. It consists in making to be its northerni limit. So far as I cani ascertain, it has -in inic,isioni thlrouglh the fibro-fatty pad at the top of the not been recorded in any of thle other large Yorkshire linger downi to the bone. Care should be taken not to cut towlns, Bradford, Halifax, Huddersfield, Hull, York, etc.* so higlh as to endan-ger opening the tendon sheath. This It has not affected the Manchester or Liverpool districts. incisioni gives free drainage; about a month later one is Further north at Newcastle-on-Tyne it appears to be able to remove so much of the ungual phlalanx as has quite unknown. necrosed. Witlh few exceptions the base of the bone witl To the east of this affected Midland area I cannot hear the attachmen-ts of the flexor and extensor tendon survives of any cases, either at Lincoln, Gainsborough, or Retford. and the wounld heals without further trouble. Lead and To the south of Leicester a certain number of cases, spirit lotioin (3ss of eaclh to 1 oz. of water) is the best withl one death, have been reported to me by the courtesy application I know of for all forms of terminal whitlow. of Dr. Horace Savory of Bedford. I lhope I have interested you in what I have said. My Inquiries from various hospital authorities in London own feelinig is that all tIme operations whicll I have point to its not occurring there. {described this afternooni can.be performed successfully by The area over wllichl tlle practice of usinlg diachylon as any surgeoni provided the few conditions whicll I have an abortifacient has spread is tlhus bouniided on the north laid down are accepted and followed out-namely, that by the upper part of South Yorkslhire, on the south by operation on the affected parts should be undertaken as Bedfordshire, and oni each side by the widtlh of the early as possible; thlat the operative measures should be coun-ties of Leicester, Warwicksliire, Notts, anid East -arried out after the limb lhas been made as nearly blood- Derbyshire. This area comprises a large number of less as can be, and tllat if one is uncertain of the intimate manufacturing towns, eaclh containing thousanids of the anatomy of the region inivolved, one should take thle workinig classes, together witlh a counitr-y betwveen largely trouble to look up the subject before the operation, so as occupied by mining populations. to be well aware of the position and relations of the Local Statistics as to Prevalence of the Customn.-Dr. several structures with which one may have to deal in the Ransom has attempted to obtain somle details as to the course of the operation. Seldom can one hope to obtain extent of this custom in and around Nottinglham-that is, suclh a result as will give entire satisfaction to tIme patient, in the southlern lalf of the area; whilst I lave attempte(d but it is no small tlling to be able to say that the result to do the same in and around Slheffield. obtained is time best possible in the circumstances of tIme A circular suggested by Dr. Ransom lhas been forwarded case. And this slhould be the aim of our treatment. to every medical man withlini an area of some twenty or thirty miles of Slheffield, asking for informationi. About 200 have replied. Of these 50 have had suclh PLUMBISM FROM THE INGESTION OF cases of plumbism under their care during the last two years (vide Appendix A). DIACHYLON AS AN ABORTIFACIENT. From their replies one can accounit for one or two BY hundred cases in this district during thle last twvo years. ARTHIUR HALL, and W. B. RANSOM, One may add to these the large number of women wlho M.A., M.D., F.R.C.P. M.A., M.D., F.R.C.P. come to our hospitals suffering from plumbism every THYSICIAN, ROYAL HOSPITAL, PHYSICIAN, GENERAL HOSPITAL, month, and even then get a very modest estimate of the SHEFFIELD. NOTTINGHAM. extent of the practice. And this for two reasons: In the first place, a consider- OIBSERVATIONS BY DR. HALL. able number of medical meni have tol(d me they have had DURING the last few years outbreaks of lead poisoning suclh cases but have Inot answered my eircular for fear of of varying extent and severity have occurred in dif- making a breach of professional secrecy, whilst the fear ferent localities whiCh could not be traced to the ordinary of being found out prevents a large number of sufferers sources of plumbism, such as water contamination or froin going to their medical meni at all.. dangerous occupation. The cases were always limited I believe we slhall not be far wrong in saying that to women of child-bearing age, anid eventually the several hundred women have takeii diaehyloni in this source of the poisoning was traced to the custom of district alone during the last two years. taking diaclhylon as an abortifacient. From the previous statement one is warranted in saying In a paper read before the Yorkslhire Bran-ch of the that this abuse of diachylon is a grave public scandal; for, Britislh Medical Association at Bradford in January, 1904,* apart from the social and moral questions connected witlh I recorded 30 cases of this kind, and referred in detail to it, there is the added evil of the harmful effects of the drug the numerous articles which have appeared in various itself. journals from time to time oni this subject (vide Biblio- Unfortunately this is not limited to thle severe ab- graphy at end of paper). dominal pains and lheadache wlich immediately follow This custom of taking diachylon, instead of dimin- its use-themselves a cause of sufficiently serious suffer- ishinlg, lias spread over such1 a large area of country, and ing-but there is the prolonged anaemia, with complete assumed sucli serious proportions, that steps must be inability to carry oni the duties of a houselhold for many takeni to check it, or if possible to stop it altogether. How weeks or months afte?r the drug has been stopped. this nlay best be done remains to be settled, but it is not so simple a matter as miglht at first sight appear. * Since writing the above I am informed tlhat the practice is not The subject is a somewhat delicate onie, which cannot unknown to cimemists in sollme of thlese towns, and timat even in Dundce cimemists have lrecently bveen a.ked for diachylon, apparently for this * BRITISH MEDICAL JOrURN-AL,, Mareli 18th, 1904. purpose.