NI.~ I;ERIIS VOL. VIII, No. 2 Beck-Infection of Hand & Fingers A m&can J~urrt:tl of Surqcq 30 I

method of injections into varicose veins. Prorres I!‘&& 38: 31-35, 1923.

4. KAHLE. The injection treatment of varicose veins. AM. J. SURG. N. S., 6: 813-814, 1929.

5. LINSER, I(. Treatment of varicose veins with IocaI injections of Is-25 o/0 sodium chloride solution; vnricophtin. Darmut. B’chnscbr., 81: 1345--13jI, 1925.

6. LINSER, I<. Treatment of varices with artificiaIIy induced thrombosis, Dermat. Ztschr., 45: 22-27, 1925.

7. RZCPHEETERS, H. O., and RICE, C. 0. Varicose veins; compIications direct and associated

IO. NOFILE, G. Varices of the Iegs treated with injec- tions of caIorose for the purpose of causing artiticia1 thrombosis. Wien. Med. %‘cbnschr., 76: 1280, 1926.

I I. NOBLE, G. CaIorose as an agent for obliteration of varicose veins. Wein klin. W’cbnschr., 30: 1217-1219, 1926.

12. SICARD, 3. A., and GAUGIER, L. The treatment of varices with scIerosing injections. Presse Med., 34: 689, 1926.

13. SICARD, J. A., and GAUGER, L. The treatment of varices of the Ieg by sclerosing injections. In: l\laIadies de Ia Circulation, Paris, Masson,

folIowing the injection treatment. J. A. M. A., 1927. 01: I00lF100d. 1028. Ia. TWICH. I. S.. DEBIK. S.. and SCHMIER. A. The

8. IL’ICPIIEE~RS,‘~ 6. Varicose veins: the injection . injection treatment bf varices and u&s of the versus the operative treatment. Surg., Gynec. lower extremities. AM. J. SURG., N. S. 6: 479-486, U Obst., 48: 819-822, 1929. 1929.

9. RICPHEETERS, H. 0. The injection treatment of 15. WOOLSEY, J. H., and MILLZNER, K. J. Varicose varicose veins by the use of sclerosing soIutions. veins; their chemical obliteration. Callj. PT &~,e., GJmec. r?+ Obst., 45: 541-547, 1927. \l’estern Med. 30: 325-327, 1929.

INFECTION OF HAND & FINGERS*

CARL BECK, M.D.

CHICAGO

C ONSIDERING the fact

hand comes in contact taminated objects more

other part of the body, and that are exposed to more injuries

that the wiII meet a pIiabIe skin yieIding readiIy to with con- the formation of an abscess. But when the than any inner surface of the fingers or hand is

the fingers punctured and infected, the skin, being than any of a tougher character and the underlying

other organ, it is remarkabIe that infec- tions of the hand and fingers are not more

fat of coarser structure, does not yield and hence the infection penetrates Into the

common than they reaIIy are. They beIong, deep tissues. This endangers the vitaIity nevertheIess, to the most frequent patho- of the deeper structures and leads to a11 IogicaI conditions the genera1 practitioner kinds of compIications. It is important, is caIIed upon to treat. therefore, that punctured wounds and

smaI1 cuts of the voIar surface alwavs be PATHOLOGY regarded with suspicion, and treateddwith

- Infections of hand and fingers are due a presumption that they are apt to be to the entrance of microorganisms through infected more than those of other parts wounds, among which the punctured of the hand. Another pecuIiarity of infec- wounds pIay the most important r6Ie. tions of hand and fingers, again referabIe And here again it is the voIar surface of to an anatomica pecuIiarity, is that the the hand and fingers which is more apt to wound infections of the dorsai surface are be infected and where infection is of greater apt to Iead to rapid propagation through danger, owing to the predisposing histo- the Iymph channels in the form of lym- IogicaI structure of the skin of this surface. phangitis, whiIe the infections of the votar When a sharp instrument or sharp body surface are more apt to be IocaIized and makes a puncture on the soft part of the restricted to the phaIanges as so-caIIed skin of the dorsum an ensuing infection feIons, or to the paIm as abscesses within

* Submitted for publication November 19, I929

302 American JOUI~ of Surgery Beck-Infection of Hand & Fingers FEBRUARY, ,930

the tendon sheaths, intercommunicating with joints or other structures. The infecting micrrooganisms are either strep- tococci, staphyIococci or other pus-forming microorganisms which enter the tissues of the fingers or hand through punctured wounds with or without a foreign body, such as a smaI1 sIiver, sphnter, a piece of cIoth, or other materia1.

SYMPTOMS

The symptoms of infection may be cIear and manifest or they may be very obscure and misIeading. As a ruIe the foca1 symp- toms predominate and Iead the physician to an earIy diagnosis. The IocaI signs of infIammation : heat, sweIIing, tenderness, redness, as we11 as a throbbing of the part, wiI1 make an earIy diagnosis of acute infection very probabIe. The genera1 symp- toms are those common to a11 other infections, nameIy chiIIs, fever, genera1 maIaise, headaches, rapid puIse, etc. How- ever if the infection has Iasted for some time these acute symptoms may subside or may become very insignificant. The acute infection usuaIIy turns into a sub- acute one and may lead to a chronic infection, which is characterized by a different symptomnoIogy, nameIy: the formation of exudate and IocaIized death of tissues or necrosis. The exudate is as a ruIe puruIent. The tissue underneath the tough skin is meIting away into a debris consisting of pus and bIood, and structures Iike tendon and bone which have onIy a meager circuIation easiIy die off, becoming entireIy deprived of nutrition because of the thrombosis of the bIood vesseIs and the pressure of the exudate. These abscesses foIIow predisposing channeIs aIong the sides of the tendon sheathes and in many instances Iead to their necrosis. This is a very important compIication as it has its effect upon the function and the use of the hand. Once estabIished, such an abscess of the tendon sheath is apt to push forward into the paIm of the hand, destroying the tendon and perforating into the Ioose tissue of the dorsa1 surface, thus

circuIating the pus into important struc- tures of the hand and Ieading to destruc- tion of various kinds with contracture or stiffness as common sequeIae.

The symptoms of abscess are in many instances characteristic. FIuctuation shows the presence of Iiquid exudates. Edema is strongIy indicative of deep suppuration. Besides the tendon, the bones are very often exposed to the effect of pus. The periosteum is one of the structures which are easily infected through propagation of the process, and a subperiostea1 abscess Iifts the periosteum from the bone, depriv- ing the bone of its nutrition. This resuIts in an osteitis and osteomyeIitis foIIowed by partia1 or tota necrosis of the bone (sequestrum formation).

One of the most dangerous compIica- tions is that of infection reaching the cap- suIe of the phaIangea1 joints and the joints themseIves. WhiIe we are capabIe of deaIing favorabIy with the other compIica- tions, this one inevitabIy destroys the function of the joints by Ieading to a necro- sis of the cartiIage, which is very poorIy nourished by the surrounding bIood suppIy. FortunateIy the capsuIes of the Iarger joints are very resistant to the acute infection, and as a ruIe onIy the smaI1 jomts suffer in this manner.

DIAGNOSIS

The diagnosis is made from the symp- toms aIready mentioned. The x-ray is a very vaIuabIe asset in clinching the diagno- sis of infections. WhiIe inflamed structures do not show any specia1 shadows, the infIammations change the structures of the bone to such an extent that the trained eye of the roentgenoIogist easiIy detects the presence of osteomyeIitis, osteitis and periostitis. The shadows and the structure of norma bone disappear and the irreguIar, transparent shadows of the diseased bone take their pIace. The sequestrum becomes visibIe. One of the most characteristic symptoms of this infection is the appearance of pus, which by breaking down the tissues forms a

\EM SE.RIES VOL. VIII, No. z Beck-Infection of Hand & Fingers A mericnn Journ:~l of S.lrgery 303

fist&t from which it escapes. As soon as this stage is reached, either spontaneousIy or through the interference of the doctor cutting into the abscess, the general symptoms usually disappear and the acute infection turns into the subacute, chronic stage.

COURSE AND RESULTS

There are hundreds of possibilities foI- lowing infections of the hand, many depending upon their management and treatment. General sepsis and fatalities are rare. Spontaneously and unaided by the physician many infections yieId excel- lent results, even if treated only by home remedies such as poultices. The infection leads to an abscess, which ripens and breaks through, emptying the pus, and then heaIs up without Ieaving a trace behind except a tiny scar. There are other instances in which treatment begins too late. Complications wiI1 have arisen, but prompt action can stiI1 save the appearance and function of the fingers or hand. There are others which are fauItiIy treated and become so extensive that when they come under the care of the reIiabIe physician irreparabIe destruction has taken place and function and shape may suffer greatIy. Contractures or stiffness of the joints may resuIt from these infections so that the grasp, the hand’s most important function, is impossibIe. Besides the acute, subacute and chronic septic infections there are other infections by different microbes, as the syphiIitic and tubercuIar, which have a protracted chronic course. They require specia1 consideration.

Among the IocaI infections of the fingers and hand are some of trivia1 nature, starting from hangnaiIs and smaI1 injuries on the side of the naiIs, the so-caIIed run-arounds or paronychia, which lead to very superficia1 abscesses and are easiIv deaIt with.

TREATMENT

The treatment of the infection in the hands of the expert surgeon is standardized

and agreed upon. But the treatment by the genera1 practitioner in his olhce needs some discussion. First of aI1, ever) infection of the fingers shouId be Iooked upon as a serious matter, because of its possibilities and compIications. The consid- eration that the infection may? disappear without any interference and hea sponta- neousIy shouid never be accepted too Iight- Iy. Most of the septic infections lead to abscess formation. It is, therefore, the ob- ject of the physician to watch this abscess formation to stem its tide, and localize it if possibie. This can often be done by using the passive hyperemia method of Bier on the infected finger. This consists of shutting off the circulation of the finger by -the circu- Iar constriction of a rubber band used as a tourniquet. I d o not believe that many formations of abscess have been prevented, but fortunateI\; we have seen cases threat- ened with rapid propagation, which were Iimited to one or two phaIanges, or to a felon, by such a rubber band. Heat and moist dressings are the most advantageous remedies, aIso hot baths and alcohol appIications. Heat brings more bIood to the infected area and accelerates the formation of abscess. Whether we appIy a hot bath, pouItice or electric pad is immateria1. Moist dressing with acetate of Iead in the form of so-called BiIIroth soIution, boric acid appIications, or the thermic Iamps are very beneficial. The crucia1 part of the treatment is the question whether surgica1 interference is necessary or not, and herein most of the mistakes are made. Sometimes very aggressive activity in the first pIace is harmfu1. It is best to decide first when to incise, second, where to incise, and third, how much to incise. As to the first question, when to incise: Many make the mistake of incising too earIy and therefore unsuc- cessfuhy, because the pus formation has not yet reached the stage of a melting process. FIuctuation, the characteristic sign of abscess in a finger, is diffrcuIt to diagnose. The second question, where to incise: There are certain rules about this.

304 American Journal of Surgery Gordon-Gonorrhea in Women FEBRUARY. 1930

It is best to incise in the direction of the blood vesseIs, not too cIose to the tendons or joints, yet into the abscess. The Iast question, how much to incise: Here the practitioner sins most. If he is of an aggressive nature he is IiabIe to incise too much, but many practitioners are too timid and their incisions reach onIy the superficia1 surface, not the abscess, and therefore are useIess. The incision, how- ever, is not the onIy thing the practitioner has to think of. He has to estabIish a successfu1 drainage, and that is best estabIished in many instances by con- necting two incisions through an under- ground channe1 which is kept open by siIk thread, catgut, or tube or gauze.

An important consideration is the after- treatment of such incisions. Moist warm dressings shouId be contiriued, irrigations and IocaI baths, with or without additiona antiseptics. These depend upon individua1 taste more than upon absoIute indication and have changed from time to time according to the vogue and, perhaps, mostly because of the advertising by commercia1 interests.

This treatment of incision of abscess

can be done in rare instances with a IocaI anesthetic, but in most cases the patient because of sIeepIessness and pain for days is in an excitabIe condition and is better off when put to sIeep for a few minutes. LocaI anesthesia by freezing is onIy appIi- cabIe for very smaI1 incisions. Hypodermic injections are very painfu1 so that a few sniffs of gas are most convenient. The after-treatment of a case of chronic suppu- ration becomes an offIce routine, as it is often of long duration or the resuIt of a radica1 and extensive operation in the hospita1 and the patient does not require hospita1 care. The after-treatment of cases of chronic infection, after they have heaIed, in order to improve the function shouId not be negIected. The offrce treat- ment does not terminate when the suppu- rative process has stopped, but shouId be continued in the form of massage, eIectric pads, IocaI baths, and active and passive motion unti1 the function of the hand is restored to the best efficiency possibie. Many fingers and hands have been surgi- caIIy cured, but have remained stiff and useIess because of negIect of the aII- important after-treatment.

PRACTICAL POINTS IN THE MANAGEMENT OF GONORRHEA IN WOMEN*

CHARLES A. GORDON, M.D., F.A.C.S.

BROOKLYN, N. Y.

G ONORRHEA is so common that have to discuss birth controI at aII. Perhaps

it shouId interest every one of the figures are extravagant, but in a11 us. Just how common no one probabiIity they are not. Even hasty

knows, but amazing statistics might be consideration of its possibihties shouId quoted. We have a11 seen figures which convince us of that. One of the most show that 80 per cent of our popuIa- destructive diseases, it is responsibIe for tion have at some time or other been more sickness and disabiIity than tuber- infected, and that go per cent of these cuIosis or any other disease we encounter. have not been cured. It is the commonest Every day, in its chronic forms at Ieast, cause of steriIity, yet it must cause it is seen by every physician. To the sterihty comparatively infrequentIy, eIse, gynecoIogist it is omnipresent. So common, with so many not cured, we shouId not that he sees it everywhere and has but to

* Submitted for publication November 18, rgq.