In palmar abscess the danger of delay is especially great, as already shown. A free incision is imperatively demanded, the line followed being that of the meta carpal bone nearest the abscess. In do ing this, however, the location of the pal mar arch should be borne in mind, and the artery avoided. Should it accidently be cut both ends should be carefully picked up and ligated. In some cases, the abscess appears to have "broken" spontaneously early in the history of the case, and a flow of pus seems to verify this conclusion. The pus originates in small superficial abscesses, which some times form in addition to the deeper and greater one, and rupture early through the pressure exerted from below. They tend to mislead the operator by causing him to delay the evacuation of the main abscess. The danger involved not only includes extension of the purulent proc ess beyond the hand, but also destruction of the tendons of the latter, followed by permanent flexion of the finger: the "main en griffe." In whitlow. or felon, the general indi cations are similar, but the chances of arresting the inflammation early are greater if the case is seen early. This may often be effected by keeping the finger wet with alcohol, diluted with an equal quantity of camphor-water. A thin bandage well soaked with the solu tion is wrapped around the finger and oiled silk is carefully wrapped around the whole to prevent evaporation. A strong solution of borax, or a bichloride solution 1 to 3000 may also be used in the same manner, but carbolic-acid so lutions should not be employed, several cases of gangrene having been ascribed to their use. If after forty-eight hours no improvement is noted, a free incision, reaching the hone in the distal phalanx and down to the tendons in the two others, is needed, the sheath being laid open. When this is not resorted to early, the distal phalanx maybe found necrosed; hence the deformity left in so many cases of whitlow. If necrosis is present, dead portions of the bone should be re moved; but little apprehension need be felt, since it rarely extends beyond the epiphyseal line. In the two lower pha langes, however, necrosis is of more seri ous import; the dead bone must either be removed or the finger amputated, according to the amount of osseous tis sue involved.
Chronic Tenosynovitis. — Although this term implies an inflammatory proc ess, the disease it is intended to represent is, in reality, but a manifestation of tuberculosis in the sheath. A nodular, more or less spindle-shaped swelling fol lowing the long axis of a tendon is formed, which contains, besides liquid, small bodies resembling rice or melon seeds; hence called "riziform" bodies. These are either buried in the sac-wall or float freely in its liquid, and are found to contain, upon microscopical examina tion, tubercle bacilli. The local disease may assume a fungous form, and not only destroy the tendon, but spread to neighboring tendons and joints. Tuber culous tenosynovitis usually develops near the wrist, and much less frequently in the tendons of the fingers, knee, and ankle. It gives rise to but little suffer ing, and, as a rule, interferes but slightly, if at all, with the functions of the af fected extremity until well advanced. Its progress is, as a rule, quite slow. It may, if the health of the patient is materially improved, disappear spontaneously, or become fungous after penetrating the superficial tissues, as does typical tuber cular abscess. It may occur as the com plication of a joint tuberculosis. The riziform bodies facilitate diagnosis by conveying to the finger exerting pressure upon the swelling a crepitation recalling the presence of gravel.
—The tendency to relapse which characterizes this disorder renders it imperative to thoroughly eliminate the local trouble and to treat the general dyscrasia as well. When the sac is purely cystic—i.e., devoid of fungoid vegeta tions—a small incision, followed by evacuation and the injection of a solu tion of iodoform in olive-oil or in ether, will often suffice. When riziform bodies
are present, however, more effective means are necessary, since they represent as many foci for tubercle bacilli. The sheath should be laid open and its in terior surface and the tendon thoroughly cleared with the curette. FUngoid vege tations still further complicate the case, and, unless every vestige be removed, in , eluding affected external tissues, sheath, and tendon, recurrence is sure to occur. Asepsis is of the greatest importance, general toxmmia occurring readily if proper precautions are not taken. The general treatment should include the ad ministration of creasote and other meas ures indicated in pulmonary tubercu losis.
Wounds and Injuries of Tendons.
-A tendon is sometimes displaced from its normal position by a violent motion in which its normal axis of traction is more or less departed from, the sheath being torn. Often it immedi ately returns to its normal position, but sometimes it does not, and local pain, with impairment of motion, result. The peroneus brevis probably shows the greatest predilection in this direction, and comparatively often slips out of its groove, being felt over the malleolus when the foot is flexed and extended. Displacement is most frequently ob served in connection with dislocations and fractures, and in the latter a tendon may insinuate itself between the frag ments, and thus prevent approximation and union.
Treatment.—By gentle manipulation with flexion or extension of the ex tremity, as required to reduce the tension upon the tendon, the latter can usually be restored to its normal position. Once displaced, a tendon is liable to again leave its bed. A suitable retentive dress ing and bandage should be so applied as to hold in situ until thorough repair of the torn sheath has occurred.
—Under the influence of a sudden effort the contraction of a muscle may exceed the resistance of the fibres of its tendon, and the latter gives way. The tendon of the rectos femoris above and below the patella, the tondo Achillis, the tendon of the triceps near the olec ranon, and that of the biceps near the forearm are those which are most ex posed to this accident. The rupture is usually complete, and a cavity may read ily be felt where before the tendon was continuous, the gap being increased by extension. When the knee is the seat of rupture, there is marked effusion in the joint, and the patella is drawn up ward: a deformity very readily noticed. There is a distinct snap when the rupt ure occurs, immediate loss of power in the limb, and sometimes severe pain.
Treatment. — Approximation of the ends by full extension of the limb, ap plication of retention bandages and splints, and immobilization of the limb at once suggest themselves. If these can be carried out satisfactorily, perfect union occurs at the end of two months, and, with a little care for a few weeks subsequently, perfect cure ensues. This happy result is not always met with, however, and in the majority of instances the tendon-ends cannot be held together by simple means, especially when the muscle draws the proximal end away to such a degree that traction has to be ex erted to bring its extremity down to the lower. In such a case, therefore, it is better to suture the ends. This is espe cially important when the traction is due to the action of large muscles, such as those of the calf or thigh. Under care ful antisepsis this can now be done with out the least danger, even at the knee. The incision should, if possible, be made to one side of the tendon, and not over it, to reduce chances of adhesion. Rupture of the tendo Achillis is some times managed with difficulty, or tends, if union is obtained, to cause pes equino varus. Poncet avoids this by cutting the edges of the tendon zigzag fashion to elongate it, as shown in the cut, or by Czerny's method, described below.