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INFECTIONS OF THE HAND.! By W. H. OGILVIE, M.CH., F.R.C.S.

THE pathology and treatment of infections of the hand have now for some years been based upon the anatomical researches of KanaveI. Yet the textbooks available to students deal with this vital matter in the most inadequate manner, and it is still possible and usual for a man to qualify without knowing its essentials. I have taken as the subject of my lecture the more common infections of the han9,. For a full and interesting discussion on the subject, I would refer readers to the small book written by the late L. R. Fifield of the London Hospital.

ANATOMY.

The skin of the hand is fine and 'hairy on the dorsum, thick, hairless, and marked by characteristic papillary ridges and creases on the flexor aspect. The subcutaneous tissue on the palm is scanty, and subdivided by dense meshes of connective tissue in a manner similar to that of the scalp; it is absent at the flexion creases in the palm and fingers, and here the skin is practically in contact with the deep fascia and the theCal of the flexor tendons.

The skin and subcutaneous tissue over the terminal phalanx are modified in a special manner for a special purpose, and a knowledge of the anatomy of this phalanx is important in the surgery of infection (fig. 1).

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FIG. l.-Schematic longitudinal section of terminal phalanx.

The nail is a cutaneous organ developed for protection and aggression, chiefly against the smaller enemies of mankind. It is limited at the sides by a shallow groove, and above it is overhung by a semicircular fold of skin, the cuticle or paronychium. The root of the nail extends about i inch under the paronychium,and here the nail is formed by cornification

1 A Clinical Lecture delivered at Guy's Hospital. Published by ~ermission of the Medical World.

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262 Infections of the Hand

of the stratum lucidum of a specialized strip of epidermis. As the nail is formed it is pushed forwards, and appears on the surface, as yet unfinished; while cornification is incomplete, the nail is imperfecHy translucent, ,and this immature nail is the opaque area known as the moon. The nail grows at the rate of 1/32nd to 1/25th of an inch a week, and as it advances over the nail bed its thickness is added to from below. There is no subcutaneous tissue under the nail bed, the deeper layers of th~ dermis being continuous

FIG. 2.-Synovial sheaths and cellular tissue spaces in the hand. A, radial bursa. B, ulnar bursa. C, thenar space. D, middle palmar space.

with the periosteum. On the flexor aspect of the distal phalanx, the finger pad, the subcutaneous tiss'ue is very abundant, and is divided by a number of strong fibrous septa which radiate from the periosteum to the skin. The distal four-fifths is a closed space, containing loose fat, which therefore fluctuates. When an inflammatory exudation occurs in this space it cannot

. escape, and the tension rises rapidly, obstructing the blood-supply. The lymphatic vessels of the hand and arm tend, as elsewhere, to follow

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W. H .. Ogilvie 263

the veins. Thus the .lymph channels from the fingers pass backwards to join others running on the dorsum of the hand. The arrangement on the palni is peculiar, for all .the vessels are very fine, and they run .towards the nearest part of the periphery of the palm to reach the dorsum of the hand ; thus, the lower vessels run downwards, those in the middle towards the sides of. the palm, those above, towards the wrist. The lymphatics from the ulnar side of the hand end in the supratrochlear gland, whence fresh channels run to the glands along the axillary vein. The lymphatics from the radial side of the hand run directly to the axillary glands. A few vessels from the outer side of the hand and arm accompany the cephalic vein, and end in the infraclavicular glands.

The fibrous sheaths of the long. flexor tendons, the themB, extend from the base of the proximal to the base of the distal phalanges, being attached to the edge of theIr palmar surfaces. The sheaths are strong opposite the phalanges, weak opposite the joints, where they are closely related to the skin, and therefore exposed to injury. The theme of the fingers contain the flexor sublimis and profundus tendons, that of the thumb the flexor longus pollicis tendon. The synovial sheaths of the flexor tendons are disposed at the wrist in two sacs, the radial and ulnar bursffi (fig. 2). The radial bursa (A) contains the sheath of the flexor longus poIIicis only; ~t extends into the forearm about It inches' above the anterior anmilar ligament, and downwards to the insertion of the tendon in the distal phalanx of the thumb. The ulnar bursa (B) is a large cavity containing the flexor sublimis and profundus tendons and the median nerve. This synovial sac consists of a common cavity to the ulnar side of the tendons, whence three pouches open towards its radial side, one in front. of the tendons, one between the superficial and deep tendons, and one deep to the tendons. The ulnar bursa extends proximally It inches above the anterior annular ligament, and distaUy sends a prolongation along the tendons of the little finger as far as the terminal phalanx, but ends as regards the other three tendons at the middle of the palm, just proximal to the superficial arterial arch. The radial and ulnar bursffi communicate at the wrist in nearly fifty per cent of cases. The thecffi of the index middle and ring fingers are lined by synovial sheaths. which end PFoximallyopposite the necks of the metacarpals.

Deep to the flexor· tendons, and between the~e·andthe muscles which cover the metacarpus, are two cellular tissue spaces, known as the thenar space and the middle palmar space (figs. 2 and S). : These are only potential spaces, but, since they are liable to become infected by -various routes, a knowledge of their site and anatomical relatiolls is impor,tant. The .thenar space (fig. 2 c) is bounded behind by, the fascia. covering the adductor muscle~of the thumb, in front by the flexor tendons oUhe index and the first and second lumbricals and the thenar portion of .the palmar fascia, to the outer side bytbe flexor longus pollicistendon_ and the radial b.ursa, and to the inner side by a septum which divides it,from .the middle ,pal.l;llar

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264 Infections of the Hand

space, a sheet of connective tissue passing from the third metacarpal to the fascia behind the flexor .tendons (fig. 3). The middle palmar space (fig. 2 D) is bounded·behind by the fascia covering the interosseous muscles of the third and fourth interosseous spaces, in front by the long tendons to· the middle, ring and little fingers, to the inner side by the hypothenar muscles, and to. the outer side by theseptum lllen.tioned above (fig. 3). Distally, diverticulre pass from these spaces along the lumbrical muscles (fig. 2). There is a third connective tissue space in the same plane which belongs to the wrist and not the hand, the space of Parona, which lies between the pronator quadratus behind, and the long flexor tendons in front.

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FIG. 3.-Transverse section across metacarpal region of right hand to show the cellular tissue spaces.

INFEC'l'IONS OF THE HAND.

Lymphangitis.-Lymphangitis very commonly affects the harid because it is the organ of exploration and prehension, and is often pricked, scratched, or cut by septic objects. When such infections are acquired in the post­mortem room or the operating theatre, they are apt to be of a very virulent type and are not infrequently fatal.

In lymphangitis the site of the infection may be seen, or it may be too small to appear. The surrounding area is red,hot and swollen, and feels stiff and burning. The dorsum of the hand is oodematous. In the arm the lymphatic vessels are seen as red streaks, and the lymphatic glands to which they lead are enlarged and tender. When the infection has started in a finger, tenderness is diffuse, and not limited to one phalanx or to the line of the tendon sheath; movement of the finger within a moderate range does not increase the pain. In the hand the contour of the palm is not altered, the swelling being entirely On the dorsum. These observations enable us to distinguish a lymphangitis from an infection of the tendon sheaths or of the.tissuespaces of·. the hand, an important distinction when treatment is considered. .

Treatment of lymphangitis is never operative in the early stages. Rest is the first essential. The 'patient is put to bed, the hand splinted, and the

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W. H. Ogilvie 265

arm put ,in a sling. Hot fomentations or arm baths are applied frequently, and 20 to 50 cubic centimetres of polyvalent anti streptococcal serum are given subcutaneously, and given again if, necessary Dn subsequent days. In' a severe case 60 cubic centimetres of the serum,preferably 20 cubic centimetres of three different makes, may be given intravenously in a pint of saline solution. The local condition will subside and the general symptoms improve within forty-eight hours in ,the majority of cases. Abscesses may form at any part in th<il line of the lymphatic channels or in the glands, and require to be opened. Lymphangitis is said to be most dangerous when it starts on the outer side of tbe hand, because the infection may then travel directly to the axillary or even the sub- or supraclavicular glands without being arrested by intervening nodes.

Whitlows.-Infections of the fingers are commonly called whitlows, an'a of these four varieties are described: the subcuticular, the subcutaneous, the thecal and the subperiosteal (fig. 4). The first two are usually primary

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FIG. 4.

infections; the third and fourth varieties are rarely primary, but are due in most cases to extension from a subcutaneous whitlow.

Subcuticular whitlows are of two varieties :-(1) The purulent blister is a superficial infection that may follow any

trivial scratch, or may even arise where there is no visible injury. Pus accumulates under the cuticle, forming a rounded yellow swelling.

There is little pain and no constitutional symptoms. Treatment consists in snipping away the cuticle and applying antiseptic dressings. Should there be much pus or any swelling of the phalanx, a subcutaneous whitlow must be suspected, and the base of the blister examined for a small track leading to pus under the skin.

(2) Pa1·onychia.~This form of subcuticular whitlow is much more important, because of. itschronicity. The infection may enter through a fissure at the side oLthe nail, or be caused by a small injury in manicuring. It is a frequent cause of casualties among dressers; because daily scrubbing with strong antiseptics impairs the resistance of the skin, and. the entry of pathogenic organisms from septic dressings is rendered easy.

Paronychia in its early stages' is seen as a reddening and thickening of

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266 . Infections of the Hand

the fold at the edge or the base of the nail; when the fold is pressed,abead bf pus appears between it and the nail. At this stage a wisp of gauze soaked in eusol or hypertouic saline should be pushtld in between the thickened fold and the nail, and changed every few hours. If the handis rested and this treatment pursued energetically, the infection will usually subside in a few days; otherwise pus gets under the nail itself, where free drainage is impossible. Exuberant granulations form betweeIi the nail and its bed, and cure is much more difficult.

A B c FIG. 5.-Treatment of paronychia. A, incisions outlining flap. B, flap turned back. Incision across nail. C, proximal half of nail removed. Gauze strip under skin flap.

It is usually possible to determine, by pressing on the nail, whether infection has spread to the nail bed. If this has occurred the nail feels wobbly, and pressure produces considerable pain and causes a bead of pus to appear at the root of the naiL An anresthetic should now be given, and a band tied round the root of the finger to act as a tourniquet. Two paralld incisions are made upwards, starting at the sides of the nail and turning up the skin covering its base as a flap (fig. 5). The nail base is then inspected. If pus only extends under one side of the nail, that side is cut away. If, as in most cases, the whole nail base is undermined, the proximal half should be cut away, leaving the distal half as a protection, which will later be displaced by the growth of the new nail.

FIG. 6.--1ncision for subcutaneous whitlow.

A su&cutaneous whitlow is a cellulitis of the finger. It usually follows a prick and affects the pulp of the distal phalanx, which is red, hot,swollell and painful, throbbing with the pulse. The swelling is limited to the last joint, movements of the finger are not resented and there are no constitutional disturbances.

The terminal phalanx should always be opened by horseshoe-shaped incision, parallel to the nail, and just anterior to it (fig. 6). In mild cases

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only one side of the horseshoe need he incised .. This incision divides all the septa going from periosteum to skin, and therefore completely relieves the tension in the" closed space"; it passes behind the digital nerves; it cannot injure the tendon sheath or the periosteum, and it leaves a scar which is not on the site of pressure. '

A thecal whitlow is commonly a sequel of a pulp infection. The pus reaches the tendon sheath by direct extension, by lymphatic spread, or by infection with the point of the knife when the obsolete mid-line incision bas been employed to open a subcutaneous whitlow. The tendon sheaths may also be infected by the direct injury of a prick or scratch in the ftexion crease of the fingers, where they lie close to the skin; by direct extension' from a suppurative arthritis or in the palm from a tissue space abscess; or, rarely, by organisms carried by the blood-stream.

When a thecal whitlow is present, the patient looks and feels ill; his temperature and pulse are raised. 'rhe affected finger is swollen through­out i,ts length, and held in the semiflexed position; active movements are very limited, and can only be carried out in the direction of flexion. The finger feels hot and may be a little reddened. Passive extension, and pressure along the line of the flexor tendons as far as the metacarpo­phalangealjoint, cause extreme pain. If the tendon sheath of the thumb or little finger is involved, extension of the infection to the radial bursa is probable.

Infections of the ulnar bursa show, in addition to the symptoms and signs of a thecal whitlow of the little finger, pain and tenderness over the anatomical site of tbe bursa in the palm and wrist. There is a very slight loss of concavity in the inner half of the palm and a more obvious swelling above the anterior annular ligament. '1'he dorsum of the hand is oode­matous. Voluntary movement of the index, middle and ring fingers is limited, and passiv·e extension of these fingers causes pain, but to a less degree than in the case of the little finger. Infection of the radial bursa is shown by pain and tenderness over the palmar surface of the metacarpal bone of the thumb and the radial side of the wrist, with slight swelling of the thenar eminence; the other signs of whitlow, fixed ftexion, loss of voluntary movements, pain on passive extension, and tenderness OIl pressure along the' line of the fibrous sheath in front of the phalanges, are also present.

A thecal whitlow is one of the most serious emergencies that you may be required to treat in practice. Correct treatment undertaken immediately ~ill ensnre full restoration of function in a fair proportion of the cases; in the majority there will remain some adhesiolls of the tendons to their sheaths, so that the finger, though useful, has a limited range of movement. Delayed or faulty operation leaves at best a stiff, useless, and painful finger, which requires amputation later; more often it leads to wide infection of the sheaths and tissue spaces in the palm, so that the hand, after months of treatment and repeated drainage, remains a useless. claw; at worst, and

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268 infections of the, Hand

by no means infrequently, it is responsible for the amputation of the limb or the death of the patient.

An incision in the' mid-line of the palmar aspect of any part of any finger is evidence of the most gross and inexcusable incompetence on the part of the operator. The reasons why such an incision should never be made in the distal phalanx have already been given. In the proximal and middle phalanges, a mid-line incision also fails to relieve tension in the sub-

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FIG, 7.-Incisions for draining pnlp infections (shown on index finger), thecal whitlows, and abscesses of the synovial burSal.

cutaneous layers, and leaves, after healing, a scar which limits movements, and is exposed to pres.sure. When the theca is opened by such an incision the tendons dislocate forwards, and lie exposed on the surface of the wound so that they must slough.

All incisions in the fingers should therefore be lateral. In the terminal phalanx, such lateral incisions may take the form of a horseshoe surround­ing the pulp. In the other phalanges they may be made on either side, but an exposure oIi the ulnar side avoiding the lumbrical muscle' is preferable,

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except in the index, where an incision on the radial side has obvious advantages (fig. 7). The incision is just anterior to the digital nerve.

When dealing with a thecal whitlow a tourniquet should be applied before operation, since the degree of infection present and the amount of drainage necessary can only be estimated in a bloodless field. If the tendon sheath is seen to be distended, it is slit up along the side. In some cases of mild infection it may be sufficient to. open the theca along the phalanges only, leaving it intact opposite the joint; in the majority the whole length of the sheath should be incised. When the ulnar bursa is infected, the theca of the little finger should first be opened on the ulnar side; a probe is then passed from the tendon sheath into the bursa, and the latter opened widely to the ulnar side of the flexor tendons. When the radial bursa is involved, the theca of the flexor longus pollicis should first be opened by an incision along its ulnar side; and the incision prolonged over the ulnar side of the thenar eminence, laying open the bursa as far as the annular ligament, In operations for drainage of the ulnar and radial bursm, the deep branch of the ulnar and the muscular branch of the median nerve must. be avoided at the upper end of the incision.

In order to obtain good function after suppuration in the tendon sheaths, of the hand, it is essential that infection should be overcome before there is any destruction of tissue, and movements started before adhesions have formed. The exposure described provides the freest possible drainage, while the tendons remain in their sheaths and are protected from direct exposure by the anterior flap of skin, so that they do not slough. Drainage should be provided along the incision in the case of thecal infections, and into the retrotendinous pouch in the case of the ulnar bursa. ThIS may be obtained by laying a Carrell tube along the wound and approximating the skin over it by two or three loosely tied stitches, after which two-hourly irrigation is instituted; or by placing a drain of rubber dam in position and putting the hand in a hypertonic bath every four hours. As soon as the general symptoms subside and the wound begins to look clean, the drain should be removed and voluntary movements of the fingers started. Fomentations will be required for a few days, after which they may be replaced by eusol dressings.

A sub-periosteal whitlow is usually the result of interference with the blood-supply to the terminal phalanx, following an infection in the closed space; this necrosis rarely affects the base of the phalanx, because this receives its blood-supply from the artery before it enters the closed space. 'l'hecal whitlow and suppurative arthritis, which is itself usually secondary to a thecal whitlow, may lead to osteomyelitis of the phalanges.

Necrosis of the terminal phalanx should not occur if pulp infections are widely opened at an early stage by the horae shoe incision. Prolonged suppuration after drainage suggests bone· disease, and the diagnosis' is confirmed by the probe and X-ray. Usually all that is necessary is to .remove a loose seguestrum representing the diaphysis of the phalanx, the

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270 Infections oj the Hand

base and the joir;t being healthy. The final result of sequestrectomy is, however, apt to be unsatisfactory because the nail bed remains deformed, and disarticulation at the distal joint will be required after the sinus has healed. When a horseshoe incision has been employed, the palmarfia{) required to cover the end of the finger is healthy and unscarred.

TISSUE SPACE INFECTIONS.

'['he middle palmat· space may be infected directly by penetrating wounds of the palm, or indirectly, by extension from suppurating foci, especially from infected callosities over the metacarpal heads, and thecal whitlows of the middle and ring fingers. A collection of pus forming in the sub­cutaneous tissues under a callosity tends to pass backwards in the web between the digitations of the palmar fascia; a whitlow in the tendon sheath of the middle or ring fingers will ultimately rupture at the proximal closed end of the synovial pouch opposite the neck of the metacarpal; in each case infection reaches the middle palmar space along the l~mbrical muscle. These isolated infections of the space are, however, uncommon. In those lamentable cases where the whole hand has become involved, following del!1yed or unsound treatment of a localized lesion, the palmar spaces take part in the general suppuration.

Where there is an abscess in the middle palmar space, the constitutional symptoms are usually severe. Locally there is marked swelling of the· palm, whose normal concavity is converted to a moderate convexity. CEdema of the dorsum is also present.

Later, pus may track along the lumbrical muscles, and point in the webs between the middle, ring and little fingers. The characteristic points which serve to distinguish an infection of the middle palmar space from one of the ulnar bursa which it closely resembles are, that the bulging of the palm is much more marked and the swelling does not extend above the annular ligament, the pain and tenderness are less accurately localized, and the limitation of movements of the fingers is inconsiderable, while passive extension does not cause extreme paiu.

Drainage of the middle palmar space is attained by making a longitu­dinal incision in the interval between the middle and ring fingers, extending from the free edge of the web to the distal transverse crease in the palm (fig. 8 A). This incision is deepened till the lumbrical muscle is exposed. A pair of Spencer Wells forceps is pushed along the dorsal surface of the lumbrical into the palmar space .and opened widely; a glove drain is then inserted along its track.

The thenar space may be infected by punctured wounds, by extension from infected abrasions or subcutaneous whitlows on the thumb, or by rupture of a thecal whitlow in the index finger or an abscess in the radial bursa. Isolated infections of the thenar space are rather more commonly seen" than those of the middle space. In late cases infection may spread from one space to the other by rupture of the intervening septum.

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W •. H. Ogilvie 271

The clinical signs of an abscess in the, thenar space are unmiE1takable. Because of the thinness of the radial expansion of the palmar fascia, swelling of the thenar eminence is very marked, the ball of the thumb becoming globular,red and hot; the web shares in this rotundity. CEdema of the dorsum of the hand is only moderate. The movements of the thumb are little limited unless the radial bursa is also involved.

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FIG. S.~Incisions for draining the palmar spaces. A, middle palmar space. . B, alternative incision for middle palmar space. C, thenar spaqe.,

The thenar space is drained by an in{)isioil just anterior to, and, narallel with, the web between the thumb and the index (fig. 8 c). Where infection has followed a thecal whitlow' of the index. the incision along the radial side of that finger is contihued along the web. Spencer ,Wells forceps ar~ thrust inwardsalongthe anterior surface 'of the adductors, of the thumb till the pus is evacuated. The opening, should, be made large, and a glove drain placed in position.

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272

DISCUSSION 01" HAND INFECTIONS.

A knowledge of the anatomy of the tendon sheaths, sy novial bursre, ana tissue spaces in the hand is essential in order that their illfections lUay be diagnosed accurately and treated effectively. But tbese iufections are rarely primary. The most importallt of all primary lesions is a subcutaneous infection of the pulp of the terminal phalanx. 'rhecal and subperiosteal whitlows are, in the great majority of cases, secondary to sueh ,tn iufection; abscesses in the bursal sacs and tissne spaces are stiIllatel' sequeloo. Correct and energetic treatment, if it be applied ,,:hile infectiol1 18 limited to the terminal phalanx will, in most cases, save the finger; if tbe sheath is

FIG. 9.- Abou: Corree ... posit.ion for anky lo!'lis of the hand. Below: Mould ed plaster sp liut u.pphcd.

infected it will StLVe the hand, but will rarely restore the finger to full nse; when pus has reached the palm, the freest drainage scientifically carried out is n. desperate measu re which may prevellt infection of the bones and joints, but cannot avert sorno loss of CUlldioD.

'llhe neglected septic hand , no conditioll encountered too often evell to-day. defies anaton1ical analysis; synovial bursm and cOlluecLi ve tissue spaces are alike involved in a widespread ~uppLlration ill , .. !hiel! even the Larriers of these compartments have been transgressed. .Pus has found its way iuto all the spaces in the palm, and in the forearm has burst through the upper limits of the uUl'sm and spread widely in the spa-ce between the loug tendons and the deep muscles. R ere, all tha.t '\le call do is to drain the tissue spaces and bursal sacs in the palm; to make a

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W. H. Ogilvie 273

wide openirigfrom side to side above the wrist and behind the long tendons, avoiding the vessels and nerves ,; to lay rubber drains in tbese ,cavities, and to persevere with splinting and frequent baths. Recovery, if it comes, will be slow and complicated by infection of the bones and joints of the carpus and metacarpus. The final result will be a hand that has lost most of its use.

When dealing with such a hand, which will almost certainly'be stiff, it is important to realize that a small amount of movement maY'be very valuable in one position and almost valueless in another. Metacarpo­phalangeal joints with a range of movement of only 20° are useless when fully extended; if they are flexed to 45° the same amount of movement is most useful. At the inter-phalangeal joints, stiffness in either full extension or pronounced flexion is a serious handicap; if the stiff fingers are in a gradual curve, they can grasp large objects and be brought into opposition to the thumb. The optimum posi tion for ankylosis of the hand is therefore one with the wrist dorsi flexed 45°, the thumb in full opposition, the metacarpo-phalangeal joints flexed 45°, and the fingers bent in the arc of a circle of about three inches in diameter (fig. 9). In this position, even though the long flexor tendons have sloughed or are anchored in their sheaths and the joints are fixed by a fibrous ankylosis, the hand is not useless. It can hold large objects or pick up small ones, and can wield pen or brush.

, Shortly after the operation, while the drains are in position, and arm hatbs are being given every four hours, it is sufficient to keep the arm on a straight anterior splint with a ball of wool the size of a cricket ball lying in the hollow of the palm and fingers. As soon as less frequent dressings and diminished " discharge allow it, a more permanent splint should be applied. The best form of splint to maintain any desired posit.ion of the hand is one made of plaster of Paris for the individual case (fig. 10 D). ' Tbe hand is smeared with vaseline, and a freshly made slab of plaster is applied and smoothed into even contact with all its surfaces. As soon as the plaster has set, the slab is removed and the outline of the proposed splint drawn upon it with indelible ink pencil. If necessary, additional ribs of plaster bandage are applied on the surface of the slab away from the hand along the lines of stress, where the splint requires reinforcement. It is then trimmed to the marked lines with a sharp knife and set aside. When dry, the surface next to the hand is covered with a layer of lint fixed with flour paste. If soiling is anticipated, or permanence desired, the splint may be painted with white cellulose paint before the lint is applied. I have had splints so prepared in daily use for more than a year.

The most difficult cases of all to treat are those in which the fingers and thumb have been allowed to become stiff in a straight position. I must therefore warn you -against two splints. The first is sometimes known as the long cock-up splint, an atrocious piece of apparatus· shaped like a tennis racket (fig. 10 A). There is only one occasion in surgery when this

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274 Infections of the Rand

splint may legitimately he used, that is, for the first fortnight after an operation for transplantation of the llexors of the wrist into the extensors of the wrist and fingers. For all otber purpOseS it is thoroughly vicious and cannot be t.oo strongly condemned. fi'be second is an ordinary fitraight splint applied from the elbow to tbe tips of tbe fingers. The board-like

A H c D

FIG. 1O.-A, the cock_up a.trocity. B [l,ud C, C()rtceL Iorms ()f cuck-up. 13 is fo r eith,w hn.nd; C is for the ri ght. haud, !loud aUowR fnll oppo!'.iLion of tbtl LhuUlh. n, monlded plaster lOplillt to holtllmud iu con'ed po~ition for ankylof..ifl.

bands which result from the use of those two splints were Jamilia, objects in the plaster rooms of the military ortbop::edic hospitals at the end of the war. 'l'be dangers of tbe first can be ",voided by destroying all such splints wherever they Rl'e found; the second danger is not 80 easily over~ome, for it is the m18applicat.ion of a splint which has its legiLimute uses.

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