WOUNDS OF THE HAND. 
BY 
GEORGE W. SPENCER, M. D., 
Demonstrator of Surgery, Jefferson Medical College, 
Philadelphia. 
REPRINTED FROM THE 
Neto York fUetncal .Journal 
/or August 7, 1897. Reprinted from the Neu York Medical Journal 
for August 7. 1897. 
WOUNDS OF THE HAND. 
By GEORGE W. SPENCER, M. D., 
DEMONSTRATOR OF SURGERY, JEFFERSON MEDICAL COLLEGE. 
PHILADELPHIA. 
For several years past my attention has been par- 
ticularly called to wounds of the hand. When we con- 
sider how extremely common these wounds are, and that 
they occur principally in the laboring class, whose daily 
bread largely depends on the usefulness of their hands, 
we arrive at a just estimate of the importance of such 
accidents. Too much can not be said in regard to the 
necessity for the early recognition and radical treatment 
in an injury of this region. I have had under my care 
patients that have been treated daily in the surgical dis- 
pensary for weeks and months, suffering from the effects 
of a palmar abscess. Palmar abscess is apt to produce 
disastrous results. Suppurative teno-synovitis arising 
from wounds of the fingers and palm leads in some 
instances to palmar abscess, agglutination of the flexor 
tendons, and suppurative cellulitis of the forearm. The 
following cases are typical of these conditions: 
Case I.-In November, 1892, a Jewess came to the 
Jefferson Hospital complaining of severe pain in the 
Copyright, 1897, by D. Appleton and Company. 2 
WOUNDS OF THE HAND. 
little finger and palm of the left hand. She said one 
week previously she had been pricked in the little finger 
by a splinter. When she was admitted, the finger was of 
almost twice its normal size, was hot and red, the palm 
somewhat elevated, and the pain was severe. A diagnosis 
was made of pyogenic infection of the finger followed by 
a palmar abscess. She was told of her danger, was advised 
to go home and bring a relative or friend, and at once be 
anaesthetized and have the abscess opened. Instead of 
coming back that day, as requested, she did not return 
until the afternoon of the next day, when I discovered 
just above the annular ligament a swelling of the size of 
an English walnut. The lower fourth of the forearm was 
red, swollen, and (edematous, and the axillary glands 
were beginning to enlarge. This case not only demon- 
strates the danger of a punctured wound of the little 
finger, however small it may be, but also shows the 
progress infection is capable of making in a short time, 
and the necessity for the earliest possible interference. 
She was anaesthetized, and at once an incision half an 
inch in length was made to the bone, in the long axis of 
the little finger. The palmar abscess was opened over 
the deep palmar arch by Hilton's method, a counter open- 
ing was made just above the wrist, and a piece of iodo- 
form gauze was passed from this opening into the palmar 
incision. After soaking the hand in a bichloride solution 
(1 to 1,000) for five minutes, the incision in the finger 
was swabbed with pure carbolic acid and the hand was 
dressed with wet bichloride dressings. The area of cellu- 
litis of the forearm was painted with iodine and alcohol, 
equal parts, and covered with lint saturated with lead 
water and laudanum. An internal angular splint im- 
mobilized the arm and hand. The girl made a rapid and 
good recovery, and went to work in two weeks with a 
good hand. 
Case II.-In June, 1894, an employee on the Balti- 
more and Ohio Bailroad presented himself at the dis- 
pensary with a palmar abscess and cellulitis of the fore- 
arm, caused by a slight contusion of the palm. He WOUNDS OF THE HAND. 
3 
was advised by his family physician to put on a flaxseed 
poultice and wait for the abscess to point. He waited for 
four nights. During the fourth night he became frantic 
with pain, plunged the blade of his pocket knife into the 
palm, and let out the pus. This man was prevented from 
performing his daily work for three months, and still 
has stiffness of the flexors. 
Case III.-In May, 1894, a seamstress was admitted 
to the dispensary with a broken needle lodged in the 
palm near the thenar eminence. Dr. M. H. Williams, of 
the department, made an incision and extracted the piece 
of rusty needle, which had been there for five days. 
An ounce of green pus escaped which had been con- 
cealed by the tense, unyielding palmar fascia. No sign of 
pus existed except pulsatile pain, and there was hardly 
enough swelling to be noticeable. This was one of the 
worst abscesses that any of us had seen; still there was 
only one sign, and that was pulsatile pain. This patient 
was prevented from doing her daily work for ten weeks, 
and her arm was saved with great difficulty. 
Case IV.-In February, 1895, A. B., aged sixty-four 
years, shoemaker by occupation, applied at the dispensary, 
and stated that in 1864 he had received a lacerated wound 
on the posterior surface of his hand just below the annu- 
lar ligament of the wrist joint. For thirty years this 
wound was continually dressed with flaxseed poultices and 
salves, and as a result he was found to have lost all power 
of flexing the hand. The flexor tendons had sloughed 
away. He carried with him a two-ounce bottle half full 
of the sloughed tendons, the pieces varying in length from 
an eighth to half an inch. This man has a permanently 
useless hand. 
Case V.-L. S. was placed under my care by Dr. 
Erwin, August, 1896. The patient stated that a month 
before his appearance at the hospital he noticed that 
his index finger began to swell and pain him. He con- 
sulted a barber, who advised him to apply pitch. After a 
month of the pitch treatment it was found that the tis- 
sues as well as the bones of the finger had undergone ne- 4 
WOUNDS OF THE HAND. 
crosis, and nothing short of an amputation would do any 
good (see Photograph No. 1). 
Photograph No. 1. Case V 
Case VI.-In August, 1896, W. J., carpenter, ap- 
peared at the dispensary and stated that while at his work 
he struck the middle finger of his right hand against a 
Photograph No. 2, Case VI, palmar surface. 
board. That night the finger began to pain and swell. 
Three days after the traumatism he consulted an old 
army surgeon, who advised him to put on slippery-elm WOUNDS OF THE HAND. 
5 
poultices, which he did for one week. At the expira- 
tion of that time the finger felt as though it was getting 
worse, so he consulted him a second time, when the doc- 
tor told him to discontinue the slippery-elm poultice and 
try a flaxseed poultice. After five visits and three weeks 
of poulticing he came to the dispensary. When admitted 
he had symptoms of septic infection. The tissues on 
the palmar surface of the middle finger had sloughed 
and were discharging pus. The finger measured six 
inches in circumference at the middle of the middle pha- 
lanx. The palm was tense, swollen, and painful. Photo- 
Photograph No. 3, Case VI, dorsal surface. 
graphs 2 and 3, which were taken five days after the 
operation, show the condition of the dorsal and palmar 
surfaces. He was anaesthetized, and multiple incisions 
were made on the dorsal and palmar surfaces of the 
linger and hand in the direction of the tendons down 
to the bones. The necrosed tissue was removed and the 
hand soaked in bichloride-of-mercury solution (1 to 500). 
The incisions were swabbed with pure carbolic acid, and a 
large tube was passed from the palmar to the dorsal 
surface, between the third and fourth metacarpal bones. 
Iodoform was dusted on, and the hand was dressed with 6 
WOUNDS OF THE HAND. 
hot antiseptic fomentations and placed on a splint. The 
constitutional symptoms were treated by a saline purge, 
light diet, two milk punches a day, quinine sulphate, 
five grains three times a day, and tincture of chloride of 
iron, fifteen diops three times a day. 
This patient, after being treated for three weeks, dis- 
continued his visits. When last seen his hand was in good 
condition. This hand, and particularly the finger, looked 
hopeless. Through the courtesy of Professor Brinton I 
operated on a similar case last winter before the clinic 
at the Jefferson Hospital that made a good recovery, 
and now has a useful hand. 
Case VII.-In April, 1895, J. A., a blacksmith by 
trade, while at his work received a small punctured 
wound of his little finger. He paid no attention to it and 
went on with his work. At the expiration of three days he 
had a suppurative teno-synovitis, a palmar abscess, and 
beginning lymphangeitis of the forearm. The abscess was 
opened by Hilton's method; a counter opening was made 
above the wrist, and connected with the palmar inci- 
sion. The hand was soaked in a hot bichloride solu- 
tion (1 to 1,000), and drained with iodoform gauze 
passed from the counter opening into the palmar incision. 
The hand was dressed with a hot antiseptic fomenta- 
tion, covered with a rubber dam, and placed upon a 
splint. This man made a rapid recovery with no im- 
pairment to the use of his hand. 
Case VIII.-In May, 1896, M. M., a woman, applied 
to the dispensary for the treatment of a sinus which fol- 
lowed an amputation at the middle third of the arm. 
She said that six months previously she had been pricked 
in the thumb by a splinter; this was followed by intense 
pain in the thumb, and to ease it she put on a poultice. 
Three days later swelling appeared in the palm, and 
was opened, but in spite of the treatment the infection 
extended up the arm and her doctor amputated at the 
middle third to save her life (see Photograph No. 4). WOUNDS OF THE HAND. 
7 
Photograph No. -1, Case VIII. 
If one considers the anatomy of the hand, it becomes 
evident that by the arrangement of the two lateral por- 
tions of the palmar fascia wounds of the little finger and 
thumb must be more dangerous than wounds of the 
other fingers. The palmar fascia is a common sheath 
which invests all the muscles of the hand. It consists of 
a central and two lateral portions. The central portion 
is triangular in shape; the apex above is attached to the 
annular ligament. The base is expanded, and opposite 8 
WOUNDS OF THE HAND. 
the heads of the metacarpal bones divides into four slips 
for the four fingers. Each slip divides into two pro- 
cesses, which inclose the tendons of the flexor muscles. 
The tendons with their sheaths and with their slips are 
attached laterally to the fibrous structures on either 
side of the metacarpo-phalangeal joints. Opposite the 
heads of the metacarpal bones there are numerous strong 
transverse bands which bind the tendons down and at 
the same time hold down the integument, thus serving 
to cut off the communication of the three middle fin- 
gers with the palm. This is why thecitis in these three 
fingers is generally arrested at the level of the web. In 
considering the anatomical relations of the two lateral 
portions of this fascia we have a different state of affairs. 
These lateral portions are composed of thin fibrous lay- 
ers, one going to cover the muscles of the little finger, the 
other going to cover the muscles of the thumb. These 
layers practically form drainage-tubes, and are con- 
tinuous with the palmar and dorsal fascia. There are 
no transverse bands as in the three middle fingers. By 
this one can see how easily infection may spread from 
either the thumb or little finger to the dorsal or palmar 
surface of the hand by the path of least resistance, and 
how when once present this hidden enemy will cause 
widespread disaster if not immediately removed. The 
diagnosis of this trouble is comparatively easy. There 
will be a wound on the finger or palm, which may be fol- 
lowed by teno-synovitis; if so, there will be pain and 
tenderness, with distinct moist crepitus along the tendon 
sheaths, due to inflammatory roughening. This crepitus 
will increase as the inflammation decreases, and will 
decrease as the inflammation increases, because se- 
vere inflammation means copious fluid effusion. If it WOUNDS OF THE HAND. 
9 
is suppurative, and the lesion is of any of the three 
middle fingers, there will be pulsatile pain, swelling, and 
dusky discoloration extending to the lower part of the 
web, and if of some duration there may be rupture of 
the integument. If the traumatism is of the thumb or 
little finger, there will be the same symptoms, but rup- 
ture of the integument is rare. There will be intense 
pulsatile pain in the palm, slight swelling (palmar ab- 
scess), and constitutional disturbance. Do not depend 
upon fluctuation, discoloration, or great tumefaction, as 
these symptoms are often absent. If this condition is 
not immediately relieved, the pus will dissect the struc- 
ture of the palm, and may reach the dorsum, but most 
probably will work its way beneath the anterior annular 
ligament of the wrist into the connective tissue of the 
forearm, and will then spread like wildfire, and a burn- 
ing sensation, pulsatile pain, swelling, dusky discolora- 
tion, and oedema will be prominent. If with this you 
find small hard, red streaks running up the arm, with 
enlargement of the associated lymph glands, you may 
be confident that you are dealing with beginning con- 
stitutional sepsis, and, if not acted upon by this time, 
the patient is liable to lose his arm or life, and it may be 
both. The very best prognosis will often be that of a 
useless arm. 
Treatment of Contusions.-Contusion of the hand is 
best treated as follows: First clean with soap and water, 
then rub well with soap liniment; if the skin is not 
broken, apply a number of small pieces of lint saturated 
with lead water and laudanum. If there are abrasions, 
wash them with bichloride of mercury (1 to 1,000), 
cover with wet bichloride gauze, over which put a rubber 
dam. The dam will not only keep the exposed surface 10 
WOUNDS OF THE HAND. 
aseptic, but will prevent the absorption of the lead water 
and laudanum, which must be put on lint and applied 
after the exposed surfaces have been protected. The 
hand must be supported on a well-padded palmar splint, 
with plenty of cotton under the palm, and must be held 
in place by a firm but not too tightly applied bandage, 
beginning at the finger tips and extending to the elbow. 
Bandaging of the fingers is necessary to prevent swelling. 
Under this treatment any ordinary contusion will mod- 
erate in a short time; but if it persists, multiple punc- 
tures are employed to relieve the congestion, the wounds 
are dressed with acetanilide, and an antiseptic fomenta- 
tion is applied. This is made by wringing out gauze in 
a hot l-to-1,000 solution of bichloride of mercury and 
placing on while hot, covering with rubber dam, and 
changing often. If the condition assumes a chronic 
form, with stiffness of the flexors, thickening of the tis- 
sues, and pain on motion, employ hot- and cold-water 
douches night and morning, the water being poured 
from a distance of three feet, and between the douches use 
fifteen grains of an ointment composed of two drachms 
of ichthyol and half an ounce of lanolin. Apply this 
ointment twice daily. If the contusion is severe, put the 
patient to bed and immobolize the arm as well as the fore- 
arm and hand by applying an internal angular splint. 
After a contusion watch closely for such sequelae as 
sloughing, periostitis, bone necrosis, palmar abscess, 
and gangrene. If a slough forms, promote the separa- 
tion of the necrosed tissue, and encourage the vitality 
of the tissues whose recovery is possible by hot fomenta- 
tions. When the sloughs are well removed, dress with 
acetanilide and iodoform (equal parts), and suppress ex- 
uberant granulations by removing them with scissors WOUNDS OF THE HAND. 
11 
or by applying nitrate of silver. If there are heat and 
pulsatile pain at the end of a finger, and the pain is in- 
creased by motion of the finger, a deep felon should be 
suspected, and an incision should be made at once to the 
bone, followed by washing out with bichloride, pack- 
ing in a small piece of iodoform gauze, applying hot 
antiseptic fomentations, and putting the finger on a 
splint. The incision should run in the long axis of the 
finger and by the side of the tendon. Osteitis or peri- 
ostitis will be manifested by severe pain, boring or aching 
in character, deep-seated, and worse at night. Good re- 
sults can be obtained by applications of lead water and 
laudanum or inunctions of ichthyol, and rest on a splint. 
If these means fail, apply equal parts of alcohol and 
iodine, and cover the part with lint containing a thick 
layer of unguentum hydrargyri. In severe cases, incis- 
ing the periosteum to relieve the tension gives good re- 
sults. If the probe elicits evidence of necrosed bone, 
open, remove the detached fragments, curette, scour 
with gauze dipped in hot bichloride solution (1 to 1,000), 
swab with pure carbolic acid, and dress as usual. Se- 
vere pain in the palm should make us suspect a palmar 
abscess. Do not wait for the cardinal signs of an ab- 
scess. The integument is thick, and, as it has between 
it and the pus the tense fascia, it will not in the majority 
of cases become discolored. The dense fascia prevents 
much swelling, and fluctuation does not occur until the 
abscess is very large. Never treat such a condition with 
a poultice; open as quickly as possible, irrigate with 
bichloride (1 to 1,000), pack in a small piece of iodo- 
form gauze, put on hot antiseptic fomentations, cover 
with wax paper or rubber dam, and put the hand on a 
splint. In many cases considerable damage has taken 12 
WOUNDS OF THE HAND. 
place before the surgeon sees the case. There may be 
an accumulation of pus, which has formed in the palm, 
traveled up the arm, causing pain, oedema, and discolora- 
tion above the annular ligament, with cellulitis of the 
lower fourth of the forearm and constitution! symp- 
toms. The patient, after being told of the impending 
danger, should be anaesthetized, and the pus evacuated 
by a free opening. An incision running toward the tips 
of the fingers, beginning at a point below a transverse 
line from the web of the thumb across the palm, will 
clear the palmar arches and do little or no harm to the 
tendons and blood-vessels. This incision just penetrates 
the palmar fascia. Through this incision introduce a 
blunt forceps, and force it gently in several directions, re- 
tracting with the blades open (Hilton's method). The 
blunt points will affect a good opening and push aside 
important structures without damaging them. A coun- 
ter opening above the wrist should be made and con- 
nected with the palmar incision. Irrigate from above 
downward with bichloride (1 to 1,000), and drain with 
iodoform gauze passed from the counter openings into 
the palmar incision. Paint the forearm with alcohol 
and tincture of iodine, equal parts, cover it above the 
wound with lint saturated with lead water and laudanum, 
and keep moist. Dress the entire hand with a hot anti- 
septic fomentation. Provide rest to the part by placing 
it upon a well-padded splint. 
The constitutional symptoms should be treated by rest 
in bed, light diet, a saline purge, free stimulation, five 
grains of quinine a day. and fifteen drops of the tinc- 
ture of chloride of iron three times a day. If from 
loss of tissues or gangrene an amputation be demand- 
ed, spare as much as possible, particularly of the index fin- WOUNDS OF THE HAND. 
13 
ger and thumb. If it is necessary to amputate above the 
middle of the middle phalanx, the flexor tendon must be 
anchored to the periosteum, otherwise the extensor tendon 
will pull the stump directly backward. After an amputa- 
tion of a finger the fibrous tendon sheath known as the 
theca must be closed to prevent the transmission of infec- 
tion. This is best effected by pushing back the perios- 
teum for a distance of an eighth of an inch and passing 
catgut sutures vertically through the theca and the peri- 
osteum. In a workingman avoid, if possible, cutting 
off the head of a metacarpal bone, as it weakens the hand. 
Sew the flaps with few stitiches, so as to allow drainage 
between them. Most of the bad results so often seen 
following amputation of the fingers are due to the non- 
closure of the theca and an excessive number of stitches 
in the flaps. 
Incised Wounds.-Incised wounds are the most com- 
mon but the least dangerous injuries, as the free bleeding 
washes out most of the infectious material. Union by 
first intention should be sought for; in the majority of 
cases this can be accomplished by thoroughly scrubbing 
the parts with soap and water, following with the free 
use of bichloride (1 to 500), and follow this by luke- 
warm boiled water, dusting with acentanilide, sewing with 
as few stitches as possible, dressing with bichloride gauze 
(moist), covering with rubber dam, and putting the hand 
on a splint. Not a few of these cases are complicated by 
severing of the tendons and a severe haemorrhage. If the 
tendons be cut, make the part bloodless, approximate 
tbe ends, and sew them with a curved needle threaded 
with fine silk. Photographs 5 and 6 show extension 
and flexion of the same hand, which followed suturing 
the flexor tendon of the little finger; this tendon was 14 
WOUNDS OF THE HAND. 
divided in an accident and was sutured by Dr. J 
Chalmers Da Costa. 
Photograph No. 5. 
If the wound is not very recent, and the tendons arc 
contracted to such a degree that it is found impossible 
to bring the ends together, then resort to Czerny's meth- 
od of tendon lengthening. If the gap can not be satisfac- 
torily filled by a portion of the divided tendon, bridge 
over with catgut or graft in a tendon from the lower 
animals. If a flexor tendon of the wrist is cut, it is with 
difficulty that the proximate end is isolated, owing to its 
retraction. This can be accomplished in some cases by 
flexing the finger of the cut tendon and extending the 
rest (Manual of the Modern Surgery, J. Chalmers Da 
Costa). If only one end can be found, stitch it with 
fine silk to the nearest tendon of like anatomical func- 
tion. After suturing tendons, dress with gauze and 
apply plaster of Paris. The finger of the cut tendon WOUNDS OF THE HAND. 
15 
should be partly flexed, the others extended. Passive 
motion should be begun after two weeks. 
Photograph No. 6. 
Lacerated Wounds.-Lacerated wounds require a 
thorough scrubbing with Johnson's ethereal soap, fol- 
lowed by immersing the hand into bichloride (1 to 1,000), 
and scrubbing with a brush while the hand of the patient 
is in the solution. Suture the tendons, ligate the bleed- 
ing vessels, and with a pair of scissors trim the edges and 
treat the case as an incised wound, immobilizing on a 
splint if the wound is slight, but confining the patient 
to bed if the wound is severe. 
Punctured Wounds.-Punctured wounds are the most 
dangerous, since infection is almost inevitable. They 
should be incised to the very bottom the moment they are 
seen. Foreign bodies should be removed, free bleeding 
encouraged, and the wound should be syringed out with 
peroxide of hydrogen, followed by bichloride (1 to 500), 
then dusted with acetanilide, and drained with iodo- 16 
WOUNDS OF THE HAND. 
form gauze. If the wound is inflamed, accompanied by 
a cellulitis of the adjacent parts and lymphangeitis of 
the forearm, it should be opened, curetted, swabbed out 
with pure carbolic acid, and drained with iodoform gauze. 
The cellulitis should be treated with alcohol and iodine, 
equal parts, applied locally, and covered by lint satu- 
rated with lead water and laudanum. If there is no re- 
sponse to this treatment, multiple incisions should be 
made. 
Hcemorrhage.-Contused, lacerated, and punctured 
wounds are accompanied by very little haemorrhage, un- 
less the palmar arches have been severed. Incised 
wounds bleed freely. Bleeding from the digital vessels 
can be controlled by a dressing held in place by a firm 
bandage extending from the tips of the fingers to the 
web and ending by a figure eight of the wrist' and root 
of the finger. The interosseous arteries should be ligated 
when they bleed. If necessary, enlarge the primary in- 
cision; a small semicurved needle, threaded with moder- 
ately fine catgut, should be passed above and below the 
bleeding point and the ligature tied. In the majority 
of cases this will arrest the haemorrhage; if it does not. 
then try hot water, 120° to 130° F., followed imme- 
diately by a graduated compress of iodoform gauze, 
over which place a small pad; put a gauntlet on the hand 
and bind firmly to a well-padded palmar splint. The 
ends of the fingers should be exposed to ascertain the 
condition of the circulation. The dressings should be 
changed and the packing removed at the end of three 
days, when the splint may be omitted, unless the original 
traumatism counterindicates it. Haemorrhage from the 
palmar arches is troublesome and dangerous. Under no 
circumstances should styptics be applied to check the WOUNDS OF THE HAND. 
17 
bleeding. Professor Keen reports a case, in the Annals 
of Anatomy and Surgery, Brooklyn, 1888, vol. v, in which 
an aneurysm of the superficial arch, of the size of a 
cherry, formed, following a traumatism. The physician 
in charge injected ten drops of undiluted Monsel's solu- 
tion into the sac. As soon as this was injected the whole 
hand became blanched, and soon well-marked gangrene 
followed. It was necessary to amputate above the wrist. 
In the Philadelphia Medical Times, September 10, 
1881, p. 795, is related a case in which a few drops 
of nitrate of silver injected into a naevus caused gangrene 
of two fingers. The same styptics applied to open wounds 
of the arch might produce the same results. If the blood 
is bright red, and comes out in jets in the vicinity of a 
transverse line running across the palm from the root of 
the thumb while hyperextended, haemorrhage from the 
superficial arch should be suspected. An Esmarch elastic- 
bandage or something equivalent should be applied to 
allow a dry dissection. The primary wound is then to be 
enlarged, and on a line with the arch the divided ends 
are found and are to be tied with silk ligatures. A blunt- 
pointed instrument should be used in the dissection to 
avoid injuring the divisions of the median and ulnar 
nerves which lie beneath the arch. The deep palmar 
arch when divided bleeds profusely. The divided ends 
should be sought for even by an extensive dissection, if 
necessary, before ligating the radial and ulnar arteries. 
The Esmarch bandage will be of great assistance. A 
good method for gaining access to the arch is to make a 
skin flap with its convexity downward, starting over the 
middle of the shaft of the metacarpal bone of the thumb, 
running downward and inward, keeping a quarter of an 
inch above the line of the superficial arch and ending on 18 
WOUNDS OF THE HAND. 
the ulnar side of the hand an inch below the pisiform 
bone. This will also give access to the superficial arch. 
Dissect this flap upward for an inch and a half and ample 
room will be afforded to work with a blunt instrument. 
The tendons should be drawn to the sides by small blunt 
retractors. If the original injury has not opened widely 
the palmar fascia, this should be done by a blunt pair of 
scissors and the margins drawn to each side. An assistant 
now relaxes the Esmarch bandage and by the bleeding 
the exact site of the vessels may be seen. Both ends of the 
arch should be ligated with silk. J. Chalmers Da Costa 
has suggested that the arch might be ligated readily by 
the incision that Mynter employs in resecting the wrist, 
that is, an incision separating the metacarpal bones and 
the bones of the carpus. If this does not control the 
haemorrhage the ulnar and radial arteries must be ligated 
in the lower third of the forearm. It may in rare cases, 
especially in secondary haemorrhage, be necessary to 
ligate the brachial just above the bend of the elbow 
or to amputate above the wrist. In 1893 Professor Brin- 
ton had under his care at the Jefferson Hospital a patient 
who received a lacerated wound of the palm and a lacera- 
tion of the deep palmar arch. The graduated compress 
failed to restrain the haemorrhage. Ligation of the radial 
and ulnar arteries failed. Ligation of the brachial artery 
at the bend of the elbow failed. Amputation of the hand 
was necessary. 
The photographs used in this article were taken by 
Dr. T. G. Buchanon. 
No. 1838 Christian Street.