matter, show him that his brain is in direct connection with all parts of the body, and that, therefore, the highest degree of general health is the best guarantee of healthy brain function.

As for moral hygiene, one prone to brain disease, should so order his life, so far as he may, that stress and worry and feverish excitement may not be his daily portion. He should not enter on the mad race for riches, but having chosen a business that will bring him food and raiment, let him be therewith content. In view of the hereditary nature of his diathesis he should be advised not to marry. Such people are sometimes advised to marry into healthy families with the idea of diluting the evil and thus diminishing the chances of defective offspring. I never give such advice; it spoils good stock of which the world has all too little, and besides is manifestly unjust to the other contracting party. In his capacity of public advisor, in matters of public health, the General Practitioner finds his field of greatest usefulness in the management of insanity, and one in which he is accustomed to labor without fee or personal reward. All that tends to promote the general health of the people is prophylactic of insanity, and I need say nothing on that head, but I wish in conclusion to call your attention to a question in state medicine that is as yet sub judice, namely the regulation by law of the right of those suffering from, or strongly predisposed to hereditary disease, to contract marriages.

Lest I be thought chimerical in advocating this, I will say that I have been charged with holding fanatical views on the subject of state interference by my professional brethren, because I do not believe in forcible vaccination and was opposed to a medical practice act that goes further in the restriction of the practice of medicine than to deprive the unlicensed practitioner from collecting his fees by law. Notwithstanding my belief that the progress of the race is best promoted by leaving to individual effort the greatest possible liberty, I think it high time that some restraint be placed on the reckless propagation by criminals of their kind to prey on society, and the multiplication of the insane by marriage when all but an insignificant number of them sooner or later, become a public charge. We should be careful not to go too far in advance of public opinion in advocating such legislation, nor to bring too many subjects within its provisions.

Your President in his admirable address last night, called your attention to the enormous financial loss caused by the criminal classes. His adversion is timely and should set us to thinking, at least, on this subject. Other states have laws forbidding the marriage of the insane and of epileptics, and why should not Tennessee? The criticism that they are not general and that those forbidden to marry in one state can go into another, is not valid. Nothing can be effected unless a beginning is made, and if nothing more is done by the passage of such a law in Tennessee than to call attention to the evil it is intended to suppress, much will have been accomplished.

A PLEA FOR CONSERVATIVE SURGERY OF THE

HAND.*

BY PAUL F. EVE, M. D., OF NASHVILLE, TENN.

In presenting this subject I am fully aware that I have nothing new to bring before the Association; yet its great importance, the unneccessary amputations and the many deformities of the hand, have encouraged me to tax your patience for a short time.

When we view the immensity of space and see within it worlds upon worlds, held by the mysterious force of gravity, ever obeying the mandates of law and order, we are compelled to bow and own that He who made them, is an infinite being and one whom we worship as God. It seems to me that in all the creative power of God, there is nothing so marvelous or so intricate in mechanism as the humen hand; and I speak with all reverence when I say that infinite capacity was taxed almost to its utmost in making of the hand.

Man, who when created, was made a little lower than the angels, has imitated many of the mechanical creations of God, but when called upon to supply the deficiency of a hand, has utterly failed; his ingenuity by no means being adequate for the occasion. No wonder in the Divine Writing, we hear men

*Read at Annual Meeting of the Tennessee State Medical Association, April 15, 1904.

of old, moved by inspiration, exclaiming that the heavens are the handiwork of God; and as if to present the most wonderful of all creative parts to draw humanity to a better life, they are often heard to say, "The hand of the Lord is stretched out all the day long."

Early in my professional career, I was impressed with the wonderful mechanism of the hand, and as I dissected its various parts or supervised others in their dissection of it, I was lost in amazement and wonder at the intricacies and the combination of the various parts which enter into its formation as a whole.

Fully convinced of the importance of an adequate study of the anatomy of the hand and the useful part which it plays in obtaining daily bread for the sustenance, not only of our own body, but those dependent upon us, we should insist upon a much more careful diagnosis of the diseases and surgical affections, in order that the same might receive prompt attention, thus not only saving portions, but often the whole of the hand. It is not my purpose to enter minutely into the various diseases which lead up to surgical operations on the hand, as this paper would not only be too long but unnecessarily weary the patience of this Society; but I do desire, in as cursory manner as possible, to call attention to the more important conditions demanding

treatment.

Before proceeding further, it is well to call your notice to some of the anatomical peculiarities of the hand. "The muscles of the hand are subdivided into three groups: those of the thumb, which occupy the radial side and produce the thenar eminence; those of the little finger, which occupy the ulna side and give rise to hypothenar eminence; and lastly, those of the middle of the palm and within the interosseous spaces There are also two synovial membranes, which enclose all the tendons as they pass beneath the annular ligament. One for the flexor sublimis. and profundus digitorum; the other for the flexor longus pollicis. These extend into the fore-arm for about an inch above the anular ligament and then downward about one half way along the metacarpal bones where they terminate in a blind diverticulum around each pair of tendons with the exception of

that of the thumb and of the little finger. In these two digits, the diverticulum is continued on and communicating with the synovial sheath of the tendons of the fingers, the synovial sheath of the tendons begins as a blind pouch without communicating with the large synovial sac." I also desire to call attention to the deep palmar fascia which forms a common sheath investing the muscles of the hand. This fascia is divided into a central and two lateral portions; the central portion occupying the middie of the palm is triangular in shape and binds down the tendons, while it also protects the vessels and nerves. It is attached above to the lower margin of the annular ligament receiving the expanded tendon of the palmaris longus muscle, while below it expands and divides into four slits for the four fingers. The lateral portions of the palmar fascia are thin, covering on the radial side the muscle of the ball of the thumb and on the ulnar side the muscle of the little finger and is continuous with the dorsal fascia. It should also be remembered that not only has the the hand its own separate muscles, but it receives tendons from a number of the muscles of the fore-arm. All of these points must be carefully studied and taken into consideration as a guide for the proper management and treatment of these surgical affections.

The group of injuries resulting from rheumatism, gout, tuberculosis, and syphilis, and which are so frequently followed by either an acute or chronic synovitis or even an arthritis, call for prompt treatment that must be conducted upon rational principles, or they will lead not only to great deformities, but to a complete loss of the function of the hand.

The various means of diagnosis of these diseases are familiar, I therefore only propose to offer some suggestions in treatment. It is now an axiom with all surgeons, and I am glad to state this is being taught in medical colleges, viz., that the only adequate and proper means to carry out the great fundamental principles in the treatment of general inflammation of the hand is to enjoin rest with proper position, this being done by placing the hand upon a splint, thus preventing any movement. Every orthodox medical treatment should be fully tried before resource should be had to surgical interference. Long before

nature has thrown out its great signs or red light signals, as I am pleased to call them, informing the surgeon that great devastation has already begun, not only in the soft, but in the bony structures, viz., the establishment of fistulous openings, the contents of which are frequently gritty upon pressure between the fingers, treatment should be instituted so as to prevent great suppuration and loss of tissue.

In case of tubercular thecitis, the most heroic of all surgical methods should be adopted, especially when superative tenosynovitis involves the thumb or little finger. A free incision should be made in the suppurating area, the sheath of the tendon laid wide open and all the surfaces curetted. If this plan is not adopted, the surgeon will soon wake up to the realization that not only will the tendons become involved by adhesions, but the bony structures suffer themselves, and that the hope of saving the hand is very meager, and even if saved, will at best be a stiff and useless member.

In the treatment of the various wounds of the hand, every attention should be paid to thorough cleansing and drainage, and no wound should be thought too trivial to receive proper attention. For some of the most trivial wounds we have had the most disastrous results. If it should be a punctured wound, it calls for a thorough opening to the bottom, the wound then being packed until it heals from the deepest point. If the wound involves either the superficial or deep palmer arch, I do not believe it wise surgery simply to control the hemorrhage by a compress and bandage, as I have had under my observation not a few cases where aneurysms have resulted and where an operation was necessary for the relief of the blood tumor. I would therefore advise that an incision sufficiently large should be made for the ligation of the bleeding vessels and after these are secured the wound sutured. Too many cases of unsightly and deformed hands have resulted from burns for me not to call special atention to the treatment of such conditions. It is as I believe, a very erroneous impression among some members of our profession, that in the vast majority of burns we have a contraction of the tendons of the fingers, while the truth is, that in only a few cases and those of very deep burns, are these