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Fritz De Quervain, MD (1868-1940): Stenosing Tendovaginitis at the Radial Styloid Process

December 17, 2004

Fritz de Quervain was the first surgeon to describe and treat chronic stenosing tendovaginitis at the radial styloid process. The current management of this condition differs little from his initial description and as a result the condition now bears his name. He and his mentor, Nobel Prize winner Theodor Kocher, advanced the understanding and treatment of thyroid disease, especially subacute nonsuppurative thyroiditis, another condition to which his name is attached. He was a pioneer of surgical technology and author of books and articles read worldwide and is largely responsible for the introduction of iodized table salt. (J Hand Surg 2004;29A:11 64-11 70. Copyright 2004 by the American Society for Surgery of the Hand.)

Key words: Fritz de Quervain, stenosing tendovaginitis, hand surgery.

de Quervain’s stenosing tendovaginitis is a condition that is well known to all hand surgeons but most may not he familiar with the important Swiss surgical figure himself, whose academic accomplishments influenced many generations of surgeons. Fritz de Quervain was a prominent ligure in his time. He was Nobel Prize- winning Theodor Kocher’s first assistant of surgery and he later succeeded Kocher as Chief of the University Surgery Clinic in Bern, Switzerland.

The only publication by de Quervain available in English is a translation of his original ( 1895) work on stenosing tendovaginitis entitled On a Form of Chronic Tendovaginitis1 and there is very little historical information regarding the Swiss surgeon. Consequently we translated several German and French publications2- 6 that detail the life of this innovative surgeon. We also obtained documents from his grandson-in-law, Dr. Ulrich Trhler, Professor of Medical History at the University of Freiburg, to gain a more personal, original perspective on Dr. de Quervain.

The Early Years (1868-1887)

On May 4, 1868 Johann Friedrich de Quervain (who would later call himself Fritz) was born in the Swiss town of Sion in the Valais Canton to Johann Friedrich de Quervain, a pastor, and his wife Anna, daughter of Charles F. Girard, professor of French literature at the University of Basel.^ He was of Huguenot descent, related distantly to a Protestant lord, Jean de Juzd, who owned a piece of land called Kervain in England. In 1683, fearing persecution for his Protestant beliefs de Juzd liquidated his assets and relocated to Switzerland where his descendents, the de Quervains, became part of the bourgeoisie/

The de Quervain family was very large: Fritz had 4 brothers and 5 sisters, many of whom became notable in their own right. For example, his brother Alfred was a professor at the University of Zurich and vice-director of the Central Institute of Meteorology and led 2 expeditions into Greenland. His brother Theophil was a minister and a writer who wrote biographies of famous personalities such as James Garfield, Abraham Lincoln, and General Alfred Girard (his uncle, who immigrated to the United States and became ultimately chief of the military health service). It is to this large family structure that Fritz de Quervain’s traits of consideration, compassion, and unselfishness are generally attributed.2

de Quervain attended the Lerber School in Bern and in the spring of 1887 he passed an entrance examination to begin his medical studies at the University of Bern. According to his brother Theophil he could have been a competent professor of old and new languages or an engineer.2 His decision to go into medicine was influenced by a family history of pursuing medical careers. His maternal great- grandfather had been a doctor,2 as had his mother’s brotherGeneral Alfred Girard-to whom he was very attached.3

Medical School and Residency (1888-1894)

de Quervain matriculated at the University of Bern in 1888 and over the course of his time there he learned from many esteemed faculty members including Theodor Kocher who in 1909 received the Nobel Prize in Physiology of Medicine “. . . in recognition for his work concerning the physiology, pathology, and surgery of the thyroid gland.”7 Other notable members of the faculty were Theodor Langhans, an eminent pathologist for whom the Langhans cell is named, and Hermann Sahli, an internist who contributed to the diagnostic methods of many fields of internal medicine, especially hematology. The time de Quervain spent with these professors undoubtedly had a profound impact on him and influenced his research endeavors throughout the course of his career. According to some of his professors at the medical school de Quervain possessed “clear intellect, tremendous capacity for work, [and] extraordinary memory.”2

de Quervain completed medical school and in the spring of 1892 he passed the state licensing examination. He then immediately started work as third assistant to Dr. Kocher at the surgical hospital at Bern. After only 18 months he became first assistant, or chief, of the surgical clinic.2 His ties to Bern would remain strong and for the remainder of his days he would remain in close correspondence with his mentors from the University, especially Theodor Kocher.

de Quervain in La Chaux-de-Fonds (1894-1910)

In November 1894, pushed by a need for independent activity, de Quervain decided to leave the University of Bern and settle in La Chaux-de-Fonds, a watch-making district in the Neuchtel Mountains. This district of 30,000 people provided him with an abundance of patients with varied illnesses and conditions that broadened his knowledge of medicine and provided the basis for his publications. In his 15 years in La Chaux-de-Fonds he wrote a number of books and articles such as his first publication describing chronic tendovaginitis8 and his book on surgical diagnosis entitled Clinical Surgical Diagnosis for Students and Practitioners.9 These publications paved the way for his subsequent academic positions.3

From 1894 to 1897 de Quervain worked both in the hospital of La Chaux-de-Fonds, which was too small and outdated to provide adequately for its patients, and in his own private clinic. In 1897 he decided to enter into a group practice with Dr. Bourquin, an internist, and Dr. Theodore de Spuir, an ophthalmologist.3 Both of these physicians shared de Quervain’s attraction to new and innovative technologies and his affinity for clinical research. Also in 1897 de Quervain was named Chief of the Surgical Service, which allowed him to oversee construction of a modern 70-bed hospital at La Chaux-de-Fonds. With the pathophysiologic approach to surgery he learned from Kocher, de Quervain transitioned his hospital “from the era of pragmatic medicine to scientific medicine.”6

There existed another hospital in the region of La Chaux-de- Fonds, the hospital of Locle, which in 1900 named de Quervain to the newly created post of surgical consultant. Thus his expansive practice included 2 hospitals and his own private clinic and this gave him a huge pool of patients from which to draw experience.3 de Quervain later remarked that during this time period, “The total number of my clinically handled patients amounted to 600 per year, and the number of operations 500 per year.”2

de Quervain’s Disease (Stenosing Tendosynovitis at the Radial Styloid Process)

During his time at La Chaux-de-Fonds de Quervain recognized an affliction that had not received much prior attention. On December 18, 1894 he saw a 35-year-old woman, Mrs. D, who suddenly became afflicted of “a severe pain in the region of the thumb extensor.”‘ de Quervain excluded tuberculosis as a diagnosis “with moderate certainty” because of the “acute inceptions” and “quick reductions of acute symptoms” and “because no palpable visible changes had developed despite an 8-month duration of pain.”1

de Quervain then remembered a prior similar case that he had observed while working under Dr. Kocher as first assistant of clinical surgery in Bern. That patient, Mrs. L. had noticed that “motion of her right thumb had gradually become painful.” He also remarked, “She showed no evidence in her whole body of syphilis, tuberculosis, or gout.” He noticed no physical abnormalities except a slight “thickening of the tendon-sheath compartment at the distal radial end of the muscle extensor pollicis |brevis] and abductor longus.” Based on de Quervain’s description of his treatment of the patient” it does not appear that he attempted to treat the condition nonsurgically. Rather, in that patient he opened the compartment of those tendons and placed them in the subcutaneous tissue. One year after the surgery he noted that the patient remained fully healed and that the surgery had caused her no discomfort.1

de Quervain then performed the same surgery on Mrs. D on January 8, 1895 and noted that it had the same salutary effect as in the first case and remained so at the 5-month follow-up examination. He saw an additional patient with the same affliction and received case reports of another 2 patients. He communicated his findings to Dr. Kocher and in response Kocher commented he had seen β or 4 similar cases, which he had treated with partial excision of the tendon sheath and had attributed to “a passive type of work hypertrophy.” In the same letter Kocher referred to the condition as “fibrous, stenosed tendovaginitis.” It was de Quervain’s name, however, that became attached to the eponym.1

de Q\uervain then published his findings-both of the 3 cases he had seen and the 2 cases to which Dr. Sandos, his partner, had granted him publication rights-in an article in 1895 entitled “Ueber eine Form von chronischer Tenovaginitis”8 (“On a Form of Chronic Tendovaginitis”). In this article he detailed both his observations and the surgical technique with which to correct this pain syndrome and made a note of differentiating it from the previously described “trigger finger.” In May 1912 he followed up on his findings with another article detailing 8 additional cases with further comments on the etiology and pathogenesis of the condition.10

Figure 1. The Eichhoff test: the thumb is gripped in the fist and the wrist is placed in ulnar deviation, which causes pain at the radial styloid process in a positive test result.

An American surgeon at the Hospital for Joint Diseases in New York City, Harry Finkelstein, read de Quervain’s descriptions of stenosing tendosynovitis and began reviewing the literature of other physicians who had added their own observations of the condition. He then published a paper of his own in 1930 summarizing these previous publications and adding 24 cases of his own, noting that in the United States the condition was often misdiagnosed as “rheumatism, neuritis, periostitis,.. . and even tuberculous osteitis.”" Interestingly, he quoted the surgeon Eichhoff’- who described initially a test for de Quervain’s disease by saying, “A simple experiment will verify this assumption. If one places the thumb within the hand and holds it tightly with the other fingers, and then bends the hand severely in ulnar abduction, an intense pain is experienced on the styloid process of the radius, exactly at the place where the tendon sheath takes its course. The pain disappears the moment the thumb is again extended, even if the ulnar abduction is maintained”11 (Fig. 1).

This test, which for many years was considered diagnostic of dc Quervain’s disease, is now referred to generally as the Finkelstein test although in fact it was Eichhoff who had described it in 1927. This test is not actually the test that Finkelstein described and in recent years this test described initially by Eichhoff has been criticized for giving false-positive results.13

The test Finkelstein described differed from Eichhoff s test in that it did not involve gripping the thumb within the fist. Rather, the test Finkelstein described is as follows: “On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating”11 (Fig. 2).

Figure 2. Finkelstein’s test: the patient’s thumb is grasped and the wrist is placed in ulnar deviation, causing pain at the radial styloid process.

In 2003 Brunelli published an article4 stating that he had devised a new test for de Quervain’s disease that was more accurate than Finkelstein’s test. The test Brunelli categorized as Finkelstein’s test is the true test that Finkelstein described, not the test described by Eichhoff. Brunelli states that in Finkelstein’s test the tendons of the abductor pollicis longus and extensor pollicis brevis are “moved away from the pulley”4 and that this technique may stretch the radial collateral ligament, the scaphotrapezial ligament, or the thumb carpometacarpal ligament, which could result in false-positive findings. Brunelli’s test is administered by maintaining the wrist in radial deviation and forcibly abducting the thumb (Fig. 3). Brunelli further states that he has been using this test for 30 years and has found it to be quite accurate.4

A Pioneer in La Chaux-de-Fonds

de Quervain pioneered a number of technologies during his stay in La Chaux-de-Fonds including endoscopy, radiology, and sterilization techniques; he also had a hand in the creation of the modern surgical table, de Quervain met with considerable resistance from the hospital when requisitioning new equipment; many times he had to procure the necessary materials at his own expense. This resistance quickly melted away as everyone realized the value of these new and innovative surgical techniques.3

The antimicrobial principles that he learned at Bern stayed with him and he applied them to his practice at La Chaux-de-Fonds. He had all of the instruments sterilized along with the drapes and dressing materials. With the help of a Bernese artisan, Maurice Schaerer, he created autoclaves that would create pressures of 2 atmospheres, a large improvement over the then-standard 0.5-atmosphere variants. These advanced autoclaves were accepted instantaneously and were produced industrially.3

de Quervain, again with the help of Schaerer, constructed a new kind of surgical table. This new surgical table included features such as adjustability to patients’ varying body types and sizes, a concave headrest, and the ability to elevate the surgical field. He first displayed this new surgical table in 1905 at the International Congress of Surgeons at Brussels. He then published 2 articles in 1906 and 1909 detailing the construction of this table.5 This endeavor was well received by the surgical community and within a few years 600 of the new Quervain-Schaerer tables had been sold worldwide.3

In 1898 de Quervain acquired the necessary parts from Germany and constructed an x-ray machine in his clinic. This was a remarkable event because the discovery of x-rays by Rntgen had just occurred in 1895 and the machines existed only in a few places in Switzerland in 1898.3 Of this device de Quervain remarked, “Each visitor wanted to see . . . out of curiosity . . . the hand skeleton and the transparent purse [with coins in it].”2 de Quervain was convinced of the utility of this new technology and contributed to the progress of radiologie technique, especially with respect to its application to gastrointestinal pathology.3

An Author of International Renown

de Quervain authored a number of works while residing in the Neuchtel mountains and these works were largely responsible for bringing him worldwide renown.2 With Kocher he coedited Die Encyklopdie der gesamten Chirurgie14 (The Encyclopedia of Entire Surgery), which initially appeared only in German from 1901 to 1903. This encyclopedia of surgery contained contributions from over 100 eminent specialists drawn mostly from the German-speaking world.3

Figure 3. Brunelli’s test: the wrist is maintained in radial deviation and the thumb is abducted, causing “a painful attrition of the tendons against the pulley.”4

Being enamored with both the utility of surgery and recognizing the crucial nature of proper diagnosis, as well as combining the pathophysiologic approach he learned at Bern with the art of medical intuition he learned at La Chaux-de-Fonds,6 de Quervain spent 4 years organizing both his acquired knowledge and real life experiences into a comprehensive work entitled Spezielle chirurgische Diagnostik fr Studierende und Arzte9 (Clinical Surgical Diagnosis for Student and Practitioners), which appeared in 1907. This book was acclaimed highly and became the book of reference for many surgeons. It had 5 subsequent editions and was translated into English, French, Spanish, Italian, and Russian.3 Professor Jacques Louis Reverdin of Geneva, who many times was critical of the University of Bern, wrote “[the book] . . . is a real life book, reflecting a rich personal experience happily placed in valor. This volume will be a precious guide for the practitioner, and a life saver for patients.”3 This work, perhaps more than any other singular work of de Quervain’s, brought him worldwide fame within the medical community in a relatively short period.

In 1908 de Quervain wrote a chapter on surgery of the head and neck with a large emphasis on thyroid diseases for Wullstein and Wilms’s publication, Lehrbuch der Chirurgie15 (Textbook of Surgery).

de Quervain’s Thyroiditis

In addition to his busy practice and his exploration of new technologies, de Quervain retained his interest in clinical research. He remained especially interested in the thyroid, an organ with which his mentor, Kocher, spent a great deal of time, de Quervain’s doctorate thesis, written in 1893, was entitled ber die Vernderung des Centralnervensystems bei experimeteller Kachaxia thyreopriva der Thiere16 (On the Change of the Central Nervous System by Experimental Hypothyroid Cachexia) and was the result of research on cachexia in animals caused by hypothyroidism. His work with the thyroid continued and on April 5, 1902 he presented to the Congress of the German Society for Surgery his work on a thenunknown form of thyroid inflammation, “Ueber acute, nicht eiterige Thyreoiditis”17 (“Subacute Nonsuppurative Thyroiditis”). In 1904 he published a complete work on this subject18 and this condition would later be known as de Quervain’s thyroiditis.3 As a result of his work on the thyroid de Quervain was largely responsible for the introduction of iodized table salt.19

Stepping Stones

Finally, while in La Chaux-de-Fonds de Quervain obtained 2 positions on the medical faculty at Bern that were awarded to him in an interesting way. In 1901 he requested that he be admitted to the faculty of medicine at Bern as a private practitioner, stating that it would help him to remain in contact with the academic world and stimulate him to create progress in surgery.3 The faculty hesitated initially because it was not customary to award such a position to a physician who was so geographically remote from the university. Thanks to the urging of Dr. Kocher, however, they eventually acquiesced and Dr. de Quervain was accepted to the faculty of medicine at Bern as a private surgeon.3

In 1906, “urged by Kocher,”2 he sought to become a Titular Professor at Bern and wrote to the state council of Bern regarding this matter. Again the faculty was initially hesitant to provide a professorship to a distant practitioner but de Quervain’s reputation for relentless promo\tion of modern surgery, the already proven value of his scientific work, and the urging of the highly respected Dr. Kocher persuaded them to grant him this title in 1907. This professorship at Bern would provide a means to later academic positions.3

In 1910 the University of Basel offered de Quervain the position of Chair of Surgery and he accepted, although he was reluctant to leave La Chauxde-Fonds. In a letter to his friend Paul Pettavel, a pastor in La Chaux-dc-Fonds, de Quervain wrote, “I also leave excellent friends-pastors, doctors, watchmakers, etc.-at an age where solid friendships are not made so easily any more. I leave in La Chauxde-Fonds a piece of myself.”3

Evidently the medical community at La Chaux-deFonds held de Quervain in similar esteem because on September 24, 1910 they held a banquet for de Quervain at the hotel of Paris and gave him a gold stopwatch as a gift in remembrance.3

de Quervain at Basel and Bern (1910-1940)

Dr. de Quervain lectured and practiced very happily in Basel, so much so that he rejected an offer from the new surgical hospital in Geneva in 1916. Said one resident of Basel, “. . . our admired surgeon, Professor de Quervain, who received a call to Geneva and whose departure in high measure would be regretted. For public relief, you should hear that the scholar did not find missing anything in our instructional department that would cause him to move from our town.”2

In his time at Basel de Quervain ensured the creation of a new surgical theater and lecture building for the surgical hospital and the construction began in 1917.3

Perhaps de Quervain would have finished out his career at Basel but on July 27, 1917 an unexpected event changed the course of his life drastically: his beloved mentor, Theodor Kocher, died suddenly. Rather than open the position to application, as was customary, the faculty of Bern voted unanimously to offer it to de Quervain, a stark contrast from their earlier reservations when he applied to become a private practitioner and then again when he applied to be a professor. Along with this offer they also promised him the construction of a brand new, stateof-the-art surgery clinic.3

de Quervain struggled with this decision because he enjoyed great respect in Basel and as a result his “suggestions gained a foothold very rapidly.”2 He had resolved, especially after rejecting the position in Geneva, to stay at Basel indefinitely. Said de Quervain, “When I declined Geneva last year, I had foreseen to stay in Basel indefinitely since I would not have applied to this job in Bern if it has been announced as usual.”2

He was ultimately swayed, however, by the unanimous vote of confidence by the faculty at Bern and his deep attachment to the university at which he had begun his medical studies. He felt also that at Bern he could work more efficiently on resolving certain “social” issues, such as tuberculosis.2

Thus it came to be that in 1918 de Quervain became the head of the University Clinic of Surgery at Bern, succeeding his life-long mentor, Theodor Kocher. For the next 2 decades, until October of 1938, he ran the University Clinic of Surgery, where he helped to train and shape the next generations of Swiss physicians who would go on to work all around the country and the world. It was not only from Switzerland that physicians came to study at Bern, however; the hospital received visitors from all over the globe. For example, one of de Quervain’s former Japanese pupils wrote to him “[we] have a meeting every three months, where we speak of you often … we call our small community the Swiss Doctor Company!”2

On May 4, 1938 de Quervain reached 70 years of age. In honor of this the Swiss Medical Weekly dedicated to him a commemorative publication, which contained contributions of many prominent European surgeons.2

de Quervain retired from the University of Bern in October 1938 although he remained active, still performing some surgeries and conducting some research.2 On January 24, 1940, 3 days after performing his last surgery, Fritz de Quervain died suddenly of complications from a thrombosis of a portal vein.3

Awards, Accomplishments, and Involvement in the International Community

Throughout his life de Quervain was the recipient of a number of distinctions and awards and he held numerous positions in various medical societies. Furthermore he was very active in the international medical community, visiting many of his colleagues abroad and attending many international conferences. In 1899 he received the Haller Medal from the University of Bern. The Haller Medal, named after the famous humanist Albert de Haller, was awarded to a young doctor who distinguished himself by conduct, application, and talent.3

He was secretary of the Medical Society of Neuchtel in 1896 and then became president in 1898. He attended the first International Congress of Surgeons in 1905 where he spoke on the treatment of tuberculosis and his new surgical table. He also attended the second and third International Congress of Surgeons in 1908 and 1911 where he spoke on breast cancer, spinal cord trauma, and x-ray diagnosis of the gastrointestinal tract. He attended the founder’s meeting and all of the congresses of the Swiss Society for Surgery save one and was president of the Swiss Society for Surgery from 1919 to 1920.2

In 1963 a bust of de Quervain was placed in the Hall of Fame of the International College of Surgeons in Chicago. Upon placement of the bust the secretary of the International College of Surgeons said to de Quervain’s daughters, “This bust will be an addition of great value, since there is not a single surgeon who has not heard about your illustrious father or read his work.”2

Fritz de Quervain was a master surgeon, often regarded as one of the last great surgical giants. His keen observation and treatment of stenosing tendovaginitis of the thumb dorsal compartment remains an important contribution to the field of hand surgery that has withstood the test of time. He pioneered a number of technologies including endoscopy, radiology, and sterilization techniques and developed the modern surgical table. He was one of the first to recognize the power of epidemiologic studies and strove endlessly to bridge the widening gap between scientists in opposing countries during and after the First World War. Truly, Dr. Fritz de Quervain was a remarkable man who did remarkable things in a remarkable time. Perhaps the Austrian surgeon Anton von Eiseisberg said it best in 1907 when he wrote to de Quervain, “You are an amazingly industrious man.”2

We would like to thank Dr. Ulrich Trhler, Professor of Medical History at the University of Freiburg, for his help. Without his extensive work on Dr. Fritz de Quervain, especially his work Der Schweizer Chirurg J.F. de Quervain (1868-1940). this article would have been largely impossible.

References

1. de Quervain F. On a form of chronic tendovaginilis [translated by Illgen R, Shortkroff S]. Am J Orthop 1997:26:641644.

2. Trhler U. Der Schwei/er Chirurg J.F. de Quervain (18681940): Wegbereiter neuer internationaler Be/Jehungen in der Wissenschaft der Zwischenkriegszeit. Aarau: Sauerlnder, 1973:5-63.

3. Terrier G. Le docteur Frit/, de Quervain la Chaux-de-Fonds (1894-1910). Rev Med Suisse Romande 1998;! 18:193-201.

4. Brunelli G. Finkelstein’s versus Brunclli’s test in Dc Quervain tenosynovitis. Chir Main 2003;22:43-45.

5. Grundmann R. Zur Operationstischfrage (anlsslich des 126. Geburtstags vol F. de Quervain). (The operating room table (on the 126th birthday of F. de Quervain).]. Zentrallbl Chir 1994;119;449- 450.

6. Trhler U. Quelques mdecins suisses et leur apport la chirurgie de la main. (Swiss physicians and their contribution to surgery of the hand.]. Helvetica chirurgica acta 1977;44:569-576.

7. Mrner KAH. Presentation speech: the Nobel Pri/,e in physiology or medicine in 1909. Nobel e-Museum. 1995. The Nobel Organization. Available at: http://www.nobel.se/ medicine/laureates/1909/ press.html. Accessed March 30, 2004.

8. de Quervain F. Ueber eine Form von chronischer Tendovaginitis. Korrespondenzblatt fr Schweizer Arzte 1895;25: 389-394.

9. de Quervain F. Spezielle chirurgische Diagnostik fr Studierende und Arzte. Vogel: Leipzig, 1907.

10. De Quervain F. Veber das Wesen und die Behandlung der stenosierenden Tendovaginitis am Processus styloideus radii. Munchen Med Wochenschr 1912; 59:5-6.

11. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 1930; 12:509-540.

12. Eichhoff E. Zur Pathogenese der Tendovaginitis stenosans. Bruns’ Beitrage Zur Klinischen Chirurgie 1927;139:746-755.

13. Elliot BG. Finkelstein’s test: a descriptive error that can produce a false positive. J Hand Surg 1992;17B:481-482.

14. Kocher T, de Quervain F. Die Encyklopdie der gesamten Chirurgie. Vogel: Leipzig, 1903.

15. Wullstein L, Wilms M. Lehrbuch der Chirurgie. Jena, Germany: Fischer, 1908:360-449.

16. de Quervain F. ber die Vernderung des Centralnervensystems bei experimenteller Kachexia thyreopriva der Thiere. MD thesis. Bern: University of Bern, 1893.

17. de Quervain F. Ueber acute, nicht eiterige Thyreoiditis. Archiv fr klinische Chirurgie 1902;67:706-714.

18. de Quervain F. Die akute, nicht eitrige Thyreoiditis und die Beteiligung der Schilddrse an akuten Intoxikationen und Infektionen berhaupt. Jena, Germany: Fischer, 1904, 1-23.

19. Rang M. De Quervain’s stenosing tenovaginitis: Fritz de Quervain (1868-1940) [reprinted]. Orthopedic Nursing 1982;1:24-25.

Naveen K. Ahuja, BS, Kevin C. Chung, MDx Ann Arbor, Ml

From the University of Michigan Medical School and section of Plastic Surgery, Department of Surgery, the University of Michigan Health System, Ann Arbor. Ml.

Received for publication April 14. 2004; accepted in revised form May 19. 2004.

No benefits in any form have been received or will be received from a commercial party related directly or indirec\tly to the subject of this article.

Reprint requests: Kevin C. Chung, MD. MS. section of Plastic Surgery. The University of Michigan Health System. 15(X) E Medical Center Dr. 2130 Taubman Center. Ann Arbor. Ml 48109-0340.

Copyright 2004 by the American Society for Surgery of the Hand

03630 -5023/04/29A060 -0029$30.00/0

doi:10.1016/j,jhsa.2004.05.019

Copyright Churchill Livingstone Inc., Medical Publishers Nov 2004




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