The section of surgical disease treated in the following pages is unambitious in its scope, but it is, nevertheless, one that deserves the attention of every surgeon and pathologist, because it comprises a group of ailments which are the source of much pain and crippling, and because it offers many problems of causation that are still unsolved. It is true that none of these affections threaten life, but in medicine, as in law, it is often the value of the principle involved rather than the magnitude of the interests immediately at stake that invests the case with importance.
There is a material advantage to be gained by studying the deformities of the hands together with those of the feet, for it will be found that nearly all the forms of contraction that appear in the one are represented in the other, and a comparison of the conditions under which the two sets of affections arise may throw light upon the pathogeny of both. At the same time, if we glance at the structural and functional differences in the hand and foot, and at the fact that civilised life imposes artificial restraints upon the freedom of action of the one, while it cultivates to a marvellous degree of perfection the variety and precision of movement in the other, we shall understand that although certain deformities of the fingers may have a strict pathological analogy with those of the toes, the effects produced, and the treatment required may differ essentially in the two sets of cases.
It will be seen that our knowledge of some of the affections to be described is of very recent date, and that certain diseases, frequent in occurrence, obvious in character, and very inconvenient or painful in results, have only found a place in our text-books within recent years. Even the most ancient in point of literary existence scarcely dates beyond the third decade of the present century; while the youngest, when regarded in the same aspect, is merely a child of a few winters; and yet both the one and the other may be nearly as old as mankind.
SECTION I
CONTRACTIONS OF THE FINGERS
These may be grouped as follows: 1. Contractions due to pathological processes taking place in the cutaneous and fascial structures of the palm and palmar surface of the fingers. This includes the so-called “contraction of the palmar fascia,” with which the name of the great surgeon Dupuytren is inseparably connected, as well as another affection of similar character, but different pathological origin. 2. Contractions due to developmental irregularities in the bony and ligamentous elements of the articulations. Under this heading come the deformity which may be termed “hammer finger” and the closely allied lateral distortions of the digits—affections which are chiefly of importance in their bearing upon analogous conditions of the toes. 3. Contractions arising from shortening of the finger flexors, without paralytic or spastic complications. 4. Contractions due to unbalanced action of the flexor muscles after accidental solution of continuity of the extensor tendons. 5. Contractions arising from nutritive changes in the motor apparatus consequent upon long immobilisation of the part, with pressure; or from inflammatory processes in the inter-muscular planes, or in the muscles themselves. 6. Contractions dependent upon inflammatory articular disease of traumatic or constitutional origin. 7. Contractions of neuropathic origin, paralytic or spastic. Under this denomination, as under the last, only those questions which concern the surgeon will be taken into consideration. 8. Trigger finger; a condition not yet susceptible of scientific classification. 9. Congenital deformities not included under any of the preceding headings.
CONTRACTIONS INVOLVING THE DIGITAL AND PALMAR FASCIÆ.
The clinical features of the disease called Dupuytren’s “contraction of the palmar fascia” were well known before the true seat of the morbid process was surmised; but the Greek and Arab writers, and their European followers down to the end of the last century, make no reference to it. The first accessible descriptions are those of Sir Astley Cooper in his “Treatise on Fractures and Dislocations” published in 1822, and of Boyer in the eleventh and last volume of his “Maladies Chirurgicales,” issued in 1826. The latter is really a very correct account from the clinical aspect; and although the author could suggest no better pathological explanation than that implied by the name “crispatura tendinum,” which he found already given to the disease by previous writers, in works that cannot now be traced, he accepts it with commendable hesitation.[1] Sir Astley Cooper, on the other hand, supplies a less detailed description, but recognises the non-tendinous origin of the disease. The classical essay, however, was that of Dupuytren (1831), which, partly from its intrinsic merits and partly from the fame of the writer, attracted wide attention, and called forth within the next few years a number of eminently scientific observations upon the pathology of the complaint. More recently the affection has received close attention from many distinguished surgeons in France, Germany, America, and England.
Symptomatology.—Before entering into the symptomatology, I ought to premise that there are to be distinguished two forms of the so-called contraction of the palmar fascia: one in which the condition occurs independently of any definite traumatism and tends to multiplicity of lesion, the other appearing as a result of an ordinary wound, and confined to the parts in direct relation to the injury. The first of these I propose to speak of as true Dupuytren’s contraction, the second as traumatic contraction. The characteristics of the latter will be referred to later.
The symptoms of the true form have been so often and so graphically described that little can be added to the current accounts. I shall, then, limit my clinical picture to a simple outline, filled in with a few details taken from the series of examples which have been under my own observation. In a typical case, a middle-aged or elderly man notices in the course of the distal furrow, and directly over the head of the metacarpal bone of the ring or little finger, a small nodule in the skin, or perhaps only a puckering and exaggeration of the flexion line. By-and-by a ridge appears running proximally from this point towards the wrist, and distally along the central axis of the finger. The ridge is prominent, round, and very hard, especially between the flexion fold and the root of the digit, and the skin is usually drawn to it tightly at the seat of the initial sign. It passes on to the front of the first phalanx, nearly always preserving the central position, but spreading out and usually sending processes to the deep surface of the integument as it reaches the first joint of the finger, and as it contracts, draws down the metacarpal phalanx towards the palm. After a while the second phalanx may become bent in like manner, and by exception even the distal bone. The articular structures show no trace of disease, the tendons are normal, the finger retains all its strength within the progressively narrowing range of motion left to it by the disease, and the utility of the hand may for a long while be little impaired. Sooner or later other fingers may become involved, and the affection may appear in the opposite hand, to follow a like course. The process of contraction is slow in progress, perhaps extending over ten or twenty years; it is painless, and is uncomplicated by any signs of active inflammation. At length, after a more or less protracted period, it may terminate spontaneously in any of its stages, but the mischief wrought is permanent, and unless the surgeon intervenes, the patient carries it to his grave.