The deformities of the fingers and toes

by William Anderson

This is the more ordinary course, but the signs show great variety in different cases. 1. The disease may remain limited to the palm, not giving rise to flexion of the finger; this is especially frequent in women. 2. Any or all of the fingers may be attacked, and the rigid bands may implicate also the thenar and hypothenar eminences. 3. Either or both inter-phalangeal joints may become flexed, while the metacarpo-phalangeal joint remains free. 4. The palmar cord may remain single and central, or it may send off a lateral branch on either or both sides in the inter-digital web, and so implicate two or three fingers. 5. A central band, after reaching the root of the finger, may bifurcate, sending a branch to either side of the digit; this, in my experience, is the least common variety. 6. The cord, instead of running along the central axis of the finger, may pass towards the inter-digital cleft and then divide, giving branches to two digits; a band of this kind would be in dangerous relation to the digital vessels and nerves in the event of operation by excision. ([Fig. 1.])

The statistics as to fingers affected in my series of cases correspond closely to those already published by Adams, Keen, and others. They are as follows: Thumb, four times; index finger, three times; middle finger, twenty-two times; ring finger, thirty-nine times; little finger, twenty-eight times (these numbers include the purely palmar bands where they were placed over the metacarpo-phalangeal articulation, but had not yet led to contraction of the digit; traumatic cases are excluded). The most common association where more than one digit was affected was that of the ring and little fingers; when a single finger was attacked, it was most frequently the fourth. The flexion involved in almost equal proportions the metacarpo-phalangeal joint alone, and this together with the first inter-phalangeal joint. In four cases the first inter-phalangeal joint was contracted, while the metacarpo-phalangeal articulation was free, and in one case the distal joint alone was flexed, although the band extended from the palm. In only two cases were all the fingers implicated. The condition was bilateral in twenty-four cases out of thirty-nine, right-handed in ten, and left-handed in five. Thus the right hand was attacked thirty-four times, and the left twenty-nine times. Of the twenty-four bilateral cases, nine were worse in the right hand, six in the left; in the rest the severity differed little on the two sides. Nearly one-third were unsymmetrical as to the fingers attacked. In eight patients, six of whom were women, the band was purely palmar, and did not cause any contraction of the fingers.

Fig. 1.

Diagram showing the various types of the abnormal bands in Dupuytren’s contraction. The position of the initial lesions over the heads of the metacarpal bones and opposite the flexion lines is indicated by the black spots. 1. Thenar band; 2. Axial band extending to distal joint; 3. Axial band giving off lateral branches to adjoining fingers; 4. Axial band bifurcating to send branches to sides of finger; 5. “Interosseous” band bifurcating to join two adjacent digits; 6. Hypothenar band; 7. Band more developed at distal than at proximal extremity, and leading to contraction of first or second inter-phalangeal joint, the metacarpo-phalangeal joint remaining free.

Two interesting points to be especially noted in reviewing the series were—first, the tendency to multiplicity of the initial lesions; and, secondly, the close coincidence of their position with that of the heads of the metacarpal bones. In no case did the disease commence in the finger itself. These facts probably have a bearing upon etiology. In only one instance was there any association with a corresponding disease of the sole.

The inconveniences resulting from the affection are less urgent than might have been expected, partly because the flexion power remains, partly because there is no pain, and partly because the contraction seldom attains an aggravated form until an age when æsthetic considerations are of minor importance and the more active period of working life is drawing to a close. In some extreme cases, however, the nail of the contracted finger may press against the palm, and cause ulceration, and in one instance brought under my notice by a friend the deformity was nearly the cause of a fatal accident, the bent finger becoming hooked in the handle of a moving railway carriage in such a manner that it could not be disengaged. The patient saved himself by seizing a pillar, while the traction force tore asunder the diseased fibrous bands and set the straightened finger free. It is needless to say that the benefit of the impromptu operation was limited to the immediate service rendered.

The frequency of the complaint is difficult to estimate. With a view to forming some opinion as to its prevalence in the poorer classes I took advantage of the kindness of Mr. J. Lunn of the Marylebone Infirmary, Mr. Percy Potter of the Kensington Infirmary, Dr. A. H. Robinson of the Mile End Infirmary, and Dr. S. G. Litteljohn of the Central District Schools at Hanwell, to select cases from the large body of patients in the institutions under their control; and in the cases of Kensington and Mile End I had also the privilege of access to the workhouses in connection with the infirmaries. The total numbers of the persons thus open to investigation were 2600 adults, and 800 children under the age of sixteen. All of these were carefully examined, and every example of Dupuytren’s contraction (as well as of the other conditions included in these lectures) was systematically recorded. Of the 2600 adults, of whom about five-sixths were over middle age, 33, or 1·27 per cent., were found to be suffering from various stages of the affection, while in the 800 children no trace of the disease was to be detected. This proportion is very much smaller than that discovered by Mr. Noble Smith, who was fortunate enough to detect no fewer than 70 examples in 700 persons. His facts and deductions have been fully discussed at the Royal Medical and Chirurgical Society and in the medical papers.

Sex.—The influence of sex is very noteworthy, but much less than was formerly conjectured. Cases of any degree of severity in the female are rare, but the slighter forms are fairly common. Of thirty-nine non-traumatic cases, twenty-five were in men and fourteen in women, but of the latter number in only eight was there any contraction of the fingers. This proportion is larger on the side of the female sex than that given by Dr. Keen in the valuable series analysed by him in 1882 (20 females to 106 males); but it must be pointed out that most of the cases in my list would have escaped notice altogether without a close examination of the palm.

Age.—True Dupuytren’s contraction is almost essentially a disease of middle or later life at its onset. It was estimated by Dr. Keen that about five-sixths of the cases began after the age of thirty, but his examples included some of the traumatic form, which may of course originate at any period of life. In my own series only one, a man of thirty-two, was below the age of forty when the disease first appeared, and in the number seen in hospital practice before I began to keep notes of the cases, I do not recollect one in which the symptoms commenced in youth or early adult life. My friend Surgeon-Captain A. H. De Lom, has kindly obtained for me some statistics that bear very directly upon this point. He finds by reference to the Army Reports that in a force averaging 203,000 soldiers, between the ages of seventeen and thirty-five, only three cases of contraction of the fingers came under treatment in five years (1885-89), and it is not certain whether these were of the traumatic or of the specific variety. It is of course possible that some incipient cases escaped attention, but the magnitude of the figures gives a value to the record in spite of this source of fallacy. It is stated, however, that exceptions to the rule do occur, and that conditions bearing a resemblance to true Dupuytren’s contraction have been seen in childhood, and some of these are even believed to be congenital; but it is probable that a closer examination of such cases would prove them to be of a different pathological nature. There appears to be no limit to the period of onset in the other direction. In eighteen cases in my list the disease was unnoticed until after the age of sixty, and in six of these it did not appear until the eighth decade; and it is significant that the majority of these patients, a portion of whom were women, had given up laborious employment before the symptoms appeared.