The deformities of the fingers and toes

by William Anderson

Class and occupation.—It is very difficult to obtain any information of statistical value as to the proportionate distribution of the complaint in the “classes” and “masses,” and there is great difference of opinion upon the question amongst our best authorities. It is at any rate certain that our workhouses contain a considerable number of examples, and that the disease is also very often found in men and women of the educated ranks. The same doubt exists with reference to the influence of occupation, but there is no question that the earlier observers greatly exaggerated the importance of this factor. It appears, indeed, that in various callings which involve much rough treatment of the palm the affection is even less common than in the rest of the community. Its infrequency amongst soldiers has been already remarked, and Mr. Johnson Smith informs me that it is very rare amongst sailors. In about two hundred patients at the Seamen’s Hospital, whom he was kind enough to examine in order to put the question to the test, only one example of the disease was found, and this was probably of traumatic origin. Shoemakers have been said to suffer frequently, and for mechanical reasons, but there seems to be no substantial foundation for the belief. I have only met with one of the craft so affected, and by a somewhat curious coincidence the disease was of older date, and more severe in the left hand than in the right. This man told me that he had never seen or heard of the complaint amongst his fellow workmen. Two of the worst cases in my own series were in clerks. With reference to the question of occupation, it may be remembered that the affection is bilateral in nearly two-thirds of the cases, and that the left hand is affected almost as frequently as the right—in my own cases in the proportion of six to seven. This and the other facts named would appear to negative the view that mere friction and pressure of the palm by tools or other objects habitually held within the hands can account for the disease. On the contrary, it is possible that habitual rough usage of the hands, by leading to epidermic thickening, protects the deeper structures; and that the horny-handed toiler is proportionately less liable to the disease than his more fortunate and more tender-palmed fellow citizen. Nevertheless, when the condition has once started it is likely that its progress would be hastened by any external source of irritation, and hence the strong conviction of the sufferers as to the mechanical origin of their deformity.

Constitutional condition.—If a generalisation would be permissible solely upon the cases in my own list, I should be inclined to think that the patients were rather above than below the average in health. Twenty-six out of the thirty-nine had passed threescore and ten when they came under my notice, and with four exceptions all were in good physical condition, and one (a woman with fairly well-marked contraction in both hands) had reached the span of ninety-three years. In each case careful inquiries were made with reference to the inheritance or past or present existence of gout, rheumatism, and rheumatoid arthritis, and the result, confirmed as far as possible by direct examination of the patients, was altogether contrary to my preconceived notions on the subject. Of the whole number, only one had suffered from gout, one from rheumatic fever, three from rheumatoid arthritis (all in women, whose Dupuytren’s disease was limited to slight palmar lesion), and six from mild subacute or chronic rheumatism. A possible gouty inheritance was traced in three cases. All were free from nervous disorders except two of the women, who were subject to neuralgias of an ordinary kind, and one (aged seventy-three) with a double contraction of thirty years’ standing, who was suffering from hemiplegia of three years’ duration. No complaint as to the digestive functions was made in any case.

The evidence brought forward by different observers with regard to constitutional tendency appears to be extremely conflicting. Thus, Dr. Keen, whose contribution is one of the most careful records we possess, found no fewer than forty-two gouty patients out of forty-eight cases; and Mr. Adams expresses his opinion that the disease is a gouty thickening of the palmar fascia. Dr. Abbe of New York, on the other hand, has noticed a remarkable frequency of nervous symptoms in connection with Dupuytren’s contraction, and believes that the complaint is of neuropathic origin, while other surgeons have in like manner assigned to rheumatism, rheumatoid arthritis, alcoholism, and other conditions an important causative relation with the disease. There is, of course, no doubt that such widespread affections as gout and rheumatism, neuroses and alcoholism are present in certain cases—it would be strange were it not so; but it is noticeable that the writer who gives a prominent place in the causation to any one of these conditions always holds the claims of the rest in very low esteem; and it appears probable that the associated constitutional tendencies noticed in the different groups of cases depended rather upon the particular class or set from which the observer drew his patients than upon any essential connection between the local and internal affections. My own experience of the disease has been based principally upon cases in hospitals, and hence the remarkable absence in my series of the neurotic or gouty predispositions that might have appeared in persons whose worldly circumstances favoured either of those conditions.

Habits.—In my inquiries as to habits, the usual difficulty of obtaining trustworthy replies was experienced. Three of the more severe cases pleaded guilty to long-standing intemperance, but the rest all regarded themselves as moderate drinkers—an elastic term. There was, however, nothing in their general condition to indicate that alcoholism had exercised any material influence in favouring the palmar lesion.

Race and climate.—We have at present no statistics with regard to the effects of race and climate upon the disease; but so far as we are at present informed it must be rare, if not altogether absent, in certain countries. During my own residence of six years in Japan I did not meet with a single instance; and the far larger experience of my friend Surgeon-General Takaki has been equally negative as to this particular affection. My friend Surgeon-Colonel Owen tells me that in an extensive experience amongst the natives of Bengal, Central Asia, and Afghanistan, he does not recollect more than one or two cases, and that these may have been traumatic. At any rate, the condition is extremely rare.

Inheritance.—There is unquestionably a strong predisposition to the disease in certain individuals and families, and so many examples of hereditary transmission of the tendency have been related that it is useless to add further to the list. We can no more explain the cause of this special predisposition than we can account for the idiosyncrasy which renders certain persons inordinately liable to erysipelas and some other affections; and although Dupuytren’s contraction is often associated with such widespread complaints as gout, rheumatism, and various neuroses, its relation to these is probably to be regarded as a coincidence.

Morbid anatomy.—It has long been a subject of dispute whether the complaint is or is not a contraction of the palmar fascia. There is, of course, no doubt that the palmar fascia is always implicated to some extent, but its exact relation to the morbid tissue that constitutes the essence of Dupuytren’s disease can only be decided by a consideration of the anatomy of the healthy structure.

It is perhaps not easy to say what is meant by the expression “palmar fascia,” since the text-books are by no means agreed upon the point. We have really to notice four palmar structures which may claim a share in the title. These are (1) the radiating fascia, spreading towards the fingers from the palmaris longus and annular ligament; (2) the aponeuroses investing the muscles of the thumb and fingers; (3) a delicate connective tissue blending with 1 and 2 and forming sheaths for the flexor tendons, the lumbricales, and the digital vessels and nerves; (4) the fascia of Gerdy, which runs transversely across the bases of the second, third, fourth, and fifth fingers and in the inter-digital webs, and is continuous with the superficial fascia of the digits and dorsal surface of the hand. Lastly, in addition to these, we might regard the ligamenta vaginalia and the transverse ligaments connecting the metacarpo-phalangeal articulations as specialisations of the family. We are, however, mainly concerned with the radiating fascia and fibres of Gerdy.

The radiating fascia consists of a strong fibrous expansion extending subcutaneously from the anterior annular ligament and palmaris longus tendon, and consisting of an outer or thenar portion, spreading over the muscles of the thumb and blending with the muscular aponeurosis; an inner or hypothenar portion similarly related to the muscles of the little finger; and a central digital expansion which is derived almost entirely from the palmaris longus when this is present, but is well developed even when the muscle is wanting. The central portion spreads out in a fan-like manner as it approaches the fingers, giving off some strong fibres from its anterior surface through the palmar fat to the connective tissue of the superjacent corium, especially in the situation of the palmar folds, and attached by its deep surface to the delicate fascial investment surrounding the tendons, vessels, and nerves; finally, a little beyond the middle of the palm it divides into four segments, one for each digit, each of which soon breaks up into two lateral bands that embrace the sides of the metacarpo-phalangeal joint to blend with its ligaments and the periosteum of the first phalanx, and running on become similarly connected with the first inter-phalangeal joint and middle phalanx. Where the four digital bands diverge they are joined together by deep transverse fibres which pass from the inner to the outer border of the hand, blending in these situations with the muscular aponeurosis. ([Fig. 2.])