The deformities of the fingers and toes

by William Anderson

Between the proximal border of the fibres of Gerdy and the point of bifurcation of the digital bands of the radiating fascia is a space about half an inch in length, in which is seen a portion of the vaginal fascia that invests the tendons, vessels, and nerves in the palm. ([Fig. 3.]) The connective-tissue fibres in this latter are for the most part transversely arranged. They are connected superficially with the deep surface of the radiating fascia, where they lie beneath it, and deeply with the aponeuroses of the interossei, transverse metacarpal ligament, and glenoid plates, and form septa between the flexor tendons of the four fingers. Where they ensheath the tendons above the ligamenta vaginalia they are separated from them by a kind of lymph space.

If we examine a case of Dupuytren’s contraction in the light of our anatomical knowledge, we shall be struck by the circumstance that the morbid structure which causes the permanent flexion of the fingers bears no resemblance in position or character to the normal fibrous tissues of the part, although it is apparently continuous in the proximal direction with the digital bands of the radiating fascia. The band is best developed beyond the point where the radiating fascia normally ceases, and maintains its longitudinal fibrillation while crossing the vaginal fascia and the transverse fibres of Gerdy. The varieties and modes of branching already described are only to a limited extent related to the anatomical arrangements—that is, where the morbid tissue spreads proximally over the radiating fascia, and sends lateral branches along the course of Gerdy’s fibres; but it is certain that the tendon-like cords are of entirely new formation, and that they exist at the expense of the normal structures. The well-known preparation in St. Bartholomew’s Hospital, which has been figured by Mr. Adams, affords a demonstration of this, as the band, instead of following the direction of the radiating fascia, runs towards the inter-digital cleft and there bifurcates, sending branches to the adjacent sides of two fingers. In a specimen of my own the band runs axially to the little finger and spreads out in front of the first phalanx as a fatless fan-like expansion, that differs altogether in character and arrangement from the normal subcutaneous tissue and becomes closely connected with the skin, the structure of which, however, remains unchanged. The firmest point of integumental adhesion is opposite the distal flexion fold over the head of the fifth metacarpal bone. The first phalanx is flexed to about 90°, and over the metacarpo-phalangeal joint the contracted cord lies in a plane considerably anterior to the tendons, vessels, and nerves, all of which maintain their normal relation to the bones and muscles. There is no tendency on the part of the morbid growth to follow the deep connections of the fascia in the palm.

The radiating fascia, and perhaps even the tendon of the palmaris longus, are made tense and prominent by the shrinking of the new material, but the palmaris longus has no primary share in the production of the deformity, and in fact the disease may be present where the muscle is undeveloped. Repeated experience in operations has proved that the flexor tendons are not affected, and that even in long-standing cases the joints may be fully extended immediately after the division of the morbid fibrous bands. It may be accepted as a principle that the development of a tendon once completed, the tissue has little or no disposition to retrograde changes in the direction of its length. When the most prominent parts of the contracted cords are exposed for excision they bear much resemblance to tendon in contour and striation, but they are less bluish and lustrous in aspect. On dissecting them away from the radiating fascia the transverse fibres interlocking the digital segments of the latter may often be seen unchanged, and in one case in which the disease had attacked the sole the new fibrous tissue could easily be detached from the fascial fibres, which retained all their lustre.

The histological appearances of the new growth are those of fibrous tissue. If the disease is spreading, the fibrous strands are intermingled with nuclear proliferation, which extends especially along the course of the vessels.

Pathology.—The study of the character and relations of the diseased structure indicates that it is an inflammatory hyperplasia commencing in the skin and subcutaneous tissue of the palm, involving the fascia secondarily, and replacing the adipose connective tissue which normally serves as an elastic cushion for the palmar surface of the hand and fingers. It must now be considered what is the cause of the morbid process. The view of Dupuytren has already been referred to. He believed that the affection was provoked by repeated injuries of the palmar fascia by pressure and friction from implements used habitually in different mechanical callings; but the facts I have adduced in the discussion of the etiology conflict strongly with the hypothesis. It has been shown that in artisans both hands may be equally affected where only one is brought in contact with the tool, that aggravated forms of contractions may appear in persons who are not at all exposed to any such habitual source of irritation, and, moreover, that the disease appears to be of less than average frequency in certain employments in which the palms are subject to an unusual degree of friction.

Some source of irritation, however, must be present, and it has been suggested that this is to be found in gouty deposits. In one case recently brought forward by Mr. Lockwood, uric acid crystals were actually present in connection with the bands; but this experience is exceptional. That the new tissue might become the seat of such a deposit in gouty subjects is more than probable, but in the majority of cases of Dupuytren’s contraction seen in this country the patients are not, and have not been, subject to gout. It would, moreover, be difficult to find any condition that presents less resemblance in its course and tendencies to known manifestations of the gouty poison. The changes, indeed, are much more suggestive of chronic rheumatism than gout, but even the probability of this source of origin is not supported by observed facts. The situation of the initial lesions, and the peculiar tendency of the new growth to feed like a parasite upon the tissues in which it spreads and which it replaces have led me to believe strongly that the active cause of the disease is a chronic inflammation probably set up by a micro-organism, which gains access to the subcutaneous tissue through accidental lesions of the epidermis overlying the bony prominences formed by the heads of the metacarpal bones. This would explain better than any existing hypothesis the persistent course of the disease and its proneness to recur after the most skillfully devised operation, while the almost constant limitation of the disease to the declining years of life corresponds mainly to lessened resistance in the bodily organism, and partly perhaps to senile absorption of the palmar fat cushion and atrophy of the protective thickening of the epidermis. The almost complete immunity of the foot is accounted for by the protection afforded by the shoes and stockings. Individual and inherited susceptibilities are exemplified here as in other complaints of known bacterial origin. To determine the question I have sought the experienced aid of my colleague, Mr. Shattock, in carrying out a series of bacteriological researches.

In a patient in whom it was decided to excise the contracted tissue in two hands the more recently affected member was selected for experiment. The skin was incised under strict antiseptic precautions, portions of the growing tissue were cut away with the aid of a knife and forceps, sterilised by heat immediately before use, and the fragments excised were at once placed in cultivating tubes of agar-agar and gelatine. In a second case a commencing nodule upon the plantar fascia of a patient, suffering also from Dupuytren’s contraction of the hands, was treated in a similar manner. In Case 1 two of the three fragments quickly showed a growth obviously due to contamination. On the third and fourth days a yellow nodule appeared in all three specimens, and on cultivation assumed a form which led us to believe that a specific organism had been isolated; but on making a cover-glass preparation of this it proved to be merely a form of yellow sarcina. In the jelly tube containing one of the original pieces of tissue, and in the agar tube a second growth, micrococcus candidans, subsequently developed, and a like growth appeared in Case 2. It is desirable that these experiments should be repeated; but it must not be assumed that negative evidence necessarily disproves the agency of organisms; partly because our present means of detection are not yet perfected, and partly because the tissue examined may merely offer the result of a morbid process that has already come to a natural termination. Sections from Case 1 stained with fuchsin and by Gram’s method showed no organisms as viewed under 1/12 homogeneous immersion.

False Dupuytren’s contraction.—There is a form of digital contraction usually classed with that just described, but differing from it in origin and several other respects. It is always due to obvious traumatisms, such as incised or lacerated wounds, involving the palmar or digital fascia. The age at which the lesion begins is governed by the period of injury, and hence the condition is as common in childhood and early adult life as in middle or old age. The seat of initial lesion is single, and the affection is confined to the injured hand, not tending to appear subsequently in other parts of the same hand or in the opposite member, as in most examples of the ordinary form. The contraction progresses rapidly to a certain point, and then ceases to get worse. It rarely becomes so strongly marked as in the worst cases of the true Dupuytren’s disease. The contracted band, starting from the point of injury (which is indicated by an ordinary scar) has seldom the tendon-like form of the well-marked “Dupuytren,” the characteristic puckers in the skin are represented only by ordinary cicatricial adhesions, and the digital extensions are usually in the form of one or two lateral bands following the bifurcation of the digital process of the radiating fascia. Lastly, the effect of operation is different. Subcutaneous division is less efficacious when the skin is extensively implicated in the cicatrix, and the excision of the band or the transplantation of a flap after division of the cicatrix is not followed by the strong tendency to recurrence observable after similar proceedings in the true form. In all the seven cases in my list the nature and traumatic origin of the disease could be recognised without difficulty.

A subcutaneous cicatricial contraction of the finger may also result from violent and sudden super-extension of the joint. The lateral bands extending from the radiating fascia are ruptured, and if the finger is not kept straight by mechanical appliances a contraction of the joint is liable to occur. In such cases the resistance to extension is felt to depend upon two tense lateral bands, while the movements of the articulation in the direction of flexion remain strong and normal.

Treatment.—Some eighty years ago Baron Boyer, speaking of the disease now under consideration, said that it had been advised to expose and divide the contracted tendon, and even to excise a portion, afterwards keeping the hand extended upon a splint; but, he remarks, “Le succès d’une telle opération est trop incertain; elle n’a probablement jamais été pratiquée et un chirurgeon prudent devra toujours s’en abstenir.” It was he who expressed the congratulatory belief that surgery had already in his day reached its final limits, and all that had then not been accomplished could scarcely be regarded as attainable. For many years after his time it cannot be said that the treatment made any real progress. It is true that Sir Astley Cooper advised subcutaneous section of the contracted bands, but the suggestion was not carried into practice till much later, when Dupuytren, having decided that the tendons were not affected, did what Boyer considered unpermissible, cut the contracted cords and superjacent integument, and straightened the hand upon a splint. The results appeared to fully justify the remarks of his predecessor, for under this treatment the gaping wound suppurated; and if the patient recovered without loss of the hand the process of cicatrisation at length restored the deformity in a more hopeless and distressing form than before. A few years afterwards Goyrand recommended an improved method: that of exposing the tense bridle of morbid tissue by a longitudinal incision, dividing it, and then reuniting the edges of the cutaneous wound; and this plan was adopted with various modifications by other surgeons. The absence of antiseptic precautions, however, exposed the wound to all the dangers of infection, and as the treatment mostly failed to secure the advantage hoped for it fell into disrepute, and patients were usually dissuaded by their friends, and even by their medical attendants, from submitting to any operative measures. It is to Jules Guérin that we are indebted for the first demonstration of the value of the subcutaneous method proposed by Sir Astley Cooper, and the practice was carried out in this country by Messrs. Tamplin and Lonsdale, and perfected by Mr. William Adams. For a time the subcutaneous operation held its ground without a rival, but the introduction of the antiseptic principle in surgery rendered it possible to reconsider the discredited open method, and the plan was revived with various modifications by Kocher, Busch, Hardie, and others, with encouraging though variable results.