No. 3541.

JULY 11, 1891.

LecturesON

CONTRACTIONS OF THE FINGERS AND TOES;THEIR VARIETIES, PATHOLOGY, AND

TREATMENT.Delivered in the Theatre of the Royal College of Surgeons,

BY WILLIAM ANDERSON, F.R.C.S.,HUNTERIAN PROFESSOR OF SURGERY AND PATHOLOGY TO THE ROYAL

COLLEGE OF SURGEONS.

LECTURE I.&mdash;(<7oMcM<.) )Pathology.-The study of the character and relations of

<ihe diseased structure indicates that it is an inflammatoryhyperplasia commencing in the subcutaneous tissue of thepalm, involving the skin and fascia secondarily, and re-placing the adipose connective tissue which normally servesas an elastic cushion Hf the palmar surface of the handand fingers. It must now be considered what is the cause ofthe morbid process. The view of Dupuytren has already beenreferred to. He believed that the affection was provokedby repeated injuries of the palmar fascia by pressure andfriction from implements used habitually in differentmechanical callings; but the facts I have adduced in the dis-cussion of the etiology conflict strongly with the hypothesis.M has been shown that in artisans both hands may be

equally affected where only one is brought in contactwith the tool, that aggravated forms of contractionsmay appear in persons who are not at all exposedtwo any such source of irritation, and, moreover, that

. the disease is of no more than average frequency in certainemployments in which men are peculiarly and constantlyliable to palmar friction. Some source of irritation, however,must be present, and it has been suggested that this is toibe found in gouty deposits. In one case recently broughtforward by Mr. Lockwood, uric-acid crystals were actuallypresent in connexion with the bands ; but this experience isexceptional. That the new tissue might become the seat ofsuch a deposit in gouty subjects is more than probable, butin the majority of cases of Dupuytren’s contraction seen inthis country the patients are not, and have not been, subjectto gout. It would, moreover, be difficult to find any con-dition that presents less resemblance in its course andtendencies to known manifestations of the gouty poison.The changes, indeed, are much more suggestive of chronicrheumatism than gout, but even the probability of this sourceef origin is not supported by observed facts. The situationof the initial lesions, and the peculiar tendency of the newgrowth to feed like a parasite upon the tissues in which itspreads and which it replaces, have led me to believestrongly that the active agent of destruction is a specificmicro-organism, which gains access to the subcutaneoustissue through accidental lesions of the epidermis, mostlyeffected by the finger-nails. This would explain far better thanany existing hypothesis the persistent course of the disease&nd its proneness to recur after the most skilfully de-vised operation. The almost constant limitation of thedisease to the declining years of life corresponds mainly tolessened resistance in the bodily organism, and partlyperhaps to senile absorption of the palmar fat cushion. Thealmost complete immunity of the foot is accounted for bythe protection afforded by the shoes and stockings, andthe impossibility of contact of the toe nails with the sole.individual and inherited susceptibilities are exemplifiedhere as in other complaints of known bacterial origin.Lastly, the absence of the affection in certain countriesmay be due either to the absence of the specific organismor to antagonistic influences developed in the constitutionby racial, climatic, dietetic, and other conditions. Todetermine the question I have sought the experienced aid- sf my colleague, Mr. Shattock, in carrying out a series of(bacteriological researches, which are still in progress. Theresults are, unfortunately, still incomplete, but they maybe related’so far as they go.

In a patient in whom it was decided to excise the con-treated irv +.&bgr;7^ hn",;J +_hn.. ,...."..n..n. "’1’ln.n._+l.,’P

member was selected for experiment. The skin wasincised under strict antiseptic precautions, portions of thegrowing tissue were cut away with the aid of a knife andforceps, sterilised by heat immediately before use, and thefragments excised were at once placed in cultivating tubesof agar-agar and gelatine. In a second case a commencingnodule upon the plantar fascia of a patient, suffering alsofrom Dupuytren’s contraction of the hands, was treated in asimilar manner. In Case 1 two of the three fragments quicklyshowed a growth obviously due to contamination. On thethird and fourth days a yellow nodule appeared in all threespecimens, and on cultivation assumed a form which led usto believe that a specific organism had been isolated ; buton making a cover-glass preparation of this it proved to bea form of yellow sarcina, and hence merely a contamination.In the jelly tube containing one of the original pieces of tissueand in the agar tube a second growth has now appeared,liquefying the jelly. This is not a putrefactive organism,as the tube is odourless, but some time will be necessarybefore it can be followed up. In Case 2 no sarcina ap-peared, but there is a white growth, probably identicalwith that in Case 1. Sections from Case 1 stained withfuchsin and by Gram’s method showed no organisms asviewed under 12 homogeneous immersion. We trust that ibwill be possible to publish this and other experimentsin extenso within a short time. Meanwhile it can only besaid that they do not negative the view expressed as to theorigin of the disease.

False Dupuytren’s contraction, traumatic form.-There isa form of palmar contraction usually classed with that justdescribed, but I believe essentially of different nature. Thisis always due to obvious traumatisms, such as incised orlacerated wounds of the palmar fascia, and the cases pre-sent noteworthy features which separate them from thetrue forms. A distinction of the kind was recognised nearlythirty years ago by Eulenburg, but his views attracted littleattention. The points for especial notice are as follows :-1. The age at which the lesion begins is governed by theperiod of injury, and shows none of the limitations obser-vable in the true disease. The condition is hence as commonin childhood and early adult life as in middle or old age.In the seven cases (five male and two female) in my list theages of commencement ranged from seventeen to sixty-one,four of the patients being under forty. 2. The seat ofinitial lesion is single, and the affection is confined to theinjured hand, not tending to appear subsequently in otherparts of the same hand or in the opposite member, as in mostexamples of the specific form. 3. The contraction progressesrapidly to a certain point, and then ceases to get worse. Ib

rarely becomes so strongly marked as in the worst cases ofthe true Dupuytren’s disease. 4. The contracted band,starting from the point of injury (which is indicated byan orainary sear) has seldom the tendon-like form ofthe well-marked "Dupuytren," the characteristic puckersin the skin are represented only by ordinary cicatricialadhesions, and the digital extensions are usually in theform of one or two lateral bands following the bifurca-tion of the digital process of the radiating fascia.5. The effect of operation is different. Subcutaneousdivision is less efficacious when the skin is extengively im-plicated in the cicatrix, and the excision of the band or thetransplantation of a 6:tp after division of the cicatrix isnot followed by the strong tendency to recurrence observableafter similar proceedings in the true form. In all the sevencases in my list the nature and traumatic origin of thedisease could be recognised without difficulty. It is pro-bable, however, that a true Dupuytren’s contraction mightbe set up by a process of infection in connexion with anopen wound, and in such cases the distinction between thetwo forms of disease would disappear. A subcutaneouscicatricial contraction of the finger may also result fromviolent and sudden super-extension of the joint. Thelateral bands extending from the radiating fascia are

ruptured, and if the finger is not kept straight by mechani-cal appliances a contraction of the joint is liable to occur.In such cases the resistance to extension is felt to dependupon two tense lateral bands, while the movements ofthe articulation in the direction of flexion remain strongand normal.Treatment -Some eighty years ago Baron Boyer said with

regard to the disease now under consideration, that it hadbeen advised to expose and divide the contracted tendon,"and even to excise a portion, afterwards keeping the handextended upon a splint; but, he remarks, 11 lie succes d’une

B

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telle op&eacute;ration eat trop incertain ; elle n’a probablementjamais etc pratiquce et un chirurgeon prudent devratoujours s’en abstenir." " It was he who expressed the con-gratulatory belief that surgery had already in his dayreached its final limits, and all that had not then been ac-complished could scarcely be regarded as attainable. Itcannot be said that the treatment made any real progressfor many years after his time. It is true that Sir AstleyCooper advised subcutaneous section of the contractedbands, but the suggestion waq not carried into practice tillmuch later. Dupuytren, having decided that the tendonswere not affected, did what Boyer considered unpermissible,cut the contracted cords and superjacent integument, andstraightened the hand upon a splint,with results that appearedto fully justify the remarks of his predecessor, for under thistreatment the gaping wound suppurated; and if the patientrecovered without loss of the hand the process of cicatrisa-tion at length restored the deformity in a more hopeless anddistressing form than before. A few years afterwards Goyrandrecommended an improved method : that of exposing thetense bridle of morbid tissue by a longitudinal incision,dividing it, and then reuniting the edges of the cutaneouswound; and this plan was adopted with various modifica-tions by other surgeons. The absence of antiseptic pre-cautions, however, exposed the wound to all the dangers ofinfection, and as the treatment mostly failed to secure theadvantage hoped for it fell into disrepute, and patientswere usually dissuaded by their friends, and even by theirmedical attendants, from submitting to any operativemeasures. It is to Jules Guerin that we are indebted for thefirst demonstration of the value of the subcutaneous methodproposed by Sir Astley Cooper, and the practice was carriedout in this country by Messrs. Tamplin and Lonsdale, butwas brought to perfection by Mr. William Adams. For atime the subcutaneous operation held its ground withouta rival, but the introduction of the antiseptic principle insurgery rendered it possible to reconsider the discreditedopen method, and the plan was revived with various modi-fications by Kocher, Busch, Hardie, and others, withencouraging though variable results.The therapeutical measures now eligible may be briefly

enumerated:&mdash;Non-operative tre,,tt)i2eitt. -There is no doubt that in

the milder cases and when the morbid process has cometo a standstill a considerable improvement may beeffected by massage and persevering extension. I haveseen in a patient of seventy the fourth and fifthfingers brought from an angle of 90&deg; with the palmnearly to a straight line within a year, but the con-traction relapsed completely in three months, when a severeillness made it necessary to suspend the treatment. Wehave heard much of the wonders effected by hypnotismduring the latter days, but the surgeon hardly expected tobe told that Dupuytren’s contraction, of all diseases, couldbe cured by " suggestion." Yet in a recent volume of oneof our medical journals we find a successful result claimedfor such a treatment. The chief interest of the record liesin the example it affords of the survival at the close of thenineteenth century of the peculiar mental condition thatbrought patients to the feet of Greatrakes and Perkins in abyegone generation.The operative may be divided into three classes-

subcutaneous, open, and plastic.The sttbc?et(t2icotis method deserves the first place. Mr.

Adams, to whom we owe the establishment of the operationin the favour of surgeons, sums up its principles as follows :" 1. The subcutaneous division of all the contracted bandsof fascia which can be felt; the bands to be divided byseveral punctures with the smallest fascia knife passed underthe skin and cutting from above downwards, a pledget oflint being at once placed over each puncture and retained inposition by a strip of plaster. 2. Immediate extension tothe full extent required for the complete straighteningof the fingers when this is possible, and the applica-tion of a retentive, well-padded, metal splint from thewrist along the palm of the hand and fingers; thefingers and hand to be bandaged to the splint. Whenthe extension cannot be immediately made to the full Iextent, as in those cases where the second phalanx issharply flexed upon the first, it must be carried as far aspossible without producing pain or incurring the risk oftearing the skin." This plan I have followed, with slightand unimportant variations, but I have found it easier,after making the preliminary puncture (which should be

longitudinal in direction to prevent gaping during thesubsequent extension), to pass the knife beneath the bandand to cut from within outwards, except in places wherethe deep surface of the skin is very tightly adherent. The.sensation conveyed to the operator by the division of the-round palmar cords is very similar to that experienced in.tenotomy, and the effect of each section is immediate andencouraging. In some examples, however, the morbidtissue has become so firmly blended with the corium, e8pe-cially over the proximal phalanx, that a satisfactorydivision is difficult, or even impossible; and if the extensionbe carried too far ominous fissures begin to appear in therigid integument. When this happens the surgeon, ifiwise, will be satisfied with whatever he has beenable to achieve, without proceeding further at the time.The extension may be immediate or deferred. Where theskin has held good there is no reason why the fingers shouldnot be put in position at once and fixed in place by a.

splint of plaster-of- Paris or other material ; but if it be,evident that the integument at any point has been severelystrained, it is desirable to wait for a few days before theparts are put on the stretch, and there is no reason tdbelieve that the delay will be attended by any disadvantage-The operation may with benefit be preceded by carefutwashing of the hand and packing with a weak solution ofperchloride of mercury solution or’other antiseptic, andantiseptic dressings should be applied until the incisionware completely healed. The after-treatment consists in theuse of splints of various forms. The palmar splints ofMr. Adams are very convenient, but in the early periods.plaster- of -Paris are equally satisfactory, and render the.intervention of the instrument maker unnecessary. What-ever form be adopted it should be worn day and night fortwo or three weeks, and then be replaced by a well-mouldedfront splint of sheet iron, to be applied at night only, andkept in use for several months. The hand once set fre&during the day the patient is to be urged to practisefriction with passive extension and active movements ofthe joint at every possible opportunity, and it is onlyby strict attention to these rules that permanency ofthe improvement can be ensured. In private practice the.instructions are usually carried out with a good will, and hence-relapses are exceptional. Mr. Adams and Mr. Macreadyestimate them as less than 10 per cent. But in hospital’practice the case is different. The artisan has seldom.much leisure or inclination for unpleasant manipulations.for which, despite the assurances of the surgeon, he sees-little immediate necessity, and he frequently allows the handto drift into a condition which, if not worse, is at least little’better than before.The open opcmtions may be placed under two separate.

headings-one in which the bands are merely divided in,one or two places, and the other in which the morbid tissueis excised as far as possible. The first of these, however-the original method of Goyrand,-may now be held as.

superseded, since it has neither the safety of the subcutaneous.method nor the thoroughness of the more radical measure..We need therefore only discuss the latter. The cutaneousincision may be either longitudinal and linear, as practiseby Goyrand, Kocher, and others, or V- or Y-shaped, after themethod of Busch, Madelung, and Richer. In any case the:reflected skin should be very gently dealt with, and the-wound carefully closed after the removal of the diseasedbands. In most instances the simple linear incision gives al1’that is required, but the other varieties are useful when thedistal end of the band branches or expands. The isosceles.flap of Busch is made with the base opposite the metacarpo-phalangeal joint, the apex at the distal extremity of thehollow of the palm. (Fig. 4.) When thehand is extended aftersection or excision of the contracted tissue the apex of theflap is drawn away from the angle of the incision, and thewound when closed assumes a Y-shape. A Y-incision, withthe fork over the first phalanx and the stem correspondingto the palmar cord, is of advantage where the fibrous bandspreads out broadly and becomes adherent to the skinbeyond the metacarpo-phalangeal joint, the reflection oifthe angular flap beyond the fork allowing the safe removalof the diseased tissue. In any of these operations theanatomical relations of the vessels and nerves should be-carefully borne in mind.", Fortunately the morbid tissue-seldom encroaches upon the nerve tracts in such a way as.to expose them to danger. The best rule for the surgeon is’to confine his dissection as far as possible to the tissueoverlying the axes of the flexor tendons, and not to m&k&t

59

;any further lateral excursion than is absolutely necessary.Extreme care, however, will always be needed in excisingthe cords which run towards the inter-digital web, as thesetie directly over the nerves. The tendons are quite safe inthe palmar incisions, as they lie much deeper than the,fibrous cords, but the diseased tissue is closely related tothe theca. in the fingers. The after-treatment is similarto that recommended for the subcutaneous operation,

- FiG. 4.

UIA.GRAB1 S[IOWING INCISIONS FOR OPEN .1BD SMALLER PLASTIC IfOPERATIONS.

A, Straight incision (Goyrand). 2, Y-incision modified toallow excision of digital expansion of band. 3, V-incisionof Busch. 4, Position of flap to fill gap left by sectiun ofcontracted band and superjacent integument.

SECTION OF FIG 4. I

DIAGRAM

Showing lateral flap transplanted into gap left by division ofthe contracted band, with the superjacent integument at thelevel of the interdigital web.

(but for obvious reasons the necessity for antiseptic pre-cautions is more vital in the open method. No drainage isrequired.

Plastic operations may be conducted under the sameprinciples as those which guide the surgeon in the treat-ment of cicatricial contractions from burns or other causes.In two cases of contraction at the metacarpo-phalangealjoint, in which the skin was greatly involved, I have madea transverse incision through the integument and fibrouscord at the root of the finger and filled up the wide gap lefton extending the joint by the transplantation of a flap from

the side of the digit. The result was good and permanentin one case, of traumatic origin ; in’ the other, a trueDupuytren’s contraction, the union and healing went onwith ideal perfection, but the operation failed in consequenceof the supervention of a gouty inflammation of the parts inthe third week, after all the difficulties appeared to havebeen surmounted. The dissection of the flap must be carefullyconducted in order to avoid injury to the digital nerves.In some cases it might be permissible to carry the plasticprinciple still further by the transplantation of a flap on theTagliacotian principle from the chest or upper arm or anyother convenient point. The details of the operationneed not be described, as it has already been carriedinto practice in cases of cicatricial contraction, althoughit has not, I believe, been recommended in Dupuytren’sdisease.‘

Of these various procedures I believe that the best opera-tion in all advanced cases is the subcutaneous plan of Mr.Adams. It is speedy and safe, the immediate results arevery satisfactory, the risks of relapse probably less than inthe open method, and in the event of a recurrence the otherlines of treatment still remain open. The excision operationinvolves a more extensive surgical injury, but under anti-septic precautions will usually do well. There is, however,a greater risk of casualties. It is perhaps most applicableto the slighter cases, in which the whole of the disease canbe removed, but it may also be employed where the subcu-taneous plan has failed. The plastic operations are mostuseful in the traumatic forms, and in those cases of trueDupuytren’s contraction where the skin is so far involvedthat full or satisfactory extension is impossible. The littleoperation I have suggested produces an immediate result,and under ordinary circumstances a long after-treatment isunnecessary, because the flap of integument does not tend tocontract. The larger operation can only be called for in verysevere cases where all other measures have failed. It is notcertain in any given example whether the surgeon will be snc-cessful in giving lasting relief to the patient. Were it simplya question of dividing or excising a common cicatricial band,there is no reason why the result of every well-devisedoperation should not be permanent; but experience showsthat even with the greatest care it is always difficult, andsometimes impossible, to prevent a return of the conditionwhich gave rise to the deformity in the first place-that is,a growth of fibrous tissue which tends to contract, andoccasionally this new formation may become diffusedaround the articulations in such a way as to impedeboth flexion and extension, and by leading to a kind offalse ankylosis induces a more serious loss of functionthan that which existed before the intervention of thesurgeon.[A number of patients were introduced during and after

the lecture to show the varieties of the affection and theresults of treatment.] ]The main conclusions arrived at may be stated as

follows :-1. There are two forms of disease comprisedunder the name " contraction of the palmar fascia," theone traumatic in origin, dependent upon common inflamma-tory changes in the integumental and fascial structures,and occurring at all ages; the other unassociated withobvious traumatism, tending to multiplicity of lesion, andalmost confined to middle and advanced life. 2. The lattercondition, true "Dupuytren’s contraction," is not, strictlyspeaking, a contraction of the palmar fascia, but consistsof a chronic inflammatory hyperplasia, commencing in thesubcutaneous connective tissue and involving secondarilythe palmar fasciae and the deep fibres of the corium. Themorbid bands are for the most part formed at the expenseof the normal tissues. 3. It does not appear to be connectedprimarily with pressure or friction of the palm by tools orother objects employed in manual occupations, but is pro-bably caused by a specific infective agent which effects itsentrance through epidermic lesions made by the finger-nailsor otherwise. 4. It is almost essentially a disease of middleand advanced age, more common in men than in women,occurring in all classes, tending to progress slowly througha long course of years, and to return after operation. 5. Itis connected with a special diathesis, inherited or acquired, Iwhich cannot yet be expressed in any known terms ; bubneither gout, rheumatism, rheumatoid arthritis, nor anyother of the ordinary constitutional ailments has beenshown to have any causative relation to the disease. 6. Itappears to be almost, if not quite, unknown in certainparts of the East, as in India and Japan.