THE DEFORMITIES OF THE FINGERS AND TOES




                          THE DEFORMITIES OF THE
                             FINGERS AND TOES

                                    BY
                        WILLIAM ANDERSON, F.R.C.S.
       SURGEON TO ST. THOMAS’S HOSPITAL; EXAMINER IN SURGERY AT THE
           UNIVERSITY OF LONDON, AND ROYAL COLLEGE OF SURGEONS
              OF ENGLAND; PROFESSOR OF ANATOMY IN THE ROYAL
                ACADEMY OF ARTS, ETC.; FORMERLY HUNTERIAN
                  PROFESSOR OF SURGERY AND PATHOLOGY IN
                      THE ROYAL COLLEGE OF SURGEONS

                              [Illustration]

                                  LONDON
                            J. & A. CHURCHILL
                        7 GREAT MARLBOROUGH STREET
                                   1897




PREFACE


The following pages are developed from a course of Hunterian Lectures
delivered by the Author in the theatre of the Royal College of Surgeons,
in 1891. The matter has been revised and brought up to date, and
augmented by a section upon the congenital deformities of the hands and
feet.

                                                         WILLIAM ANDERSON.

2 HARLEY STREET, W. _March 1897._




CONTENTS


                                SECTION I

                       CONTRACTIONS OF THE FINGERS

                                                                      PAGE

    INVOLVING THE DIGITAL AND PALMAR FASCIÆ (DUPUYTREN’S CONTRACTION)    4

    FROM DEVELOPMENTAL IRREGULARITIES IN THE BONY AND LIGAMENTOUS
      ELEMENTS OF THE ARTICULATIONS                                     44

    FROM UNBALANCED ACTION OF THE FLEXOR MUSCLES AFTER RUPTURE,
      DIVISION, OR DESTRUCTION OF THE EXTENSOR TENDON                   63

    FROM NUTRITIVE CHANGES IN THE MOTOR APPARATUS                       65

    FROM TENDO-VAGINITIS OF THE BURSAL SHEATH OF THE FLEXOR TENDONS     67

    FROM INFLAMMATORY AND DEGENERATIVE CHANGES IN THE ARTICULAR
      STRUCTURES                                                        68

    PARALYTIC AND SPASTIC CONTRACTIONS FOLLOWING LOCAL INJURY           70

    CONGENITAL AND INFANTILE CONTRACTIONS                               77

    TRIGGER FINGER                                                      78

                               SECTION II

                         CONTRACTION OF THE TOES

    FROM PATHOLOGICAL LESIONS IN THE CUTANEOUS AND FASCIAL STRUCTURES   86

    FROM DEVELOPMENTAL IRREGULARITIES IN THE ARTICULAR STRUCTURES AND
      COMPRESSION BY MISSHAPEN SHOES                                    87

    HAMMER TOE                                                          88

    HALLUX FLEXUS                                                      104

    HALLUX VALGUS                                                      115

    HALLUX VARUS                                                       120

    LATERAL DEVIATION OF THE LESSER TOES                               122

    ARTHRITIC CONTRACTIONS                                             124

    PARALYTIC CONTRACTIONS                                             127

                               SECTION III

              CONGENITAL DEFORMITIES OF THE HANDS AND FEET

    MAKRODACTYLY                                                       128

    SUPERNUMERARY FINGERS AND TOES                                     144

    SYNDACTYLY                                                         145

    ECTRODACTYLY                                                       147

    BRACHYDACTYLY                                                      149




THE DEFORMITIES OF THE FINGERS AND TOES


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.

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.

[Illustration: 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.

_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.)

[Illustration: FIG. 2.

THE PALMAR FASCIÆ.

1. Palmaris longus tendon; 2. Palmaris brevis; 3. Muscular aponeurosis
of hypothenar eminence; 4. Fibres from radiating fascia to hypothenar
eminence; 5. Innermost digital portion of central segment of radiating
fascia; 6. Fibrous band passing to integumental fold; 7. Transverse
fibres appended to radiating fascia; 8. Lateral digital branches of
radiating fascia; 9. Portion of vaginal fascia exposed between 5 and 10,
Fibres of Gerdy; 11. Superficial digital fascia continuous with fibres
of Gerdy; 12. Thenar portion of radiating fascia blending with muscular
aponeurosis.]

The _transverse fibres of Gerdy_ are really the proximal portion of a
superficial fascia which invests the whole of the four inner digits
immediately under the skin, forms the subcutaneous web of the fingers,
and is continuous posteriorly with the superficial fascia of the back of
the hand. As seen in the palm, it consists of loose fibres intermingled
with fat, running for the most part in a transverse direction from the
second to the fifth metacarpo-phalangeal joint. Proximally it presents
a somewhat sharply defined free border placed nearly opposite the joint
fissure, and extends distally, as before stated, to the fingers and
the inter-digital web, and is connected with the deeper tissues by a
few fibres, but is for the most part separated from them by loose,
whitish fat. On the fingers the tissue constitutes a sheath investing
the tendinous, bony, and ligamentous structures and the lateral bands
derived from the radiating fascia. It takes the form of a distinctly
membranous sheet dorsally and at the sides, but in front it appears as
a coarse irregular network supporting the digital vessels and nerves,
and containing a large quantity of fat in its meshes. It is connected
strongly with the corium, especially at the palmar folds, and more
loosely with the deeper structures by fine fibres.

[Illustration: FIG. 3.

TRANSVERSE SECTION OF HAND THROUGH THE THIRD, FOURTH, AND FIFTH
METACARPAL BONES.

1. Palmar integument; 2. Fat transversed by fibres from 3; 3. Radiating
fascia; 4. Vaginal fascia, superficial portion; 5. Palmar vessels and
nerve; 6. Flexor tendons and lumbricales; 7. Vaginal sheath blending
with fascia of interossei; 8. Septal fibres from vaginal fascia to bone;
9. Interossei; 10. Middle metacarpal bone; 11. Extensor tendon and
sheath; 12. Superficial fascia beneath dorsal integument; 13. Fascia of
hypothenar eminence; 14. Muscles of little finger.]

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.

The therapeutical measures now eligible may be briefly enumerated:

_Non-operative treatment._—There is no doubt that in the milder cases
and when the morbid process has come to a standstill, a considerable
improvement may be effected by massage and persevering extension. I have
seen in a patient of seventy the fourth and fifth fingers brought from
an angle of 90° with the palm nearly to a straight line within a year,
but the contraction relapsed completely in three months, when a severe
illness made it necessary to suspend the treatment.

We have heard much of the wonders effected by hypnotism during the
latter days, but the surgeon hardly expected to be told that Dupuytren’s
contraction, of all diseases, could be cured by “suggestion.” Yet in
a recent volume of one of our medical journals we find a practitioner
gravely claiming a successful result for this treatment in a case of
the kind; a curious demonstration of the survival, at the end of the
nineteenth century, of the peculiar mental condition that brought
patients to the feet of Greatrakes and Perkins in a bygone generation.

The _Operative measures_ may be divided into three classes: subcutaneous,
open, and plastic.

The _Subcutaneous method_ deserves the first place. Mr. Adams’s operation
consists in the subcutaneous division of all the contracted bands of
fascia which can be felt; “the bands to be divided by several punctures
with the smallest fascia knife passed under the skin and cutting from
above downwards, followed by immediate extension to the full extent
required for the complete straightening of the fingers when this is
possible, and the application of a retentive, well-padded, metal splint
from the wrist along the palm of the hand and fingers; the fingers and
hand to be bandaged to the splint. When the full extension cannot be
safely made, it must be carried as far as possible without tearing the
skin.” This plan I have followed, with slight variations, but I have
found it easier, after making the preliminary puncture (which should
be longitudinal in direction to prevent gaping during the subsequent
extension), to pass the knife beneath the band and to cut from within
outwards, except in places where the deep surface of the skin is very
tightly adherent, and the little wounds are sealed with cotton wool
impregnated with collodion and dusted over with iodoform. 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 and encouraging. In some examples, however, the
morbid tissue has become so firmly blended with the corium, especially
over the proximal phalanx, that a satisfactory division is difficult, or
even impossible; and if the extension be carried too far ominous fissures
begin to appear in the rigid integument. When this happens the surgeon,
if wise, will be satisfied with whatever he has been able to achieve,
without proceeding further at the time. The splint extension may be
immediate or deferred. Where the skin has held good there is no reason
why the fingers should not 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 severely strained, it is
desirable to wait for a few days before the parts are put on the stretch,
and there is no reason to believe that the delay will be attended by
any disadvantage. The operation may with benefit be preceded by careful
washing of the hand and packing with a weak solution of perchloride of
mercury solution or other antiseptic, and antiseptic dressings should be
applied until the incisions are completely healed.

The after-treatment consists in the use of splints of various forms. The
palmar splints of Mr. Adams are very convenient, but in the early periods
plaster of Paris is equally satisfactory, and renders the intervention
of the instrument-maker unnecessary. Whatever form be adopted it should
be worn day and night for two or three weeks, and then be replaced by a
well-moulded front splint of sheet iron, to be applied at night only, and
kept in use for several months. The hand once set free during the day
the patient is to be urged to practise friction, with passive extension
and active movements of the joint, at every possible opportunity; and
it is only by strict attention to these rules that permanency of the
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. Macready estimate them as less than ten 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 hand to drift into a condition, which, if not
worse, is at least little better than before.

The _Open operations_ 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 tissue is 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 cutaneous incision may be either
longitudinal and linear, as practised by Goyrand, Kocher, and others,
or V- or Y-shaped, after the method 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 diseased bands. In most
instances the simple linear incision gives all that is required, but
the other varieties are useful when the distal 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 the
hollow of the palm. (Fig. 4.) When the hand is extended after section
or excision of the contracted tissue the apex of the flap is drawn away
from the angle of the incision, and the wound when closed assumes a
Y-shape. A Y-incision, with the fork over the first phalanx, and the
stem corresponding to the palmar cord, is of advantage where the fibrous
band spreads out broadly and becomes adherent to the skin beyond the
metacarpo-phalangeal joint, the reflection of the angular flap within the
fork allowing the safe removal of the diseased tissue. In any of these
operations the anatomical 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 tissue overlying the axes of the flexor tendons, and not to make any
further lateral excursion than is absolutely necessary. Extreme care,
however, will always be needed in excising cords which run towards the
inter-digital web, as these lie directly over the nerves. The tendons
are quite safe in the palmar incisions, as they lie much deeper than the
fibrous cords, but the diseased tissue is closely related to the thecæ
in the fingers. The after-treatment is similar to that recommended for
the subcutaneous operation, but for obvious reasons the necessity for
antiseptic precautions is more vital in the open method. No drainage is
required.

[Illustration: FIG. 4.

DIAGRAM SHOWING INCISIONS FOR OPEN AND SMALLER PLASTIC OPERATIONS.

1. Straight incision (Goyrand); 2. Y-incision modified to allow incision
of digital expansion of band; 3. V-incision of Busch; 4. Position of flap
to fill gap left by section of contracted band and superjacent integument
(Author’s method).]

_Plastic operations_ may be conducted under the same principles
as those which guide the surgeon in the treatment of cicatricial
contractions from burns or other causes. In cases of contraction at the
metacarpo-phalangeal joint, where the skin is greatly involved, I have
made a transverse incision through the integument and fibrous cord at the
root of the finger and filled up the wide gap left on extending the joint
by the transplantation of a flap from the side of the digit. (Fig. 5.)
The dissection of the flap must be carefully conducted in order to avoid
injury to the digital nerves. The result is usually good and permanent.
In some cases it might be permissible to carry the plastic principle
still further by the transplantation of a flap on the Tagliacotian
principle from the chest or upper arm or any other convenient point; or
the more simple resource of grafting, after the manner of Thiersch, may
be employed with advantage, as it has been proved to have a remarkable
effect in lessening cicatricial contraction.

[Illustration: FIG. 5.

Diagram showing lateral flap transplanted into gap left by division of
the contracted band, with the superjacent integument at the level of the
inter-digital web.]

Of these various procedures I believe that the best operation in most
cases is the subcutaneous plan. It is speedy and safe, the immediate
results are very satisfactory, the risks of relapse are in my experience
less than in the open method, and in the event of a recurrence the other
lines of treatment are still available. The open operation involves a
more extensive surgical injury, and although it will usually do well
under antiseptic precautions, there is a greater risk of casualties. It
is perhaps most applicable to the slighter cases, in which the whole
of the disease can be removed, but it may also be employed where the
subcutaneous plan has failed. The plastic operations are most useful in
the traumatic forms, and in those cases of true Dupuytren’s contraction
where the skin is so far involved that full or satisfactory extension is
impossible. The method I have suggested produces an immediate result,
and under ordinary circumstances a long after-treatment is unnecessary,
because the flap of integument does not tend to contract. The larger
operation can only be called for in very severe cases, where all other
measures have failed.

It is not certain in any given example whether the surgeon will be
successful in giving lasting relief to the patient. Were it simply a
question of dividing or excising a common cicatricial band, there is
no reason why the result of every well-devised operation should not be
permanent; but experience shows that even with the greatest care it is
occasionally difficult to prevent a return of the condition which gave
rise to the deformity in the first place—that is, a growth of new fibrous
tissue which tends to contract.

The main conclusions arrived at may be stated as follows:

1. There are two forms of disease comprised under the name “contraction
of the palmar fascia,” the one traumatic in origin, occurring at all
ages, and not tending to spread far beyond the seat of injury; the other
unassociated with obvious traumatism, tending to multiplicity of lesion,
and almost confined to middle and advanced life.

2. The latter condition, the true “Dupuytren’s contraction,” is not,
strictly speaking, a contraction of the palmar fascia, but consists
of a chronic inflammatory hyperplasia, commencing in the corium and
subcutaneous connective tissue, involving secondarily the palmar fasciæ,
and tending to the formation of dense bands of cicatricial tissue which
replace the normal structure.

3. It does not appear to be especially connected with pressure or
friction of the palm by tools or other objects employed in manual
occupations, but is probably caused by infective organisms which gain
admission through epidermic lesions, usually located over the prominent
heads of the metacarpal bones.

4. It is almost essentially a disease of middle and advanced age, more
common in men than in women, occurring in all classes, tending to
progress slowly through a long course of years, and liable to recurrence
after operation.

5. It is connected with a special susceptibility, inherited or acquired,
which cannot yet be accounted for or expressed in any known terms; but
neither gout, rheumatism, rheumatoid arthritis, nor any other of the
ordinary constitutional ailments has been proved to have any causative
relation to the disease.

6. Cicatricial deformities of the digits resulting from burns and other
severe injuries are often of a very distressing character, and especially
those which prevent opposition of the thumb to the fingers. When the
joints are not destroyed, the utility of the member may generally be
restored by well-devised plastic measures, the new material being either
an epidermic graft, or a skin flap taken from a convenient portion of the
surface; but it is useless to lay down laws in detail for the treatment
of these conditions, as the variations in the extent and position of the
loss of substance are so great that only the ingenuity of the operator
can guide him in the application of the general principles of plastic
surgery.


CONTRACTION OF THE FINGERS DUE TO DEVELOPMENTAL IRREGULARITIES IN THE
BONY AND LIGAMENTOUS ELEMENTS OF THE ARTICULATIONS.

There are certain affections of the fingers which have hitherto attracted
little notice, but are interesting on account of their relationship to
deformities of much greater frequency in the lower extremity. These are
conditions of abnormal flexion and of lateral deviation of the phalanges
at the inter-phalangeal articulations, the first of which corresponds
exactly to the well-known deformity of the foot called “hammer toe.”

[Illustration: FIG. 6.

“Hammer Finger.”]

“_Hammer finger_” (Fig. 6) is not a rare complaint, although much less
familiar, possibly because much less troublesome, than hammer toe. It
may be defined as a permanent flexure of one or more digits, nearly
always at the first or second inter-phalangeal joint, and unassociated
with inflammatory or degenerative disease in the articular structures,
or with any evidence of paralytic or spastic phenomena in the muscles.
It is strictly limited in onset to the developmental period, and may
manifest itself at any time between birth and adult life, possibly even
before birth in some instances. It is more common in girls than in
boys. The digit most frequently attacked is the little finger, and the
proximal inter-phalangeal joint is more often affected than the distal
joint. It is usually symmetrical. The contraction is slow, progressive,
and painless, and becomes arrested spontaneously at any degree of
flexion, but seldom goes beyond an angle of 90°. The joint cannot be
extended by any ordinary force except in the earliest stage, and even
then the bent position is immediately resumed after the cessation of the
effort. Flexion, on the other hand, is complete and of fair power. No
alteration is produced in the deformity by flexion of the wrist, a fact
which proves that the main obstacle to extension does not lie in the
tendons. There are no contracted fascial bands, and, as a rule, the skin
is normal, but occasionally a small longitudinal fold may be present in
the angle of flexion. In rare instances the resistance to extension is
capable of yielding suddenly with a spring-like action, and a similar
movement recurs as the joint is replaced in the position of flexion.
These cases are usually classed with the condition known as “trigger
finger.” The contraction also occurs in the metacarpo-phalangeal joint,
but very rarely attains a degree marked enough to attract the attention
of patient or surgeon. In 800 children examined at the Central District
School at Hanwell by Dr. Litteljohn and myself, this affection was found
seven times—five times in girls, twice in boys, the ages of the subjects
ranging between eight and fourteen. In all these the deformity was
confined to the little finger, and in six cases it was bilateral. The
proximal inter-phalangeal joint was affected in ten, and the distal joint
in three of the thirteen digits. The angle of flexion measured from the
prolonged metacarpal axis, ranged between 20° and 80° in the different
cases. A contraction of less than 20° was frequent, but the deformity
was so slight that the cases were not recorded as pathological. Besides
these examples, I have met with several cases in adult women, in whom the
defect is said to have originated in early childhood. The little finger
was affected in all, but in one the ring finger, and in another the ring
and middle fingers were also involved. Only the last was unilateral. The
following case may serve as a type of the more troublesome forms:

    G. B., a domestic servant, aged twenty-two, was admitted into
    St. Thomas’s Hospital in June 1889, with contraction of the
    third, fourth, and fifth fingers of the right hand at the first
    inter-phalangeal joints. The patient, a strong, healthy girl,
    quite free from neurotic tendencies, stated that her little and
    ring fingers had been contracted from early childhood, and that
    the condition had increased slowly but progressively to the
    present time. The middle finger became similarly affected about
    five months before admission. She had never suffered from pain,
    and the parts had been free from all sign of inflammation;
    the deformity, however, caused very great inconvenience in
    her occupation. Two months before admission an attempt had
    been made to relieve the flexion of the little finger by
    subcutaneous section of the fascia, with the result of inducing
    a traumatic contraction of the metacarpo-phalangeal joint.
    The family history was negative. On examination the little
    finger was found to be flexed at an angle of 90° at the first
    inter-phalangeal joint, and the metacarpo-phalangeal joint was
    bent at an angle of 120° by cicatricial contraction of the skin
    and subcutaneous tissue (the result of the operation alluded
    to). The ring finger was flexed at the first inter-phalangeal
    joint to about 110°, and the middle finger at the corresponding
    articulation to about 150°. In the case of the inter-phalangeal
    joints, the movements in the direction of flexion were quite
    free and of normal power, but extension was strongly resisted
    by ligamentous tension at the points named. No increase in the
    range of movement was gained by flexion of the wrist. A first
    operation was undertaken for the relief of the cicatricial
    contraction at the proximal joint of the little finger. The
    tense integumental band was divided, and after straightening
    the joint a flap was dissected from the ulnar side of the
    digit opposite the point of incision and twisted into the gap.
    (Fig. 4.) The wound united by first intention, and the result
    was permanent. A week later an operation was performed upon
    the first inter-phalangeal articulation of the same finger.
    The lateral ligaments were divided subcutaneously near their
    proximal attachment, and it was found that the joint could
    then be straightened by the use of moderate force; but on the
    discontinuance of the extension the contraction was reproduced
    by the elastic tension of the flexor, except during flexion of
    the wrist. The hand was placed upon a splint. The patient, who
    did not bear restraint well, left the hospital, and has since
    been lost sight of.

There is little doubt that in this case the primary contraction was due
to imperfect evolution of the ligaments, and that the shortening of the
tendons was secondary. The reason for accepting this order of phenomena
is that a pure myogenic contraction does not readily lead to changes
in the joint structures, because the articulations are capable of full
extension while the flexor tendons are relaxed by bending the wrist, and
hence the limitation of movement is not constant. (See Case recorded on
page 58.) On the other hand, in a permanent contraction of a finger-joint
occurring during the period of active growth the flexors are never
stretched to their full extent, and consequently do not undergo their
normal longitudinal development; but should such a contraction originate
in an adult the case is different, as muscle and tendon show very little
disposition to undergo active involution in the direction of their length
after their complete development is attained; and hence after division of
the abnormal bands in true Dupuytren’s disease the tendons do not impede
the complete extension of the digit. This law, that joint contractions
commencing in youth lead to shortness of muscle tendon, while those
beginning in adult life do not, is worthy of the attention of the surgeon.

_Pathology._—The affection is of some pathological importance, because
it affords a simple test case by which many other questions of larger
moment may be decided. It has been demonstrated that the permanent
obstacle to extension of the contracted joint is to be found in the
ligaments, there is no evidence of either muscular or nervous impairment
or of any inflammatory changes in or about the joint, the process of
contraction is slow and painless, and the condition always originates
and progresses to its maximum during the term of active growth. In
order to understand the significance of the complaint, it is necessary
to dwell upon some facts in digital anatomy and physiology that have
not received the consideration they deserve. If we examine a number of
hands, it will be found that there is a remarkable wide physiological
variation in the range of movement at the phalangeal articulations in
different individuals, and it requires but a small departure outside
the physiological limits of variation to constitute the pathological
deformity under consideration. The results of my own observations are
as follows: (1) At each of the digital joints the distal bone, starting
from the position of extreme flexion, passes through a variable number of
degrees before it reaches the point at which it is arrested by tension
of the ligaments. In the metacarpo-phalangeal joint the angle formed
between the two bones during extreme flexion is usually about 80°, and
the entire extending movement from this point may be represented in the
healthy hand by any number of degrees between 90 and 190. That is, in one
person the motion is arrested a little before the axis of the phalanx
reaches a line with that of the metacarpal bone; in another it may be
possible to continue the extension until the two bones form an angle with
a dorsal opening of 90°. At the first inter-phalangeal joint there is a
similar but less extensive variation. The extreme flexion angle is 60°
or 70°, and the full extension may be checked as soon as the axes of the
two bones are in the same line (frequently a little before this point
is reached), or may be carried on 30° beyond. In the distal joint the
flexion angle is about 80°, and extension may be checked when the two
bones are in the same line, or may be capable of continuation for 40°
or more. In the thumb the range of movement at the metacarpo-phalangeal
joint varies from 80° to 170°, and at the inter-phalangeal joint from
90° to 120°, in different persons—i.e., the physiological variation in
the two articulations is 90° and 30° respectively. The diagram (Fig. 7)
may help to render this clear. It is not only in different individuals
that such variations are apparent, but the fingers of the same hand and
corresponding fingers in opposite hands may differ from each other to
a marked degree in range of extension. The super-extension is usually
greatest in childhood, and undergoes great diminution as adult life
is approached, although in many cases it is persistent; as a rule,
however, the limitation is in direct proportion to the strength of the
hand, and is hence nearly always greater in the left hand than in the
right. These peculiarities are matters of common observation, and popular
expressions have ever been coined to represent the extremes in the range
of variation. Thus a person who is able to bend his joints backwards to
a conspicuous degree is said to be “double-jointed,” and one who cannot
extend them beyond the straight line is called “stiff-jointed”; and it
is well known that “double-jointedness” and “stiff-jointedness” run in
families, and in some cases may be traced through several generations.
In the author, for example, the metacarpo-phalangeal joints of the index
and middle fingers of the right hand are “stiff,” while those of the
left are capable of a super-extension of 45° beyond the metacarpal axis;
and precisely the same condition was present in his father, and has been
transmitted to his son.

[Illustration: FIG. 7.

A. Skeleton of finger with lateral ligaments; 1. Metacarpal bone;
1_a_. Anterior fibres of lateral ligament blending with glenoid plate;
2. Metacarpal phalanx; extension checked by short anterior fibres of
lateral ligament (1_a_) at line of metacarpal axis; 2_a_. Super-extension
permitted when 1_a_ long; 3 and 3_a_. Middle phalanx under conditions
similar to 2 and 2_a_; 4 and 4_a_. Ungual phalanx.—B. Hammer finger;
extension at first inter-phalangeal joint arrested by imperfect
longitudinal development of anterior fibres of lateral ligament.—C.
Palmar aspect of first inter-phalangeal joint (left middle finger); 1.
Metacarpal phalanx; 2. Middle phalanx; 3. Anterior fibres of lateral
ligament decussating with those of the opposite side; 4. Glenoid plate.]

It may be of advantage to describe the articular structures of one of
the finger-joints somewhat in detail. The capsule of an inter-phalangeal
joint is formed on the dorsal aspect by the expansion of the extensor
tendon, reinforced by the transverse fibres (the _ligamenta dorsalia_ of
Henle), which bind the tendon to the bone and lateral ligaments; on the
palmar surface of the articulation is a glenoid plate of fibro-cartilage
firmly attached to the anterior border of the distal bone, but very
feebly connected with the neck of the proximal bone, and fused intimately
with the anterior fibres of the lateral ligaments; lastly, at the sides
of the joints are the radial and ulnar lateral ligaments, the attachment
of which it is important to study closely, as they are often imperfectly
described in anatomical text-books. The fibres of each lateral ligament
are attached above to a little tubercle at the side of the head of the
first phalanx, and from this point they radiate in a fan-like manner—the
more posterior passing to the side of the base of the second phalanx,
the rest blending with the glenoid plate, and through the intermediation
of this are connected with the anterior border of the base of the distal
bone, decussating to some extent with fibres of the opposite ligament.
(Fig. 7, C.) The strongest part of the glenoid plate, in fact, is made up
of these ligamentous fibres; and it is these which, relaxed in flexion,
become progressively more and more stretched during extension, and at
length by their tension bring the movement to a close, but, as already
shown, the point at which the maximum tension is reached varies to a
large extent in different individuals.

The physiological variations in the range of movements are thus to be
explained by variations in the relative length of the anterior fibres
of the lateral ligaments. The ideal constitution of a joint depends
upon the existence of a certain ratio between the growth of bone and
that of ligament. Should the ligaments grow in excess, their redundant
length will permit great super-extension, and may even cease to check
the movement; but if the bone grow relatively faster than the ligaments,
the anterior portion of the latter will the sooner become tense during
extension, and where this disproportion is exceptionally great the
motion may be checked before it attains physiological completeness, the
result being a “hammer finger.” Irregularities of development are most
likely to occur in those joints which, for one or other reason, have the
least functional activity. In the hand the little finger is much less
powerful than its fellows; and in association with this it may often be
noticed that the fourth tendon of the flexor sublimis is reduced to a
mere thread; in the foot the same thing is observed in the corresponding
digit, but in a more marked degree, and it is the degenerate little toe
which is most liable to the “hammer deformity.”

We may then define hammer finger as the result of a developmental
irregularity of the first or second inter-phalangeal joint (rarely of
the metacarpo-phalangeal joint) by which the anterior fibres of the
lateral ligaments become prematurely tense during extension, and so check
that movement before it attains its normal physiological limit. It is
precisely analogous to hammer toe; but it is of less frequency than the
latter affection, because while civilisation sedulously cultivates the
freedom and precision of action in the fingers, it devises foot-coverings
to repress the natural play of the toes. The tendency to the deformity
may be transmitted by descent through an indefinite number of generations.

_Diagnosis._—Spurious hammer finger, like false hammer toe, may occur
from—(1) articular lesions due to rheumatism, rheumatoid arthritis,
gout, tuberculosis, and inflammations of traumatic origin; or (2) from
interference with the muscular functions by paralysis of the extensors or
by spastic contraction of the flexors. In the first group the joint will
be found in a more or less complete state of ankylosis, movements in all
directions being impeded. In the second group the articulation, although
contracted, is freely mobile under passive force, unless, as in some
congenital paralyses, irregularities of development in the articulations
be superadded.

_Treatment._—The treatment of hammer finger is a far less simple problem
than that of hammer toe, because in the toe the sacrifice of the movement
of the affected articulation does not sensibly impair the utility of the
digit, while in the fingers an ankylosis of the first inter-phalangeal
joint in the position of either flexion or extension would be even more
inconvenient than the ligamentous contraction. The measures available
are (1) passive movement; (2) subcutaneous section of lateral ligaments,
with or without tendon lengthening; and (3) amputation. In the milder
cases a persevering use of passive motion will in time effect a cure;
but when the contraction has reached an advanced degree it may be
impossible to make an impression by this means. We may then divide the
lateral ligaments, and keep the fingers straight by means of an extension
splint while the tendons are relaxed by flexion of the wrist, trusting
to subsequent massage and passive motion, or, failing this, to tendon
lengthening (by a process to be described later), to overcome the
resistance of the shortened muscles. Section of tendons within the theca
is useless, because no uniting material is thrown out between the divided
ends. As a last resource, amputation may be demanded to remove a useless
and inconvenient member.

_Lateral versions of the phalangeal joints._—Lateral versions of the
fingers are intimately associated with hammer finger in pathology, and
the two distortions are sometimes combined. The lateral inclination,
which seldom exceeds 25°, may affect either of the inter-phalangeal
joints, but is more frequently in the distal phalanx. Like the “hammer”
deformity, it is usually found in the little finger, and is symmetrical.
The version is nearly always towards the radial side, and the movements
of the joint are a little impaired. Amongst eight hundred children in
the Hanwell School were found six cases, of which five were double
and affected the little fingers, the sixth being in the fourth digit
and unilateral; in two the version was associated with slight hammer
flexion. It is occasionally seen in the index finger, and the version
is then towards the ulnar side. The condition is rather unbecoming than
inconvenient, and cases are seldom brought to the surgeon for relief. It
is a result of irregularity of development, the condyle growing a little
more rapidly on one side than on the other. The constancy of the radial
direction of the version of the little finger is probably explained by
the fact that any lateral pressure to which this digit is subjected is
from the ulnar side, while in the index finger the pressure is more often
from the radial side, and hence an ulnar distortion is here the more
usual. The deflected joint may be straightened by the use for a few weeks
of a narrow metallic side splint, jointed opposite the articulations. No
operation is required.

Exaggerated forms of distortion of the fingers may occur in rheumatoid
arthritis, gout, or chronic rheumatism, and in various nervous
affections,[2] but these rarely call for surgical treatment.


CONTRACTIONS ARISING FROM INTERRUPTED EVOLUTION OF THE FLEXORS OF THE
FINGERS, WITHOUT PARALYTIC OR SPASTIC COMPLICATIONS.

This condition necessarily belongs to the pre-adult stage of development.
It is characterised by persistent flexion of one or more digits, without
any articular abnormality, and unassociated with spasm or paralysis,
but the contraction is of a different kind from that found in hammer
finger and hammer toe. The degree of flexion varies with the position
of the hand, and when the wrist is strongly bent forwards the fingers
may be extended, perhaps completely, but extension of the wrist is
accompanied by a return of the contraction, the degree of which increases
progressively as the wrist extension is carried nearer to its limit. The
power of grasp is little impaired. Any attempt to overcome the flexion
by violence is met by powerful resistance, and great pain is induced.
If the patient be anæsthetised, the contraction remains unaltered, but
the resistance is felt to be of a peculiar elastic character, and yields
to a slight extent during the application of passive force. The defect
leads to great interference with the functions of the hand. The pain
caused by anything that tends to stretch the shortened muscles induces a
voluntary exaggeration of the flexion, and after a time the control over
the extensors is apt to become impaired. The causes are often obscure,
but some examples have been traced to traumatic injuries of the flexor
side of the forearm in infancy or childhood. In any case the essential
factor appears to be a trophic lesion of local or central origin, which
retards or arrests the due growth of a muscle or a portion of a muscle
without causing its atrophy or paralysis. The following cases will
serve to illustrate the phenomena so far as they have come under my own
observation:

    CASE 1.—M. O., a domestic servant aged seventeen, was
    admitted into St. Thomas’s Hospital in September 1889. On
    examination the third, fourth, and fifth fingers of the right
    hand were found to be flexed at the metacarpo-phalangeal and
    inter-phalangeal joints—the two latter strongly, the former
    slightly. When the wrist was fully extended the contraction
    became more marked, and the distal phalanges of the ring
    and little fingers touched the palm, but when the wrist was
    fully flexed the fingers could be voluntarily brought into
    a state of complete extension. The power of grasp was good,
    although somewhat less than in the left arm; the bones were
    normal in form and size; and the joints were quite free in
    their movements when the flexors were relaxed by position. The
    forearm muscles appeared to be of normal size. A small scar
    was seen about two inches below the elbow, over the inner side
    of the front of the arm, the result of a fall thirteen years
    before. The patient was strong and healthy in appearance, and
    showed no sign of neurotic disorder. She had never suffered
    from rheumatism or any other severe illness, and the family
    history appeared to be good. She stated that the contraction
    began to appear in childhood, shortly after the injury to the
    arm, but that it had been making more rapid progress in the
    past eighteen months, during which she had been growing very
    quickly. After a fruitless attempt to improve the condition
    by passive motion and splint extension, neither of which was
    well borne, it was determined to lengthen the tendons by
    operation. On October 18, 1889, the patient was chloroformed,
    and it was observed that the deepest anæsthesia caused no
    relaxation of the contraction. A semicircular incision was made
    over the inner side of the front of the forearm just above
    the wrist, the convexity overlapping the tendon of the flexor
    carpi ulnaris, the horns reaching to a line midway between the
    radial and ulnar borders of the limb. The flap of integument
    and fascia was reflected towards the radial side, exposing
    the inner portion of the flexor sublimis. The tendon of this
    muscle going to the ring finger was then isolated, transfixed
    by a fine tenotomy knife, and split longitudinally for a
    distance of two inches. At each end of the fissure so made
    the tendon was divided in such a manner as to leave one-half
    of the split portion attached to the proximal, the other to
    the distal, end of the tendon. (Fig. 8.) The tendon, a very
    slender one, to the little finger was similarly treated. The
    effect of this measure upon the contraction was very slight.
    The portion of the flexor profundus common to the middle,
    ring, and little fingers was then drawn out and divided after
    the same method, and the section was followed by immediate
    and complete extension of the digits. When the fingers were
    fully straightened, the ends of the divided tendons still
    overlapped each other to the extent of about a third of an
    inch, and these portions, in each tendon, were then carefully
    sewn together by catgut sutures. The wound was then closed and
    dressed antiseptically (without drainage), and the hand was
    placed upon a plaster-of-Paris splint; the wrist and fingers
    being moderately flexed, in order that no undue tension should
    be thrown upon the united tendons. Healing took place by first
    intention. At the end of a week the fingers were partially
    extended, and four days later the extension was made complete,
    the alteration of position on each occasion being effected
    without difficulty, and at the expense of little pain. In the
    middle of the fourth week after the operation a feeble power of
    flexion had appeared. The patient was discharged on November
    13, twenty-six days after the operation. Two months later
    the condition had much improved, and the voluntary flexion,
    although still weak, was almost complete as to range. All
    the tendons had evidently united firmly. She was directed to
    wear an extension splint at night, and to practise active
    and passive movement at intervals in the day-time. At the
    end of a further three months the patient, who lived in the
    country, came again to London. She had been growing taller in
    the interval, and said that the contraction had been gradually
    reappearing. On inquiry it was found that she had neglected her
    instructions as to extension and motion. Some slight return
    of the flexion had appeared in the ring and little fingers,
    and has since been steadily increasing, till it is now almost
    as great as when she first attended. She has made no adequate
    effort to oppose the retrogression, but has almost entirely
    discontinued to use the affected hand. She is still, however,
    able to move the fingers freely at all the joints. She desires
    to undergo another operation; but has been advised to obey the
    directions given to her after the first, and to wait until
    her growth is quite complete before any more active surgical
    treatment is undertaken.

[Illustration: FIG. 8.

DIAGRAMS SHOWING METHOD OF TENDON LENGTHENING.

A. Tendon split longitudinally; B. Section completed by incisions at
extremities of fissure; C. Divided tendon elongated and sutured.]

The pathology of this case is very obscure. The contraction evidently
depended upon a trophic lesion, perhaps due to the injury in childhood,
involving the ulnar portion of the flexor profundus, impeding the growth
of the muscle, and so preventing it from keeping pace with the normal
growth of the bone, but not causing paralysis. The contraction of the
flexor sublimis was evidently secondary. The recurrence of the deformity
may be explained by the progressively increasing length of the bones
of the forearm, the muscle remaining stationary; in other words, the
original cause of the condition—the incapacity of the profundus for
development—persisted, and led to a return of the effect. Under these
circumstances it would obviously be advisable to delay a second operation
until the osseous system had reached its permanent proportions. The
operation I believe to be original; and so far as the restoration of
continuity of tendon is concerned, the result proved a complete success.
It might possibly be applied with advantage in various conditions as a
substitute for tenotomy.

The operation was performed independently by Professor Keen,[3] about a
twelvemonth after this case, and has since been adapted to lengthening
and shortening of tendons by Drs. H. A. Wilson,[4] Colgan,[5] and
Ochsner, in America.

    CASE 2.—H. L., a youth aged seventeen, was admitted as an
    out-patient at St. Thomas’s Hospital, in November 1890. He
    complained of a contraction of the thumb and fingers of the
    right hand of three years’ duration. The condition began
    without apparent cause, and has increased progressively. He was
    fairly well grown, but of somewhat delicate aspect. He had an
    attack of rheumatic fever at the age of six, but had since been
    in good health. The contraction was of the same nature as that
    in Case 1, but less in degree, and involved all the digits. The
    hand was well formed, and all the bones, joints, and muscles
    were normal. The power of finger extension was complete during
    flexion of the wrist. The forearm flexors are rather small,
    but there is no distinct atrophy; the movements at the wrist,
    elbow, and shoulder are perfect. He said that the defect
    crippled him greatly for work, and that forcible extension
    caused pain in the forearm. He was instructed to carry out a
    system of massage, with active and passive movements of the
    fingers and wrist.


CONTRACTIONS DUE TO UNBALANCED ACTION OF THE FLEXOR MUSCLES AFTER
RUPTURE, DIVISION, OR DESTRUCTION OF THE EXTENSOR TENDON.

These accidents are not uncommon in ordinary hospital experience. The
effect of such a solution of continuity over the back of the hand is to
leave the first phalanx in a state of flexion, while the second and third
phalanges may be voluntarily straightened without difficulty, especially
if the metacarpo-phalangeal joint be passively fixed in the position of
extension. The reason for this of course is that the common extensor, by
virtue of its ligamenta dorsalia and its connection with the aponeurotic
fibres derived from the interossei, acts with peculiar advantage upon the
metacarpal phalanx, although it has no direct attachment to it, while its
nominal “insertion” into the middle and ungual phalanges is subservient
to the interossei and lumbricales, which are the true extensors of these
bones. On the other hand, if the lesion fall just on the proximal side of
the first inter-phalangeal joint, the first phalanx may be susceptible
of almost complete voluntary extension; but the second and third
phalanges are bent by the unopposed action of the superficial and deep
flexors, because the influence of the true extensors, the lumbricales and
interossei, has been cut off. In like manner, a division of the tendon
over the middle phalanx leaves the terminal phalanx in the position of
flexion; and a similar result follows the accident first described by
Segond, in which the extensor tendon is torn away with a portion of the
bone during forcible flexion of the ungual phalanx.

_Treatment._—If the injury be seen in the early stage and there
is no loss of substance at the point of lesion, it may be treated
satisfactorily by fixing the finger, hand, and wrist in full extension,
to allow the passive approximation of the divided extremities of the
tendon; but should the case not come under notice until a later period it
will be necessary to cut down and suture the tendon. If there is loss of
substance and the two ends of the tendon cannot be brought together, the
treatment must vary with the position of the injury. In some cases, where
the metacarpal portion of the tendon is involved, a good result may be
obtained by joining the distal end to the adjacent tendon so as to bring
it again within the control of the muscle, but if the digital portion be
the seat of the lesion this is impracticable, and a remedy may be found
by lengthening the tendon, either by splitting one or both ends and
suturing the extremities of the portions detached, or by transplanting
a portion of a tendon from a dog into the gap. As a last resource the
traction of the flexors may be balanced by an elastic extension band
replacing the destroyed tendon, and attached by one end to a little cap
drawn over the finger, by the other to the dorsal aspect of a wrist
gauntlet.


CONTRACTIONS ARISING FROM NUTRITIVE CHANGES IN THE MOTOR APPARATUS.

There are at least three well-known forms of pathological change in the
motor apparatus of the forearm (independent of the ordinary paralytic
or spastic conditions due to nerve lesions) that may give rise to
contractions of the fingers. These are—the ischæmic paralysis of
Volckmann, inflammatory processes in the muscular sheaths, and gummatous
formations, or more rarely other tumour growths in the muscles.

(_a_) The affection described by Volckmann as muscular paralysis of
ischæmic origin is now seldom met with. It is a result of prolonged
immobilisation of forearm fractures by any form of apparatus that
intercepts the free circulation of blood through the muscles and nerves
of the part. When the splint is removed the hand is found painful, dusky,
and swollen, and the fingers are bent like claws, any attempt to extend
them causing great pain. Volckmann believed that the nerves in these
cases have preserved their power of conduction, but that the muscular
fibres are structurally injured and have lost their excitability. The
lesion, however, is seldom of a permanent character, and the function
may generally be restored by systematic active and passive movements,
with massage, and if necessary the use of a galvanic current. Its
existence is a reproach to surgery, since a careful observation of the
hand and fingers during the use of splints will always give due warning
of the danger.

(_b_) Diffuse inflammation of the inter-muscular planes and perimysial
connective tissue may occur as a result of poisoned wounds, and other
injuries, and may lead to a like deformity in the fingers. In a case
under my own charge it was caused by a sting in the forearm by an adder.
The injury was followed by the usual pain and swelling, accompanied by
a painful contraction of the fingers, which lasted for nearly three
months, but was ultimately relieved by the measures recommended for the
ischæmic paralysis. Wounds implicating the flexors may occasionally lead
to permanent contraction—either as a result of actual loss of substance,
or in young subjects from interference with the development of the
muscle (as in the case already mentioned). Under these circumstances
the operation of tendon lengthening may be required if the endeavours
to secure gradual extension are unsuccessful. König describes a case
of flexion of the hand and fingers in a newly-born child, caused by a
tearing of the flexors at the moment of disengagement of the arm in the
course of delivery.

(_c_) Gummatous formations in the forearm flexors, causing painful
contraction of the finger, are comparatively rare. A very interesting
case of the kind is reported by Dr. A. G. Barrs in the _Medical
Chronicle_ for May 1891. The muscle affected was evidently the flexor
profundus in its ulnar portion; and the finger contraction which bore a
superficial resemblance to Dupuytren’s disease, was complicated by other
symptoms indicating a concomitant affection of a portion of the cord.


CONTRACTION OF THE FINGERS DEPENDENT UPON A TENDO-VAGINITIS OF THE BURSAL
SHEATH OF THE FLEXOR TENDONS.

The following notes of an example of this somewhat rare condition under
my observation may be of interest:

    The patient, a girl, aged twenty, attended St. Thomas’s
    Hospital for a swelling of the front of the right wrist, with
    contraction of the fingers and complete loss of use of the
    hand. She stated that the contraction appeared six days before
    without apparent cause. On examination a large swelling was
    found, extending upwards for about an inch and a half above
    the anterior annular ligament, and distally along the ulnar
    side of the palm as far as the root of the little finger. The
    phalangeal joints of all the fingers were flexed, and any
    attempt to straighten them caused considerable pain, while the
    movements of the little finger were accompanied by a peculiar
    coarse grating, that could be felt along the whole length of
    the theca and in the palm, ceasing, however, at the level
    of the carpus. The thumb was flexed and adducted, and the
    movements of flexion and extension were painful, apparently
    because they led to disturbance of the enlarged bursal
    sheath of the finger flexors. The affection was evidently a
    tendo-vaginitis involving the carpal bursal sheath of the
    finger flexors and the palmar extension which brings this into
    communication with the digital bursal sheath of the little
    finger. The crepitation indicated that the intra-vaginal
    portion of the tendon was roughened by inflammatory deposits,
    and it is possible that these irregularities may lay the
    foundation for a subsequent trigger finger. The case was
    successfully treated by immobilisation of all the joints of the
    wrists and fingers in plaster of Paris, followed by passive
    movement as soon as the acute stage was passed.

A tendo-vaginitis of the extensors over the back of the hand may induce
considerable functional impairment of the fingers, with more or less
contraction at the metacarpo-phalangeal joints. Such a condition has been
described by Vogt as an occasional result of gonorrhœa, and Verneuil has
met it as a manifestation of syphilis. The majority of examples, however,
occur without any ascertainable constitutional cause.


CONTRACTIONS DEPENDENT UPON INFLAMMATORY AND DEGENERATIVE CHANGES IN THE
ARTICULAR STRUCTURES.

The deformities induced by gout, rheumatism, and rheumatoid arthritis
fall more directly within the domain of the physician, while those due
to tuberculous or traumatic lesions are of more immediate concern to the
surgeon, but the characters which distinguish the various conditions
from each other are of interest for every practitioner. The chief points
bearing upon diagnosis are as follows: In the _gouty form_ the personal
and family history of the patient, the acute and painful nature of the
local inflammatory attacks, the presence of urate of soda deposits in
the part, and the evidence of similar disease in other portions of the
body. In _chronic rheumatism_, which is more often present in women and
in the poorer classes, the moderately painful attacks of synovitis with
crepitation, and evidence of wearing away of cartilage. In _chronic
rheumatoid arthritis_ the presence of bony outgrowths around the margin
of the articulation is the main element of distinction from the latter
condition. In _tuberculous disease_ the personal and family history,
the soft fusiform swelling, the tendency to breaking down of the morbid
tissue, and the more or less complete destruction of the articular
capsule in the later stages. Contractions with ankylosis may also occur
in acute rheumatism and acute rheumatoid arthritis, and in a peculiar
neuropathic condition simulating the latter. These will be referred to
in connection with the contractions of the toes. In the traumatic forms
the history and marks of injury will usually be sufficient for diagnosis;
but it must, of course, be understood that common injuries, by weakening
the resistance of the part, may localise the attack of a specific
disease, such as tuberculosis or gout, and hence the onset of tubercular
or gouty arthritis may coincide with an ordinary traumatism. It is, as
a rule, only in the tuberculous and traumatic forms that the surgeon is
consulted. The treatment must, of course, be based on general principles;
but it is necessary to recollect that an ankylosed finger-joint
nearly always renders the digit worse than useless, especially if the
articulation be fixed in the position of extension.

It is only necessary to mention that contractions without joint lesion
may occur in the fingers as a result of disease or injury of the bone.
Simple fracture in the neighbourhood of an articulation may produce a
deformity closely resembling that of dislocation. Caries or necrosis may
also lead to a breach of continuity in the shaft of a bone, and various
distortions may follow the cure of the disease.


CONTRACTIONS OF PARALYTIC AND SPASTIC ORIGIN FOLLOWING LOCAL INJURY.

A complete account of the various conditions falling under this
denomination would require an entire course of lectures, and it is hence
necessary to confine our attention to those forms which belong to the
surgeon rather than to the physician.

Spastic conditions following local injury are very rare. An example was
brought before the Medical Society by Dr. Beevor[6] in April 1888, in
which a contusion of the right hand in a boy of fifteen was followed five
days later by permanent contraction of the hand with total anæsthesia as
far as the shoulder and loss of the muscular sense, the movements of the
arm and forearm remaining unimpaired. In the discussion a similar case
was referred to by Dr. Hadden.

All the nerves which govern the muscles acting upon the fingers are
liable to injury—the median and ulnar more particularly by wounds,
usually in the wrist, and the musculo-spiral by pressure of a crutch.

An injury involving solution of continuity of the _Ulnar nerve_ is a very
grave accident, unless it can be treated surgically without any long
delay. The symptoms are such as might be inferred from a knowledge of
the distribution of the branches. It will be remembered that the nerve
supplies the flexor carpi ulnaris and ulnar half of the flexor profundus
digitorum in the forearm, the whole of the muscles of the hand, except
the abductor, opponens, and outer head of the flexor brevis pollicis, and
the two inner lumbricales, and it gives sensation to the skin over the
inner side of the wrist and hand, to the palmar and dorsal surfaces of
the little and ulnar half of the ring finger, and sometimes also to the
radial half of the ring finger and ulnar half of the middle finger. The
effects of the nerve lesion will, of course, vary with the position of
the injury. If the trunk be divided just above the wrist, the branches
to the two forearm muscles and the cutaneous branch to the back of the
hand and fingers will be spared; but the palmar cutaneous filament will
probably be implicated by the wound. The paralysis of the interossei
produces an inability to flex the first phalanges and extend the second
and third, while the unbalanced action of the extensor, and superficial
and deep flexors, causes the position of super-extension of the
metacarpo-phalangeal joint with flexion of the inter-phalangeal joints,
which constitutes the _main en griffe_ of French pathologists (Fig. 9).
The clawing is chiefly marked in the ring and little digits, especially
the latter, but is lessened in the index and middle fingers by the
continued integrity of the first and second lumbricales. There is, in
addition, great loss of power in flexion and adduction of the thumb, and
complete loss of sensation over the front and distal part of the back of
the little finger and the corresponding portion of the ulnar side of the
ring finger. At a later stage nutritive changes appear in the paralysed
structures, and the deformity becomes complicated by the atrophy of the
skin and subcutaneous fat, the hollowing of the interosseous spaces and
the wasting of the thenar and hypothenar eminences. If the nerve be
injured at the elbow, the paralysis of the two forearm muscles, and the
loss of sensation over the ulnar side of the back of the hand would add
to the symptoms, but would not sensibly affect the deformity.

[Illustration: FIG. 9.

Deformity in case of wound of ulnar nerve above wrist.]

The treatment is to seek for the divided ends of the nerve, and to unite
them if possible. Should the interspace be too great to allow direct
suture, an attempt might be made to restore continuity by cutting a long
flap from the proximal extremity of the nerve and bringing it down to
the distal end; or by the transplantation of a portion of nerve from an
amputated limb, or from one of the lower animals. Where the wound lies
immediately above the wrist, it is well to remember that the ulnar nerve
and vessels are covered by a fibrous band, which passes from the radial
side of the flexor carpi ulnaris tendon in this situation to blend with
the anterior annular ligament. It should also be recollected that the
deep branch of the nerve, which is occasionally implicated in penetrating
wounds over the hypothenar eminence, runs around the ulnar side of the
tip of the unciform process, and may there be exposed without much
difficulty.[7] After operation the hand should be placed in a position of
adduction and flexion, and the wound dressed antiseptically. Should this
measure fail, the apparatus devised by Duchenne may be applied to replace
the action of the paralysed muscles.

_Musculo-spiral paralysis_ may be induced by ordinary wounds or
contusions, by fractures of the humerus, or by long-continued compression
of the nerve against the bone, either by the handle of a crutch, or
while the patient is sleeping with his head resting upon an arm which
is supported by the back of a chair. The consequences are paralysis of
the elbow extensors, the supinator longus, the supinator brevis, and
the whole of the extensors of the wrist, thumb, and fingers; and loss
of sensation over the cutaneous areas supplied by the nerve in the
arm, forearm, and hand. For the patient the most striking symptoms are
the flexion of the wrist and fingers, the loss of power to abduct the
thumb, and especially the enfeeblement of grasp due to the inability
to fix the wrist during the action of the finger flexors. If the wrist
be held firmly by the other hand, or by another person, in the position
of extension, the power of grip becomes restored. A similar condition
is present in lead poisoning; but here the loss of power is confined
to the extensor muscles, and the supinator longus remains unaffected.
The possibility of a crutch paralysis should lead the surgeon to warn
every patient who is compelled to use the implement, in order that the
paralysis may be prevented, or, should it occur, that it may be perceived
and arrested in its earliest stages. When the condition has become
established, an attempt should be made to restore function by massage and
electricity, and if these fail, the nerve should be exposed at the seat
of injury, and its continuity restored by the excision of the atrophic
portion and union of the two free extremities.

In paralysis of the _Median nerve_ by a wound above the wrist, the
most distressing symptoms are referable to the trophic lesions in the
integuments of the thumb, index, middle, and ring fingers (radial side)
on their palmar surface and the distal half of their dorsal aspect. There
is, in addition, a partial loss of power of flexion and abduction of the
thumb, with wasting of the thenar eminence and some interference with
the delicacy of the movements of the index and middle fingers, owing
to the paralysis of the first and second lumbricales. If the nerve be
divided above the elbow, the pronators and all the flexors of the wrist,
thumb, and fingers, except those supplied by the ulnar nerve (flexor
carpi ulnaris, and ulnar half of the flexor digitorum profundus), are
paralysed, and consequently the hand is, for all practical purposes,
quite useless. The rules for treatment are similar in principle to those
laid down for injuries of the musculo-spiral and ulnar nerves.

_Spastic Paralyses_, in connection with central disease, need not be
discussed; but the surgeon is sometimes consulted for conditions of
persistent spasm which apparently depend upon excessive use of certain
muscles. Erichsen refers to, and figures, a case of flexion with
pronation attributed to cutting with heavy shears. He notes that when
the wrist was extended the fingers became flexed, and when the wrist
was extended the fingers became bent in. It is not stated whether the
permanency of the contraction was tested by the use of an anæsthetic,
but the patient, as well as another in whom the extensors were affected
in like manner, became cured by means of friction and galvanism, with
the use of a straight splint. A case of spastic contraction of the right
little finger of thirty-five years’ duration was recently in the Mile End
Infirmary. The flexion of the finger is associated with slight adduction
of the hand, but the parts can be straightened completely by passive
force. The condition is attributed to a wound near the elbow. There is no
lesion of sensation.

The group of affections known as _Writer’s cramp_ usually fall within the
province of the physician, and will only be briefly referred to. They are
of uncertain pathology, vary considerably in their manifestations, and,
although most common in persons much engaged in writing, are by no means
confined to these. The symptoms may assume three different types—spastic,
paralytic, and tremulous—affecting the muscles of the hands and forearm,
and these may be combined in various ways. The prognosis is unfavourable;
but the treatment found most hopeful is to relieve the affected muscles
from the strain to which they have been accustomed, and strengthen them
by massage and galvanism. Interference by surgical operation has been
unsuccessful, except in one case, in which Stromeyer divided the flexor
longus pollicis tendon.


CONGENITAL AND INFANTILE CONTRACTIONS.

These are usually of paralytic origin, but include a proportion of
cases of true hammer finger. The common form is that already described
by Mr. William Adams (Medical Society, December 1890), in which the
inter-phalangeal joints of one or more fingers (most frequently the
fifth) are flexed, and the integument on the palmar aspect forms a
longitudinal fold, which becomes tense when an attempt is made to
straighten the digit; the metacarpo-phalangeal joint is super-extended.
At first the finger may be fully extended by passive force, but after a
few years the position of flexion at the first inter-phalangeal joint is
rendered permanent by imperfect development of the ligamentous fascial
and even cutaneous structures in front of the articulation, while the
terminal phalanx usually remains more or less helpless. The condition
is probably dependent upon an infantile paralysis of the flexors of the
affected digit. The use of friction, passive movement, and electricity,
may be of value in the early stages.


TRIGGER FINGER.

The description of this curious affection has been left until the
last because its true nature is still an unsolved problem, and it is
hence difficult to place it in any of the groups already described. It
is indeed rather a pathological curiosity than an important item in
surgical disease, and many surgeons of long experience have never met
with a single example. Of the mechanism of its causation we know almost
nothing, of its ultimate tendencies we know little more, and its morbid
anatomy is almost entirely speculative. Nevertheless, it has a literature
extending over forty years, and comprising nearly a hundred separate
contributions, the last of which, a model in its way, is a monograph of
250 closely printed large octavo pages, the work of Dr. Carlier.

Trigger finger, the _doigt à ressort_ of French authors, may be defined
as a peculiar defect in the motions of the digit, consisting, first, of
an impediment which obstructs the movement of flexion or of extension,
or of both, followed, if the motive force be continued, by a sudden
cessation of the resistance, and a brusque, spring-like action that often
bears a remarkable resemblance to that which accompanies the opening
and closure of the blade of a penknife. The first observation was that
of Notta in 1850. A finger attacked by this affection generally lies
when at rest in a position of flexion, and by a voluntary effort or by
passive force may be straightened, with the peculiar result described
in the definition, the resistance to extension suddenly yielding with a
trigger- or spring-like action; and the same phenomenon is usually but
not necessarily repeated when the digit is again bent. In exceptional
cases a reverse condition obtains: the passive finger is kept in a state
of extension, and it is during flexion that the trigger phenomenon is
elicited. The movement may be merely inconvenient, or it may be more or
less painful. The sign may be constant, accompanying every movement,
or it may be intermittent, disappearing and recurring without any
obvious reason. It is usually confined to a single finger, but it may
be multiple. The digits most frequently involved are the middle finger,
the ring finger, and the thumb, while the index and little fingers are
relatively free, and the right side is more often affected than the
left. It is rather more common in women than in men (in the proportion
of three to two); and much more frequent in adults than in children, but
may appear at all ages. The etiology is ill understood. In many cases an
important influence, direct or remote, has been assigned to rheumatism;
in others the condition has been attributed to injuries of various
kinds; in others to occupations necessitating over-use of the digital
articulations (as in sempstresses); but no cause has yet been recognised
which can account for any large proportion of the examples.

_Pathology._—The explanations of the peculiar movement which
characterises the disease are for the most part of a purely theoretical
character, for, as might be anticipated, the opportunities for direct
examination of the structures have been extremely rare. It speaks highly
indeed for the ingenuity of our investigators that so many plausible
hypotheses have been constructed upon so small a basis of observed fact.
The views now open for consideration are as follow: (1) The development
of a fringe or other growth in the synovial sheath of the flexor tendons.
Such a tumour lying in the synovial cul-de-sac, which projects beyond
the proximal end of the tendon sheath when the fingers are flexed, would
be drawn within the theca during extension of the digit, and might in
this way oppose a resistance to the movement which would be overcome
as soon as the body had passed the constricted entrance of the theca.
(2) A nodose condition of the tendon due to the development of a growth
within the tendon or upon its synovial investment. Such a nodosity
is said to have been unmistakably palpable in many cases; but in two
examples examined by Carlier, where the tactile impression of a node
was remarkably strong, the tendons were found perfectly healthy at the
point of examination. On the other hand, Leisering of Hamburg actually
exposed a nodosity in the profundus tendon at the level of the point
at which it entered the canal of the flexor sublimis, excised it, and
cured the disease. In another case a fringe-like tumour was discovered
springing from the synovial covering of the flexor sublimis. The
nodosity accepted as a fact, the “spring” phenomenon accompanying must
be explained by the varying resistance of different parts of the theca,
the impediment occurring at either of the firm, resistant portions of
the canal which lie at the proximal opening of the sheath and opposite
the shafts of the first and second phalanges, and the sudden release
occurring at the weaker points, just above the metacarpo-phalangeal
joint, and in front of the first inter-phalangeal articulation. In the
case of the thumb, however, the fibrous sheath is much thinner than in
the fingers, and the variations of strength in its different parts are
comparatively slight after the inter-sesamoid portion of the canal is
passed. An obstruction offered to a nodule in the flexor profundus by
the channel in the flexor sublimis has been proposed as a cause; but
although this might be accepted for the fingers, it would not apply to
the thumb, which has but one tendon within its theca. (3) An alteration
in the shape of the articular surface, such as was first pointed out by
König in hammer toe. In these cases the movement of the distal bone is
intercepted by the presence of a ridge extending transversely across the
head of the proximal bone, and when by voluntary or passive force the
ligaments are made to yield sufficiently to allow the obstacle to be
surmounted, the movement is terminated by a sudden spring-like action of
the extensors or flexors, as the case may be. This condition undoubtedly
exists in certain cases of hammer toe and hammer finger; but it must
be recollected that these two affections are developmental, and always
begin during the period of active growth; while the great majority of
examples of trigger finger appear in adult life, after the osseous and
ligamentous elements of the articulation have assumed their permanent
form. Corresponding changes of form, however, might occur in rheumatoid
arthritis. (4) The development on the side of the head of the proximal
bone of an osseous excrescence, so placed that the narrow (proximal)
attachment of the lateral ligament must pass over it during the movements
of flexion and extension. The possibility of this condition, suggested
on theoretical grounds by Poirier, cannot be denied; it is, in fact,
normal in the tibio-tarsal joint of the ostrich; but its existence in
the human subject has yet to be demonstrated. It might well appear in
connection with rheumatoid arthritis, but indications of this disease are
found in only a small proportion of cases of trigger finger. (5) Spastic
irregularities of muscular action. According to this view, advanced by
Carlier, the muscle at fault is nearly always the flexor sublimis. It
must be recollected that the flexion of the first phalanx is effected
mainly by the interossei and lumbricalis, that of the second principally
by the flexor sublimis, and that of the third entirely by the flexor
profundus; the extension of the first phalanx is due to the common
extensor aided by the special accessory extensors in the case of the
index and little fingers; the corresponding movement of the second and
third phalanges is accomplished by the interossei and lumbricales. In the
thumb the metacarpo-phalangeal joint is acted upon by the long and short
flexors in the one direction, and by the extensores primi et secundi
internodii in the other, while the distal phalanx is flexed by the
long flexor and extended principally by the abductor and flexor brevis,
which send expansions to the long flexor tendon. If, then, we assume the
existence of a reflex spasm of the flexor of a joint the resistance must
be overcome by vigorous action of the extensors, or by passive force;
and if under these circumstances the spasm yield suddenly the spring
phenomenon might be closely simulated. The theory is ingenious, but it
involves certain difficulties in its application to trigger finger in
general: first, that the “spring” ought to be confined to the movement
of extension, unless we assume—and this perhaps is too much to ask—that
a similar spasm may affect the extensor also, and be overcome in an
analogous way; secondly, that the spring movement should be greatly
altered when the tendon of the sublimis is relaxed by flexion of the
wrist and metacarpo-phalangeal joint, a modification that has not yet
been recorded; thirdly, that it should disappear during complete muscular
relaxation under chloroform, and in some cases at least this has not
happened.

For the present we must confess our inability to decide the question.
In the majority of cases the tendon nodule hypothesis would explain the
phenomenon; and the articular theory might be tenable in adolescent
cases or where there is rheumatoid arthritis; but more direct evidence
is required and closer observation should be directed to the effect of
relaxation of groups of muscle by position, and of the muscular system
generally by anæsthetics.

The treatment must to some extent share in the uncertainty that attaches
to the pathology. The safest and most hopeful measures appear to be a
persevering use of passive movement, combined with massage. Surgical
operation has been successful in two or three cases, but in others it has
missed its mark and has probably left the patient in worse condition than
before.




SECTION II

CONTRACTIONS OF THE TOES


The whole of the morbid conditions described in connection with the
fingers are probably represented in the toes, and the classification
adopted in the former case may be applied with but slight modification to
the latter.


CONTRACTIONS DEPENDENT UPON PATHOLOGICAL LESIONS IN THE CUTANEOUS AND
FASCIAL STRUCTURES.

Lesions of the sole corresponding to Dupuytren’s disease in the hand are
extremely rare, on account of the protection afforded by the shoe and
the thickness of the plantar pad, and although cases have been mentioned
by Mr. Adams and other surgeons, I believe none has yet been shown or
discussed at any medical society. The following example deserves record:

    The patient, a gardener, aged fifty-seven, was admitted to St.
    Thomas’s Hospital in May last with contraction of both hands.
    He stated that he first noticed a slight contraction beginning
    in the ring finger of the left hand twelve years ago; in the
    course of a year or two the disease extended to the little
    finger, and afterwards to the middle finger. Four years since
    a similar affection appeared in the right hand, and shortly
    before admission he observed a superficial nodule on the sole
    of each foot. He had never suffered from gout or rheumatism,
    and had always enjoyed good health; the family history was
    negative. On examination the third, fourth, and fifth fingers
    were found contracted in both hands; the fourth and fifth
    fingers of the left hand being strongly bent at the first and
    second joints, and brought into contact with the palm, while on
    the right side the lesions were similar in character but less
    advanced. In each sole a flat subcutaneous nodule could be felt
    adherent to the plantar fascia and slightly to the integument
    over the head of the second metatarsal bone, but there was
    no puckering of the skin, and the position of the toes was
    quite unaffected. The contracted cords in both hands were
    divided by multiple subcutaneous incisions, and the fingers
    were extended by plaster-of-Paris splints. The nodule upon the
    right sole was excised, and found to consist of white fibrous
    tissue, longitudinally striated, and adherent to the fascia,
    but could be detached from it without difficulty. Under the
    microscope the appearances presented were identical with those
    in the early stage of Dupuytren’s contraction, and there is no
    doubt that the foot nodule was pathologically the same as the
    contracted tissue in the hands. The operations upon the hands
    and feet were successful.


CONTRACTIONS DUE TO DEVELOPMENTAL IRREGULARITIES IN THE ARTICULAR
STRUCTURES.

This group includes the conditions known as hammer toe, hallux flexus,
and some of the lateral versions of the toes.


HAMMER TOE.

This complaint may be described as a permanent flexion from the straight
line at either or both of the inter-phalangeal joints, without paralysis
of muscles, unattended with any primary degenerative or inflammatory
disease of the articular structures, and essentially confined in origin
to the period of active growth. Some precision of definition is necessary
to exclude similar deformities of wholly different pathological nature.

Hammer toe was known long before it became the subject of scientific
observation. According to Dr. Cohen,[8] the first printed description
was that by a French surgeon named Laforest, in a volume published in
1782, and entitled “L’Art de Soigner les Pieds”; but Laforest was the
successor of one Rousselot, who thirteen years earlier wrote a book to
which he gave the formidable name of “La Toilette les Pieds, ou Traité
de la Guérison des Cors, Verrues, et autres Affections de la Peau, et
Dissertation abrégé sur le Traitement et la Guérison des Cancers.” In
this essay a flexion of the toes attributed to the use of short shoes is
alluded to with sufficient clearness to make it probable that Laforest
had succeeded to the ideas as well as to the practice of his predecessor.
The first account, however, with any pretensions to science, was that
given by Boyer in 1822.[9] Since that time the subject has been discussed
repeatedly in France, and within the last few years has been brought
forward twice in England, at the Clinical Society in 1887, and at the
Medical Society in 1889.

The deformity is found in both sexes, but appears to be somewhat more
frequent in the male (three to two). The influence of _age_ is very
strongly marked. The condition invariably begins within the developmental
period, and may show itself at any time between birth and adult life, but
most frequently attracts the notice of the patient for the first time
during the third quinquennial period. Amongst a number of incipient cases
seen at Hanwell not more than one-tenth were under twelve years of age,
the little toe being usually the seat of the earlier manifestations. It
is said to be occasionally congenital. So far as my own observations go,
neither class, occupation, nor constitutional condition, appears to have
any share in its production.

It has long been a popular as well as a medical opinion that the
deformity is handed down by inheritance. Even Laforest, who contests
the belief, says, “Je m’entends souvent dire que l’on est né avec un
doigt ainsi; que c’est un doigt de famille.” Boyer asserted that it was
frequently inherited, and Blum and others have adduced examples in
support of this view. In a paper read before the Clinical Society in
1887, I referred to a history in four cases out of twenty-two which had
the same bearing; and other striking examples have since been brought
forward by Mr. Adams. In fact, some evidence of the influence of the
hereditary principle may be traced in at least a fourth of the examples
that come under notice, and is particularly frequent and clear amongst
patients of the educated classes.

                      F.*               M.*
                      |                 |
             +--------+--------+        |
             |        |        |        |
             F.       F.       F.*      M.*
                               \----v----/
                                    |
    +--------+--------+--------+--------+--------+--------+
    |        |        |        |        |        |        |
    F.       F.*      M.       M.       F.*      M.       F.*
                                        |
                               +--------+--------+
                               |        |        |
                               F.       M.*      F.*

    * The Asterisk indicates the members of the family who suffered from
    hammer toe. M. and F. signify sex.

The subjoined pedigree of a family in which the affection has arisen,
illustrates the descent through four generations. It was noted that the
children attacked were those who presented most resemblance in feature
and temperament to the grandfather. The deformity usually appeared about
the age of four, and was confined to the second toe. “Double-jointed”
thumbs were also an inheritance in the family. In another example
the condition developed in five children out of eleven. Here too
there was a history of “double-jointedness” in the fingers and thumb,
extending through three generations; and an aunt on the male side was
also the subject of hammer finger. This association of hammer toe with
other developmental irregularities is significant enough to deserve
attention. In addition to the instances mentioned, there are amongst
the seventy-three surgical cases on my list three accompanied by hallux
flexus, and one with retraction of both little toes; and there is little
doubt that coincidences of a like kind would more frequently be found
were it always possible to ascertain the facts by inquiry.

_Seat of attack._—In surgical cases the toe most commonly affected is the
second. In my list of 73 patients who had applied for treatment, this
digit was affected in all but four, while the third was attacked in five,
the fourth in one, and the fifth in three cases. In one instance the
affection of the third toe was symmetrical, each afforded only a single
example; but if all cases of contraction of the joint for 30° or more be
counted without reference to symptoms, the condition is far more frequent
in the little toe than in the others. Thus in an examination of a series
of 800 children under sixteen years of age the little toe was found to
be involved in forty-one cases, nearly all of which were double, while
the second toe was affected in six only, and the third toe in five. It
may be noted also that the projection of the extremity of the second toe
beyond that of the first—a condition regarded as a type by the ancient
sculptors—was present in only three instances. This is confirmed by
Professor Flower, who failed to find a single instance in many hundreds
of children.

The deformity is bilateral and symmetrical in nearly a third of the
cases, in the rest having a slight preference for the right side,
in the proportion of five to four. It is usually localised in the
first inter-phalangeal articulation, but occasionally implicates both
inter-phalangeal joints, or the distal joint only.

_Symptoms._—The stages of the deformity in a typical case may be
described as follows: In the _first_ period, which is rarely seen by
the surgeon, the toe is slightly extended at the metatarso-phalangeal
articulation, and flexed at the proximal inter-phalangeal joint. By
passive movement the flexed joint may often, but not always, be extended;
but the range of motion, even in the early stage, is found to be less
than that of the neighbouring or opposite toe. The distal joint is
usually unaffected, and may be held straight or slightly flexed, but
occasionally it undergoes contraction, either alone or in association
with the proximal articulation. There is no evidence at this or any
subsequent time of inflammation in or around the joint structures, except
in association with corns or bursæ. How long this period may last it is
difficult to say, as it may altogether escape the notice of the patient.
In the _second_ stage the flexion of the inter-phalangeal joint becomes
more pronounced, and the secondary extension at the metatarso-phalangeal
joint increases _pari passu_. At this period the affected articulation
is fixed for all movement of extension, but the power of flexion within
the limits left to it remains unimpaired; in other words, the angle may
be diminished, but not widened, and the toe, although contracted, is
neither ankylosed nor paralysed. In exceptional instances the flexion may
be overcome by strong passive force, and a distinct trigger-like action
established, the middle phalanx becoming extended and flexed again with
a movement very comparable to that which takes place during the opening
and shutting of the blade of a pocket-knife. As secondary results of the
contraction of the proximal inter-phalangeal joint the patient is subject
to certain inconveniences which may give rise to much suffering, and are
usually the immediate cause of his appeal to the surgeon. The chief of
these are a bursal formation, which is very liable to inflammation, over
the angle of flexion, and two associated callosities, one above the head
of the retracted phalanx, the other beneath the head of the metatarsal
bone, both consequent upon the pressure exercised by the boot. (See
Fig. 10.) A third callosity may develop over the tip of the toe, and
the soft parts over the terminal joint may become somewhat swollen, so
that the digit presents a clubbed appearance. The degree of interference
with functions and comfort varies greatly in different cases, partly in
relation to the degree of the contraction and partly to the sensibility
of the patient. In some persons a hammer toe of a marked kind will cause
so little trouble that no medical advice is sought—this is especially the
case when the contraction is limited to the little toe; in others the
suffering is so great that the patient begs the surgeon to remove the
offending member with the knife, and remains absolutely crippled until an
operation is practised for his relief. When the deformity affects more
than a single digit, an interval varying from a few months to five or six
years may elapse before the second attack appears. As a rule, it is the
corresponding toe on the opposite foot that suffers, but occasionally a
neighbour is selected; or even the distal joint of the same or another
toe.

[Illustration: FIG. 10.

A. Diagram showing position of bones in hammer toe, involving the
proximal joint; 1. Metatarsal bone; 2. Head of first phalanx; slight
groove corresponding to position of dorsal border of base of second
phalanx; 3,4, and 5. Callosities due to boot pressure; 6. Bursa over
contracted joint; 7, 8. Shoe. The arrow indicates the direction in
which the pressure of the upper leather tends to force downwards the
head of the metatarsal bone towards the sole. B. Dissection of first
inter-phalangeal joint in hammer toe; C. The same preparation after
section of plantar fibres of lateral ligaments.]

_Morbid anatomy and pathology._—The earlier opinions upon the pathology
of hammer toe were very conflicting. Gosselin, who dissected a specimen,
was unable to find any lesion. Fano, in 1855, mentions as the chief
defect a cartilaginous nucleus in the extensor tendon. Blum described a
luxation of the first phalangeal joint, with a thickening of the whole
capsule, and maintained that the contraction of the toe was due to a
peri-arthritis set up by the inflammation resulting from corns—a curious
example of “hysteron proteron.” Blandin attributed the affection to a
shortening of the plantar fascia; Boyer to a retraction of the extensor
tendons; Roche and Sanson to a contraction of the flexor tendons, and
other surgeons to a paralysis of the interossei, but no attempt was made
to separate true hammer toe from the arthritic and traumatic deformities
which simulate it. It is now beyond doubt that the essential seat of
the contraction is in the joint itself. The specimen represented in B,
C, Fig. 10, is one prepared by myself in 1882 from a toe which had been
amputated by a colleague. It showed that the deformity was not affected
by section of the tendons, but that it yielded immediately upon division
of the plantar fibres of the lateral ligaments where they blended with
the glenoid plate. This observation, which has been confirmed by a
dissection of Mr. Walsham’s, was not published until 1887, and it was
by Mr. Shattock, who, working independently, had found the same lesion,
that the condition was first made known at the Clinical Society in the
same year. The preparation illustrating his paper is now in the museum
of St. Thomas’s Hospital, as well as a second dissection demonstrating
the absence of disease in the interossei. The results of these and later
investigations may now be stated.

(1) There are no essential alterations of muscle or tendon except those
secondary to the contraction of the joint—namely, an undue tension
and prominence of the extensor tendon over the metatarso-phalangeal
articulation, and an adaptive deficiency of length in the flexors,
which are prevented by the permanently bent state of the articulation
from keeping pace in growth with the osseous structures. (2) The skin
and fasciæ in like manner are unaffected or only undergo a secondary
shortening on the flexor side in severe and long-standing cases. (3)
The articular surfaces generally show no change beyond atrophy of that
portion of the cartilage of the head of the proximal bone, which is
permanently excluded from contact with the distal bone in consequence of
the imperfect range of extension of the joint. In some cases, however, a
distinct transverse groove is present on the head of the proximal phalanx
at the point where it comes in contact with the dorsal border of the
base of the distal bone during the attempt at extension, and behind this
groove the bone may be heaped up into a little ridge. It is the existence
of this irregularity that explains the trigger phenomenon previously
alluded to. (4) The ligaments present no structural change, but an
important quantitative defect is always found in the plantar fibres of
the lateral ligaments, which are so short that they check prematurely the
movement of extension of the joint.

The real origin of the articular defect has been the source of much
argument. At all times, whatever may have been the opinion as to
the exact morbid anatomy of the condition, there has been a strong
disposition to blame the shoemaker, or rather the fashion that dictated
the arbitrary form the shoe was to assume, as the prime cause of the
disease. There is, of course, no question that the mistaken ideal of
elegance which finds expression in the demand for tight and pointed
boots has been the cause of much misery and deformity, and it appears
only natural to assume that the artificial crowding together of the toes
might force one of the members to assume a position of retraction, in
order to make room for the rest, and the digit so drawn up might after
a time become permanently fixed in its abnormal attitude. This view is
well expressed by Mr. Ellis,[10] but the study of a number of cases of
hammer toe furnishes strong reason for doubting this fatally plausible
hypothesis. The deformity may be seen in early infancy, before any rigid
foot covering has been adopted; and a precisely analogous condition is
known to exist in the fingers, which are not subjected to any artificial
restraints. Moreover, in the great majority of the feet affected with
hammer toe there is a complete freedom from the deformities which are
known to result from overcrowding of the digits, and there is seldom
anything in the history of the cases to indicate the past use of improper
boots.

It has been said that hammer toe is unknown in countries where boots
are not worn; but the subject has yet to be studied in those parts of
the world on a scale that sanctions generalisation. Moreover, as hammer
toe is painful only in consequence of the friction and pressure induced
by the foot-covering, its existence would be unlikely to attract much
attention in a bootless race. During my own residence of six years in
Japan I never met with an example, and my friend Surgeon-General Takaki
writes to me that his observations, covering a period of fifteen years,
are equally negative; but it must be noted that it is the rising and
boot-wearing generation that has been especially brought under our
notice, and the conclusions to be drawn from our experience tend as much
to contradict the view that boots are an immediate cause of hammer toe,
as to support the belief that the Japanese are exempt from the defect.
There is little doubt, however, that the use of shoes is to some extent,
and in a remote sense, a predisponent to this and to other analogous
deformities, for it is certain that a rigid leather foot-covering, even
when shaped according to the most scientific principles, must necessarily
impede the free action of the toes, and so interfere with the processes
of nutrition and development; but I am equally confident that few,
if any, of the examples of hammer toe that have come within my own
experience could be traced to any special defect in the form of the shoe.
Out of the whole number only six confessed to having worn tight boots.
In the rest, neither history nor inspection indicated any fault of the
kind, and the feet in the great majority were perfectly well formed in
all other respects, and bore no marks of injurious compression. In a case
of inherited hammer toe in which the proximal joint of the second digit
of the right foot was straightened by operation, the boots worn before
and after the operation were made upon sound anatomical principles; but
nevertheless the patient came two years later with a contraction of the
distal joint of the same toe and of the middle toe of the opposite foot,
and a lateral distortion of the fourth toe.

The pathological explanation I believe to be that advanced to account
for the occurrence of hammer finder. The examination of a large number
of healthy feet will reveal physiological variations in the condition
of the inter-phalangeal joints exactly comparable with those noted in
the hands. The second phalanx may in some persons be super-extended 30°
beyond the axial line of the proximal bone, while in other instances the
movement is arrested by tension of the plantar fibres of the lateral
ligaments before this line has been attained;[11] and in the distal joint
even greater variation may be found. There is, in fact, a physiological
tendency to hammer toe in large numbers of people who never actually
suffer any inconvenience from it, and it is in the exaggeration of this
physiological irregularity that we have to seek the pathology of the
surgical hammer toe. The tendency ceases at adult life, because the
ligamentous and bony structures of the articulation have then assumed
their permanent condition, and any later deformity simulating it can only
occur as a result of a totally different set of conditions.

Hammer toe, then, like hammer finger, must be regarded as the result
of inadequate longitudinal evolution of the ligaments which limit the
movement of extension at the inter-phalangeal joints, and the symptoms
induced by the deformity are mainly dependent upon the formation of
callosities and bursæ by contact with the opposed hard surfaces of the
foot covering. This irregularity of development may be either inherited
or accidental.

_Treatment._—It is probably not within our power to prevent the
occurrence of hammer toe, even by the greatest care in the selection of
boots. For its relief when developed many plans have been adopted, the
chief of which are as follow:

1. Extension by splints of various kinds in the early stages, while the
contraction may be overcome by passive force. The condition is rarely
seen by the surgeon in this period, but should it fall under observation
the persevering use of passive extension is preferable. When the
deformity is well marked, splints are painful and useless.

2. Tenotomy of the extensor tendon (Boyer). This measure, which was
doubtless suggested by the visible tension of the tendon in many cases,
is more likely to aggravate than to relieve the symptoms.

3. Tenotomy of the flexor tendons. This to be successful must involve
also the section of the glenoid and lateral ligaments. Such an operation
has been practised both by the subcutaneous and by the open methods,
but it involves the risk of division of the plantar digital nerves, and
the necessity for a prolonged after-treatment to prevent recurrence.
It has even been advised by Petersen to treat the contraction by a
transverse incision, through integuments, tendons, and ligaments, down
to the articulation, but the promptitude of the method is its sole
recommendation.

4. Subcutaneous division of the lateral ligaments has been performed with
good results by Mr. Adams, but it has the disadvantage of requiring a
long after-treatment.

5. Resection of the joint. This is unquestionably the most eligible
measure, and has been successfully practised on different plans by
various surgeons during the last twelve years or more, both in England
and France. The articular extremities of both bones may be removed or the
head of the proximal bone only, the distal bone being left intact. In
either case the toe is subsequently fixed for a period of three or four
weeks in an extended position. The procedure I have found most speedy and
satisfactory is as follows: An incision is made on the lateral aspect of
the affected articulation, following the axis of the bones and exposing
the lateral ligament, while leaving intact the vascular and nervous
trunks. The ligament is then divided, by a touch of the knife, and by a
forcible lateral movement the head of the proximal phalanx is made to
protrude through the wound, and is removed with a pair of bone nippers.
The toe is straightened, the wound closed by sutures (without drainage),
and dressed. Antiseptic precautions must be strictly observed, and the
operation must not be performed until all inflammatory signs have been
removed from the superjacent corn. The operation can be completed within
two or three minutes, and, what is a far more important consideration,
it involves the least possible interference with the structures of the
toe. The wound heals by first intention, and after a fortnight’s rest
the patient is able to walk, the toe being extended for a few weeks
upon a dorsal splint of flat steel, such as was used in making the now
obsolete appendages to the back of the feminine skirt. The result is all
that could be desired, and the relief immediate and permanent. The same
operation is applicable for the distal joint, but is less easy.

6. Amputation was, until within the last ten or twelve years, the usual
resource after the failure of tenotomy of the extensor. It affords a
curious comment upon the surgery of the pre-antiseptic period that the
chief reason given against this operation by the early writers was its
danger to life. At the present time it can rarely be needed unless, by
any accident, the antisepsis of the resection operation fails and acute
inflammation sets in. The objections to it are the mutilation, and the
tendency to lateral distortion of the adjacent toes to fill the gap left
by the lost member.


HALLUX FLEXUS.

_Hallux flexus_ appears to have been first recognised as a separate
affection only a few years ago, in 1887, and it is to Mr. Davies-Colley
that we are indebted for the name and for the earliest discussion of
the characters and causation of the disease. It is stated, however,
by Blum that Nélaton described a “cou de cygne” of the great toe, and
attributed it to the use of short boots. I have been unable to discover
the reference in the works of this surgeon, but if the citation can be
verified, the credit of recognising the existence and nature of the
deformity will fall to him, for there is no doubt that hallux flexus is
pathologically a “cou de cygne” or hammer toe. Since Mr. Davies-Colley’s
introduction of the subject various contributions have been made, by Mr.
Howard Marsh, Mr. Reginald Lucy, Mr. Cotterell, Mr. Ellis, and others,
and I must draw especial attention to a valuable analysis of thirteen
cases by my colleague, Mr. Makins, in the St. Thomas’s Hospital Reports
for 1888. The complaint is by no means a rare one, for since 1887,
when I began to take notes of all the cases that were brought under my
observation in private and hospital practice, I have accumulated a list
of thirty examples of what may be termed true “hallux flexus,” besides a
number of contractions presenting a superficial resemblance to it, but
resulting from arthritic lesions. I propose, as in the case of hammer
toe, to separate these latter entirely from the former, because the
pathological, and even the clinical, distinctions between the two classes
are perfectly well marked, and it hence can only mislead to place them in
the same category.

Hallux flexus may be defined as a progressive diminution of the normal
range of extension at the metatarso-phalangeal, or, more rarely, at
the inter-phalangeal joint of the great toe. It is unassociated with
any disease of the bones, cartilages, or synovial membrane of the
articulation, and originates only during the period of active growth.
It is, in fact, a “hammer great toe,” and it will be found strictly
analogous to the disease just described, occurring under the same
conditions and affecting the corresponding articulations.[12] The name
proposed by Mr. Davies-Colley has been objected to on more grounds
than one. In the first place, there is perhaps a lack of soundness in
the pedigree of the word “hallux.” It is a rather modern addition to
anatomical nomenclature, and its sanction in classical literature is
very dubious. In Plautus there is an expression “hallex viri,” implying
a little man, a “thumbling,” and the words “hallex,” “allex,” and
“hallux” have been used by other writers with a somewhat questionable
signification for the great toe. A purist might indeed be justified in
opposing the adoption of either “hallex” or “hallux,” and especially the
latter; but the convenience attached to a distinctive name for the great
toe in place of that of “pollex,” which is applied also to the thumb,
is so great that we are not tempted to be hypercritical on philological
grounds. A more serious objection has been raised against the adjective
“flexus,” because in the majority of cases the toe is not actually in
the position of flexion; but the term “flexion” may be applied in the
sense of movement as well as in that of position; and although the great
toe in hallux flexus may not reach the position of flexion, it has
passed through the motion of flexion before it has attained the line of
direction in which it is found in the disease.

_Symptoms._—In a typical case of hallux flexus the patient, usually
a boy near the age of puberty, suffers some little pain about the
metatarso-phalangeal articulation of the great toe in walking, at the
moment when the weight of the body falls chiefly upon this joint. Rest
affords complete relief, and the structures about the articulation
show no signs of inflammation. As time goes on the pain increases and
becomes associated with a sense of rigidity of the toe, and the power
of full extension becomes lost. The diminution of the range of movement
is very gradual, and usually it is not until the proximal phalanx can
no longer be extended beyond a line corresponding to the prolonged
axis of the metatarsal bone that the condition is brought before the
surgeon, but in more extreme examples the toe becomes actually bent below
this axis, so that it forms with the metatarsal bone an obtuse angle
with plantar opening. The foot is now seriously crippled. Over-use in
walking induces much suffering, and any attempt at passive extension
is extremely painful, while flexion still remains unimpaired. The head
of the metatarsal bone thrown into prominence by the unwonted position
of the proximal phalanx looks abnormally large. In some cases a reflex
hyperæmia of the tissues surrounding the joint may be induced by forced
exercise; but there is rarely, if ever, any effusion within the capsule.
The patient finds walking more and more difficult, and to avoid pressure
upon the contracted articulation limps on the outer edge of the foot; but
this gives little relief, and at last he is compelled to rest. In the
more severe cases the patient consults the surgeon; in the slighter forms
he puts up with the inconvenience, and we may assume that he recovers
without professional assistance, for the condition is very seldom found
after the attainment of full adult life.

An analysis of my series of thirty cases shows that the deformity is
much more frequent in boys the number including only three girls. (In
the series of thirteen cases recorded by Mr. Makins the proportion
of males to females was eleven to two). It was bilateral in one case
only, right-sided in nineteen cases, left in ten, and affected the
metatarso-phalangeal articulation in every instance, except two in
which the distal joint was involved. (Fig. 11.) In only three cases
did the flexion pass the prolonged axis of the metatarsal bone, the
angle reached in the worst example being 150°; in the rest the toe
during full extension was either in a line with the metatarsal bone,
or formed with the latter a very obtuse angle, 170° to 160°, with the
opening towards the dorsal aspect. The ages at which the symptoms were
first noticed ranged from twelve to eighteen, in the greater number
lying between fourteen and sixteen. The associated deformities were:
excessive length of toe in two cases, this amounting to a distinct giant
growth in one, hammer toe (second) in one, hallux valgus (slight) in
three, flat-foot in four, and slight varus in one. In the other cases
the feet were perfectly normal in shape. The duration of the disease
before the patient came under treatment varied from three months to four
years. Occupation appeared to exercise little influence; the subjects
were mostly schoolboys, labourers, and errand boys, but there was no
reason to believe that there had been any unusual strain upon the powers
of endurance, except in two instances. In two cases the condition was
attributed to the use of short boots, but in the others no complaint was
made as to the foot covering, and that in wear at the time of attendance
was as unobjectionable as the materials and plan of the modern boot will
allow. Constitutionally, the patients were, for the most part, a little
below the average in physique; one (a girl) was tuberculous, and one was
a child of rheumatic parents, but none had suffered from rheumatism.
The result of inquiries with respect to inherited tendencies was less
striking than in the case of hammer toe. In one instance the father had
double hammer toe, in another a brother had suffered from hallux flexus
at the age of sixteen, and became cured without medical intervention
in the course of three years; but in the majority no satisfactory
information on the point could be obtained.

[Illustration: FIG. 11.

Hallux flexus of the distal joint.]

_Progress._—There can be little doubt that the natural tendency of the
complaint is to subside under the mechanical influence of ordinary
exercise, and hence, although the deformity is fairly common in youth,
it is rarely found in fully developed adults, except where the distal
joint is affected. In one case of this kind the contraction began about
puberty, and was still present at the age of fifty-two, but the defect
never interfered materially with locomotion. It is possible that some
of the ordinary cases terminate, as suggested by Mr. Davies-Colley, by
conversion into hallux valgus, but my inquiries have failed to confirm
this.

_Pathology._—The origin of the condition may be explained in the same
manner as that of hammer finger and hammer toe. There is a physiological
variation in the range of movement permitted in the articulations of
the great toe similar to that demonstrated in the fingers and lesser
toes, and in examining a number of healthy feet it will be found that
the position of extreme super-extension at the metatarso-phalangeal
joint may lie at any point between 30° and 110° beyond the prolonged
axis of the metatarsal bone; but if the movement of extension be checked
at less than 30°, the symptoms of hallux flexus supervene. The chief
distinctive feature in the anatomy of the joint lies in the substitution
of two sesamoid bones, with their tendons and connecting tissue, for the
glenoid plate developed in all the other articulations, and it is those
structures that receive the distal attachment of the plantar fibres of
the lateral ligaments. (Figs. 12 and 13.) The function of the lateral
ligaments, however, remains the same as in the other toes, and the range
of the movement of extension is governed by the development of their
plantar fibres.

[Illustration: FIG. 12.

Bones and ligaments in hallux flexus. 1. Lateral ligament of
metatarso-phalangeal joint; inferior fibres attached to sesamoid bone; 2.
Lateral ligament of inter-phalangeal joint; inferior fibres blending with
glenoid plate.]

[Illustration: FIG. 13.

Hallux flexus of the distal joint.]

The opportunities of examining the morbid anatomy of the complaint are
necessarily very few. Mr. Davies-Colley’s specimen proves that the
structures restraining the movement of extension correspond to those
concerned in the production of hammer toe, those fibres of the lateral
ligaments which blend with the osseo-tendinous structures replacing the
glenoid plate; and the cause of the deformity in both cases appears to
be an irregularity of nutrition by which the ligamentous fibres undergo
imperfect longitudinal development, and consequently induce premature
arrest of the movement of extension. This developmental defect is
probably unconnected with any special error in the form of the shoe.
Like hammer toe, the deformity occurs at the age most prone to nutritive
disturbance; but hallux flexus tends to undergo cure without the help of
the surgeon, because the weight of the body serves as an extending force,
which sooner or later proves stronger than the resistance opposed; while
in hammer toe the lesser digit is not essential to locomotion, and its
retraction at the metatarso-phalangeal joint frees the inter-phalangeal
joint from all necessity for action, and favours the permanency of the
vicious position.

Hallux flexus of the distal joint must be distinguished from the
paralytic hallux retractus which simulates it (see p. 127).

_Treatment._—Bearing in mind the fact that true hallux flexus has a
natural tendency to recovery, it is obvious that the graver surgical
operations can seldom be called for. In the case of hammer toe a
resection of the articulation may be undertaken without hesitation,
because the deformity is more likely to become aggravated than relieved
by lapse of time, and because the function of the digit is not sensibly
interfered with by obliteration of the joint; but the destruction of
the metatarso-phalangeal joint of the great toe entails a permanent
alteration of gait. The treatment I have adopted in the milder cases
is to instruct the patient to perform a regulated series of passive
movements of the toe by the use of his hands, aiding the process by
massage of the lower and inner side of the foot, and as the tenderness
passes away to practise walking on tiptoe until the normal degree of
extension is restored. In more severe examples I have extended the joint
forcibly under an anæsthetic, afterwards fixing it in the super-extended
position in a plaster splint for three weeks. The result of this plan
has been so satisfactory that I have found it unnecessary to do more,
but should it fail, we have the choice of several plans: (1) Section of
the lateral ligaments, subcutaneously or by means of an open wound. (2)
Excision of the head of the metatarsal bone, an operation necessarily
involving obliteration of the joint and a shifting of the point of
support to the distal joint, which is less well fitted to discharge the
office. It might, however, be permissible in certain cases. (3) Excision
of the proximal half of the first phalanx. This has been successfully
effected by Mr. Davies-Colley. (4) Osteotomy of the metatarsal bone above
the head, with excision of a dorsal wedge proportioned to allow the toe
to be placed in a position of slight super-extension, the articulation
being preserved intact.

It is improbable that any of these more severe measures will be required
if the method of forcible reposition be well carried out.


HALLUX VALGUS.

This, the most common of all digital deformities, may be defined as an
eversion of the great toe at the metatarso-phalangeal joint, and in some
instances of the phalangeal joint also, with alterations, adaptive or
causative, in the bony and ligamentous apparatus of the articulation. It
is often accompanied by deformities of the other toes and by flat foot.
In its milder forms it must be regarded as a simple malposition caused
by the use of boots constructed on the principle of median symmetry; and
as this fault is more common in the shoes made for women than in those
worn by men, the distortion is far more frequent in the latter sex. In
a large number of patients examined by Dr. Robinson and myself in the
female wards of the Mile End Infirmary, over ten per cent. were found
to be affected in greater or less degree; while in the male wards the
proportion did not exceed three per cent. It is a noteworthy fact that
the deformity is comparatively rare in the period before puberty. I was
able to find only three examples, and these of a very slight kind, among
800 children under the age of sixteen; while incipient hammer toes and
hammer fingers were present in considerable numbers. This early immunity
is probably due to the fact that the vanity which leads the adolescent
to sacrifice comfort to a false elegance has not awakened in the child.
The more severe cases of hallux valgus in which the toe is so far everted
as to form an angle of from 120° to 90° with the metatarsal bone are
comparatively rare, the total number amongst 2600 persons amounting to no
more than thirty (twelve male and eighteen female). It is with these that
we are especially concerned, and it is probable that they are closely
related in origin to hallux flexus.

_Morbid anatomy._—On examining a well-marked hallux valgus it is seen
that the facetted surface of the head of the metatarsal bone has been
extended considerably over the external aspect, the prominent inner side
of the head lies beneath the stretched joint capsule, the sesamoid bones
are displaced outwards from their normal grooves, the internal lateral
ligament is greatly elongated and considerably thickened, the external
ligament undergoes an inversely proportionate shortening and opposes the
reposition of the displaced phalanx (Fig. 14); and the cartilage over the
portion of the joint surface, removed from its normal contact with the
opposed bones, presents marked degenerative changes. The integumentary
structures over the projecting head of the metatarsal bone are affected
in the same way as those over the angle of flexion in hammer toe, as a
consequence of friction by contact with the shoe leather; callosities and
bursal formations, often of great size, are found, and inflammation of
the abnormal bursa may give rise to great suffering.

[Illustration: FIG. 14.

Hallux valgus. From a preparation at St. Thomas’s Hospital.

A. _Dorsal aspect._—1. Metatarsal bone; 2. Elongated and thickened
internal lateral ligament, a large bursa lay over this; 3. First phalanx;
4. Shortened external lateral ligament; 5. Displaced external sesamoid
bone.

B. _Plantar aspect._—1. Metatarsal bone; 2. Degenerating cartilage over
disused sesamoid furrow; 3. Displaced internal sesamoid bone; 4. Section
of thickened capsule (the structure had here assumed the character of a
glenoid ligament); 5. First phalanx; 6. Displaced external sesamoid bone.]

Although the great majority of cases of hallux valgus are undoubtedly
provoked by ill-shaped boots, it is probable that some, and especially
those of a very aggravated type, are, like hallux flexus and hammer
toe, dependent essentially upon causes not obviously connected with any
vice in the foot covering. It is at least certain that some examples of
extreme deformity are confined to one foot, the opposite member being of
normal shape—a fact that strongly negatives the boot theory; and there
are also bilateral cases in which the form of the distortion and the
history given by the patients and friends make it equally difficult to
accept the common explanation. In one instance recently under my notice
the first, second, and third toes of the left foot were carried outwards
over the fourth, producing a deformity of a strongly marked kind, while
the right foot was perfectly well formed, and the patient, an intelligent
woman, insisted that “the toes went wrong by themselves while she was
growing up,” and that her shoes had nothing to do with it. In some cases
the conditions may be traced to paralytic or spastic affections, and if
we accept the developmental theory with respect to hammer toe and hallux
flexus, we may assume that hallux valgus occasionally arises in the same
way.

_Treatment._—Hallux valgus, like hammer toe, is often rather a question
of æsthetics than of pain or inconvenience, and the patients are only
moved to see the surgeon by a natural desire to get rid of a deformity;
but in many cases the inflammatory complications occuring in connection
with the associated “bunion,” or the interference with the neighbouring
toes, upon whose territory the larger digit is encroaching, may give rise
to actual and even intolerable suffering. In the milder examples the
use of a well-shaped boot, and a stocking made with a separate pocket
for the great toe, as recommended by Mr. Ellis, will be sufficient to
allow the rectification of the defect, and to these elementary measures
may be superadded Bigg’s bunion spring, which can be obtained from most
instrument makers, or a vertical septum may be introduced into the boot
in the normal position of the cleft between the first and second toes. In
the more severe cases these plans of treatment are insufficient, and we
then have the choice of several alternatives.

1. Section of the neck of the metatarsal bone with excision of a
cuneiform segment from the tibial side has been performed successfully
by Mr. A. E. Barker.[13] This allows the articulation, together with
the entire toe, to be restored to the straight line, but the abnormal
disposition of the articular surfaces and ligaments remains uncorrected,
and there is reason to fear that trouble would arise later.

2. Forcible rectification under an anæsthetic is satisfactory for
slighter cases. It may be aided if necessary by subcutaneous section of
the opposing tendinous and ligamentous structures on the tibular side,
and the toe is fixed for two or three weeks in plaster of Paris. The
rectification should be preserved by the use of properly constructed
shoes with a septum between the first and second toes, when the patient
begins to walk.

3. Resection of the joint is undoubtedly the best operation in the
more severe operations of hallux valgus. Involving the obliteration of
an important articulation, it was feared that it might induce serious
crippling, but the plan has been adopted with perfect success by Mr.
Clutton[14] who, excising the cartilaginous extremities of the bones and
fixing the shafts in suitable position by means of an ivory peg, has
secured the best results. During the last two years I have applied the
principle of the operation recommended for hammer toe. Excision of the
head of the metatarsal bone is performed through a longitudinal incision
over the inner side of the joint, the toe is then replaced and fixed
for three weeks in a slightly extended position by means of plaster of
Paris. The success of these measures is far more complete than could have
been anticipated on theoretical grounds. The distal joint appears to
replace almost perfectly that which is lost, and the locomotion is easy
and unfatiguing. In a case of my own the patient was able to walk twenty
miles a day within three months of the operation.


HALLUX VARUS.

[Illustration: FIG. 15.

Hallux varus. A. Before operation; B. Three years after operation. The
relatively small size of the great toe in B is due to the abnormally
great development of the other toes (not represented in Fig. A).]

The following is a curious example of this rare condition, in association
with macrodactyly. The patient, a boy aged eleven, was admitted into
St. Thomas’s Hospital in March 1887, with a deformity of the right great
toe, dating from infancy. The member was somewhat imperfectly developed,
and projected inwards almost at right angles with the metatarsal bone.
(See Fig. 15, A.) A slightly prominent integumental fold was present on
the inner side of the metatarso-phalangeal joint, and the ligamentous
and other fibrous tissues beneath this resisted the replacement of the
digit in its normal line. The toe could be moved feebly by an effort of
the will, but the abnormal direction of the member prevented the muscles
from exercising any useful function. The smaller toes were distinctly
hypertrophied, but were otherwise well formed. The boy was unable to wear
a boot, and was completely crippled. The toe was apparently useless, but
it was judged advisable to restore it to its natural position rather than
to amputate. This was effected by subcutaneous division of the internal
lateral ligament and the application of a small plaster apparatus.
Fifteen days later the child left the hospital with a light metal splint
fixed to the inner side of the foot and toe. Three years afterwards he
presented himself for examination, and it was found that the good result
was more than maintained, as the toe was not only straight, but had
acquired its normal size and considerable power of movement. The boy said
he was able to walk seven or eight miles without fatigue. The relative
hypertrophy of the lesser toes was still obvious.


LATERAL DEVIATION OF THE LESSER TOES.

This is frequent in childhood. It was found in twenty-five children,
twelve males and thirteen females, out of 800, the ages of the subjects
ranging between five and fourteen. The version is usually at the first
inter-phalangeal joint, but may also be present in the distal joint, and
the toe much more frequently diverges towards the tibial than towards
the fibular side (six to one). It may lie over or under its neighbour.
The fourth toe is affected in about two-thirds of the cases, while the
second, third, and fifth toes take an almost equal share in making
up the remaining third. It is symmetrical in nearly two-thirds of the
examples (sixteen out of twenty-five). In the early stage the joint may
be straightened by passive force; but in the later, reposition is opposed
by ligamentous tension, and perhaps by some alteration in the form of the
bone. Like hammer toe, it occurs only during the developmental period,
and there is no reason to connect it with any special defect in the
shape of the shoe. In none of the examples under my own observation was
it associated with hallux valgus; but a double hammer toe (third) was
present in one case, and version of the fingers in three others. The
children appeared to be in good health. The deformity may usually be
relieved by the use of a splint, like that recommended for hammer toe;
but in some cases a partial resection might be advisable.

_Inversion of the little toe at the metatarso-phalangeal joint_ is
occasionally met with. It appears always to arise during the period of
active growth and is associated with shortening of the extensor tendon.
Subcutaneous section of the tendon allows complete reposition, and
the cure may be made permanent by temporary fixation in plaster, and
subsequent attention to the feet. The origin of the condition is obscure.


ARTHRITIC DEFORMITIES OF THE TOES.

_Arthritic hammer toe_ may be due to rheumatoid arthritis, gout,
rheumatism, or traumatic inflammation. The variety dependent upon
rheumatoid arthritis is the most common of these, and the most likely
to be brought under the eye of the surgeon. Its characteristics are
as follows: 1. It is not limited to the developmental period, and may
occur at any age in association with the causative disease, but it
is most frequently met with after middle life. 2. The deformity is
usually present in many or all of the toes and in both feet, and may
be associated with lateral (fibular) displacement of the digits, and
with bony outgrowths at the margin of the affected articulations. The
movements of the joints are much more impaired than in true hammer
toe, owing to changes in the cartilage; and fibrous ankylosis is often
present. 3. Manifestations of the causative disease may be found in other
parts of the body.

In the great toe the direction of the distortion appears to depend upon
the size and position of the osteophytic developments at the margin of
the affected articulation. Most commonly the position simulated is that
of hallux valgus, more rarely that of hallux flexus, and we may also find
a condition in which the distal phalanx is bent upwards, so that the
nail approaches or even touches the dorsal surface of the first phalanx.
(See Fig. 16, A.) This is a painful deformity and calls for treatment. I
have not yet seen an arthritic hallux varus. It is probably rare, because
the form of the boot opposes the divergence of the toe in the inward
direction.

[Illustration: FIG. 16.

Rheumatoid arthritis. Retracted hallux with arthritic hammer toes.

A. Before operation; B. After operation. The dotted outline in A
indicates the position of the flap made to expose the diseased joint.
From casts at St. Thomas’s Hospital.]

It is unnecessary here to say anything as to the nature and course
of the general disease. As a rule the case falls into the hands of
the physician, and the surgeon is rarely asked to intervene. It must
be pointed out, however, that the contractions may cause severe
inconvenience, and that despite the intractable nature of the complaint
the reaction of the patient to surgical operation is favourable, recovery
being nearly as speedy as in true hammer toe. I have on two occasions
operated with the result of considerable relief to suffering, and without
any surgical casualty. In one instance eight toes underwent operation at
a single sitting, and the wounds all healed by immediate union.

In gouty contractions of the toes the history of the sudden and painful
inflammatory attacks preceding the deformity, the almost constant
implication of the first metatarso-phalangeal joint, and the presence
of other indications of gout leave no question as to the nature of the
disease. In this affection the surgeon can rarely be called upon to
interfere. The distortions of the great toe are generally associated with
eversion—a valgus—and complete ankylosis may supervene. Contractions
in association with acute rheumatism or acute rheumatoid arthritis are
comparatively rare. Lastly, certain arthritic affections of neuropathic
origin may produce ankylosis of the joints, sometimes in association with
rapid atrophy of the muscular and integumentary structures, as in a case
shown by the author at the Medical Society in 1893 (_Trans._, vol. xvii.
p. 104).


PARALYTIC CONTRACTIONS OF THE TOES.

Deformities of this kind may be met with in association with various
diseases of the nervous system. The most common condition is a hammer
deformity of the lesser toes, with retraction at the metatarso-phalangeal
joint, and an exaggeration of the plantar arch (paralytic cavus). This
is probably due to paralysis of the interossei in nearly all cases.
Occasionally a single toe is affected. In the great toe it may arise
from paralysis either of the short flexors or of the tibialis anticus
(as pointed out by Mr. Davies-Colley), and is associated with retraction
of the first phalanx and flexion of the second. In the smaller toes
the digits assume a position like that of the clawed finger in ulnar
paralysis, with extension of the proximal and flexion of the middle and
distal phalanges, but, unlike in true hammer toe, there is distinct
evidence of paralysis, and the capacity of the flexed joints for passive
extension is usually retained for long periods. In these cases where the
unopposed extensor leads to very inconvenient retraction of the first
phalanx the tendon may be divided, and Mr. Davies-Colley suggests that
the proximal cut end should be fixed to the metatarsal bone in order
to preserve its utility as a dorsal flexor of the ankle. The return of
the deformity must be prevented by the subsequent use of splints and
manipulation.




SECTION III

CONGENITAL DEFORMITIES OF THE HANDS AND FEET


The congenital deformities of the hands and feet are very numerous.
They include excessive growth, a variety of other irregularities and
deficiencies of nutrition, numerical increase of parts and abnormal
union of digits. These defects are often hereditary, they may co-exist
in various combinations, and may be associated with faults of evolution
in other parts of the body. In most cases the _rôle_ of the surgeon is
limited to the removal of useless or unsightly parts, but occasionally a
higher function is open to him.

The most interesting of the congenital defects of the digits is the
curious and often complex condition known as makrodactyly.

[Illustration: FIG. 17.

Various congenital defects of the hands and feet (from Förster,
Missbildungen des Menschen).

1 to 4 and 15.—Numerical defects of fingers.

5 to 14.—Hands and feet with combination of hypertrophy and defective
development of fingers and toes, all from the same individual. 10 to 14
show the crab-like deformity described in the text (p. 147).

16, 17, 18, 19.—Syndactyly. In 16 and 19 the united fingers are larger
than their neighbours. In 17 and 18 the union involves all the fingers
except the first, and on one hand the number of digits is reduced to four.

20, 21.—Hand and foot with suppression of first four digits. In 20 there
is a rudiment of the index or middle finger.]


MAKRODACTYLY.

The earliest examples of “congenital hypertrophy” recorded in this
country were those of Dr. Reid, published in the _London and Edinburgh_
_Monthly Journal of Medical Science_ for March 1843, but before this date
a characteristic case of makrodactyly had been carefully described by
von Klein,[15] and other instances had been brought forward by Beck[16]
and Wagner.[17] Reid’s paper was followed by a valuable article by
Curling,[18] and contributions by Ideler,[19] Adams,[20] Devouges,[21]
Chassaignac,[22] Annandale,[23] and others, but the first attempt to
classify the cases was that of Busch,[24] in 1866. Since this time many
additions have been made to the literature of the subject, the most
important of which are those of Trelat and Monod,[25] Vogt,[26] von
Fischer,[27] Wittelshöfer,[28] and Humphry.[29]

The condition may be defined as a gigantic growth, congenital in
origin, of various segments of the body exclusive of the viscera. It
is generally unilateral, and limited to one extremity or portion of an
extremity; it tends to implicate especially the bones and joints, and the
adipose and vascular elements of the subcutaneous tissue. It does not,
as a rule, impair to any important extent the functional capacity of the
part.

The name “congenital hypertrophy” is open to criticism. There is little
doubt that the abnormality always has its origin in fœtal life, but
it has seldom been noticed immediately after the delivery of a child;
and, on the other hand, in one case recorded by Lannelongue,[30] a
“_macrodactylie elephantiasique_” in a child is said to have followed an
operation for the separation of two united fingers. It is, at any rate,
certain that if the enlargement be always present at birth, it is seldom
so disproportionate as to attract attention and never so great as to
interfere with parturition. Hence the colossal proportions subsequently
observed are the result of excessive growth in early infancy and
childhood, and occasionally in adult life.

The hyperplasia, moreover, is rarely hypertrophic in the higher sense
of the term, for, although in a few cases the increased growth has been
associated with apparent increase of functional utility, in the great
majority of instances it is relegated to a lower status by its unequal
distribution amongst the different tissues of the parts involved, its
frequent association with other congenital deformities, and especially by
the defective ratio of functional capacity to the amount of constructive
material. In other words, the process is wasteful and unserviceable.

The origin of the affection is very obscure. It is not hereditary,
although inheritance plays a notable part in many other congenital
deformities, and it cannot be attributed to any known influences arising
during intra-uterine life, but, as might be expected, the mother is often
able to conjure up some reminiscence of the period of gestation which to
her mind affords a perfectly satisfactory clue to the mystery. Von Klein
relates that in his case of makrodactyly the mother while pregnant was
bitten in the hand by a goose. A history of a fright was given in Adams’s
case, and in an instance reported by the author[31] a giant growth of the
lower extremity was attributed to the mother having been trodden upon
by a cow. Such mental impressions are probably mere coincidences, and
are often greatly exaggerated in narration, but until the possibility of
their connection with fœtal lesions is disproved it is advisable to place
them on record.

_Parts affected._—The abnormality is usually limited to one side of the
body. Comparatively few bilateral cases have been observed, and in most
of these the makroplasia was limited to the digits.[32]

The nævi with which the hypertrophy is often associated are nearly
always confined to the affected side, but in two cases of Chassaignac
and Friedberg they were found also upon the non-hypertrophied side, and
in a second case of Chassaignac’s were present only upon the unenlarged
parts of the body. The upper extremity is attacked nearly twice as often
as the lower, and the right side much more frequently than the left.
In bilateral cases the affection is seldom symmetrical; thus, on one
of Friedberg’s cases the predominant enlargement of the right lower
extremity was associated with a small degree of hypertrophy of the left
upper limb.

The extent of the parts involved ranges from a single digit to an
entire half of the body. When a whole limb is implicated the growth is
always proportionately greater at the distal extremity, but colossal
development of the hand or foot seldom includes the whole of the digits.
The localisation of the affection does not appear to be related to any
special vascular or nervous territories; thus, in makrodactyly, the
regions of distribution of the digital branches of both median and ulnar
nerves may be encroached upon, while parts supplied by either or both of
these may escape intact.

[Illustration: FIG. 18.

Congenital hypertrophy of lower extremity, with lymphangeiomata (from a
case of the author’s).]

Commonly, however, both in the hand and foot, the hypertrophy selects
two or three neighbouring digits, for example, the second and third; and
co-existent lipomata are almost invariably limited to that portion of the
palm or sole which corresponds to the enlarged fingers or toes. In the
hand the digit most commonly affected is the third, the fifth is that
most exempt.

Its _course_ is always in a certain sense progressive. Occasionally it
appears to keep pace throughout with the general growth of the body,
but nearly always the abnormal growth strides in advance, sooner or
later, so that the disproportion of the affected part to the rest of the
body becomes more and more pronounced. Its progress may be uniform and
continuous, or terms of slow increase or apparent arrest may alternate
with a new and rapid development.

In some instances the process does not extend beyond the primary limits,
while in others it may spread centripetally, and often at a very rapid
rate, as in v. Fischer’s case (_l.c._), in which amputation of an
hypertrophied finger was followed within a few months by hypertrophy
of the whole limb. In two cases reported by Mr. F. S. Eve[33] a growth
became disproportionally active at the ages of twenty-three and
thirty-seven respectively. Similar instances have been published by
Wittelshöfer, and the author (_l.c._).

The addition of new tissue goes on, as a rule, without pain,
inflammation, or interference with function; but in a case of von
Fischer’s, burning pain was associated with trophic ulceration;
and Friedberg’s patient,[34] who appeared to be the subject of an
associated elephantiasis Arabum, had symptoms that somewhat resembled the
inflammation crises of elephantiasis.

In the majority of cases the _functional power_ of the enlarged part
is not augmented, but true unilateral hypertrophy, _i.e._, increased
tissue hypertrophy with proportionally increased functional activity,
is sometimes found. The cases described long since in general terms by
Geoffroy St. Hilaire,[35] as marked by an unequal development of the
two sides of the body in one or more regions, were probably of this
nature, and those of Ollier, Finlayson, and Langlet, may also claim a
place in the same class. In Ollier’s case[36] the face, thorax, abdomen,
and both extremities of one side, were uniformly larger than the
corresponding parts of the opposite half of the body, the vascularity
of the hypertrophied side was increased, the temperature elevated, and
the limbs were more powerful. There were no nævoid growths, and it is
noteworthy that in association with an absence of evident abnormality of
thoracic, pelvic, and abdominal viscera, the mammary glands preserved
their symmetry. The cases of Devouges, Adams, and Finlayson, also
presented certain points of resemblance to true hypertrophy. In the
first the whole of one side was hypertrophied, except perhaps the
abdominal wall, where nothing unusual was noticed. The details are very
imperfect, but according to the patient’s statement, the strength of
the arm on the hypertrophied side was greatly in excess of that of its
fellow. In Adams’s case the giant growth of the right lower extremity was
apparently uniform, and the femoral and all other accessible arteries
were considerably enlarged, but nothing is said as to muscular power. In
this as in the last example nævi were present. In an unpublished case of
the author’s the hypertrophied hand was much stronger than its fellow;
but in the example[37] already quoted there was no evidence of increased
development of muscle. In two instances of unilateral hypertrophy of
the face described by Friedrich[38] and Passauer,[39] the increased
growth involved the whole of the parts of the affected side, even to the
teeth and tongue, and in Friedrich’s patient, and in a case brought by
Dr. Heumann before a Medical Congress in Darmstadt, the hair was more
developed, and the secretion of saliva was excessive on the affected
side, but the muscular power and arterial supply were not specially
referred to. In a case of Eve’s the facial hypertrophy extended to the
brain.

In the ordinary forms of congenital hypertrophy the size of the part is
augmented by an unequally distributed hyperplasia of the skeleton and
soft parts. Almost all the cases narrated in detail are of this kind.
In nearly all, the arterial supply is proportionate only to the normal
size of the part, and the functional capacity (power, sensibility, &c.),
although not seriously altered, is to some extent deteriorated. The cases
may be for practical purposes divided into two groups:

1. Without deformity, the enlarged segment preserving the normal contour
in other respects.

2. With deformity.

    _a._ From predominant development of the adipose or vascular
    tissues.

    _b._ From secondary articular distortions.

    _c._ From associated defects of development, as syndactyly, &c.

The condition of the different elements of the enlarged part is as
follows:

The _bones_ are always enlarged. Their general shape is commonly
preserved, but occasionally their extremities are deformed by outgrowths
at the line of junction with the articular cartilage. The hypertrophy
reaches its greatest proportionate extent in the digits, while increase
in size of the bones of the forearm, arm, leg, and thigh, is, as a rule,
only demonstrable during life by admeasurement of length. No histological
abnormality has been detected in the osseous tissue, but Eve (_l.c._)
found the cancellous tissue of the enlarged bone soft and the medulla
fatty.

The _articular surfaces_ may present no peculiar features, but in some
cases the cartilages show irregularities of surface. The ligaments
are usually greatly thickened. The synovial membrane commonly has the
ordinary characters, varied only by an excessive development of the plicæ
adiposæ.

The range of motion is sometimes normal; in other cases the voluntary
movements are more or less diminished in extent, while a fair amount of
passive mobility is preserved; and in others there is complete ankylosis.

Distortions, such as lateral deviation and hyper-extension, are frequent.
The former appears to depend upon malformation of bone.

The _tendons_ inserted into the enlarged bones have been found
proportionately over-developed. The _muscles_, however, are seldom
hypertrophied, and occasionally, as in Busch’s case, they may undergo an
atrophy secondary to the impaired mobility of the joint. In a case of
von Fischer’s, muscular hypertrophy was demonstrated, but no evidence of
increased power was present; and, judging by the comparative disuse of
the limb, it is probable that the strength was lessened. The muscular
power is, as a rule, so far augmented in response to functional necessity
that the enlarged part may be used without more sense of effort than
that which accompanies the same actions on the normal side, as in
Wagner’s case (_l.c._), in which the hand weighed about twelve pounds
and yet could be moved with perfect ease; there is seldom, however, any
such absolute increase of strength as would indicate a genuine muscular
hypertrophy.

The _arteries_ in all the instances of false hypertrophy, with the
exception of Reid’s[40] cases, were of ordinary size and apparently not
enlarged in proportion to the gigantic development of the part to be
nourished. This is a fact of considerable pathological significance.

The _veins_ and _capillaries_, unlike the arteries, appear especially
liable to change. Varicosities of the veins are very common, and in some
cases great thickening of the walls may be superadded (Busch, _l.c._). In
Dr. Finlayson’s case the cutaneous vessels over the enlarged parts and in
patches over the trunk became enlarged when the child cried, but subsided
during quiescence.

In Wagner’s case the fingers of the hypertrophied hand were said to
become as red as a “Blutschwamm” when the member hung down, the arteries
being nevertheless of normal size.

Angiectases and angiomata are frequently seen. Capillary nævi of enormous
extent sometimes co-exist (as in Adams’s case, in which the whole
lower extremity and buttock were involved), and are usually, but not
invariably, confined to the hypertrophied parts.

The _lymphatics_ are liable to dilatation, and may form diffuse swellings
or soft tumours of considerable extent. The glands, however, are never
affected.

The _nerves_ appear to be normal. The condition of the nerve centres has
not yet been investigated except in a case of Eve’s, in which the lateral
asymmetry of the head and face extended to the brain.

The _integuments_ nearly always participate in the changes, and are
necessarily augmented in extent where covering the enlarged bones. The
derm does not appear to be much altered in structure, but Eve found in
the skin over the hypertrophied sole a thinning of the rete with almost
complete obliteration of papillæ and enormous thickening of the fibrous
tissues and inter-fascicular lymph spaces; but these changes were
probably due to the abnormal pressure and friction to which the part
was exposed. The subcutaneous adipose layer commonly shows a diffuse
thickening, and in addition may undergo a circumscribed hypertrophy in
the form of large lipomatous pads, which are mostly found upon the flexor
aspect of the member affected, and correspond in situation and extent to
the bony enlargement (Fig. 18); but the papillary and epithelial layers
do not undergo any sensible changes, nor, as a rule, are the hairs or
sebaceous follicles more developed than on the opposite side. The nails
of hypertrophied digits generally undergo proportionate development. The
secretion of perspiration is seldom altered in amount or character, but
in a case of Wittelshöfer the patient complained of profuse sweating
from the affected limb. The cutaneous sensibility is variously described
as unaffected or diminished, never increased. A reduction of the
sensibility to heat and pain was found to accompany the tactile defect
in von Fischer’s case, and it is probable, as he suggests, that careful
examination would generally reveal an impairment of the faculties. Pain
is rarely complained of. Burning pain was present in association with
trophic ulceration in a case of von Fischer, and pains of a rheumatic
character appeared in the author’s case, but this symptom probably formed
no part of the original disease.

The _temperature_ of the part is generally normal. By exception, a rise
of 2°-2½° Fahr., of 2°-6° Fahr. (Reid), 2°-4° Fahr. (Finlayson), and of
½°-1° Cent. (Trelat and Monod) has been recorded.

_Pathological complications_ are rarely met with. Trophic ulceration
appeared in a case of von Fischer’s; and in Friedberg’s case an eruption
resembling pemphigus was noted, but probably was not directly connected
with the congenital hypertrophy. Inflammatory crises, corresponding to
those of elephantiasis Arabum, have been seen in only one instance, and
in this the condition appeared to be complicated by true elephantiasis.

_Associated defects of development_ are frequent in connection with
makrodactyly. They may consist of multiplication, dwarfing, absence,
or fusion of parts. The most common defect is syndactyly. Secondary
distortions of the spine are found, however, when the hypertrophy of
a single limb is very great. The general health does not appear to be
affected by the condition.

_Pathology._—The older views as to the pathological origin of congenital
hypertrophy leave us little advanced towards a solution. The condition
has been attributed to a congenital lesion of the vaso-motor centres;
to a primitive vice in the mesoblast; and to an inherent tendency of
the affected tissues to appropriate an excess of nutriment; but these
theories only lead to the same point—that for some reason which our
pathology is still inadequate to explain, there is a weakening of the
governing power that regulates the ratio between supply and demand in
the tissues; or, to quote from Professor Humphry (_l.c._), “The cases
obviously consist in an excess, an abnormally excessive growth of a
normal part of the body—an excess not depending upon any superabundance
of nutritive supply, or any modification of nerve influence, but upon an
excess, a want of due restraint, of that developmental force by which
the several organs and structures acquire and maintain their proper
dimensions and relations to one another, and by which their relative
growth at different periods of life and under different circumstances (as
of the genital organs at puberty). The nature and essence and habitat or
source of the force is a mystery, perhaps past finding out.”

This sums up the whole question. It is probably the same kind of
misgovernment of tissue that leads to certain other deformities occurring
both before and after birth, and to the development of some forms of new
growth. How it originates remains for the pathologists of the future to
decide.

_Treatment._—No means yet devised has any power of restraining the
tendency for the excessive and irregular growth in this condition. The
only resources of the surgeon are to correct associated deformities as
far as possible, and to remove parts that are sufficiently inconvenient
or disfiguring to warrant the use of the knife.


SUPERNUMERARY FINGERS AND TOES.

The occasional occurrence of supernumerary fingers and toes is well
known. As a rule the extra digit is a mere pediculated appendage bearing
a nail and a more or less perfect representative of the ungual phalanx;
in other cases, however, it is complete and well formed, and furnished
with a metacarpal or metatarsal bone of its own, or sharing the proximal
bone with a neighbouring finger or toe. In rare instances the digits may
undergo still further numeral increase even to a complete duplication of
the normal complement.

The condition is commonly bilateral, and may affect all four extremities.
It is liable to association with syndactyly and other congenital
deformities, and it is occasionally handed down by inheritance as a
family peculiarity. Sir William Lawrence refers to a condition of the
kind which was traced through four generations, and other examples are on
record.


SYNDACTYLY.

The absence of one or more of the normal clefts between the fingers
or toes is a common congenital deformity, and, like most of the other
inherited defects of the parts, is often transmitted by descent, and
associated with other malformations.

Syndactyly presents all varieties in extent and degree. Most frequently
two neighbouring digits are joined together by a web of integument
involving the whole or a portion of their length, but in some instances
the connecting material is much thicker, and in the most extreme cases
even the bones and joints are fused, leaving nothing but a furrow to
indicate the line of union. (Fig. 17, Nos. 16 to 19.)

Treatment is rarely necessary in the case of the foot, and in the hand is
practicable only when the band of union is cutaneous or cellulo-cutaneous.

If the web is composed only of a thin double fold of integument it is
sufficient to divide it, provided that a return of the condition is
prevented from taking place through union of the raw surfaces at the
root of the web. This was formerly effected in the slighter cases by a
preliminary perforation of the base of the fold, and the insertion of
a piece of gold wire until a cicatricial canal has been established—as
in piercing the lobule for the suspension of an ear-ring—and the same
end may be gained after the division by putting a small epidermic graft
upon the angle. Zeller’s flap method is, however, the best. A small
triangular flap is cut from the dorsum of the hand with its base opposite
the heads of the metacarpal bones, its apex at the level of the first
inter-phalangeal joint. This being dissected up and reversed, the whole
length of the web is divided. The apex of the flap is then brought
forwards between the separated digits into the proximal end of the cleft,
and fixed to the cut edge of the palmar integument.

When the membrane is very thick, and the bones are drawn close together,
a more complicated proceeding is required, and the ingenious method of
Didot may be employed. A longitudinal incision is carried through the
whole thickness of the integument along the middle of the dorsum of one
of the two united fingers, a second along the middle of the palmar aspect
of the other finger, and by dissection each digit is made to furnish
a rectangular flap to cover in the raw surface of its neighbour. The
division of the tissue left after raising the flaps must be made with
great care, in order to avoid injury to the digital nerves.


ECTRODACTYLY.

Simple congenital ectrodactyly, like the loss of a larger segment of an
extremity, may arise either by intra-uterine traumatism or defective
development. Amputation by an amniotic band or a coil of umbilical cord
probably explains the majority of the cases, as well as the congenital
constrictions sometimes found in the limbs or digits of the newborn
child, but the occasional appearance of fingers or toes at the end of
a congenital stump can only be accounted for on the hypothesis of a
temporary suspension of development in the proximal portion of the stump,
and we may assume the possibility of a like origin for the absence of
the most distal portions of a member. In some instances an ectrodactyly
is complicated with other developmental errors, and may be transmitted
through several generations. Attention has been especially drawn to
cases of this class in the last few years. Two were recorded in detail
in 1886 by Dr. Fotherby[41] and the author,[42] and a third was added
five years ago by Messrs. Parker and Robinson.[43] In all of these the
defect was traced through three or four generations, selecting in an
apparently indiscriminate way a large portion of the members of the
family, whilst leaving others exempt. In some individuals all four limbs
were attacked, in others the upper or lower only, but usually with a more
or less perfect bilateral symmetry. In most cases the ectrodactyly was
associated with deformities of the remaining digits, such as syndactyly,
hypertrophy, and joint distortions; and where, as frequently happened,
the middle digits were imperfectly developed and the others hypertrophied
and distorted, the member assumed the appearance of the pincers of a
lobster. (Fig. 17, Nos. 11 to 14.)

In Dr. Fotherby’s and Messrs. Parker and Robinson’s cases the defects
were traced through three generations, affecting sixteen out of
thirty-seven descendants in the one and sixteen out of thirty-three
in the other; in the author’s case the history extended to four
generations, attacking twenty-four out of thirty-six children, and the
divergence from the normal state tended to increase with the later scions.

As a rule, little or no treatment is called for in this condition,
because habit has given the member a good deal of functional utility that
surgical interference might injure or destroy; but sometimes, and more
particularly in the feet, it is permissible to operate for the purpose of
lessening the deformity, as in Messrs. Parker and Robinson’s case, where
a plastic operation was performed with much benefit to the patient.


BRACHYDACTYLY.

Undue shortness of the fingers or toes may occur either as a congenital
or as an acquired defect. The congenital form, due to imperfect formation
of any or all of the bony elements of a digit (including the metacarpal
bone), is insusceptible of treatment except by amputation, should that
step be justified by the inconvenience or deformity attached to the
defective member.

Acquired brachydactyly may arise in several ways. Occasionally it is to
be traced to an arrest of development either due to an injury during
childhood or adolescence, or without apparent explanation, but more
frequently it is a result of disease. In younger subjects the most
common cause is the destruction of bone in tuberculous disease, which
may practically eliminate a phalanx, leaving the rest healthy. In older
people it may be met with in cases of perforating ulcer, the proximal
phalanx of the great toe and sometimes other bones undergoing a slow and
painless disintegration, which is manifested chiefly by a progressive
shortening of the digit with few or none of the more obvious signs of
caries.




FOOTNOTES


[1] “Les doigts, et particulièrement les trois derniers, sont sujets
à une flexion permanent involontaire; à laquelle on a donné le nom de
‘contracture,’ et que quelques auteurs out appelée en latin ‘crispatura
tendinum.’” This name is usually attributed to Boyer himself. (“Maladies
Chirurgicales,” vol. ii. p. 55, first edition, 1826).

[2] See “The Hand as a Diagnostic Factor in Diseases of the Nervous
System” (Long-Fox: _Med. Annual_, 1891, p. 54).

[3] _Transactions of the College of Physicians_, 1895, p. 67.

[4] _Therapeutic Gazette_, February 15, 1892.

[5] _Ibid._ October 16, 1893.

[6] _Brit. Med. Journal_, 1888, vol. i. p. 961.

[7] See _Transactions of the Anatomical Society_ (1892), “On the Course
and Relations of the Deep Branch of the Ulnar Nerve,” by W. Anderson.

[8] “Orteil en Marteau” (Baillière, 1888).

[9] “Traité des Maladies Chirurgicales.”

[10] “The Human Foot,” 1889.

[11] It is unnecessary to enter minutely into the conformation of the
inter-phalangeal joints, but it must be understood that the proximal
attachment of the plantar fibres of the lateral ligaments lies at a point
below the centre of the dorsal half of the condylar curve, and hence
these fibres become more and more stretched as their distal attachment
is carried upwards in the direction of extension, until at last the
motion is checked by their tension. The point at which the arrest occurs
necessarily depends upon the relation existing between the length of the
fibres and that of the radii of the condylar curve. If the ligaments of
a joint be artificially elongated by acrobatic training in early life,
they may lose their power of fixing the range of movement, and extension
may then go on until it is stopped by contact of bones or by contraction
of opposing muscles. The latter factor, of course, is always an important
one, but it does not affect the present aspect of the question.

[12] It must be recollected that morphologically the metatarso-phalangeal
joint of the great toe corresponds to the first inter-phalangeal joint of
the smaller digits.

[13] _Lancet_, 1885, vol. i.

[14] _St. Thomas’s Hospital Reports_, vol. xxii. (1893).

[15] _Journal der Chirurg. und Augenheilk._, v. Graefe u. Walther, 1824.

[16] _Med. Annalen_, v. Puchelt, Chelius, u. Nägele, 1836.

[17] _Schmidt’s Jahrbucher_, 1842.

[18] _Medico-Chirurgical Transactions_, vol. xxviii.

[19] “Dissertation” (Berlin). Quoted by Busch.

[20] _Lancet_, August 1858.

[21] _Bulletin de la Soc. Anat._, 1856.

[22] _Bulletin de la Soc. de Chirurg._, first series, vol. xviii.;
_Gazette des Hôpitaux_, 1858.

[23] “Malformations, Diseases, and Injuries of Fingers and Toes,” 1865.

[24] “Beiträge z. Kentniss der angeb. Hypert. der Extrem.,” _Langenbeck’s
Arch._, 1867.

[25] “De l’Hypertrophie Unilaterale,” _Arch. Gén. de Médecine_, May and
June 1869.

[26] _Deutsche Chirurgie_, Lief. 64.

[27] “Der Riesenwuchs,” _Deutsche Zeitschrift für Chirurgie_, 1880, Bd.
12.

[28] _Archives für Klin. Chirurg._, Bd. xxiv. 1879.

[29] _Trans. Med. Chi. Society_, vol. lxxiv. 1891.

[30] _Bulletin de la Soc. de Chirurgie_, December 1880.

[31] _St. Thomas’s Hospital Reports_, vol. xi. 1881, p. 165.

[32] V. Fischer describes the case of Devouges as one in which parts
on both sides were affected, but a reference to the original and to
Chassaignac’s report upon the same patient shows that the hypertrophy was
unilateral.

[33] _Trans. Path. Society_, 1883, p. 298.

[34] _Virchow’s Archives_, 1867, vol. xl.

[35] “Histoire Général et Particulière des Anomalies de l’Organization
chez l’Homme.”

[36] _Gazette Médicale de Lyon_, July 1862 (Ollier); _Union Médicale et
Scientifique du Nord est_, 1882 (Langlet).

[37] _St. Thomas’s Hospital Reports_, vol. xi. 1881.

[38] _Archives für Path. Anat._, vol. xxviii. 1863.

[39] _Virchow’s Archives_, Bd. xxxvii. 1866.

[40] It is somewhat curious that in all three of Dr. Reid’s cases, which
in most respects were of the ordinary type, the arteries are said to have
presented the exceptional peculiarity of enlargement.

[41] _Brit. Med. Journ._, May 22, 1886.

[42] _Brit. Med. Journ._, June 12, 1886.

[43] _Clin. Soc. Trans._, vol. xx. p. 181.

                   _Printed by BALLANTYNE, HANSON & CO.
                          London and Edinburgh_




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=A Manual of the Diseases of India=: With a Compendium of Diseases
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=The Prevention of Disease in Tropical and Sub-Tropical Campaigns.=
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=The Principles and Practice of Medicine.= (Text-book.) By the late
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                          _By the same Authors._

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                          _By the same Author._

=On Slight Ailments=: And on Treating Disease. Fourth Edition. 8vo, 5s.

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                          _By the same Author._

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=Clinical Lectures on Diseases of the Nervous System.= 8vo, 7s. 6d.

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=Operations on the Brain (A Guide to).= By ALEC FRASER, Professor
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=The Operations of Surgery=: Intended for Use on the Dead and Living
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                          _By the same Author._

=The Student’s Guide to Surgical Diagnosis.= Second Edition. Fcap. 8vo,
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                                 _Also._

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=Abdominal Surgery.= By J. GREIG SMITH, M.A., F.R.S.E. Sixth Edition.
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=The Surgery of the Alimentary Canal.= By ALFRED ERNEST MAYLARD, M.B.
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                          _By the same Author._

=A Student’s Handbook of the Surgery of the Alimentary Canal.= With 97
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                          _By the same Author._

=Injuries and Diseases of Nerves and their Surgical Treatment.= 8vo, with
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=Diseases of the Thyroid Gland and their Surgical Treatment.= By JAMES
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=Short Manual of Orthopædy.= By HEATHER BIGG, F.R.C.S. Ed. Part I.
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=Royal London Ophthalmic Hospital Reports.= By the Medical and Surgical
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=Ophthalmological Society of the United Kingdom.= Transactions, Vol. XX.
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=Manual of Ophthalmic Surgery and Medicine.= By W. H. H. JESSOP, M.A.,
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=On Diseases and Injuries of the Eye=: A Course of Systematic and
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=Normal and Pathological Histology of the Human Eye and Eyelids.= By
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                          _By the same Author._

=The Ophthalmoscope=: A Manual for Students. Third Edition. Crown 8vo,
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=Atlas of Ophthalmoscopy.= Composed of 12 Chromo-lithographic Plates (59
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=Eyestrain.= (commonly called Asthenopia). By ERNEST CLARKE, M.D., B.S.
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=Diseases and Injuries of the Ear.= By Sir WILLIAM B. DALBY, F.R.C.S.,
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                          _By the same Author._

=Short Contributions to Aural Surgery, between 1875 and 1896.= Third
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=Diseases of the Ear=, Including the Anatomy and Physiology of the Organ,
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London Hospital, and Lecturer on Diseases of the Throat in the College.
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=A System of Dental Surgery.= By Sir JOHN TOMES, F.R.S., and C. S. TOMES,
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=Dental Anatomy, Human and Comparative=: A Manual. By CHARLES S. TOMES,
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=Dental Caries: an Investigation into its Cause and Prevention.= By J.
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=Dental Materia Medica, Pharmacology and Therapeutics.= By CHARLES W.
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=A Manual of Dental Metallurgy.= By ERNEST A. SMITH, F.I.C., Assistant
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=A Practical Treatise on Mechanical Dentistry.= By JOSEPH RICHARDSON,
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D.D.S. Roy. 8vo, with 690 Engravings, 22s.

=A Manual of Nitrous Oxide Anæsthesia, for the use of Students and
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Text, Roy. 8vo, 12s. 6d.

=A Handbook on Leprosy.= By S. P. IMPEY, M.D., M.C., late Chief and
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=Diseases of the Skin= (Introduction to the Study of). By P. H.
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Fourth Edition, Roy. 16mo, 6s. 6d.

=Cancerous Affections of the Skin.= (Epithelioma and Rodent Ulcer.) By
GEORGE THIN, M.D. Post 8vo, with 8 Engravings, 5s.

                          _By the same Author._

=Pathology and Treatment of Ringworm.= 8vo, with 21 Engravings, 5s.

=The Operative Surgery of Malignant Disease.= By HENRY T. BUTLIN,
F.R.C.S., Surgeon to St. Bartholomew’s Hospital. Second Edition, with 12
Engravings. 8vo, 14s.

                          _By the same Author._

=Malignant Disease (Sarcoma and Carcinoma) of the Larynx.= 8vo, with 5
Engravings, 5s.

                                 _Also._

=Sarcoma and Carcinoma=: Their Pathology, Diagnosis, and Treatment. 8vo,
with 4 Plates, 8s.

=Cancers and the Cancer Process=: a Treatise, Practical and Theoretic.
By HERBERT L. SNOW, M.D., Surgeon to the Cancer Hospital, Brompton. 8vo,
with 15 Lithographic Plates. 15s.

                          _By the same Author._

=The Reappearance (Recurrence) of Cancer after apparent Extirpation.=
8vo, 5s. 6d.

                                 _Also._

=The Palliative Treatment of Incurable Cancer.= Crown 8vo, 2s. 6d.

=Ringworm and some other Scalp Affections=: their Cause and Cure. By
HAYDN BROWN, L.R.C.P.Ed. 8vo, 5s.

=The Diagnosis and Treatment of Syphilis.= By TOM ROBINSON, M.D.,
Physician to the Western Skin Hospital. Second Edition, Crown 8vo, 3s. 6d.

                          _By the same Author._

=The Diagnosis and Treatment of Eczema.= Second Edition, Crown 8vo, 3s.
6d.

                                 _Also._

=Illustrations of Diseases of the Skin and Syphilis, with Remarks.= Fasc.
I. with 3 Plates. Imp. 4to, 5s.

=Selected Papers on Stone, Prostate, and other Urinary Disorders.= By
REGINALD HARRISON, F.R.C.S., Surgeon to St. Peter’s Hospital. 8vo, with
15 Illustrations. 5s.

=Chemistry of Urine=; A Practical Guide to the Analytical Examination of
Diabetic, Albuminous, and Gouty Urine. By ALFRED H. ALLEN, F.I.C., F.C.S.
With Engravings, 8vo, 7s. 6d.

=Clinical Chemistry of Urine (Outlines of the).= By C. A. MACMUNN, M.A.,
M.D. 8vo, with 64 Engravings and Plate of Spectra, 9s. By SIR HENRY
THOMPSON, Bart., F.R.C.S.

=Diseases of the Urinary Organs.= Clinical Lectures. Eighth Edition. 8vo,
with 121 Engravings, 10s. 6d.

=Practical Lithotomy and Lithotrity=; or, An Inquiry into the Best
Modes of Removing Stone from the Bladder. Third Edition. 8vo, with 87
Engravings, 10s.

=The Preventive Treatment of Calculous Disease=, and the Use of Solvent
Remedies. Third Edition. Crown 8vo, 2s. 6d.

=Tumours of the Bladder=: Their Nature, Symptoms, and Surgical Treatment.
8vo, with numerous Illustrations, 5s.

=Stricture of the Urethra, and Urinary Fistulæ=: their Pathology and
Treatment. Fourth Edition. 8vo, with 74 Engravings, 6s.

=The Suprapubic Operation of Opening the Bladder for the Stone and for
Tumours.= 8vo, with 14 Engravings, 3s. 6d.

=The Clinical Examination of Urine=, with an Atlas of Urinary Deposits.
By LINDLEY SCOTT, M.A., M.D. With 41 Original Plates (mostly in Colours).
Crown 4to, 15s. net.

=Electric Illumination of the Bladder and Urethra=, as a Means of
Diagnosis of Obscure Vesico-Urethral Diseases. By E. HURRY FENWICK,
F.R.C.S., Surgeon to London Hospital and St. Peter’s Hospital for Stone.
Second Edition. 8vo, with 54 Engravings, 6s. 6d.

                          _By the same Author._

=Tumours of the Urinary Bladder.= The Jacksonian Prize Essay of 1887,
rewritten with 200 additional cases, in four Fasciculi. Fas. I. Royal
8vo. 5s.

                                 _Also._

=Ulceration of the Bladder, Simple, Tuberculous, and Malignant=: A
Clinical Study. Illustrated, 8vo, 5s.

                                 _Also._

=The Cardinal Symptoms of Urinary Diseases=: their Diagnostic
Significance and Treatment. 8vo, with 36 Illustrations. 8s. 6d.

=Atlas of Electric Cystoscopy.= By Dr. EMIL BURCKHARDT, late of the
Surgical Clinique of the University of Bâle, and E. HURRY FENWICK,
F.R.C.S., Surgeon to the London Hospital and St. Peter’s Hospital. Royal
8vo, with 34 Coloured Plates, embracing 83 Figures. 21s.

=Urinary and Renal Derangements and Calculous Disorders.= By LIONEL S.
BEALE, F.R.C.P., F.R.S., Consulting Physician to King’s College Hospital.
8vo, 5s.

=Male Organs of Generation (Diseases of).= By W. H. A. JACOBSON, M.Ch.
Oxon., F.R.C.S., Assistant Surgeon to Guy’s Hospital. 8vo, with 88
Engravings. 22s.

=The Surgical Diseases of the Genito-Urinary Organs, including Syphilis.=
By E. L. KEYES, M.D., Professor in Bellevue Hospital Medical College, New
York (a revision of VAN BUREN and KEYES’ Text-book). Roy. 8vo, with 114
Engravings, 21s.

=Diseases of the Rectum and Anus.= By ALFRED COOPER, F.R.C.S., Senior
Surgeon to the St. Mark’s Hospital for Fistula; and F. SWINFORD EDWARDS,
F.R.C.S., Senior Assistant Surgeon to St. Mark’s Hospital. Second
Edition, with Illustrations. 8vo, 12s.

=Diseases of the Rectum and Anus.= By HARRISON CRIPPS, F.R.C.S.,
Assistant Surgeon to St. Bartholomew’s Hospital, &c. Second Edition. 8vo,
with 13 Lithographic Plates and numerous Wood Engravings, 12s. 6d.

                          _By the same Author._

=Cancer of the Rectum.= Especially considered with regard to its Surgical
Treatment. Jacksonian Prize Essay. 8vo, with 13 Plates and several Wood
Engravings, 6s.

                                 _Also._

=The Passage of Air and Fæces from the Urethra.= 8vo, 3s. 6d.

=Syphilis.= By ALFRED COOPER, F.R.C.S., Consulting Surgeon to the
West London and the Lock Hospitals. Second Edition. Edited by EDWARD
COTTERELL, F.R.C.S., Surgeon (out-patients) to the London Lock Hospital.
8vo, with 24 Full-page Plates (12 coloured), 18s.

=On Maternal Syphilis=, including the presence and recognition of
Syphilitic Pelvic Disease in Women. By JOHN A. SHAW-MACKENZIE, M.D. 8vo,
with Coloured Plates, 10s. 6d.

=A Medical Vocabulary=: An Explanation of all Terms and Phrases used
in the various Departments of Medical Science and Practice, their
Derivation, Meaning, Application, and Pronunciation. By R. G. MAYNE,
M.D., LL.D. Sixth Edition by W. W. WAGSTAFFE, B.A., F.R.C.S. Crown 8vo,
10s. 6d.

=A Short Dictionary of Medical Terms.= Being an Abridgment of Mayne’s
Vocabulary. 64mo, 2s. 6d.

=Dunglison’s Dictionary of Medical Science=: Containing a full
Explanation of its various Subjects and Terms, with their Pronunciation,
Accentuation, and Derivation. Twenty-second Edition, much enlarged. By
RICHARD J. DUNGLISON, A.M., M.D. Super-royal 8vo, 30s.

=Terminologia Medica Polyglotta=: a Concise International Dictionary of
Medical Terms (French, Latin, English, German, Italian, Spanish, and
Russian). By THEODORE MAXWELL, M.D., B.Sc., F.R.C.S. Edin. Royal 8vo, 16s.

=A German-English Dictionary of Medical Terms.= By Sir FREDERICK TREVES,
K.C.V.O., Surgeon to the London Hospital; and HUGO LANG, B.A. Crown 8vo,
half-Persian calf, 12s.

=A Handbook of Physics and Chemistry=, adapted to the requirements of the
first Examination of the Conjoint Board and for general use. By HERBERT
E. CORBIN, B.Sc. Lond., and ARCHIBALD M. STEWART, B.Sc. Lond. With 120
Illustrations. Crown 8vo, 6s. 6d.

=A Manual of Chemistry, Theoretical and Practical.= By WILLIAM A. TILDEN,
D.Sc, F.R.S., Professor of Chemistry in the Royal College of Science,
London; Examiner in Chemistry to the Department of Science and Art. With
2 Plates and 143 Woodcuts, crown 8vo, 10s.

=Chemistry=, Inorganic and Organic. With Experiments. By CHARLES L.
BLOXAM. Eighth Edition, by JOHN MILLAR THOMSON, F.R.S., Professor of
Chemistry in King’s College, London, and ARTHUR G. BLOXAM, Head of the
Chemistry Department, The Goldsmiths’ Institute, New Cross. 8vo, with
nearly 300 Illustrations, 18s. 6d.

                          _By the same Author._

=Laboratory Teaching=; Or, Progressive Exercises in Practical Chemistry.
Sixth Edition. By ARTHUR G. BLOXAM. Crown 8vo, with 80 Engravings, 6s. 6d.

=Watts’ Organic Chemistry.= Edited by WILLIAM A. TILDEN, D.Sc., F.R.S.,
Professor of Chemistry, Royal College of Science, London. Second Edition.
Crown 8vo, with Engravings, 10s.

=Practical Chemistry= And Qualitative Analysis. By FRANK CLOWES, D.Sc.
Lond., Emeritus Professor of Chemistry in the University College,
Nottingham. Seventh Edition. Post 8vo, with 101 Engravings and
Frontispiece, 8s. 6d.

=Quantitative Analysis.= By FRANK CLOWES, D.Sc. Lond., Emeritus Professor
of Chemistry in the University College, Nottingham, and J. BERNARD
COLEMAN, Assoc. R. C. Sci. Dublin; Professor of Chemistry, South-West
London Polytechnic. Fifth Edition. Post 8vo, with 122 Engravings, 10s.

                          _By the same Authors._

=Elementary Quantitative Analysis.= Post 8vo, with 62 Engravings, 4s. 6d.

                                 _Also._

=Elementary Practical Chemistry and Qualitative Analysis.= Third Edition.
Post 8vo, with 68 Engravings, 3s. 6d.

=Qualitative Analysis.= By R. FRESENIUS. Translated by CHARLES E.
GROVES, F.R.S. Tenth Edition. 8vo, with Coloured Plate of Spectra and 46
Engravings, 15s.

                          _By the same Author._

=Quantitative Analysis.= Seventh Edition.

    Vol. I., Translated by A. VACHER. 8vo, with 106 Engravings, 15s.

    Vol. II., Translated by C. E. GROVES, F.R.S. 8vo, with 143
    Engravings, 20s.

=Inorganic Chemistry.= By SIR EDWARD FRANKLAND, K.C.B., D.C.L., LL.D.,
F.R.S., and FRANCIS R. JAPP, M.A., Ph.D., F.I.C., F.R.S., Professor of
Chemistry in the University of Aberdeen. 8vo, with numerous Illustrations
on Stone and Wood, 24s.

=Inorganic Chemistry= (A System of). By WILLIAM RAMSAY, Ph.D., F.R.S.,
Professor of Chemistry in University College, London. 8vo, with
Engravings, 15s.

                          _By the same Author._

=Elementary Systematic Chemistry for the Use of Schools and Colleges.=
With Engravings. Crown 8vo, 4s. 6d.; Interleaved, 5s. 6d.

=Valentin’s Practical Chemistry and Qualitative and Quantitative
Analysis.= Edited by W. R. HODGKINSON, Ph.D., F.R.S.E., Professor of
Chemistry and Physics in the Royal Military Academy, and Artillery
College, Woolwich. Ninth Edition. 8vo, with Engravings and Map of
Spectra, 9s. [The Tables separately, 2s. 6d.]

=Practical Chemistry, Part I. Qualitative Exercises and Analytical Tables
for Students.= By J. CAMPBELL BROWN, Professor of Chemistry in Victoria
University and University College, Liverpool. Fourth Edition. 8vo, 2s. 6d.

=The Analyst’s Laboratory Companion=: a Collection of Tables and Data for
Chemists and Students. By ALFRED E. JOHNSON, A.R.C.S.I., F.I.C. Second
Edition, enlarged, crown 8vo., cloth, 5s., leather, 6s. 6d.

=Volumetric Analysis=: Or the Quantitative Estimation of Chemical
Substances by Measure, applied to Liquids, Solids, and Gases. By FRANCIS
SUTTON, F.C.S., F.I.C Eighth Edition. 8vo, with 116 Engravings, 20s.

=Commercial Organic Analysis=: a Treatise on the Properties, Modes of
Assaying, Proximate Analytical Examination, &c., of the various Organic
Chemicals and Products employed in the Arts, Manufactures, Medicine, &c.
By ALFRED H. ALLEN, F.I.C, F.C.S. 8vo.

    Vol. I.—Introduction, Alcohols, Neutral Alcoholic Derivatives,
    &c., Ethers, Vegetable Acids, Starch and its Isomers, Sugars,
    &c. Third Edition. 18s.

    Vol. II.—Part I. Fixed Oils and Fats, Glycerin, Nitro-Glycerin,
    Dynamites and Smokeless Powders, Wool-Fats, Dégras, etc. Third
    Edition. 14s.

    Vol. II.—Part II. Hydrocarbons, Petroleum and Coal-Tar
    Products, Asphalt, Phenols and Creosotes, &c. Third Edition.
    14s.

    Vol. II.—Part III. Terpenes, Essential Oils, Resins and
    Camphors, Acid Derivatives of Phenols, Aromatic Acids. [_In
    preparation._

    Vol. III.—Part I. Tannins, Dyes and Colouring Matters, Inks.
    Third Edition. 18s.

    Vol. III.—Part II. The Amines and Ammonium Bases, Hydrazines
    and Derivatives, Bases from Tar, The Antipyretics, &c.,
    Vegetable Alkaloids, Tea, Coffee, Cocoa, Kola, Cocaine, Opium,
    &c. Second Edition. 18s.

    Vol. III.—Part III. Vegetable Alkaloids, Non-Basic Vegetable
    Bitter Principles, Animal Bases, Animal Acids, Cyanogen and its
    Derivatives, &c. Second Edition. 16s.

    Vol. IV.—The Proteïds and Albuminous Principles, Proteoïds or
    Albuminoïds. Second Edition. 18s.

=Cooley’s Cyclopædia= of Practical Receipts, and Collateral Information
in the Arts, Manufactures, Professions, and Trades: Including Medicine,
Pharmacy, Hygiene and Domestic Economy. Seventh Edition, by W. NORTH,
M.A. Camb., F.C.S. 2 Vols., Roy. 8vo, with 371 Engravings, 42s.

=Chemical Technology=: A Manual. By RUDOLF VON WAGNER. Translated and
Edited by SIR WILLIAM CROOKES, F.R.S., from the Thirteenth Enlarged
German Edition as remodelled by Dr. FERDINAND FISCHER. 8vo, with 596
Engravings, 32s.

=Chemical Technology=; Or, Chemistry in its Applications to Arts and
Manufactures. Edited by CHARLES E. GROVES, F.R.S., and WILLIAM THORP,
B.Sc.

    Vol. I.—FUEL AND ITS APPLICATIONS. By E. J. MILLS, D.Sc,
    F.R.S., and F. J. ROWAN, C.E. Royal 8vo, with 606 Engravings,
    30s.

    Vol. II.—LIGHTING BY CANDLES AND OIL. By W. Y. DENT, J.
    MCARTHUR, L. FIELD and F. A. FIELD, BOVERTON REDWOOD, and D. A.
    LOUIS. Royal 8vo, with 358 Engravings and Map, 20s.

    Vol. III.—GAS LIGHTING. By CHARLES HUNT. With 2 Plates and 292
    Engravings. Royal 8vo, 18s.

=Technological Handbooks.= EDITED BY JOHN GARDNER, F.I.C., F.C.S., and
JAMES CAMERON, F.I.C.

    BREWING, DISTILLING, AND WINE MANUFACTURE. Crown 8vo, with
    Engravings, 6s. 6d.

    BLEACHING, DYEING, AND CALICO PRINTING. With Formulæ. Crown
    8vo, with Engravings, 5s.

    OILS, RESINS, AND VARNISHES. Crown 8vo, with Engravings. 7s. 6d.

    SOAPS AND CANDLES. Crown 8vo, with 54 Engravings, 7s.

=Chemistry an Exact Mechanical Philosophy.= By FRED. G. EDWARDS.
Illustrated. 8vo, 3s. 6d.

=The Microscope and its Revelations.= By the late WILLIAM B. CARPENTER,
C.B., M.D., LL.D., F.R.S. Seventh Edition, by the Rev. W. H. DALLINGER,
LL.D., F.R.S. With 21 Plates and 800 Wood Engravings. 8vo, 26s. Half
Calf, 30s.

=Methods and Formulæ= Used in the Preparation of Animal and Vegetable
Tissues for Microscopical Examination, including the Staining of
Bacteria. By PETER WYATT SQUIRE, F.L.S. Crown 8vo, 3s. 6d.

=The Quarterly Journal of Microscopical Science.= Edited by E. RAY
LANKESTER, M.A., LL.D., F.R.S.; with the co-operation of ADAM SEDGWICK,
M.A., F.R.S., W. F. R. WELDON, M.A., F.R.S., and SYDNEY J. HICKSON, M.A.,
F.R.S. Each Number, 10s.

=The Microtomist’s Vade-Mecum=: A Handbook of the Methods of Microscopic
Anatomy. By ARTHUR BOLLES LEE, Assistant in the Russian Laboratory of
Zoology at Villefranche-sur-Mer (Nice). Fifth Edition. 8vo, 15s.

=Photo-Micrography= (Guide to the Science of). By EDWARD C. BOUSFIELD,
L.R.C.P. Lond. 8vo, with 34 Engravings and Frontispiece, 6s.

=A Treatise on Physics.= By ANDREW GRAY, LL.D., F.R.S., Professor of
Natural Philosophy in the University of Glasgow. Vol. I. Dynamics and
Properties of Matter. With 350 Illustrations. 8vo, 15s.

=An Introduction to Physical Measurements=, with Appendices on Absolute
Electrical Measurements, &c. By Dr. F. KOHLRAUSCH, Professor at the
University of Strassburg. Third English Edition, by T. H. WALLER, B.A.,
B.Sc, and H. R. PROCTER, F.I.C. F.C.S. 8vo, with 91 Illustrations, 12s.
6d.

=Tuson’s Veterinary Pharmacopœia=, including the Outlines of Materia
Medica and Therapeutics. Fifth Edition. Edited by JAMES BAYNE, F.C.S.,
Professor of Chemistry and Toxicology in the Royal Veterinary College.
Crown 8vo, 7s. 6d.

=The Veterinarian’s Pocket Remembrancer=: being Concise Directions for
the Treatment of Urgent or Rare Cases. By GEORGE ARMATAGE, M.R.C.V.S.
Second Edition. Post 8vo, 3s.

=Chauveau’s Comparative Anatomy of the Domesticated Animals=, revised
and enlarged, with the Co-operation of S. ARLOING, Director of the Lyons
Veterinary School. Edited by GEO. FLEMING, C.B., LL.D., F.R.C.V.S., late
Principal Veterinary Surgeon of the British Army. Second English Edition.
8vo, with 585 Engravings, 31s. 6d.

=Human Nature, its Principles and the Principles of Physiognomy.= By
PHYSICIST. Part I., Imp. 16mo, 2s. Part II. (completing the work), 2s. 6d.

=Encyclopædia Medica=, under the general editorship of CHALMERS WATSON,
M.B., M.R.C.P.E. About 12 Volumes, 20s. each net. Vols. I. to VI. now
ready.


INDEX TO J. & A. CHURCHILL’S LIST.

  Allen’s Chemistry of Urine, 11

  — Commercial Organic Analysis, 13

  Armatage’s Veterinary Pocket Remembrancer, 14

  Auld’s Pathol. Researches, 2

  Barnes (R.) on Obstetric Operations, 3

  — on Diseases of Women, 3

  Beale (L. S.) on Liver, 6

  — Slight Ailments, 6

  — Urinary and Renal Derangements, 12

  Beale (P. T. B.) on Elementary Biology, 2

  Beasley’s Book of Prescriptions, 5

  — Druggists’ General Receipt Book, 5

  — Pharmaceutical Formulary, 5

  Bell on Sterility, 4

  Bentley and Trimen’s Medicinal Plants, 5

  Bentley’s Systematic Botany, 5

  Berkart’s Bronchial Asthma, 6

  Bernard on Stammering, 7

  Berry’s (Jas.) Thyroid Gland, 9

  — (R. J.) Regional Anatomy, 1

  Bigg’s Short Manual of Orthopædy, 9

  Birch’s Practical Physiology, 2

  Bloxam’s Chemistry, 12

  — Laboratory Teaching, 12

  Bousfield’s Photo-Micrography, 14

  Bowlby’s Injuries and Diseases of Nerves, 9

  — Surgical Pathology and Morbid Anatomy, 9

  Brockbank on Gallstones, 8

  Brown’s (Haydn) Midwifery, 3

  — Ringworm, 11

  — (Campbell) Practical Chemistry, 13

  Bryant’s Practice of Surgery, 8

  Bulkley on Skin Diseases, 10

  Burckhardt’s (E.) and Fenwick’s (E. H.) Atlas of Cystoscopy, 11

  Burdett’s Hospitals and Asylums of the World, 2

  Butler-Smythe’s Ovariotomies, 4

  Butlin’s Operative Surgery of Malignant Disease, 11

  — Malignant Disease of the Larynx, 11

  — Sarcoma and Carcinoma, 11

  Buzzard’s Diseases of the Nervous System, 7

  — Peripheral Neuritis, 7

  — Simulation of Hysteria, 7

  Cameron’s Oils, Resins, and Varnishes, 14

  — Soaps and Candles, 14

  Carpenter and Dallinger on the Microscope, 14

  Cautley’s Infant Feeding, 4

  Charteris’ Practice of Medicine, 6

  Chauveau’s Comparative Anatomy, 14

  Chevers’ Diseases of India, 5

  Churchill’s Face and Foot Deformities, 9

  Clarke’s Eyestrain, 10

  Clouston’s Lectures on Mental Diseases, 3

  Clowes and Coleman’s Quantitative Analysis, 13

  — Elementary Practical Chemistry, 13

  Clowes’ Practical Chemistry, 13

  Coles on Blood, 6

  Cooley’s Cyclopædia of Practical Receipts, 14

  Cooper on Syphilis, 12

  Cooper and Edwards’ Diseases of the Rectum, 12

  Corbin and Stewart’s Physics and Chemistry, 12

  Cripps’ (H.) Ovariotomy and Abdominal Surgery, 9

  — Cancer of the Rectum, 12

  — Diseases of the Rectum and Anus, 12

  — Air and Fæces in Urethra, 12

  Cripps’ (R. A.) Galenic Pharmacy, 4

  Cuff’s Lectures to Nurses, 4

  Cullingworth’s Short Manual for Monthly Nurses, 4

  Dalby’s Diseases and Injuries of the Ear, 10

  — Short Contributions, 10

  Dana on Nervous Diseases, 7

  Day on Headaches, 8

  Domville’s Manual for Nurses, 4

  Doran’s Gynæcological Operations, 3

  Druitt’s Surgeon’s Vade-Mecum, 8

  Duncan (A.), on Prevention of Disease in Tropics, 5

  Dunglison’s Dictionary of Medical Science, 12

  Edwards’ Chemistry, 14

  Ellis’s (T. S.) Human Foot, 9

  Encyclopædia Medica, 14

  Fagge’s Principles and Practice of Medicine, 6

  Fayrer’s Climate and Fevers of India, 5

  Fenwick (E. H.), Electric Illumination of Bladder, 11

  — Tumours of Urinary Bladder, 11

  — Ulceration of Bladder, 11

  Fenwick (E. H.), Symptoms of Urinary Diseases, 11

  Fenwick’s (S.) Medical Diagnosis, 6

  — Obscure Diseases of the Abdomen, 6

  — Outlines of Medical Treatment, 6

  — Ulcer of the Stomach and Duodenum, 6

  — The Saliva as a Test, 6

  Fink’s Operating for Cataract, 9

  Fowler’s Dictionary of Practical Medicine, 6

  Fox (G. H.) on Skin Diseases of Children, 10

  Fox (Wilson), Atlas of Pathological Anatomy of Lungs, 6

  — Treatise on Diseases of the Lungs, 6

  Frankland and Japp’s Inorganic Chemistry, 13

  Fraser’s Operations on the Brain, 8

  Fresenius Qualitative Analysis, 13

  — Quantitative Analysis, 13

  Galabin’s Diseases of Women, 3

  — Manual of Midwifery, 3

  Gardner’s Bleaching, Dyeing, and Calico Printing, 14

  — Brewing, Distilling, and Wine Manuf., 14

  Glassington’s Dental Materia Medica, 10

  Godlee’s Atlas of Human Anatomy, 1

  Goodhart’s Diseases of Children, 4

  Gorgas’ Dental Medicine, 10

  Gowers’ Diagnosis of Diseases of the Brain, 7

  — Manual of Diseases of Nervous System, 7

  — Clinical Lectures, 7

  — Medical Ophthalmoscopy, 7

  — Syphilis and the Nervous System, 7

  Granville on Gout, 7

  Gray’s Treatise on Physics, 14

  Green’s Manual of Botany, 5

  — Vegetable Physiology, 5

  Greenish’s Materia Medica, 4

  Groves’ and Thorp’s Chemical Technology, 14

  Guy’s Hospital Reports, 7

  Habershon’s Diseases of the Abdomen, 7

  Haig’s Uric Acid, 6

  — Diet and Food, 2

  Harley on Diseases of the Liver, 7

  Harris’s (V. D.) Diseases of Chest, 6

  Harrison’s Urinary Organs, 11

  Hartridge’s Refraction of the Eye, 9

  — Ophthalmoscope, 9

  Hawthorne’s Galenical Preparations of B.P., 5

  Heath’s Injuries and Diseases of the Jaws, 8

  — Minor Surgery and Bandaging, 8

  — Operative Surgery, 8

  — Practical Anatomy, 1

  — Surgical Diagnosis, 8

  Hedley’s Therapeutic Electricity, 5

  Hellier’s Notes on Gynæcological Nursing, 4

  Hewlett’s Bacteriology, 3

  Hill on Cerebral Circulation, 2

  Holden’s Human Osteology, 1

  — Landmarks, 1

  Holthouse on Strabismus, 9

  Hooper’s Physicians’ Vade-Mecum, 5

  Horton-Smith on Typhoid, 7

  Hovell’s Diseases of the Ear, 10

  Human Nature and Physiognomy, 14

  Hyslop’s Mental Physiology, 3

  Impey on Leprosy, 10

  Ireland on Mental Affections of Children, 3

  Jacobson’s Male Organs of Generation, 12

  — Operations of Surgery, 8

  Jellett’s Practice of Midwifery, 3

  — Gynæcology, 3

  Jessop’s Ophthalmic Surgery and Medicine, 9

  Johnson’s (Sir G.) Asphyxia, 6

  — Medical Lectures and Essays, 6

  — (A. E.) Analyst’s Companion, 13

  Journal of Mental Science, 3

  Kellogg on Mental Diseases, 3

  Kelynack’s Pathologist’s Handbook, 1

  Keyes’ Genito-Urinary Organs and Syphilis, 12

  Kohlrausch’s Physical Measurements, 14

  Lancereaux’s Atlas of Pathological Anatomy, 2

  Lane’s Rheumatic Diseases, 7

  Langdon-Down’s Mental Affections of Childhood, 3

  Lawrie on Chloroform, 4

  Lazarus-Barlow’s General Pathology, 1

  Lee’s Microtomist’s Vade-Mecum, 14

  Lewis (Bevan) on the Human Brain, 2

  Liebreich (O.) on Borax and Boracic Acid, 2

  Liebreich’s (R.). Atlas of Ophthalmoscopy, 10

  Lucas’s Practical Pharmacy, 4

  MacMunn’s Clinical Chemistry of Urine, 11

  Macnamara’s Diseases and Refraction of the Eye, 9

  Macnamara’s Diseases of Bones and Joints, 8

  McNeill’s Epidemics and Isolation Hospitals, 2

  Malcolm’s Physiology of Death, 9

  Marcet on Respiration, 1

  Martin’s Ambulance Lectures, 8

  Maxwell’s Terminologia Medica Polyglotta, 12

  Maylard’s Surgery of Alimentary Canal, 9

  Mayne’s Medical Vocabulary, 12

  Microscopical Journal, 14

  Mills and Rowan’s Fuel and its Applications, 14

  Moore’s (N.) Pathological Anatomy of Diseases, 1

  Moore’s (Sir W. J.) Family Medicine for India, 5

  — Manual of the Diseases of India, 5

  Morris’s Human Anatomy, 1

  — Anatomy of Joints, 1

  Moullin’s (Mansell) Surgery, 8

  Nettleship’s Diseases of the Eye, 9

  Notter’s Hygiene, 2

  Ogle on Tympanites, 8

  Oliver’s Abdominal Tumours, 3

  — Diseases of Women, 3

  Ophthalmic (Royal London) Hospital Reports, 9

  Ophthalmological Society’s Transactions, 9

  Ormerod’s Diseases of the Nervous System, 7

  Parkes’ (E.A.) Practical Hygiene, 2

  Parkes’ (L.C.) Elements of Health, 2

  Pavy’s Carbohydrates, 6

  Pereira’s Selecta è Prescriptis, 5

  Phillips’ Materia Medica and Therapeutics, 4

  Pitt-Lewis’s Insane and the Law, 3

  Pollock’s Histology of the Eye and Eyelids, 9

  Proctor’s Practical Pharmacy, 4

  Pye-Smith’s Diseases of the Skin, 10

  Ramsay’s Elementary Systematic Chemistry, 13

  — Inorganic Chemistry, 13

  Richardson’s Mechanical Dentistry, 10

  Richmond’s Antiseptic Principles for Nurses, 4

  Roberts’ (D. Lloyd) Practice of Midwifery, 3

  Robinson’s (Tom) Eczema, 11

  — Illustrations of Skin Diseases, 11

  — Syphilis, 11

  Ross’s Diseases of the Nervous System, 7

  St. Thomas’s Hospital Reports, 7

  Sansom’s Valvular Disease of the Heart, 7

  Scott’s Atlas of Urinary Deposits, 11

  Shaw’s Diseases of the Eye, 9

  Shaw-Mackenzie on Maternal Syphilis, 12

  Short Dictionary of Medical Terms, 12

  Silk’s Manual of Nitrous Oxide, 10

  Smith’s (Ernest A.) Dental Metallurgy, 10

  Smith’s (Eustace) Clinical Studies, 4

  — Disease in Children, 4

  — Wasting Diseases of Infants and Children, 4

  Smith’s (F. J.) Medical Jurisprudence, 2

  Smith’s (J. Greig) Abdominal Surgery, 8

  Smith’s (Priestley) Glaucoma, 10

  Snow’s Cancer and the Cancer Process, 11

  — Palliative Treatment of Cancer, 11

  — Reappearance of Cancer, 11

  Solly’s Medical Climatology, 8

  Southall’s Materia Medica, 5

  Squire’s (P.) Companion to the Pharmacopœia, 4

  — London Hospitals Pharmacopœias, 4

  — Methods and Formulæ, 14

  Starling’s Elements of Human Physiology, 2

  Sternberg’s Bacteriology, 6

  Stevenson and Murphy’s Hygiene, 2

  Sutton’s (J. B.), General Pathology, 1

  Sutton’s (F.) Volumetric Analysis, 13

  Swain’s Surgical Emergencies, 8

  Swayne’s Obstetric Aphorisms, 3

  Taylor’s (A. S.) Medical Jurisprudence, 2

  Taylor’s (F.) Practice of Medicine, 6

  Thin’s Cancerous Affections of the Skin, 10

  — Pathology and Treatment of Ringworm, 10

  — on Psilosis or “Sprue,” 5

  Thompson’s (Sir H.) Calculous Disease, 11

  — Diseases of the Urinary Organs, 11

  — Lithotomy and Lithotrity, 11

  — Stricture of the Urethra, 11

  — Suprapubic Operation, 11

  — Tumours of the Bladder, 11

  Thorne’s Diseases of the Heart, 7

  Thresh’s Water Analysis, 2

  Tilden’s Manual of Chemistry, 12

  Tirard’s Medical Treatment, 6

  Tobin’s Surgery, 8

  Tomes’ (C. S.) Dental Anatomy, 10

  Tomes’ (J. and C. S.) Dental Surgery, 10

  Tooth’s Spinal Cord, 7

  Treves and Lang’s German-English Dictionary, 12

  Tuke’s Dictionary of Psychological Medicine, 3

  Tuson’s Veterinary Pharmacopœia, 14

  Valentin and Hodgkinson’s Practical Chemistry, 13

  Vintras on the Mineral Waters, &c., of France, 8

  Wagner’s Chemical Technology, 14

  Wallace on Dental Caries, 10

  Walsham’s Surgery: its Theory and Practice, 8

  Waring’s Indian Bazaar Medicines, 5

  — Practical Therapeutics, 5

  Watts’ Organic Chemistry, 12

  West’s (S.) How to Examine the Chest, 6

  Westminster Hospital Reports, 7

  White’s (Hale) Materia Medica, Pharmacy, &c., 4

  Winks’ Diseases of the Nervous System, 7

  Wilson’s (Sir E.) Anatomists’ Vade-Mecum, 1

  Wilson’s (G.) Handbook of Hygiene, 2

  Wolfe’s Diseases and Injuries of the Eye, 9

  Wynter and Wethered’s Practical Pathology, 1

  Year-Book of Pharmacy, 5

  Yeo’s (G. F.) Manual of Physiology, 2


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