No. 3544.

AUGUST 1, 1891.

LecturesON

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

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

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

COLLEGE OF SURGEONS ; SENIOR ASSISTANT SURGEONTO ST. THOMAS’S HOSPITAL.

LEC rURE III.

CONTRACTIONS OF THE TOES.THE whole of the morbid conditions described in con.

mexion ;with the fingers are probably represented in the

toes, and the classification adopted in the former case maybe applied with but slight modification to the latter.

1. Contractions dependent r onath,oZogieaL lesions in the,cutaneous and fascia structures. - Cicatricial contractionfrom traumatic injuries is much less frequent in the footthan in the hand, on account of the protection afforded bythe shoe. The treatment may be conducted on the same

principles. A contraction of the sole corresponding to

Dupuytren’s disease in the hand is extremely rare, andalthough cases have been mentioned by Mr. Adams andother surgeons, I believe none have yet been shown or dis-missed at any medical society. The following exampledeserves record.The patient, a gardener aged fifty-seven, was admitted to

St. Thomas’s Hospital in May last with contraction of bothhands. He stated that he first noticed a slight contractionbeginning in the ring finger of the left hand twelve yearsago; in the course of a year or two the disease extended tothe little finger, and afterwards to the middle finger. Fourjears since a similar affection appeared in the right hand,and shortly before admission he observed a superficialaodule on the sole of each foot. He had never suffered-from gout or rheumatism, and had always enjoyed goodhealth; the family history was negative. On examinationthe third, fourth, and fifth fingers were found contracted inboth hands; the fourth and fifth fingers of the left handbeing strongly bent at the first and second joints, andbrought intj oontact with the palm, while on the rightside the lesions were similar in character but less advanced.in each sole a flat subcutaneous nodule could be feltadherent to the plantar fascia and slightly to the in-tegument, but there was no puckering of the latter,and the position of the toes was quite unaffected. Thecontracted cords in both hands were divided by multiplesubcutaneous incisions, and the fingers were extended byplaster- of-Paris splints. The nodule upon the right solewas 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 ithe microscope the appearances presented were identicalwith those in Dupuytren’s contraction. Portions were,placed in tubes of agar-agar and gelatine, and are now undercultivation. The operation upon the hand has so far beenquite successful, and the wound on the foot healed by firstintention. (The patient was shown at the close of the firstlecture.) There is no doubt that the foot nodule was patho-logically the same as the contracted tissue in the hands.An explanation of the extreme rarity of the foot lesion hasalready been offered (Lecture 1. ).

Contractions duc to developmental irregularities in the,91,tiezilcii- structures. - Tnis group includes the conditionsknown as hammer toe, hallux flexus, and some of thelateral versions of the toes.Hammer toe.-This complaint in its complete form may

be described as a permanent flexion of not less than 30°from the straight line at either or both of the inter-phalangeal joints, without paralysis of muscles, unattendedwith any primary degenerative or inflammatory disease ofthe articular structures, and essentially confined in origin tothe period of active growth. Sjme precision of definitionis ,!1ec:ry to exclude similar deformities of wholly

different pathological nature as well as the lesser degreesof contraction which give rise to no inconvenience.Hammer toe was well known long before it became the

subject of scientific observation. According to Dr. Gohen1the 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 tht3succeseor of one Rousselot, who thirteen years earlier wrotea book to which he gave the formidable name of " LaToilette des Pieds,ouTrait6 de la Goérison des Cors, Verruel’,et autres Affections de la Peau, et Dissertation abregee surle Traitement et la Guérison des Cancers." In this essay aflexion of the toes attributed to the use of short shoes illalluded to with sufficient clearness to make it probable thatLaforest had succeeded to the ideas as well as to thepractice of his predecessor. The first account, however,with any pretensions to science, was that given by Boyerin 1822 2 Since that time the subject has been discussedrepeatedly in France, and within the last few years hasbeen brought forward twice in England, at the ClinicalSociety in 1887 and at the Medical Society in 1889.The deformity is found in both sexes, but is somewhat

more frequent in the male (3 to 2). The influence of age isvery strongly marked. The condition invariably beginswithin the developmental period, and may show itself abany time between birth and adult life, but most frequentlyattracts the notice of the patient for the first time duringthe third quinquennial period. Amongst a number of in-cipient cases seen at Hanwell not more than one-tenth wereunder twelve years of age, the little toe being usually theseat of the earlier manifestations. It is said to be occasionallycongenital. So far as my own observations go neither class,occupation, nor constitutional condition appears to have anyshare in its production.

It has long been a popular as well as a medical opinionthat the deformity is handed down by inheritance. EvenLaforest, who contests the belief, says, "Je m’entendssouvent dire que l’on est ne avec un doigt ainsi; que c’estun doigt de famille." Boyer asserted that it was frequentlyinherited, and Blum and others have adduced examples insupport of this view. In a paper read before the ClinicalSociety, four years ago, I referred to a history in four casesout of twenty-two which had the same bearing ; and otherstriking examples have since been brought forward byMr. Adams. In fact some evidence of the influence of thehereditary principle may be traced in at least a fourth ofthe examples that come under notice, and is particularlyfrequent and clear amongst patients of the educated classes.The subjoined pedigree, kindly furnished by a colleague in

whose family the affection has arisen, illustrates the descentthrough four generations. It was noted that the children

F. -’ M.*

I IF. F. F.* £ M.*

’----y---’__

I _____ _ __

F. F. M. M. F.’ M. F.

IF. M." x- F."

The asterisk indicates the members of the family who sufferedfrom hammer toe. M. and F. signify sex.

attacked were those who presented most resemblance infeature and temperament to the grandfather. The de-formity usually appeared about the age of four, and wasconfined to the second toe. "Double-jointed" thumbswere also an inheritance in the family. In another examplethe condition developed in five children out of eleven.Here too there was a history of " double ointedness

" in thefingers and thumb, extending through three generations ;and an aunt on the male side was also the subject ofhammer finger. This association of hammer toe with otherdevelopmental irregularities is significant enough to deserveattention. In addition to the instances mentioned, therewere amongst the forty surgical cases on my list threeaccompanied by hallux flexus ; and there is little doubt thatcoincidences of a like kind would more frequently be foundwere it always pMtdble to ascertain the facts by inquiry.

Seat of attack -In surgical cases the toe most commonlyaffected is the second. In my list of forty patients who

1 Orteil en Marteau. Baillière, 1888.2 Traité des Maladies Chirurgicales.

214

had applied for treatment, this digit was affected in thirty-seven, while the third, fourth, and fifth toes each affordedonly a single example ; but if all cases of contraction ofthe joint for 30° or more be counted without reference tosymptoms, the condition is far more frequent in the littletoe than in the others. Thus in an examination of a

series of 800 children under sixteen years of age the little toewas found to be involved in forty-one cases, nearly all ofwhich were double, while the second toe was affectedin six only, and the third toe in five.The deformity is bilateral and symmetrical in nearly a

third of the cases (13 in 40), in the rest having a slightpreference for the right side, in the proportion of 5 to 4. Itis usually localised in the first inter-phalangeal articulation(9 times in 10), 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 israrely seen by the surgeon, the toe is slightly extended atthe metatarso-phalangeal articulation, and lexed at theproximal inter-phalangeal joint. By passive movement theflexed joint may be extended, although at the expense ofsome pain to the patient; but the range of motion, even inthe early stage, is found to be less than that of the neigh-bouring or opposite toe. The distal joint is usually un-affected, and may be held straight or slightly flexed, butoccasionally it undergoes contraction, either alone or inassociation with the proximal articulation. There is noevidence at this or any subsequent time of inflammation in

FiG. 8.

A, Diagram showing position of bones in hammer toe. 1, Meta-tarsal bone. 2, Head of first phalanx; slight groove cor-responding to position of dorsal border of base of second !phalanx. 3, 4, and 5, Callosities due to boot pressure. 6, burs ’,over contracted joint. 7, 8, Shoe. The arrow indicates thedirection in which the pressure of the upper leather tends toforce downwards the head of the metatarsal bone towards thesole. B, Dissection of first inter-phalaugeal j oint in hammer toe.c, The same preparation after section of plantar fibres of lateralligaments.

or around the joint structures, except in association withcorns or bursse. How long this period may last it is difficultto say, as it may altogether escape the notice of thepatient. In the second stage, the flexion of the inter-phalangeal joint becomes more pronounced, and thesecondary extension at the metatarso-phalangeal jointincreases pari passu. At this period the affected articula-tion is fixed for all movement of extension, but the powerof flexion within the limits left to it remains unimpaired ; inother words, the angle may be diminished, but not widened,and the toe, although contracted, is neither ankylosed norparalysed. In exceptional instances the flexion may be over-come by strong passive force and a distinct trigger-likeaction established, the middle phalanx becoming extendedand flexed again with a movement very comparable tothat which takes place during the opening and shuttingof the blade of a pocketi-knife. As secondary resultsof the contraction of the proximal inter-phalangeal jointthe patient is subject to certain inconveniences whichmay give rise to much suffering end are usually theimmediate cause of his appeal to the surgeon. The chief ofthese are a bursal formation, which is very liable toinflammation, over the angle of flexion, and two associatedcallosities, one above the head of the retracted phalanx,the other beneath the head of the metatarsal bone, bothconsequent upon the pressure exercised by the boot.(See Fig. 8.) A third callosity may develop over the tip

of the toe, and the soft parts over the terminal jointmay become somewhat swollen, so that the digit pre-sents a clubbed appearance. The degree of interferencewith functions and comfort varies greatly in differentcases, partly in relation to the degree of the contractionand 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 isespecially the case when the contraction is limited to the.little toe; in others the suffering is so great that the patientbegs the surgeon to remove the offending member with theknife, and remains absolutely crippled until an operation ispractised for his relief. When the deformity affects morethan a single digit, an interval varying from a few monthsto five or six years may elapse before the second attackappears. As a rule, it is the corresponding toe on theopposite foot that suffers, but occasionally a neighbour is,selected ; or even, as in a case on my own list, the distaljoint of the same toe.Morbid anatomy and pathology.-The earlier opinions.

upon the pathology of hammer toe were very conflicting.Gosselin, who dissected a specimen, was unable to findany lesion. Fano, in 1855, mentions as the chief defect a,cartilaginous nucleus in the extensor tendon. Blum describeda luxation of the first phalangeal joint, with a thickeningof the whole capsule, and maintained that the contrac-tion of the toe was due to a periarthritis set up by theinflammation 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 theextensor 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 hammertoe from the arthritic and traumatic deformities which simu-late it. It is now beyond doubt that the essential seat of thecontraction is in the joint itself. The specimen representedin B, c, Fig. 8, is one prepared by myself in 1882 from a toewhich had been amputated by a colleague. It showed thatthe deformity was not affected by section of the tendons,but that it yielded immediately upon division of the plantarfibres of the lateral ligaments where they blended with theglenoid plate. This observation, however, was not pub-lished until 1887, and it was by Mr. Shattock, who workingindependently had found the same lesion, that the conditionwas first made known at the Clinical Society in the sameyear. The beautiful preparation illustrating his paper is.now in the museum of St. Thomas’s Hospital, as well as %second dissection demonstrating the absence of disease inthe interossei. The results of these and later investigations,may now be stated.

1. There are no essential alterations of muscle or tendonexcept those secondary to the contraction of the joint-namely, an undue tension and prominence of the extensorover the metatarso-phalangeal articulation, and an adaptivedeficiency of length in the flexors, which are prevented bythe permanently bent state of the articulation from keepingpace in growth with the osseous structures. 2. The skin andfasciae 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 iacchange beyond atrophy of that portion of the cartilage of thehead of the proximal bone, which is permanently excludedfrom contact with the distal bone in consequence of the im-perfect range of extension of the joint. In some cases, how-ever, a distinct transverse groove is present on the head of theproximal phalanx at the point where it comes in contactwith the dorsal border of the base of the distal bone duringthe attempt at extension, and behind this groove the bonemay be heaped up into a little ridge. It is the existenceof this irregularity that explains the trigger phenomenonpreviously alluded to. 4. The ligaments present no

structural change, but an important quantitative defect isalways found in the plantar fibles of the lateral ligaments,which are so short that they check prematurely the move-ment of extension of the joint. This is the essence of thedisease.The real origin of the articular defect has been the source

of much argument. At all times, whatever may have beenthe opinion as to the exact morbid anatomy of the con-dition, there has been a strong disposition to blame theshoemaker, or rather the fashion that dictated thearbitrary form the shoe was to assume, as the primecause of the disease. There is, of course, no question thatthe mistaken ideal of elegance which finds expression in

215

the demand for tight and pointed boots has been thecause of much misery and deformity, and it appears onlynatural to assume that the artificial crowding together ofthe toes might force one of the members to assume a posi-tion of retraction, in order to make room for the rest, andthe digit so drawn up might after a time become perma-nently fixed in its abnormal attitude. This view is wellexpressed by Mr. Ellis,3 but the study of a number of casesof hammer toe furnishes strong reason for doubting thisfatally plausible hypothesis. In the first place, the de-formity may be seen in early infancy, before any rigid footcovering has been adopted ; and a precisely analogous con-dition is known to exist in the fingers, which are not sub-jected to any artificial restraints. Moreover, in the greatmajority of the feet affected with hammer toe there is acomplete freedom from the deformities which result fromovercrowding of the digits, and there is nothing in thehistory of the cases to indicate the past use of improperboots.

It has been said that hammer toe is unknown incountries where boots are not worn; but although thismay be true, the evidence in support of the statement isnot to be regarded as conclusive, because the subject hasyet to be studied in those parts of the world on a scale thatsanctions generalisation. It must also be remarked that ashammer toe is painful only in consequence of the friction andpressure induced by the foot-covering, its existence wouldbe unlikely to attract much attention in a bootless race.During my own residence of six years in Japan I nevermet with an example, and my friend Surgeon-GeneralTakaki writes to me that his observations, covering a periodof fifteen years, are equally negative ; but it must be notedthat it is the rising and boot-wearing generation that hasbeen especially brought under our notice, and the con-clusions to be drawn from our experience tend as much tocontradict the view that boots are an immediate cause ofhammer toe, as to support the belief that the Japaneseare exempt from the defect. I have little doubt, however,that the use of shoes is to some extent, and in a remote sense,z predisponent to this and to other analogous deformities,for it is certain that a rigid leather foot covering, even whenshape according to the most scientific principles, mustnecessarily interfere with the free action of the toes, and sowith the processes of nutrition; but I am equally confidentthat few, if any, of the examples of hammer toe that have’come within my own experience could be traced to aiayapecial defect in the form of the shoe. Out of the wholenumber only four confessed to having worn tight boots. Inthe rest, neither history nor inspection indicated any fault ofthe kind, and the feet in the great majority were perfectlywell formed in all other respects, and bore no marks ofinjurious compression. The true explanation I believe to’be that advanced to account for the occurrence of hammerfinger. The examination of a large number of healthy feetwill reveal physiological variations in the condition of theinter-phalangeal joints exactly comparable with those notedin the hands. The second phalanx may in some persons besuper-extended 30&deg; beyond the axial line of the proximalbone, while in other instances the movement is arrestedby tension of the plantar fibres of the lateral ligaments ibefore this line has been attained ;4 and in the distaljoint an even greater variation may be found. Thereis, in fact, a physiological tendency to hammer toe inlarge numbers of people who never actually suffer any in-- convenience from it, and it is in the exaggeration of thisphysiological irregularity that we have to seek the pathology<of the surgical hammer toe. The tendency ceases at adultife, because the ligamentous and bony structures of thearticulation have then assumed their permanent condition,and any later deformity simulating it can only occur as aresult of a totally different set of conditions.Hammer toe, then, like hammer finger, must be regarded

3 The Human Foot, 1889.4 It is unnecessary to enter minutely into the conformation of the

inter-phalangeal joints, but it must be understood that the proximalattachment of the plantar fibres of the lateral ligaments lies at a pointbelow the centre of the dorsal half of the condylar curve, and hencethese fibres become more and more stretched as their distal attachmentis carried upwards in the direction of extension, until at last the motionis checked by their tension. The point at which the arrest occurs neces-sarily depends upon the relation existing between the length of thefibres and that of the radii of the condylar curve. If the ligaments of ajoint be artificially elongated by acrobatic training in early life, theymay lose their power of fixing the range of movement, and extension maythen go on until it is stopped by contact of bones or by contraction ofopposing muscles. The latter factor, of course, is always an importantone, but it does not affect the present aspect of the question.

as the result of insufficient longitudinal evolution of thosefibres of the lateral ligaments which have for their functionsthe limitation of the movement of extension at the inter-phalangeal joints, and the symptoms induced by the de-formity are mainly dependent upon the formation of cal-losities and bursse by contact with the opposed hard surfacesof the foot covering. This irregularity of development maybe either inherited or accidental.

T1’eatment.-It is probably not within our power to preventthe occurrence of hammer toe, but care in the selection ofboots might lessen its frequency and severity. For itsrelief when developed many plans have been adopted, thechief of which are as follows:-1. Extension by splints ofvarious kinds in the early stages, while the contractionmay be overcome by passive force. The condition is, how-ever, rarely seen by the surgeon in this period. 2. Teno-tomy of the extensor tendon (Boyer). This measure,which was doubtless suggested by the visible tension ofthe tendon in many cases, is more likely to aggravatethan to relieve the symptoms. 3. Tenotomy of theflexor tendons. This to be successful must involve alsothe section of the glenoid and lateral ligaments. Such anoperation has been practised both by the subcutaneousand by the open methods, but it involves the immediatethough not very serious danger of division of the plantardigital vessels and nerves, and the necessity for a prolongedafter-treatment to prevent recurrence. It has even beenadvised by Petersen to treat the contraction by a transverseincision, through integuments, tendons, and ligaments,down to the articulation, but the promptitude of the methodis its only recommendation. 4. Subentaneous division of thelateral ligaments. This operation has been performed withgood results by Mr. Adams, but it has the disadvantageof requiring a long after-treatment. 5. Resection of thejoint. This is unquestionably the most eligible measure,and has been successfully practised on different plans byvarious surgeons during the last twelve years or more inEngland and France. The articular extremities of bothbones may be removed or the head of the proximal boneonly, the distal bone being left intact. In either case thetoe is subsequently fixed for a period of three or four weeksin an extended position. The procedure I have found mostspeedy and satisfactory is as follows: An incision is madeon the lateral aspect of the affected articulation, followingthe 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 aforcible lateral movement the head of the proximal phalanxis made to protrude through the wound, when it is removedwith a pair of bone nippers. The toe is straightened,the wound closed by sutures (without drainage), anddressed. Antiseptic precautions must be strictly observed.The operation can be completed within two or three

minutes, and, what is a far more important consideration, itinvolves the least possible interference with the structuresof the toe. The wound heals by first intention, and after afortnight’s rest the patient is able to walk, the toe beingextended for a few weeks upon a dorsal splint of flat steei,such as was used in making the now obsolete appen-dages to the back of the feminine skirt. The result is all thatcould be desired, and the relief immediate and permanent.6. Amputation was, until within the last ten or twelveyears, the usual resource after the failure of tenotomyof the extensor. It affords a curious comment uponthe surgery of the pre-antiseptic period that the chiefreason given against this operation by the early writers wasits danger to life. At the present time it can rarely beneeded unless, by any accident, the antisep3is of the resec-tion operation fails and acute inflammation sets in.

(To be concluded.)

MEDICAL STAFF CORPS, LEEDS.&mdash;On the 25thult. the annual inspection of the 6th Leeds Division of thiscorps took place in Bagby Fields, Archery-road. Eighty-five out of 100 of all ranks were on parade. The men pre-sented a smart appearance as they formed in open order toreceive the inspecting officer, Deputy Surgeon-GeneralDonaldson, principal medical officer of the North-EasternDistrict. The operations were confined to bearer companydrill, every department of which was most creditably per-formed. Waggon and cacolet drill, and the method oftransmitting messages, were also witnessed by the inspect-ing officer, who expressed himself highly satisfied with whathe had seea.