518 



ABNORMAL CONDITIONS OF THE HAND. 



the living. When we have opportunities of 

 examining, in the dead subject, a hand in which 

 this contraction of the palmar aponeurosis has 

 existed, and have raised the skin in all its ex- 

 tent from the palm of the hand and palmar sur- 

 face of the fingers, its folds and rugae all dis- 

 appear, and it then becomes evident that this 

 defect does not reside in the skin. When the 

 aponeurosis is exposed, it is found contracted, 

 thickened, and diminished in length. From its 

 inferior part, the tense fibrous chords which 

 were already supposed to exist are now exposed, 

 and seen to be inserted into the periosteum on 

 the lateral aspects of the contracted finger. 



Dupuytren, by various anatomical and pa- 

 thological investigations of this disease, satisfied 

 himself that this peculiar contraction of the 

 fingers depends essentially on this shortening, 

 thickening, and organic alteration of the palmar 

 aponeurosis and the digitations proceeding from it 

 to the sides of the fingers ; for he invariably found 

 when he had opportunities of investigating this 

 disease in the dead subject, that the tendons 

 were of their accustomed volume and mobility. 

 He cut them across, and then made efforts in 

 vain to extend the finger. The bones were 

 found of their natural form, and no alteration 

 was perceptible in either the synovial mem- 

 branes or lateral ligaments ; but as soon as the 

 section of the expansions of the fascia which go 

 to the fingers was effected, the flexion dis- 

 appeared, and the finger could be brought to 

 its normal position. Finally, he infers, and 

 indeed, as far as a few instances go, he proves, 

 that a similar result will follow the division of 

 the fascia in the living subject, and that the 

 proper use and adjustment of a peculiar splint 

 on the back of the forearm and hand, so as to 

 keep the affected fingers for a time extended, 

 will complete the cure of this disease. 



Sir A. Cooper alludes to these deformities 

 when he says, " The fingers are sometimes con- 

 tracted by a chronic inflammation of the theca 

 and aponeurosis of the palm of the hand, from 

 excessive action of the hand in the use of the 

 hammer, the oar, ploughing, &c.," evidently 

 recognising two species, in one of which the 

 aponeurosis is the cause of the contraction, and 

 the contracted hand is narrow. " And this 

 hand," he adds, " may with advantage be di- 

 vided by a pointed bistoury, introduced through 

 a small wound in the integuments; the finger 

 may be then extended, and a splint applied to 

 preserve it in the straight position." But he 

 observes that " where the theca is contracted, 

 nothing should be attempted for the patient's 

 relief, as no operation or other means have suc- 

 ceeded." 



Anchylosis of some of the joints of the 

 phalanges sometimes succeeds to an attack of 

 acute or chronic inflammation of one or more 

 of these small articulations; this may have 

 arisen from disease ; for example, paronychia or 

 accident; but from whatever cause the inflam- 

 mation has arisen, anchylosis of a finger in the 

 extended position, which cannot be contracted, 

 or of a joint in the flexed position, which can- 

 not be extended, is the too frequent result. The 

 history of the case, and the actual state of the 



anchylosed joint, which cannot be overlooked, 

 will prevent the surgeon from falling into any 

 eiror in his diagnosis. A contracted state of 

 the ring finger and little finger is frequently to 

 be noticed in those who have suffered much 

 from gout; but we are acquainted with no dis- 

 ease which more frequently produces deformity 

 of the hand and fingers than chronic rheuma- 

 tism (chronic rheumatic arthritis). This mor- 

 bid condition of the joints of the hand is too 

 cursorily alluded to by authors under the head 

 of rheumatic gout, nodosity of the joints of the 

 fingers, &c. &c. It is a complaint which is erro- 

 neously supposed to be met with only in elderly 

 persons. We have, however, in the pauper de- 

 partment of the House of Industry in Dublin, 

 examples of it in females under the age of 30; 

 but of course it is more frequently observed in 

 the aged and rheumatic patient. When the 

 disease has existed long, the whole hand be- 

 comes greatly deformed, and the distortion the 

 fingers have undergone in these cases is of it- 

 self calculated to impress us with a correct idea 

 of the sufferings the victims of this disease 

 have endured. The carpus is usually preter- 

 naturally convex on its dorsal aspect, owing to 

 the thickening and distension of the synovial 

 bursae, which become like solid ganglions. All 

 the joints of the hand and fingers become en- 

 larged, particularly those which are formed by 

 the junction of the first phalanges and metacar- 

 pal bones ; at these joints the fingers are more 

 or less flexed towards the palm, and are, at the 

 same time, adducted or drawn to the ulnar side 

 of the hand. 



The head of the metacarpal bone, where it 

 joins with the first phalanx of the index finger, 

 seems particularly swelled and enlarged, and 

 projects much towards the radial side and dor- 

 sal aspect of the hand, as is represented infg. 

 231. 



Fig. 231. 



Chronic rheumatism, or nodosity of the joints. 



The last phalanx of a finger is frequently 

 flexed, while the middle phalanx is extended. 

 Whatever be the faulty position which the fin- 

 gers happen to have assumed, they are usually 

 found to be remarkably rigid. All movements 



