DOI: 10.7925/drs1.ucdlib_280590
title: Congenital hypertrophy of the middle finger

description: Watercolour medical illustration depicting congenital hypertrophy. It has the alternative reference number 1080 and P11 on the front. The Richmond Hospital Museum reference is C.d. which is congenital malformation. The handwritten note above the illustration reads 'Congenital Hypertrophy of Middle Finger'. The artist's name is in the bottom right corner 'J. Connolly fec.t' and in the bottom left 'Case of Mary McGann Aet 11'. This illustration relates to P263/589 portfolio 10.1. The typescript and handwritten notes on the back begin 'Case of Congenital Hypertrophy of the Index and Middle Fingers of the Left Hand.
description: Scope and content: The full typescript and handwritten notes on the back read 'Case of Congenital Hypertrophy of the Index and Middle Fingers of the Left Hand. BY ROBERT ADAMS, Esq., Surgeon to the Hospital. At a meeting of the Pathological Society, April 8th, 1854, Mr Robert Adams brought forward the case of a girl, aet twelve years, who had been born with the index and middle fingers of her left hand in a state of hypertrophy. The subject of this observation is a native of the Isle of Achill, and was sent up to be placed under the care of Mr Adams in the Richmond Hospital, by his relative, Dr George Montgomery. At the period of her admission into hospital (viz., April 7th, 1853), the enlargement from congenital hypertrophy of the middle finger had proceeded to such a degree, and one of the fingers had reached such a magnitude, that Mr Adams could not meet among the cases of this lesion recorded any parallel to it. The cast of the hand (represented by the woodcut) laid on the table, he said, would at once give an idea of the nature of the deformity. The girl is healthy and intelligent, and, with the exception of the left hand, is in other respects well formed. When we look at the cast of the forearm and hand, we notice that the hypertrophied middle finger is an enormous bulk and length, compared with that of the opposite hand; for example, while the middle finger of the right or normal hand of this little girl measures three inches and a-half, the length of the hypertrophied middle finger of the left hand amounts to eight inches; its circumference at its largest part gives the same measurement. The nail of this middle finger is very broad and strong, fully an inch square, and constitutes a very remarkable feature in this extraordinary case. The direction of this finger was altered, and much adducted towards the ulnar side; the index finger was also hypertrophied, but by no means to the same degree as the middle finger, it was drawn towards the radial side, and at the same time incurvated in this direction, so as to be greatly divaricated at its extremity from the middle finger. The index was four inches and a-half long, and the measurement of the circumference of it, at its greatest part, amounted also to four inches. On the dorsum of the metacarpus, as it were continuous with the root of the hypertrophied middle finger, there existed a tumour apparently fatty, and the size of half an egg; above this, and corresponding to the back of the carpus, another distinct swelling was situated, nearly of the same size and form; a third tumour, also apparently of a fatty nature, but not circumscribed, existed on the upper part of the forearm (see woodcut). The skin covering the hypertrophied fingers was of a dark pink colour, its temperature was natural, as was also the sense of feeling. She had the power of moving the joints, but imperfectly, and she noticed that their movements had been becoming each day more difficult from the increasing growth of the middle finger. As the girl grew older the feeling of personal deformity became a more constant source of discomfort and unhappiness to her. As to the history of the origin of the abnormal condition of the hand, I learn from Dr Montgomery that the child with the index and middle fingers three times their natural size. The child's father said, that when she was born her middle finger was just the size of his own little finger. Its growth at first was only in proportion to the child's growth; a year or two ago it had commenced to increase, and continued to grow more rapidly so as to attain its present size. It this case it was a matter for deliberation, whether anything further should be done than to cut off the principal offending parts, namely, the hypertrophied fingers, which it was thought could be readily done, and without being very likely to be productive of any danger to life or the functions of the wrist joint, so important to preserve in a state of perfect integrity. At the same time it has to be borne in mind, that such an operation would not remove the whole of the abnormal parts, and the patient should thus be liable to some recurrence of the evils she now laboured under. To remove all the fatty mass which lay on the dorsum of the wrist and forearm, together with the whole of the two metacarpal bones, might be feasible, but on due deliberation I do not think that in such a case, where the life of the girl was not in danger from the deformity, it would be justifiable to have recourse to such an extensive dissection, and to encounter the danger which might be anticipated to result from the constitutional irritation which might be expected to follow the mere dissection out of the fatty masses. Moreover, I feared much that the attempt to remove the entire of the hypertrophied metacarpal bones would involve the opening into some of the metacarpal joints, and thus would indirectly be made a communication with the external air and the interior of the wrist joint, likely to be followed by the worst consequences. Of the two evils, therefore, it was decided, that it appeared to be the lesser to leave the three fatty diffused swellings of the dorsum of the hand and forearm, together with some portions of the two hypertrophied metacarpal bones, than to encounter the risk of exciting constitutional irritation, and more particularly that of exciting inflammation in the wrist joint. We therefore came to the determination not to interfere with the tumours, but to remove the two hypertrophied fingers by sawing through their metacarpal bones as high up as we conveniently could. Operation – An incision was made on the radial side and dorsum of the metacarpal region down to the bone, upwards towards the annular ligament of the wrist joint; a similar incision was extended to the ulnar side of the hypertrophied middle finger, to meet the former at an acute angle salient upwards; each metacarpal bone was cut through obliquely with a small saw in the direction of the two incisions (see lines marked in woodcut), and the hypertrophied fingers removed: the greatly divaricated fingers were then approximated as much as possible, and the integument which had covered the radial side of the index finger was applied to the cut surface on the radial side of the ring finger and its metacarpal bone; one suture was applied at the lower angle of the wound. There was but very little haemorrhage, and as of course chloroform was used, we may say there was no pain. Mr Adams laid on the table the amputated part, comprising also the lower extremities of the two corresponding metacarpal bones, which were also somewhat hypertrophied. A longitudinal section of the middle finger was made, and exhibited the hypertrophied head of the metacarpal bone and the three phalanges of a length greater than they measure in the skeleton of any giant preserved in any museum. The epiphyses were not yet ossified, the cartilages and synovial apparatus were perfect, the bones were firm and of a natural structure, but the section of the finger every where exhibited a vast predominancy of adipose structure, which constituted, with the elongated and hypertrophied bones, the bulk of the deformed mass. The extensor and flexor tendons were thrown to the radial and ulnar side of the index and middle fingers, thereby accounting for the deviations from the right line which the fingers had undergone. The wound healed rapidly, and the patient was discharged July 23rd. Mr Adams wishing to learn how this plan had succeeded, before he brought the case forward, wrote to Doctor George Montgomery for information on this point, and learned from him, by letter dated the 14th March, 1854, that this little girl has excellent use of her left hand; she can earn her bread, sew, and do crochet work, and pass unobserved, which she could not do before. Her mother told him she could make as good use of this hand as any other girl in the village could make of theirs. She expresses herself as much gratified by having been relieved of a source of “discomfort and reproach” (See Dr Jacob's observations on the operation of removing from a man a production resembling a tail, Dublin Hospital Reports, vol. iv, p. 576).Observations – The cases of congenital hypertrophy of the fingers as yet published are not very numerous John Reid (London and Edinburgh Monthly Journal of Med. Science, 1843, p. 198) has given the particulars of a case of this kind, in which the radial artery of the affected side seemed to be double the size of the opposite and healthy one. Surgeon Robert Power, of this city, some years ago adduced a case in the Dublin Journal (Dublin Journal of Med. Sciences, May, 1840, vol. xvii, p. 243), of congenital malformation of the middle finger, in a child of five years; in this case, if we are to judge from the engraving, the fatty tissue was very great, increasing the breadth of the finger more…in proportion than the length and in this case also there was apparently a fatty tumour connected with the base of the first phalanx. Mr J.B. Curling[?] has introduced into the Medico-Chirurgical [?] a very interesting account of a case of congenital hypertrophy of the fingers in a girl with a notice of some similar cases. In Mr Curling's case the finger most enlarged was the index which measured 5 ½ inches in length & 4 inches in circumference, he noticed that the middle finger has a lateral inclination outwards occasioned apparently by the displacement of the exterior tendons which formed a bridle along its outer edge. He Also remarked that there was a fullness in these parts of the hand from which the hypertrophied fingers proceed as was the case also in Mr Powers as well as in this I have adduced. In the Museum of the King's College, London there is a cast of the left hand of an adult in which the middle finger is hypertrophied, the others remaining their natural size. This case is congenital & the hands of other members of the family were deformed on a similar manner. There is a cast of congenital hypertrophy of the fingers in the Museum of the College of Surgeons in Dublin presented by Dr Thomas Beatty. In conclusion Mr Adams said that he thought the case worthy of the notice of the Society on the following grounds: First That the middle finger in this example of an abnormal hand had attained a size unequalled in any yet published. Secondly As it is the only case in which the anatomy of the affected fingers has been displayed. Thirdly He might add the only case yet recorded in which any feasible medical measures had been either proposed or adopted'.
description: Numbering/sequence: Original reference number: 1080.