"The Oldie is an incredible magazine - perhaps the best magazine in the world right now" Graydon Carter, founder of Air Mail and former Editor of Vanity Fair

Subscribe to the Oldie and get a free cartoon book

Subscribe

Watch out, alcoholics and Mrs T. By Dr Theodore Dalrymple

Blog | By Theodore Dalrymple | Jun 20, 2024


Sometimes – for example, when I try to find out the prevalence of Dupuytren’s contracture – I wonder whether Pontius Pilate wasn’t on to something when he asked what truth was.

A search into Dupuytren’s contracture – a thickening of tissues in the palm of the hand – gave me figures that ranged from a third of one per cent of the population to 20 per cent.

It depends on the age group, and also on what stage of the contracture counts as a case.

One estimate for Britain was 0.69 per cent of the adult population, which sounds at least plausible. Apparently, the incidence has doubled in the last 15 years or so, for reasons that are not understood.

Dupuytren’s contracture is caused by an overgrowth of the connective tissue of the palm of the hand which can lead to a permanent bending of the fingers, most commonly the ring and little fingers, and an inability to straighten them. Naturally, this can interfere with what are now called the activities of daily living.

The disease is named – at least until someone discovers that he once did something very bad – after the French anatomist and surgeon Guillaume Dupuytren (1777-1835), who first described it. There is a rue Dupuytren in Paris’s 6th arrondissement.

Mrs Thatcher suffered from the condition, though it is far more common in men. It is rare before the age of 40 and more than twice as common in people who have used vibrating machinery in their work. Northern Europeans are particularly susceptible.

There is a hereditary predisposition to it, and both diabetics and alcoholics are more likely to develop it. For some reason, the association between alcoholism and Dupuytren’s contracture sticks at once in every medical student’s mind and is never forgotten, unlike so much of what he or she is taught.

Epileptics who take phenytoin often develop Dupuytren’s contracture. There is also an association with smoking – I presume independently of drinking.

When it’s stated in medical literature that smokers are more susceptible to something or other, one detects almost a satisfaction, as though it served them right; that they only had themselves to blame. In a sense, I suppose, this is right.

What is the best treatment for this annoying and sometimes incapacitating condition? Traditionally, the treatment has been surgical, though it is not entirely satisfactory: the condition often returns.

Other treatments now exist, including collagenase injection or needle fasciotomy. The former is the injection of an enzyme that dissolves the tissue in the palm that’s causing the contracture. The latter is a simplified surgical outpatient procedure lasting about 30 minutes, in which a needle is inserted and the fibrous bands cut in a kind of sawing movement.

But which is best? A study from Finland compared the results of all three treatments – surgery, enzyme injection and needle fasciotomy – with nearly 100 patients in each group. After three months, the results were very similar, with just over 70 per cent of patients being markedly improved.

At two years, however, there was a difference: surgery was better than enzyme injection and much better than needle fasciotomy. Only a quarter of the surgery group had had a recurrence, compared with half of the needle fasciotomy group.

This illustrates a general point: that it may be necessary to wait for some time before differences in the results of treatments manifest themselves. Immediate results may be deceptive.

When I look at and feel the palms of my hands, I see thickening of bands of palmar fascia, and I can feel nodules also. I have had this for years without further deterioration.

Will I get full-blown Dupuytren’s contracture? Luckily, it’s not difficult for me to refrain from using vibrating machinery.