AINHUM

Synonym.—Dactylolysis spontanea.

Definition.—A disease characterized by a slow but gradual
linear strangulation of one or more of the toes, especially the smallest,
and resulting eventually in spontaneous amputation. This affection,
an account of which was first presented by Clark,¹ and since by Da
Silva Lima² and others, is seen most frequently in the negro and Hindu

¹ Clark, Trans. Epidemiolog. Soc'y, 1860, vol. i, p. 105 (brief notice).

² Da Silva Lima, Arch. Derm., 1880, p. 367. Accounts are also to be found in
Hirsch‘s Geograph. and Histor. Pathology, New Syd. Soc‘y‘s Translation, 1886, vol. liii,
p. 728 (with bibliography), and Fox and Farquhar‘s Endemic Skin Diseases of India,
etc, app. vii, p. 114, London, 1876; De Brun, “L‘ainhum des auteurs, constitue-t-il une

AINHUM

627

races, although cases have occurred in Arabs, Mussulmans, and Chinese.
But few cases have been recorded in white individuals. It is met with
not infrequently on the west coast of Africa, Egypt, Trinidad, India,
in Bahia, Rio de Janeiro, Buenos Ayres, and some other parts of the
world. It is also rarely seen in parts of the United States, as Virginia,¹
North Carolina, and Illinois.²

Symptoms.—The affection begins with a furrow on the plantar
aspect, usually of the little toe, at the interphalangeal articulation.
This furrow extends quite slowly around the toe, and becomes gradually
deeper, until the constriction completely surrounds that member. The

Fig. 148.—Ainhum; small toe of left foot already gone, beginning “ligation” of
the third toe, and similar tendency in some toes of the other foot, and on the small
finger of the left hand; in fact, this constricting tendency is noted on almost all the
fingers and toes. Patient is a male adult, aged about twenty-eight, a farmer, native
born, with a generalized condition of the skin suggestive of a pityriasis rubra pilaris,
and existing since childhood (case referred to in the text).

end of the toe enlarges to twice its normal size. After several years,
varying from four to ten, the phalanx is absorbed, the blood-vessels
become obliterated, and the toe drops off. The process, as a rule, is

entité morbide distincte, ou bien n‘est-il qu‘une modalité de la léprose,” Bull, de
l'acad. méd., 1896, vol. xxxvi, p. 248 (an excellent review, with many references);
Pyle, “Ainhum,” Medical News, 1895, i, p. 85 (a complete presentation with bibliogra­
phy); Ohmann-Dumesnil's paper in Medicine, 1895, p. 202, also contains bibliography;
N. D. Brayton (Jour. Amer. Med. Assoc, July 8, 1905), review, case report, and bibli­
ography.

¹ Duhring, “A Case of Ainhum, with Microscopic Examination by H. Wile,” Amer.
Jour. Med. Sci., 1884, vol. lxxxvii, p. 150.

²Herrick, Phila. Med. Jour., 1898, vol. i, p. 246 (with illustrations); Shepherd
(Montreal, Canada) also reports a case—Amer. Jour. Med. Sci., 1887, vol. xciii, p.
137; both of these cases were male negroes.

628

ATROPHIES

not accompanied by subjective symptoms, although later it is some­
times painful, and toward the end there may be inflammation or ulcera-
tion. Sometimes a small ulcer forms in or near the digitoplantar fold,
and in such instances the pain is usually very severe. At times other
toes on the same or on the other foot may be involved, and even a linger
may become affected. Involvement other than the small toe is, how­
ever, exceptional. It would seem that it may be associated with other
maladies in which epidermic thickening and keratosis are noted. Hyde
and Montgomery¹ noted a similar, gradually constricting band in three
white subjects, associated with symmetric palmar and plantar keratosis;
and in a patient under my care presenting features suggestive of a general
pityriasis rubra pilaris there had been gradual amputation and loss of
one small toe, and the little finger and others of the digits and toes were
showing beginning evidences of such constriction. The diseased parts
usually retain their normal sensibility, and the nail is rarely affected.

Etiology and Pathology.—The disease usually attacks adults,
although a few cases have been reported in children. It is quite rare
in the white race. More cases occur in males than females. Da Silva
Lima, Duhring, and a few others believe that it may occasionally be
hereditary. In Duhring‘s case the father of the patient (negro, aged
forty) had lost both his small toes in the same manner, and the mother,
at the time of observation of the patient, had the same malady. We
are in the dark, however, as to its true causation. It is thought by some
to be of parasitic origin. By others it has been attributed to traumatism,
owing to the habit of negroes of going barefooted, and also to the wearing
of a ligature applied intentionally, but such hypotheses are not borne out
by the facts. Nor does the view advanced by Zambaco Pacha² that it
is an attenuated form of leprosy have any substantial support. It is
probably a trophoneurosis. Microscopic examination shows the epider­
mis and papillary layer, especially the former, to be hypertrophied, the
interpapillary downgrowth being quite marked. The blood-vessels
are the seat of the following changes: in the walls of the larger arteries
the adventitia is greatly increased and the intima much thickened, thus
interfering with the caliber of the vessel. The constriction is usually
about the shaft of the proximal phalanx, although it also has occurred
(Crombie) at the interphalangeal articulation; absorption of the osseous
tissue occurs as constricting fibrous tissue takes its place (Eyles).³
Pyle, from his review of the subject, largely guided by Eyles’ histologic
study, states that the findings show it to be a direct ingrowth of the
epithelium, with a corresponding depression of the surface, due to rapid
hyperplasia that pushes down and strangles the papillae, thus cutting
off the blood-supply from the epithelial cells, causing them to undergo a
horny change. It would seem that the malady might be pathologically
analogous to congenital amputation, as Proust⁴ has suggested, a view,
however, which does not find general acceptance.

¹ Hyde and Montgomery, Diseases of the Skin, seventh edit., 1900, p. 609.

² Zambaco Pacha, Bull. de l'acad. de méd., July 28,1896; see De Brun‘s paper (loc.
cit.).

³ Eyles, “The Histology of Ainhum,” Lancet, 1886, ii, p. 576.

⁴ Proust, Gazette des hôpitaux, 1889, p. 369.

PERFORATING ULCER OF THE FOOT                  629

Treatment.—It is stated by Da Suva Lima, Murray, and others,
that if, in the earlier stage of the disease, the constricting band is trans­
versely incised freely, the affection may be brought to a stand. When,
however, the disorder is of long duration, amputation of the toe is the
only recourse.

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