Universidad de Buenos Aires. Facultad de Derecho y.

The American practitioner online

. (page 17 of 109)
Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 17 of 109)
Font size
QR-code for this ebook

various contractions and consequent disuse of the parts implicated.

Cicatricial Contraction of the Hand. Dr. S. Lloyd presented a little
boy with cicatricial deformity of the right hand, the result of burns
received a year ago. About six weeks ago the little finger, being very
much twisted and distorted, was amputated, and superficial tissue was
removed from the remaining digits. To replace the cicatricial tissue
with normal skin, a flap including a little of the fatty tissue was par-
tially dissected from the abdomen, being attached at the top and bottom.
Under this the boy's hand was slipped, and a plaster of Paris bandage
was applied. This being removed, the attachment of the fingers to
the abdomen was very well shown. At a later stage the flap would be
entirely detached from the abdomen. There had been no suppuration.

Digitized by


The American Practitioner and News. 139

Meeting of January 20, 1899.

Secondary Pulmonary Osteo- Arthropathy in a Child, Dr. R. Whit-
man presented a girl, eight years of age, rather undersized, but in
fair physical condition. There was moderate kyphosis and rigidity
of the spine, the result of Pott's disease of the tenth dorsal vertebra,
accompanied by an abscess in the left iliac fossa, for which she had
been treated by the application of a plaster of Paris jacket in 1893,
when she was two years old. The abscess disappeared, and the patient
was recovering favorably till 1896, when persistent cough and expec-
toration followed an attack of whooping-cough. In 1897 enlargement
of the fingers was noted, the gait was feeble and shuffling, and there
was pain in the knees and ankles, with exaggerated patellar reflex and
ankle clonus, and marked effusion into the knee and ankle joints.
The terminal phalanges and the nails were enlarged, and there was
cough with abundant expectoration and rales at the apex of the left
lung. In 1898 the pain was relieved by the anti-rheumatic administra-
tion of salicylate of soda, and although there was a marked general
improvement, the swelling of the knees and ankles persisted, and the
increased clubbing of the nails had attracted much attention and was
thought to be an instance of the so-called hippocratic fingers, due to
obstruction of the circulation caused by disease of the lungs. Expec-
toration was moderate in amount, and bacilli were not found. In
October, however, an examination showed thickening and enlargement
of the bones of the lower arms, and sensitiveness to pressure and swell-
ing of the wrist joints. This made the diagnosis clear, and at once
connected the clubbing of the fingers, the arthritis, and the enlarged
bones as symptomatic of the affection known as secondary pulmonary
hypertrophic osteo-arthropathy. The child was found to have no
psoas contraction or other trace of abscess, and there was apparent
recovery from the disease of the spine. There was slight dullness at
the apex of the lung, and increased respiratory sounds at the base of
the right. The most marked peculiarity was the great size of the
hands as compared with the size of the child, and of the lower arms
and legs as compared with the upper segments of the extremities, giv-
ing the impression of atrophy of the thighs and upper arms. The
bones of the legs and forearms were sensitive to pressure. The knees,
ankles, and wrists were enlarged by an effusion into the joints and by
thickening of the surrounding parts without redness, heat, or muscular
spasm. Motion was very slightly limited. The digits were thickened.

Digitized by


140 The American Practitioner and News.

and their terminal phalanges remarkably enlarged, with nails rose red
in color but not especially thickened or curved. The circumference of
the ends of the fingers and the breadth of the nails were about twice
as great as normal. This condition was somewhat less marked in the
feet than in the hands. The affection of the bones in this disease
appeared to be a form of malacia in which the organic material is
somewhat increased and the mineral substance correspondingly dimin-
ished, so that the structure of the bone is weakened. The charac-
teristic change is a deposit of new bone beneath the periosteum of the
shafts of the phalanges, the metacarpal and metatarsal bones, and the
lower part of the bones of the lower arm and leg, with local sensitive-
ness, sympathetic arthritis, and clubbing of the ends of the digits
and hypertrophy of the nails. The affection had been first described
in 1888 by Bamburger, and independently by Marie, who differentiated
it from acromegalia, with which it had been confounded. In practically
all of the cases reported, upward of eighty in number, it was second-
ary to chronic disease of other parts ; in seventy-five per cent to tuber-
cular or suppurative disease of the lung or its coverings. The cause
of the periosteal and other changes was supposed to be the absorption
of irritating substances from the focus of suppuration in or about the
lung, combined with impaired circulation. Thus the first evidences
appeared in the ends of the fingers. It was a rare disease, and this was
believed to be the first typical case reported in a child.

Dr. H. E. Pearse, referring to the great increase in the size of the
bones, called attention to the fact that the radiographs showed that the
enlargement was longitudinal as well as transverse.

Dr. A. M. Phelps said that he had been impressed with the remark-
able bony enlargement. A post-mortem examination of the brain
and cord would be of great interest. Acromegaly was due to a tumor
or growth in one of the ventricles of the brain, and he questioned
whether or not in the case presented there was a central lesion due to
poisoning from the diseased area. The lungs had not been sufficiently
involved to cause obstructed pulmonary circulation. In tabetic joints
there was destruction of bone from a central lesion, and cases of
rheumatoid arthritis might perhaps have a similar origin and not have
been rheumatism at all. He doubted whether such a thing as a single
rheumatic joint existed. They were always multiple.

Dr. R. H. Sayre said that the pathological views presented were not
entirely convincing. It was not clear why proliferation of the perios-

Digitized by


The American Practitioner and News. 141

teum should visit the phalanges rather than other parts of the skeleton.
In a patient aflFected with a tubercular knee-joint the radiograph had
shown a very marked proliferation of the periosteum of the lower end
of the femur, and there were marked clubbed fingers. The patient had
the appearance of a consumptive in whom the destruction of the lung
was far advanced, but her lungs showed no change. In another patient
there was the same condition of the fingers, which were more tender
some times than at others. Movement greatly aggravated the inflam-
mation, and nothing gave relief but absolute rest.

Dr. H. S. Stokes said that the etiology was far from being estab-
Hshed, as might well be in a disease that had been recognized for only
eight or ten years. It had not yet been positively determined even
that the condition was dependent on disease of the lungs. If it were,
why did it not occur more frequently? In the absence of the charac-
teristic bacilli it was not certain that the child presented had tubercu-
losis. In view of her history it would not have been strange if her
general condition had been worse. It was almost impossible to make
a diagnosis of lung affections in children with deformed chests. He
had seen a specimen of kyphosis from a case in which the diagnosis of
tuberculosis of both lungs had been made, and yet at the autopsy the
lungs had been found to be normal. Similar cases were not uncommon.

Dr. G. R. Elliott said that if speculation were in order, he would
agree with Dr. Phelps that the cause of this rare condition was to be
sought for through the central nervous system. There was reason to
believe that the cause of various distal bony changes and peculiar vas-
cular phenomena presented by the distal extremities, including great
sensitiveness, together with certain well-marked types of so-called
osteo arthropathy, were traceable to central lesions. In the patient
presented there were clinical and X-ray evidences of a disturbance of
the normal equilibrium between the bone-producing and organic-pro-
ducing cells leading to the enlargement. The signs were bilateral and
symmetrical evidences of central irritation. To say that such a condi-
tion was associated with a chronic disease meant very little; to say that
it was circulatory was untenable. He believed that the explanation
would be found in this, that the trophic and vaso-motor cells had been
thrown off" the track by some poison, be it tubercular or other, circu-
lating through the central nervous system, selective in its nature, and
degenerative in its final expression.

Dr. Stokes said that in the five or six autopsies which had been

Digitized by


142 The American Practitioner and News.

made no nerve lesions had been found, in spite of careful and thorough

Dr. Elliott said that that was true of other diseases which were con-
sidered to be due to central nervous lesion.

Dr. Whitman said that many cases of osteo-arthropathy were proba-
bly not true examples of the disease in question. In many the only
change observed was clubbing of the fingers, which was sometimes
seen in cases of simple obstruction of the circulation, described by
Hippocrates as a symptom of advanced phthisis, and not very uncom-
mon in cases of empyema of long standing. One fact had been estab-
lished, viz : that hypertrophic osteo-arthropathy was practically always
secondary to some chronic disease ; in the case presented, for example,
to Pott's disease and chronic bronchitis. Speculation as to its cause
would seem to be less important than further and more careful descrip-
tions and classification of cases.

Cyst of Femur; Double Coxa Vara, Dr. Whitman presented a boy
eleven years of age with evidences of femur rachitis and the usual
signs of double coxa vara. For several years he had complained of dis-
comfort and pain in the left hip and thigh, the pain at times being
severe, especially after exertion. When about five years of age he was
treated by a physician for eighteen months for supposed hip disease*
and a year later by the application of a plaster jacket for spinal deform-
ity. On September 8, 1898, an operation was begun for the correction
of the deformity of the femora by removing wedges of bone from the
trochanters. On removing the periosteum from the upper end of the
left femur a peculiar dark color and a somewhat reticulated appearance
of the bone were noticed, and at the first touch the chisel broke
through the brittle cortex and entered a cavity from which spurted a
quantity of serum of the color of prune juice. The cavity was of the
size of a hen's egg, its base being shut off" from the medullary cavity of
the diaphysis by a cone-shaped projection covered apparently with car-
tilage. Its upper extremity reached about half way to the apex of the
trochanter. Its walls were lined by a smooth, fibrous covering which
bled freely on manipulation. As it was feared that the inner part of
the femur was weakened by the cyst, and as it was evident that union
in case of fracture would be doubtful, to restrain hemorrhage the cav-
ity was simply packed with gauze, which was removed at the end of
four weeks and the boy began to walk about. The sinus closed one

Digitized by


The American Practitioner and News. 143

month later. It was evident that spontaneous fracture, as in other
cases of coxa vara, could not have been long delayed. If the symptoms
should recur, a second operation for the removal of the walls of the cyst
would be indicated. Cysts of the femur were usually found at the
extremity of the diaphysis, most often at its upper extremity. A diag-
nosis before operation had not been recorded. They were said to be the
result of softening or transformation of an originally more solid growth
of a cartilaginous or fibro-cartilaginous nature, probably a displaced
fragment of epiphyseal cartilage.

Dr. Sayre had examined the boy two or three months ago. As he
had not offered to operate, the patient passed out of his care. At that
time he had taken a radiograph of the hips, and had observed a spot on
the femur which might have been the cyst.

Value of Radiographs, Dr. T. H. Myers said that he had tried, but
usually in vain, to detect abscesses, tubercular foci, and other lesions in
the bones by means of skiagraphy. In a case of abscess of the head
of the tibia an area of diminished density at the site of the abscess
had been clearly revealed, with increased density about it, similar to
the contrast seen between the center and the pheriphery of a long bone
in any skiagraph.

Dr. Phelps said that a radiograph would usually show a shadow
where there was a lesion, but it could not tell what it was. He had
been deceived by pictures taken by good machines, and had cut down
upon lesions which did not exist. It was not possible to diagnosticate
lesions of the soft parts by means of radiography, but if an abscess
was known to exist it would aid in locating it.

Dr. H. L. Taylor said that radiographs could not, until further
improved, be expected to more than indicate certain physical changes
in bone. If the structure had become so attenuated by disease that
the X-ray could pass, the focus of disease would be indicated, not
otherwise. Intelligence and experience should be brought to the inter-
pretation of these pictures, which are subject to all the distortions of
shadows and the errors of photographic processes. A radiogram which
was said to reveal the epiphyseal line had really shown a crack in the
photographic film. He had a picture of tuberculosis of the carpus in
which the diseased foci were shown with the greatest clearness. A
cyst of the bone would be revealed if the walls were sufficiently thin
-o allow the rays to pass.

Digitized by


1 44 The American Practitzoner and News.

Dr. Whitman thought that all X-ray pictures should be interpreted.
They were of g;reat service to one who had clear ideas of what he was
looking for.

Polios Disease : Death Caused by an Abscess in ike Thorax, Dr. Whit-
man also related the history of a boy of four years of age who, with an
angular projection at the fourth dorsal vertebra, was subject to occa-
sional prolonged asthmatic attacks of such severity that fatal asphyxia-
tion seemed to be imminent. The character of the dyspnea seemed to
warrant a diagnosis of abscess pressing upon the trachea. A plaster
jacket and jury-mast were applied with good eflFect, and a month later
the jacket was removed for the purpose of examining the chest more
carefully, but the symptoms of dyspnea, caused apparently in part
by the removal of the support and in part by the recumbent position,
became so urgent that it was immediately reapplied without further
examination. The boy died suddenly that evening. The internal
organs showed no sign of disease. On removing the lungs and heart
a tense, fluctuating tumor was apparent in the median line, the size of
a large hen-egg, between the esophagus and the anterior longitu-
dinal ligament, on a level with the upper border of the third dorsal
vertebra, its apex at the sixth dorsal. The abscess contained about
two ounces of purulent fluid. It appeared to have escaped from behind
the longitudinal ligament into the retro-esophageal space at about the
time of the greater obstruction of breathing, or about six weeks before
death. The greatest projection of the tumor was opposite the third
vertebra, where it was forced forward by the spine above the collapsed
vertebral body against the trachea near its bifurcation. An abscess
obstructing the respiratory passages in the upper cervical region could
be reached and evacuated, but within the chest walls its diagnosis and
treatment were not easy. The significance of what might be called
asthmatic breathing as distinguished from the embarrassed respiration
symptomatic of Pott's disease in this region should be borne in mind.
If the abscess were large and could be percussed posteriorly, costo-
transversectomy would be indicated. But in this case there was no
dullness on percussion, and the small abscess lay at a distance of three
inches from the exterior of the body, so that it was probable that the
large opening of so-called posterior thoractomy would have been nec-
essary, a justifiable operation if the difficulties of diagnosis could have
been overcome.

Digitized by


The American Practitioner and News. 145

Dr. Phelps recalled two cases in which the abscess had ruptured
into the lung, but in neither did suffocation, which had caused death in
Dr. Whitman's patient, occur. On the other hand, he had seen cases
of cervical disease in which the abscesses had ruptured into the
pharynx and caused suffocation. When the abscess was high enough
it should be opened the very moment it was detected by an external
incision, for it might rupture during sleep at any time, and, if the patient
did not suffocate, he would die later of tuberculosis due to infection of
the lung.

Dr. A. B. Judsou said that the walls of the trachea were not easily
compressible, except by force, as by the grasp of a strangler or the
hangman's rope. When a foreign body in the gullet produced suffoca-
tion it was from spasm of the glottis and not from compression pf the
trachea. At the level of the third dorsal vertebra, however, the trachea
occupied, together with the esophagus and the deep cardiac plexus of
the sympathetic nerve, a narrow strait bounded behind by the vertebral
bodies and in front by the upper piece of the sternum, and here, if at any
point, its lumen might be diminished by the pressure of a fluctuating
tumor. Above this level and below, where the anterior and posterior
walls of the thorax diverged, no such pressure was likely to occur. It
was not uncommon for abscesses, as in Dr. Whitman's patient, to occupy
this critical position. The conservative tendency of cold abscesses to
move where there was least resistance often perhaps prevented inter-
ference with the vital function of the trachea. He suggested that the
fatal result might have been due to spasm of the glottis following the
passage of a part of the contents of the abscess into the trachea or to
some interference with the cardiac plexus.

Dr. Taylor was reminded of a case of Pott's disease reported by Dr.
W. R. Townsend, in which the abscess was in this region. An unusual
form of dyspnea was a feature of the clinical history, and the child died
suddenly a few days after admission to the hospital. A rather small
abscess which had not ruptured was found in front of the spinal
column at the root of the neck. It was supposed that suffocation had
been due to some traction upon the nerves rather than to pressure.

Dr. Myers recalled, and continued, the history of a boy, seven years
of age, who was before the Section on March 18, 1898.*

The abscess had burrowed forward into the neck from the fifth dor-
sal vertebra and discharged behind the right sterno-mastoid. The

<* American Praclitioncr and News, October 15, 1898.

Digitized by


146 The American Practitioner and News.

evening temperature rose two degrees when the boy was allowed to be
up, and was normal when he was kept recumbent, in which position
the drainage was free. He had therefore been kept in bed for two
months, after which his general health was entirely restored, and the
sinus remained closed for several months. He had, however, returned
with a profuse recurrence of the discharge, an enlargement of the post-
cervical glands on the right side, and an abscess over the manubrium,
but with no rise of temperature. An irrigating fluid passed from the
old sinus out of the pharynx by a passage which was open for a month,
but which had been closed for four weeks. It was a question whether
one of the abscesses perforated, or whether one of the cervical glands
ruptured and discharged.

Dr. Judson recalled a case in which, during the progress of purulent
hip disease, an abscess over the manubrium turned out to be from
caries at the junction of the upper and middle piece of the sternum.
There was spontaneous rupture externally, consolidation, a scar
attached to the bone, and recovery with angular deformity, anterior
instead of posterior, as in Pott's disease. The angle formed by the
manubrium and the gladiolus measured more than twenty-five degrees.
The sinus had closed seventeen years ago. Recovery from the hip dis-
ease had been very favorable, and the caries of the sternum had left no

Dr. Homer Gibney said that it was reasonable to believe that
abscesses occurred as often with disease of the upper dorsal region as
of the cervical, but they were not so easily detected in the former, and
were too often overlooked.

Dr. Whitman said that in the case reported by him the abscess had
not ruptured, but was strictly confined to the retro-esophageal space in
front of the spine. There had been no change in voice or diflSculty in
swallowing. An abscess in this region was a direct menance to life,
the dangerous symptom being attacks of inspiratory dyspnea. It is
probable that an operation would have saved life in this case.

Aluminium Corset. Dr. Phelps exhibited an aluminium corset for
the treatment of spinal disease. He had experimented largely with
various materials, such as sole leather, celluloid, wood, etc., and con-
sidered this material, which was light, clean, able to keep its shape and
durable, as the best that he had found for the purpose.

Digitized by


The American Practitioner and News. 147

HepietDS an6 Bibliograpt^y.

Human Anatomy. A Complete, Systematic Treatise by Various Authors. Including
a Special Section on Surgical and Topographical Anatomy. Edited by Henry
Morris, M. A. and M. B. (Lond.), Senior Surgeon to the Middlesex Hospital ;
Examiner in Surgery in the University of London, etc. Illustrated by seven
hundred and ninety woodcuts, the greater part original and made especially
for this work by special artists. Over 200 printed in colors. Second edition,
revised and enlarged. 1274 pp. Price, $6.00. Philadelphia : P. Blakiston's Son

. &Co. 1898.

Among the contributors to this work are the foremost anatomists of
England. The list embraces the names of William Anderson, J. N. C.
Davies CoUey, R. Marcus Gunn, A. Jacobson, Henry Morris, J. Bland Sut-
ton, Frederick Treves, W. J. Walsham, and Arthur Robinson, all teachers
in the foremost English schools and anatomists of the widest reputation.

The work already so excellent in the first edition has in this been thor-
oughly revised, both in regard to the descriptive text and the illustrations.
A description of the skin has been added, and an additional section at the
end of the volume, on Vestigial and Abnormal Structures, has been sup-
plied by Dr. Robinson.

It is a work of monumental character, and able to contest the field with
the best treatise on anatomy yet produced. The student who does not fall
in love with anatomy adorned with such beautiful illustrations and pre-
sented in such attractive dress of language as characterizes this work, had
better give up medicine and return to the plow, the anvil, or the counter.

D. T. s.

Diseases of Women. A Manual of Gynecology. Designed Especially for the Use of
Students and General Practitioners. By F. H. Davbnport, A. B., M. D., Assistant
Professor in Gynecology, Harvard Medical School, etc. Third edition. Revised
and enlarged. With 156 illustrations. 391 pp.

The author in the production of this book avows two main objects : In
the first place, to give the student clearly, but with considerable detail, the
elementary principles of the methods of examination and the simple forms
of treatment of the most common diseases of the pelvic organs ; and, in the
second place, to help the busy general practitioner to understand and treat
the gynecological cases which he meets with in the course of his every-day

We must confess to have asked with the author what useful purpose a
new work of the range of this can have, but after perusing it were con-
vinced that a useful purpose has been accomplished, and that the author
has succeeded in his aim. The call for a third edition is evidence that not
a few others are of the same opinion. d. t. s.

Digitized by


148 The American Practitioner and News.

Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 17 of 109)