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The American practitioner online

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the proper thing to do? I must differ with him radically when he says
of all sites of the body, that the rectum affords the best operative field,
so far as relief is concerned, for carcinoma. I believe of all portions
of the body, this affords the least opportunity to the surgeon to relieve
the patient. I say this, first, for the reason that the patient never con-
sults you in the incipiency of cancer. Secondly, that if a cancer has
existed any length of time in the rectum, the contiguous parts are
infiltrated — there can be no question about this, because it is natural
that they should be — and every surgeon knows that ro remove a rectum
with any part contiguous infiltrated would not relieve the patient or
even prolong life; but if it is located in the sigmoid flexure, what
should be the treatment? Now, gentlemen, after twenty-one years in
dealing with this condition of affairs, and treating it in every manner,
and seeing surgeons in almost every portion of the country operate for
it, I must say that I believe that a surgical operation is in the vast
majority of cases unjustifiable. I saw Dr. Cartledge do the admirable
operation to which he has referred. The result in that case was very
positive. Bacon, of Chicago, has suggested that anastomosis should
be done around the cancer of the sigmoid, attaching the colon to the
rectum. We must recognize that this procedure would leave the
growth, although the anastomosis might be successfully practiced.
The same objection to aniastomosis might be preferred as is preferred to
colostomy, you give vent to the feces, but you leave the growth. The
person must die of cancer in the same length of time, because total
obstruction is very rare, if you will examine the literature of the sub-
ject, in cases of cancer of the sigmoid flexure. Anybody will admit
that if there is total obstruction which can not be overcome, that the



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The American Practitioner and News. 391

surgeon is perfectly justified in doing either resection, anastomosis or
colostomy; but if you will take the class of patients I am sure the
essayist has mentioned, old women, and it has been my privilege to see
a number of them with Dr. Ouchterlony, old women sixty to seventy
years of age, feeble because of the cancerous condition, not suflFering
much pain, why subject them to either of these operations? Every
one knows that patients with cancer of the sigmoid flexure do not
sufiFer much pain ; I never saw one that did ; they do not sufiFer as
much as they would with chronic dysentery; pain is not a factor in
cancer of the sigmoid ; neither is it in cancer of the rectum except it
involves the sphincter muscle. Then pain not being a factor, you are
certainly not going to perform a capital surgical operation to relieve
pain, because it does not exist.

Such patients have actions from the bowels, it may not be a normal,
well-formed action, but these patients are dieted and they pass fluid,
watery feces and are relieved by the procedure. Therefore total
obstruction can only be operated for when total obstruction exists. If,
then, you do not operate for pain, if you do not operate for total
obstruction, and neither of these conditions exists ; if you do not operate
for hemorrhage, and hemorrhage seldom occurs, why should you operate
upon these patients at all? You may say to prolong life; how much
will operative measures prolong life ? If I had a cancer of the sigpmoid
flexure I would not want any one to do a major surgical operation
upon me to prolong my life and leave the cancer in my body. That
is a strong argument. If it was to relieve suffering, it would seem
reasonable to operate, but my experience teaches me that this does not
occur. If you are going to do a surgical operation, what shall it be ?
From a rational surgical standpoint I believe that Dr. Cartledge is
right. Here you have a loop or bag, it is not contiguous to other parts,
nor bound to other tissues ; you can take it out, you can resect it, you
can anastomose it. It does look to me that is plausible; but if the
patient is an old, enfeebled woman, do you want to take out the sigmoid
flexure ? Do you want to resect it ; do you want to make an anasto-
mosis ? Of course this is rational, ideal surgery. Secondly, a colostomy.
I am on record as a non-believer in this operation for cancer. I have
performed it seven times. I always say that I have regretted seven
times that I have done it. It is an ugly operation, and leaves the cancer
there. By this operation you may relieve the obstruction, give vent to
the feces, but you leave the cancer.



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392 The American Practitioner and News.

I have seen one case of cancer of the sigmoid flexure and rectum
in a girl seventeen years of age, and one case in a boy twelve years of
age. I believe I am correct in my statistics that the vast majority of
cases of cancer of the sigmoid and rectum occur in patients over fifty
years of age; that it is a disease of advanced life.

LOUIS FRANK, M. D., Secretary,



NEW YORK ACADEMY OF MEDICINE— SECTION IN ORTHOPEDIC

SURGERY.

Meeting of March 17, 1899.

Lateral Deviation of the Spine and Pes Cavus in Friedreich's Ataxia,
Dr. W. R. Townsend presented a boy twenty years of age. Since an
attack of scarlatina at the age of seven his nutrition had been very
poor. The first signs of ataxia were an unsteady gait and inability to
keep from falling if pushed. For the past seven years he had had fre-
quent pain in the knees. Lateral curvature of the spine appeared
three years ago and has steadily increased, a long curve to the right
extending from the ninth dorsal vertebra downward, with rotation. A
plaster of Paris corset had been applied with moderate suspension.
There was pes cavus but no equinus. The gait was markedly ataxic.
Standing with the feet separated and eyes closed, there was swaying of
the body. The patellar reflexes were lost. Speech was slow. There
was nystagmus, but no Argyle-Robertson pupil.

Dr. J. Collins said that it was a clinically typical case. In addition
to disease of the posterior columns, there was sclerosis of the lateral
parts of the cord, including the direct cerebellar tracts, shown in per-
sistent efforts of the patient to balance himself, and producing the
peculiar condition found in every case and heretofore undescribed,
aptly named the fork-prong condition of the extensor tendons, the feet
being in continual balancing action, with the tip of the toes digging
into the substance of the floor. The dynamic deformities, which later
became static, were the result of some connate lack of development in
the anisotropous muscular substance. The deformity might be
explained by postulating the existence of some congenital incapacity
of development, some abnormal condition of the proton of the muscu-
lar substance. The disease was progressive and usually uniformly so,
and might extend through half a normal lifetime. There was some-



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The American Practitioner and News, 393

thing attractive about the theory that some fibers of the spinal cord
might have sufiFered death fifty or sixty years before the normal time,
a death without active inflammatory or degenerative changes and akin
to that which attended senility. The plaster of Paris corset could have
no influence on the disease, but it had, in his experience, contributed to
comfort. A potent agent in restoring the function of the muscles was
the re-education of the extremities. The patient might be so taught
that in a few months he would be able to walk into the room without
perceptible disturbance of gait.

Dr. S. Ketch said that the association of nervous disease with lateral
curvature was suggestive. Many features of the latter affection could
not be explained except by the presence of some prior defect in
the nervous system. The case came near being an argument for the
neural etiology of lateral curvature.

Dr. H. L. Taylor said that the argument was not convincing. The
coincidence of nervous disease could not establish the neuropathic
origin of lateral curvature, which we saw also in collapse of the lung,
without rating pulmonary disease as an important etiological factor.

Dr. A. B. Judson said that a nervous origin was not altogether
improbable from the observation that the curvature appeared to be due
to inability of the muscles to sustain weight, while the muscular failure
seemed to be the result of faulty innervation.

Dr. Ketch said that in the absence of a demonstrable etiology he
would adhere to the opinion that a large number of cases were caused
by an antecedent fault in the nervous system.

Congenital Deformity of the Lower Extremity. Dr. Ketch presented
a girl baby two months old with great bony deformity of the right lower
extremity. There was a shortening and twisting of the upper end of
the femur, and all the bones were smaller than those of the left leg.
The fibula was indistinct, giving only the feeling of cartilaginous hard-
ness. The place of the patella was marked by a slight immovable
eminence. There was marked equinus with inversion ; the motion of
the knee was greatly limited in extension, and the spine was slightly
deviated to the left in the lower dorsal region. There was dimpling
and adhesion of the skin to the outer side of the lower end of the
femur. The head had presented in an easy labor with the cord wound
around the body so that it held the right foot on the left buttock, ** so
tightly bound there was no blood in the leg until an hour." The



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394 The American Practitioner and News.

cause of the deformity was evidently retention of the parts in the fetal
position by pressure of the cord, the limb being unable to escape and
develop normally.

Dr. Taylor said that the bones were all present, but the fibula
seemed to be fully developed only at its lower end, and the deformity
of the foot was not the one usually associated with absent fibula. In
these cases some bone was usually lacking or rudimentary.

Dr. V. P. Gibney said that the clear history sufficiently explained
the cause of the deformity. He recalled the case of a child born with
dislocation of both hips and both knees, arrest of development being
found at the knees, and double club-feet of an exaggerated type. The
elbows were defective, and the movements of the shoulders rather
limited. Repeated operations had been required with plaster of Paris
retention, and, as a result, the patient had for several years been walk-
ing about and going to school without apparatus or any other assist-
ance. He had under observation another child with prenatal amputa-
tion of several fingers and double club-foot with arrested tibial develop-
ment. The fibulae being very much elongated, he had divided them
obliquely about two inches above the malleoli and slipped the distal
portion up on the proximal, thus bringing the foot into very good
position.

Congenital Lateral Curvature of the Spine, Dr. R. Whitman pre-
sented a girl seven years of age whom he had first seen when she was
nine months old. She then presented a well-marked rotary lateral
curvature of the spine that had been noticed by her mother imme-
diately after birth. In spite of the application of braces and manipu-
lation the curvature grew worse rapidly until two years ago, when the
tilting of the pelvis was so extreme that there appeared to be marked
inequality in the length of the legs. The degree of the deformity was
seen in a Roentgen picture. Since that time she had been under
treatment by irremovable plaster jackets, applied with as much cor-
rective force as could be borne, with most gratifying results. The pel-
vis became level, and the limp had disappeared. The spine had be-
come flexible, and its deformity had been in a great part corrected.
This method of forcible correction and retention in severe curvatures
of this class in young children appeared to ofiFer the best chance of
ultimate success.

Dr. G. R. Elliott said that the child's head, shoulders, hips, and
lower extremities were developed far beyond the thorax as one of the



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The American Practitioner and News. 395

results in two years' encasement. The plaster of Paris jacket is advis-
able in proper cases, but it should be renewed once in three months,
and should be removed at least weekly to permit breathing exercise
and massage.

Dr. R. H. Sayre said that bad eflFects do not necessarily follow pro-
longed treatment in the plaster jacket. He recalled the case of a boy
aflFected with rachitic lateral curvature, who was unable voluntarily to
stand in an upright position. He was kept in solid plaster of Paris for
a period of three years. When the jacket was removed, treatment to
develop the muscles restored them to as good condition as the muscles
of the rest of the body.

Dr. Taylor said that he did not hesitate to immobilize joints and
their acting muscles for years, if necessary, to arrest disease. He had
never seen a case in which, after such treatment, the muscles were not
developed to the limit imposed by ioint-motion. It had been demon-
strated clinically that when motion was restored to knees ankylosed
for many years the muscles assumed their functional activity.

Dr. Ketch said that atrophy of muscles and stiffness of joints caused
by the application of plaster of Paris or a brace were of no serious
moment, and were followed by no ultimate bad effect.

Dr. Elliott believed that permanent injury followed prolonged con-
finement of children in plaster of Paris forcibly applied. He had a
patient under treatment who had been thus treated for seven years,
and was, as a result, a hopelessly bed-ridden invalid. It might be an
exceptional case, but with a neurasthenic temperament and enfeebled
muscles present the injury would extend beyond the possibility of
rehabilitation. The muscles might revive, but the bones and cartilage
of the thorax would be atrophied to the ultimate impairment of the
heart and lungs.

Dr. Townsend suggested that the same improvement might have
been secured if the jacket had been replaced by a firmly-applied corset,
whose occasional removal would have permitted the employment of
massage.

Dr. Whitman said that the child had worn a brace, which the
mother was instructed to remove and give the child massage, but until
the jacket was applied, as described, the patient grew steadily worse.

The Effects of Gymnastic Exercises in Remedying the Displacement
of the Heart in Lateral Curvature, Dr. T. E. Satterthwaite presented



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396 The American Practitioner and News.

a paper to the effect that the mal-position of the thoracic and abdom-
inal viscera, which attended well-advanced cases of lateral curvature,
might be considered as a constant menace to health, and it could be
inferred that the thoracic pain of this aflfection due in some patients
to neurotic conditions was due in others to the faulty position of the
heart, which was generally displaced toward the concavity. He pre-
sented a patient, a young woman twenty-four years of age, aflFected with
lateral curvature toward the right in the dorsal region of the spine.
The pelvis was tilted, and the left breast was prominent. When first
seen in the summer of 1898 she was pale, anemic, and short-winded.
The heart's action was weak, and the apex one inch to the left
of the nipple. After three months* treatment with resistant exer-
cises, electricity, gymnastics, and massage, the anemia was corrected,
the heart's action was improved, and the apex was well to the inner
side of the nipple line. Its change in position was traced in diagrams
taken successively during the progress of treatment. Two other
patients were presented with similar histories and with diagrams show-
ing the migration of the apex during treatment and coincidently with
the improvement in the general and local condition of the patient.
These patients illustrated in person a long series of appropriate exer-
cises, in many of which indicated muscles were called into action by
resistance applied by a medical attendant. The exercises were taken
by the patient standing erect, leaning against a support, sitting, recum-
bent, semi-recumbent, or suspended by the hands. In the majority of
cases there was an advantage in combining force for the reduction
of the deformity with some of the prescribed exercises, and manual
force should be applied without the assistance of mechanical apparatus.
Double pressure should be made when practicable, one hand being
placed upon the dorsal convexity and the other on the lumbar con-
vexity, each pressing toward the spine. As a rule, tonics or nutrients
were required — iron, strychnine, codliver oil, and malt extracts. Mas-
sage of the muscles of the back was a valuable adjuvant, and the
faradic current might be applied successfully during the entire course
of the treatment, employed so as to contract actively the muscles of the
back. An eflFort should be made, where practicable, to do away with
the spinal brace, which should be advocated only as a temporary
expedient or in cases in which all other measures had failed. By
pursuing a more thorough and painstaking course than that com-
monly in vogue, the heart, and with it the lungs, and in time the



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The American Practitioner and News. 397

abdominal viscera, might in a measure be restored to their natural
position.

Dr. Sayre said that inspection of a preparation of lateral curvature
showed that suflfering from impeded action of the heart and lungs prob-
ably attended cases of well-marked deformity. As a rule, however,
such patients were not prone to die of disease of the heart or lungs,
and, although perhaps somewhat disturbed, they lived to a good old
age. He had seen distinct relief of shortness of breath from treatment
by exercises, and patients in whom the rapidity of the heart-beat had
been materially reduced. In one case the pulse-rate came down from
120 to 90 when suspended, and 10 T when in a plaster of Paris jacket.
He had a patient under observation in whom a murmur distinctly aud-
ible at some distance and in certain positions of the body, and sound-
ing very much like a tin whistle, had disappeared under the influ-
ence of exercises.

Dr. Satterthwaite said that the murmur has been probably due to
anemia and a flabby condition of the chambers and ostia of the heart.
He did not think that cardiac displacement in these cases gave rise to
abnormal sounds, extrinsic or intrinsic.

Dr. H. S. Stokes said that he thought it was very diflBcult to say
whether the position of the heart had changed or not. It was the
opinion of some observers that the heart could not be accurately
mapped out during the life of a normal chest. In a chest deformed by
lateral curvature the element of possible error must certainly be a large
one. In his observation, the result of treatment had been an improve-
ment in the general condition of the child, and the prevention of an
increase of the deformity rather than an obliteration of the curvature.

Dr. Satterthwaite said that while many physicians among the Ger-
mans and English rejected methods of mapping out the heart, in this
country observing the heart in this manner was accepted as practicable
and important. He believed that it was easy to determine the position
of the apex by the impulse, and also by the use of the stethoscope.

Dr. J. Teschner said that the heart could not be directly affected to
an appreciable extent unless the deformity was so great as to crowd and
displace it. He had not mapped out the heart in his cases, but its
change of position as the result of treatment by heavy gymnastics had
been obvious. In a girl nineteen years of age a very severe rotary
lateral curvature of at least ten years* duration was combined with
cardiac trouble dating from acute articular rheumatism and peri- and



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398 The American Practitioner and News.

endo-carditis at the age of four. There was marked hypertrophy and
dilatation, a double aortic murmur, a double mitral murmur, and a very
decided murmur over the pulmonary with the second sound. The
murmurs were very widely transmitted. Dyspnea was marked.
Slight cyanosis at rest became marked on the slightest exertion. The
heart had been growing rapidly weaker, edema had appeared, and her
physician believed that she would live only a year or two longer.
Beginning with very gentle exercises, in six months she was practicing
heavy gymnastics, and her physician expressed surprise at her improved
condition. He found the heart smaller and changed in its relative
position to the chest wall, and none of the murmurs except the pre-
systolic mitral transmitted to the side and back as before. Dr. Tesch-
ner believed that the deformity could be reduced by the voluntary and
resisted efforts of the patient and not by external force. Electricity
and massage were valueless when compared with voluntary exercise.
The more the patient exercised the muscles through the medium of the
will the greater would be the benefit. He thought that the exercises
described and exhibited fell far short of what was required, and that
their effect in severe cases would be like that of an infinitesimal dose
of a drug whose full physiological effect was desired. He thought that
one curve could not be modified without a corresponding effect on the
compensating curve. The trouble was not the deflection of a single
vertebra, but of several, leading to the production of the sigmoid
deformity.

Dr. Satterthwaite agreed that the different curves should be con-
sidered together as making up the deformity, and added that in the
treatment the muscles should be also considered together, as it was
impossible to exercise or develop one muscle or group without acting
on all the muscles of the region.

Dr. Taylor said that while electricity and massage were good, they
were not suflBciently good to cure lateral curvature. Reliance should
be chiefly on muscular training and suitable apparatus. He would
welcome any possible way of dispensing with apparatus which, useful
in selected cases, left much to be desired. The hygiene of the patient
was of great importance. The physician should regulate the food,
schooling, exercise, and rest. Piano playing was a pernicious occupa-
tion for a patient with a weak back. It should be moderated and,
usually, stopped. One of the things which had held us back in the
treatment of this affection was the diflBculty in measuring and record-



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The American Practitioner and News. 399

ing changes which take place. The position of the heart might, per-
haps, in some cases be a useful indication. Measurement of the height
from time to time was more easy, and likely to furnish more reliable
observations.

Dr. Sattertbwaite said that he was in the habit of recording the
height as a routine matter, but in growing children such measure-
ments might be misleading.

Dr. Ketch said that apparatus was of value in retaining the improve-
ment gained through exercise, which, when properly conducted, pro-
duced a good eflfect on the deformity, and indirectly on the condition
of the heart, for there was no doubt that the changes in the vertebrae
themselves and in the chest walls and the diameter of the thorax gave
rise to changes in the viscera. As long as rotation persisted no case of
lateral curvature could be said to be really cured. This was always a
menace, and liable to increase, and was the most diflScult element to
control. The bony changes which followed the muscular changes also
made the treatment of lateral curvature very diflBcult. Curvature
depending on simple muscular weakness was the easiest to control,
but these were not cases of true rotary lateral disease. Each man
should work out his own ideas in regard to the question of exercises,
remembering that no form of treatment would he of the slightest value
unless it was continued for a long time.

Dr. Sattertbwaite agreed that not all cases were suitable for the
treatment which he had described. It could not easily be made suc-
cessful in the case of out-patients, especially those who lived far away
and thus were unavoidably irregular in their attendance. The patients
presented were all improving in general condition, the spine was grad-
ually moving forward toward the normal position, while the heart in
each had taken an improved position.

A Pelvic Rest. Dr. Townsend presented a simple apparatus to
facilitate the application of a plaster of Paris spica to the hip. It held
the pelvis and thigh up so that the roller might be conveniently passed



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 45 of 109)