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of Achill, and was 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 7, 1853), the enlargement from congenital hypertrophy of the middle finger had proceeded to such a degree, and had reached such magnitude, that Mr Adams could not meet any parallel to it among the recorded cases of this lesion. The cast of the hand (represented by the wood-cut) will at once give an idea of the nature of the deformity.
The girl was healthy and intelligent, and, with the exception of the left hand, was in other respects well formed. On looking at the cast of the forearm and hand, we notice that the hypertrophied middle finger is of 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 measured three inches and a half, the length of the hypertrophied middle finger of the left hand amounted to eight inches ; its circumference, at its largest part gave the same measurement. The nail of this middle finger was very broad and strong, fully an inch square, and constituted 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 that direction, so as to be greatly divaricated at its extremity from the middle finger.
The index was four inches and a half long, and its circumference, 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 consisting of fat, the size of half an egg ; above this tumour, and corresponding to the back of the carpus, another distinct swelling was perceptible, which was 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 deep 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 were 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 frequent source of discomfort and unhappiness to her.
As to the history of the origin of this abnormal condition of the hand, it was ascertained from Dr Montgomery that the child was born with the index and middle fingers three times their natural size. The child's father stated, 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 with the child's growth ; a year or two since it had commenced perceptibly to increase, and continued to grow more rapidly than the rest of the hand, until it attained its present excessive size.
It was a matter for deliberation, whether anything should be done further than to cut off the principal offending parts, namely, the hypertrophied fingers, which it was thought could be readily accomplished without danger to life or interfering with the functions of the wrist joint, so important to be preserved in a state of perfect integrity. At the same time, it was to be borne in mind, that such an operation would not remove the whole of the abnormal parts, and the patient would thus be liable to some recurrence of the evils she laboured under. To remove all the fatty mass which lay on the dorsum of the wrist and forearm, together with the entire of the two metacarpal bones, might be feasible, but, on due deliberation, Mr Adams did not think that in such a case, where the life of the girl was not in danger from the deformity, it would be justifiable either to have recourse to such an extensive dissection, or to encounter the danger which might be anticipated to arise from constitutional irritation following the mere dissection of the fatty masses. Moreover, the attempt to remove the entire of the hypertrophied metacarpal bones would probably involve the opening into some of the carpo-metacarpal joints, and thus indirectly lead to a communication between the external air and the interior of the wrist joint, likely to be followed with the worst consequence.
Of the two evils, therefore, it was decided that the lesser appeared to be leaving the three fatty diffused swellings on the dorsum of the hand and forearm, together with some portions of the two hypertrophied metacarpal bones, rather than encounter the risk of exciting constitutional irritation, and more particularly of exciting inflammation of the wrist joint. Mr Adams hence determined not to interfere with those tumours, but to remove the two hypertrophied fingers, by sawing through their metacarpal bones as high up as he conveniently could.
Operation.-An incision was made on the radial side and dorsum of the metacarpal region down to the bone, extending upwards towards the annular ligament of the wrist joint; a similar incision was made 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 very little hemorrhage during the operation ; and as, of course, chloroform was used, there was no pain experienced.
Mr Adams also laid before the meeting the amputated part, comprising the lower extremities of the two corresponding metacarpal bones, which were somewhat hypertrophied. A longitudinal section of the middle finger being made, displayed 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 normal structure; but the section of the finger everywhere exhibited a vast predominance 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 sides of the index jand 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 from hospital on July 23.
Mr Adams wishing to learn how this operation had succeeded, before bringing the case forward, wrote to Dr George Montgomery, and learned from him, by a letter dated the 14th March 1854, that this little girl had excellent use of her left hand; she could earn her bread, sew, and do crotchet work, and pass unobserved, which she could not previously. Her father told him she could make as good use of this hand as any other little girl in the village could make of theirs. She expressed herself much gratified by having been relieved of a source of " discomfort and reproach." Observations.—The cases of congenital hypertrophy of the fingers, as yet published, are not very numerous. Dr John Reid 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.-Monthly Journal, 1843, p. 198. Surgeon Robert Power, of this city, some years ago, adduced a case in the Dublin Journal, of congenital malformation of the middle finger, in a child aged 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 T. B. Curling has introduced into the Medico-Chirurgical Transactions a very interesting account of “a case of congenital hypertrophy of the fingers in a girl, with a notice of some similar cases."
In conclusion, Mr Adams said, that he thought the case worthy of notice on the following grounds :—First, that the middle finger in this example of abnormal hand had attained a size unequalled in any as yet published. Secondly, as it is the only case in which the anatomy of the affected fingers has been displayed ; and thirdly, he might add, the only case yet recorded in which any feasible remedial measures had either been proposed or adopted.
DR BENJAMIN SIMPSON of the Hon. E.I.C.S., now at Lahore, records the following interesting case :-“ I met with the subject of the following sketch, in marching through the upper provinces of India, where I have seen numerous cases of a similar nature, though by no means so exaggerated in form. This is also the experience of many medical men of long standing in the service, to whom I have showed the case. I made the present sketch in my tent, when I first saw him, and at the same time, took accurately the measurement of the feet, which were as follows:
Right Foot. — Circumference of the foot, 9 inches; length of big toe, 13 inches; circumference of leg near ancle, 8 inches. Left Foot. -Circumference of foot, 15 inches ; length of big toe, 44 inches ; circumference of leg near ancle, 71 inches ; circumference of big toe, 7 inches ; circumference of second and third toe together, 8 inches; circumference of fourth and fifth toes, 12 inches ; length of second and third toes (united) 31 inches.
The patient could give no account of his case further than that the swelling had existed from his childhood, gradually increasing, and was free from all pain, though a
source of much inconvenience from its excessive size and weight. On looking at the measurements, the following may be observed :—The circumference of the big toe is exactly the same as that of the leg on that side, which is slightly atrophied. This latter may be accounted for by the fact that he was in the habit of merely dragging the limb after him, the muscles never being called into play on the diseased side.
The second and third toes form but one heap, and equal in size the sound leg. The bones, however, are distinct, and can be felt moving one on the other ; the fourth and fifth toes (of which a small portion only is visible in the sketch) are of the normal size, measuring together 17 inch; the nails are all perfect, but proportional to the size of the toe in each case. I omitted to mention that the patient was one of the class called in India “grass cutters," who supply the camps with provender for the cattle. This man was in the habit of walking fifteen miles per diem, on an average, carrying for half the distance a large bundle of grass on his head. --Dublin Hosp. Gazette.
ON CYSTIC TUMOURS, BY VERNUEIL, VELPEAU, MALGAIGNE, ROBIN, ETC. Three modes of origin are recognised for the development of cystic tumours(1) by the enlargement of spaces in the areolar or other tissues of the body ; (2) by the dilation of natural ducts, sacculi, or blood vessels ; (3) by the growth of newly-formed elementary structures, having the characters of cells or nuclei. Of the first variety, specimens are familiar to all in the burse mucose, which form wherever two hard moveable substances come into contact in the body. Of the second, we have several additional illustrations in the recent records of surgery. Of the third, to which Rokitansky attaches no small importance, no considerable additional confirmatory evidence has been received. The hydatid testicle of Sir A. Cooper is shown by Mr Curling to consist in dilatation of the seminal tubes. 1 Sir B. Brodie's statement of the origin of cystic disease of the mammary gland in dilatation of the lactiferous tubes has been confirmed by frequent dissections. Mr Quekett's injections have satisfactorily proved that cystic degeneration of the kidneys commences in the Malpighian capsules, or the tubuli uriniferi. Mr Coote has traced the origin of certain cystic tumours to dilated bloodvessels, and especially veins. Dr Verneuil? has contributed the account of cyst formation in consequence of dilatation of the ducts of the sweatglands. Cysts about the joints have been shown, not only by most English writers on surgery, but also by the French-namely Velpeau, Malgaigne, Foucher, Bauchet, etc., to be derived either from some synovial bursa or sheath, connected with the tendons, or from some process of the synovial membrane. In skin, in mucous membrane, in gland-structures, in bloodvessels, and about joints, cystic tumours may be referred to the dilatation and enlargement of pre-existing tubes. In the 'Gazette Medicale de Paris' (Nos. 22 and 23, 1854), M. Robin classifies erectile tumours, according to the experience of many English surgeons, into -(1) tumours formed by the dilatation of capillaries, nævi materni ; (2) tumours formed by the dilatation of veins; (3) tumours formed by the dilatation of arteries ; (4) tumours formed by the extravasation of blood, around which a wall forins; or aneurisms by erosion. Rokitansky objects to the term - erectile tumours," as universal in such cases, assigning a different mode of origin, and substituting the name " cavernous tumours," as more accurately expressing their character. He states, that the stroma of erectile tumours is formed of a network of fibres, analogous to those of cellular tissue. The thickness of the septa is very variable ; from the thicker ones that radiate others, more delicate, which incompletely circumscribe irregular spaces, communicating one with another. In these varieties we find blood, either liquid or coagulated, or concretions resembling phlebolithes. The seat of these tumours is variable; but they are most commonly met with in the liver. Next in order of frequency, Rokitansky puts the subcutaneous cellular tissue, the skin ; the face, the trunk,
1 Med. Chir. Trans., xxxvi.
2 Gazette de Paris, 53, 1853. 3 Zeitschrift der K. K. Gesellschaft der Aerzte zu Wien, von Hebra, 1854.
the limbs; the cranial bones, the dura mater, and the pia mater. The primitive element of development in these tumours consists, according to the Viennese professor in trabeculæ (minute septa), sometimes transparent and smooth, sometimes slightly striated, in oblong nuclei, and in fusiform caudate cells. From these trabecules extend processes which bound irregular spaces, in which bloodvessels become developed. He affirms that the independence of these tumours from surrounding vessels at the commencement of their formation is illustrated by their development in the liver, where it will be found that the blood does not enter them, except by the perforation of their areoles. We cannot say that in our opinion these views, however elaborately worked out and cleverly expressed, are yet substantiated. On the contrary, the immediate dependence of such tumours upon bloodvessels seems to receive, from dissection and examinations, yet further corroboration.
The dependence of cystic degeneration of the kidney upon dilatation of the Malpighian capsules and uriniferous tubules has received confirmation from an observation of MM. Guilleton and L. Ollier, entitled, “ Upon the Abnormal Development of the two Kidneys, in a Fætus, offering an Obstacle to Accouchement."i The patient, æt. 33, the mother of four children, had reached the full term of her fifth pregnancy without the occurrence of any circumstance worthy of note, except that the abdomen was much more prominent than usual. July 1. She felt something slip into the vagina, while making a violent effort at stool ; it proved to be a foot-presentation. Manual efforts to extract the child were unavailing, and the patient was conveyed to the Charité Hospital, where delivery took place, by the contractions of the uterus, and the patient recovered, although the case was complicated with an attack of metro-peritonitis.
The abdomen of the fætus, of great size, seemed, when opened, to be entirely occupied by two enormous tumours, extending from the sides to the mesial line. They were the kidneys enormously enlarged, and containing a multitude of cysts. Microscopical examination showed that the tumours contained, as principal elements, uriniferous tubules and closed vesicles; and the authors consider, after noting the relations of the vesicles with the vascular element of the organ, and the disposition in the middle of the cortical substance, that the hydatiform element belonged to the glomerules of Malpighi. Thus the morbid change consisted in hypertrophy, of hydatiform character, of the glandular substance, without the formation of any new product.-Brit. and. For. Med. Chir. Rev. MR JOSEPH B. BROWN'S CASE OF EPILIPSY, TREATED BY LIGATION OF THE
COMMON CAROTID ARTERY. “ June 2, 1848.—Miss Elizabeth W., æt. 22, has been subject to attacks of epilepsy since her 17th year. Some four years before this time, she first felt a strange sensation in her right forearm ; it gradually passed above the elbow, and now appears at the intersection of the omohyoideus by the trapezius, and precedes the convulsions as a true aura, being described by the patient as a stream of warm fluid issuing from this spot. Menstruation was normally established before the disease became confirmed. The patient is now constantly afflicted with convulsions, which vary in character and intensity; those occurring in the night being of the most violent convulsive character, while those during the day are generally less aggravated. Sometimes a week or two intervenes without any attack; but she states that she has had as many as twentyfour of the fits in the twenty-four hours. Her face bears constant marks of the violent injuries she receives from falls against articles of furniture, when prostrated, as she often is, without warning, while engaged at her usual avocations, or walking across the floor. She is remarkably intelligent, and of excellent physical development.
“Her attending physician, Dr Z. Pitcher, of Detroit, despairing of affording
1 Gazette Médicale de Lyon, Août. 31, 1853.