CONGENITAL DEFORMITIES OF THE HANDS AND FEET
The congenital deformities of the hands and feet are very numerous.
They include excessive growth, a variety of other irregularities and
deficiencies of nutrition, numerical increase of parts and abnormal
union of digits. These defects are often hereditary, they may co-exist
in various combinations, and may be associated with faults of evolution
in other parts of the body. In most cases the _rôle_ of the surgeon is
limited to the removal of useless or unsightly parts, but occasionally a
higher function is open to him.
The most interesting of the congenital defects of the digits is the
curious and often complex condition known as makrodactyly.
[Illustration: FIG. 17.
Various congenital defects of the hands and feet (from Förster,
Missbildungen des Menschen).
1 to 4 and 15.—Numerical defects of fingers.
5 to 14.—Hands and feet with combination of hypertrophy and defective
development of fingers and toes, all from the same individual. 10 to 14
show the crab-like deformity described in the text (p. 147).
16, 17, 18, 19.—Syndactyly. In 16 and 19 the united fingers are larger
than their neighbours. In 17 and 18 the union involves all the fingers
except the first, and on one hand the number of digits is reduced to four.
20, 21.—Hand and foot with suppression of first four digits. In 20 there
is a rudiment of the index or middle finger.]
MAKRODACTYLY.
The earliest examples of “congenital hypertrophy” recorded in this
country were those of Dr. Reid, published in the _London and Edinburgh_
_Monthly Journal of Medical Science_ for March 1843, but before this date
a characteristic case of makrodactyly had been carefully described by
von Klein,[15] and other instances had been brought forward by Beck[16]
and Wagner.[17] Reid’s paper was followed by a valuable article by
Curling,[18] and contributions by Ideler,[19] Adams,[20] Devouges,[21]
Chassaignac,[22] Annandale,[23] and others, but the first attempt to
classify the cases was that of Busch,[24] in 1866. Since this time many
additions have been made to the literature of the subject, the most
important of which are those of Trelat and Monod,[25] Vogt,[26] von
Fischer,[27] Wittelshöfer,[28] and Humphry.[29]
The condition may be defined as a gigantic growth, congenital in
origin, of various segments of the body exclusive of the viscera. It
is generally unilateral, and limited to one extremity or portion of an
extremity; it tends to implicate especially the bones and joints, and the
adipose and vascular elements of the subcutaneous tissue. It does not,
as a rule, impair to any important extent the functional capacity of the
part.
The name “congenital hypertrophy” is open to criticism. There is little
doubt that the abnormality always has its origin in fœtal life, but
it has seldom been noticed immediately after the delivery of a child;
and, on the other hand, in one case recorded by Lannelongue,[30] a
“_macrodactylie elephantiasique_” in a child is said to have followed an
operation for the separation of two united fingers. It is, at any rate,
certain that if the enlargement be always present at birth, it is seldom
so disproportionate as to attract attention and never so great as to
interfere with parturition. Hence the colossal proportions subsequently
observed are the result of excessive growth in early infancy and
childhood, and occasionally in adult life.
The hyperplasia, moreover, is rarely hypertrophic in the higher sense
of the term, for, although in a few cases the increased growth has been
associated with apparent increase of functional utility, in the great
majority of instances it is relegated to a lower status by its unequal
distribution amongst the different tissues of the parts involved, its
frequent association with other congenital deformities, and especially by
the defective ratio of functional capacity to the amount of constructive
material. In other words, the process is wasteful and unserviceable.
The origin of the affection is very obscure. It is not hereditary,
although inheritance plays a notable part in many other congenital
deformities, and it cannot be attributed to any known influences arising
during intra-uterine life, but, as might be expected, the mother is often
able to conjure up some reminiscence of the period of gestation which to
her mind affords a perfectly satisfactory clue to the mystery. Von Klein
relates that in his case of makrodactyly the mother while pregnant was
bitten in the hand by a goose. A history of a fright was given in Adams’s
case, and in an instance reported by the author[31] a giant growth of the
lower extremity was attributed to the mother having been trodden upon
by a cow. Such mental impressions are probably mere coincidences, and
are often greatly exaggerated in narration, but until the possibility of
their connection with fœtal lesions is disproved it is advisable to place
them on record.
_Parts affected._—The abnormality is usually limited to one side of the
body. Comparatively few bilateral cases have been observed, and in most
of these the makroplasia was limited to the digits.[32]
The nævi with which the hypertrophy is often associated are nearly
always confined to the affected side, but in two cases of Chassaignac
and Friedberg they were found also upon the non-hypertrophied side, and
in a second case of Chassaignac’s were present only upon the unenlarged
parts of the body. The upper extremity is attacked nearly twice as often
as the lower, and the right side much more frequently than the left.
In bilateral cases the affection is seldom symmetrical; thus, on one
of Friedberg’s cases the predominant enlargement of the right lower
extremity was associated with a small degree of hypertrophy of the left
upper limb.
The extent of the parts involved ranges from a single digit to an
entire half of the body. When a whole limb is implicated the growth is
always proportionately greater at the distal extremity, but colossal
development of the hand or foot seldom includes the whole of the digits.
The localisation of the affection does not appear to be related to any
special vascular or nervous territories; thus, in makrodactyly, the
regions of distribution of the digital branches of both median and ulnar
nerves may be encroached upon, while parts supplied by either or both of
these may escape intact.
[Illustration: FIG. 18.
Congenital hypertrophy of lower extremity, with lymphangeiomata (from a
case of the author’s).]
Commonly, however, both in the hand and foot, the hypertrophy selects
two or three neighbouring digits, for example, the second and third; and
co-existent lipomata are almost invariably limited to that portion of the
palm or sole which corresponds to the enlarged fingers or toes. In the
hand the digit most commonly affected is the third, the fifth is that
most exempt.
Its _course_ is always in a certain sense progressive. Occasionally it
appears to keep pace throughout with the general growth of the body,
but nearly always the abnormal growth strides in advance, sooner or
later, so that the disproportion of the affected part to the rest of the
body becomes more and more pronounced. Its progress may be uniform and
continuous, or terms of slow increase or apparent arrest may alternate
with a new and rapid development.
In some instances the process does not extend beyond the primary limits,
while in others it may spread centripetally, and often at a very rapid
rate, as in v. Fischer’s case (_l.c._), in which amputation of an
hypertrophied finger was followed within a few months by hypertrophy
of the whole limb. In two cases reported by Mr. F. S. Eve[33] a growth
became disproportionally active at the ages of twenty-three and
thirty-seven respectively. Similar instances have been published by
Wittelshöfer, and the author (_l.c._).
The addition of new tissue goes on, as a rule, without pain,
inflammation, or interference with function; but in a case of von
Fischer’s, burning pain was associated with trophic ulceration;
and Friedberg’s patient,[34] who appeared to be the subject of an
associated elephantiasis Arabum, had symptoms that somewhat resembled the
inflammation crises of elephantiasis.
In the majority of cases the _functional power_ of the enlarged part
is not augmented, but true unilateral hypertrophy, _i.e._, increased
tissue hypertrophy with proportionally increased functional activity,
is sometimes found. The cases described long since in general terms by
Geoffroy St. Hilaire,[35] as marked by an unequal development of the
two sides of the body in one or more regions, were probably of this
nature, and those of Ollier, Finlayson, and Langlet, may also claim a
place in the same class. In Ollier’s case[36] the face, thorax, abdomen,
and both extremities of one side, were uniformly larger than the
corresponding parts of the opposite half of the body, the vascularity
of the hypertrophied side was increased, the temperature elevated, and
the limbs were more powerful. There were no nævoid growths, and it is
noteworthy that in association with an absence of evident abnormality of
thoracic, pelvic, and abdominal viscera, the mammary glands preserved
their symmetry. The cases of Devouges, Adams, and Finlayson, also
presented certain points of resemblance to true hypertrophy. In the
first the whole of one side was hypertrophied, except perhaps the
abdominal wall, where nothing unusual was noticed. The details are very
imperfect, but according to the patient’s statement, the strength of
the arm on the hypertrophied side was greatly in excess of that of its
fellow. In Adams’s case the giant growth of the right lower extremity was
apparently uniform, and the femoral and all other accessible arteries
were considerably enlarged, but nothing is said as to muscular power. In
this as in the last example nævi were present. In an unpublished case of
the author’s the hypertrophied hand was much stronger than its fellow;
but in the example[37] already quoted there was no evidence of increased
development of muscle. In two instances of unilateral hypertrophy of
the face described by Friedrich[38] and Passauer,[39] the increased
growth involved the whole of the parts of the affected side, even to the
teeth and tongue, and in Friedrich’s patient, and in a case brought by
Dr. Heumann before a Medical Congress in Darmstadt, the hair was more
developed, and the secretion of saliva was excessive on the affected
side, but the muscular power and arterial supply were not specially
referred to. In a case of Eve’s the facial hypertrophy extended to the
brain.
In the ordinary forms of congenital hypertrophy the size of the part is
augmented by an unequally distributed hyperplasia of the skeleton and
soft parts. Almost all the cases narrated in detail are of this kind.
In nearly all, the arterial supply is proportionate only to the normal
size of the part, and the functional capacity (power, sensibility, &c.),
although not seriously altered, is to some extent deteriorated. The cases
may be for practical purposes divided into two groups:
1. Without deformity, the enlarged segment preserving the normal contour
in other respects.
2. With deformity.
_a._ From predominant development of the adipose or vascular
tissues.
_b._ From secondary articular distortions.
_c._ From associated defects of development, as syndactyly, &c.
The condition of the different elements of the enlarged part is as
follows:
The _bones_ are always enlarged. Their general shape is commonly
preserved, but occasionally their extremities are deformed by outgrowths
at the line of junction with the articular cartilage. The hypertrophy
reaches its greatest proportionate extent in the digits, while increase
in size of the bones of the forearm, arm, leg, and thigh, is, as a rule,
only demonstrable during life by admeasurement of length. No histological
abnormality has been detected in the osseous tissue, but Eve (_l.c._)
found the cancellous tissue of the enlarged bone soft and the medulla
fatty.
The _articular surfaces_ may present no peculiar features, but in some
cases the cartilages show irregularities of surface. The ligaments
are usually greatly thickened. The synovial membrane commonly has the
ordinary characters, varied only by an excessive development of the plicæ
adiposæ.
The range of motion is sometimes normal; in other cases the voluntary
movements are more or less diminished in extent, while a fair amount of
passive mobility is preserved; and in others there is complete ankylosis.
Distortions, such as lateral deviation and hyper-extension, are frequent.
The former appears to depend upon malformation of bone.
The _tendons_ inserted into the enlarged bones have been found
proportionately over-developed. The _muscles_, however, are seldom
hypertrophied, and occasionally, as in Busch’s case, they may undergo an
atrophy secondary to the impaired mobility of the joint. In a case of
von Fischer’s, muscular hypertrophy was demonstrated, but no evidence of
increased power was present; and, judging by the comparative disuse of
the limb, it is probable that the strength was lessened. The muscular
power is, as a rule, so far augmented in response to functional necessity
that the enlarged part may be used without more sense of effort than
that which accompanies the same actions on the normal side, as in
Wagner’s case (_l.c._), in which the hand weighed about twelve pounds
and yet could be moved with perfect ease; there is seldom, however, any
such absolute increase of strength as would indicate a genuine muscular
hypertrophy.
The _arteries_ in all the instances of false hypertrophy, with the
exception of Reid’s[40] cases, were of ordinary size and apparently not
enlarged in proportion to the gigantic development of the part to be
nourished. This is a fact of considerable pathological significance.
The _veins_ and _capillaries_, unlike the arteries, appear especially
liable to change. Varicosities of the veins are very common, and in some
cases great thickening of the walls may be superadded (Busch, _l.c._). In
Dr. Finlayson’s case the cutaneous vessels over the enlarged parts and in
patches over the trunk became enlarged when the child cried, but subsided
during quiescence.
In Wagner’s case the fingers of the hypertrophied hand were said to
become as red as a “Blutschwamm” when the member hung down, the arteries
being nevertheless of normal size.
Angiectases and angiomata are frequently seen. Capillary nævi of enormous
extent sometimes co-exist (as in Adams’s case, in which the whole
lower extremity and buttock were involved), and are usually, but not
invariably, confined to the hypertrophied parts.
The _lymphatics_ are liable to dilatation, and may form diffuse swellings
or soft tumours of considerable extent. The glands, however, are never
affected.
The _nerves_ appear to be normal. The condition of the nerve centres has
not yet been investigated except in a case of Eve’s, in which the lateral
asymmetry of the head and face extended to the brain.
The _integuments_ nearly always participate in the changes, and are
necessarily augmented in extent where covering the enlarged bones. The
derm does not appear to be much altered in structure, but Eve found in
the skin over the hypertrophied sole a thinning of the rete with almost
complete obliteration of papillæ and enormous thickening of the fibrous
tissues and inter-fascicular lymph spaces; but these changes were
probably due to the abnormal pressure and friction to which the part
was exposed. The subcutaneous adipose layer commonly shows a diffuse
thickening, and in addition may undergo a circumscribed hypertrophy in
the form of large lipomatous pads, which are mostly found upon the flexor
aspect of the member affected, and correspond in situation and extent to
the bony enlargement (Fig. 18); but the papillary and epithelial layers
do not undergo any sensible changes, nor, as a rule, are the hairs or
sebaceous follicles more developed than on the opposite side. The nails
of hypertrophied digits generally undergo proportionate development. The
secretion of perspiration is seldom altered in amount or character, but
in a case of Wittelshöfer the patient complained of profuse sweating
from the affected limb. The cutaneous sensibility is variously described
as unaffected or diminished, never increased. A reduction of the
sensibility to heat and pain was found to accompany the tactile defect
in von Fischer’s case, and it is probable, as he suggests, that careful
examination would generally reveal an impairment of the faculties. Pain
is rarely complained of. Burning pain was present in association with
trophic ulceration in a case of von Fischer, and pains of a rheumatic
character appeared in the author’s case, but this symptom probably formed
no part of the original disease.
The _temperature_ of the part is generally normal. By exception, a rise
of 2°-2½° Fahr., of 2°-6° Fahr. (Reid), 2°-4° Fahr. (Finlayson), and of
½°-1° Cent. (Trelat and Monod) has been recorded.
_Pathological complications_ are rarely met with. Trophic ulceration
appeared in a case of von Fischer’s; and in Friedberg’s case an eruption
resembling pemphigus was noted, but probably was not directly connected
with the congenital hypertrophy. Inflammatory crises, corresponding to
those of elephantiasis Arabum, have been seen in only one instance, and
in this the condition appeared to be complicated by true elephantiasis.
_Associated defects of development_ are frequent in connection with
makrodactyly. They may consist of multiplication, dwarfing, absence,
or fusion of parts. The most common defect is syndactyly. Secondary
distortions of the spine are found, however, when the hypertrophy of
a single limb is very great. The general health does not appear to be
affected by the condition.
_Pathology._—The older views as to the pathological origin of congenital
hypertrophy leave us little advanced towards a solution. The condition
has been attributed to a congenital lesion of the vaso-motor centres;
to a primitive vice in the mesoblast; and to an inherent tendency of
the affected tissues to appropriate an excess of nutriment; but these
theories only lead to the same point—that for some reason which our
pathology is still inadequate to explain, there is a weakening of the
governing power that regulates the ratio between supply and demand in
the tissues; or, to quote from Professor Humphry (_l.c._), “The cases
obviously consist in an excess, an abnormally excessive growth of a
normal part of the body—an excess not depending upon any superabundance
of nutritive supply, or any modification of nerve influence, but upon an
excess, a want of due restraint, of that developmental force by which
the several organs and structures acquire and maintain their proper
dimensions and relations to one another, and by which their relative
growth at different periods of life and under different circumstances (as
of the genital organs at puberty). The nature and essence and habitat or
source of the force is a mystery, perhaps past finding out.”
This sums up the whole question. It is probably the same kind of
misgovernment of tissue that leads to certain other deformities occurring
both before and after birth, and to the development of some forms of new
growth. How it originates remains for the pathologists of the future to
decide.
_Treatment._—No means yet devised has any power of restraining the
tendency for the excessive and irregular growth in this condition. The
only resources of the surgeon are to correct associated deformities as
far as possible, and to remove parts that are sufficiently inconvenient
or disfiguring to warrant the use of the knife.
SUPERNUMERARY FINGERS AND TOES.
The occasional occurrence of supernumerary fingers and toes is well
known. As a rule the extra digit is a mere pediculated appendage bearing
a nail and a more or less perfect representative of the ungual phalanx;
in other cases, however, it is complete and well formed, and furnished
with a metacarpal or metatarsal bone of its own, or sharing the proximal
bone with a neighbouring finger or toe. In rare instances the digits may
undergo still further numeral increase even to a complete duplication of
the normal complement.
The condition is commonly bilateral, and may affect all four extremities.
It is liable to association with syndactyly and other congenital
deformities, and it is occasionally handed down by inheritance as a
family peculiarity. Sir William Lawrence refers to a condition of the
kind which was traced through four generations, and other examples are on
record.
SYNDACTYLY.
The absence of one or more of the normal clefts between the fingers
or toes is a common congenital deformity, and, like most of the other
inherited defects of the parts, is often transmitted by descent, and
associated with other malformations.
Syndactyly presents all varieties in extent and degree. Most frequently
two neighbouring digits are joined together by a web of integument
involving the whole or a portion of their length, but in some instances
the connecting material is much thicker, and in the most extreme cases
even the bones and joints are fused, leaving nothing but a furrow to
indicate the line of union. (Fig. 17, Nos. 16 to 19.)
Treatment is rarely necessary in the case of the foot, and in the hand is
practicable only when the band of union is cutaneous or cellulo-cutaneous.
If the web is composed only of a thin double fold of integument it is
sufficient to divide it, provided that a return of the condition is
prevented from taking place through union of the raw surfaces at the
root of the web. This was formerly effected in the slighter cases by a
preliminary perforation of the base of the fold, and the insertion of
a piece of gold wire until a cicatricial canal has been established—as
in piercing the lobule for the suspension of an ear-ring—and the same
end may be gained after the division by putting a small epidermic graft
upon the angle. Zeller’s flap method is, however, the best. A small
triangular flap is cut from the dorsum of the hand with its base opposite
the heads of the metacarpal bones, its apex at the level of the first
inter-phalangeal joint. This being dissected up and reversed, the whole
length of the web is divided. The apex of the flap is then brought
forwards between the separated digits into the proximal end of the cleft,
and fixed to the cut edge of the palmar integument.
When the membrane is very thick, and the bones are drawn close together,
a more complicated proceeding is required, and the ingenious method of
Didot may be employed. A longitudinal incision is carried through the
whole thickness of the integument along the middle of the dorsum of one
of the two united fingers, a second along the middle of the palmar aspect
of the other finger, and by dissection each digit is made to furnish
a rectangular flap to cover in the raw surface of its neighbour. The
division of the tissue left after raising the flaps must be made with
great care, in order to avoid injury to the digital nerves.
ECTRODACTYLY.
Simple congenital ectrodactyly, like the loss of a larger segment of an
extremity, may arise either by intra-uterine traumatism or defective
development. Amputation by an amniotic band or a coil of umbilical cord
probably explains the majority of the cases, as well as the congenital
constrictions sometimes found in the limbs or digits of the newborn
child, but the occasional appearance of fingers or toes at the end of
a congenital stump can only be accounted for on the hypothesis of a
temporary suspension of development in the proximal portion of the stump,
and we may assume the possibility of a like origin for the absence of
the most distal portions of a member. In some instances an ectrodactyly
is complicated with other developmental errors, and may be transmitted
through several generations. Attention has been especially drawn to
cases of this class in the last few years. Two were recorded in detail
in 1886 by Dr. Fotherby[41] and the author,[42] and a third was added
five years ago by Messrs. Parker and Robinson.[43] In all of these the
defect was traced through three or four generations, selecting in an
apparently indiscriminate way a large portion of the members of the
family, whilst leaving others exempt. In some individuals all four limbs
were attacked, in others the upper or lower only, but usually with a more
or less perfect bilateral symmetry. In most cases the ectrodactyly was
associated with deformities of the remaining digits, such as syndactyly,
hypertrophy, and joint distortions; and where, as frequently happened,
the middle digits were imperfectly developed and the others hypertrophied
and distorted, the member assumed the appearance of the pincers of a
lobster. (Fig. 17, Nos. 11 to 14.)
In Dr. Fotherby’s and Messrs. Parker and Robinson’s cases the defects
were traced through three generations, affecting sixteen out of
thirty-seven descendants in the one and sixteen out of thirty-three
in the other; in the author’s case the history extended to four
generations, attacking twenty-four out of thirty-six children, and the
divergence from the normal state tended to increase with the later scions.
As a rule, little or no treatment is called for in this condition,
because habit has given the member a good deal of functional utility that
surgical interference might injure or destroy; but sometimes, and more
particularly in the feet, it is permissible to operate for the purpose of
lessening the deformity, as in Messrs. Parker and Robinson’s case, where
a plastic operation was performed with much benefit to the patient.
BRACHYDACTYLY.
Undue shortness of the fingers or toes may occur either as a congenital
or as an acquired defect. The congenital form, due to imperfect formation
of any or all of the bony elements of a digit (including the metacarpal
bone), is insusceptible of treatment except by amputation, should that
step be justified by the inconvenience or deformity attached to the
defective member.
Acquired brachydactyly may arise in several ways. Occasionally it is to
be traced to an arrest of development either due to an injury during
childhood or adolescence, or without apparent explanation, but more
frequently it is a result of disease. In younger subjects the most
common cause is the destruction of bone in tuberculous disease, which
may practically eliminate a phalanx, leaving the rest healthy. In older
people it may be met with in cases of perforating ulcer, the proximal
phalanx of the great toe and sometimes other bones undergoing a slow and
painless disintegration, which is manifested chiefly by a progressive
shortening of the digit with few or none of the more obvious signs of
caries.
FOOTNOTES
[1] “Les doigts, et particulièrement les trois derniers, sont sujets
à une flexion permanent involontaire; à laquelle on a donné le nom de
‘contracture,’ et que quelques auteurs out appelée en latin ‘crispatura
tendinum.’” This name is usually attributed to Boyer himself. (“Maladies
Chirurgicales,” vol. ii. p. 55, first edition, 1826).
[2] See “The Hand as a Diagnostic Factor in Diseases of the Nervous
System” (Long-Fox: _Med. Annual_, 1891, p. 54).
[3] _Transactions of the College of Physicians_, 1895, p. 67.
[4] _Therapeutic Gazette_, February 15, 1892.
[5] _Ibid._ October 16, 1893.
[6] _Brit. Med. Journal_, 1888, vol. i. p. 961.
[7] See _Transactions of the Anatomical Society_ (1892), “On the Course
and Relations of the Deep Branch of the Ulnar Nerve,” by W. Anderson.
[8] “Orteil en Marteau” (Baillière, 1888).
[9] “Traité des Maladies Chirurgicales.”
[10] “The Human Foot,” 1889.
[11] It is unnecessary to enter minutely into the conformation of the
inter-phalangeal joints, but it must be understood that the proximal
attachment of the plantar fibres of the lateral ligaments lies at a point
below the centre of the dorsal half of the condylar curve, and hence
these fibres become more and more stretched as their distal attachment
is carried upwards in the direction of extension, until at last the
motion is checked by their tension. The point at which the arrest occurs
necessarily depends upon the relation existing between the length of the
fibres and that of the radii of the condylar curve. If the ligaments of
a joint be artificially elongated by acrobatic training in early life,
they may lose their power of fixing the range of movement, and extension
may then go on until it is stopped by contact of bones or by contraction
of opposing muscles. The latter factor, of course, is always an important
one, but it does not affect the present aspect of the question.
[12] It must be recollected that morphologically the metatarso-phalangeal
joint of the great toe corresponds to the first inter-phalangeal joint of
the smaller digits.
[13] _Lancet_, 1885, vol. i.
[14] _St. Thomas’s Hospital Reports_, vol. xxii. (1893).
[15] _Journal der Chirurg. und Augenheilk._, v. Graefe u. Walther, 1824.
[16] _Med. Annalen_, v. Puchelt, Chelius, u. Nägele, 1836.
[17] _Schmidt’s Jahrbucher_, 1842.
[18] _Medico-Chirurgical Transactions_, vol. xxviii.
[19] “Dissertation” (Berlin). Quoted by Busch.
[20] _Lancet_, August 1858.
[21] _Bulletin de la Soc. Anat._, 1856.
[22] _Bulletin de la Soc. de Chirurg._, first series, vol. xviii.;
_Gazette des Hôpitaux_, 1858.
[23] “Malformations, Diseases, and Injuries of Fingers and Toes,” 1865.
[24] “Beiträge z. Kentniss der angeb. Hypert. der Extrem.,” _Langenbeck’s
Arch._, 1867.
[25] “De l’Hypertrophie Unilaterale,” _Arch. Gén. de Médecine_, May and
June 1869.
[26] _Deutsche Chirurgie_, Lief. 64.
[27] “Der Riesenwuchs,” _Deutsche Zeitschrift für Chirurgie_, 1880, Bd.
12.
[28] _Archives für Klin. Chirurg._, Bd. xxiv. 1879.
[29] _Trans. Med. Chi. Society_, vol. lxxiv. 1891.
[30] _Bulletin de la Soc. de Chirurgie_, December 1880.
[31] _St. Thomas’s Hospital Reports_, vol. xi. 1881, p. 165.
[32] V. Fischer describes the case of Devouges as one in which parts
on both sides were affected, but a reference to the original and to
Chassaignac’s report upon the same patient shows that the hypertrophy was
unilateral.
[33] _Trans. Path. Society_, 1883, p. 298.
[34] _Virchow’s Archives_, 1867, vol. xl.
[35] “Histoire Général et Particulière des Anomalies de l’Organization
chez l’Homme.”
[36] _Gazette Médicale de Lyon_, July 1862 (Ollier); _Union Médicale et
Scientifique du Nord est_, 1882 (Langlet).
[37] _St. Thomas’s Hospital Reports_, vol. xi. 1881.
[38] _Archives für Path. Anat._, vol. xxviii. 1863.
[39] _Virchow’s Archives_, Bd. xxxvii. 1866.
[40] It is somewhat curious that in all three of Dr. Reid’s cases, which
in most respects were of the ordinary type, the arteries are said to have
presented the exceptional peculiarity of enlargement.
[41] _Brit. Med. Journ._, May 22, 1886.
[42] _Brit. Med. Journ._, June 12, 1886.
[43] _Clin. Soc. Trans._, vol. xx. p. 181.
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INDEX TO J. & A. CHURCHILL’S LIST.
Allen’s Chemistry of Urine, 11
— Commercial Organic Analysis, 13
Armatage’s Veterinary Pocket Remembrancer, 14
Auld’s Pathol. Researches, 2
Barnes (R.) on Obstetric Operations, 3
— on Diseases of Women, 3
Beale (L. S.) on Liver, 6
— Slight Ailments, 6
— Urinary and Renal Derangements, 12
Beale (P. T. B.) on Elementary Biology, 2
Beasley’s Book of Prescriptions, 5
— Druggists’ General Receipt Book, 5
— Pharmaceutical Formulary, 5
Bell on Sterility, 4
Bentley and Trimen’s Medicinal Plants, 5
Bentley’s Systematic Botany, 5
Berkart’s Bronchial Asthma, 6
Bernard on Stammering, 7
Berry’s (Jas.) Thyroid Gland, 9
— (R. J.) Regional Anatomy, 1
Bigg’s Short Manual of Orthopædy, 9
Birch’s Practical Physiology, 2
Bloxam’s Chemistry, 12
— Laboratory Teaching, 12
Bousfield’s Photo-Micrography, 14
Bowlby’s Injuries and Diseases of Nerves, 9
— Surgical Pathology and Morbid Anatomy, 9
Brockbank on Gallstones, 8
Brown’s (Haydn) Midwifery, 3
— Ringworm, 11
— (Campbell) Practical Chemistry, 13
Bryant’s Practice of Surgery, 8
Bulkley on Skin Diseases, 10
Burckhardt’s (E.) and Fenwick’s (E. H.) Atlas of Cystoscopy, 11
Burdett’s Hospitals and Asylums of the World, 2
Butler-Smythe’s Ovariotomies, 4
Butlin’s Operative Surgery of Malignant Disease, 11
— Malignant Disease of the Larynx, 11
— Sarcoma and Carcinoma, 11
Buzzard’s Diseases of the Nervous System, 7
— Peripheral Neuritis, 7
— Simulation of Hysteria, 7
Cameron’s Oils, Resins, and Varnishes, 14
— Soaps and Candles, 14
Carpenter and Dallinger on the Microscope, 14
Cautley’s Infant Feeding, 4
Charteris’ Practice of Medicine, 6
Chauveau’s Comparative Anatomy, 14
Chevers’ Diseases of India, 5
Churchill’s Face and Foot Deformities, 9
Clarke’s Eyestrain, 10
Clouston’s Lectures on Mental Diseases, 3
Clowes and Coleman’s Quantitative Analysis, 13
— Elementary Practical Chemistry, 13
Clowes’ Practical Chemistry, 13
Coles on Blood, 6
Cooley’s Cyclopædia of Practical Receipts, 14
Cooper on Syphilis, 12
Cooper and Edwards’ Diseases of the Rectum, 12
Corbin and Stewart’s Physics and Chemistry, 12
Cripps’ (H.) Ovariotomy and Abdominal Surgery, 9
— Cancer of the Rectum, 12
— Diseases of the Rectum and Anus, 12
— Air and Fæces in Urethra, 12
Cripps’ (R. A.) Galenic Pharmacy, 4
Cuff’s Lectures to Nurses, 4
Cullingworth’s Short Manual for Monthly Nurses, 4
Dalby’s Diseases and Injuries of the Ear, 10
— Short Contributions, 10
Dana on Nervous Diseases, 7
Day on Headaches, 8
Domville’s Manual for Nurses, 4
Doran’s Gynæcological Operations, 3
Druitt’s Surgeon’s Vade-Mecum, 8
Duncan (A.), on Prevention of Disease in Tropics, 5
Dunglison’s Dictionary of Medical Science, 12
Edwards’ Chemistry, 14
Ellis’s (T. S.) Human Foot, 9
Encyclopædia Medica, 14
Fagge’s Principles and Practice of Medicine, 6
Fayrer’s Climate and Fevers of India, 5
Fenwick (E. H.), Electric Illumination of Bladder, 11
— Tumours of Urinary Bladder, 11
— Ulceration of Bladder, 11
Fenwick (E. H.), Symptoms of Urinary Diseases, 11
Fenwick’s (S.) Medical Diagnosis, 6
— Obscure Diseases of the Abdomen, 6
— Outlines of Medical Treatment, 6
— Ulcer of the Stomach and Duodenum, 6
— The Saliva as a Test, 6
Fink’s Operating for Cataract, 9
Fowler’s Dictionary of Practical Medicine, 6
Fox (G. H.) on Skin Diseases of Children, 10
Fox (Wilson), Atlas of Pathological Anatomy of Lungs, 6
— Treatise on Diseases of the Lungs, 6
Frankland and Japp’s Inorganic Chemistry, 13
Fraser’s Operations on the Brain, 8
Fresenius Qualitative Analysis, 13
— Quantitative Analysis, 13
Galabin’s Diseases of Women, 3
— Manual of Midwifery, 3
Gardner’s Bleaching, Dyeing, and Calico Printing, 14
— Brewing, Distilling, and Wine Manuf., 14
Glassington’s Dental Materia Medica, 10
Godlee’s Atlas of Human Anatomy, 1
Goodhart’s Diseases of Children, 4
Gorgas’ Dental Medicine, 10
Gowers’ Diagnosis of Diseases of the Brain, 7
— Manual of Diseases of Nervous System, 7
— Clinical Lectures, 7
— Medical Ophthalmoscopy, 7
— Syphilis and the Nervous System, 7
Granville on Gout, 7
Gray’s Treatise on Physics, 14
Green’s Manual of Botany, 5
— Vegetable Physiology, 5
Greenish’s Materia Medica, 4
Groves’ and Thorp’s Chemical Technology, 14
Guy’s Hospital Reports, 7
Habershon’s Diseases of the Abdomen, 7
Haig’s Uric Acid, 6
— Diet and Food, 2
Harley on Diseases of the Liver, 7
Harris’s (V. D.) Diseases of Chest, 6
Harrison’s Urinary Organs, 11
Hartridge’s Refraction of the Eye, 9
— Ophthalmoscope, 9
Hawthorne’s Galenical Preparations of B.P., 5
Heath’s Injuries and Diseases of the Jaws, 8
— Minor Surgery and Bandaging, 8
— Operative Surgery, 8
— Practical Anatomy, 1
— Surgical Diagnosis, 8
Hedley’s Therapeutic Electricity, 5
Hellier’s Notes on Gynæcological Nursing, 4
Hewlett’s Bacteriology, 3
Hill on Cerebral Circulation, 2
Holden’s Human Osteology, 1
— Landmarks, 1
Holthouse on Strabismus, 9
Hooper’s Physicians’ Vade-Mecum, 5
Horton-Smith on Typhoid, 7
Hovell’s Diseases of the Ear, 10
Human Nature and Physiognomy, 14
Hyslop’s Mental Physiology, 3
Impey on Leprosy, 10
Ireland on Mental Affections of Children, 3
Jacobson’s Male Organs of Generation, 12
— Operations of Surgery, 8
Jellett’s Practice of Midwifery, 3
— Gynæcology, 3
Jessop’s Ophthalmic Surgery and Medicine, 9
Johnson’s (Sir G.) Asphyxia, 6
— Medical Lectures and Essays, 6
— (A. E.) Analyst’s Companion, 13
Journal of Mental Science, 3
Kellogg on Mental Diseases, 3
Kelynack’s Pathologist’s Handbook, 1
Keyes’ Genito-Urinary Organs and Syphilis, 12
Kohlrausch’s Physical Measurements, 14
Lancereaux’s Atlas of Pathological Anatomy, 2
Lane’s Rheumatic Diseases, 7
Langdon-Down’s Mental Affections of Childhood, 3
Lawrie on Chloroform, 4
Lazarus-Barlow’s General Pathology, 1
Lee’s Microtomist’s Vade-Mecum, 14
Lewis (Bevan) on the Human Brain, 2
Liebreich (O.) on Borax and Boracic Acid, 2
Liebreich’s (R.). Atlas of Ophthalmoscopy, 10
Lucas’s Practical Pharmacy, 4
MacMunn’s Clinical Chemistry of Urine, 11
Macnamara’s Diseases and Refraction of the Eye, 9
Macnamara’s Diseases of Bones and Joints, 8
McNeill’s Epidemics and Isolation Hospitals, 2
Malcolm’s Physiology of Death, 9
Marcet on Respiration, 1
Martin’s Ambulance Lectures, 8
Maxwell’s Terminologia Medica Polyglotta, 12
Maylard’s Surgery of Alimentary Canal, 9
Mayne’s Medical Vocabulary, 12
Microscopical Journal, 14
Mills and Rowan’s Fuel and its Applications, 14
Moore’s (N.) Pathological Anatomy of Diseases, 1
Moore’s (Sir W. J.) Family Medicine for India, 5
— Manual of the Diseases of India, 5
Morris’s Human Anatomy, 1
— Anatomy of Joints, 1
Moullin’s (Mansell) Surgery, 8
Nettleship’s Diseases of the Eye, 9
Notter’s Hygiene, 2
Ogle on Tympanites, 8
Oliver’s Abdominal Tumours, 3
— Diseases of Women, 3
Ophthalmic (Royal London) Hospital Reports, 9
Ophthalmological Society’s Transactions, 9
Ormerod’s Diseases of the Nervous System, 7
Parkes’ (E.A.) Practical Hygiene, 2
Parkes’ (L.C.) Elements of Health, 2
Pavy’s Carbohydrates, 6
Pereira’s Selecta è Prescriptis, 5
Phillips’ Materia Medica and Therapeutics, 4
Pitt-Lewis’s Insane and the Law, 3
Pollock’s Histology of the Eye and Eyelids, 9
Proctor’s Practical Pharmacy, 4
Pye-Smith’s Diseases of the Skin, 10
Ramsay’s Elementary Systematic Chemistry, 13
— Inorganic Chemistry, 13
Richardson’s Mechanical Dentistry, 10
Richmond’s Antiseptic Principles for Nurses, 4
Roberts’ (D. Lloyd) Practice of Midwifery, 3
Robinson’s (Tom) Eczema, 11
— Illustrations of Skin Diseases, 11
— Syphilis, 11
Ross’s Diseases of the Nervous System, 7
St. Thomas’s Hospital Reports, 7
Sansom’s Valvular Disease of the Heart, 7
Scott’s Atlas of Urinary Deposits, 11
Shaw’s Diseases of the Eye, 9
Shaw-Mackenzie on Maternal Syphilis, 12
Short Dictionary of Medical Terms, 12
Silk’s Manual of Nitrous Oxide, 10
Smith’s (Ernest A.) Dental Metallurgy, 10
Smith’s (Eustace) Clinical Studies, 4
— Disease in Children, 4
— Wasting Diseases of Infants and Children, 4
Smith’s (F. J.) Medical Jurisprudence, 2
Smith’s (J. Greig) Abdominal Surgery, 8
Smith’s (Priestley) Glaucoma, 10
Snow’s Cancer and the Cancer Process, 11
— Palliative Treatment of Cancer, 11
— Reappearance of Cancer, 11
Solly’s Medical Climatology, 8
Southall’s Materia Medica, 5
Squire’s (P.) Companion to the Pharmacopœia, 4
— London Hospitals Pharmacopœias, 4
— Methods and Formulæ, 14
Starling’s Elements of Human Physiology, 2
Sternberg’s Bacteriology, 6
Stevenson and Murphy’s Hygiene, 2
Sutton’s (J. B.), General Pathology, 1
Sutton’s (F.) Volumetric Analysis, 13
Swain’s Surgical Emergencies, 8
Swayne’s Obstetric Aphorisms, 3
Taylor’s (A. S.) Medical Jurisprudence, 2
Taylor’s (F.) Practice of Medicine, 6
Thin’s Cancerous Affections of the Skin, 10
— Pathology and Treatment of Ringworm, 10
— on Psilosis or “Sprue,” 5
Thompson’s (Sir H.) Calculous Disease, 11
— Diseases of the Urinary Organs, 11
— Lithotomy and Lithotrity, 11
— Stricture of the Urethra, 11
— Suprapubic Operation, 11
— Tumours of the Bladder, 11
Thorne’s Diseases of the Heart, 7
Thresh’s Water Analysis, 2
Tilden’s Manual of Chemistry, 12
Tirard’s Medical Treatment, 6
Tobin’s Surgery, 8
Tomes’ (C. S.) Dental Anatomy, 10
Tomes’ (J. and C. S.) Dental Surgery, 10
Tooth’s Spinal Cord, 7
Treves and Lang’s German-English Dictionary, 12
Tuke’s Dictionary of Psychological Medicine, 3
Tuson’s Veterinary Pharmacopœia, 14
Valentin and Hodgkinson’s Practical Chemistry, 13
Vintras on the Mineral Waters, &c., of France, 8
Wagner’s Chemical Technology, 14
Wallace on Dental Caries, 10
Walsham’s Surgery: its Theory and Practice, 8
Waring’s Indian Bazaar Medicines, 5
— Practical Therapeutics, 5
Watts’ Organic Chemistry, 12
West’s (S.) How to Examine the Chest, 6
Westminster Hospital Reports, 7
White’s (Hale) Materia Medica, Pharmacy, &c., 4
Winks’ Diseases of the Nervous System, 7
Wilson’s (Sir E.) Anatomists’ Vade-Mecum, 1
Wilson’s (G.) Handbook of Hygiene, 2
Wolfe’s Diseases and Injuries of the Eye, 9
Wynter and Wethered’s Practical Pathology, 1
Year-Book of Pharmacy, 5
Yeo’s (G. F.) Manual of Physiology, 2
_N.B.—J. & A. Churchill’s larger Catalogue of about 600 works on Anatomy
Physiology, Hygiene, Midwifery, Materia Medica, Medicine, Surgery,
Chemistry, Botany, &c. &c., with a complete Index to their Subjects, for
easy reference, will be forwarded post free on application._
AMERICA.—_J. & A. Churchill being in constant communication with various
publishing houses in America are able to conduct negotiations favourable
to English Authors._
_LONDON: 7, GREAT MARLBOROUGH STREET._