> 
 
 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 1.0 
 
 1.1 
 
 IA2|2j8 |2.5 
 
 ^ ^ 12.2 
 
 ui Hi 
 
 2.0 
 
 
 iJ4 
 
 
 1.25 1,,. 4. ,,.6 
 
 
 ^ 
 
 6" 
 
 ► 
 
 ^ 
 
 /2 
 
 n 
 
 7 
 
 
 
 %' 
 
 O 
 
 7 
 
 Photographic 
 
 Sciences 
 
 Corporation 
 
 \ 
 
 A 
 
 .V 
 
 s? 
 
 \\ 
 
 
 
 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14380 
 
 (716) 872-4503 
 
 
CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHM/ICMH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques 
 
Technical and Bibliographic Notas/Notaa tachniquaa at bibliographiquas 
 
 The Institute has attempted to obtain the best 
 original copy available for filming. Features of this 
 copy which may be bibliographically unique, 
 which may alter any of the images in the 
 reproduction, or which may significantly change 
 the usual method of filming, are checked below. 
 
 Coloured covers/ 
 Couverture de couleur 
 
 I I Covers damaged/ 
 
 D 
 
 n 
 
 Couverture endommagAe 
 
 Covers restored and/or laminated/ 
 Couverture restaur^ et/ou pelliculie 
 
 I — I Cover title missing/ 
 
 Le titre de couverture manque 
 
 □ Coloured maps/ 
 Cartes giographiques an couleur 
 
 D 
 
 Coloured ink (i.e. other than blue or black)/ 
 Encre de couleur (i.e. autre que bleue ou noire) 
 
 Coloured plates and/or illustrations/ 
 Planches et/ou illustrations en couleur 
 
 Bound with other material/ 
 ReliA avec d'autres documents 
 
 Tight binding may cause shadows or distortion 
 along interior margin/ 
 
 La re liure serrie peut causer de I'ombre ou de la 
 distorsion le long de la marge intiriaure 
 
 Blank leaves added during restoration may 
 appear within the text. Whenever possible, these 
 have been omitted from filming/ 
 II se peut que certaines pages blanches ajoutAes 
 lors d'une restauration apparaissent dans le texte. 
 mala, lorsque cela Atait possible, ces pages n'ont 
 pas 6ti filmAes. 
 
 Additional comments:/ 
 Commentaires supplimentaires: 
 
 L'Institut a microfilm* le meilleur exemplaire 
 qu'il lui a M possible de se procurer. Les details 
 de cet exemplaire qui sont peut-4tre uniques du 
 point de vue bibliographique, qui peuvent modifier 
 une image reproduite. ou qui peuvent exiger unc 
 modification dans la m^thode normala de filmage 
 sont indiquis ci-dessous. 
 
 r~| Coloured pages/ 
 
 D 
 
 Pages de couleur 
 
 Pages damaged/ 
 Pages endommagies 
 
 Pages restored and/oi 
 
 Pages restauries et/ou pelliculies 
 
 Pages discoloured, stained or foxei 
 Pages dicolortes, tachetAes ou piquies 
 
 pn Pages damaged/ 
 
 I — I Pages restored and/or laminated/ 
 
 r~7| Pages discoloured, stained or foxed/ 
 
 □ Pages detached/ 
 Pages ditachies 
 
 EShowthrough/ 
 Transparence 
 
 Transparence 
 
 Quality of prir 
 
 Qualiti inigale de I'impression 
 
 Includes supplementary materii 
 Comprend du materiel supplAmentaire 
 
 Only edition available/ 
 Seule Edition disponible 
 
 I I Quality of print varies/ 
 
 rn Includes supplementary material/ 
 
 rn Only edition available/ 
 
 Pages wholly or partially obscured by errata 
 slips, tissues, etc.. have been refilmed to 
 ensure the best possible image/ 
 Les pages totalement ou partieilement 
 obscurcies par un feuillet d'errata. une pelure, 
 etc., ont M filmies A nouveau de fapon d 
 obtenir la meilleure image possible. 
 
 This item is filmed at the reduction ratio checked below/ 
 
 Ce document est film* au taux de reduction indiqui ci-dessous. 
 
 10X 
 
 
 
 
 14X 
 
 
 
 
 18X 
 
 
 
 
 22X 
 
 
 
 
 26X 
 
 
 
 
 30X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 y 
 
 
 
 
 
 
 
 
 
 
 
 12X 
 
 16X 
 
 20X 
 
 24X 
 
 28X 
 
 32X 
 
Th« copy ftlm«d h«r« has bMn raproducad thanka 
 to tha ganaroaity of: 
 
 Medical Library 
 McQill University 
 Montreal 
 
 Tha imagaa appaaring hara mrm tha baat quality 
 poaaibia eonaidaring tha condition and iagibility 
 of tha originai copy and in icaaping with tha 
 filming contract apaclficationa. 
 
 Original oopiaa in printad papar covara ara fllmad 
 baginning with tha front covar and anding on 
 tha laat paga with a printad or illuatratad impraa- 
 sion, or tha bacic covar whan appropriata. All 
 othar original copiaa ara fllmad baginning on tha 
 f irat paga with a printad or illuatratad impraa- 
 aion, and anding on tha laat paga with a printad 
 or illuatratad impraaaion. 
 
 Tha laat racordad frama on aach mieroficha 
 •hall contain tha aymbol ^»> (moaning "CON- 
 TINUED"), or tha aymbol y (moaning "END"), 
 whichavar appliaa. 
 
 IMapa, plataa, charta, ate., may ba fllmad at 
 diffarant raductlon ratioa. Thoaa too iarga to ba 
 antiraly includad in ona axpoaura ara fllmad 
 baginning in tha uppar laft hand comar, laft to 
 right and top to bottom, aa many framaa aa 
 raquirad. Tha following diagrama iiluatrata tha 
 mathod: 
 
 L'axamplaira film* fut raprodult grica A la 
 ginAroait* da: 
 
 Medical Library 
 McGill University 
 Montreal 
 
 Laa imagaa auhrantaa ont «t4 raproduitaa avac la 
 plua grand aoin, compta tanu da la condition at 
 da la nattatA da l'axamplaira film*, at an 
 conformity avac laa condltiona du contrat da 
 fllmaga. 
 
 Laa axamplairaa origlnaux dont la couvartura 9n 
 papiar aat imprimia aont filmia an commandant 
 par la pramiar plat at an tarminant aoit par la 
 darnlAra paga qui comporta una amprainta 
 d'impraaaion ou d'illuatration, aolt par la aacond 
 plat, aalon la eaa. Toua laa autraa axamplairaa 
 origlnaux aont fllmte an commandant par la 
 pramlAra paga qui comporta una amprainta 
 d'impraaaion ou d'illuatration at •n tarminant par 
 la darnlAra paga qui comporta una taila 
 amprainta. 
 
 Un daa aymbolaa auivanta apparattra sur la 
 darnlAra imaga da chaqua mieroficha, salon la 
 caa: la aymbola — *> signifia "A SUIVRE", la 
 aymbola ▼ aignifia "FIN". 
 
 Laa cartaa, planchaa, tablaaux, ate, pauvant Atra 
 fllmte i daa taux da rMuction diffAranta. 
 Loraqua la document aat trap grand pour Atra 
 raprodult an un aaul cliche, 11 aat film* A partir 
 da I'angia aupAriaur gaucha, da gaucha h droita, 
 at da haut an baa, an pranant la nombra 
 d'imagaa nAcaaaaira. Laa diagrammaa auivanta 
 illuatrant la mAthoda. 
 
 1 
 
 2 
 
 3 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
^^■'■•••:«,- 
 
 W ' do 
 
 iB4t^(^^ 
 
 
 WITB THX OOMFUXEHTS OF THE AUTHOB 
 
 -A. a-A.SE OF 
 
 mmim&L itpieteofiy 
 
 OF THE LEFT FOOT 
 
 wmf} fissoQ5ipseD liieofflp. 
 
 BY 
 
 A. D. BLACKADER, M.D., M.R.C.S., Eng., 
 Instnustor in Diseaaea of Children in MoOill Uhivergity, Montreal. 
 
 \ 
 
 Reprintkd from the "Archives op Pediatrics," October, 1884. 
 
 PHILADELPHIA 
 
 JOHN E. POTTER & CO., Publishers, 
 
 617 Sansom Street. 
 
 1884. 
 
 -»fe#a. ?>t,-«,^,.5tJI^^^^^ 
 
v-|W^^.«^S>»»it,«l 
 
ittiniaiX fBfiLtmoKixnAm. 
 
 A CASE OF CONGENITAL HYPERTROPHY OF 
 THE LEFT FOOT WITH ASSOCIATED LIPOMA* 
 
 BY A. D. BLACKADER, M.D., M.R.C.S., ENG. 
 iTUtruetor in JHteattt of Children in McOiU UnivertUy, MojUreal. 
 
 In bringing this case before the notice of the association 
 I am aware, to use the words of Curling when presenting a 
 Birailar case before the Medico-chirurgical Society of Lon- 
 don, that such facts as these do not offer the same interest 
 as do others more frequently met with, and perhaps more 
 practical ; still they should be deemed worthy of record, 
 and may become of much interest to the physiologist. 
 Since Curling first recorded his cases, and he was one of 
 the earlier ones in England to do so, other cases have been 
 recorded, and several writers have called attention to the 
 many curious facts in connection with them. One of the 
 latest is Mr. William Anderson, who has reported a case in 
 St. Thomas Hospital Reports for 1882, and along with his 
 case has given a most excellent resum^ of what is known 
 on the subject. To his paper I am indebted for much 
 which I now lay before you. 
 
 Among the earlier cases described was one by v. Klein, 
 of hypertrophy of the right hand of a boy, in which the four 
 fingers were enlarged and associated with fatty tumors. 
 Wagner about the same time mentions the case of a girl of 
 sixteen years in whom the second toe of the left foot was 
 much hypertrophied and the plantar surface of the foot cov- 
 ered with a thick layer of fat. Reid followed in England, 
 and then Curling ; and since then numerous contributions 
 
 * Bead before (he Canada Medical AsBociation. 
 
Blackader : A Case of Congenital Hypertrophy. 
 
 have been made in Germany, England, and America. 
 Of a few of the more interesting cases I present you here 
 with sketches and short notices. 
 
 Anderson defines the condition as follows: A gigantic 
 growth, probably congenital in origin, of various segments 
 of the body, exclusive of the viscera. It is almost in- 
 variably unilateral, and is generally limited to one ex- 
 tremity or portion of an extremity. It tends to implicate 
 especially the bony, ligamentous and integumentary tis- 
 sues, and is frequently associated with lipomata and with 
 angiectases, and angiomata in connection with the circu- 
 latory and lymphatic system. It does not, as a rule, impair 
 to any important extent the functional capacity of the 
 part. 
 
 With regard to the term "congenital" he says, 
 " although there is little doubt that the abnormality has 
 its origin in foetal life, as yet direct evidence of its exist- 
 ence at birth has seldom been adduced. In only three 
 Cfises, Owen, Higginbottom, and Friedberg, has it been 
 averred that the deformity was seen immediately after 
 birth of the child. In one case an operation seems to 
 have been the exciting cause. 
 
 To the term "hypertrophy" Anderson also objects, 
 stating that although in a few cases the general characters 
 of true hypertrophies are present, in most their histolog- 
 ical character and associations should delegate them to a 
 lower pathological status than that occupied by the true 
 hypertrophies. 
 
 Of the etiology little is known. It does not appear to 
 be hereditary. There was certainly no such history in 
 my own cases for several generations back. Mental im- 
 pressions on the mother during gestation are quoted. 
 In Anderson's case the mother referred the deformity to 
 the fact that she had been trodden on by a cow while 
 carrying the child. In m}' own case the mother is firm 
 in the belief that the whole trouble is owing to a some- 
 what prolonged fright about the tenth week of her preg- 
 nancy. She was out driving with her family in an open 
 wagon, with her left foot, for want of room, hanging out- 
 
.»■ 
 
 Blackader : A Case of Congenital Hypertrophy. 
 
 side. The road was narrow, and a carelessly driven 
 heavy cart came up from behind and was driven along- 
 side them for some distance. She said ahe expected every 
 moment her foot would be crushed. While these impres- 
 sions may be mere coincidences, until we can prove thein 
 so, it were better that facts of this kind should be noted. 
 
 The extent of the part hypertrophied varies from a 
 single digit to the entire half of the body. The hyper- 
 trophy always increases towards the distal end, thus the 
 phalanges will be more hypertrophied than the metatarsal 
 or -carpal bones, and they more in proportion than the 
 bones of the fore-arm or leg. The hypertrophy, however, 
 seldom includes the whole of the digits. The localiza- 
 tion of the afiection does not appear to be related to any 
 special vascular or nervous territories. Its course is gen- 
 erally progressive; sometimes, for a time, the growth 
 appears uniform with the rest of the body, but generally 
 sooner or later the hypertrophy becomes more marked, 
 and its nutrition evidently excessive. The rate of increase 
 may vary from time to time ; periods of slow develop- 
 ment, or even apparent arrest, may be followed by new 
 and rapid growth. In most cases the process does not 
 extend beyond the seat of the original hypertrophy, but 
 in a few we notice extension towards the trunk. As a 
 rule, the growth goes on without pain, inflammation, or 
 much interference with function. 
 
 As to the classification of these cases, Ande»". on sets 
 aside as unsatisfactory, and I think justly, that of v. 
 Fischer, which is founded in great part on the extent of 
 the hypertrophy, and prefers the division into true and 
 false. The first class forms a very small one, yet there 
 are a few cases sufficiently well-marked where all the 
 structures of one side are hypertrophied, the vascular 
 supply on that side enlarged, the temperature elevated, 
 and the power of the limb increased. Into the other 
 division is placed all those where the size of the part is 
 augmented by an unequally distributed hyperplasia of 
 the skeleton and soft parts. This forms by far the larger 
 division. In these the arterial supply is proportionate 
 
Blackader : A Case of Congenital Hypertrophy. 
 
 only to the normal size of the part, and the functional 
 capacity is somewhat deteriorated. These cases for prac- 
 tical purposes he divides into two groups : 
 
 1. No deformity — parts being symmetrical. 
 
 2. Deformity. Arising from 
 
 a. Excess of adipose tissue or vascular tissues. 
 
 6. Articular distortion. 
 
 c. Associated defects of development, c.^r. syndactyly. 
 With regard to the several tissues of the hypertrophied 
 part we notice that the bones are always enlarged, but 
 principally in their extremities. The cartilages and liga- 
 luents of the joints and the tendons, are usually thickened. 
 The muscles, themselves, the arteries, and the nerves are 
 seldom increased in size. 
 
 The pathology, like the etiology, is very obscure. 
 Friedberg suggested some affections of the vaso-motor 
 nerves, or some impediment in the circulation of a lymph 
 vessel during intra-uterine life. A primitive vice of the 
 middle lamina of the blastodermic membrane is opposed 
 by the fact that che walls of the trunk, which are directly 
 formed from the middle lamina, are comparatively sel- 
 dom implicated. The theory of partial intra-uterine 
 strangulation fails to explain cases where half the body 
 is effected. We were surprised that Mr. Anderson makes 
 no reference to the writings of Dr. S. C. Busey, of Wash- 
 ington, who has carefully studied these growths in con- 
 nection with a case of congenital lymph-angiectasis, 
 which came under his observation. In a most exhaustive 
 article published some years ago in the American Journal 
 of Obstetrics he thus suras up : These considerations lead 
 me to the conclusion that thelipomatousandfibromatous 
 degenerations exhibited in the foregoing cases of giant 
 growth are the pathological results of a stagnation of 
 lymph. This stasis may be occasioned by conditions 
 which affect the lymph channels, or which primarily in- 
 volve the circulatory apparatus causing excessive transu- 
 dation of blood-serum, or both systems may be concerned 
 either proximately or remotely. In the lipomatous form 
 of degeneration the altered nutrition is due principally 
 
, 
 
 
 ' Blackader : A Case of Congenital Hypertrophy. 
 
 to some defect of the lymph apparatus producing lymph 
 stasis, while connective tissue hyperplasia is due to aug* 
 mented venous supply. 
 
 And again, it cannot, however, be denied that inflam- 
 matory processes, either erpsipelatous or elcphantoid, do 
 constitute the beginning of many of the cases of hyper- 
 trophic development, which are characterized by all the 
 phenomena which I have ascribed to occlusion and dilata- 
 tion of lymph channels, and consequent stasis of lymph. 
 But this fact does not antagonize my view, for it is ad- 
 mitted that such changes as result from the inflammatory 
 processes necessarily cause lymph-angiectasis, and the 
 argument relates to the effects, not the causes of the stasis 
 of lymph. I have previously referred to the suggestion 
 that the congenital cases of ectasia, stenosis, and oblitera- 
 tion of lymph channels, may have been caused by inflam- 
 matory conditions taking place during intra-uterine life, 
 and am willing to accept this hypothesis as a probable 
 explanation, but the numerous cases of congenital defect 
 of formation of portions of the lymphatic system, accom- 
 panied by hypertrophic enlargements, will not admit of 
 its universal application. The one essential condition is 
 interruption to the current and detention of the lymph, 
 it matters not whether it be caused by devastated glands, 
 absence of valves, absence of anastomotic connection 
 between the superficial and deep-seated system of vessels, 
 or other congenital or acquired conditions. 
 
 The following is the history of my case : 
 
 In March of last year, Mrs. W., aged thirty-four years, 
 was confined by me of her fourth child. The confinement 
 was in every respect a normal one, and her recovery good. 
 The child was a strong, healthy one, of more than aver- 
 age weight, well-formed in every respect excepting the 
 peculiar formation of the left foot, which was noticed the 
 night of the birth, and more carefully examined the fol- 
 lowing morning. The following are my notes about that 
 time : Both legs and thighs apparently the same, and well 
 developed ; no distinguishable difference in size, firmness 
 nor appearance ; no marks on skin ; posterior half of foot 
 
Blackader: A Ckse of Congenital Hypertrophy. ( 
 
 scarcely if at all enlarged, but anterior half enlarged in 
 all its diameters, and presents on its plantar surface a 
 large, firm, yet somewhat elastic tumor of smooth, rounded 
 surface, extending whole breadth of foot, and from mid- 
 dle of foot to root of toes •, the second and third toes are 
 webbed, much larger than the great toe, and project a 
 full half inch beyond it ; the fourth and fifth toes are 
 both enlarged, but to a much less extent; the skin is 
 perfectly normal in appearance; the movement of the 
 toes is considerably interfered with, apparently by the 
 tumor; there is no perceptible tenderness over the en- 
 largement, and no increase of temperature above its fel- 
 low. 
 
 Dr. Itoddick was called in consultation, and it was 
 decided that there should be no immediate interference. 
 
 About six months afterwards, the mother again brought 
 the child to me, saying that the foot was rapidly increas- 
 ing in size — growing, she thought, faster than the other. 
 I now determined on using continuous pressure by means 
 of a Martin's bandage, and obtained one 2J inches broad ; 
 had numerous holes punched in it, and then slit it up 
 lengthwise through the middle for about two yards, that 
 I might apply it more evenly. Very gentle pressure was 
 made, but after a few night's use of it the mother got dis- 
 couraged, as it caused the child much irritation, and has 
 made it very restless and wakeful. 
 
 After this I did not see it again until the beginning of 
 the year, when I again saw it, and as Dr. Roddick was 
 out of town, called in Dr. Fenwick in consultation. He 
 strongly advised me to persevere with the pressure for 
 the present. This was now with great care kept almost 
 constantly applied for nearly two months. Twice a day 
 the skin was sponged with spirits of wine, well dusted 
 with starch powder, and the bandage reapplied. Till I 
 was confident that they could apply it well I called every 
 day, and either applied it myself or saw it done. The 
 results were not very encouraging to the mother, although 
 I convinced myself it had some slight effect in retarding 
 the growth, as the measurements, which were very care- 
 fully taken, will show. 
 
Blackader : A Case of Covgaiital Hypertrophy, 
 
 An operation was now decided on. The child was 
 about, fourteen months old imd in j)erfoct health. To 
 flecure a good room, quietness and skilled nursing, it was 
 taken to a private hospital, where, with the assistance of 
 Dr. James Bell, and myself, Dr. Roddick performed the 
 operation. Jusl; before the operation, while the child was 
 under ether, the following ni>tcs and measurements were 
 taken : Heel enlarged ; about centre of plantar surface a 
 
 CoNCBNITAL HYPERTROPHY. 
 
 tumor-like mass, extending to base of big and little toe, 
 and forward to terminal phalanx of second and third 
 toes, which latter are webbed and much hypertrophied, 
 and project beyond the large toe three-quarters of an inch, 
 as if carried forward ; third toe also much enlarged, but 
 considerably shorter than the two previous; great toe 
 scarcely at all enlarged, but small toe two or three times 
 the size of opposite ; the dorsum of the foot also consider- 
 ably thickened ; no apparent enlargement of either the 
 
Blackader : A Case of Congenital Hypertrophy. 
 
 posterior tibial or anterior dorsal arteries ; no alteration 
 of the skin over the whole leg noticeable, and no appar- 
 ent alteration in the lymphatic or venous system; no 
 nevus to be seen on any part of the body. 
 
 The operation was commenced by an incision commenc- 
 ing on tue under surface at junction of ^eat and second 
 toes, and extending backwards to centre of foot at poster- 
 ior edge of tumor, where it was joined by another similar 
 incision from the junction of third and fourth toes; sim- 
 ilar incisions were made on the dorsal surface, and the 
 whole of the second and third toes, with anterior two- 
 thirds of the metatarsal bones, were removed. Finding 
 that the third metatarsal bone was also hypertrophied, 
 that toe, with the anterior portion of its metatarsal bone, 
 was removed, and as much of the tumor-tissue, which 
 was now seen to be a diffuse lipoma, was removed, and 
 the edges brought together. The whole operation was 
 done under strict antiseptic precautions. The tempera- 
 ture never rose over 99J°, the parts seemed to unite by 
 first intention, there was scarcely any discharge, and by 
 the tenth day most of the stitches were taken out. 
 
 After the operation I asked Dr. Wilkins, as a pathologist, 
 to examine the tumor, which he pronounced to be 
 principally fatty, but to contain numerous bands of 
 fibrous tissue. Dr. William Sutherland, Assistant De- 
 monstrator of Anatomy in McGill University, kindly 
 examined the amputated toes, and reported : Phalanges 
 enlarged but principally at their articular extremities, 
 which were much increased in size ; cartilages apparently 
 thickened ; tendons hypertrophied at their insertion. 
 
 As to the full results from this operation, a much 
 longer time must be allowed to elapse before we can make 
 any assertions. It will be sufficient for the present to 
 say that the child can now walk well. A slight tendency 
 to talipes varus is developing ; but we think that can be 
 easily overcome ; and the foot, though still somewhat 
 larger than its fellow, can be accommodated in a shoe of 
 ordinary size, and thus presents no deformity : 
 
Adams: Strabismus Coiivei-gem. 
 
 MEASUREMENTS. » 
 
 Normal/ool. Hvpertrophied foot. 
 
 T^r.„fl, f X. -. January. May. January. May. 
 
 Length (inches) 4 4^ g^ ^ "'"y- 
 
 Circumference around ball of foot..4J 5 7^ 7! 
 
 Circumf. around heel and ankle... 6 64 6i fif 
 
 Circumference around calf. 7 7^ 71 -f 
 
 Circumference around thigh 9 9^ gj nf 
 
•./ 
 
 4 
 
 -4^ 
 
.; 
 
 <h* 
 
<•< 
 
 THE 
 
 THE ONLT JOURNAL IN THE ENGLISH LANOUAOE 
 
 DEVOTED TO THE 
 
 Diseases of Infants and Children. 
 
 EDITED BY 
 
 WILLIAM PERRY WATSON, A.M., M.D., 
 
 Assistant to the Chair of Diseases of Children in the New York 
 
 Polyclinic. 
 
 dOHN E. POTTER & CO., Publishers. 
 
 617 Sansom street, PHILADELPHIA 
 
 • y 
 
 ■^g: