Clinical Lectures.

CASE OF ACROMEGALY.1

BY JOHN V. SHOEMAKER, M.D., LL.D., Professor of Materia Medica, Therapeutics, Clinical Medicine, and Diseases of the Skin in the Medico-Chirurgical College and Hospital of Philadelphia.

GENTLEMEN: This patient, Miss S. McD; age, 28; nativity, Ireland; occupation, cook; presents an interesting case for study.

Family History.-Is negative owing to the fact that she has little or no knowledge of her family.

Personal History.-When a child she had measles and mumps, menstruated first during her sixteenth year, the periods being regular, the flow normal and not accompanied by unusual pain. She drinks coffee and tea but not to excess and her

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head. Pain in the joints and muscles, especially in the limbs. After meals she has a sense of fullness and soreness in the epigastric region. Her appetite, as a rule, is good; bowels constipated and sleep is restless and disturbed by frightful dreams. The patient says her memory is getting poorer every day. She passes large quantities of urine, pale in color.

She states that two years ago she noticed her hands and feet becoming much larger so she was not able to wear the same size gloves and shoes as formerly. The patient likewise noticed a change in her voice, not being able to speak as clearly as before the present illness. She had menstruated last eighteen months ago.

Physical Signs on Admission.-General examination shows a female, tall, above average weight, muscular though the muscles are soft and flabby. Her hair is black, coarse and thin. The skin is dark in color,

cannot remember any other sickness until two years ago, when she first had rheumatic pain in her limbs and back, which has been more or less constant up to the present time.

Chief Symptoms on Admission.-A dull constant headache, which at times is quite

severe and localized in the back of the

face and body. Her face is broad and elongated. Her cheekbones are prominent,. the lower jaw greatly projects so that the teeth in front do not articulate. Her ears are large and thick; eyes widely set apart, large and prominent, and the tip of the nose is thick and enlarged in width; lips are almost as thick as those of a negro; teeth widely set apart, tongue is thick,

difficult, owing to the enlargement of her tongue and larynx; hands and feet are broad and thick; fingers and toes comparatively thick and broad and the finger nails are marked by longitudinal ridges.

Percussion over the chest reveals a dull note over the sternum from the suprasternal notch to a level with the fourth costal cartilage, otherwise nothing abnormal, probably due to remains of thymus gland. Respiration is full and regular. The heart beats are rapid, but the sounds are normal. There is slight arterio-sclerosis and varicosity of the veins.

The abdominal viscera are apparently

normal.

The joints of her hands and feet are painful on motion and the bones of the hands, feet and legs are much enlarged. She has a marked posterior curvature of the spine in the cervico-dorsal region.

The reflexes are all normal excepting the patellar is slightly increased.

Bimanual examination revealed atrophy of the uterus and vagina. The external genital is about normal in size.

symmetrically enlarged. There is usually hypertrophy of the tongue and larynx and a persistence of the thymus gland as in this case. Varicosity of the superficial veins especially in the lower extremities, are also present in this patient. Generally there is atrophy of the uterus in the female and of the testicle in the male, while in many cases the external genitalia share in the enlargement.

Etiology. Many theories have been advocated as the probable cause of acromegaly, but not sufficient evidence of the cases reported has been demonstrated to support the assumptions presented. Marie who first recognized and described the disease as a separate entity, assumed it to be a systemic distrophy analogous to myxedema, due to a deranged function of the pituitary body. Erb and Klebs found the thymus gland persistent and concluded that its presence had an influence on the development of the disease. The precedence of certain diseases such as syphilis, nervous disorders and specific fevers have been considered as etiological features, but

Urinalysis revealed nothing abnormal excepting large quantities of urine voided daily (90 ounces in 24 hours), and a low specific gravity (1008).

The Blood Examination was negative throughout.

Diagnosis. In the advanced stages of the disease the diagnosis is quite easy. One knowing the pathological conditions, can scarcely confound the disease with any other affliction.

Pathology.-Marked enlargement of the bones of the face and skull, especially of the superciliary ridges, the antrum and the inframaxilla in its entirety, together with hypertrophy of the ears, nose and lips. Exophthalmos is often present and in some rare cases to such an extent that there is almost a subluxation of the eyeballs. The bones of the hands and feet are

quency in the cases reported to support this belief.

Treatment. Thus far the treatment in these patients has been very unsatisfactory. The iodides, phosphorus, arsenic iron and the rest of the haematinics and alteratives have no influence in curing or arresting the development of the disease.

A few cases have been reported in which the extract of the pituitary gland gave temporary relief and improvement. Thyroid extract as well had its trial by many men, but likewise proved itself of no avail.

Thyroid extract, grains three, were administered to this patient three times daily and gradually increased to five grains three times daily. The effects as far as we were able to ascertain, were practically nil.

THE OPEN METHOD OF TREATING THIERSCH'S GRAFTS.

BY ERNEST LAPLACE, M.D., LL.D., Professor of Surgery, Medico-Chirurgical College, Philadelphia, Pa.

WHEN Reverdin first observed that epithelial cells which accidently fell upon. a granulating surface would form islands. of epithelium, thereby developing over the whole surface of a wound, a great step was made in the direction of hastening the normal healing process. The Reverdin method of skin grafting, which consists of snipping off pieces of epithelium from healthy surfaces, and transplanting them to a healthy granulating surface, was soon superseded by Thiersch's idea of removing from a healthy epithelial surface, as much epithelium as would be physically required to cover a granulating surface to be healed. As is often the case in the introduction of a new procedure, the technic used is likely to be necessarily complicated. When the Thiersch method first appeared, it was considered necessary to pass the strips of epithelium through a warm salt solution, to have an absolutely sterile granulating surface, to cover the transplanted surface with a protective membrane, and finally, with a large amount of gauze and cotton of various antiseptic power, with the object of obtaining as completely as possible, a full adhesion and development of the grafts.

It is well known that in spite of all these precautions, this method has been accompanied by a proportion of failures, owing to purulent development, by which the grafts were loosened and gradually sloughed.

Meeting with a certain amount of discouragement, or at best, with incomplete success in a fair proportion of cases by the above method, I determined in a measure at least, to simplify the technic with the object of being able to watch the process of the adhesion of the grafts for the purpose of stopping any purulent de

velopment here, as we would stop it elsewhere, without prejudice to the tender grafts, but on the contrary, keeping them alherent to the spot where they have been transplanted.

In order to accomplish this purpose, it is necessary to render the receiving surface as sterile as possible, and especially necessary that it should be dry. I therefore wait until the surface to be grafted is thoroughly covered with granulations. Two days before transplanting, I apply a two per cent solution of picric acid to the surface. This acts both as a mild antiseptic and as an astringent, leaving the granulating surface clean and dry.

The Thiersch grafts are made in the usual manner by using a sharp razor, and with a see-saw motion, shaving off the surface epithelium from a spot aseptically prepared. This is facilitated by allowing a few drops of the sterile water to fall on the blade of the razor while the grafts are being cut. The surface being now covered with grafts, a single layer of gauze is applied directly over the grafted surface, projecting about 1% of an inch beyond the edges of the wound. This single layer of gauze is bound in place by strips of adhesive plaster placed about the edges of the gauze so as to completely encircle it.

The plaster, however, should not impinge upon the wound. Preferably, I use gauze having a very open mesh. It is evident that now the grafted surface can be sponged with cotton or gauze, and made to drain into a surface dressing, without any risk of displacing the grafts. Should any secretion appear, it is immediately soaked up into a very light dressing consisting of two or three layers of gauze placed over the subjacent layer, and which can be removed at any time without in any way disturbing the lowermost layer.

The principle that we seek to apply is that of imitating Nature in scab formation, whereby the serum is allowed to evaporate from the surface of the wound

on account of there being so little dressing; and also the ability which we thus have to clean the wound through the meshes of the lowermost layer of gauze, just as we would clean any other open wound, without fear of disturbing the grafts at any time.

A very remarkable fact is the almost total absence of secretion when the process of grafting has been made over a surface already prepared by a picric acid solution.

The lowermost layer of gauze is not removed for eight or ten days, while the layers of gauze above this may be removed at any time in order to watch the healing process. The uniformity of good results under these conditions is quite remarkable in every instance where the surface to be grafted presents a healthy appearance. In following this procedure, it has never happened to us to lose a single graft, but on the contrary, we find that grafts treated by this method, will take and further develop under the most unfavorable circumstances, as in the following instance:

A patient still under observation, a woman 80 years of age, was burned over the shoulder and arm from an exploding coal oil lamp. She suffered from a burn of the third degree over an area extending to the middle of the arm, but directly over the shoulder, the burn extended to the

through this the surface was cleaned, and special attention given to the necrosis. On the tenth day, the lowermost layer of gauze was removed, and every graft was found to have taken, the whole surface being completely healed up to the very edge of the necrosis, which still gave out the foul odor characteristic of this condition.

I firmly believe that this was an extreme test of our modification of Thiersch's technic; for the infection incident to the necrosis, would, under the old technic, have absolutely destroyed the grafts, or more probably the case would not have been grafted.

Should at any time exuberant granulations protrude between the grafts after they have thoroughly taken root, the healing process will be materially hastened through compression by strapping the parts.

In view of the absolute simplicity of the whole matter, based upon an imitation of Nature's method of healing by scabbing, and of the uniform success that follows its use, I have become less and less anxious to save flaps or to unduly stretch the skin in plastic operations on the trunk or extremities of the body, preferring to use the tissue without any undue stretching, and resorting subsequently to a process of skin grafting by the above method whereby the ultimate result is just as satisfactory without the risk of having retained any skin which still has some pathological element.

there was no disposition of the dead bone to become sequestrated, we could not sterilize it, nor could it be removed surgically. Under these circumstances, the whole granulating surface was covered with grafts to the very edge of the necrosis.

The operation was conducted as described above. Daily, however, the surface dresssings were removed, leaving the lowermost piece of gauze in position fastened by adhesive plaster about its edges;

WALL AFTER SUPPURATIVE APPENDICITIS.

An unfortunate condition follows cofferdamming and gauze drainage, which is necessary to save life after an operation for suppurative appendicitis. The be havior of the tissues following the operation, makes the secondary closure of the abdominal wound a matter of great difficulty and risk; or, it may be done without