v’OLUME III NUMBER 10

MINNESOTA MEDICINE

Journal of the Minnesota State Medical Association

EDITOR Cant B. Drake, M. D., St. Paul ASSISTANT EDITORS Srantey R. Maxeiner, M. D., Minneapolis Pau. D. Berrisrorn, M. D., St. Paul ASSOCIATE EDITORS First District Third District Fifth District Gro. S. Warram, M. D., Warren E. L. Tuony, M. D., Duluth Gro. B. Weiser, M. D. New Ulm

Second District Fourth District Sixth District A.W. Ine, M. D., Brainerd F. L. Apair, M. D., Minneapolis A. E. Sratptine, M. D., Luverne

Seventh District Eighth District H. B. Arrxens, M. D., Le Sueur Center A. F. Scumrrr, M. D., Mankato

OCTOBER, 1920

CONTENTS ORIGINAL ARTICLES M. S. HeNpERSOoN, M. D.—Tuberculosis of the Knee Joint in Children.......... 463

E. L. Tuony, M. D—A Study of Chest Conditions Associated with Aortic

ee ee Re Pn ee eer eee 471 Roop Taytor, M. D.—Chronic Interstitial Nephritis in Children.............. 481 O. W. Hotcomr, M. D.—Acute Dilatation of the Stomach ................... 486 A. L. McDonaLtp, M. D.—Pre-Eclamptic Toxemia and Post Partum Eclampsia.... 494 CHARLES N. Henset, M. D.—The Mechanics of Digestion Lidia eae ama oareenigete oie 497

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MINNESOTA MEDICINE

Journal of the Minnesota State Medical Association

Vout. III

OCTOBER, 1920

No. 10

ORIGINAL ARTICLES

TUBERCULOSIS OF THE KNEE JOINT IN CHILDREN*

M. S. Henverson, M. D. Section on Orthopaedic Surgery, Mayo Clinic, Rochester, Minn.

Tuberculosis of the joints in the order of fre- quency affects first the vertebral column, sec- ond the hip, and third the knee. The knee joint being superficially placed presents more objec- tive signs than the hip or the spinal column. Tuberculosis of the knee is commonly supposed to be about evenly divided in the sexes, and a little more common on the right side than on the left. It is more often encountered in child- hood and in early adult life, but is to be seen at all ages. Since the disease is further away from the trunk it is less dangerous to life than tuberculosis of the hip or of the spine. The treatment of this joint is easier than of the hip for the two long levers making up the joint permit of comparatively easy fixation, whereas in the hip joint the fixation apparatus must at least include the entire pelvis in order to pro- vide rest for the affected joint.

ETIOLOGY AND PATHOLOGY

The disease is caused by the tuberculosis bacillus, either human or bovine. It is hemato- genous in origin, always being secondary to a tuberculous focus elsewhere in the body. The usual primary focus is the lymph glands, par- ticularly the upper deep cervical, bronchial, or mesenteric group. As a result of the caseation of these glands and a breaking down of one of the vessels, the debris with some of the tu- berculosis bacilli enter the blood stream and are carried as small emboli to the right side of the heart and thence through the lungs into the

*Presented before the Southern Minnesota Medical As- sociation, Fairmont, Minn., June, 1920.

systemic circulation. It is possible also that the bacilli may gain entrance to the thoracic duct and be carried through it into the gen- eral circulation. ,

The reason that the bacilli select the bones and joints for a habitat may be explained on anatomic grounds. The blood supply to the long bones may be divided into three systems: (1) diaphyseal, (2) metaphyseal, and (3) epiphyseal (Fig. 1). The diaphyseal system is the least concerned with the subject under dis- cussion, but the vessels of this group run to- ward the epiphyseal end of the bone and anastomose with the metaphyseal vessels, the latter gaining entrance from the periosteal structures. All three systems anastomose quite freely at the metaphyseal area and, the vessels being larger, the circulation is correspond- ingly slower than elsewhere; therefore, any emboli of bacilli are apt to be arrested here. Fraser of Edinburgh did a large amount of experimental work on surgical conditions of bones and joints and found that it was difficult to infect bone marrow with tuber- culosis, even when he injected the bacilli directly into the marrow cavity; since he knew that clinically bone tuberculosis is com- mon he concluded that some change must first take place in the marrow in order to make the field suitable for the growth of the tuberculosis bacilli. He decided that a gelatinous degenera- tion in the marrow substance must first occur, and that such degeneration must be caused by the tuberculous toxemia or a hemorrhage in the bone substance. On such a medium the tu- bereulosis bacilli flourish. Sir Harold Stiles, for many years chief surgeon to the Royal Edin- burgh Hospital for Sick Children, reminds us that comparatively mild trauma may loosen an epiphysis and he therefore believes that some of the so-called sprains may easily cause a hemorrhage in the metaphyseal area and thus provide, in the hemorrhage, a suitable field for

464

TUBERCULOSIS OF KNEE JOINT IN CHILDREN

\ ‘Nutrient artery

Lower end

Femur

Epiphyseal arteries:

Tibia

SO pethes Lae 4 Ae

Fig. 1. Blood supply

tuberculosis bacilli to be deposited by the blood stream to begin their deadly work. This may happen many more times than would seem pos- sible and the resistance of the victim be so great that he is able to cope with the infection. It is possible that an embolus of tuberculosis bacilli may be locked up in this way during childhood, leaving an area that is a good site for the development of tuberculosis in adult life.

Just how the tuberculosis bacillus gains entrance into the human body is of great inter- est. It is often thought that the dried exere- tion and sputum in the form of dust is inhaled, thus introducing the bacillus. Lawrason Brown has recently reported some experiments in which he collected dust and dirt from hovels previously occupied by persons who had died of pulmonary tuberculosis. This material was emulsified and injected into guinea pigs intra- peritoneally with negative results. It was only by practically taking the material from the lips of patients with open pulmonary tuberculosis that he was able to produce positive results in guinea pigs. Such experiments seem to indicate

to bone ends (Lexer).

that we have over-estimated the danger of in- fection by dried bacilli, but this should in no way permit of fewer precautions, From clini- eal experience, we well know the danger from contact and intimate associations.

In 1901, when Koch read his paper at the In- ternational Medical Congress in London, he made some statements that show how far from the truth even so great a man as he can stray when he states as facts what are in reality mere- ly impressions. He stated that, ‘‘the bacillus of human tuberculosis is incapable of produc- ing tuberculosis in the bovines’’ and ‘‘the bacillus of bovine tuberculosis is to be con- sidered as practically incapable of transmission to man and that consequently the danger of contracting phthisis from the milk or meat of tuberculous bovines need no longer be guarded against’’. This brought forth much criticism

and the question remained open until the work of Stiles and Fraser proved the error of Koch’s These observers had under their care many cases of surgical tuberculosis in children in the Royal Edinburgh Hospital for Sick Children and when a patient with tubercu-

statement.

= none

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TUBERCULOSIS OF KNEE JOINT IN CHILDREN 465

losis was brought to the hospital, the home of the patient was visited to investigate the living conditions, and to determine whether any mem- bers of the household or family were or had been suffering from tuberculosis in any form. The food was looked into and it was not long before the investigators were convinced that the milk supply, at any rate in the vicinity of Edin- burgh, was a great medium for conveying bovine tuberculosis bacilli. Miller and Mitchel} concluded that from 16 per cent to 20 per cent of the Edinburgh milk was infected with tu- bereulosis bacilli.

Fraser very carefully examined the material obtained from the cases of surgical tuberculosis and determined whether it was due to the human or bovine type. He proved by various laboratory tests that 62 per cent of a series of cases of proved bone and joint tuberculosis owed their origin to the bovine type of bacillus. Seventy-one per cent of the 38 per cent said to be due to the human type pre- sented a history of tuberculosis, usually pul- monary, existing or having existed in some member of the family with whom the patient had been intimately associated. Fraser found while carrying on these experiments that it was easy to produce synovial tuberculosis in animals by introducing bacilli into the blood stream. Stiles believes that the infection is apt to be in the synovia more commonly in the knee than in any of the other joints. Trauma, as shown by this experimental work, at least as far as the bones are concerned, plays a prominent part in the production of tuberculosis; these observers agreed that a comparatively slight injury to the metaphyseal area may cause a slight hemor- rhage and thus provide the field for growth to the bacillus.

DaCosta says, ‘‘To deny the possibility of traumatic tuberculosis is to deny many of the truths of pathology and some of the plainest les- sons of clinical medicine.’’ As far back as 1880, Max Schuller injected tuberculosis bacilli into the trachea of dogs and at the same time in- jured the right knee. Some of the animals de- veloped a general tuberculosis and some a con- dition that appeared histologically to be a tu- berculosis of the right knee. The knee that was not subjected to trauma was not affected in any case. Koenig maintained that trauma was

Six months’ history. Disease apparently primary in patella.

Fig. 2. Gir] aged 5.

the causal influence in one half the cases of tuberculous joints.

As shown by the anatomic work of Lexer, the synovial vessels, the metaphyseal vessels, and the diaphyseal vessels freely anastomose. Stiles states that there is no reason why both synovial and métaphyseal tuberculosis should not exist at the same time and that consequently there is no reason why one should not be secondary to the other.

While from the viewpoint of treatment there is a great difference between tuberculosis of the knee joint in the adult and the like condi- tion in the child, the same is not true of the pathology. Although the pathologic picture is apparently different, the difference is readily explained by the fact that there is a preponder- ance of cartilage in the knee joint of the child. It is generally conceded that tuberculosis rare- ly, if ever, develops in cartilage. How then can we explain’ the common occurrence of the disease in childhood? In the first place, milk is a more common article of diet for the child than for the adult; second, trauma of the joint and possibly injury to the epiphyseal (meta- physeal) line is more common; third, children are more susceptible to all forms of infections, the immunity they possess being hereditary and not acquired, and fourth, the infection may often be primary in the synovia, gaining entrance through synovial vessels. It is not ex-

466 TUBERCULOSIS OF KNEE JOINT IN CHILDREN

tremely rare to meet with the disease primarily in the patella (Fig. 2). SYMPTOMS

The train of symptoms is more or less defi- nite and if there is any symptom of more im- portance than others it is the presistency of the complaint (Fig. 3). There are remissions but no intervals of complete freedom, Often a his- tory of trauma is elicited definitely preceding the onset of symptoms. A limp worse in the morning due to stiffness may be noted by the parents even before the child complains. Pain, although generally ‘mild, may be severe; in the latter case the onset is actte, simulating an acute infection. The suffering in such instances is extreme. Pain is a much less prominent symptom than in tuberculosis of the hip joint. Also, since the knee joint is a simple hinge joint, the mechanism back of the deformity produced is much simpler than that in the hip joint. The joint is superficially placed and the changes in the capsule of the joint are not hidden by muscular structures. The swelling produced by

the effusion within the cavity and the inflamma- tory thickening of the capsule are at once evi- dent. Local heat can be detected on palpation but redness is only present when secondary in- fection supervenes, hence, the name ‘‘white swelling’’.

Flexion is the primary deformity but as the disease progresses, the secondary deformities of external rotation with consequent knock- knee and subluxation develop (Fig. 4). Flex- ion advances rapidly due to the fact that once it is present the hamstrings have a great ad- vantage over the extensors. The biceps femoris through its insertion into the head of the fibula tends to flex and rotate outward and abduct the tibia, producing knock-knee. As the flexors gain the advantage, they tend to pull directly back on the tibia as it is flexed and produce a subluxation, a most troublesome deformity with which to deal. Atrophy of the thigh and calf muscles ensues and it appears to be more than the mere atrophy of disuse. Asssociated with this is atrophy of the bone, which shows

Tuberculosis of the mee in Childhocd

Persistency of j

symptoms

Stiffness Limp Local heat Pain Trauma Deformities ‘' Muscle spasm Swelling | Periarticular Effusion Atrophy thigh thickening and calf Flexion | Subluxation Outward rotation of tibia with knock= knee

Fig. 3. Chart showing

prominent symptoms.

Sener re

TUBERCULOSIS OF KNEE JOINT IN CHILDREN

Fig. 4. little complaint for three years except limp. Exacerbation last year with development of flex- ion and subluxation.

Girl aged 6. Injury at two years. Very

up as an osteoporosis in the roentgenogram. Fever of one or two degrees is generally present but may be due to many other causes, especially in children; it should not, therefore, be taken too seriously. The von Pirquet test is of value, especially in young children, and should be used as an aid but should not be relied on to the exclusion of other means of diagnosis. The roentgen ray should always be employed but the picture in the early stages is not very defi- nite; so much cartilage is present that the amount of destruction may be minimized in the plate (Fig. 4). The area near the epiphyseal lines in both the tibia and the femur should be closely scanned to determine whether or not there is a bony abscess which might be drained extra-articularly. Joint symptoms of a mild nature almost premonitory in character may be produced by these metaphyseal abscesses. The roentgen ray is of less aid in diagnosing tu- berculosis of the knee in children than it is in the adult. If more than one joint is involved extreme caution should be used in diagnosing tuberculosis. The patient may be and generally is in good general physical condition, The

467

family history is important. Fraser, as I have stated, showed that in 70 per cent of the cases due to the human bacillus, a positive family his- tory was elicited. Aspiration and intraperiton- eal injection of the fluid or debris in a guinea pig is a very valuable test and should be used when practical. The occurrence of tuberculous glands of the neck, tuberculous peritonitis, or tuberculous involvement elsewhere naturally is evidence in favor of tuberculosis in the affected knee, Pulmonary tuberculosis is rare in chil- dren but when present is of serious moment. DIFFERENTIAL DIAGNOSIS

Syphilis may simulate tuberculosis of. the knee joint ahd not infrequently causes effusion in the knee but it is apt to be present in both knees. Careful questioning may bring out the fact that syphilis is or has been present in one or both of the parents. The child, and the parents in suspected cases, should have a Wassermann test although a negative test, if the clinical signs point more to syphilis than to tuberculosis, should not be accepted as final. Iritis and Hutchinson’s teeth may throw the balance in favor of syphilis in an obscure case and should always be looked for.

An arthritis due to an ordinary infectious cause is usually more acute and rapid in its course. The more chronic form of infectious arthritis, in reality an arthritis deformans first described by Still and hence ealled Still’s disease, may be confusing, but in such cases other joints soon show involvement and the patients are usually in a poor general condition (Fig. 5). General glandular enlargement and an enlarged spleen are common findings in Still’s disease and are absent in tuberculosis of the joints.

Sarcoma of the lower end of the femur or upper end of the tibia produces joint symptoms, but on careful examination the enlargement will be noted in one or the other of these bones. A roentgenogram will definitely show the lesion and for this reason, if for no other, it should always be made in all affections of the joints or bones.

TREATMENT

The treatment may be roughly divided into general and local (Fig. 6). The fact should never be lost sight of that the disease being treated is tuberculosis and every means possible

468

Fig. 5 ans. Indefinite diagnosis until year later when other joints became involved.

Infant, aged 20 months. Arthritis deform- Roentgenogram shows synovial thickening.

should be used to raise the patient’s general re- sistance. Open air, sunshine, tonics, nourishing food, and congenial and at the same time sensible surroundings, should be insisted on. In several instances I have seen children, who in spite of all our efforts were in a steadily downward course, change to a steadily upward course on merely having their companions changed and sensible amusements substituted for those caus-

TUBERCULOSIS OF KNEE JOINT IN CHILDREN

ing nervous strain. Tuberculous children are often precocious and may read books in too great numbers and fit only for mature minds. It may be necessary to take a firm hand and dismiss a fond parent as an attendant and substitute a less interested and more phlegmatie person. The best of local treatment may be of no avail if the general treatment is not carefully supervised.

The keynote to local treatment is conserva- tism. If treatment is instituted early and the proper means are taken to prevent the develop- ment of deformities, the management is easy. The patient coming late with subluxation and knock-knee and external rotation of the tibia is, on the other hand, most difficult to treat. <A properly applied plaster of Paris cast affords excellent fixation (Fig. 7A and B). The ordinary stiff legged brace, in mild cases, is often suffi- cient. In the more acute cases rest in bed with extension may be necessary and when the pa- tient is allowed to be up a plaster of Paris cast is indicated, with a high soled shoe on the opposite foot and crutches to prevent weight bearing. The Thomas extension splint (Fig. 8 A) is ex- cellent, but unless guarded against is especially prone to cause a relaxed knee joint.: As the con- dition improves, a walking caliper Thomas splint may be used (Fig. 8 B). All apparatus must be carefully supervised and care taken once the flexion is overcome to prevent genu-recurva- tum. When subluxation is present more elabo-

Treatment of Tuberculosis of the Knee in Children

| ! General Time indefinite Locel Open air Good food Tonics Proper surroundings Heliotherapy Fats

Splints Casts weight pulley

Stiff legged Thomas and extension brace with knee brace without weight bearing weight bearing

Fig. 6.

Extension by Aspiration and

Walking Caliper brace with some weight bearing

Correction by Resection force under anesthesia

and injection

Correction gradually by change of cast

Chart showing essentials of treatment.

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Fig. 7. A. Outline showing short cast giving poor

fixation. B. Long cast giving good fixation.

rate measures are necessary. Prolonged traction with weight and pulley, with the line of pull carefully directed, may straighten the knee. So many hindrances may be put in the way of this method, such as little tricks of the patient to lessen the pull, and kind-hearted but really med- dlesome relatives and attendants who lift up the weights to ease the patient, that it may be better to give the patient a light anesthetic and gently force the knee straight. At the first indication of a tendency to further subluxation, the force should be stopped and a cast applied with the flexion deformity only partially corrected. This may be repeated and usually the knee can be brought straight in three or four attempts. The knee must never be moved back and forth, but

TUBERCULOSIS OF KNEE JOINT IN CHILDREN

469

merely forced straight to the point where it seems safe. Not infrequently the knee can be brought down without the use of an anesthetic by merely applying a cast and at the end of a week or ten days removing it; at this time it will be found possible to obtain a few degrees more of extension, in which position a new cast is put on and the process is repeated until the knee is straight. This method always takes more time than when an anesthetic is used, and may be very slow and in some cases impossible.

Aspiration of the joint and injection with some antiseptic solution such as formalin in gly- eerin or iodoform in glycerin is ordinarily looked on with disfavor. In ‘certain cases in which the effusion is extensive and the bony involvement apparently nil it may well be used. This should not be carried out with disregard to the proper mechanical measures to prevent. deformity, but should be used only in conjunc- tion with them.

It has never been our custom in the Mayo Clinie to resect tuberculous knees in children. Stiles has reported a large series of resections and the results have been astonishingly good. In America, however, we have not thought it necessary to resort to surgery. The type of tu- berculous knee that is seen in the children in the Edinburgh clinic is more malignant than is seen in this country, and there seem to be very good grounds for the radical measures.

When the patient comes late in the disease with probable multiple draining sinuses the prognosis is poor. Fixation must be provided. Surgery only serves to spread the trouble unless there is a definite sequestrum. Heliotherapy, with general measures, offers the most. Under proper instruction, the child should be exposed to the sun’s rays until the whole body is thoroughly tanned, care being taken not to burn the skin.

Tubereculin is used by some but there is con- siderable controversy over its value. Its use was abandoned some time ago in the Mayo Clinic as we could see no benefit from it.

The prognosis is reasonably good, especially if the treatment is started early and general and local measures are well and properly carried out. The question always asked by the parents is how long the treatment is to last. This can be an- wered only indefinitely ; the parents should be

Fig. 8. A. Thomas extension knee splint showing ring resting on tuberosity of the ischium, thus giving a fixed point for extension.

B. Thomas walking caliper split with the irons fastened in the shoe and the heel just short of contact in the shoe.

told frankly that the treatment will mean years of observation and that a cure may mean a stiff knee, athough many patients recover with considerable motion and a few with practically full motion. A proper understanding with the parents at the start will secure their confidence and understanding. RESUME

1. Tuberculosis of the knee is always secon- dary to a focus elsewhere in the body and may be caused either by the human or bovine tuber- culosis bacillus.

2. Trauma is a prominent etiologic factor.

TUBERCULOSIS OF KNEE JOINT IN CHILDREN

3. The disease may be either primary in the synovia or in the bone. It is difficult to deter- mine which is the more common. It is the im- pression of the author from clinical experience that the synovial type is fully as commuu in children as the osteal type. fa >

4. The symptoms are usually mild and the deformity develops surreptitiously with but little complaint from the child.

5. The treatment is essentially conservative, and if instituted early, carefully planned, and carried to completion affords a good prognosis.

BIBLIOGRAPHY

Brown, L.; Petroff, S. A. and Pasquera, G.—Etiologic studies in tuberculosis. Jour. Am. Med. Assn., 1919, lxxiii, 1576-1578.

DaCosta, J. C-—The causal relation of traumatism to tuberculosis. Tr. Am. Surg. Assn., 1914, xxxii, 195-216,

Fraser, J.—The etiology and pathology of bone and joint tuberculosis. Jour. Am. Med. Assn., 1915, Ixiv, 17-24.

Henderson, M. S.—The intraperitonea] inoculation of animals; its diagnostic value in orthopedic surg- ery. Am, Jour. Orthop. Surg., 1916, xiv, 320-326.

Koch—Quoted by Stiles.

Koenig—Quoted by DaCosta. /

Lexer, E.—General surgery. New York, Appleton, 1908, 1015 pp.

Miller and Mitchell—Quoted by Fraser.

Schuller, M.—Experimentelle und histologische Un- tersuchungen uber die Entstehung und Ursachen der skrophulosen und tuberkulosen Gelenkleiden. Stuttgart, 1880.

Stiles, H. J—Pathology and treatment of tuberculosis of the bones and joints. Jour. Am. Med. Assn., 1912, lviii, 527-534.

Stiles, H. J—Discussion on the after results of major operations for tuberculous disease of the joints. Brit. Med, Jour., 1912, ii, 1356-1362.

DISCUSSION

DR. EMIL S. ‘GEIST, Minneapolis: I wish to con- gratulate Dr. Henderson on his paper because it ful- fills the requirements just as a modern woman’s dress does, in that it was short enough to be interesting and long enough to cover the subject. (Latghter.)

When I see a patient afflicted with tuberculosis of the knee or other forms of joint tuberculosis, I ask why? We ” ow there are two ways of infecting children, either by means of some patient who has an e~°n tuberculosis, or from inadequate supervision o. . * ilk supply. Every case of joint tuberculosis in a child is really unnecessary and means that in some way or another a mistake has been made in the surroundings of the child or on part of the health authorities.

I am sorry Dr, Henderson did not mention the dif- ferential diagnosi- of tuberculosis of the hip joint.

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A case comes in with a beautiful cast on the knee while the disease started in the hip joint. The thigh being atrophic makes the knee look larger and swol- len. It is not an uncommon thing to have this hap- pen and it is rather difficult to explain why that cast is on the knee and not on the hip. The first picture 1 owed of blood vessels in the knee joint explains that.

Another reason why these children should have tuberculosis of the knee more often than adults is because there are more blood vessels growing in the knee joint of the child than in the adult. Lexer’s studies show very nicely how the number of blood vessels in the adult knee joint is much less than in the knee joint of the child. Of course, the more blood vessels, the more bifurcations, the more chance there is for embolus and all that sort of thing.

Conservative treatment is the thing in tuberculosis of the knee joint in children; at the same time, op- erative treatment must sometimes be resorted to,

Regarding resection, I happened to have in Paris about ten years ago immediately following an epi- demic of resections of knee joints. In other words, children at the age of eight or twelve had their knee joints resected, and I saw those cases twenty-two and twenty-four years of age with their legs eight or ten inches shorter than on the other side. Resection involves the epiphysis. The active growing centers of the leg are situated about the knee joint, and re- section is an operative procedure which, if done at all, must be done with the idea of conserving the epiphyseal cartilage. If an operation is to be done, I think the new operation of Dr. Hibbs, of New York, whereby he fixes the knee by using the patella a3 a graft, taking out the patella, making a place for it between the tibia and femur, and embedding the graft in there, making a bony bridge across from the femur to the tibia, and not involving the epiphysis should be done. This can be done in children who are ten or twelve years of age who have the very virulent type of tuberculosis that Dr. Henderson mentioned. Dr. Hibbs told me a few weeks ago he was doing that operation on this class of cases and has seen no reason to regret it. Operative treatment in tubercu- losis of the knee in children will occupy a rather small but definite place in surgery.

CHEST CONDITIONS ASSOCIATED WITH AORTIC DISEASES

471

A STUDY OF CHEST CONDITIONS ASSO- CIATED WITH AORTIC DISEASES, SPECIFIC AND NON-SPECIFIC*

By E. L. Tuony, B. A., M. D., F. A. C. P. Duluth, Minn.

This paper will deal with an analysis of a group of cases classified primarily as aortic aneurysm, aortic aneurysm with aortic insuf- ficiency, syphilitic aortic insufficiency, syphili- tie mesaortitis, rheumatic endocarditis with aortic insufficiency, angina pectoris, and mis- cellaneous mediastinal conditions simulating aortic disease.

We will find that as far as etiology is known we will deal chiefly with the results of (a) Syphilis, (b) Streptococeus or Rheumatic In- fection, (¢) Chronic Degenerative Vascular and Myocardial Changes. Statistical data will be given on the two latter groups, chiefly to ac- centuate and compare them with the first, which is virtually the chief subject of this compila- tion.

In those conditions known to be due to syphilis, or in which we can prove it to be the cause, the absolute advantage and need of an early diagnosis is beyond ecavil. On the other hand, a word of caution is needed not to over- work it in assigning it as the cause particularly in the groups classified above as (c). Our sta- tistics of true major angina, for example, will not confirm the often expressed relationship to syphilis; they fall in a later decade of life, and occur with a different pathologico-anatomi- cal complex. Our possession of incomparable therapeutic weapons to overcome the destruc- tive propensities of the spirocheta pallida is only equaled by the amazing faculty of this organism to insinuate itself and devise its own protection. An apparently simple and evanes- cent ‘‘soft sore’’ at twenty can be the true source of aortic aneurysm at seventy.

Nothing exemplifies better our changing standards than an historical survey of syphilitic aortic disease. The principle is not confined to any special field in Medicine, as witness the means now at our disposal to identify duodenal uleer. Compare our present knowledge of the incidence and importance of that condition with

ae before the Minnesota Academy of Medicine, May, 1920.

472

the teachings and practice of a scant twenty years ago. In changing from period to period, courage and conviction are necessary to cast off any of the traditions of the past, for fear lest in the mass of straw a few precious kernels of wheat might be concealed. Hence we have our massive and unwieldy text books and medi- cal systems ; the best excuse extant for our ever increasing periodical literature. THE INFLUENCE OF ROENTGEN-RAY AND SERO- LOGICAL STUDY

The development of the X-ray and perfection of the fluoroscope, together with the Wasser- mann blood test, have done for the study of syphilitic ortitis what many specific tests previ- ously have done for other diseases: they have put into the background the elucidation of a great mass of less definite data. The distinct loss arising from the failure of younger clin- ‘jicians to train their faculties and perceptions in the older lines of ‘‘physical diagnosis’’ is at least in part overbalanced by the enormous ad- vantage accuring to the patient, through earlier and more accurate diagnosis. The tendency, however, is not without its critics. Hoover’ has recently challenged an editorial in the A. M. A?’ which stated briefly, that aside from early Roentgen signs and serum findings, early speci- fie aortitis awaited a reliable means of identifi- cation, Even accepting Hoover’s proposition at its face value, and acknowledging all the claims, we only need refer back to his state- ment that ‘‘The older established methods of bringing out physical signs serve equally well as the newer diagnostic criteria’. We are con- fronted then, with the conclusion that the skill needed in the interpretation of the signs he mentions depends so greatly on personal fac- tors, the cultivation of particular senses in the examiner, as to render decisions by those less skilled liable to error and faulty judgment. In other words, while instrumental data and labor- atory technique may lead us away from in- tensive individual development, they are fortu- nately subject to standardization and therefore to a wider and more universal usefulness. We may state unequivocally that the Roentgen-ray is indispensable in modern chest diagnosis, and it is fit and proper that the clinician should know fully its possibilities and its limitations.

The laboratory tests for syphilis no longer

CHEST CONDITIONS ASSOCIATED WITH AORTIC DISEASES

need defenders, and in searching for the earliest evidence of syphilitic invasion of the aorta we may well heed the words of Elliott’: ‘‘From the practical clinical standpoint ac- cumulating evidence is forcing the conclusion that a persistently positive Wassermann reac- tion in a patient without evidence of syphilis in the skin, mucous membrane or nervous sys- tem, points to the aorta as the next, most prob- able seat of the disease’. In speaking of sub- sternal oppression or pain in a middle aged individual, Schneider*—‘‘Should be proven clinically, radiologically, serologically and therapeutically to be free of syphilis’. Our own experience abundantly affirms the correct- ness,of both of these statements. The extent with which the X-ray and properly safeguarded Wassermann tests are used, is of far more than academic interest ; because the life and efficien- cy of a very large number of people depend up- on the accuracy and intensity with which the average doctor examines the average patient. There are few disease states in which the pathology has been worked out so definitely as syphilitic aortic disease. Yet, at the two ex- tremes—its terminal stage and its incipiency —there are few conditions more often mis- judged; aortic aneurysm in its various stages masquerades as bronchitis, asthma, tuberculosis, malignancy, ete.; or, in those with beginning substernal oppression and in the curable stage are either designated a neuralgia or a neuras- thenia.

Little mention was made of the use of the X-ray in diagnosis until about 1905. Bab- cock’s. book’, published in 1903, refers to the X-ray as ‘‘useful in certain cases’’, Salinger’s translation of Leube’, scarcely mentions the X- ray at all. C. L. Green’s diagnosis’, published in 1907, ends the discussion strikingly by stat- ing: ‘‘The last 20 cases of thoracic aneurysm coming under the Author’s attention, have been subjected in each instance to the X-ray, and without it fully 50 per cent would have gone unrecognized’’. Osler himself wrote the article for ‘‘Osler’s Modern Medicine’, published in 1909. In it he devoted 52 pages to a discussion of the general aspects of the disease, and only one brief page mentioning the possibilities of the X-ray. He had, however, the great gift of prophecy, and evidenced it by dividing his

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