N THE course of a neurological and psychological study of children showing I low arithmetic achievement in comparison with their other educational attainments, we examined a boy who presented a very marked discrepancy in this respect. Clinically, one of his outstanding peculiarities was found to be "finger agnosia."This clinical anomaly was first pointed out by Gerstmann in Vienna in 1924. He discovered that certain individuals were unable to recognize, indicate on request, name, or choose with open eyes, individual fingers either of their own hands or the hands of others. This disturbance Gerstmann called "finger agnosia." He regarded finger agnosia, right-left disorientation and impairment of writing ability (so-called agraphia) as the essential elements of the new syndrome with which deficiency in number operations (so-called acalculia) is loosely associated.' Since Gerstmann's contribution, cases of finger agnosia have been reported by Hermann, Potzl, Lange, Muncie and others.2 The defect in finger recognition is present in different degrees in individual patients. As is true of any kind of agnosia, the appearance of the disturbance fluctuates from day to day; it may be more severe on one day than on another, and sometimes may even become unnoticeable. It is usuallyonly demonstrable in the middle fingers; the thumb and the little finger are the least affected.Due to anatomical findings of tumors and hemorrhages when these cases come to autopsy, the view is generally held that this defect is caused by a lesion within the area around the angular gyrus in its transition to the second occipital gyrus. We are in accord with Gerstmann's interpretation that here we are dealing with * From the Section on "Problems and Results in the Treatment and Training of Mentally Defi-
The internist confronted with chronic jaundice in a young patient usually diagnoses it as catarrhal jaundice. If he encounters it in an older patient, he is likely to consider it as due to carcinoma of the head of the pancreas.The surgeon, on exploring, may find no carcinoma at the head of the pancreas and no stones in the common duct. He then usually performs a cholecystectomy, or a cholecystectomy and drainage of the common duct, or he decides that he is dealing with intrahepatic cirrhosis with jaundice and closes the abdomen without further intervention. We believe that in such cases the condition is due to an infection which begins as duodenitis and ascends the pancreatic and common ducts. This triangular infection produces inflammation and hypertrophy of the ampulla of Vater, which in turn give rise to spasm and obstruction of the common duct, biliary stasis and ultimately a breaking down of the liver cells and cirrhosis.As proof that our contention is correct we present twenty-two cases in all but two of which cures followed when we did away with the obstruction in the common duct and side-tracked the infection by choledochoduodenostomy and gastro-enterostomy. In seven other cases we obtained cures by the following surgical pro¬ cedures : in four by drainage of the common duct alone ; in one by gastric resection and cholecystoduodenostomy, and in two by choledochoduodenostomy alone. In these twenty-nine cases the destruction in the liver had not proceeded so far that regeneration could not take place when the obstruction in the com¬ mon duct was relieved. The remaining ten cases were found in patients so critically ill that only drainage of the common duct could be attempted. These ten patients died of the disease within two years. It is clear, therefore, that as regards surgical intervention the element of time is of great importance. We arrived at our analysis of the condition and at the method of treating it somewhat fortuitously.In 1918 we operated on a man, aged 38, who had been deeply jaundiced for two months and who had had mild attacks of pain in the region of the liver. He was emaciated and had the appearance of one suffering from a carcinoma of the head of the pancreas. At operation, we found a mass at the head of the pancreas having the appearance of a small carcinoma. The gall¬ bladder was markedly inflamed and distended, which threw some doubt on the diagnosis of carcinoma. The Because of lack of space, the article is abbreviated in The Journal by the omission of some of the illustrations. The complete article appears in the authors' reprints. common duct was likewise markedly distended. In preference to anastomosing the thickened and inflamed gallbladder to the stomach, the gallbladder was removed and a choledochoduodenostomy was performed. When the common duct was opened, we found definite thick¬ ening and narrowing (edema and infiltration) at the ampulla, and when the duodenum was opened for the purpose of the anastomosis, we saw a large, swollen, reddish, nipple-like projection where the pa...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.