A RARE CASE OF ACCESSORY RIB HUGO A. FREUND, M. D. Rare anatomical specimens of malformations, faulty development, or accessory parts, are reported every now and then from large pathological institutes or from dissecting rooms. For many years Wenzel Gruber conducted a section in Virchow's Archives where he published accounts of some remarkable anatomical curiosities that he had, from time to time, collected from the large material, dissected in St. Petersburg. Though unusual specimens are reported from every system of the body, probably none claim more oddities than the skeleton. The bony framework, both from its embryology and comparative morphology, permits of many anomalous formations. Especially is this true of the thoracic cage where reversions and clefts are frequently seen. Perhaps the most common costal anomaly is the supernumary rib, either cervical or lumbar. The former is sometimes of clinical significance, in that it is mistaken for other structures or it gives the individual a peculiar appearance. There are innumerable reports of accessory ribs covering series diagnosed during life, found at operation, or met with on the dissecting table. Next in importance come cleft ribs, of which there are many instances on record. These clefts extend a variable distance back from the sternum and the two ends articulate separately. Pepper records a case of bifurcation of the fourth rib on the right side, two and one-half inches from the stenum. Stru From the clinic of Internal Medicine, University of Michigan, George Dock, M. D., Director, thers cites several cases of bifurcated ribs with more than one articulation with the sternum. Of cases of union between two ribs those in which there is a flat plate (with perhaps only a slight groove) are occasionally seen. Scott reports a rare instance of a bony outgrowth extending from one rib, running to and uniting with the other by distinct articulation. The anomaly that I wish to report differs from any that I have been able to find mentioned in the literature exceping one-a somewhat similar case reported by Gruber in Virchow's Archives. In this case the anatomical specimen was that of a deeply forked third rib on the left side, which had no counterpart on the right. It had no articular surfaces. (The text shows a fair picture of his specimen.) What adds interest to the case here reported is that it was disclosed during life by a radiograph made for the purpose of detecting early pulmonary tuberculosis. expanded less than the right. The left apex was about one-half centimeter lower than the right and the percussion note slightly higher pitched. The vesicular breathing was markedly diminished and the expiration was prolonged. The whispered voice was better heard on the left side down to the first interspace. A few crepitant supra-clavicular fossa. and sub-crepitant rales were heard in the left There was a slight cough occurring mostly in the morning. No other symptoms. The sputum was copius in amount and contained many alveolar and epithelial cells. No tubercle bacilli found after several examinations. At this time the patient was able to be taken from her room and a radiograph was made. In addition to the slight density of the left apex, the presence of an additional rib on the right side was seen. All the pairs of ribs were normally attached and articulated with the vertebral column. Springing from the upper surface of the sixth rib, about seven centimeters from the median line, a small protuberance could be seen. Joining this by what appears to be a separate and distinct articular surface, an accessory rib springs and courses downwards and around the thorax between the fifth and sixth ribs. Its course in the anterior part of the body cannot be seen. On examination of the sternal articulations each rib joins separately. Moreover, there is no fusion of costal cartilages. Still the ribs on the right side lie much closer together anteriorly and apparently there is one more costochondrosternal joint on the right than on the left side. The left side has no structure corresponding to the extra rib. Moreover, there are twelve distinct ribs on the left and thirteen on the right. This can be easily demonstrated on the radiograph or on the patient herself, where the ribs are easily counted. On palpation of the back, on the right side just within the angle of the scapula, a small protruberance can be felt, but the extra rib coursing from it is not palpable. It would be difficult to explain the formation of this anomaly on any other basis than that of a cleft. Early in the formation of the sixth rib when it existed merely as a small protruberance, a longitudinal cleft must have occurred. which extended as the development of the rib proceeded. Finally, when ossification set in, the divided rib took its position between the true fifth and sixth ribs. Whether a simple diarthrosis exists between the head of the extra rib and the tubercle arising from the sixth rib, can only be conjectured. From the distinctness of its outline and from its shape it would appear as if a ball and socket joint had developed to allow for freedom of motion with respiration, inasmuch as the direction of the articular surfaces differs from that of any other in the thoracic cage. The anomaly is an unusual one and finds no exact counterpart in medical literature. It is only with the X-ray that the diagnosis of such a condition is possible ante-mortem, for physical examination does not often lead us so minutely into the close inspection and palpation of the bony framework. I am indebted to Mr. Vernon J. Willey for the excellent radiograph which he placed at my disposal. REFERENCES. (1) Gruber-Virchow's Archives, Bd. 78, p. 98. "Ein Beispiel-tief gefurchten Rippe...." (2) Pepper-American Journal of Medical Sciences, 1867, iv., p. 148. (3) Scott-Journal of Anatomy and Physiology, 1878, xii., p. 577. (4) Sandefort-Museum Anatomicum, XLVII. Plate (5) MacDonnell-Journal of Anatomy and Physiology, xx., p. 405. (6) Struthers-Journal of Anatomy and Physiology, ix., p. 17. "Variations of Vertebrae and Ribs in Man," The Journal of the Michigan State Medical Society All communications relative to exchanges, books for review, manuscripts, advertising and subscriptions should be addressed to B. R. Schenck, M. D., Editor, 502 Washington Arcade, Detroit, Mich. Subscription Price, $2.00 per year, in Advance. OCTOBER Editorial Medical Organization and the Insurance Companies. Medical organization has accomplished much during the last five years, but we are, nevertheless, just beginning to realize the immense influence which a united profession can exert, provided only that the influence be directed toward things which are right and just. When certain of the old line life insurance companies, in their campaign of economy, reduced the fee for examinations from $5.00 to $3.00, an undoubted injustice was done, not only to the physicians who make the examinations, but also to the policy holders of the companies. Doubtless the ordinary examiner will make as complete and thorough an examination for the lower fee as for the higher, providing he consent. to continue-an argument which the companies have repeatedly used-but that, it seems to us, is not the point. The reduction in the fee results and has resulted in the resignation of good men all over the country and the employment in their places of men who are inferior, men at least who put a lower valuation on their services, which in ninety per cent of the instances means inferior men. That the companies should dictate the fees which the profession shall receive naturally aroused much indignation, and resulted in a protest so widespread that several companies have apparently been convinced of the injustice, or perhaps poor policy, of the reduction and have returned to the old schedule. Recently the Equitable Assurance of New York, the Union Central of Cincinnati, the Fidelity Mutual of Philadelphia, and the Mutual Life of New York, have restored the old fees. The letter of the Mutual Life is as follows: New York, July 23, 1907. Circular No. 88. Dear Doctor:-I am glad to announce to the Medical Evaminers of the Company that on and after Aug. 1, 1907, the company will pay a fee of $5 for each completed examination for new insurance, irrespective of the amount of insurance applied for. This has been rendered possible by rigid economy in other directions, whereby a saving in the expense of obtaining new business has been effected of sufficient size to warrant this step. All extra allowances for mileage, obtaining additional information, urine, etc., will be abolished, beginning August 1. The fee for a microscopical examination of the urine will be $5, as heretofore, but this will only be made when directly called for by the company. The fee for a certificate of health for the restoration of a lapsed policy will be $2 unless a full examination is called for, in which case it will be $5. Very truly yours, BANDRETH SYMONDS, M. D., Medical Director. In order that our readers may discriminate between $5.00 and $3.00 companies, the following list of $5.00 companies, doing business in Michigan, is appended. This list has been compiled from good authority, but we shall be glad to make a note of any errors which may exist: Aetna, Hartford. Connecticut Mutual, Hartford. Manhattan, New York. Massachusetts Mutual, Springfield. Mutual Benefit, Newark. New England Mutual, Boston. Provident Life and Trust, Philadelphia. State Life, Indianapolis. that the practice of repeating is not of a high moral order. Those who are guilty of it sometimes have difficulty in offering their wares to the best periodicals. On the part of editors, great caution is observed and much work is necessitated in keeping their pages free from such repeaters. Therefore, it would seem that, for the sake of both the author and the editor, this undesirable habit of repeating should be abated. Apropos of the optometry bill which was introduced in the Michigan legislature last spring, and which was not reported out by the Committee on Public Health, the action of Governor Hughes, of New York, in vetoing a similar bill is of special interest. As in our own state, the matter had been up at successive sessions in New York and the bill defeated either in committee or on the floor. This year, however, despite the strenuous objection of the legislative committee of the state medical society, the optometry bill was passed. Governor Hughes, however, vetoed the bill, and in doing so, filed the following memorandum: Repeaters in medical literature are common to a certain class of medical journals, which take no pains to reserve their pages for original or exclusive articles. By repeaters we mean the publication of a paper in numerous journals, thus assuring a wide circulation. Physicians of skill and wide reputation have occasionally indulged in this practice, but those who are most careful avoid it. Moreover, the best medical publications will print articles only when assured that they are not to appear or have not appeared in other journals. Even with this restriction there is no dearth of medical writings. Every article presenting original matter is indexed in the library of the Surgeon-General's provided that the prescribed course of profes office at Washington. There it is best known who are the men perpetrating repeaters and which are the journals fostering them. Editors who look over their exchanges carefully have also the same knowledge. There is probably no intrinsic wrong in multiple publication of one article; if a man desires the advertisement, he undoubtedly has a right to it. But intrinsic right and wrong do not rule men's opinions and there is a feeling abroad. It is the intent of this bill that the board of examiners in optometry, to be appointed by the Board of Regents, shall be selected from those nominated by the Optical Society. It is also sional study in schools of optometry shall be had in such schools as maintain a standard satisfactory to the board of examiners. These provisions remove from the jurisdiction of the Board of Regents matters which it is important should be placed in their control. If the practice of optometry is to have the recognition and regulation contemplated by this bill the appointment of examiners should not be limited to those nominated by a particular society, and the determination of the standards of professional schools should be unequivocally left to the proper state authority. This is the policy established by the law enacted this year regulating the practice of |