Clinical Lecture on Antiseptic Osteotomy for Ankylosis and Deformity
BMJ (Clinical Research Edition)
May 25, 1878.] THE BRITISH MEDICAL. _URVAL. 747 strengthening of the elastic coat by this .hypertrophic thickening, the elongation and tortuosity of the arterioles would be much greater than they are. The tortuosity of the hypertrophied renal arterioIes is well shown in my first illustration of this subject (Med.-Csir. Trans., vol. xxxiii, p. i i4), a copy of which-is here given. (Figs. I and 2.) Fig. I--Portion of Renal Artery in the normal state, showing the relative thickness of its coats.
... ess of its coats. c. Circular fibres. /. Longitudinal fibres. Magnified 200 diameters. In a leading article in the JOURNAL of April 6th, reference is made to Dr. Ewald's paper in Virchow's Archiv on the Changes in the Arterioles in Bright's Disease. Dr. Ewald appears to have looked for hypertrophy of the arterioles in the pia mater alone, and therefore his Fig. 2.-Portion of Artery from a Granular Kidney, showing great hypertrophy of its coats. c. Circular fibres. Z. Longitudinal fibres. The canal of the vessel is filled with injection. Magnified 2co diameters. observations are incomplete, and insufficient to support the objections which he raises to my explanation of the relationship between the arterial and the cardiac hypertrophy. In the cases in which he found hypertrophy of the heart without hypertrophy of the arterioles of the pia mater, it is probable that the arterioles in other tissues, more espe. cially in the skin, may have been sufficiently hypertrophied to explain the cardiac hypertrophy; and, on the other hand, it is obvious that hypertrophy of the arterioles of the pia mater without arterial hypertrophy in other tissues would not cause cardiac hypertrophy. Therefore arterial hypertrophy limited to the pia mater may be unassociated -with hypertrophy of the left ventricle. In reply to Ewald's argument, that " the absence of cardiac hypertrophy in amyloid and atheromatous thickening of the arterioles is against the vascular changes as causes of the heart-affection", I beg to say, as I have often said before, that, while this shows that mere degeneration of the walls of the arterioles, with consequent loss of contractile power, is not the cause of the hypertrophy of the heart, it is entirely in accord with the view that arterial contraction and resistance, with resulting arterial hypertrophy, are the main cause of the hypertrophy of the left ventricle associated with chronic renal disease. Ewald's theory, that the resistance which causes the arterial tension and the cardiac hypertrophy originates in the capillaries, and not in the contracting muscular arterioles, appears to me to be inconsistent with the facts and with. the doctrines of vasomotor physiology. It is suggested that the polyaria of granular kidney is the result of increased pressure on the Malpighian capillaries consequent on capillary obstruction in front. To this I object, that increased pressure on the Malpighian capillaries would cause, not a copious secretion of urine, but an abundant transudation of albumen; whereas we find that, in cases of granular kidney with the evidence of high arterial resistance afforded by the great hypertrophy of the arterioles, albumen in the urine is rarely copious, usually scanty, and sometimes entirely absent. On the other hand, we have the clinical fact that when, as a result of valvular disease of the heart, the return of venous blood from the kidney is impeded, the increased pressure on the Malpighian capillaries is associated with a scanty secretion .of highly concentrated urine, which, too, is often copiously albuminous. It appears, then, that the effect upon the urinary secretion of an impediment in front of the Malpighian capillaxies is the exact opposite of that which the theory in question assames it to be. DR. MENZEL of Trieste, a surgeon who had already gained for him. self a considerable reputation, has recently died at the early age of 32. While attending the Congress of German Surgeons in Berlin last month, he was attacked with htemoptysis, and, after a brief illness, died of acute phthisis in the Augusta Hospital. He was one of the most eminent disciples of Billroth's school. [Concluded fromt siage 707 of last numzbet.] GENTLEMEN,-A few words remain to be spoken concerning a different deformity, which I have kept for separate consideration, because of late some curative operations, with which I will contrast my own, have been introduced. The ordinary knock-knee, or genu vasgum-a very common deformity-is always accompanied by obliquity of the femoral condyles, in such manner that the inner lies on a plane lower than the outer. I say accompanied by, and not, as is usually said, produced by, because I conclude from the great lateral looseness of the knee-joint that a certain yielding outwards of the tibia is likely to be the primunt mobile of the deformity, and the faulty growth at the lower end of the femur, a secondary condition, superinduced by changes in the amount of pressure. I conceive, then, the malady not as a mere lengthening of the inner condyle, but as an obliquity of the whole lower epiphysis, caused by increased thickness of the entire epiphysal mass on the inner, or decreased thickness on the outer side. However this may be, it is certain that when the deformity is fully developed, the exaggerated projection downward of the internal condyle-in other words, the obliquity of the joint-surface-is the obstacle to rectification of the limb. The problem of surgery is to discover the best and safest method of overcoming or evading this obstacle. Examination of the results obtained or not obtained by instrumental treatment, criticism of some earlier operations, such as cutting out a piece of the tibia, even sawing off the lower end of the femur, lie beside my purpose: I only wish to direct attention to the operations of Dr. Ogston (Aberdeen) and of Dr. Macewen (Glasgow). Dr. Ogston's method consists in passing a knife, then a saw, obliquely from above the inner condyle into the knee-joint, over the anterior surface of the femur, to midway between the two condyles: the inner one is then very nearly sawn off from before backward ; the thin remaining portion of bone is broken by forcing the tibia into its normal position; and the condyle, thus pushed up on the fe6mur, is allowed to attach itself in the new position (Eminbxrgk Medical uornal, 1877, p. 782-; Langenbeck's Archiv, vol. xxi, p. 537). Dr. Macewen's meth6d is thus described:-" An incision was made over the inner condyle of the right femur, the centre of Nwhich corresponded with the upper part of the condyle, the object being to go as near the knee-joint as possible without opening it. A V-shaped portion of bone was struck out by the chisel from the inner side of the condyloid extremity of the femur; the remainder of the bone was broken, and the limb was brought round straight."* (Lancet, March 30th, i878.) Both these operations appear to me more severe than the exigencies demand. Of Dr. Macewen's, it is to be observed that two of the three cases suppurated, and under such circumstances there would seem to be some danger of extension of the inflammation, to the knee-joint. From the description given in that gentleman's paper, and quoted above, it is difficult to make out in what direction the triangle of bone is struck out; but I suppose it to be horizonltal. If I be correct in this supposition, the section would, I think, of necessity interfere with the epiphysal function, thereby in all probability affecting the subsequent growth ofthe limb.t Dr. Ogston's operation is also rather severe-even, it would seem, * In his paper, Dr. Macewen claims to be the first in England who performed antiseptic osteotomy. I am not concerned here to dispute the assertiop, which, although his case has only just been published, is doubtless correct. I would, however, point out that, in his osteotomy for ankylosis of the knee he cut out a wedge of bone from the front of the femur. This procedure is not only different to mine, but is one that I deprecate as unnecessarily severe. Nature supplies a wedge of new bone to fill up an angular gap left between a deflected straight section with much greater precision than that with which a surgeon can cut out a piece to avoid a gap: the limb will not be shortened, and the bone will heal much more quickly and sMtely a mere straight division be made. t While the above was in .press, I have received a note from Dr. Macewen, in which he informs me that the incision in the soft parts is vertical; the wedge-shaped piece of bone is oblique, sometimes horizontal.