PRELIMINARY NOTE ON TWO CASES TREATED BY RIB TRANSPLANTATION

W. I. D. C. Wheeler
1915 BMJ (Clinical Research Edition)  
T9I5 288 MDICAL JouRt'NkL ] I-F B 13 1(I5 as he had done on the previous occasions, and I drew off cerebro-spinal fluid. As tlle fluid canme axway the pulse gradually becanie weaker ; wlhen 12 c.crn. lhacl come away tlle puls3 wyas iimiperceptible at tlle wrist ; we then stopped, and injected 8 c.cm. of tlle antitoxin. As this was done the pulse again appeared at the wrist. The remainder of the pliial of serum was injected sub-eutaneouLsly. He did not sleep at all tllat night, and on the
more » ... of January 17th the nurse gave hlim an injection of pituitary extract, as his condition became very bad. We found him later -quite unconscious, with scarcely perceptible pulse, 150 to the iiiintute, and the head still m-iore retracted. The anterior chamber of the left eye now containied tlhicl, curdy-lookiing pus. He was again injected witlh lhalf a million of hiis autogenous vaccine. The eveninig of the sanme day he was again seen by Dr. Diglhton, who fotund hlim extraordinarily improved; he was able to take food by the mouth, was rational, and looked as if he was now really going to recover. At 4 o'clock the niext morning, Janiuary 18ti, lie took a stidden turn for the wVorse, became cyanosed, the pulse faile(i and lie died the samiie nmorninog. Tlhe oiily commiuent I liave to nalke on the case is that we were disappointed withi thle antimeniingococcic serium, wlhich, as far as we could jucige produced no clinical iniprovemlent. On thle two occasionis on whiich the vaccine was giveni-a.notable imuprovement followed. --Th1e sterilization of the vaccine was effected by lieating to 58-C. for tliirty-minutes. Two recelnt cases of transplantationi of bonie hlave iipressed on me the usefulness of portion of a rib as a transplant instead of the anterior crest of the tibia, which is muore usually employed. CoIngenttial Disloca tO the -Hip. I11 tllis case tLe Child, aged 4, was treateCd uInsuccessfully by Lorenz's Ineth1od. The followilng operation was performed on March 5th1, 1914, thiroughi Kochler's posterior incision. The upPer and posterior rim of the acetabuluRm was freely exposed, and the bone in tlhis region freshened by liglht touches of a gouge and chisel. A finger-lengitlh of onle of the upper ribs was removed in a position where tlle curve seemed suitable for re-eniforcing', and deepening tlle posterior portion of the acetabuluni. Before redcLction of the dislocation tllree sinale suturies of fine alurninium bronze wire were passed tlhrougalh the bone in the requiired position witlh a strong. fully curved needle. The hiead of the bone was tlen levered into place and the )ib fixed with its centre at the point wlhere the head of the bone appeared to escape miiost easily from tlle socket. Skiagrams taken at frequent intervals showed, first, the rib in good position; afterwards it almost disappeared, and later still a 'well-defined slhadow marked the position of tlhe. transplant. The head of the bone, judgino by the skiagranis, did not appear in the best position, and the joint wvas again exposed througlh Murplhy's "goblet" incision eiglht nonths after the first operation. rlhe lhead was fotund, after rotation of the leg inwvards, to be in norm:ial relation to the acetabuluin, and thse latter slhowed an excellent formation of new bolne deepening tlhc socket considerablv at the site of introdLuction of thle rib. Tlhe shape aind size of the elw bone corresponded in a large imeasutre to the original tranisplant.. 1odificat-iom of the Albec Op)eratiod, fi?r S1piaal Caries. In tllis case the clhild, aged 5 years, was operated upon on January 19tll for ever-increasing kyphosis in the luiddorsal region of the spine. Slhe lhad been treated witlhout stuccess since May, 1914. Absolute rest withi extenision oni a Wllitman's splint and subsequently witlh a spinal jacket did not arrest the progress of the disease. Skiagrams showed active caries in tllree vertebrae. An incision was inade slightly to one side of the spines of the vertebrae aiid carriedI wvehh above anId below theQ dlisease. The laminae and transverse processes were cleared of tthe soft tissues and tlhe exposed bone freshene(d with Jones's arthrodesis gouge. The articulations of the adjacent ribs were freely exposed. A superficial horizontal incision approximately at right angles to the vertical incision was carried forwards in tlle direction of thie ribs. The erector spinae muscle and dense aponeurosis was carefully preserved and pulled backwards. Tlle rib was divided with bone forceps just outside tlle articulation anid was easily separated forwards under the muscle to tlle required length and remnoved. The cutrve of the rib suited admirably the kyplhotic curve of the spine. The rib was laid on the freslhened bolne and lheld firmily in' position by interrupted suttures of catgut tlhrotugh tlle divided soft parts. Thle fragmuents of boiae (detaclhecl during the freshening of the vertebrae were carefully preserved and placed deeply in the wound. The application of thle graft alongside of the spinons processes after Jones's metlhod, instead of tlle original plan of splitting the spinious processes to receive it, and. the procuring of the transplant from thle operation area witlh very little addition to thle original incision, mllade tlle operationi simple and rapid. The size and slhape of the graft, as in the first-mientioned case, was adtmlirable. In botlh cases, in trying to save the periosteumii of thle rib, the pleuira was in;juced, but at tlle time of operationl it was obviotus that this was avoidable and in nieitlher case did the patient suiffer an-y ill effects froml the developn-ient of transient pneuumlotlhorax. MIEDICAL, SURGICAL, OBSTETRICAL. SUGGESTED FORM OF TREATMENT FOR TETANUS.* THE bacillus of tetaanus produces toxins wlliclh affect thle nervons system. No doubt the toxin becones incorporated with the nerve centres-it passes to tlle nerve centres, not by way of the lymphatics of the nerve, but tlhrouiglh the plasma of the nerve fibres. I can well imaginie wvly tlhe treatment of tetantus witlh antitoxic serum so freqnclltly fails to cure. Flexner states that Trypanosomna gaar bieense can be ssuppressed by drugs in tlle blood anid lynmph vessels withiout being dlestroyed in the central niervous oroans, and the virtis of poliomyiyelitis prevenitecl from developing through intraspinous injectiolns of ani immune serum tllat is witlhout effect wlhen introduced into tlle blood. I may add that wlhen I Was working on pellagra in Columlxbia, S.C., I gave monkeys subdural injections of a bacillus wvliicl I fonund in the nodes of patients who suffered from pellagra; in twelve hours I made a klumlbar punieture and inoculated ascitic veal brotlh tubes wvitl the cerebro-spinal fluiid which was withdrawn. In tweenty-four lhours I had a vigorous growlth of the sanme bacillus. The treattmient by antitetanus serumi is a general treatment, but wlhat we require is a local treatment to conic into contact witlh the local infection of the nervous centres of the brain antd cord. We certainlly lhave not had brilliant results in treatincg syplhilis of the nervous systemii by inijecting salvarsan inito a vein-in other wvords, bv general treatment-and it is dangerouis to inject salvarsai directly into a subaraclhnoid space. Swift anid Elliott were thie first to employ tlle serum of salvarsan-treated patienits for initraspinous inijectioni, and m-laniy brillianlt results lhave beeni mnet witlh by this aeneralized local form of treatment. As Flexnier remarks, it is known, for examyiple, tllat the cerebro-spinal liquid produces a mueans oL direct and inimediate contact witlh tlhe structutra tissues of the brain; wlhatever clhemical is_ initroducecl into tllis liquid will immiediately find its way to thie suipporting clemelnts-thle nerve cells anid fibres of tlle cortex. Whly not treat tetanius by the same method as sypllilitic diseases of the nerve centres? The cases are parallel. We recogniize the fact tllat the toxin or toxins of the tetanus bacillus are incorporated withi tle nerve centres anid fibres. We know that general treatment witlh aniti-Abridged.
doi:10.1136/bmj.1.2824.288 fatcat:hx7wvojwcnhm3a4rdf3al2yfuq