TRANSPLANTATION IN FRESH FRACTURES

No matter what method of reduction we may employ, a large number of our fracture cases will show more or less shortening. I believe that, when the röntgenogram shows a marked overlapping of fragments with considerable shortening, the case should be treated surgically. Then, instead of metal plates, autoplastic transplantation will afford a perfect reduction, with no shortening and with assured union.

I employ Albee's technic. The fracture is exposed by a generous incision in the soft tissues, always keeping in mind the anatomic relations of important blood-vessels and nerves. A gutter about 4 to 6 Cm. long is cut on one fragment and about 3 to 4 Cm. on the other. The long transplant is made to lock over the fracture; the short one I place in the remaining gap. The transplants are held in place with kangaroo tendon sutures applied according to described technic. Immobilization is obtained by means of a plaster-of-Paris cast.

TECHNIC OF SPINAL TRANSPLANTATION IN POTT'S DISEASE

The excellent results obtained by Albee in the treatment of Pott's disease by the use of a spinal autoplastic transplant have been so convincing that the entire surgical profession has become enthusiastic over this procedure.

While the field of application is necessarily restricted to early cases, before ankylosis and excessive spinal curvature have developed this procedure is of great merit in properly-selected cases. Obviously, it can be of no benefit in the correction of a deformity of many years' standing; it is essentially a procedure to effectively prevent the deformity.

The seat of operation (the affected portion of the spinal column as determined by the röntgenogram) is exposed by a liberal incision in the soft parts over the spinous process of the vertebræ. With the aid of Albee's twin motor saw, a gutter is cut in each spinous process in as many vertebræ as it may seem necessary. An osteoperiosteal transplant, cut with the same saw, so as to be the exact size of the gutter, is now cut from the tibia and applied in the gutter bed. The transplant is secured with kangaroo tendon sutures through properlydrilled holes. The soft parts are closed, secundum artem. A plaster-ofParis jacket is usually applied, or a perfect immobilizing brace can be used.

GENERAL CONCLUSIONS

1. Autoplastic bone transplantation can be said to be one of the most useful and successful procedures in modern surgery.

2. From all the experimental work and clinical observations, it remains proved that the periosteum is of the highest importance in transplantation. This is clearly demonstrated by the fact that transplantations done with bone and periosteum are successful in 98 to 100 per cent. of cases, while those done without periosteum are successful only in 41 per cent. of cases. The controversy as to whether periosteum has or has not a distinct osteogenetic function is of no great importance in the face of such marked clinical evidence.

3. In the treatment of ununited fractures, autoplastic bone transplantation is not only always successful, but gives us the means to overcome the shortening of limbs, which is by far the most marked deformity.

4. Autoplastic bone transplantation in fresh fractures is the best procedure to secure immobilization and perfect correction with assured union, superseding in the majority of cases all foreign bodies, such as steel plates, screws, etc.

5. Autoplastic osteoperiosteal transplantation gives us the means of saving many limbs and correcting many deformities.

I want to emphasize the importance of the great fundamental principles that will secure success; namely, perfect asepsis, careful hæmostasis, and accurate immobilization, with strict adherence to technical details described.

ABNORMAL CONDITIONS FOUND IN OPERATING FOR

FIXATION OF MOVABLE KIDNEY

BY SIDNEY F. WILCOX, M.D., F.A.C.S.
New York

A MOVABLE kidney is usually a healthy kidney, so far as its structure is concerned. The symptoms which arise from its mobility are due to interference with its function. This interference may, later on, induce conditions which may be considered pathological or, at least, abnormal.

In a series of over two hundred cases, many of them bilateral, in which I have operated for fixation of the kidney, four abnormal conditions have been met with.

Hydronephrosis, while not uncommon, is rarely met with during the operation, because the manipulation necessary to bring the kidney into view is likely to undo the kink or twist in the ureter and allow the imprisoned urine to escape into the bladder (Fig. 1).

Kinking of the ureter, with its train of agonizing symptomsordinarily known as "Dietl's crisis"-is not an unusual condition where the kidney has attained a considerable degree of mobility, and the symptoms are often ascribed to causes other than the true one.

I have seen the subjective symptoms closely simulate the passage of biliary calculi, except that the attacks were of short duration and occurred with greater frequency than in a gall-stone case and, of course, were not followed by jaundice or finding the calculi.

Many cases of Dietl's crisis are mistaken for attacks of appendicitis, and I have been called a hundred miles to see a case where appendicitis had been diagnosed and immediate operation urged, to find that all the symptoms had disappeared immediately on a change in position of the kidney. I am of the opinion that many healthy appendices have been removed under a wrong impression as to the true cause of the symptoms.

In operating on one case for a palpably displaced kidney, where the patient was suffering great pain, an expansion of the renal end of the ureter was found which held over a pint of urine. Aspiration of the fluid was necessary before room could be had to manipulate the organ and secure it in the loin.

In one case an unsuspected abscess was found on cutting down upon the displaced kidney. It is possible that a more skilful urinalysis might have established the diagnosis. However, there was no question as to the displacement of the organ. Fixation and drainage led to a cure.

In one case of bilateral operation both ureters were found wrapped once around their respective kidneys like the single turn of a thread around a spool. In another case one kidney was so affected (Fig. 2).

In a number of cases where the reflex symptoms have been severe and of long standing fissured kidneys have been found. In these cases the kidney resembles a beef kidney, with fissures or grooves running irregularly over its surface. These fissures are caused by a cordlike thickening of the fibrous capsule. These cords are like an irregular network incorporated in the sheet of the capsule, and they cut into the cortex of the kidney. In some cases they are so tightly adherent to the kidney that some force is required to strip back the capsule, and sometimes even causing slight laceration and bleeding (Fig. 3).

That movable kidney may produce many serious reflex symptoms cannot be doubted by one who has had much experience. On the other hand, there are cases who suffer but little. As a rule, however, the very fact that the patient presents herself for examination proves that she is suffering from some cause or another, and I know of no other condition that can give rise to more and more varied reflex symptoms than a movable kidney, and the severity of the symptoms is not always proportionate to the degree of mobility of the organ. At the same time, the importance of concurrent enteroptosis, diseased appendix, uterine retroversion, and other abnormal conditions should not be underestimated.

The benefit received from operation in suitable cases is often remarkable, and I know of no operation which is followed by a greater proportion of satisfactory results than nephropexy properly performed and followed by a sufficiently long rest in bed. I believe that the failures to obtain good results come largely from allowing the patient to get up too soon, and for that reason I insist on five weeks in bed and an additional week in the hospital. This is necessary, not for the healing of the wound, but to allow the new adhesions to become firm.