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CHORDOTOMY IN THE TREATMENT OF OSTEOARTHRITIS OF THE HIP.
378 was no suspicion of osteitis deformans and the only clinical sign, albeit somewhat remote, that could be elicited was that her brother had remarked that she had become " bow-legged." Examination of the limbs by X rays did not reveal any curving of the bones, but there may have been slight alteration of the shape of the necks of the femora.
there
FIG 5.
panied by sclerosis when the inflammation is chronic. On the contrary, when the inflammation is acute sclerosis is absent. 4. The histological and radiographic examinations correspond in general with the clinical findings. 5. The particular image of the bone in the dental radiograms of thecase of osteitis deformans may permit of an earlier diagnosis of this malady.
CHORDOTOMY IN THE TREATMENT OF OSTEOARTHRITIS OF THE HIP.
BY A. S. BLUNDELL BANKART, M.CHIR., F.R.C.S., ORTHOPEDIC SURGEON TO THE MIDDLESEX HOSPITAL; SURGEON TO THE ROYAL NATIONAL ORTHOPÆDIC HOSPITAL AND THE HOSPITAL FOR EPILEPSY AND PARALYSIS, MAIDA VALE.
OSTEOARTHRITIS, particularly when it affects the
is one of the classical diseases of old age, and it is often difficult to treat when palliative measures have failed and the patient is crippled with pain and deformity. It is essentially a senile degeneration of the joints characterised by atrophy and eventual disappearance of the articular cartilage in the centre of the joint, with hypertrophy leading to the formation of osteophytic outgrowths at the periphery. It is therefore a true arthritis deformans, but unfortunately this term has been used to include other conditions besides osteoarthritis. As will be seen presently, the age of the patient is not the sole factor in determining this " senile " type of degeneration, and osteoarthritis, particularly of the monarticular traumatic variety, is often seen in comparatively young subjects. But most of the patients are at least middleaged or elderly and, it may be remarked, unsuitable for drastic surgical operations upon the affected
hip-joint,
joints. During life the joints are not passive pieces of transformation. mechanism, but living structures which react to use like other living tissues. Every functional use of a The skiagram of the skull showed a suspicious thickening joint is in a sense an injury-that is, friction and of the vault, but the change was not sufficient to warrant a pressure tend to wear away the opposed articular diagnosis upon that alone. Microphotograph of cancellous bone. x 90. The trabeculae irregular and the medullary spaces have undergone a cystic
are
The slide (Fig. 5) does not show all the characteristics of bone subject to this disease, perhaps because the change is very early, and also because the bone is infected.
surfaces.
This normal
wear
and tear is at
once
made
good by the increased blood-supply and nutrition which always accompanies function in normal ; hence the balance between wear and repair In Specimen 1 there were no signs of inflammation tissues is dependent upon an adequate vascular response to in the bone, and the radiographic appearance was function. If for any reason the vascular response brilliantly clear. In Specimens 2, 4, 5, 6, and 7 there in a joint is deficient, so that the process of repair was lymphocytic infiltration of the marrow, excess of to the demands made upon it, the joint is not osteoclasts, and the delicate network of the bone had simply equal to wear out and the cartilage becomes begins become more coarse and the trabeculae thickened and Where the bone trabeculse had become thickened the so-called lines of secondary calcification appeared. In Specimen 3 there was an osteoporosis. The bone trabeculse are finer. The infiltration of the bone-marrow by polymorphonuclear leucocytes is an indication of a more acute inflammation. In Specimen 8 normal bone-marrow was absent. The bone trabeculse were short and in certain sites replaced by fibrous tissue. In this case the lymphocytic infiltration warranted the removal of the teeth. The radiographic image of the alveolar bone in this disease has an appearance quite particular. It resembles that of ground glass. Conclusions. 1. None of the slides revealed micro-organisms. Perhaps bacteriological culture would be necessary to establish their presence. 2. The osseous lesions are those that result from inflammation. 3. The radiographic appearance corresponding to the inflammatory lesions are : (a) Sclerosis, when the trabeculae present the so-called lines of secondary calcification. (b) A haziness of the trabecular shadows when the microscopic examination revealed the signs of inflammatio. (c) This inflammation is accom-
hazy.
worn
away where the friction and pressure are But the products of degeneration act as irritants to living tissues, so that in addition to degeneration in the centre of the joint there is also irritation, which makes itself evident in hypertrophic changes at the periphery where the blood-
greatest.
is still abundant. Thus the characteristic features of osteoarthritis are degeneration leading to atrophy, erosion, and eventual disappearance of the cartilage in the centre of the joint, and hypertrophy leading to the formation of osteophytes at the periphery. In old people the vascular response to function is less efficient than in the young, and often the power of repair is insufficient to make up for the normal wear and tear in a joint, so that the joint begins to wear out. Osteoarthritis is then a polyarticular affection beginning more or less simultaneously in I many joints, although usually some of the larger joints, such as the hips, shoulders, or knees, are most obviously affected first. Naturally, any condition which greatly increases the wear of a joint, such as over-use, excessive weight-bearing in the case of the lower extremities, or repeated injuries, may predispose to or initiate the onset of osteoarthritis. So also any condition which enfeebles the vascular
supply
379
Arthroplasty or reconstruction of the hip, as it is response-for example, arterio-sclerosis, endarteritis, now the fashion to call it, is an attempt to form a or other circulatory disorder-may do likewise. It has already been remarked that " senile new joint which shall be reasonably painless and yet retain some useful movement. The classical operadegeneration is not necessarily confined to the aged, tion of J. B. Murphy has not yet fulfilled the hopes which that interferes with and permanently anything the blood-supply of a joint may bring about similar which he and others entertained for it. The operation changes at a much earlier age. Thus injury suffi- now usually performed consists essentially in excision of the head of the femur and transciently severe to produce lasting effects is a common of more or less plantation of the great trochanter to a lower level on cause of monarticular traumatic osteoarthritis. shaft of the bone, so as to give greater leverage Lastly, osteoarthritis may be superimposed upon the to the muscles attached to it. It is by no means a of chronic such as forms rheumaother joint disease, in an elderly patient, and the results trivial operation toid arthritis, for precisely the same reason, and failure to recognise this sequence has led to endless as regards both the relief of pain and the preservation confusion between these entirely different diseases. of useful movement are uncertain. The operation described by Robert Jones for There is no evidence whatever that osteoarthritis pseudarthrosis at the hip without disproducing properly so-called is due to any infective or toxic
articulation of the head of the femur is seldom performed nowadays. It may give relief of pain, but at Treatment. the cost of great instability. Excision of osteophytes From the very nature of the disease it is obvious from the periphery of an osteoarthritic joint (cheilothat there is no actual cure for osteoarthritis. Exacer- tomy) is utterly useless ; it does not relieve either bations of pain and stiffness may occur from time to pain or stiffness. time and subside with or without treatment. But From the foregoing considerations it is clear that the fundamental pathological changes in the joints the accepted treatment of osteoarthritis of the hip is are permanent and slowly progressive.. extremely unsatisfactory, there being no middle Treatment consists in (a) palliative measures for course between ineffective palliative treatment and the relief of pain and stiffness, and (b) surgical opera- drastic surgical operations for which the majority of tions also for the relief of pain, or less often for the the patients are entirely unsuited. This has induced correction of deformity. Palliative measures, com- me to approach the subject from an entirely different prising various forms of physiotherapy and hydro- point of view-namely, the relief of pain regardless therapy, all resolve themselves into different ways of its local origin. of producing an increase of the local blood-supply, Chordotomy. and their effects usually last just so long as the treatthe dominant feature of osteoarthritis is Clinically, ment continues, or a little longer. Many cases of Pain drives these cases to the surgeon, and osteoarthritis have their teeth, tonsils, and appendices pain. is almost the sole indication for drastic pain operaremoved without benefit to their arthritis, while tions, such as arthrodesis or arthroplasty in this vaccine therapy, founded as it is upon an erroneous disease. If sensibility to pain is abolished in an osteoconception of the disease, is equally futile. arthritic joint, the patient is not only relieved of his It would seem rational to take the body-weight suffering immediately, but he is enabled to recover off a painful hip-joint that is wearing out. But much of the mobility which hitherto has been preelderly patients, especially if they are fat and heavy, vented by pain and muscular spasm. Sensibility to do not take kindly to a calliper splint, and the relief pain can be completely and permanently abolished so obtained seldom compensates them for the added by section of the anterolateral (spinothalamic) tracts discomfort. in the spinal cord at a level above the entrance of In the earlier stages of the disease, before there the nerve roots from the affected part. By this are marked osteophytic outgrowths, much of the pain operation the temperature sense is also abolished, but and stiffness may be due to fibrous adhesions at the that is a small inconvenience if the patient is warned periphery of the joint, and in some such cases a great not to burn himself accidentally afterwards. Tactile improvement may be secured for a time by forcible sensibility is not interfered with. To those who are not familiar with spinal surgery manipulation under an anaesthetic. it may appear that this is an operation at least as severe as those which have been considered above. Operative Treatment. When palliative measures have failed, and the But actually it is not so. The removal of at most patient is crippled with pain and deformity, operative two or three laminse in the dorsal region of the spine treatment may be indicated despite the fact that can be done with hardly any haemorrhage and with of shock, even in an elderly patient, many of these patients are poor subjects for surgical the minimum section of the cord is not necessarily attended while the two interference. are Practically only operations risk. As compared with operations with serious any performed nowadays for the relief of painful osteoarthritis of the hip-namely, arthrodesis or destruc- like arthrodesis and reconstruction of the hip, chordotion of the joint, and arthroplasty or reconstruction tomy is far less disturbing to the patient, while the results hitherto have been remarkable. of the joint. 1. Man, aged 59. Fell on left hip three years ago ; was It is generally agreed that arthrodesis is the surest not laid up, and had no treatment except rubbing with way of relieving pain in the joint. As usually per- liniment. has been painful and getting progressively formed, it is a very severe operation, entailing dis- worse ever Hip since. Walks with a pronounced limp. Left articulation of the head of the femur, the removal great trochanter somewhat raised and prominent. Flexion of the articular cartilage from both the head and the of left hip limited to 40 degrees ; rotation and abduction acetabulum, the replacement of the head, and pro- absent. Constant pain. X rays show advanced osteolonged fixation of the limb in plaster afterwards. arthritis of left hip. Operation, April 18th, 1929 : chordoEven then it is by no means assured that bony tomy. Right spinothalamic tract divided at level of fifth Result: complete loss of sensibility to ankylosis will follow, although the pain is usually dorsal vertebra. to level of left costal margin. Movements of left relieved. The modification of arthrodesis described pain up much increased and quite painless. Discharged by Albee consists in removing approximately the hip 18th, walking well. May one-third the of femoral a head horizontal upper by 2. Man, aged 40. History of contracted hips following cut, leaving a flat surface which is then brought into typhoid 27 years ago. Has scar of old abscess over right contact with a corresponding flat surface cut with a great trochanter ; otherwise right hip is apparently normal. chisel in the roof of the acetabulum. This operation Complains of gradual onset of pain and stiffness in left hip looks very simple on paper-for example, in a flat for five years. Is now in constant pain. Walks with pronounced limp. Left hip palpably enlarged ; all moveskiagram-but most surgeons have found that it is ments much restricted and painful. X rays show impossible to bring the two cut surfaces into contact chronic very arthritis with gross enlargement of head of left without either reducing the diameter of the head of femur and acetabulum. Operation June llth, 1929: the femur or considerably enlarging the acetabulum. chordotomy. Right spinothalamic tract divided at level agency.
380 of fifth dorsal vertebra. Result : complete loss of sensibility to pain up to left costal margin. Left hip can be manipulated vigorously without pain. Movements much freer. Discharged July 10th, walking well.
Conclusions. A great many people are going about in more or less constant pain and disability from osteoarthritis of the hips and other joints of the lower extremities. After spending a considerable part of their lives and fortunes in seeking relief from palliative treatment many of them seek surgical advice on account of the continued pain and disability. The forms of surgical intervention hitherto available-namely, arthrodesis and arthroplasty-are far too severe for most elderly patients, and it is usual to advise operation in such cases only when the pain is intolerable and something must be done. Chordotomy affords a means of giving immediate, complete, and permanent relief from pain in these cases without interfering with the hips or other joints. It is not suggested that chordotomy is a trivial operation which can be lightly undertaken in all cases. But it is a much less severe operation than either arthrodesis or arthroplasty, and since it accomplishes the same object-namely, the relief of pain-more surely and with less risk, I venture to think that it may become the operation of choice in some of these cases.
Clinical THE
it is stored in the liver unchanged. An examination of the liver fats of rats which had received excess of carotin has led the writer to a different conclusion. Albino rats (litter mates), employed in an experiment to demonstrate the absence of vitamin D in carotin, were placed upon the Steenbock rachitogenic diet No. 2965, and were given daily graded doses of a sample of carotin (M.P. 174° in air), which had been prepared from carrots and recrystallised five times from chloroform by the methyl-alcohol method. At the conclusion of the experiment, which lasted 36 days, the livers were minced, digested with 5 per cent. caustic potash, and extracted with ether. The liver fats were obtained by washing, drying, and evaporating the ethereal extracts, and were analysed for carotin and for vitamin A by colorimetric and spectroscopic methods. The data obtained are shown in the Table.
and Laboratory Notes.
RELATION OF CAROTIN TO VITAMIN A. BY THOMAS
MOORE, D.Sc.
(From the Medical Research Council’s Nutritional Attention may first be directed to the striking case Laboratory, Cambridge.) of rat No. 6, which received carotin at the high level of 0’75 mg. daily. Although this amount of pigment, if IN an earlier paperl in THE LANCET I supported the absorbed unchanged, would have been sufficient to claim of Euler, Euler, and Hellstrom,2 that the pigment render the whole rat intensely yellow, it is noteworthy carotin, even after many recrystallisations, possesses that on autopsy the body fat was found to be as colour-
physiological
action similar to that of vitamin A.
Duliere, Morton and Drummond,3 using a fat-free basal diet, subsequently failed to confirm this view, but further investigations by the writer4 and by Collison, Hume, MacLean and Smith,5 in both of which basal diets containing fat were used, furnished a weight of evidence in favour of the intense activity of the pigment, even when in the purest form obtainable. Notwithstanding such high activity, it has been obvious to all investigators that carotin cannot
less
as
that of control animals.
Even in the liver fat
only feeble yellow pigmentation was observed, but on the other hand an unusually intense reaction was given with the antimony trichloride reagent. Since the absorption band observed spectroscopically in the blue solution was situated at 610-630 [L[L (characteristic of vitamin A) and not at 590[L[L (characteristic of carotin), strong evidence was afforded that a proportion of the pigment had been
transformed in vivo to vitamin A. This possibility is supported by the other results be identified with the familiar form of 1 I vitamin A found in cod-liver oil. To reconcile theobtained. The colorimetric units adopted represent common physiological action of substances so different, those amounts of material which when dissolved in a Euler and his colleagues have suggested that vitamin cube of 1 cm. side of either chloroform or the antimony A activity may not be the special property of any trichloride reagent would produce colorations equivaindividual molecule, but may be possessed by several lent in depth to 1’0 Lovibond unit (yellow or blue molecules of the carotinoid type. The factor presentt respectively), when viewed through the cube. 1 mg. in cod-liver oil, for example, may well be a carotinoid ’, of carotin under these conditions contains 1800 yellow derived from marine algee, or possibly a hydrocaroti- or 165 blue units. It will be seen at once that in the noid. On seeking support for this hypothesis, case of Nos. 2 and 3, to which carotin was adminishowever, Euler, Euler, and Karrer6 have found that out tered at less than the minimal physiological dosage, of numerous substances investigated-only carotin and no opportunity for storage was afforded, and the blue dihydro-a-crocetin (a polybasic acid obtained by unit contents of the livers of these rats did not rise the reduction of crocetin, a pigment of saffron) above the level of the negative control rat No. 1. In the case of all three rats (Nos. 4, 5, and 6), which possess growth-promoting power. The case of dihydro-o.-crocetin is surprising, and its received carotin in excess of the minimal dose, discussion may well be postponed until confirmatory decidedly higher values in blue units were observed, evidence has been put forward. With regard to but no appreciable increases in yellow units, such as carotin and vitamin A, however, my preliminary must inevitably have accompanied the storage of experiments, recorded below, have indicated the carotin, were observed. This evidence, considered possibility that the pigment may not independently in conjunction with spectroscopic data, makes it plain exert the same action as the vitamin, but that it may that the high values in blue units shown in these cases act as a precursor capable of giving rise to the vitamin were due to vitamin A. in vivo. The above experiments indicate clearly that carotin Euler, Euler, and Karrer’ have claimed that when does not appear unchanged in the liver of the rat in carotin is administered to rats above a certain level more than minute traces, even when large excess of
possibly
there
FIG 5.
panied by sclerosis when the inflammation is chronic. On the contrary, when the inflammation is acute sclerosis is absent. 4. The histological and radiographic examinations correspond in general with the clinical findings. 5. The particular image of the bone in the dental radiograms of thecase of osteitis deformans may permit of an earlier diagnosis of this malady.
CHORDOTOMY IN THE TREATMENT OF OSTEOARTHRITIS OF THE HIP.
BY A. S. BLUNDELL BANKART, M.CHIR., F.R.C.S., ORTHOPEDIC SURGEON TO THE MIDDLESEX HOSPITAL; SURGEON TO THE ROYAL NATIONAL ORTHOPÆDIC HOSPITAL AND THE HOSPITAL FOR EPILEPSY AND PARALYSIS, MAIDA VALE.
OSTEOARTHRITIS, particularly when it affects the
is one of the classical diseases of old age, and it is often difficult to treat when palliative measures have failed and the patient is crippled with pain and deformity. It is essentially a senile degeneration of the joints characterised by atrophy and eventual disappearance of the articular cartilage in the centre of the joint, with hypertrophy leading to the formation of osteophytic outgrowths at the periphery. It is therefore a true arthritis deformans, but unfortunately this term has been used to include other conditions besides osteoarthritis. As will be seen presently, the age of the patient is not the sole factor in determining this " senile " type of degeneration, and osteoarthritis, particularly of the monarticular traumatic variety, is often seen in comparatively young subjects. But most of the patients are at least middleaged or elderly and, it may be remarked, unsuitable for drastic surgical operations upon the affected
hip-joint,
joints. During life the joints are not passive pieces of transformation. mechanism, but living structures which react to use like other living tissues. Every functional use of a The skiagram of the skull showed a suspicious thickening joint is in a sense an injury-that is, friction and of the vault, but the change was not sufficient to warrant a pressure tend to wear away the opposed articular diagnosis upon that alone. Microphotograph of cancellous bone. x 90. The trabeculae irregular and the medullary spaces have undergone a cystic
are
The slide (Fig. 5) does not show all the characteristics of bone subject to this disease, perhaps because the change is very early, and also because the bone is infected.
surfaces.
This normal
wear
and tear is at
once
made
good by the increased blood-supply and nutrition which always accompanies function in normal ; hence the balance between wear and repair In Specimen 1 there were no signs of inflammation tissues is dependent upon an adequate vascular response to in the bone, and the radiographic appearance was function. If for any reason the vascular response brilliantly clear. In Specimens 2, 4, 5, 6, and 7 there in a joint is deficient, so that the process of repair was lymphocytic infiltration of the marrow, excess of to the demands made upon it, the joint is not osteoclasts, and the delicate network of the bone had simply equal to wear out and the cartilage becomes begins become more coarse and the trabeculae thickened and Where the bone trabeculse had become thickened the so-called lines of secondary calcification appeared. In Specimen 3 there was an osteoporosis. The bone trabeculse are finer. The infiltration of the bone-marrow by polymorphonuclear leucocytes is an indication of a more acute inflammation. In Specimen 8 normal bone-marrow was absent. The bone trabeculse were short and in certain sites replaced by fibrous tissue. In this case the lymphocytic infiltration warranted the removal of the teeth. The radiographic image of the alveolar bone in this disease has an appearance quite particular. It resembles that of ground glass. Conclusions. 1. None of the slides revealed micro-organisms. Perhaps bacteriological culture would be necessary to establish their presence. 2. The osseous lesions are those that result from inflammation. 3. The radiographic appearance corresponding to the inflammatory lesions are : (a) Sclerosis, when the trabeculae present the so-called lines of secondary calcification. (b) A haziness of the trabecular shadows when the microscopic examination revealed the signs of inflammatio. (c) This inflammation is accom-
hazy.
worn
away where the friction and pressure are But the products of degeneration act as irritants to living tissues, so that in addition to degeneration in the centre of the joint there is also irritation, which makes itself evident in hypertrophic changes at the periphery where the blood-
greatest.
is still abundant. Thus the characteristic features of osteoarthritis are degeneration leading to atrophy, erosion, and eventual disappearance of the cartilage in the centre of the joint, and hypertrophy leading to the formation of osteophytes at the periphery. In old people the vascular response to function is less efficient than in the young, and often the power of repair is insufficient to make up for the normal wear and tear in a joint, so that the joint begins to wear out. Osteoarthritis is then a polyarticular affection beginning more or less simultaneously in I many joints, although usually some of the larger joints, such as the hips, shoulders, or knees, are most obviously affected first. Naturally, any condition which greatly increases the wear of a joint, such as over-use, excessive weight-bearing in the case of the lower extremities, or repeated injuries, may predispose to or initiate the onset of osteoarthritis. So also any condition which enfeebles the vascular
supply
379
Arthroplasty or reconstruction of the hip, as it is response-for example, arterio-sclerosis, endarteritis, now the fashion to call it, is an attempt to form a or other circulatory disorder-may do likewise. It has already been remarked that " senile new joint which shall be reasonably painless and yet retain some useful movement. The classical operadegeneration is not necessarily confined to the aged, tion of J. B. Murphy has not yet fulfilled the hopes which that interferes with and permanently anything the blood-supply of a joint may bring about similar which he and others entertained for it. The operation changes at a much earlier age. Thus injury suffi- now usually performed consists essentially in excision of the head of the femur and transciently severe to produce lasting effects is a common of more or less plantation of the great trochanter to a lower level on cause of monarticular traumatic osteoarthritis. shaft of the bone, so as to give greater leverage Lastly, osteoarthritis may be superimposed upon the to the muscles attached to it. It is by no means a of chronic such as forms rheumaother joint disease, in an elderly patient, and the results trivial operation toid arthritis, for precisely the same reason, and failure to recognise this sequence has led to endless as regards both the relief of pain and the preservation confusion between these entirely different diseases. of useful movement are uncertain. The operation described by Robert Jones for There is no evidence whatever that osteoarthritis pseudarthrosis at the hip without disproducing properly so-called is due to any infective or toxic
articulation of the head of the femur is seldom performed nowadays. It may give relief of pain, but at Treatment. the cost of great instability. Excision of osteophytes From the very nature of the disease it is obvious from the periphery of an osteoarthritic joint (cheilothat there is no actual cure for osteoarthritis. Exacer- tomy) is utterly useless ; it does not relieve either bations of pain and stiffness may occur from time to pain or stiffness. time and subside with or without treatment. But From the foregoing considerations it is clear that the fundamental pathological changes in the joints the accepted treatment of osteoarthritis of the hip is are permanent and slowly progressive.. extremely unsatisfactory, there being no middle Treatment consists in (a) palliative measures for course between ineffective palliative treatment and the relief of pain and stiffness, and (b) surgical opera- drastic surgical operations for which the majority of tions also for the relief of pain, or less often for the the patients are entirely unsuited. This has induced correction of deformity. Palliative measures, com- me to approach the subject from an entirely different prising various forms of physiotherapy and hydro- point of view-namely, the relief of pain regardless therapy, all resolve themselves into different ways of its local origin. of producing an increase of the local blood-supply, Chordotomy. and their effects usually last just so long as the treatthe dominant feature of osteoarthritis is Clinically, ment continues, or a little longer. Many cases of Pain drives these cases to the surgeon, and osteoarthritis have their teeth, tonsils, and appendices pain. is almost the sole indication for drastic pain operaremoved without benefit to their arthritis, while tions, such as arthrodesis or arthroplasty in this vaccine therapy, founded as it is upon an erroneous disease. If sensibility to pain is abolished in an osteoconception of the disease, is equally futile. arthritic joint, the patient is not only relieved of his It would seem rational to take the body-weight suffering immediately, but he is enabled to recover off a painful hip-joint that is wearing out. But much of the mobility which hitherto has been preelderly patients, especially if they are fat and heavy, vented by pain and muscular spasm. Sensibility to do not take kindly to a calliper splint, and the relief pain can be completely and permanently abolished so obtained seldom compensates them for the added by section of the anterolateral (spinothalamic) tracts discomfort. in the spinal cord at a level above the entrance of In the earlier stages of the disease, before there the nerve roots from the affected part. By this are marked osteophytic outgrowths, much of the pain operation the temperature sense is also abolished, but and stiffness may be due to fibrous adhesions at the that is a small inconvenience if the patient is warned periphery of the joint, and in some such cases a great not to burn himself accidentally afterwards. Tactile improvement may be secured for a time by forcible sensibility is not interfered with. To those who are not familiar with spinal surgery manipulation under an anaesthetic. it may appear that this is an operation at least as severe as those which have been considered above. Operative Treatment. When palliative measures have failed, and the But actually it is not so. The removal of at most patient is crippled with pain and deformity, operative two or three laminse in the dorsal region of the spine treatment may be indicated despite the fact that can be done with hardly any haemorrhage and with of shock, even in an elderly patient, many of these patients are poor subjects for surgical the minimum section of the cord is not necessarily attended while the two interference. are Practically only operations risk. As compared with operations with serious any performed nowadays for the relief of painful osteoarthritis of the hip-namely, arthrodesis or destruc- like arthrodesis and reconstruction of the hip, chordotion of the joint, and arthroplasty or reconstruction tomy is far less disturbing to the patient, while the results hitherto have been remarkable. of the joint. 1. Man, aged 59. Fell on left hip three years ago ; was It is generally agreed that arthrodesis is the surest not laid up, and had no treatment except rubbing with way of relieving pain in the joint. As usually per- liniment. has been painful and getting progressively formed, it is a very severe operation, entailing dis- worse ever Hip since. Walks with a pronounced limp. Left articulation of the head of the femur, the removal great trochanter somewhat raised and prominent. Flexion of the articular cartilage from both the head and the of left hip limited to 40 degrees ; rotation and abduction acetabulum, the replacement of the head, and pro- absent. Constant pain. X rays show advanced osteolonged fixation of the limb in plaster afterwards. arthritis of left hip. Operation, April 18th, 1929 : chordoEven then it is by no means assured that bony tomy. Right spinothalamic tract divided at level of fifth Result: complete loss of sensibility to ankylosis will follow, although the pain is usually dorsal vertebra. to level of left costal margin. Movements of left relieved. The modification of arthrodesis described pain up much increased and quite painless. Discharged by Albee consists in removing approximately the hip 18th, walking well. May one-third the of femoral a head horizontal upper by 2. Man, aged 40. History of contracted hips following cut, leaving a flat surface which is then brought into typhoid 27 years ago. Has scar of old abscess over right contact with a corresponding flat surface cut with a great trochanter ; otherwise right hip is apparently normal. chisel in the roof of the acetabulum. This operation Complains of gradual onset of pain and stiffness in left hip looks very simple on paper-for example, in a flat for five years. Is now in constant pain. Walks with pronounced limp. Left hip palpably enlarged ; all moveskiagram-but most surgeons have found that it is ments much restricted and painful. X rays show impossible to bring the two cut surfaces into contact chronic very arthritis with gross enlargement of head of left without either reducing the diameter of the head of femur and acetabulum. Operation June llth, 1929: the femur or considerably enlarging the acetabulum. chordotomy. Right spinothalamic tract divided at level agency.
380 of fifth dorsal vertebra. Result : complete loss of sensibility to pain up to left costal margin. Left hip can be manipulated vigorously without pain. Movements much freer. Discharged July 10th, walking well.
Conclusions. A great many people are going about in more or less constant pain and disability from osteoarthritis of the hips and other joints of the lower extremities. After spending a considerable part of their lives and fortunes in seeking relief from palliative treatment many of them seek surgical advice on account of the continued pain and disability. The forms of surgical intervention hitherto available-namely, arthrodesis and arthroplasty-are far too severe for most elderly patients, and it is usual to advise operation in such cases only when the pain is intolerable and something must be done. Chordotomy affords a means of giving immediate, complete, and permanent relief from pain in these cases without interfering with the hips or other joints. It is not suggested that chordotomy is a trivial operation which can be lightly undertaken in all cases. But it is a much less severe operation than either arthrodesis or arthroplasty, and since it accomplishes the same object-namely, the relief of pain-more surely and with less risk, I venture to think that it may become the operation of choice in some of these cases.
Clinical THE
it is stored in the liver unchanged. An examination of the liver fats of rats which had received excess of carotin has led the writer to a different conclusion. Albino rats (litter mates), employed in an experiment to demonstrate the absence of vitamin D in carotin, were placed upon the Steenbock rachitogenic diet No. 2965, and were given daily graded doses of a sample of carotin (M.P. 174° in air), which had been prepared from carrots and recrystallised five times from chloroform by the methyl-alcohol method. At the conclusion of the experiment, which lasted 36 days, the livers were minced, digested with 5 per cent. caustic potash, and extracted with ether. The liver fats were obtained by washing, drying, and evaporating the ethereal extracts, and were analysed for carotin and for vitamin A by colorimetric and spectroscopic methods. The data obtained are shown in the Table.
and Laboratory Notes.
RELATION OF CAROTIN TO VITAMIN A. BY THOMAS
MOORE, D.Sc.
(From the Medical Research Council’s Nutritional Attention may first be directed to the striking case Laboratory, Cambridge.) of rat No. 6, which received carotin at the high level of 0’75 mg. daily. Although this amount of pigment, if IN an earlier paperl in THE LANCET I supported the absorbed unchanged, would have been sufficient to claim of Euler, Euler, and Hellstrom,2 that the pigment render the whole rat intensely yellow, it is noteworthy carotin, even after many recrystallisations, possesses that on autopsy the body fat was found to be as colour-
physiological
action similar to that of vitamin A.
Duliere, Morton and Drummond,3 using a fat-free basal diet, subsequently failed to confirm this view, but further investigations by the writer4 and by Collison, Hume, MacLean and Smith,5 in both of which basal diets containing fat were used, furnished a weight of evidence in favour of the intense activity of the pigment, even when in the purest form obtainable. Notwithstanding such high activity, it has been obvious to all investigators that carotin cannot
less
as
that of control animals.
Even in the liver fat
only feeble yellow pigmentation was observed, but on the other hand an unusually intense reaction was given with the antimony trichloride reagent. Since the absorption band observed spectroscopically in the blue solution was situated at 610-630 [L[L (characteristic of vitamin A) and not at 590[L[L (characteristic of carotin), strong evidence was afforded that a proportion of the pigment had been
transformed in vivo to vitamin A. This possibility is supported by the other results be identified with the familiar form of 1 I vitamin A found in cod-liver oil. To reconcile theobtained. The colorimetric units adopted represent common physiological action of substances so different, those amounts of material which when dissolved in a Euler and his colleagues have suggested that vitamin cube of 1 cm. side of either chloroform or the antimony A activity may not be the special property of any trichloride reagent would produce colorations equivaindividual molecule, but may be possessed by several lent in depth to 1’0 Lovibond unit (yellow or blue molecules of the carotinoid type. The factor presentt respectively), when viewed through the cube. 1 mg. in cod-liver oil, for example, may well be a carotinoid ’, of carotin under these conditions contains 1800 yellow derived from marine algee, or possibly a hydrocaroti- or 165 blue units. It will be seen at once that in the noid. On seeking support for this hypothesis, case of Nos. 2 and 3, to which carotin was adminishowever, Euler, Euler, and Karrer6 have found that out tered at less than the minimal physiological dosage, of numerous substances investigated-only carotin and no opportunity for storage was afforded, and the blue dihydro-a-crocetin (a polybasic acid obtained by unit contents of the livers of these rats did not rise the reduction of crocetin, a pigment of saffron) above the level of the negative control rat No. 1. In the case of all three rats (Nos. 4, 5, and 6), which possess growth-promoting power. The case of dihydro-o.-crocetin is surprising, and its received carotin in excess of the minimal dose, discussion may well be postponed until confirmatory decidedly higher values in blue units were observed, evidence has been put forward. With regard to but no appreciable increases in yellow units, such as carotin and vitamin A, however, my preliminary must inevitably have accompanied the storage of experiments, recorded below, have indicated the carotin, were observed. This evidence, considered possibility that the pigment may not independently in conjunction with spectroscopic data, makes it plain exert the same action as the vitamin, but that it may that the high values in blue units shown in these cases act as a precursor capable of giving rise to the vitamin were due to vitamin A. in vivo. The above experiments indicate clearly that carotin Euler, Euler, and Karrer’ have claimed that when does not appear unchanged in the liver of the rat in carotin is administered to rats above a certain level more than minute traces, even when large excess of
possibly