Search

These observations tend to support Selye's hypothesis that the effect of the adrenal steroids is to inhibit the capacity of the tissues to respond to a noxious stimulus by inflammatory reaction. In these experiments, the inflammatory response was well under way before the hydrocortisone was introduced into the injured tissues; however, the arthritis caused by the turpentine and the granulomatous process by which the tale was isolated from the joint cavity continued to progress. The gross appearance showed a diminution of the vascular-dilatation element of inflammation in most instances on the treated sides and the microscopic appearance showed as a rule fewer infiltrating phagocytic cells on the treated sides. These findings suggest not only that there is an inhibition to the progress of the inflammatory response, but also that the tissues tend to return to a normal state more rapidly after treatment. In our experiments, the injury was relatively mild and the hydrocortisone seemed to exert a favorable influence on recovery, although the difference between the treated and the untreated sides was not great. If the hydrocortisone had been administered at the time of the injection of the irritant, it is probable that the effect would have been more marked. There was no tendency for the hydrocortisone to accentuate the damage and to cause necrosis, as was noted by Selye in his experiments with croton oil. It seems probable to us, however, that the thick barrier between the skin and the inside of the granuloma pouch in Selye's experiments, in which the skin did not become necrotic, was a mechanical one and that the steroid really did not actually enhance the necrotizing effect of the croton oil. In more severe injury to tissues, as Selye showed in his experiments, the anti-inflammatory effect of hydrocortisone may result in greater damage to the tissues involved, because the inflammatory reaction may have a protective effect by creating a shield. In the clinical application of these principles, it seems logical to assume that hydrocortisone would be most useful in those pathological conditions which are inherently localized and self-limited, in which the symptoms are largely due to the inflammatory response per se , and which are either progressing or in which the noxious agent is continuing to act.

The authors remain convinced that process of fixation and replacement is accomplished in a similar manner in autogenous and homogenous bone grafts, but we are not at all sure that the differences in time of union and the number of failures can be explained entirely on the basis of tissue specificity. There is reason to believe that some of the cells of an autogenous graft are capable of survival and of instigating this process and thus accelerating it when host capillaries reach the graft. This could account both for the more rapid union of the autogenous graft as compared with homogenous graft and for the greater number of successes with autogenous grafts. Merthiolate-preserved bone does not compare favorably with autogenous bone grafts in that the process of fixation and replacement is definitely retarded, requiring prolonged protection with a higher percentage of failures (30.24 per cent. in this series). The merthiolate bone bank is a very satisfactory method of preserving bone. We have no evidence of sensitivity to the merthiolate or excess tissue reaction to merthiolate preserved bone. The method is certainly easier and more economical of bone than the frozen bone back. A homogenous bone graft which is adequately placed in a good bed and protected for a sufficiently long time may be expected to unite. Many of the failures listed above should not be ascribed to the bone bank or to homogenous bone grafts but to poor surgery. Still others can be attributed to the injudicious use of bone grafts; in these cases failure would probably have occurred irrespective of whether a homogenous or an autogenous graft was used. However, we have modified our original expectations of preserved homogenous bone graft and now feel that these grafts should be considered as useful aids in orthopaedic surgery rather than as universal substitutes for autogenous bone. Obliteration of cavities in bone created by sequestrectomy and saucerization for osteomyelitis, or local excision of benign tumors by homogenous bone from the bank, has given good results. Where the defect is large, bank bone is preferable to autogenous bone because of the great amount required. Homogenous peg or inlay grafts have Proved satisfactory in the treatment of minor non-unions. Likewise, bank bone has been very useful for internal splinting in arthrodesis and for treating certain fresh fractures. However, homogenous bone grafts should never be used in the treatment of major non-unions if there is any possibility of using an autogenous graft. It is our feeling that the use of bank bone should be reserved for those circumstances in which it is not feasible or advisable to use autogenous bone. These are: 1. When the available supply of autogenous bone does not fulfill the particular requirements; 2. When the taking of an autogenous bone graft will materially increase the hazard of the operative procedure: 3. In any condition where there is a chance that the graft will be lost because of infection; 4. During the course of an operation when it is decided that a bone graft would be useful and when no previous Plans for taking a graft had been made; 5. In those cases where the bank bone is used as an internal splint when the condition would not justify the taking of an autogenous graft.

Fifty-one synovial biopsies were obtained from the knee joints of 11 patients with rheumatoid arthritis and eight patients with osteoarthritis. Biopsies were taken before and repeated 3–9 days after treatment with phenylbutazone administered orally or intra-articularly. Histologic comparisons were made with reference to fibrin and fibrinopurulent material, appearance and thickness of synovial lining cells, edema, stromal hyalinization, inflammatory cell type and distribution, vascular alterations and other changes as noted on hematoxylin and eosin and special stained sections. Un total de 51 biopsias esseva effectuate in le articulationes geniculari de 11 patientes con arthritis rheumatoide e 8 patientes con osteoarthritis. Le specimens bioptic esseva obtenite (1) ante e de novo (2) inter 3 e 9 dies post le administration de phenylbutazona per via oral o intra-articular. Comparationes histologic esseva effectuate con respecto a fibrina e a materiales fibrinopurulente, al apparentia e spissitate del revestimento synovio-cellulari, al presentia de edema, de hyalinisation stromal, e de alterationes inflammatori (con attention prestate al typo cellular e al distribution), a alterationes vasculari, e a altere processos pathologic notate in sectiones tincturate con hematoxylina e eosina o con colorantes special.

The potential action of cytotoxic agents such as alkylating drugs and antimetabolites on the immune response and inflammatory process has suggested their trial in the treatment of rheumatic diseases. Nitrogen mustard was tried initially both by intravenous and intra-articular injection in the therapy of rheumatoid arthritis and gave variable responses (Jimenez Diaz, 1951; Jimenez Diaz, Lopez Garcia, Merchante, and Perianes, 1951; Shutkin, 1951; Phillips, Phillips, and Caraway, 1952; Cohen, Rose, and Cooper, 1953; Scherbel, 1957; Scherbel, Schuchter, and Weyman, 1957; Scherbel, Mackenzie, and Atdjian, 1963). Scherbel and others (1957) noted a rapid and prolonged decrease in joint swelling after the intra-articular injection of nitrogen mustard in patients with rheumatoid arthritis, but not a corresponding satisfactory relief of pain. He, therefore, combined steroids with nitrogen mustard for intra-articular injection and obtained more beneficial results. When a purine antagonist, 6-mercaptopurine, was administered to patients with systemic lupus erythematosus the responses were equivocal (Lee, Meiselas, Zingale, and Richman (1961). The development of adjuvant-induced arthritis in rats has been successfully inhibited by 6-mercaptopurine (Kalliomaki, Saarimaa, and Toivanen, 1964). Methotrexate has been used experimentally in psoriatic arthritis (O'Brien, Van Scott, Black, Eisen, and Bunim, 1962; Black, O'Brien, Van Scott, Auerbach, Eisen, and Bunim, 1964). Recently, thio-tepa (N, N', N2 triethylenethiophosphoramide) has been reported to give satisfactory improvement after intra-articular administration to patients with rheumatoid arthritis (Flatt, 1962; Gross, 1963; Pace, Kantor, and McEwen, 1964). Some of the latter results are difficult to interpret because thio-tepa was, in many instances, combined with steroids or local anaesthetics for intra-articular injection. Rheumatoid arthritis is a disease in which rheumatoid factor(s), an abnormal antibody(s) or antibody-like substance(s), is frequently present. Alkylating agents interfere with antibody production and, therefore, could inhibit the possible immune reaction and inflammatory changes characteristic of rheumatoid arthritis. It seemed appropriate to study this possibility in more detail. Thio-tepa, an alkylating agent, was selected for study because it can be placed in solution at a pH which is not irritating to the tissues and, consequently, can be given by all parenteral routes. The present investigation describes our results after intra-articular injection of thio-tepa into the knee joint of nineteen patients with rheumatoid arthritis.

SummaryIn a continuing evaluation of the intramuscular administration of steroids in the treatment of rheumatic disease, 444 injections, each of 100 mg., of TACTN have been administered to 77 patients. The desired anti-inflammatory effect was obtained in approximately 75 per cent of patients. A 50-mg. dose of TACTN was less satisfactory than an 80-mg. dose. An 80-mg. dose was less satisfactory than a 100-mg. dose and a 100-mg. dose was less satisfactory than a 140-mg. dose in most of a limited number of patients in which these doses were compared.Side effects ordinarily encountered with oral steroids were seen with TACTN. Moon facies and ecchymoses were the most common, being evident in approximately half of the treated patients, while hirsutism, muscle cramps and diuresis were noted each in 10 per cent of patients. Acne was noted in only a few patients, and other effects in only 1 or 2 patients. Gastrointestinal complications were minimal, proving a definite advantage over orally administered steroids.Th...

IN THE year 1895 deQuervain, a surgeon in the Kocher Clinic, described a painful condition of the wrist which was localized in the region of the radial styloid process. The malady was found to be a stenosing tendovaginitis of the most lateral osteofibrous canal on the dorsum of the distal end of the radius through which pass the tendons of the extensor pollicis brevis and the abductor pollicis longus. At that time deQuervain reported on five patients whom he had treated either by immobilization or incision of the stenosed osteofibrous canal. After this numerous reports appeared in the foreign literature. In 1898 Hoffman,1unaware of deQuervain's publication, reported 12 similar cases which he had seen, the first report in the American literature concerning this condition. From that time until 1930 there was little mention of the condition, the only publications being those of Schneider,2Finkelstein,3and Stein.

1. 1. Seven hundred ninety intra-articular injections of F, FTBA, ΔF, and ΔFTBA were compared in 80 patients with rheumatoid arthritis or osteoarthritis. 2. 2. Dosages varied from 5 to 100 mg. with 25 mg. the most frequently administered dose. 3. 3. No significant difference in response to the four steroids could be demonstrated when 25 mg. doses were compared. 4. 4. Fifteen, 20, and 100 mg. doses of ΔF and ΔFTBA and larger than 25 mg. doses of F and FTBA were limited in number, but produced the same improvement as the 25 mg. dose. 5. 5. Seventy-five per cent of joints with rheumatoid arthritis and 84 per cent with osteoarthritis showed satisfactory improvement. 6. 6. Duration of improvement averaged 2 to 3 weeks.

Fifteen cases of fracture of the ulnar shaft associated with dislocation of the radial head in children were studied. The injury is most common in the age range of five to nine years and consists almost entirely of the anterior or lateral type of dislocation. Early diagnosis and prompt treatment permit satisfactory stable reduction by closed methods in most cases. Although general anesthesia is sometimes necessary, many such injuries may be reduced with local anesthesia or no anesthesia. Immobilization for 5 or 6 weeks is sufficient, and recovery of full function in 2 to 4 weeks after cast removal is common.

D-penicillamine was administered to 15 patients with rheumatoid arthritis. A fall in the titer of rheumatoid factor was demonstrated in all patients. The sedimentation rate decreased in most patients. There was no consistent alteration in immunoglobulins A, G or M or in lymphocyte transformation attributable to penicillamine. Ceruloplasmin serum levels were lowered significantly in 7 patients. Clinical improvement in the arthritis resulted in 10 patients.

PHENYLBUTAZONE is an effective and widely used anti-inflammatory agent in animals as well as man. We observed a patient in whom fatal aplastic anemia developed after taking phenylbutazone prepared for veterinary use in horses. Report of a Case A 20-year-old professional jockey was admitted to the hospital on Dec 16, 1975, with a two-week history of spontaneous bruising and listlessness. He admitted taking phenylbutazone in the form of crumbled 1-gm horse tablets about 20 times in the previous three years. One month before admission, he took 2 gm of horse phenylbutazone for more than three days for mild but painful injuries sustained in a fall. He was also taking furosemide, 40 mg/day, and occasional cathartics. Results of the physical examination showed pallor and widespread ecchymoses. The blood cell count showed a hemoglobin level of 5.6 gm/100 ml, a white blood cell count of 650/μl (18% neutrophils, 79% lymphocytes, and 3%

A study of 21 cases of sewing needle fragments accidentally broken off in and about the knee joint demonstrates a uniform mechanism of injury. Penetration occurs with the patient kneeling on a carpet into which the needle has lodged. The needle is broken by the sudden extension of the knee in reaction to the pain. Full appreciation of the mechanism of injury should all but eliminate major difficulty (nine of the 21 cases in this series) in surgical recovery of the retained needle fragment.

An opportunity has existed during the past 27 years to study a series of 255 children afflicted with muscular dystrophies, muscular atrophies, and clinically similar conditions at the St. Louis unit of the Shriners' Hospital for Crippled Children. A review of these cases has been conducted in an effort to clarify the confusion that exists in relation to the terminology and to discern more of the natural history of these diseases. Because no initial examination may be made on patients over 15 years of age at this institution, the material studied cannot be considered comprehensive except for those diseases in which the onset is common in childhood. These patients may be classified under two major headings, the myopathies and the neuropathies. The former pathological conditions result from primary degenerative changes within the muscles themselves, while the latter occur secondary to disease of the nervous system. A total of 231 cases