History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: September Supplement, 1939 Vancouver Medical Association Sep 15, 1939

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 t#
Papers Read
A tit he  Annual  Meeting
of the
B.C Medical Association
SEPTEMBER 18-21, 1939.
Published by the
Bulletin of the Vancouver Medical Association
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Supplement to the Bulletin
of the Vancouver Medical Association
Speakers:
Dr. R.'Franklin Carter New York City
Associate Professor of Clinical Surgery,
Columbia University.
Dr. W. G. Cosbie Toronto
Senior Demonstrator in Obstetrics and Gynaecology,
University of Toronto.
Dr. H. B. Cushing
Emeritus Professor of Paediatrics,
McGill University.
Montreal
Dr. Alexander Gibson Winnipeg
Associate Professor of Clinical Orthopaedic Surgery,
University of Manitoba.
Dr. Roscoe R. Graham
Assistant Professor of Surgery,
University of Toronto.
Dr. E. P. Scarlett
Internal Medicine.
Toronto
Calgary
Contents
Carter, R. F., Brown, H. G., and Kipp, H. W.:
Treatment of cervical lymphadenitis in children.
Carter, R. F., Twiss, J. R., and Marroffino, B.:
Selection of cases with Gall Bladder Disease for surgery.
3D
Cosbie, W. G.:
Carcinoma of the cervix .    . ^_ 58
Maternal mortality  62
Cushing, H. B.:
Principles of the artificial feeding of infants .  68
Indications for and results of removal of tonsils and adenoids  69
Gibson, Alexander:
Fracture of the neck of the femur_L—  3 8
Fractures of the forearm k> '.<.-,.,' r  45
Mechanism of the spine   31
Graham, Roscoe R.:
Surgeon's responsibility in carcinoma :  20
Cecostomy—indications and technic .  !  2 5
Scarlett, E. R.:
Angina pectoris and coronary thrombosis  12
Common fallacies in the diagnosis of cardiovascular disease    15
Peptic  ulcer ,    17 Foreword
The Bulletin of the Vancouver Medical-Association
takes great pleasure in presenting this Supplement, embodying the papers read at the Annual Meeting of the British
Columbia Medical Association in September, 1939.
In doing so, we should like to draw attention to the fact
that this is distinctly the work and property, so to speak, of
the B. C. Medical Association. The only share we have had
in it was in the mechanical work of assembling and editing
the papers, and we are glad to have had the privilege of
doing so.
i-i,
We congratulate the B. C. Medical Association on an
excellent programme of papers. We feel that our readers
will agree that these papers are well worth preserving, and
that they will be as good to read as they were to hear. The
thanks of us all are due to those who gave the papers, and we,
as editors in the matter, can testify to the excellence of their
preparation. We are filled with admiration at the meticulous
care with which these men, mostly overwhelmed with clinical
and university work, prepared and polished their papers.
Most of them were copiously illustrated with cuts and photographs, which as yet our pocket will not let us reproduce,
as we should like to do. These men are masters in their subjects, and their papers were finished to the last degree.
There were two papers that should have been presented
here, too. and were quitev worthy of inclusion with these
others. They were read by Drs. A. W. Hunter and Lee
Smith, pinch-hitting for Dr. Patch, who was unable to
appear. They were of a very high order of excellence, and
we hope some day to reproduce them.
With these few remarks, we present this Supplement for
your use, and hope it will be of much service.
Publications Committee of
Vancouver Medical Association. Sssmssss
ffllrWRw'
THE   TREATMENT  OF  CERVICAL   LYMPHADENITIS  IN
JRlf j$ CHILDREN
R. Franklin Carter, M.D.,
Henry A. Brown, M.D.
AND
Harold W. Kipp, M.D.
(Paper presented by Dr. R. F. Carter)
In treatment of cervical lymphadenitis in children is: a problem in which a knowledge
of the basic factors involved is of the utmost importance in} the successful handling of
the numerous phases of the subject. The embryological studies of the lymph nodes in
this area have shown them to be grouped in a definite arrangement with respect to the
areas from which they receive lymph and in their relation to the fixed anatomical landmarks. The location of an infection in any area within the boundaries from which the
infected lymph is discharged into the cervical nodes can be traced to its source through
a knowledge of the anatomical arrangement of nodes and their afferent lymph channels.
The lymph channels cannot be seen as superficial red streaks, as in the extremities, where
there is little doubt of the source of the infection being the cause of the lymph node
enlargement when all the factors are visible, e.g., an infected toe with red streaks
ascending to an enlarged node in the groin leaves little doubt as to the cause, course and
result of the process. In the cervical region the node is usually the only visible portion
of the process, therefore the enlargement of the node is too frequently considered to be a
single entity.
The anatomical arrangement, histological structure as well as the pathological features of the subject can be obtained from the usual standard text books. The scope of this
paper does not permit of a detailed review of these phases other than to touch upon those
most concerned with therapeutic management. The arrangement of the nodes in groups
and their relationship to the fixed landmarks in the cervical region are constant. The sub-
mental, submaxillary, preauricular, postauricular, parotid and occipital groups of nodes
are frequently spoken of as the superficial groups, in that they receive lymph from the
skin surfaces.
The superior deep cervical group lies anterior, beneath and posterior to the origin of
the sternocleidomastoid muscle and receives lymph primarily from the mucous membrane
surfaces of the oropharynx and nasopharynx, and secondarily from the nodes in the
superficial cervical groups. The inferior deep cervical group is situated just above the
clavicle and lateral to the insertion of the sternocleidomastoid muscle. The lymph
received from exposed surfaces in the latter group comes principally through the superior
deep cervical group, the axillary and the mediastinal nodes, the occipital and omohyoid
groups furnishing a small part of the lymph supply. The principal lymph received in the
inferior deep cervical nodes has passed through the sieve process in one or more groups of
nodes before being received for sieving in the inferior group. From the inferior deep
group of nodes the lymph from the skin and mucous surface areas of the head, neck,
upper extremities, thorax, mouth, oropharynx, nasopharynx, larynx and lungs is passed
on into the thoracic duct to be carried into the inominate vein. It is possible for an infection about a bicuspid tooth to involve first the submaxillary nodes on the side affected,
thence the anterior division of the superior deep cervical group, thence to the inferior
deep cervical group and, if not checked, by localization here, to pass into the blood
stream by way of the thoracic duct.
An infection in the anterior scalp wiill go first to the corresponding postauricular
group, thence to the posterior division of the superior deep cervical group, if not checked,
into the inferior deep cervical group and possibly on into the blood stream through the
thoracic duct. Infections in the occipital area of the scalp are carried to the occipital nodes
and directly into the inferior deep cervical nodes.
The tip of the tongue is said to be the only area in the upper region that drains its
lymph primarily into the inferior deep cervical group without its passing through an
[  3   ] intervening group. The larynx drains its lymph into a small group near the mid-portion
of the anterior region of the neck mesial to the sternocleidomastoid muscle and thence
into the inferior deep cervical group. As the larynx is seldom affected with ulcerative
lesions in childhood, this group is infrequently found to be enlarged except in the carcinoma of the larynx seetn. in later life.
The tonsils in the oropharynx, and the adenoids and nasal sinuses in the nasopharynx,
are the source from which infected lymph most frequently involves the cervical nodes.
The infecting organisms entering through these zones are virulent and they cause the
most serious types of inflamation. The superior deep cervical nodes were involved: in
456 or 86% in 531 patients admitted to the babies' wards for both surgical and medical
care.
Incision and drainage of abscesses was performed in 52% of those patients with
involvement of these nodes.
The incidence of involvement of the other groups in the 531 patients was:
Acute inflamation in submental group, 2 3 % of total.
Acute inflammation in submaxillary group of nodes, 10.5% of total.
Acute inflammation preauricular group, 20% of total.
Acute inflammation in occipital group, .06% of total.
No patients were admitted to the hospital in whom the inferior deep cervical nodes
were involved by a surgical process.
There is little difficulty experienced in locating the group of nodes affected in the
average case. Once the affected group is identified the focus of the source of the infection can be placed within fairly welll-definted limits. For instance, a submaxillary node
enlargement can be differentiated from the superior deep cervical group, which indicates
the position of the infecting focus to be in the mouth propeir rather than in the oroi-
pharynx. In such an instance the dentist should be consulted rather than the Nose and
Throat specialist.
The histological structure of these lymph nodes in the neck does not differ from that
in the extremities. Nor does the inflammatory reaction of infection in these nodes vary
sufficiently from that in those in the groin to justify a different mode of treatment. Locating and treating the focus of infection in the head and neck is just as important a factor
in the cervical region as it is in the extremities.
The types of infection encountered in the cervical regions is reflected in the inflammatory reaction in the nodes. In this region the infecting organisms that enter the individual through the upper respiratory tract are prone to be virulent, to enter through an
unbroken protective surface and to have the ability to invade the host through channels
that are closed to the ordinary organisms that gain access through thei skin surfaces.
In spite of the fact that the organisms gaining access through the throat have unusual
virulence, the nodes of the cervical region have the ability to localize the infection to an
extent that an invading cellulitis of the other structures of the neck is rarely encountered.
Ludwig's angina and streptococcus phlegmon of the neck do not begin as primary cervical lymphadenitis. The nodes may be moderately involved in a spreading cellulitis, but
a cellulitis of this type is rarely if ever seen to spread from infection that has entered the
nodes through their lymph channels. For this reason the treatment of infectious lymphadenitis is safely conducted in a more conservative fashion than that for infection introduced into the tissues directly through stab wounds and other trauma. The infecting
organisms that gain access to the tissue spaces are picked up at the source by the lymph
channels in which they are conducted to the lymph node. In the event that the organ-,
isms pass this lymph node barrier, they are discharged into other lymph channels through
which they pass on to another screening process in the next group of nodes encountered.
By this means the virulent organisms, after leaving the sources are confined in the spaces
in the body that were designed for the reduction of their virulence and destruction.
The defensive forces of the body which protect it against an invasion by infectious
organisms are all marshalled in and about the lymph system. Areas of invasion by
organisms are quickly surrounded by the circulating and fixed cells of defence with a
resulting abscess wall by which the spread of infection is prevented.  In the series of 531
[ 4 ] hospital patients there was not an instance in which the blood stream became involved
by infection from a source located in the lymph system. Nor was there a positive blood
culture recorded in any patient who developed abscesses in the lymph nodes.
Infecting Organisms
328 Operations
Streptococcus   ,  70 %
Staphylococcus    17 %
Streptococcus and Staphylococcus      5%
Sterile  (Tuberculous)      8%
Pneumococcus       1   (patient)
The predominance of streptococcus infections may be interpreted as evidence of the
infection gaining access through the mucous membrane surfaces in the majority of patients having abscess formation the cervical nodes. The preponderance of infection
through the mucous membrane surface of the nasopharynx is indicated also by the
increased incidence of involvement of the superior deep cervical group into which the
lymph from this area drains primarily. The incidence of staphylococcus invasion alone
may be taken as evidence of the frequency of invasion of the cervical nodes through a
portal in the skin; the combined streptococcus of the infrequency of an invasion from
the mucous surface by the staphylococcus; the pneumococcus as a rare organism to
invade the cervical nodes through either the upper or lower mucous surfaces of the respiratory tract. The frequency of sterile or tubercular cultures has fallen very rapidly
in those patients who have been admitted during the past six years. During this) period
there have been nine patients with a clinical diagnosis of tuberculous cervical adenitis. In
the prior twelve years there were fifty-four. The cause for this has been unofficially
ascribed to the decrease in bovine tuberculosis among the cows from which the source
of milk for this area is derived.
From 1920 to 1938, the yearly incidence of tuberculous cervical adenitis in the Babies'
Ward at the Post-Graduate Hospital fell from 7 or 8 to 0. The case recorded iri 1939
had its source in the skin of the cheek and was thought to be of the adult type of
organism.
The average age of the patients admitted has been found to be 37 months in the
purulent group and 3 5 months for the simple inflammatory group. Males were affected in
46% and female 54%.
Incidence—531 Patients
Age-
Simple Inflammatory   3 5 Months
Purulent Inflammatory  3 7 Months
Bilateral Involvement—Simple  2 8 %
Bilateral Involvement—Purulent  10 %
Sex-
Males  I  46%
Females     54 %
General Admission, All Patients     8%
Number of Attacks—
Single Previous   14 Patients
Numerous Previous     5 Patients
Among the 203 patients discharged after a simple inflammatory condition there were
148 having a history of no previous occurrence, 14 with one previous occurrence, and
5 in which there had been numerous previous occurrences. Those patients admitted^ to
the hospital in whom the cervical nodes are involved in an inflammatory process comprise
about 8% of all admissions.
There was a bilateral cervical node involvement, chiefly in the superior deep cervical
groups, in 10% of the surgical patients having operations on both sides, and in the
simple inflammatory group having no operations there was noted bilateral involvement
in 28%.
[   5   ] Treatment
Treatment—Enlargement Nodes
Classification Important Factors
Group of Nodes Involved Probable Organism
Differential Diagnosis, Cause Pathological Process—
Infection— Simple Inflammation
Focus Location and Nature Purulent Inflammation
A specific classification of every factor involved in the process of enlargement of
the cervical lymph nodes is important in the successful management of the condition;
the group or groups of nodes involved; the most probable cause; in infection, the nature
of the focus present; the pathological stage of inflammation that is present at the time
of examination; and, the probable infecting organisms involved in the inflammatory
process.
1. Group of nodes involved. No considerable experience is required to become proficient in locating the group of nodes involved. In marked enlargement of the submaxillary group of nodes there may be some difficulty encountered in distinguishing them
from the anterior superior deep cervical group. In such instances both groups are usually
involved and the focus is found to be in the mouth.
A sketch of the nodes of the neck made in the record of each patient with the designation of the affected nodes is useful practice as well as the best of records for future
reference.
2. The Cause of the Enlargement.
Differential Diagnosis.
1. Cervical Cysts 4. Lipomata
Thyroglossal 5. Gumma
Pharyngeal 6. Hodgkin's Disease
Inclusion, independent origin 7. Lymphosarcoma
Sebaceous origin 8. Lymphatic Leukemia
2. Cervical Hygroma 9. Parotitis
3. Thyroid Tumors 10. Abscess of Mandible
The differential diagnosis in lymph node enlargements in the cervical region brings
up for consideration that group of conditions peculiar to the region as well as the conditions that cause enlargement of nodes in all locations. The group of conditions found
in this region that may be confused with enlargement of the nodes are chiefly those
swellings from cystic enlargement of congenital remnants of the thyroid anlage and
inclusion cysts resulting from defective pharyngeal cleft development.
Differential Diagnosis Ratio
Cervical Node Enlargement
Cervical Node Infection 531 Patients
Thyroglossal Cysts     47 Patients
Pharyngeal Cleft Cyst     29 Patients
Hodgkins Disease     17 Patients
Cervical Hygromata 4 Patients
The thyroglossal cysts are found in the midline or extending laterally from a midline origin in the region of the hyoid bone, an area in which, there are no lymph nodes to
become involved except those in the sub-mental region and they enlarge above the hyoid
sufficiently to be distinguished from the thyroglossal cyst. During the ten years in which
the 531 patients were admitted to the hospital wards with infection of the lymph nodes
there were 47 patients admitted with thyroglossal cysts. The average age was six years
and there were 31 males and 16 females.
The pharyngeal cleft cysts are difficult to distinguish from a chronic inflammatory
enlargement of the nodes in the deep nodes of the superior deep cervical group. Particular difficulty is encountered in differentiating an acutely inflamed pharyngeal cleft cyst
from an infectious enlargement of the nodes. The location, the course, and the local
signs of the inflammation may be identical in both conditions.   Conservative treatment
[   6   ] gtggjtjy^P^BggaBiM«Batffl»3ratB*WM*
may be employed in both conditions until more distinguishing signs appear. In the case
of cysts there are no additional swellings appearing in the neighbourhood, the infection
remains localized to one uniform area; in lymph node affections there appears an enlargement in other nodes in the group to distort the uniform outline of the cystic swelling.
In uninfected cysts the uniform cystic nature of the swelling below the posterior belly
of the digastric muscle and beneath the sternocleido-mastoid muscle is sufficient evidence
of a cyst to justify an exploratory incision. In all instances in which operation is decided
upon for the treatment of masses in the region, a small exploratory incision extending
down to the wall of the mass will disclose its true nature, whereupon a chronic abscess
can be drained through the small incision and in case of a cyst the incision can be
enlarged sufficiently for removal. During the period in which the 531 cases of infectious
adenitis were treated, there were admitted to the hospital 29 cases of pharyngeal cleft
or branchiogenic cysts. The average age was six years. There were 19 females and 10
males.
Inclusion cysts of Hess or the cysts that were described by him as having an origin
independent of the pharyngeal clefts occur in the submaxillary, the preauricular and submental regions. They may be confused with chronic enlargement of nodes. Because of
their slow rate of development, single nature and infrequent involvement in an acute
inflammatory process they can be differentiated as a rule. When doubt exists they should
be explored through a small incision to determine their true condition.
Swellings due to sebaceous cysts are easily differentiated by their subcutaneous position, the comedo opening and the atrophy of the skin existing over the chronic cytet.
While several of the groups of nodes have been spoken of as being superficial, none are
found to be situated in the subcutaneous fat, the zone in which sebaceous cysts and
other skin tumors invade.
Cystic Hygroma are usually found in the lower cervical regions, an area in which
lymph nodes are infrequently involved without having been preceded by enlargement
in those in the upper cervical or maxillary regions. Hygromata may appear at any age,
but usually make their appearance during the first few months of life.
Thyroid tumours are located in the thyroid region in which there are few if any lymph
nodes found in the child. Lipomata are unusual enlargements found in the neck. They may
be differentiated by their rare occurrence, single appearance and very slow growth.
The differentiation of conditions other than infection that cause a gradual enlargement in the lymph nodes is especially difficult in those patients with chronic infection of
low virulence. There is one differential point noted in tumours of lymph nodes, Hodgkins,
lymphosarcoma. The spread of other groups of nodes in infection is orderly and it usually
follows the anatomical route, from submental to anterior superior deep cervical to inferior
deep cervical. In Hodgkins and lymphosarcoma the spread may be along anatomical
channels but it is just as apt to extend from one side of the neck to the other or to occur
in the axilla or groin in the same individual. Thus a suggestion of constitutional tumour
is made by the manner in which the extension takes place. During the ten-year period
in which the 531 patients with cervical lymphadenitis were admitted to the hospital
wards there were 17 patients admitted with Hodgkins. The average age was seven years;
there were 14 males and three females in the group.
The rapid enlargement of nodes in lymphosarcoma, the rate being equivalent to that
in infection in the absence of the other signs of infection, is the most suggestive sign of
lymphomatous tumour development.
The first nodes to appear in lymphatic leukemia may occur in the cervical region.
A routine blood count is an indispensable test in all forms of chronic lymph node involvement and the differentiation of the lymphatic leukemia is made in all instances early in
the course of the disease except the aleukemic leukemia. In the latter, as in most instances
of suspected tumor, a biopsy should be resorted to without waiting for definite signs to
appear upon which a clinical diagnosis can be made.
[  7   ] 3.   Characteristic on which a diagnosis of infection is based.
History—
1. Age, Sex, Nationality
2. Past—Previous attacks
3. Present—
Chief Complaint
Onset
Course
Fever
Pain
Rash
A.   Historv— B.   Examination—
a. General Physical—
Temperature
b. Local Conditions—
Normal
Redness of the Skin
Tenderness
Fixation
Fluctuation
Pulse
Blood Count
Sedimentation Rate
Von Pirquet
X-ray
Therapeutic Test
Biopsy
The average age of occurrence in both the simple and purulent adenitis groups of
patients was approximately three years. This age is not distinctive, as there are patients
of two months as well as many between the ages of 10 and 12 years. Sex and nationality
varied considerably in both groups but in neither are there found to be characteristic
differences on which to make a definite diagnosis of infection. A past history of repeated
upper respiratory infection is important in enlargement of the superior deep cervical group
in which infection from a chronic focus in the nasopharynx is frequently encountered.
Previous attacks of lymphadenitis is a helpful finding in the past history; there were previous attacks in 19 instances in the 203 patients with simple adenitis.
In the present history the chief complaint in the acute cases is almost invariably
swollen glands of the neck. In the chronic cases a variety of chief complaint is noted.
Whatever the chief complaint may be, the most important point to be established in the
history-taking, is as accurate as possible a determination of the node in which enlargement was first noted. For in this information lies the clue to determining the original
source of the infection in patients in whom are more than one group of nodes involved
at the time the patient is first examined.
The onset and course of the enlargement is not distinctive, as there may be found to
be any type of course in infections of different virulence. The presence of fever is suggestive of infection, but in patients with Hodgkins disease the typical fever course of
the average case of infection is frequently noted. Pain in the acute infection is constant
and severe; in the simple chronic infection it is usually absent. A chronic rash is suggestive of Hodgkins or one of the poorly-classified types of tumors involving the lymph
follicles of the skin and lymph nodes. In the exanthemata the rash usually subsides before
the node enlargements appear.
A general physical examination is important in every patient with simple forms of
adenitis, both acute and chronic, in fixing the lymph node involvement in the cervical
region or in determining it to be a part of a general lymph node enlargement.
The temperature, pulse and blood count vary to a great extent with the variations
in virulence of the invading organisms. The sedimentation rate is useful in suggesting
the presence of infection or tumor as a cause for enlargement.
The Von Pirquet test for tuberculosis is indispensable in establishing the presence
of tuberculosis in the individual, but is specific for lymph node involvement in a negative way only.  The X-ray is no longer used as a diagnostic therapeutic test.
The biopsy examination is indispensable in many forms of chronic infectious lymphadenitis and tumor involvement. When in doubt a node should always be removed for
confirmation of the suspected diagnosis before any type of therapy be employed.
In the local examination of the node, the positive diagnostic points of infection are:
the presence of a tendency to spread along the known anatomical course of the lymph -
[  8   ] atics in the area; redness of the skin; tenderness; fixation; and fluctuation within the
mass.
4.   The most common lesions to be found in the various sites that cause lymphadenitis
in corresponding lymph node group:
Fever Sores, Furunculosis
Abscessed and Cutting Teeth
Conjunctivitis
Eczema of Scalp
Furunculosis, Auditory Canal
Pediculi
Diphtheria (toxin)
Tonsillitis—(Acute  and  Chronic)
Chronic Adenoid and Sinus Infections
Submental
Subaxillary
Preauricular
Postauricular
Parotid
Occipital
Omohyoid
Ant. Sup. Deep Cervical
Post. Sup. Deep Cervical
5.   Pathological Process and Therapy:
1.   Simple Inflammation—Acute—
1. Diagnostic Criteria—
Uniform Swelling
Non-Fluctuant
No Redness of Skin
2. Infecting Organisms—
a. Mucous Membrane Surface (Deep Nodes)—Streptococcus Therapy
Sulphanilamide, 1 gr. per lb. per day
Hot Poulticing, t.i.d.
Continuous Hot Water Bottle
Bed Rest for One Week after Temperature
No Radical Removal of Focus
Removal of Foci, Quiescent Stage
No Swimming in Recurrent Cases
b. Skin Surfaces   (Superficial Nodes)—Staphylococcus Therapy—
Hot Poulticing, t.i.d.
Continuous Hot Water Bottle
Bed Rest Until Fever Subsides
No Radical Removal
Incision and Drainage of Focus
2.   Simple Inflammation—Chronic—
1. Diagnostic Criteria—
Uniform Swelling
Non-Fluctuant
Long History
2. Infecting Organisms—
a. Mucous Membrane Surface (Deep Nodes)—Tuberculosis Therapy
General Hygiene
High Caloric Diet
Bed Rest for Three Months or Longer
No X-ray Therapy at Present
Light Radiation
X-ray Chest
b. Skin Surfaces   (Superficial Nodes)—Staphylococcus Therapy—
Vaccine (stock), or Staphylococcus Toxoid
General Hygiene
Treatment—Eczema, Furunculosis and Pediculi
The specific treatment of the acute simple inflammatory enlargement of all those
nodes receiving their primary lymph supply from the mucous membrane surfaces is justified by the previously mentioned preponderance of the streptococcus infections found
in cultures at operation.  When there are primary superficial groups involved before the
[  9  ] deep groups, the sulphanilamide treatment is used in patients in whom it is justified by
the additional presence of an upper respiratory infection. In both instances the use otf
sulphanilamide is watched closely through blood counts every 48 hours and the clinical
response manifested by the usual temperature drop. The drug is discontinued if there be
no evidence of a definite drop in temperature in 48 hours, irrespective of the apparent
influence upon the enlargement of the nodes.
The most important of the non-specific measures seems to be in the very strict observance of bed rest without any getting up privilege. The carrying out of this indication
is very much more strictly observed in the hospital than is usual for the home. Many
more patients with acute adenitis should be referred to the hospital for treatment on
the grounds that suppuration can be prevented in the majority of streptococcus infections by the limit of sulphanilamide therapy and strict observance of bed rest. Possibly
90% of suppuration could be avoided in this way.
The specific treatment of those patients in whom the superficial nodes are acutely
inflamed and have apparently undergone no suppuration, is not so successful in the prevention of suppuration. Suppuration can be prevented by locating and draining the
focus of infection better than any specific treatment by vaccine or bacteriophage.
The treatment of the simple chronic inflammation that has been accredited to or
proven to be tuberculous is very much interfered with by the exclusion of lymph node
tuberculosis from public institutions devoted to the care of lung and bone tuberculosis.
Whenever possible, the patient should be treated along those lines laid down for lung
tuberculosis. Dependence on the X-ray therapy and certain forms of artificial heliotherapy have militated against recovery in these patients, as well as enhanced the cause
of purulent degeneration with calcification.
ITie calcified nodes remaining after the active infection has been checked should be
removed by surgery when unsightly or the cause of annoyance.
3. Purulent Inflammation—Acute—
1. Diagnostic Criteria—
Fluctuation
Redness of Skin
2. Infecting Organisms—
a. Mucous Membrane (Deep Nodes)—Streptococcus Therapy—
Novocain—l/z inch Incision, Gauze Drain, remove 48 hours
Culture (Vaccine—Sulphanilamide therapy verified)
No removal of Focus—Incision Drainage Tonsil Abscess.
Bed Rest One Week after Cessation of Temperature
No Swimming—One Year
b. Skin Surfaces (Superficial Nodes)—Staphylococcus Therapy—
Novocain—l/z inch Incision, Gauze Drain, Remove 72 Hours
Culture (Vaccine—Bacteriophage)
No Removal of Focus
Incision and Drainage (Except Face)
4. Purulent Inflammation—Chronic—
1. Diagnostic Criteria—
Fluctuation
Bluish discolouration Skin
2. Infecting Organisms—
a.   Mucous Membrane Surface (Deep Nodes)—Tuberculosis (Streptococcus Therapy)—
Novocain, J4 inch Incision, on charact. pus, drain in Strep., No—
Tbc.
Culture (Vaccine, Sulphanilamide Therapy Verified)
Removal of Tonsils, Same Time if Tonsils Not Acute
Bed Rest, Three Months Tbc.—One Week Normal Temp. Strep.
No Swimming, Indefinitely
[ 10 ] ^B*Tfl^^^K5B!Wlg^H3^^Bi
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suSSQ !
b.   Skin Surfaces  (Superficial Nodes)—Staphylococcus, Tbc. Rarely—
Therapy
Novocain,  l/2 inch Incision, Drainage Gauze, Duration 72 Hours
Culture (Vaccine—Bacteriophage)
Incision—Abscess.
The capsule of the lymph node acts as a barrier when purulent degeneration takes
place. Apparently all of the introcapsular structure of the node undergoes liquefaction
before there takes place a rupture of the capsule. After the capsule is invaded the process
begins to work its way to the surface of the neck. This extension of the purulent process
to the surface takes place along the planes of the cervical fascia. No important vessels
have been injured by the purulent process in the series of cases reported herein. Incision
of the abscess does not appear to be necessary before the process has reached the inner
surface of the superficial division of the deep cervical fascia.
At this point there will be positive fluctuation, moderate redness of the skin and the
abscess appears to flatten out on the surface more. The extension of the purulent degeneration through the fascia and into the fat of the neck will destroy tissue that will not
regenerate, thereby leaving as an after result depressions and adhesions of the skin to the
fascia.
Plunging the knife through the skin and subcutaneous structure into an abscess
cavity may result in stabbing of a vein that, under local anaesthesia, will cause haemorrhage
unless the incision be enlarged so the vein can be ligated. After novocain, infiltration' of
the subcutaneous structures should be used through the skin only. A small pointed artery
forceps can be passed through the intervening fat, superficial, cervical fascia and abscess
wall. Separating the blades of the clamp while it is still inserted permits a large portion
of the purulent exudate to drain off, after which a gauze drain is inserted. Leaving the
drain in longer than necessary plugs up the incision. Replacing the drain is a means of
contaminating the abscess with skin organisms. The neck is a tube; it is frequently being
twisted by the movements of the head, resulting in increased pressure in the cervical
intraf ascial compartments. Drainage of pus is enhanced by the increased pressure to such
an extent that the drain does not have to be replaced. If the skin seals over before the
abscess is completely evacuated, an additional puncture through the same opening with
the forceps is all that is necessary. No drainage material need be used following; the
second puncture.
The character of purulent exudate is typical in the infections; the thin green liquid
containing flakes of calcified material or necrotic tissue should indicate the use of no
drainage materials. In suspected cases, the abscess cavity should be lightly curetted and
the incision allowed to heal per primam. Filling the cavity after drainage with a slowly
absorbing paste has been discontinued because of the foreign body reaction of the tissues
to such substances. Treatment of the infections by aspiration and injection of pastes has
been replaced entirely by incision and evacuation of exudate. Re-opening the abscess
cavity should not be done in a week or ten days to drain out the serum formed from the
blood clot which immediately follows incision and drainage; absorption is preferable.
The chronic discharging of cervical sinuses that was so prevalent during the late
period in which there were numerous cases of the adenitis, has about disappeared from the
clinic and hospital services. The sinuses seemed to be the result of prolonged use of
drainage materials in the pyogenic cases and the use of drainage materials, with secondary infection, in tuberculosis.
The treatment employed in the chronic sinuses at present is: general anaesthesia; softly
curette the granulations from the tract; swab with carbolic acid; no drainage material,
and, prolong the first dressing as long as possible. A modified Orr type of procedure for
dressing bone infections has given very good results where used in conjunction with vaccines. The X-ray therapy method of treatment has been discontinued' for chronic sinuses
because of the tendency for healing over of the surface with recurrence of abscess and
chronic sinus recurrence.
[ I ] ANGINA PECTORIS AND CORONARY THROMBOSIS
A Clinical Study of One Hundred Cases of Each Disorder.
E. P. Scarlett, M.D.
I.    Angina Pectoris.
The increasing knowledge of coronary artery disease has made possible a more accurate
clinical definition of the syndrome angina pectoris. This has served to free physician and
layman alike from the tyranny of the term, which in the past was'inadequately understood.
Wliat do we mean by angina pectoris? A summary definition may be indicated as follows
Angina pectoris is a disease of the heart manifested by pain in the region of the sternum,
such pain having a variable radiation. It is a syndrome of coronary artery disease, the pain
arising from ischaemia due to local arterial spasm of the coronary vascular tree. If the
ischaemia is transient, we call the resulting condition angina pectoris. If it is permanent
and infarction follows, we call the condition coronary thrombosis.
There is thus the link of a common pathogenesis between the two conditions. The
difference would seem to lie in the degree of the primary disturbance. The recognition of
the essential unity of the two conditions is one of the substantial achievements of our time.
Whether, of course, in the light of the above definition, the concept of angina pectoris rests
upon a satisfactory basis is a matter of opinion. The last word in this connection has not
been said. Certainly, however, we have not reached the place where the term angina
pectoris can be discarded.
The present study is based on an analysis of one hundred cases. These cases have been
selected only insofar as the diagnosis was established, full diagnostic material available,
and the subsequent course followed. There have been excluded the following conditions:
effort pain following coronary thrombosis, rheumatic heart disease, and syphilis of the
aorta. It is not supposed that any far-reaching conclusions can be drawn from a series of
this dimension. At the same time figures have a qualitative value and their consideration
may aid us in thinking more accurately of Heberden's angina.
The diagnostic criteria which have been employed in making the diagnosis of angina
pectoris are as follows:
1. Sudden onset of distress.
2. Distress of short duration—usually less than ten minutes.
3. Distress experienced is a pain on pressure or a choking sensation.
4. The region involved is the sternal region with or without radiation, and if the distress radiates it is usually to the arms.
5. The attack is precipitated by exertion.   The distress usually bears a quantitative
relation to exertion, particularly after meals.
In the 100 cases there were 85 men and 15 women. The range of age was from 32 years
to 74 years. The average age in the case of the men was 57.4 years and in the case of the
women 57.3 years. In 64% of the! cases the condition began between the ages of 50 and
65, and in 64% of the cases it began after the age of 55.
The pertinent details in connection with mortality and age incidence may be summarized as follows: 40 patients are dead and 60 patients alive. In the deaths 35 were male
and 5 female. The average age at death' in the case of the males was 64 years and in the
case of the females 56 years. It was found that one-half the patients attained the age of
60 or over; i.e., they attained the present expectation of life. Age was found to have no
bearing on prognosis.
The average duration of the disease in the fatal cases was 3.5 years. This period is
somewhat shorter than other studies which have been made and which showed a duration
of from 4 to 5 years. In general the period of survival was found to be that of a similar
group of cases with cardiovascular disease but without angina pectoris. The average
duration of the disease in the surviving cases up to the present time has been 4.6 years.
Two individuals are alive nine years after the onset of the condition, one after a period
of ten years, and one after a period of thirteen years.
With regard to the location and radiation of distress, 82% of the patients indicated
their distress as being substernal and another 10% as being high in the epigastrium. The
[ 12 ] rarest site in which distress was experienced was the apex. This is worth noting, as this is
the most common site in which pain is experienced' by patients who are not suffering from
angina pectoris but from chronic fatigue or cardiac neurosis. The most common radiation
of the pain was to both arms and this was followed closely by radiation! to the left arm.
Thirty per cent of the patients experienced aggravation of pain by exposure to cold.
The salient points in the physical findings may be briefly indicated as follows: 37%
of the patients showed hypertension (i.e., a blood pressure over 150/96). 18 of the 40
patients who died had hypertension. Extreme degrees of hypertension were found uncommonly, only 6 cases in this series showing such a finding. An important finding was the
incidence of hypertension in women. 12 of the 15 women in this series showed hypertension. From this fact we believe that one should hesitate to make the diagnosis of angina
pectoris in a woman with a low blood pressure. The cardiac findings themselves were not
significant. Cardiac enlargement was not very common. Obesity, while present in 21 %
of the cases, was not notably significant. 17% of the cases showed a normal blood pressure,
normal size of the heart, normal cardiac findings, and a normal electrocardiogram, thus
emphasizing again the fact that it is possible for an individual to have angina pectoris and
still have essentially negative findings as far as the cardiovascular system is concerned.
Diabetes played little part in this series. The findings of local chest hyperaesthesia were
uncommon. In the series there were no cases of congestive failure or auricular fibrillation.
The electrocardiographic findings were studied in detail. Three rather significant conclusions may be drawn from their analysis. The first is that the electrocardiogram offers
no positive aid in the diagnosis of angina pectoris. The second conclusion is that a normal
electrocardiogram would appear to offer a better prognosis. Of the 25 cases showing a
normal electrocardiogram 23% died, while in the 75 cases in whom an abnormal electrocardiogram was found 48% died. And the third observation is that negativity of the T
Waves in lead 1 or leads 1 and 2 was found to be an unfavourable, sign, the majority of the
patients who died showing this change.
Fifty per cent of the patients died a sudden death. This observation hasi been borne out
by other studies of angina pectoris. In general the prognosis would seem to depend upon
whether the individual with angina pectoris develops coronary thrombosis.
The difficulties are obvious when it comes to appraising the value of the factors influencing an estimate of the prognosis in angina pectoris. At the same time, certain conclusions may be drawn from this study:
1. Age and obesity are of no practical importance.
2. Hypertension is slightly unfavourable.
3. Normal electrocardiographic findings are favourable.
4. T Wave negativity in the electrocardiogram is unfavourable.
5. The patient's care of his health and the conduct of his mode of living is an important determining factor.
6. The amount of exercise which initiates the pain if some guidance in prognosis.
7. The hereditary factor with regard to vascular disease is important in charting the
future.
One final note with respect to prognosis seems justified in the light of these observations. Viewing the cases in the light of the age at onset, the age at death, the average
duration, and setting these factors over against the background of the average life expectancy of an individual today, there would appear to be sound grounds for a guarded
optimism in angina pectoris. That means that the physician can conscientiously give his
patient hope in this condition. As Parkinson has said: "Too much attention has been
centred on the anginal death and too little on the anginal life and its management."
II.    Coronary Thrombosis.
There were one hundred cases of coronary thrombosis and they were selected so that
none were included that had experienced a previous anginal syndrome. The cases were
made up of 79 males and 21 females. The average age of the men was 59.2 years and of the
women 59.8 years. The range of age was from 31 years to 83 years. Most of the cases
occurred in the 50's and 60's.  50% of the cases occurred before the 60th year.
[   13   ] In regard to the consideration of mortality it was found possible to include only 64
cases. Of the remainder 16 were dead on admission to hospital and 10 died shortly after
admission, so that no satisfactory previous history could be obtained. In the remaining 10
cases a satisfactory follow-up in all particulars was not possible. Of the 64 cases 40 patients
are dead and 24 patients alive. The deaths consisted of 32 males and 8 females. The
average age of the fatal cases was 59.9 years. The average age of the surviving cases is
57.1 years. The data concerning the number of attacks was relatively unsatisfactory.
However, roughly speaking, two or more attacks of coronary thrombosis were experienced
in 20% of the cases.
The average duration of life after the attack in the 40 fatal cases was 7l/z months and
in the 24 surviving cases 2 years and 10 months. Analyzing the duration after the attack
it was found that 14% of the cases died within the first twenty-four hours, 14% in the
period of one day to one month, 2 8 % in the period from one month to one year, 3 % from
one to three years, and 3 % from three to eight years. One patient died eight years after
the first attack. Two patients are alive nine years after an attack.
Looking at the whole series it may be said that approximately 50% of the patients survive an attack of coronary thrombosis, and by that we mean that they return to reasonably
good health before cardiac symptoms again supervene. Other points in this connection that
should be noted are that there was no correlation between the mildness of the attack and
recovery. It was common to see a patient in a mild attack who showed no complaints after
the first twenty-four to thirty-six hours, who showed nothing remarkable on examination,
and then died suddenly on the seventh to tenth day after the onset of the condition. A
converse situation was also observed; i.e., a patient could have a very severe shock and still
ultimately recover. Thus it would seem that prognosis in the individual case must be
guarded until weeks have elapsed. Again, as a general rule younger patients seem to survive
a little longer. A further interesting point was that in approximately 42% of the patients
the attack of coronary thrombosis occurred without antecedent circulatory symptoms and
in persons who had no reason to doubt the integrity of their hearts.
For the most part there was nothing characteristic in the physical findings in the
patients in this series. Established hypertension was present in 50% of the cases. Auricular
fibrillation was noted in 13%, congestive failure in 19%, pericarditis in 8%, and embolic
phenomena in 8%. Associated conditions were observed in the presence of obesity in 9%,
diabetes in 11%, and syphilis in 8%. Abnormal electrocardiographic findings were noted
in 84% of the cases. Taking the clinical findings in respect to prognosis, it may be concluded that there is no single feature which may be regarded as indicating recovery or the
reverse. Furthermore, the electrocardiogram is of no appreciable help in prognosis.
Fifty of the cases came to autopsy. Without detailed findings, it may be recorded that
in 62% of the cases the anterior descending branch of the left coronary artery was
occluded. In 30% both coronaries showed occlusion and in 8% the occurrence was caused
by interference at the mouth of the coronary vessels as the result of luetic aortitis.
Finally, viewing these cases as we did the cases of angina pectoris, certain conclusions
with regard to prognosis would seem to be justified:
1. The prognosis in the individual case of coronary thrombosis is even more uncertain
than in angina pectoris.
2. In general about 50% of cases survive an attack of coronary thrombosis.
3. The criteria for prognosis in the individual case of coronary thrombosis is so
unsatisfactory that at all times prognosis must be guarded.
4. It is possible for patients to survive an attack of coronary thrombosis for years and
remain in good health.
[   14  ] COMMON FALLACIES IN THE DIAGNOSIS OF
CARDIOVASCULAR DISEASE
E. P. Scarlett, M.D.
In no field of medicine has the March of Time wrought more changes in ideas and
clinical practice than in cardiology. I wish to discuss certain aspects of heart disease where
certain older ideas have been carried forward, giving rise to misconceptions and working
hardships on patients. It is not that the ideas are old but that they now are seen to lack
foundation in the light of newer work and further observation.
I Pain in the Chest. The evaluation of chest pain is really not a difficult problem,
but it one which is constantly before the practitioner. In the last two years we have seen
scores of people with pain in the mammary region of the left chest who come to the
physician because they are concerned about the possibility of heart disease. None of these
cases have had any cardiac disease. A few have been true examplejs of radiculitis with
dorsal root involvement. Most have been a neuralgia, in some following influenza, some
following excessive fatigue, some due to neurocirculatory asthenia, some with no apparent
cause. Practically all have had local chest tenderness. 75% have shown trigger-point
tenderness in the axilla. About 40% have shown posterior paravertebral tenderness in
the corresponding nerve segment.
The characteristics of true cardiac pain are that it is substernal in site and that it
always tends in a given individual to recur in the same site. The pain radiates most commonly in our experience to both arms. It is initiated by exertion and relieved by rest.
In character it varies from a dull ache to a sensation of pressure and again in a given
individual it always tends to be the same in character. It is never sharp and stabbing.
There is a clinical axiom that may be formulated in connection with pain in the chest and
it is this: the pain of organic heart disease is essentially substernal pain on exertion.
II Cardiac Enlargement. A useful clinical axiom may be stated at once in this connection. An enlarged heart is a damaged heart. Thus it is that the determination of
whether or not the heart is enlarged is at times a most important thing. The method of
determining cardiac enlargement can not be said to rest safely on percussion. Palpation
of the apex impulse is a much surer method. Here, however, a high diaphragm causing a
so-called "transverse heart" or scoliosis may give rise to erroneous conclusions and emphysema and obesity may add to the difficulties of determination. Further, the depth of the
heart as in mitral stenosis can not be determined by percussion or palpation. If there is
any question at all the only sure way of determining the presence of cardiac enlargement
is to do a fluoroscopic examination. We think it important to point out these facts, particularly if a person is to be condemned to a sentence of heart disease on the basis of cardiac
enlargement.
There are three other points in connection with cardiac enlargement:
(1.) The heart does not increase in size in old age as a normal process. When enlargement exists it is the result of other processes, hypertension or coronary sclerosis.
(2.) The heart in toxaemic states does not enlarge, as for example in long standing
tuberculosis or pneumonia.
(3.) Oedema which is not associated with enlargement of the heart is practically
never cardiac in origin.
III Cardiac Sounds. The situation still arises occasionally where a heart is condemned
because the heart sounds are described as "weak" or "of poor quality". It should be
emphasized that very little can safely be drawn from the loudness of the heart sounds.
Loudness is no criterion of efficiency. At the same time, however, the character of the
sounds may be of great help in diagnosis.
IV "Fatty Heart". One frequently comes across this diagnosis. Because obese people
tend to become short of breath on exertion, a diagnosis of "fatty heart" is made. It
should be remembered that even although at post-mortem it is not unusual to find fat
stored in and around the heart, during life its presence can rarely be proved to be a cause
of myocardial insufficiency.  Furthermore, clinical criteria for such a diagnosis are abso-
[   15   ] N
lutely lacking. There-is thus no justification for this term. When definite symptoms of
cardiac insufficiency in obese individuals are present, another cause must be found and it
is usually hypertension.
V Chronic Myocarditis. This term is more and more proving to be a diagnostic
stumbling block and a source of much confusion. The term as it stands means chronic
inflammation of the myocardium and implies invasion of the myocardium by bacteria
or injury by their toxins. Actually this occurs rarely with the exception of myocardial
involvement in rheumatic fever, diphtheria and rarely syphilis. In the majority of cases
in which the term is employed the patient h#s either coronary sclerosis or hypertensive
heart disease or both. Neither of these conditions is the result of infectious processes.
The term undoubtedly came into being as the result of the finding of myofibrosis
found as the response of gradual deprivation of the blood supply in coronary disease. In
such cases the left ventricle was predominantly involved. Similarly in another condition
frequently called chronic myocarditis there is left ventricular hypertrophy as the result
of long standing hypertension which goes on to failure when loss of myocardial tonicity
results.
In view of these considerations, to secure accuracy, the term "chronic myocarditis"
should be dropped. As things stand at present it is really an outdated "portmanteau"
term.
VI Physical Strain* of the Heart. It must be emphasized that the healthy heart can
not be injured by physical strain. There is convincing proof of this in work which has
been done in recent years. A heart which can be demonstrated to be reduced in efficiency
and shows abnormal signs following a period of violent exertion is the seat of disease
and the damage is due to this preceding disease and not to the strain. The etiology of
the disease should be determined if at all possible, whether rheumatic or coronary sclerosis,
etc. And finally it follows as a corollary that there is no such thing as the "athlet's
heart".
VII Syncope in relation to heart disease. In the minds of the laity dizziness and
faintness are regarded as cardinal symptoms of heart disease. Actually in practice syncope is rarely associated with cardiac lesions. Fainting is a pure example of peripheral
circulatory failure as opposed to cardiac failure. When fainting does occur and it is associated with a cardiac lesion, in the great majority of cases the cause is easily detected.
Less common cardiac conditions which produce fainting are as follows: high grade heart
block with Adams-Stokes' seizures, the onset of coronary thrombosis, ruptured aneurysm,
an attack of paroxysmal tachycardia, and, less commonly, the so-called hypersensitive
carotid sinus reflex.
VTII Extra systoles. It occasionally happens that many practitioners regard extra
systoles as an indication of organic heart disease with disastrous results to their patients.
At the least it is often labelled to the patient as a "heart irregularity." Frequently the
occurrence of extra systoles is the way in which the patient for the first time becomes
heart conscious and alarmed.  Points to remember regarding extra systoles are:
(1.)    In diagnosis if the heart is speeded up to 120 the extra systoles disappear.
(2.)   Extra systoles are of no clinical significance in themselves.
(3.)    After middle age they are almost a normal phenomenon.
(4.)    When present in a case of organic heart disease they may be safely ignored
in assessing the seriousness of the condition and in considering the prognosis.
IX The systolic murmur. There have been two extremes in considering the problem
of the systolic murmur, one school saying that the apical systolic murmur may be ignored,
the other claiming that it is most significant. At the outset it should be pointed out that
it is a crucial point in the analysis of any heart sign that emphasis should not be placed
on a single factor but that the factor should be viewed along with the other signs and the
history in the light of the functional adequacy of the circulation.
The significant points in assessing the systolic murmur are the character of the murmur, the presence or absence of cardiac enlargement, the history, the presence or absence
of such co-existing condition as hypertension, hyperthyroidism, fever, asthenia, and low
[   16  ]
4^ .>hHH.
blood pressure. In general if the systolic murmur is confined to the aortic area and tends
to be transmitted up the carotid vessels it means disease of the aorta or the aortic valves.
If the murmur is confined to the left basal area, the so-called pulmonic area, it is almost
invariably of no significance (exception—congenital defect). If the murmur is at the
apex and it is a long loud murmur transmitted widely, particularly to the left, it jis
usually significant, indicating either insufficiency of the leafllets of the mitral valve, such
as occurs in endocarditis, or functional mitral insufficiency, such as occurs in the stretching of the mitral ring consequent to hypertrophy oi the left ventricle as in hypertension.
If the murmur is at the apex, is rather soft and blowing in character, and is heard in different areas, it may indicate augmentation of cardiac activity and blood flow, which tends
to occur in hyperthyroidism severe anaemia, and during fevers.
The presence of an apical systolic murmur in children constitutes a problem of considerable magnitude. In such cases the murmur which is of no significance is typically
short, very soft, and tends to disappear with change of position. The soundest position to
assume in this problem would seem to be as follows: in the child with an apical systolic
murmur which is loud, relatively harsh and blowing, relatively prolonged and transmitted
to the left, and if at the same time there is a history of rheumatic fever, and fluoroscopic
evidence of hypertrophy of the heart or the so-called mitral configuration heart, the murmur must be regarded as an organic murmur, meaning heart disease.
The conclusion that we reach, therefore, in this whole matter is to steer a middle
course in the interpretation of such murmurs, to assess carefully all factors in the case
before coming to a conclusion, to remember that the essential considerations are the history, the size of the heart and the character of the murmur, and finally and above all,
not to treat the murmur.
X Some blood pressure considerations.
(1.) It may still be heard in some quarters that a patient's systolic blood pressure
in millimetres of mercury should equal 100 plus the age in years. Statistics prove
that this is not the case. The blood pressure should normally rise very slightly
with age.
(2.) The weekly or monthly rise or fall in blood pressure generally speaking is not
a barometer of the patient's course. We would deplore the tendency to encourage
this view and attitude in patients.
(3.)    The diastolic pressure is the significant phase of blood pressure readings.
(4.) Blood pressure should always be interpreted in the light of the functional efficiency of the heart and the kidneys. These latter determinations as a rule are
made readily.
XI Coronary Thrombosis. It often happens that the physician wonders whether
actual coronary thrombosis has occurred because on physical examination no changes can
be detected. It should be remembered that in the majority of cases of coronary thrombosis
on examination there is found a regular rhythm, no murmurs and no increase in the size
of the heart. Not infrequently, too, an electrocardiogram taken after a coronary thrombosis may be normal in every particular. Thus, in attempting to arrive at the diagnosis,
the history and the circumstances of the seizure are the things of major importance.
PEPTIC ULCER
New Variations on Old Themes
E. P. Scarlett, M.D.
This discussion essentially resolves itself into an evaluation of some of the problems
surrounding the conditions known as peptic ulcer. The literature concerning this disease
is so voluminous that there is the ever present danger that we can not see the wood' for
the trees. It is well, therefore, periodically to ask certain questions. Where do we stand?
What programme of treatment shall we adopt? If we continue the old routine and scheme
of treatment, what newer modifications are worthy of trial?
[   17   ] Certain generalizations seem clear.  These may be stated summarily as follows:
(1.) Peptic ulcer is probably not a specific disease and the etiology is unknown. It
is a disturbance with varied histo-pathological features and with variable factors in
etiology. It is essentially a chronic disease in which, for the present at least, the treatment
is empirical and therefore not entirely satisfactory. Thus, no definite standardization of
treatment is possible and the problem of treatment remains largely a specific matter in the
individual case.
(2.)   The most important factors in the causation and persistence of peptic ulcer
are:
(a) The inherent constitutional predisposition to form ulcer, the so-called ulcer
diathesis.
(b) The tissue susceptibility to ulcer.
(c) The increased gastric acidity. Inasmuch as in the state of our present knowledge little can be done to change the inherent predisposition and the tissue
susceptibility, measures have turned largely about the control of gastric
acidity.
(3.) While the term "peptic ulcer" is useful for discussion purposes, a distinction
must always be drawn between gastric and duodenal ulcer. The two lesions are dissimilar
histologically, physiologically and pathologically.
(4.)   A plan of ulcer treatment must include provisions for:
(a) Control of distress and management of complications.
(b) Plan of a regimen to promote adequate healing.
(c) Prevention of recurrences.
(5.) There is a fairly general agreement in regard to the principles of treatment.
Medical treatment has been established on broad bases and must include the immediate
and follow-up period. The indications for surgical treatment are now generally better
appreciated and especially the indications for partial gastrectomy in duodenal ulcer are
becoming clearer.
Recent studies would seem to indicate that gastric ulcers are more common than we
generally supposed. The ordinary gastric ulcer is less vocal, it is more acute and heals
readily, while the duodenal ulcer is more chronic and heals with scarring.
Medical Treatment of Ulcer.
A regimen or rest, diet and alkalies, together with the use of sedatives and antispasmodics is now the accepted basis of treatment. However, few now follow the traditional management. Some emphasize one factor; some another. Modifications in regard
to aspects of this programme are considered briefly.
(1.) Diet. The general principle that is accepted is the use of frequent feedings of
milk and bland foods. A modification which has been put forward and seems quite satisfactory is the use of tablets composed of milk powder and alkalies, which are given hourly
during the earlier stages of treatment. These neutralize acid well, are better for ambulatory patients, and their use means less tablets to be taken. They have certain advantages
and in our hands have been a satisfactory method of treatment, the only disadvantage
being the cost. A further recent suggested modification in the diet is the emphasis which
has rightly been laid upon the necessity for securing an adequate intake of vitamin C in
the diet because there is a low intake of this vitamin on the ordinary Sippy programme
and also because an ample intake of vitamin C assists in controlling bleeding tendencies.
This end may be secured by giving at least three ounces of orange juice a day in diluted"
form and it is suggested that this should be part of the routine dietary programme.
(2.) Alkali therapy. Fault has been found with the traditional alkali scheme as
advocated by Sippy. Undoubtedly the ordinary alkalies have tended to cause an increased
secretion of acid, gastric irritation and bowel disturbance in many cases. These are local
and immediate disadvantages. In a larger way, however, it should be pointed out that too
much reliance should not be placed upon the use of alkalies in the treatment of ulcer. It
now begins to appear that in the past we have been too much taken up with the acid
[  18  ] theory. Certainly alkalies are not a cure for peptic ulcer. The basis of cure is much more
complex. They have a relative value only and are distinctly less important than diet
and the general regimen of living. If food controls symptoms, some men omit the use of
alkalies.
In an attempt to get away from the unsatisfactory features of traditional alkali
therapy, certain substitutes have been put forward. These are tribasic phosphate, colloidal aluminum hydroxide gel and hydrated magnesium trisilicate. Each of these agents
is quite satisfactory and certainly obviates the danger of alkalosis and in nearly all
instances is much better tolerated than the traditional alkalies. They have been successful
in our own experience.
(3.) Antispasmodics. In nervous patients with pylorospasm and associated spastic
colitis Tincture of Belladonna has been used1 in the past with good results. Thei only
drawback which has been experienced is its undesirable side effects in some cases. In such
instances the use of Trasentin has proved satisfactory. This drug is an ester of diphbnyl
acetic acid, has a pronounced effect on the parasympathetic nerve endings, is of low toxicity, and is rapidly excreted. Its only disadvantage is its cost.
(4.) General regimen. It is of paramount importance that in peptic ulcer the patient
should be treated first; that is to> say, his mode of living should be examined and every
ecort made to secure a measure of rest and freedom from strain. Efforts expended in this
direction rather than in attempting to secure complete acid neutralization are more logical and will bring better results. This is particularly true when it comes to the question
of preventing a recurrence of the ulcer. It should be added that the condition of the
bowel must be given attention inasmuch as irritable colon is found frequently in association with peptic ulcer. Finally, tobacco is prohibited. Just how much importance attaches
to this restriction is still an open question. The treatment in the initial period should be
strict. The mode of living is of paramount importance.
Hemorrhage from Peptic Ulcer.
This problem is considered in this context because it is the one complication of ulcer
of the stomach which still remains within the purview of medicine rather than surgery.
Further, this is one phase of medical practice where traditional practice needs re-examination in the light of recent work and reports. The old conception that patients rarely die
from haemorrhage from the stomach must be discarded. A few points in this problem are
indicated. The incidence of haemorrhage from duodenal ulcer would appear to be between
20 Oand 30%. The mortality is higher than we ordinarily realize. There is a wide variation
in the studies which have been made, from 5 to 21%. We may conclude, however, that
it is at least 5%. The mortality rises with age and the presence of hypertension and
arteriosclerosis. It is higher from duodenal than from gastric ulcer. It rises rapidly with
the second and third haemorrhage.
When it comes to treatment, there is considerable controversy as to the best mode of
attack. In general one may say that 90% of cases may be carried through quite satisfactorily on medical treatment and it is the remaining 10% that present the problem. At
the present time there are at least three schools of thought in this particular:
(a) Traditional. The treatment under this scheme consists in starvation from two
to three days, large doses of morphine, intravenous 5% glucose during the starvation period, and transfusion if the haemoglobin falls below 30%. The exponents of this scheme of treatment point out that the mortality from gastric operations is higher than the mortality from bleeding ulcers and accordingly a surgical attack is not justified.
(b) Feeding school. This scheme of treatment is best represented by Meulengracht,
who, in 193 5 and again this year, has presented a large series of bleeding ulcers
with a mortality of between 1 and 2 %. His essential principle is liberal feedings
of pureed foods. The patients are encouraged to eat liberally from the onset and
are encouraged to move about in bed. Another modification of this mode of treatment is that followed at the Long Island Hospital, in which gelatine, gruel and
food are begun and progressively increased in the first four or five days after
[   19   ] hcemorrhage. A further modification is that of Woldman, who uses a continuous
aluminum hydroxide drip with milk and cream every two hours, followed by a
bland diet after the first twenty-four hours. In general, this mode of approach
would seem to have merit. The convalescence in these patients is most rapid and
the patient is not devitalized as on the old treatment. The statistics which have
been presented in support of these principles deserve respect.
(c) Surgery. With regard to the surgical attack, there is an increasing group of advocates of this method. Surgery, if it is to be used, must be within the first forty-
eight hours. It further must surmount the difficulties of diagnosis. And finally,
it must be carried out by highly skilled surgeons. Out of all the discussions concerning surgical treatment, at least three conclusions emerge:
(1) There is no clean cut indication for immediate surgery. The decision must
be based on clinical judgment in the individual case.
(2) The most obvious indication for surgical treatment during the emergency
period in haemorrhage from ulcer is a severe haemorrhage occurring in a
man over fifty years of age with a chronic ulcer, who does not show satisfactory response to transfusion.
( 3) Individuals who are over fifty and who have had two or more haemorrhages,
should have an interval operation.
And finally, of course, it should be pointed out that no type of operation gives
absolute assurance against a recurrence of haemorrhage.
In general, then, viewing the problem of haemorrhage from ulcer, it may be said that
this is a more serious problem than is generally realized by the profession. The traditional
medical treatment in the hands of the general practitioner is still probably the best plan.
A more liberal feeding along the principles of Meulengracht would seem to deserve further clinical trial. And surgical treatment would seem to be justified in selected castes,
as noted above.
Underlying the old conception and approach to the problem of peptic ulcer it should
never be forgotten that ulcer is one of what may be termed the "quadrad" of the abdomen
—ulcer, gall-bladder, appendix and colon. Many practical considerations follow from
this point of view. Only by keeping it in mind can peptic ulcer be dealt with satisfactorily.
THE SURGEON'S RESPONSIBILITY IN CARCINOMA
Roscoe R. Graham, M.B.,
Toronto
The responsibility which the surgeon must assume in the cancer problem has greatly
increased in recent years. Recent researches have opened up new avenues of approach,
with widespread physiological limits. The variation of cell growth is seen most readily
in the endometrium. That the hyperplasia which oversteps the accepted limits of normal
physiological requirements can be controlled by the administration of extracts from the
various endocrine secretions is now recognized. This ability to alter or change cell growth
by the administration of a normal secretion, given in abnormal doses, opens up vast fields
for speculation.
Our first responsibility then is to be on the alert for disturbances of normal function
which are manifested by changes in structures of various organs, thus producing a lesion
which simulates cancer. In a follow-up of cases of so-called mastitis, where for diagnostic
purposes a section of the breast had been removed, we have yet to encounter the subsequent development of a single case of carcinoma. The careful follow-up of these patients
over a long period of years leads us to conclude that there must therefore be a negligible
relationship between mastitis and carcinoma of the breast. Thus "mastitis" is a misnomer.
It is not an inflammatory process: it is but the expression oi an abnormal physiological
response.  Mastitis—a truly inflammatory reaction—surrounds all cases of carcinoma of
[  20   ] the breast, just as in carcinoma of any organ there is an adjacent protective zone of inflammatory reaction. With this conception that mastitis is an abnormal response to an endocrine secretion, one is led to enquire further afield in regard to minor disturbances. How
often do we find abnormal menstruation an accompaniment of painful breasts, or mastitis,
the latter often accompanied by a cyst or cysts. Proof of the fact that there is a definite
relationship between the internal secretory upset and the breast lesion is evident by the
relief which follows the cessation of one or other of the endocrine preparations, notably
Emmenin or A.P.L.
With these facts, we can discharge our responsibility of giving mental peace to the
patient, as well as protecting them from a serious operation. We do not have to resort
to a local mastectomy in cases of mastitis, to protect the individual from cancer. The
heartache and mental turmoil of the patient who has had an amputation of the breast
has only to be contrasted with the gratitude of the individual who has been spared such
a procedure. If the physical examination of the breast suggests the possibility of a cyist
being responsible for the tumour, there is no contra-indication to exploration with a
needle. If the fluid aspirated be other than bloody, no more radical procedure is necessary.
The aspiration may need to be repeated on two or three occasions, rarely more often. If
the aspirate, however, be bloody, a resection of the area is imperative, in order to exclude
definitely a duct carcinoma or duct papilloma.
This type of lesion seen in the breast exemplifies the mimicry of cancer which abnormal
physiological activity may present. An exhaustive history analysis may lead one to a
disturbance responsible for the local lesion, one which may be corrected.
The simulation of cancer by inflammatory lesions is a constant source of diagnostic
difficulty.   This presents the most acute problems in the oral cavity and the colon.
Actinomycosis may so simulate carcinoma of the jaw that even the most experienced have
been humiliated by this diagnostic error.
Diverticulitis of the sigmoid and lymphogranuloma venereum involving the rectum
present difficulties. The latter, however, can be definitely recognized by means of the
Frei test.  The former presents great difficulties, as examplified by the following case:
Mr. J.—aged 45—had fixed mass in rectum.  Laparotomy, and diagnosis of hopeless carcinoma—Colostomy.  Six months later all clear.  Two years later, closed Colostomy.   No biopsy taken at original operation.
Thus we have a grave responsibility to exhaust all the diagnostic means at our disposal
before arriving at the diagnosis of cancer.  A biopsy should be taken whenever possible,
and particularly exclude actinomycosis, diverticulitis and lymphogranuloma venereum.
The accurate knowledge available in regard to the etiology of cancer is so meagre
that we Have little responsibility in preventing cancer.   We should, however, not dwell
too intently on the problem of whether a certain lesion will become malignant or not.
We should concentrate all our efforts in determining whether or not the lesion is malignant now.   This problem presents itself most acutely in leucoplakia, gastric ulcer and
polypi of the colon.
It may be unnecessary to stress again the fact that in cases of leucoplakia or other
ulceration in the oral cavity, the finding of a positive Wasserman is not necessarily an
indication to dismiss the possible diagnosis of cancer, as oral cancer is so frequently found
in syphilitics.
In cases of gastric ulcer, the age-long debate as to whether such becomes malignant
or not has made little headway. The difficulties in attempting to answer this question are
so great and the evidence to support such a hypothesis so insecure that we have ceased to
maintain our interest. We are, however, ever alert and conscious of our responsibility in
determining whether the ulcer is malignant now or not. The treatment of patients with
a gastric ulcer by means of an indwelling duodenal tube, as practised by the medical staff
of the Toronto General Hospital and published by Cleaver, is most efficacious. The treatment, in brief, is feeding the patient for a period of three weeks, a special Pablum through
a duodenal tube, proven radiologically to lie in the duodenum. X-rays at the end of
three weeks may show a decrease in size of ulcer, in which case feeding is continued for
another three weeks.  If the ulcer is not then healed, or if there is no evidence of healing
[  21   ] I
at the end of the first three-week period, the diagnosis of cancer is accepted and operation
is advised.
In polypi of the colon we are confronted with a most difficult problem, as polypi so
rarely are single. While we know that malignant polypi occur, and that in many car-
cinomata of the colon there are associated multiple non-malignant polypi, the evidence
of a transformation from a benign to a malignant polypus, while probably more definite
in this area than in many others, is still based on very insecure evidence. Our real problem is to decide whether or not the polypus is now malignant. This of course is only possible if the surgeon will accept as his responsibility the accurate diagnosis of all disturbances in large bowel function, such disturbances as are manifested by a change in frequency
or content of the stool, the latter being evident by the presence of mucus or blood.
How often we still see a patient with a carcinoma of the colon or rectum, who visited
his physician, and occasionally only his druggist, requesting treatment for his bleeding
piles, and who has been given "pile ointment" without any attempt to verify the diagnosis.
Thus before we can decide whether the polypus in the colon or rectum is malignant
or not, we must be conscious of our responsibility to examine the patient. When we realize
that in our own series, forty per cent of all the carcinomata of the colon could be diagnosed
by a digital rectal examination, it is hard to understand how frequently this means of
examination, available to all, is neglected. A perfunctory rectal examination is almost
as useless as none at all. If we approach such rectal examination as if we expected to find
something, it would then reveal the maximum information. In cases where the history
suggests a lesion in this area, but which cannot be felt in the recumbent position, it should
be carried out with the patient straining in the erect position. If a diagnosis cannot
be reached by this method, we must add examination with a speculum and or a sigmoidoscope. May I commend to you the speculum designed by Gabriel. In an office examination,
with the patient in the knee-chest position, one can, with this instrument, visualize almost
the entire rectum. If a sigmoidoscope examination be necessary, may I make a plea that
if such an examination carried out in the office yield negative evidence, the patient be
admitted to hospital for a repetition of the procedure after the bowel has been thoroughly
emptied. We are in the habit of giving an ounce and a half of castor oil on the morning
preceding the examination, followed in the afternoon by cleansing enema till clear at
2 p.m. and 4 p.m. Non-residue diet is given during the day. Two drachms of paregoric
are given at 4; 6, 8 and 10 p.m.—a total of one ounce. No fluid or food is given after
midnight. The examination is carried out early the following morning. This preparation
has permitted us to secure the maximum amount of information possible by this examination.
If a polypus be discovered, it should be removed, the method of choice being by means
of a wire loop snare, through which a high frequency coagulating current is passed. If
there is a definite pedunculated polypus, and this histologically is proven to be malignant
without invasion of the pedicle, no further procedure is necessary. The longest case so
treated and followed is sixteen years.
At this point one must recognize the extreme limitations of our diagnostic ability.
The clue to the diagnosis, particularly in gastro-intestinal cancer, is an analysis of the
history of the evolution of the patient's symptons. The signs are too often conspicuous
by their absence. Thus, when the clinical history is such! as to indicate an exhaustive
investigation, and at its conclusion no cause is found, advise the repetition of the history
analysis and complete investigation in one month's time. This will so often solve the
clinical problem. Particularly is this true in cases of hasmaturia. If the first investigation
is negative, do not give the patient assurance, with no request for repetition of the investigation. By this means we are discharging our responsibility to the greatest possible degree.
The accurate diagnosis of Bone Tumours presents a difficult responsibility. The whole
question of biopsy must be faced. One can secure a multiplicity of opinions. All can
cite cases, where following a biopsy, widespread dissemination with multiple metastases
was evident. Were they the direct result of the biopsy, or were they co-incident extension
of the disease?  It is difficult to answer this query?
[   22   ] SkssbsI
As a staff, at the present time, we are unanimous in stating that no major surgical
procedure should be carried out without a biopsy, if the diagnosis be in doubt. It is true
that often a rapid microscopic examination at the time o£ the operation is inconclusive,
and actual operative procedure must be delayed for more detailed microscopic study. In
cases proven malignant, the interval between the biopsy and the operation should be as
short as possible. The advantages of this attitude far outweigh the disadvantages, as
many of the latter are at best no more than theoretical. One great responsibility in performing a biopsy, is to be certain that it be carried out with meticulous surgical technique.
An infected biopsy wound can prove disastrous. Particularly is this true in breast and
bone tumours. No biopsy, except from surface ulcerations, should be undertaken as an
office procedure, and rarely is a biopsy justifiable under conditions where an immediate
histological examination is not available. So often the frozen section will reveal the
diagnosis. The patient is thus not only saved the mental turmoil of suspense, but avoids
the necessity of two operative procedures, and this management eliminates many of the
disadvantages of a biopsy.
The multiplicity and the cost of the physical aids for the treatment of cancer has
made the decision as to the proper treatment of cancer much more difficult than was
formerly the case. The great cost has made necessary the establishment in the various
provinces, of centres for cancer treatment. So far, in this country, such centres provide
only the physical aids used in the treatment. In Sweden, the development of these centres
has progressed to a point where the cancer patient becomes a State responsibility, and the
treatment of cancer, not only by physical aids, but also by surgical therapy, is carried out.
Whether this wholesale nationalization of the treatment of cancer is wise or not is beyond
this discussion. There can be no doubt, however, that the cost alone of the physical aids
makes the grouping of cases necessary for purely economic reasons.
Thus our responsibility is to see that whatever operative therapy is indicated, or whatever physical aid is employed, in each instance the individual undertaking the treatment is
trained; adequately, and qualified to do so. We have known for years that there has been
a great deal of inadequate surgical therapy carried out. We now are realizing that inadequate radiation can be equally disastrous. The latter so often is the result, not only of
inadequate equipment, but often a very meagre knowledge of the principles underlying
radiation therapy. While such principles are imperfectly understood, there is much that
must be known before one undertakes radiation therapy.
So, too, in surgical procedures. The occasional operator should not undertake the surgical therapy of cancer. Adequate operative procedures in cases of cancer, if the patient is
to receive the maximum benefit, demand the highest technical skill, an accurate anatomical
knowledge, as well as a temperament which enables the surgeon to carry on continuously
and enthusiastically, completely undiscouraged, even though he must constantly be facing
not only the difficult technical procedures, but so often the inevitable ultimate defeat.
What is our responsibility to the patient who suffers a cancer for which there is no
permanent cure? The answer to this query will be determined almost entirely by the philosophy of the doctor who is consulted. Several questions present themselves which determine the advice given:
1. Is the relief of pain sufficient?
2. Is it worth while to prolong life, even though efficiency not restored?
3. Is it justifiable to ask a patient to accept a great immediate operative risk, when he
could otherwise be carried for 6-18 months before the inevitable fatality?
4. If at operation, remote secondaries are present, should the local lesion be dealt with
for the sake of comfort, or should we do nothing beyond an exploration?
5.   To what extent are we justified in handling the truth carelessly in order to give
the patient mental peace?
Each must formulate his own answers to these questions. We have answered them for ourselves as follows:
Our first responsibility is to use all the agencies at our disposal to prolong life.  Every
patient who suffers from cancer has a lethal disease: thus it is justifiable to ask such indi-
[  23   ] viduals to accept a great immediate risk in order to remove the local lesion and thus prolong
life. Breaking up the operative procedure into multiple minor procedures has proven not
only a factor for increased safety, but often if the preliminary procedure has been a def unc-
tioning one, such as a caecostomy, it will transform an apparently inoperable into an operable lesion. The three following cases illustrate the fact that a definite prognosis is difficult:
Female, aged 24. 15 years ago seen exsanguinated following haemorrhage from rectal
carcinoma. Transfusion. Colostomy. 3 months' interval and then perineal excision,
accomplished with the greatest technical difficulty. Since—2 Caesarean Sections;
operation for exophthalmic goitre, and well at present.
Female, aged 40. 7 years ago, operation for pelvic abscess. Sinus formed; fungating
carcinoma at opening. Resection abdominal wall, sigmoid, 2 feet of small bowel
and half bladder. Perfectly well at present.
Male, aged 34.   Complete invalid from disturbance of large bowel functions; pain;
diarrhoea. Treated two years for diverticulitis, without re-examination. Colostomy.
Four-month interval. Radical resection sigmoid, rectum, base of bladder, prostate.
Won two golf tournaments last year; five this year.  He will undoubtedly die of
cancer, but by this fundamental principle we haVe transformed an apparently
inoperable into an operable lesion.
This leads us to conclude that there are factors other than our operation which control
the patient's future. Thus we should make every effort to remove the local lesion whenever
possible. Should we carry this so far as to remove the local lesion in the presence of
irremovable secondaries? This depends entirely upon the site of the original lesion. In
most instances such a procedure would serve no useful purpose. In the breast and gastrointestinal tract, however, it may be of advantage to remove the local lesion, despite irremovable secondaries. In the breast, however, radiation can so often control the local lesion,
thus preventing ulceration, that such therapy accomplishes all operative procedure could
achieve.
In the gastro-intestinal tract, particularly in the stomach and colon, the great amelioration of symptoms accompanying the removal of the local lesion makes such a procedure
more often justifiable. If there are not more than two secondaries in the liver, we make an
attempt at local removal of carcinoma of the stomach, colon or rectum.
The mental comfort which the patient experiences when told that the growth is
removed is in itself almost sufficient justification for the procedure. We believe that any
means we may employ to add to the patient's mental peace are justifiable. When, however,
it becomes perfectly obvious to the patients that they are becoming worse, and that no
active treatment is being directed to their problem, it is then wise to tell them their exact
position. Such frankness gives further mental peace, as it banishes the thought that their
medical attendants might not "understand their case, and were not making any effort to
do so". Our responsibility to achieve amelioration of the mental distress is quite as great
as our responsibility to relieve the physical discomfort.
Conclusion.
1. Recognize excessive physiological responses which may simulate cancer. This is
particularly well exemplified in lesions of the breast.
2. Recognize the mimicry of carcinoma which chronic inflammatory lesions present,
particularly actinomycosis, diverticulitis and lymphogranuloma venereum.
3. The argument as to whether a benign lesion will become malignant is non-important, compared to determining whether or not malignancy is now present.
4. Our greatest responsibility is to examine thoroughly the patients coming for treatment. This includes history analysis, complete physical examination, and whatever physical or laboratory aids to diagnosis may be indicated. Such examination in a suspected case
should be repeated.
5. All means of establishing an accurate diagnosis, including a biopsy even on bone
tumours, should be employed before undertaking radical therapy.
[  24  ] -.\«*s**' I .-*»ja*w*4-'^.'i; wjgff»gJBWffiJBW<fcB^vjiwia<P
6. Treatment of cancer by radiation or operative therapy should be carried out only
by a highly trained personnel.
7. In the case of cancer hopeless for ultimate cure, we must use every effort to prolong fife and alleviate mental and physical suffering, even though our efforts carry a great
immediate risk.
8. Removal of local lesion in presence of irremovable secondaries is often justifiable.
CECOSTOMY—INDICATIONS AND TECHNIQUE
Roscoe R. Graham, M.B.
The basis of this discussion is an analysis of the histories of ninety-six patients upon
whom the author has performed cecostomy for either acute or chronic obstruction of the
colon during the last twenty years. The chronicle of the procedures carried out rjeally1
is the history of the evolution of surgical operations upon the colon during this period.
The principle of decompression of obstructed lumina in various parts of the body
has long been known. The earliest application was in decompression of the urinary bladder
distended as a result of obstruction of the urethra. It is in the application of this principle in the treatment of acute obstruction of the colon that a "blind" cecostomy becomes
an invaluable procedure. By "blind" cecostomy is meant a cecostomy which is performed
without coincident exploratory laparotomy. The administration of a barium enema prior
to the operation will in most instances localize the obstruction.
The the principle of decompression finds complete expression in blind cecostomy is
substantiated by the fact that in this series there were thirty-three instances of acute
obstruction of the colon which were submitted to a blind cecostomy, with but two deaths
from obstruction, a mortality of 6 per cent, which is unusually low in any group of
cases suffering acute intestinal obstruction. Following are the details of patients who
failed to recover from the obstruction: (1) a male, aged 74, obstructed for eight days,
who died of peritonitis; (2) a female, aged 56, whose cecum was so distended that gangrenous patches were present, one of which perforated during the operation. A third
patient died some weeks following the cecostomy, from inanition due to very extensive
local disease with multiple metastases.
It thus becomes obvious that as a simple safety measure a "blind" cecostomy offers
an admirable solution of the emergency resulting from an acfute obstruction of the large
bowel. It is felt that if this procedure fails to save the patient from the disasters of
obstruction, no other operative procedure would have succeeded. The details of the three
operative deaths cited above would support this contention.
The lesions for which cecostomy has been carried out in this group of patients are
shown in Table I, and provide an interesting comment on our therapy during this period.
TABLE 1
Carcinoma   of  the   colon .  74
Diverticulitis of the sigmoid .  8
Sigmoid obstruction due to band j  2
Volvulus of the cecum .  1
Perforated   appendix    2
Bullet  wound  colon     1
Colitis,   idiopathic    ,  2
Colitis, tuberculous  . j  1
Benign tumor with intussusception .. ■ i  2
Gastrojejunocolic fistula   i  3
Total number of patients having cecostomy i     96
It becomes obvious from this table that cecostomy is most useful in the malignant
lesions of the colon. Its value here lies in the relief of obstruction, either acute or chronic.
[  25   ] table ii
.  Distribution of Carcinomata
Ascending   colon  i —*- 1
Transverse colon  .  8
Descending   colon  9
Sigmoid   colon   , T  49
Rectum  .  7
A most valuable observation was made in one case, where the obstruction of the
transverse colon was due to an intussusception of a benign submucous lipoma. The
cecostomy adequately relieved the abdominal distention and an abundant fecal discharge
came from the cecal stoma. Despite this the patient suffered a persistence of the cramplike abdominal pain. The significance of the relief of the obstruction without coincident
relief of the crampy abdominal pain was not appreciated until a laparotomy was performed. We experienced the same phenomenon in a second case, and, correctly interpreting it, were able to proceed with the second stage of the operation as soon as the abdominal
distention and the biochemical upset accompanying the obstruction was relieved. This
is important with such a diagnosis, as undue delay makes the second stage of the operation more hazardous because of the edema and potential infection which persists about
the intussusception.
While only three deaths occurred when a "blind" cecostomy was performed, five died
when the cecostomy was coincident with a laparotomy. These five patients died of peritonitis. This is ample evidence of the rationality of the aphorism, "In all abdominal emergency operations, carry out only the most simple and atraumatic procedure directed
solely to saving life, dealing only with the cause of the emergency."
A secon aphorism is worthy of remembrance in acute abdominal disease: "Assess
the clinical picture carefully in order to ascertain the role which the various factors
contribute in creating the emergency." One would defer operation for carcinoma of the
breast in a patient who when first seen was also suffering from acute appendicitis. This
latter disease created the emergency, and must be dealt with adequately as a primary
manoeuvre. With similar logic, one must defer operation on a carcinoma of the colon
until the obstruction is adequately relieved. A blind cecostomy is the most simple, safe
and satisfactory primary procedure which will adequately solve the problem.
In addition to the pitfall where the chronic obstruction was due to the intussusception of a submucous lipoma, we have encountered a second lesion of the large bowel in
which a blind cecostomy alone would be inadequate to control the emergency. We refer
to a volvulus of the sigmoid colon. Our practice of using X-ray examination with} a
barium enema as a diagnostic aid will, if correctly interpreted, lead to an accurate diagnosis of this lesion. In the X-ray examination the great mass of the barium iri the colon
lies in the right upper quadrant. This observation, made in our department of radiology,
has been reported by Hall.1 With this diagnosis, the need tfor a laparotomy is obvious,
but a coincident cecostomy of real value in completing the decompression of the colon
after the volvulus is adequately dealt with. The coincident laparotomy and cecostomy do
not carry the potential, danger of peritonitis, as is the case where the obstruction is due
to an ulcerative carcinoma with associated edema.
Occasions arise, however, when one is confronted with the necessity of making the
diagnosis of intestinal obstruction in a very ill patient suffering from ill-defined, bizarre
abdominal systems, under circumstances where all the physical aids to diagnosis such as
the X-ray and other laboratory facilities are not available. The diagnosis of intestinal
obstruction can usually be made. The site and cause are of ten, difficult to determine. If
the obstruction be inflammatory, the appendix is the most common offending organ. If
the site of the obstruction be in the small bowel, and the common hernial sites are eliminated, an exploratory laporatory is essential. If the site be in the colon, the volvulus of
the sigmoid can be eliminated, an exploratory laparotomy is highly undesirable. This is
made evident by this study, as in this group of seventy-four cases of carcinoma of the
colon accompanied by obstruction there were twenty-two deaths, but only eight of these
could be attributed to the phenomena accompanying obstruction and only three of these
[ 26 ] iWWWlSW1**'.
tWJH^?
HSHEC^H^HIi
died following a blind cecostomy. Five died when the cecostomy was . accompanied by
an exploratory laparotomy, and in each instance death was due to peritonitis. The source
of the peritonitis we believe to be infection in and about the edematous, obstructed bowel
wall. The trauma incidental to the exploration, even though gently carried out, is sufficient to break the barrier and release the infection. It is very similar to the waterproof
qualities of a tent in a rainstorm. If a finger touches the inside of the tent, a break develops.
We have been impressed with the fact that patients suffering from obsruction of the
colon tolerate even the most simple operative procedures very badly. The incidence of
streptococci in and about the edematous, obstructed bowel has been admirably shown by
Garlock and Seley,2 where cultures taken from the various sites about the lesion yielded
a high incidence of hemolytic streptococci. Their suggestion to bring such patients under
control by sulfpyridine before operation would appear to be very sound.
Our method of procedure is to operate with a spinal anesthetic and explore the abdomen through a McBurney split muscle incision. The cecum and terminal ileum are
located. If the terminal ileum is not dilated, then the obstruction is in the small bowel,
and a paramedian incision is made. No harm has been done, and but a few minutes have
been consumed by making the McBurney incision. If, on the other hand, the cecum
and terminal ileum are distended, the site of the obstruction is distal to the cecum and the
obstruction will be relieved by a blind cecostomy without any of the increased hazards
which would have accompanied a coincident laparotomy. It has been our custom to bring
out a piece of cecum, which bulges into a circular mass approximately 1 inch in diameter.
This segment of cecum is fastened to the skin with four interrupted catgut sutures. Failure to sew the cecum to the skin is often followed by a retraction of the cecum to a
below-skin level. This renders the procedure less efficient, and is almost invariably accompanied by infection of the abdominal wall. The abdominal wound is closed about the
protruding piece of cecum with a few interrupted catgut sutures.
No attempt at an elaborate closure of the abdominal wall is made at this time, as we
recognize a second operation will be necessary to close the cecostomy, and at this time
the abdominal wall may be adequately repaired. After an experience which involves
many types of cecostomy operations designed to obviate the necessity for subsequent
closure, we believe that the efficiency of the procedure here described, where a mucocutaneous fistula is established, provides so much more efficient decompression as to justify
the additional operation necessary for its closure. We are insistent that no sutures be
placed in the bowel except those uniting it to the skin. To suture the bowel to the subcutaneous structures is to invite infection of the abdominal wound.
The cecum is not opened for twelve to twenty-four hours following the operation.
During this time the biochemical upset is corrected by the administration of glucose, salt,
water and blood as indicated.  It is amazing how much such patients improve during this-
period, even though the obstruction is not relieved.
The cecum is opened with the actual cautery. The incision is placed at right angles
to the long axis of the bowel. One rarely has to tie any blood vessel in the bowiel wall,
although provision should be made to do this at the time the cecum is opened. We then
immediately begin the instillation of oil into the cecum by means of a small rubber
catheter. Because it is cheap, efficient and readily available, we use raw linseed paint oil,
injecting 3 to 4 ounces two to four times in the twenty-four hours, the amount and
interval depending upon the degree of return of the oil through the cecostomy, which in
turn is in direct ratio to the completeness of the obstruction. As the edema about the
carcinoma subsides, the oil appears at the rectum, and then saline irrigations are carried
out through the cecostomy and through the rectum. This manoeuvre, together with a
low residue diet, is efficient in a large percentage of cases in keeping the colon empty and
permitting the subsidence of the edema in the bowel wall and about the tumour.
Because we plan later to repair the abdominal wall* these patients are allowed to be
up and about the ward in forty-eight to seventy-two hours after the operation. This,
we believe, is a real asset, as the general muscle tone and exercise tolerance is maintained
during the preparation, and the patient is thus much better able to withstand the next
operative procedure.
[   27  ] How long should the interval be between the cecostomy and the resection of the
obstruction lesion itself ? This question is answered by an analysis of the deaths which
have occurred after this second stage. There were thirteen deaths in this group where,
although the cecostomy was effective in relieving the acute obstruction, the patient succumbed following resection of the growth. In all but two instances, death resulted from
infection.
In reading the histories of these cases, one is impressed by the repetition of the statement in the operative note: "Bowel wall still shows edema," or "Bowel contains fecal
content." These statements are susceptible of two interpretations: first, the interval
between the cecostomy and the second stage was too short to permit adequate preparation; or the obstruction was so nearly complete that some additional procedure was necessary to enable the bowel to remain empty and free from edema. In no htstance should the
resection be undertaken less than two weeks after the cecostomy. If the cecum at the
time the cecostomy is performed shows evidence of gross edema, an interval of at least
three, and preferably four weeks should elapse between the two stages.
Even with the most painstaking and apparently adequate preparation, when the abdomen is opened for the second stage, one is occasionally chagrined to find residual edema
in the bowel wall and about the growth. Under such circumstances one should never
attempt any form of anastomosis in continuity. Rankin's3 obstructive resection of the
Mikulicz type may be used. If, however, the lesion be in the left? colon, we believe there
should be an additional operative stage, and, despite a limited experience, we are most
favorably impressed with Devine's4 defunctioning transverse colostomy. This permits
of the most adequate preparation of the distal colon.
If during an operative procedure the colon be involved or wounded, and one wishes
to provide a safety valve as a temporary procedure, the use of a Pezzer catheter witzelled
into the cecum, is an admirable procedure. This may be carried out through the laparotomy
wound. This manoeuvre permits the escape of gas and fluid content of the cecum, preventing distention, and is worthy of greater recognition than is generally accorded it.
Witzelling the catheter where it lies between the cecum and parietal peritoneum, enables
the catheter to be cut off at the .skin level when the need for the cecostomy is past. The
distal fragment will be passed per rectum and the fistula will heal readily. We have used
this type of cecostomy in cases of gastropepunocolic fistula, but the rod colostomy of the
ascending colon, as suggested by Damon Pfeiffer5 of Philadelphia, is a more efficient and
most valuable procedure.
In retrospect, and with the perspective of twenty years in the material presented by
these cases histories, one is more and more impressed with a few simple fundamental and
obvious truths in regard to obstruction of the colon, particularly when the obstructive
lesion be carcinoma: firstly, our operative therapy in cases of acute obstruction must aim
only at decompression of the colon, this to be achieved with the minimum of intraperitoneal manipulation; second, the colon must be kept relatively empty by non-residue
diets and irrigations. This must be kept up for from two to four weeks, in order to permit
the disappearance of the edema in the bowel wall and about the tumour; third, the
biochemical balance of fluids and salts must be restored and maintained. The value of
the proper proportion of glucose in saline and glucose in distilled water has been adequately
presented by Coller and Maddock.
These three fundamental truths seem so obvious that stating them, much less repeating them, would seem superfluous, and yet how often have patients been sacrificed because
of failure to completely and adequately grasp their import. In the presence of acute
obstruction of the colon, a blind cecostomy fulfills adequately and simply the requirements of the operative procedure, and it is in dealing with this problem that we have, in
blind cecostomy, a safe, simple and satisfactory method of combatting the emergency.
If, when the second stage of the operative procedure is undertaken, the edema in the bowel
wall or about the growth is not entirely relieved, or if the bowel is not adequately empty
of feces, this is not necessarily a condemnation of the value of the cecostomy, but evidence
that following the relief of the acute emergency, further and more efficient operative
means should be employed to secure an empty bowel free from edema. The Devine colos-
[  28   ] ^^HBBB^^Mi^^^^^^^^W^™SI
tomy does just this, and probably as experience increases, will become the second operative
procedure when the lesion responsible for the acute obstruction is a carcinoma in the left
large bowel. This should be seriously considered in all cases where saline does not run
through the colon freely during the irrigations. This additional step would entail two
further operative procedures—first, excision of the growth, with anastomosis, and second,
coincident closure of the cecostomy and colostomy.
The principle of multiple stage procedures is sound. We have been slow to appreciate
and apply this principle, which has contributed so much to the safety and efficiency of
surgical operations upon the colon. That multiple stage procedures are time-consuming is
no valid argument against their use. The procedures are much shorter than eternity,
which may be the alternative time to which we condemn the patient.
How long should be the interval between resection of the obstructing lesion and the
closure of the caecostomy? In only five of the ninety-six cases was the discharge from
the cecostomy so insignificant that the patient elected to carry on without further operation. The shortest interval in this series was six weeks. It has been considered Wise to
defer closure for three months, in order to permit a complete subsidence of all the inflammatory reaction about the anastomosis. If, however, there is continuous gross soiling,
which is most infrequent, with great discomfort to the patient, the cecostomy may be
closed any time after six weeks, providing X-ray examination with a barium enema shows
a good lumen at the site of the anastomosis, thus ensuring a disappearance of any obstruction from postoperative edema.
The details of the dissection which we carry out in closing the cecostomy are adequately presented in Figure 2. In most instances this can be carried out extraperitoneally.
One need have no concern, however, if the peritoneal cavity be opened. Using the technique which we have developed, there has been no case of peritonitis following closure.
The incidence of infection in the abdominal wall has been negligible. The use of BIPP
rubbed into the layers of the abdominal wall after excision of the scar tissue we believe
to be of real value in preventing wound infection. If, when the bowel has been closed,
as indicated in Figure 3, the peritoneal cavity has been opened, a continuous catgut suture
closes the anterior peritoneal peritoneum. The internal oblique and transversalis muscles,
as well as the aponeurosis of the external oblique, are united with a few interrupted catgut sutures, the skin being loosely closed with a few widely separated interrupted silk
sutures.   The patient is allowed out of bed in ten days.
Conclusions.
1. In acute obstruction of the colon, a blind cecostomy offers a safe, simple and
satisfactory means of combatting the emergency.
2. The technique of sewing the cecum to the skin ensures efficient drainage of the
cecum with a minimum of wound infection.
3. The patient is able to be out of bed within forty-eight to seventy-two hours of
the operation, and muscle tone and exercise tolerance are maintained during the preparation for the subsequent operative procedure.
4. A minimum interval of two weeks should elapse between the cecostomy and
resection of the tumour, longer intervals being required in direct ratio to the degree of
edema at the cecum.
5. If at the second operative stage, edema of the bowel wall be still present, this is
not a condemnation of cecostomy, but an indication to defer resection and carry out a
procedure to more efficiently defunction the colon.
6. Closure of the cecostomy should be deferred a minimum of six weeks, and preferably for three months following the resection.
1. Hall, M. R.: Am. J. Roentgenol., 39:925   (June)   193 8.
2. Garlock and Seley: Surgery, 5:794, 1938.
3. Rankin, F.  W\, Bargen, J. A., and Bute, L. A.: The Colon, Rectum and Anus.   Philadelphia,  1932.
W. B. Saunders Co.
4. Devine: Surgery, 3:165, 1938.
5. Pfeiffer, D.   To be published.
6. Coller, F. A., and Maddock, "W. In Bartlett, R. M., Bingham, B. L. C, and Tederson, S.: Surgery, 4:441;
614,  1938.
[   29   ] THE SELECTION OF CASES WITH GALL BLADDER
|     | DISEASE FOR SURGERY
R. Franklin Carter, M.D.,
J. Russell Twiss, M.D.
AND
Bernard Marraffino, M.D.
The results of operations upon the gall bladder patient are at present undergoing a
careful scrutiny. From this attention to follow-up results and a more searching study
of operative findings there seems to be a growing need for a revision of the selection of
patients for surgery. Particularly is this true in those patients that have been classed as
having chronic cholecystitis. The studies of the more advanced types of gall bladder
diseases have shown less need for ar radical change in the indications for or the methods
of surgery employed in the past. The results of study indicate that the more advanced
the disease is the more definite the indications are for surgical interference. A review of
the role that surgery has played in the treatment of gall bladder disease from the early
days to the present, reveals the good results that have always attended the employment
of surgical methods in the treatment of the more advanced types of disease. The employment of surgery for early gall bladder disease was justified by the dual belief that its early
use would both relieve the patient of symptoms and prevent the development of a more
serious type of disease. Convincing argument in favour of the use of surgery in the early
stages of chronic cholecystitis has appeared in the medical literature during the past
twenty years. The most convincing part of the argument has always been based upon the
high percentage of cures reported and the low mortality rate attending cholecystectomy
for chronic cholecystitis without stones, or early gall bladder disease. The internist has
apparently been so favourably impressed by the marked reduction in operative mortality
rate that he has been reluctant to state openly what has been individually said, viz., that
many of the patients were the same or worse, following cholecystectomy for chronic
cholecystitis.
A combined staff of internists, surgeons, chemists and other specialists was selected
at the N. Y. Post-Graduate Hospital in 1929 to organize a clinic for a more complete
study of patients with all types of gall bladder disease. One of the first interests of the
surgical members of the clinic was to determine some way to select those patients for
operation for chronic cholecystitis that might be expected to have a favourable result. In
addition to the early interest shown in the post-operative results of treatment in early
gall bladder disease there was formulated a routine to attempt to improve the methods of
differential diagnosis in advanced disease. An improved pre- and post-operative routine
for the detection and treatment of liver damage was established early in the operation of
the clinic. The changes in the routine of the clinic that have been made during the past
ten years have not interfered with the accumulation of data upon the follow-up results
in patients treated for chronic cholecystitis without stones; the differential diagnostic
studies in advanced disease; and the results of the pre- and post-operative treatment of the
patient with liver damage.
In this report there will be an attempt made to briefly review the details of the clinic
routine and to give the conclusions in use for the selection of patients for surgery with
all types of disease of the gall bladder and ducts.
General Routine of the Clinic.
Reference has been made from all other clinics in the hospital of patients with both
suspected and proven diagnosis of gall bladder disease—1927 individual cases up to July,
1939. The routine of study has been subjected to test upon many patients that were
found to have no gall bladder disease—11% of the total. In addition it has been employed
for patients in the clinic and hospital wards having all types of gall bladder, liver and
pancreatic involvement—approximately 20,000 patient visits with 2160 in 193 8. Age is
no contraindication, as the routine has been successfully carried out on suspected typhoid
carrier children of ten years of age. There have been approximately 8000 biliary drainages
[ 30 ] j&Kr': .SWK****»
jytaHiw«saBKa»afltgg*T»B»^^
performed with 939 in 1938. In 1291 of all new cases, the primary diagnosis of medical
gall bladder was made; 11.4% were diagnosed as being surgical; 6% as having medical
intrahepatic conditions; and, 11% as having no demonstable biliary tract pathology or
dysfunction.
There have been 220 clinic patients, which does not include private or hospital cases
worked up by this routine, subjected to 228 surgical procedures. The mortality rate in
surgery of the biliary tract not associated with malignancy nor common duct complications has been 2.1%; in cases having common duct and pancreatic complications, 7.8%;
a general mortality of 4.8% for the entire group.
The grouping of patients based upon the type of history given was resorted to by the
clinic to facilitate a quick description to be used by one clinic member to another during
casual discussion of cases. Groups include: 1, those patients with only the symptoms of
dyspepsia that are frequently associated with gall bladder disease; II, those having had
definite colicky attacks of a gall bladder nature; III, those having had jaundice; IV, those
having had cholecystectomy; V, those having had cholecystectomy; and, VI, those having
had cholecystostomy. Descriptions of patients by groups is never relied upon for formal
discussion nor for the compilation of statistical reviews; in such instances the entire history or histories is given.
Roentgen Ray: In patients subjected to operative exploration with a normal concentration of the dye in the gall bladder, there has been 95% found to be correct in diagnosing the presence or absence of stones. Stones were found at operation in 88% of patients
showing a faint concentration of the dye in the gall bladder by cholecystography.
The abbreviations in expression of Roentgen ray findings in use by the clinic that
are to be seen in the figures are:
N.V.N.E.—Normal visualization and normal emptying.
N.V.N.E. c (with) stones or N.V.N.E. s (without) stones.
F.V.N.E.—Faint visualization and normal evacuation c (with) or s (without) stones.
N.V.D.E.—Normal visualization and delayed evacuation c or s stones.
Laboratory Findings: A record of the microscopic findings in all the duodenal specimens is kept in detail on Form IV for reference in special cases. An abbreviated record is
kept on the laboratory sheet to facilitate a general view of the case.
The Follow-up Visit Form is one of the latest additions to the clinic chart, in use
for five years. This form has been constructed to serve as a means for enforcing a
review of the entire past record of the case that is adequate to bring up to date whatever
previous experience the patient may have undergone; to record the present symptoms
with a recorded expression of opinion as to their probable cause; and„ the specific means
of relief in the form of therapy.
The Comprehensive Graph is an expression of the necessity on the part of the supervisors of the clinic to have all the data in a case in a form that permits a quick review
of the entire case. The form was suggested by that commonly employed for recording
the course of the temperature, pulse and respiration in hospital cases. In order to be
able to use this form, one must have had a considerable experience in the follow-up of
the course of gall bladder patients. The form serves to present a review of the course
of any case over long periods of time, giving an accurate impression of the up and downs
of concentration of bile, sphincter of Oddi function, sympton course, crystalline sediment
findings, gastric analysis results, blood findings, jaundice, duodenal culture and the therapy
employed. In addition, the salient findings at operation are revealed for 'cross the page'
contrast with pre- and post-operative findings. Reading down from the date of examination or follow-up visit one has an accurate comparison of all data. The desired effect
as well as the direct effect of the therapy employed can be seen at a glance by anyone
familiar with the form. For the supervisor of the clinic the form is indispensable in saving time during the course of a morning when he may have to review the findings in from
ten to twenty cases with the juniors assigned to the case.
Weekly Conferences have been held since the beginning of the clinic that are comparable to grand rounds on the hospital service. Any junior or senior supervisor or hospital
attending may select cases for the weekly conference that are shown for discussion of the
[  31   ] probable diagnosis or to illustrate points in diagnosis or therapy. The conferences are
formal and under the direction of a medical or surgical senior supervisor. The cases are
presented before the entire clinic staff, student body, intern staff and they are open to
visitors. The routine procedure of examination, treatment, and probable diagnosis in the
case is read and recorded upon a special blackboard. A discussion follows the recording
upon the blackboard of a summary of the findings and their relation to the possible diagnosis in the case. The decision as to whether a finding in the symptoms or physical examination is in favour of or against the presence of any one of the conditions, is based upon
the previous findings in our cases of a retrospect examination of the data in cases of that
nature. Adding up the points in favour of and against the presence of all the possibilities
still causes a good deal of head shaking and skepticism. In the main, the arithmetical
answer stands as the final diagnosis. In the event of much dissension or doubt as to the
accuracy of the interpretation of the findings, the case is put under observation with
expectant treatment until another review is held. As in the above case, upon the first
review the author agreed with the consensus of opinion that cholecystitis, cholelithiasis
were present and that probably the jaundice was due to papillitis of the sphincter of Oddi
causing obstruction. The patient was admitted to the hospital for preparation for operation. Before admission and during the preparation after admission, the findings in the case
changed considerably. The icterus index dropped, the liver continued to enlarge and all
other symptoms began to disappear. Based on previous experience and relying on surgical
judgment, the case diagnosis was changed to one of probable cirrhosis. Operation was
deferred and the patient discharged back to the out-patient department.
Two months later the patient was again chosen for conference. The findings were
10 to 4 in favor of common duct stone against 9 to 5 against cirrhosis. An exploratory
operation was forced upon the author against a feeling that the diagnosis was probably
cirrhosis.  At operation there were 22 stones found iiq. the common duct.
The development of surgical judgment in diagnosis and treatment of patients has
been variously described as an inner sense born of trial and error. No member of the
combined clinic is prepared to say that the results of a routine of examination should
displace medical judgment in handling any medical problem. An increasing experience
with the routine examination herein outlined serves to emphasize its importance when
tempered with whatever medical judgment one may have developed. There is a natural
tendency on the part of the uninitiated to grasp at any formula of diagnosis. Errors may
lie in either direction. Either for the initiate in neglecting altogether the value of a routine
of examination or for the uninitiate in depending altogether upon the results of a rule
of thumb. In the interest of the patient and in the avoiding of errors in diagnoses and
treatment, the clinic members feel that neither the routine of examination nor the use
of medical judgment are indispensable.
The Preservation of Specimens shows the arrangement upon a board of sample specimens of the pre-operative drainage bile, the distended, dried gall bladder, operative gall
bladder bile, the operative common duct bile, the gall bladder stones, the common duct
stones, the pathological section of the gall bladder and the appendix. Below the second
row of specimens there is kept a sample of the most concentrated post-operative duodenal
drainage specimen. The label, placed below each specimen, contains the chemical analysis,
culture or other appropriate description of the specimen. On the lower half or the back
of the board a copy of the chart of the case is kept up to date. These boards of specimens
were devised in the first place for keeping together all the factors in interesting cases for
presentation upon the follow-up visit of the patients that were usd for class demonstration.
They have proven interesting and instructive in the study of variations in cases with
similar stages of gall bladder disease.
The Classification of Gall Bladder Disease that follows, is an outline for the division
of patients for the selection of cases for surgery that is at present in use by the clinic.
This classification and a more concrete and basic understanding of the clinical and actual
pathology involved is a direct outgrowth from the study to which patients with gall
bladder disease have been subjected to by the combined clinic.
[  32  ] b.
c.
The Classification of Diagnosis Used in the Clinic
I.   No gall bladder pathology nor dysfunction.
II.   Gall bladder dyskinesia without stones.
a. Reflex hypertonic type.
b. Gastric hyperacidity hypertonic type.
c. Hypotonic type.
III. Chronic cholecystitis without stones.
IV. Cholelithiasis,
a. Functioning gall bladder with dyskinesia with stones.
1. Reflex hypertonic with stones.
2. Hyperacidity hypertonic with stones.
3. Hypotonic with stones.
Chr. cholecystitis with or without dyskinesia.
Non-functioning gall bladder with or without common duct dyskinesia.
V.   Chr. Cholecystitis, cholelithiasis and choledocholithiasis functioning gall bladder,
bladder.
a. With cholangitis and liver damage.
b. Without cholangitis and liver damage.
VI.   Chr. cholecystitis, cholelithiasis, choledocholithiasis and functionless or obliterated gall bladder.
a. With cholangitis and liver damage.
b. Without cholangitis and liver damage.
VII.   Post cholecystectomy, common duct stone.
a. Retained gall bladder stone.
b. True common duct stone.
c. Presence or absence of choledochitis and liver damage.
In all diagnoses an attempt is made to determine before operation the presence or
absence of involvement of the pancreas.
The preceding review of the clinic routine is given to serve as a structure upon which
to support the following conclusions on which cases are recommended for surgical treatment. The prognosis of the after result is also based upon the results of follow-up that
has been brought out by the clinic routine in similar conditions.
Accuracy in Diagnosis: An attempt has been made to determine the accuracy or the
dependability of the various diagnostic tests that go to make up the routine of examination. This determination was made upon those cases that had had a complete examination,
positive pre-operative diagnosis, operation with complete examination of specimens and
a considerable follow-up period. The results were all studied in retrospect in order to
determine the percentage value of the results of the various tests that had been carried
out prior to operation. The results in 203 operative cases were reviewed with the finding for the complete clinic routine of 95% accuracy in the pre-operative diagnosis of
the presence of stones in the gall bladder. The pre-operative functional state of the gall
bladder was accurately determined in 63.5% of cases.
The general routine gave the correct diagnosis in 80% of all common duct lesions,
including the presence or absence of stones. The index for determining the presence of the
typical common duct stone was much higher, see section on common duct stone.
The inaccuracy of individual tests for the whole group of diseased conditions very
clearly indicates the main need for a combination of all the tests in the work-up of the
cases. Many additional factors of importance have been found to be determined by a
complete work-up in all cases, viz., in a patient in whom the Roentgen ray shows stones,
the complete work-up indicates the presence or absence of liver damage, chronic cholecystitis, hypercholesteremia, gastric acidity, gall bladder and common duct dyskinesia—all
factors of great or equal importance in the therapy needed by the patient. Especially has
this feature been demonstrated by the frequent recurrence of symptoms which demand
medical care following the removal of the obvious stones.   The belief in the importance
[  33   ] of the additional factors, those other than stone, has reached the point, in the belief of
the patients' symptoms, of becoming equal or of greater importance.
Duodenal drainage as performed pre-operatively has been found to have been correct
in one or another of its factors in determining general pathology in 79°/o of cases, and
diagnostic of the functioning state of the gall bladder as found at operation in 59% of
cases. Cultures of the duodenal contents when obtained by the encapsulated method have
been found to coincide with the findings in the gall bladder at operation in 84% of
cases.
Liver Damage: The accuracy in determining liver damage by blood examination is
difficult to evaluate in retrospect due to the sudden appearance of liver failure in some
post operatives. At present, the clinic members feel confident that no liver damage
exists in those patients showing a normal blood cholesterol and cholesterol ester ratio.
There has not been an instance of sudden liver death in any one of the post-operative
clinic patients in the past five years.
Specific Factors of Diagnosis upon which the clinic advises surgical intervention and
qualification as to operations being elective, advisable and imperative under given conditions, will be considered.
The positive findings that denote the presence of no gall bladder, liver, nor common
duct pathology or dysfunction being present to account for the symptoms of the patient
are:
1. History. The presence in any case of only those associated symptoms of dyspepsia
and others of possible gall bladder or liver disease necessitate an examination during the
period of activity of symptoms to rule out the gall bladder and liver. Under these circumstances one complete negative examination justifies a negative diagnosis. If there
are present in the past history any of the more positive gall bladder symptoms of colic,
jaundice, tenderness and fever, a period of observation and two or more complete examinations are carried out before a negative diagnosis is given. When in doubt the reservation
of again examining the patient during an active period of symptoms is required before a
negative diagnosis is finally made. In the meantime an investigation of the other possible
sources of disease that could be responsible for the symptoms is advised.
2. Physical Examination. The physical examination in the normal case should positively show no enlargement of liver and spleen; no masses that might be connected with
the gall bladder or liver. There should be no jaundice either clinically or serologically.
Tenderness over the gall bladder region is deceptive and when present without being supported by other positive findings is not considered evidence of gall bladder or liver
pathology.
3. Duodenal Drainage. A gastric specimen is obtained and examined microscopically
for the presence of blood which has no direct connection with the gall bladder investigation. The free and combined acidity is determined on the fasting specimen, the normal
being 20 to 30 units of free HCl. The presence of bile in the gastric content is of no
significance. Finding bile in the duodenum in a dilute form (Dx specimen), amber or
light green is normal. Following the use of magnesium sulphate, an ounce or two of a
darker bile (Mx specimen) should be recovered. After olive oil, one or two ounces of
dark green (Ox specimen) bile flow is normal. Then the flow should return to the amber
or light green type (Dx specimen).
Normal gall bladder function as shown by drainage should show a D1 specimen of
light amber or light green; a cloudy specimen may still be normal and it will usually
clear up upon the addition of a small amount of alkali. The chemical examination of the
specimen for bile salt is no longer used to indicate the degree of concentration of bile salt.
From having done several thousand determinations on the Dx specimen by the Katayama
method, the clinic established the average bile salt content of Dx specimen to be 100 mg.
per cent. The present arbitrary term used for the normal appearing Dx specimen is 100.
For the Mt specimen a figure of 250 is used; a darker amber or green that may either
be cloudy or clear. For the Ot specimen, 400 signifies a specimen with apparently
normal concentration of the gall bladder bile, a dark amber or black green. The D2 is
about the same color as the Dx but is more frequently turbid under normal conditions.
(Fig. XII).
[   34   1 Pancreatic ferment determinations of the duodenal bile specimens was a routine procedure carried out by the clinic during the first five years.
Normals for Pancreatic Enzymes
Bile Blood
Amylase 30-60% 2-3 %
Lipase..  2-3 cc. 2 cc.
Protease  3 -4cm.
A cultural determination of the duodenal drainage specimens is carried on as a part
of the routine in all patients suspected of gall bladder pathology.
4. The presence of abnormally high findings of blood cholesterol may be encountered
in either normal or diseased gall bladder and liver conditions; taken alone it is not significant. Normal findings is the rule for young patients in whom most of the normal gall
bladder determinations are made.
II. Dyskinesia, Dysfunction Without Stones
Dyskinesia of the gall bladder seems to have been accepted as a distinct clinical entity
by the majority of clinics. There are still a number of medical and surgical specialists
who have not relinquished the belief that infection plays the major role in the changes
that are responsible for the symptoms in early gall bladder disease. The works of Oddi,
Aschoff and Bacmeister and Berg are notable in daving opened up the field of the Neurogenic origin of disturbance of the biliary tract, and the work of Westphal, which has
been substantiated and enlarged upon by Ivy and Sandbloom, Whitaken, Best and Hicken,
Walters and others, has created an interest and belief in the functional derangements
of the gall bladder being responsible for the symptoms noted in early gall bladder disease,
whether or not one prefers to use the term bile stasis, sluggish gall bladder or some other
term than dyskinesia, makes little difference so long as the symptoms of chronic cholecystitis on an infectious basis are differential from those on a functional basis. Determining
the cause of the changes in these that are responsible for the symptoms, is of! importance
because changes due to infection are amenable only to surgery, while those due to dysfunction are better treated by medical measures.
True Infectious Cholecystitis: The patients now in this classification were formerly
included under chronic cholecystitis. The most important work of the combined clinic
has been the identification and development of a routine for the segregation of these
patients from the true chronic cholecystitis group. As was mentioned previously, one of
the first interests of the surgical side of the combined clinic was to develop some way to
determine before operation, the type of patient with chronic cholecystitis, that might be
expected to have a good symptomatic result following cholecystectomy. Group II is the
answer to that query. After becoming able to identify the patients with dyskinesia, the
post-operative follow-up symptomatic results in that group following cholecystectomy
were found to be especially disappointing. In the face of the poor follow-up results, the
surgical side continued to recommend operations in this group only for those individuals
who had undergone prolonged medical treatment without symptomatic relief. The follow-up in these patients showed that many of them experienced worse symptoms after
cholecystectomy than before. They were the intractible group whether operated upon
or not. The surgical side concluded that the answer lay in a more specific type of medical
therapy. Thereupon, all but a few patients with dyskinesia were removed from the surgical
fists. Under this ruling there has been developed a much more comprehensive type of
medical therapy and one which seldom fails to relieve the patient symptomatic ally. There
has grown up a feeling about these patients that corresponds to that' in the field of ulcer
that once an ulcer background, always an ulcer tendency, and once a reflex or reflex
hyperacidity gall bladder dyskinesia, always a dyskinesia tendency. The symptoms may
be relieved by treatment and the patient remain well so long as there is no factor to act
as a reflex, in the reflex type, or between the periods of gastric hyperacidity, in the hyperacidity type. Recurrence of symptoms is disappointing and there is still a great tendency
to subject the patient to cholecystectomy because of the repeated attacks that come on
when medical therapy is stopped.   The surgical clinic members now have such faith in
[   35   ] the clinic routine of diagnosis that all dyskinesia patients without stones are rejected for
surgery except that small group having repeated low grade jaundice, icterus index up to
50. From this group there has been selected during the past four years, a few patients
that have been recommended for cholecystogastrostomy. The general hospital surgical
staff is reluctant to perform the operation. In the majority of patients with obstructive
jaundice due to the severe papillitis of the sphincter of Oddi, there is an accompanying
gastric hyperacidity, especially noted at the onset. This factor increases the safety of the
operation and in this type of patient the author has cases that have pursued a normal
course for as long as 12 years. The operation is not recommended except in the presence
of an element of danger from obstruction and jaundice with liver damage that is considered to be as great as that from infection and! liver damage following cholecystogastrostomy.
a. Reflex Hypertonic Gall Bladder Dyskinesia makes up 25% of dyskinesia patients.
Discussion: 1. History. Intermittent periods of activity with colicky attacks, vomiting with relief of pain.  Intervals free of associated symptoms.
Synopsis of Salient Factors
STASIS IN GALL BLADDER
ENLARGED HYPERTONIC TYPE
HYPERCHLORHYDRIA
Staiis in Gall Bladder Enlarged Hypertonic Type Hyperchlorhydria
SYMPTOMS
Periodic Attacks Colic
Indigestion
FINDINGS
Gastric Hyperacidity
Enlarged Gall Bladder Shadow
Delayed Emptying, Cholecystogram
Drainage Response to Olive Oil
Crystalline Biliary Sidiment
Periodic Increased Icterus Index
Gastro-intestinal X-ray, Duodenitis
b. Hyperacidity Hypertonic Gall Bladder Dyskinesia—25% of dyskinesia patients.
Discussion:   1.   History.   Intermittant periods of activity,  spring  and fall,  severe
colicky attacks of pain, prominent associated symptoms of dyspepsia during active
phase. Mild and severe jaundice with hepatitis (catarrhal jaundice) more frequent than
in reflex type. Vomiting with the attacks prominent, a symptom not so conducive to
relief of pain as in reflex type. Between the periods of activity there is a marked intolerance to heavy foods of a fatty nature.
c   Hypotonic Type of Dyskinesia makes up 5 0 % of dyskinesia.
Discussion. 1. History. Characterized by its occurrence in the fair, fat and forty
type of individual, continuous course of associated dyspeptic symptoms, influenced by indiscretion in diet and as a rule free of colicky attacks of pain. Dull distress amounting
to a steady pain in the right upper quadrant may occasionally be felt after marked dietary
indiscretion. This is distinctly relieved by vomiting. Jaundice does not occur during
the course of this type of dyskinesia except in instances associated with recurrent chronic
cirrhosis. The chronic dyspeptic individual with overweight and a tendency for colitis
is characteristic for this group.
6. Roentgen Ray—usually described as fair filling and sluggish emptying with balloon type of enlargement. The enlargement of the gall bladder is characteristic of marked
atony. (Fig. XLX). This variation is a constant finding in the Roentgen ray. A rare case
will show enlargement of the gall bladder shadow after the ingestion of a fatty meal. Two
of this type of patient have been subjected to cholecystectomy by the author without its
having been justified by the operative findings or by the post operative course. The symp-
[   36   ] tomatic course, after operation in both patients, was materially worse and they were not
controlled by medical therapy.
The addition of the factor of infection to dyskinesia very materially alters the situation and the surgical indications. As this factor is not amenable to medical management,
the use of surgery is enforced in patients in whom it is present. The eradication by surgical
means of infection would solve the problem of symptoms were it not for the apparent
fact that it is preceded by dyskinesia which persists after operation. The persistence of
symptoms of gall bladder disease that are found to occur after operation are explained on
this basis. The effect of dysfunction of the gall bladder being transferred to the common
duct following operation, results in bile stasis in and dilation of the duct. Symptoms
result that very closely resemble those present prior to removal of the gall bladder. Nevertheless, surgery is essential at this stage to prevent the course of events that follow infection
in the gall bladder, an advance of the disease, the occurrence of acute cholecystitis and
stones with the mechanical complications that follow. It is impossible to establish as a
fact the suspicion that dyskinesia precedes infection and stone formation in the majority
of patients. There are a few conditions such as the typhoid carrier and the patient with
acute follicular cholecystis without stones in whom there cannot be elicited a history of
a pre-existing period of dyskinesia. In the majority of patients there can be obtained a
history which suggests a period of dyskinesia preceding the introduction of infection and
the occurrence of stones.
6. Roentgen Ray. Failure by the gall bladder to concentrate the dye normally is
considered to be the most characteristic diagnostic evidence of the presence of real infec-
tiou damage to the organ. Faint visualization of the dye that cannot be accounted for
by errors in technique after the test has been repeated is the most reliable preoperative sign
of cholecystitis upon which to advise surgical treatment.
IV.   Cholelithiasis
The additional factor of cholelithiasis in the course of gall bladder disease introduces
a definite indication for the employment of surgery. Surgery is accepted as being the
only means available for the removal of stones. The diagnosis and treatment of stones
in the patient with gall bladder symptoms has received more attention than all the other
factors involved in disease of the gall bladder. For this reason the symptoms that are
associated with disease of the gall bladder have long been attributed to the stones. The
existence of these symptoms prior to the development of stones and after their removal
either by cholecystostomy or cholecystectomy has not detracted from the importance
placed upon the stones in the production of non-obstructive symptoms. The existence of
infection prior to the development of stones and its existence after their removal has long
been given as a cause for the symptoms. The tendency in most clinic's at present is to
attribute the symptoms of chronic gall bladder disease in the majority of patients with a
functioning gall bladder to disturbance in function rather than to infection or to non-
impacted stones. The symptoms resulting from the mechanical influence of the stones
when obstructing the cystic and common ducts is as secure a belief today as it was when
first given. And the necessity for the removal of the stones to prevent the symptoms and
dangers of their mechanical effect exists as much today as when first performed. The
medical treatment of patients with gall stones may relieve the symptoms due to gall bladder
dysfunction without reducing the existing menace from the mechanical complications of
obstruction. For this reason all those patients with stones are recommended for surgical
treatment.
Acute Cholecystitis.
The results of a critical analysis of the experience accumulated in the surgical treatment of 574 patients with acute cholecystitis at the Post-Gradiiate Hospital during the
past 17 years were published recently by Dr. Richard Hotz in The American Journal of
Surgery, (Ref. Vol. XLIV, No. 3, June, 1939, Pages 677-722).
[   37   ] FRACTURE OF THE NECK OF THE FEMUR
Alexander Gebson, M.D.
Introduction.
It is customary to commence an article on "Fracture of the Neck of the Femur"
with a reference to the views of Sir Astley Cooper, preferably inaccurate. Not daring to
flout this convention, I shall indicate in his own words what this English surgeon really
thought.
"In all the examinations which I have made of transverse fractures of the cervix
femoris entirely within the capsular ligament, I have never met with one in which a bony
union had taken place, or which did not admit of a motion of one bone upon the other.
To deny the possibility of this union and to maintain that no exception to the general
rule can take place would be presumptuous . . . but I wish to be understood to say that
if it ever does happen, it is of extremely rare occurence, and, that I have not yet met with
a single decisive instance of it."
The causes to which he attributes this finding are three in number.
1. Want of apposition of the bones.
2. Want of pressure of one bone upon the other.
3. "But the third and principal reason which may be assigned for the want of union
of this fracture is the almost entire absence of ossific action in the head of the
thigh bone when separated from its cervix, the life being supported by the ligamentum teres which has only a few minute vessels ramifying from it to the head
of the femur."
Later in hisi book he states: "I know that some persons still believe in the possibility
of this union by surgical treatment, and that instances of success have been published,
but I cannot give credence to such cases until I see that the authors were aware of the
distinction between fractures within and external to the ligament."
In "Lectures on the Theory and Practice of Surgery" Coiles states categorically, "I
do not believe osseous union can take place and am sure that those who say they have seen
it have mistaken disease of the head and neck of the thigh bone for fracture ... I think
the difficulty of keeping the parts motionless on each other would be sufficient of itself
to account for this."
In a letter to Sir Astley Cooper, Colles makes the statement: "I must say that I have
never yet seen an instance of bony union where the fracture had been within the ligament."
The General Principles of Fracture Treatment
Until a few years ago, this pessimistic note was predominant in all the writings on
the same subject. Not until the last decade or so has a brighter outlook stejemed justified.
The risk we are facing today is that of the swing of the pendulum. From the extreme of
pessimism we are apt to find ourselves cherishing an unwarranted degree of optimism,
thinking that our conquest of the mishap is complete. It is well to keep our thinking on an
even keel and, while making use of the methods now available for the treatment of this
accident, to bear in mind that there are still some aspects of the problem which are as yet
unsolved.
In some respects, indeed, this fracture is unusual, more particularly in regard to the
advanced age at which it is frequently sustained. There is, however, nothing to justify
us in imagining it to be a fracture sui generis. The general principles of fracture treatment apply here as elsewhere throughout the body. These are simple.
1. The fractured surfaces must be brought into appostion as exact as is possible.
The fracture must be "set."
2. The apposition must be maintained uninterruptedly until bony consolidation is
complete.  The fracture must be "fixed."
3. As far as possible physiological use of the adjoining' soft parts should be encouraged.  The limb must be "used."
r 38 i It must be noted that the first and second canons must be maintained absolutely
before the third can be obeyed. Suppose we apply this reasoning to fractures of the neck
and femur.
I.   Reposition of the Fragments.
What methods are available? The) use of sandbags still to be seen at times may be
dismissed as obsolete.
Traction is a favourite method with some, either by adhesive plaster or by direct application to the bones. As an immediate measure to overcome the shortening and to draw
the bony surfaces into apposition it may be of some service. When this has been attained,
its usefulness ceases. By drawing the surf aces apart, it tends to do harm instead of good.
There is no control of rotary strains; rotation of the pelvis is not prevented; most important of all clinical experience is against it. After adequate weighing in the balance of
surgical experiment, it has been found wanting.
The Whitman-- (1904) Leadbetter (1933) Method.
Both of the latter procedures recognize the fact that co-aptation of the bony surfaces
is best obtained and kept, in the position of abduction and internal rotation. In this position, the ilio-femoral ligament is tense and is believed to act as a local splint. Leadbetter
modified the Whitman manoeuvre so as to give in his opinion 100% reduction. Here is
his own description.
"The patient is first anaesthetized, usually with ethylene gas, on the fracture table.
The uninjured leg is harnessed to the foot stirrup. The injured leg is then flexed at the
hip at 90°, with the lower leg at 90° to the thigh. Direct manual traction in the axis
of the flexed thigh is then made, together with slight addiction of the femoral shaft.
In this position, the thigh is internally rotated approximately 45s°. The leg is slowly
circumducted into abduction, the internally rotated position being maintained. The
amount of abduction varies with the individual, and can be measured accurately, representing the difference in degrees of the angle made by the fractured, neck with the shaft,
and the angle between the neck and the shaft on the normal side as evidenced by the
roentgenogram.
"The test which in our experience has indicated that the fracture has been completely
reduced is as follows. After the leg has been brought down in the measured degree of
abduction and internal rotation, the heel of the injured, leg* is allowed to rest on the outstretched palm. If the reduction is complete, the leg will not evert itself. Should there be
no interlocking of the fragments however, the leg W(ill slowly rotate externally. This
has been found to be an invariable test. In cases where the internal rotation had to> be
forced, the reduction was never complete as proven by X-rays. As the leg is circumducted into a position of abduction and internal rotation without tension the position of
the leg tends to assume the proper degree of abduction and internal rotation. If abducted
too far, one feels the definite tension of the adductors, which can be neutralised by allowing the leg to assume a smaller degree of abduction. If internal rotation is too great, the
leg under the heel-palm test, will rotate outwards, until the proper degree of internal
rotation is reached."
The experience of others has abundantly confirmed the success of this manipulation in
bringing about apposition of the fractured surfaces; the solution of the first part of the
problem is in our hands. It is possible to comply with the demand of the first canon;
we can "set" the fracture.
II.   Immobilization of the Fragments.
Plaster Fixation. What of the second demand? How can we maintain uninterrupted
fixation? When Whitman introduced his abduction method, he relied upon plaster of
Paris to maintain the position he obtained. In these days ample padding was applied
between skin and plaster to prevent the bad results of pressure. Although the results were
brilliant in comparison with those obtained by Astley Cooper, they were still far from
ideal. At best they gave 60% to 70% of bony union. The reason for the 30% to
40% of failures was not far to seek. Colles put his finger ori the spot one hundred years
ago when he said: "I think the difficulty of keeping the parts motionless on each othfeir.
[   39   ] would be sufficient of itself to account for it." Along with the modification of Whitman's method, Leadbetter employed the non-padded plaster popularised by Bohler.
"With the hip reduced, and in the proper degree of abduction and internal rotation,
a one-layer thickness of unglazed cotton is placed about the torso from the nipple line
over the affected hip to a point halfway between the hip and the knee. Then a long strip
of felt half an inch thick is placed about the pelvis extending from just above the iliac
crests to the trochanters, and completely encircling the pelvis. This is all the padding
necessary, and allows very tight application of plaster. The body portion is first applied
as tightly as possible, snug co-aptation being the aim. Firm pressure over the injured
hip is necessary. Below the hip no padding is applied. Two plaster slabs moulded carefully to the contour of the leg, one posteriorly and one anteriorly, are bandaged closely
to the skin. No padding is placed beneath the heel as it is moulded well and the plaster
is co-apted tightly."
It is evident that with the thickness of half an inch of felt and the variable thickness
of subcutaneous fat in the gluteal region of many patients, control of movement at the
site of fracture must have been far from complete. Still, even with this disadvantage,
bony union was obtained in about 70% of cases. (It would be interesting to know what
figure would be obtainable in a series composed of fractures of the neck of| the femur in
the steatopygous Hottentot.)
While the method of plaster fixation marked a great advance, it has many serious
drawbacks. Old people did badly with confinement to bed in the horizontal position;
the process of cure was at best a trying ordeal, and although every surgeon could point
with pride to an occasional case where recovery was complete, the majority of patients
never regained full activity. The worst complication was the stiffness of the knee-joint
which, in spite of being foreseen, and, in spite of attempts to prevent it by manipulation
of the patella, frequently remained to plague the individual long after the fracture itself
and indeed the hip-joint had ceased to be a disability. The method of plaster fixation,
therefore, while relatively safe, was admittedly imperfect in its fulfilment of the demand
of the second canon, and it ran directly counter to the third. The local immobilisation
was incomplete; the general immobilisation was excessive.
Direct Fixation. For this and cognate reasons, attention was directed to the problem
of fixation by some measure applied to the fracture site itself. Open exposure of the
break was at first deemed necessary; later this was abandoned as needlessly severe, and
methods of so-called "blind" approach were devised. In all such attempts the compelling
motive was to bridge the actual break by bone-graft, wires, or nail so firmly as to obviate
the need for plaster fixation for a prolonged period. That aim has been achieved thanks
mainly to the efforts of Smith-Petersen of Boston, and Johansson of Sweden. The principles of the method are soundly established, although there are many details which are
hardly as yet standardized. The invention of non-corrodible steel or later, of Vitallium,
which is said to be electrolytically inert, has meant a good deal in the development of the
technique. The method involves the close co-operation of the radiologist. Indeed he
bears a very large share of responsibility, (and might be proportionately remunerated?).
It is well to arrange that a dark-room with facilities for photographic development is
adjacent to the operating-room. This is a trifling problem, not so fearsome as it sounds;
any carpenter can solve it.
Now let us summarise the procedure.
1. X-ray, to visualise the fracture; antero-posterior and lateral if possible.
2. "Set" the fracture.  Whitman-Leadbetter manoeuvre.
Sound foot fixed. (Direction-finder stitched on.)
Injured foot held in position.
Confirm by X-rays; anteroposterior and lateral.
The hip-region is now painted and draped.
3. Expose the great trochanter and upper part of the shaft.
4. Steinmann pin inserted under guidance of radiologist.
Use direction-finder, or guide.
5. Photograph wire in two planes.
[  40   1 6. If satisfactory, thread nail on Steinmann wire, and drive it home.
Here also, the radiologist checks the depth to which the nail is driven.
7. Suture soft parts.
8. Confirm by X-ray in two planes.
What Are Some of the Possible Difficulties?
|| The position of the X-ray tube. For direct fluoroscopic guidance the tube ought
to be immediately under the hip-region. In this position the ordinary metal table interposes an opaque screen. How can this be avoided?
(a) A special table or detachable stand may be employed.
(b) A wooden table may be constructed with a specially thin panel underlying the
affected hip.
(c) The sound side may be fixed to a foot-rest such as is used in operations requiring
the lithotomy position, the sacrum being pulled down free of the table. This
leaves the affected hip unencumbered on all sides, permitting the most direct
inspection. The foot and leg of the affected limb can be supported on a separate
table or stand and held under tension by an assistant.
There is as a rule no difficulty in obtaining a lateral X-ray. All cassettes should be
wrapped in sterile towels and held in position by the surgeon. To avoid the need for
moving the position of the X-ray tube, a modified lateral view is obtainable by flexing
the thigh on the body at an angle of 90°.
2. The direction of the nail. There are numerous devices for this. Perhaps the
simplest is the hinged metal strip on which intervals are marked by holes at each quarter
inch, the "inch" holes being a little larger than the others so as to be easily distinguishable.
One limb of the strip is made to follow the line of the inguinal ligament, while the other
follows approximately the line of the femur. When an antero-posterior X-ray is taken
immediately after reduction of the fracture, it is easy to read off directly the optimum
direction. If the limb is in correct internal rotation, the Steinmann pin should be parallel
to the floor.
There are many other more elaborate instruments for determining the angle of insertion, such as those associated with the names of Hey-Groves or Bailey. The greater one's
experience, the less necessary these seem to become.
3. The nail may tend to work out, and if it has not a strong hold on the proximal
fragment it may lose its grip entirely before consolidation is complete. It has already been
pointed out that rotatory strains are not to be overlooked, and that these may be induced
by the simple movement of turning in bed. To avoid this, a small hole has been bored in
the head of the nail and through this a small rustless pin can be driven into the) cortex
of the femur. Others use a small metal plate, the upper end of which is bent away from
the bone so as to provide an obstruction at right angles* to the line of the nail.
4. Are all parts of the neck and head equally firm? A study of the architecture of
the bone in this part suggests that the lower part of the neck and the posterior part of the
head offer more resistance. Not only that, but the posterior position of the nail is said to
offer more resistance to displacement by rotation. (Watson Jones).
5. How far should the nail be driven in? Theoretically until its point is just under
the cortex covering the head. If it passes through the cortex] into the acetabulum, does
this do harm? While excessive length of the nail is not to be recommended, apparently
projection of the pin into the Haversian pad occuping the floor of the acetabulum does
no harm. It is different if the nail impinges on the articular rim; in that case, each movement is apt to be accompanied by pain.
III.    Functional Use.
It would seem then that we have at our disposal means to accomplish the first and
the second parts of the triple requirement that we formulated for the treatment of all
fractures.   If these be fulfilled, then the third principle, that of functional use should
[  41   ] follow. Surgeons have been quick to appreciate this and in their enthusiasm have gone
far. We hear of patients being out of bed in a day or two after nailing of the fractured
cervix femoris, and walking about within the first few weeks. In this way a dramatic,
indeed a spectacular presentation may be made, but such "after-treatment" can only be
described as lamentable. Even when the operation has been carried out with thorough
success, it means that the patient depends for thb stability of the lower limb on the fact
that a well-placed nail bridges the fractured femoral1 neck. Now this nail is anchored in
bone which is cancellous rather than compact; its hold upon the proximal fragment is
wholly in cancellous bone. It does not take much reflection to realise that the connection
is a precarious one, and that the limit of strain, either sudden or prolonged, is not very
high. The plain conclusion is that no undue strain ought to be imposed at the fracture
site until the union is bony, as evidenced by the X-ray. This means that at least three
months or even six months or it may be longer, shouldl be allowed to elapse before full
weight-bearing is allowed. Even if there appears to be an adequate osseous casing about
the site of fracture, full activity should not be permitted. No fracture can be regarded
as completely healed until the internal architecture of the bone is restored to the normal.
Where there is an interruption in the lines of transmission of stress—geologically speaking, a fault—as the fracture plane is traversed, there is weakness. In the simplest of
fractures, this restoration requires at least six months and may take several years. The
inevitable conclusion is that until at least a year has elapsed in comparatively young
patients, no strenuous exercises such as badminton or tennis should be sanctioned. Walking should be limited to smooth ground, running should be interdicted; the best of all
exercises is swimming, which allows of exercise without weight-bearing. Needless to
say, diving is not permissible. Golf, as a form of exercise, varies so much in its intensity
that each case would have to be considered on its merits.
Complications.
Non-union. Here, then is one of the possible complications of the fracture; nonunion. It is however not the only risk. Indeed, in about one third, of all cases, not excepting those treated with scrupulous care along the lines laid down, changes occur in the
proximal fragment. In extreme cases, the head becomes necrotic; in these cases, union is
obviously impossible.
Osteoarthritis Changes. In lesser degree, changes occur leading to shrinkage of the
head of the bone deformation, irregularity of the surface, disappearance of the covering of
articular cartilage as shown by loss of the joint-space in the X-ray, tiny cysts appear in
die head, areas of increased or diminished density. In other words, evidence of an altered
nutrition of the femoral head, depending on a diminished blood-supply, changes which are
summed up in the term osteo-arthritis. Long before these changes have appeared, warnings have been sounded by the onset of pain after exertion; as the changes increase, so,
as a rule, does the pain. Here is an aspect of the problem to which we have not afe yet
found the complete solution. One thing however, may be predicated, it does not pay to
impose undue strain on an undernourished part. If a restitution to normal is to be accomplished, the forces which build up must be in excess of those which break down. Income
must exceed expenditure.
One must test the amount of activity that the condition of the part permits and keep
within the bounds of this. Pain is the guide. One must grope along the road to recovery,
rather than rush. Before the osteo-arthritic changes are very pronounced, it usually takes
about a year; during this time the onset or persistence of pain after exertion is a danger-
signal which one ignores at one's peril.
The Concept of Pauwels.
The Angle of the Fracture Line. Up to the present, we have spoken of intra-capsular
fractures of the neck of the femur without any attempt to differentiate these. Consideration of the subject would not be complete without a reference to the work of
Pauwels. By the introduction of a simple mechanical concept, he has offered a guide to
prognosis, and to treatment.
[  42   ] The forces which may play upon the fractured surfaces are of four kinds:
1. Compression. As far as we know, provided it be not excessive, thje effect of this
is entirely beneficial.
2. Tension. Distraction of the surfaces has the reverse effect, a criticism already
levelled at the method of treatment by extension.
3. Rotation. Provided enough of the nail stretches across the (gap) fracture-line,
and the patient refrains from exceeding reasonable limits of movement of the
pelvis, this should not be serious.
4. "Shearing." (A better word is "sliding"). This is a real danger, and it is from
the point of shearing force that Pauwels has elaborated his theory. Perhaps the
conception is best explained by diagrams illustrating the three groups into which
he has divided fractures of the femoral neck.
The horizontal is taken as a line joining the two anterior superior spines. The line
of the fracture is that which joins the upper and lower interruptions of the femoral neck.
This line makes an angle with the horizontal. This: angle can be measured. The weight-
bearing force passes mainly along the line of the trabecular in the femoral neck. This
line can also be drawn, and always makes an angle with the fracture-line. This weight-
bearing force can be resolved into two components, one of which passes perpendicular to,
and the other parallel with the line of the fracture. With these premises, Pauwels has
distinguished three groups:
(a) Angle 30° or under.
(b) Angle 30° to 50°.
(c) Angle 50° to 90°.
The Three Groups of Fractures. In the first group, no interference is necessary. The
pressure component (perpendicular to the line of fracture) is predominant, and union
inevitably occurs. The great risk is that of osteo-arthritic changes following on too great
or too early activity, especially weight-bearing.
The second group, (30° to 50°) is controlled by the use of a nail.
In the third group, however, (50° and over) it has been found that immobilisation is
not sufficiently attained by the use of a nail alone. To supplement this, King of Melbourne
and Gallie of Toronto, independently used a bone graft from the fibula. The nail is
placed in the lower part of the neck of the femur, and then with a % or ]/z -inch drill,
a hole is bored parallel with the nail at a higher level, and into this hole, the graft is
driven. King has found the graft so valuable for producing not merely better fixation
but more speedy bony union that he proposes to use it in all cases. Up to the present, sufficient experience has not accumulated to warrant a final opinion on the value of the
measure, but it follows logically enough from theoretical considerations, and clinical
evidence to date suggests that the procedure is reasonable and worthy of extended trial.
Should this hope prove well-founded, it marks an important step in controlling what
Speed called, "the unsolved fracture."
The Treatment of Non-union After Fracture of the Neck of the Femur. The blood-
supply of the head and adjoining part of the neok of the femur is at best prfecariouis.
When the neck of the bone is broken, there is comparatively little collateral blood supply
available, and there is no contiguous mass of connective tissue from which there may
emerge in large numbers, swarms of fibroblasts, the "trouble shooters" of the body, to
initiate and carry on the work of repair. On this account, even when treatment of the
fracture has been impeccable, union may not occur at all, or it may be fibrous, not bony,
which is due partly to the instability and partly to the shortening; the actual shortening
is functionally accentuated by the adducted position of the lower limb. What measures
are available to us for dealing with such a situation? If the head of the bone is necrotic,
there is no chance of its ever taking part again in the economy of the articulation. If on
the other hand it is alive, there may be some chance of making use of it. There are thus
two well defined groups of cases:
1. Head Necrotic.
2. Head Alive.
[ 43   ] Necrosis of the head is usually discernible at an early date after fraqture. Generally
within four to six weeks, the X-ray picture shows areas of increased density, and the surface manifests irregularity of outline.
1. Where the head is necrotic. One of the simplest of methods is that frequently
associated today with the name of Colonna. It has been practised for many years. It consists in removing the useless head from the acetabulum, trimming off the stump of the
neck and placing the upper part of the great trochanter into the acetabular cavity. This
provides excellent stability, a fair amount of mobility, and freedom from pain.
Rather more elaborate are the various "reconstruction" operations of which the
Whitman reconstruction may be taken as a sample.
2. Where the head is alive. When the vitality of the head of the bone seemes assured,
and its configuration appears to be sufficiently good, an attempt should be made to utilise
it in the working of the articulation. Let us assume that the non-union is attributable
to some flaw in the conduct of the case, can we start as it were from scratch and obtain
union by a method similar to that employed in the treatment of the fresh fracture? This
is the procedure described by King as "Osteosynthesis".
For a week or ten days preliminary skeletal traction of about 30 pounds weight is
applied with a view to bringing the displaced fragments again into apposition. If this is
accomplished, the fragments are immobilised by the combined nail and fibula-graft. King
reported nearly 69°/o of cases of osseous union obtained by this method; he is of opinion
that there is in such cases no more likelihood of degenerative head changes occurring than
in fresh fractures. It is undoubtedly feasible to treat a certain number of ununited fractures of the neck in this way.
Failing the possibility of "Osteo-synthesis" some form of Osteotomy is usually performed. Stability is the prime consideration in regard to joints of the lower limb. This
stability can be secured by forcing the line of transmission of weight to pass directly
along the shaft of the femur instead of being transmitted to it across the angle which in
the normal is formed by the neck of the bone. There is naturally considerable loss of
mobility of the joint but this is more than made up for by the increased stability.
McMurray has popularised a simple "oblique osteotomy" for osteo-arthritis of the hip
joint, and the same technique can be used for non-union.
"The femur is approached through a six-inch vertical incision on the outer side of
the upper portion of the shaft. After the muscle attachments have been stripped off the
front of the shaft and the neck of the femur, so that the exact relationship may be appreciated, the bone is divided in an oblique line at an angle of 40°, so planned that the upper
end of the osteotomy lies between the lesser trochanter and the neck of the femur. The
osteotomy must be complete, so that splintering does not occur. After the two fragments
are separated, the lower fragment is displaced inward until its margin lies directly under
the cotyloid ligament of the hip-joint. If this displacement is not sufficient, there can at
best be only a partial relief of symptoms and a disappointing result. At first, a gap is left
between the divided surfaces of the two fragments, but gradually this space becomes
obliterated, by the rotation of the lower, end of the upper fragment, which is pulled in
this direction by the muscles which have a common attachment to both fragments. The
after-treatment demands fixation for three and a half months in plaster, until bony union
is complete."
The "Schantz Osteotomy" has been well described by Gaenslen and Schumm. The
principle underlying the operation is that "Through the angulation of the neck the fracture site is placed below the head, and the body weight no longer pushes the head dpwn-
wards past the fracture surface, but directly against it. This provides more favorable
weight-bearing relations and may even lead to late bony union." The true Schantz
osteotomy should be made at the point of closest approximation of the shadow of the
shaft to the pelvic rim which is usually at the distal end of the tuber ischii. (Schumm)
A wedge or transverse osteotomy is performed in some cases, leaving a projecting tongue
extending upwards on the lateral aspect of the lower fragment which engages in the medullary cavity of the upper fragment, thus assisting to hold the fragments in position. The
essence of the procedure is that the weight of the body is transmitted directly to the shaft
[  44  ] of the femur without the intervening angulation of the neck. By means of this operation
one can look for stability, but motion is always to some extent restricted." In the Schantz
osteotomy we see a fore-shadowing of the concept elaborated in the grouping of fractures
of the neck described above in association with the name of Pauwels. (Pauwels was, I
believe, a pupil of Schantz.)
Pauwel's "Reclination."
The operation described as the Pauwel's "Reclination" differs in no essential from that
of Schantz, except that a calculation is made to ensure that the angle made by the fracture
line with the horizontal plane will be not more than 30°. This ensures that the pressure
component of the "shearing" stress resulting from weight bearing will be predominant,
in this way assisting the process of bony union. In accordance with this, the wedge
removed should have a base which subtends at the inner border of the shaft an angle equal
to "Angle of fracture line with horizontal" diminished by 30°. The lower cut should
be transverse, the upper passing downwards. Special screws are inserted into each fragment of the shaft and by the help of the upper fragment is rotated downwards. The
lower limb is abducted until the fractured surfaces meet. The pins are fixed by a plate
or by incorporation in the plaster. After union has occurred, when the lower limb is
brought to the vertical, the plane of the fracture is 30° or less.
All these osteotomies have the disadvantage that they entail confinement in plaster of
Paris for at least three months, an irksome infliction, with both immediate and remote
disadvantages. They admittedly fall short of restoration to normal, but they have their
place in providing stability and freedom from pain. These are the two most important
characters that the hip joint must possess.
BIBLIOGRAPHY:
Cooper, Astley.   "A treatise on Dislocations and on Fractures of the Joints, 5th Edition, London, 1826.
Colles, A.   "Lectures on the Theory and Practice of Surgery" by the late Abraham Colles.   Philadelphia,
1845.
Gaenslen, F. J.  Jour. Bone and Joint Surg., 193 5, 17:76.
Hamsa, W. R. Surg. Gyn, and Obst. 1939, 69:200.
King, G. E. Brit. J. Surg. 1939, 26:721.
Karfiol, G. J. Surg. Gyn. Obst.  1939, 68:648.
McMurray, T. P.  Jour. Bone and Joint Surg., 1936, 18:319.
Schumm, H. C.   Jour. Bone and Joint, Surg., 1937, 19:955.
Speed, K. Surg. Gyn, Obst.  193 5, 60:341.
FRACTURES OF THE FOREARM
Alexander Gibson, M.D.
Just as "Stability is the keyword for the lower limb, so "Mobility" is that for the
upper limb. The essential part of the upper limb is the hand; the upper limb is so designed
as to enable the hand to exercise its activity over the greatest possible range in space,
and in grasping the greatest possible variety of surfaces. In accordance with this design
there is a ball-and-socket joint at the shoulder, a hinge joint at the elbow and! a virtual
ball-and-socket joint combination at the wrist region. The forearm, apart from its function as a place of origin for the muscles controlling 'the digits, supplies a large measure of
axial rotation to the grasping power. In the forearm itself there resides about 180° of
axial rotation; when this is combined with the axial rotation possible at the shoulder joint,
the hand is capable of being rotated through about 360°.
This axial rotation is the essence of the function of the forearm. Sometimes it is con-
genitally absent; frequently it is lost or diminished as the result of damage to the bones.
The axial movement is usually referred to as pronation-supination, without specifying
anything other than the direction of the movement of the hand. It is more satisfactory
to think of the forearm as starting its movement from a neutral position, one in which
the thumb is directed forwards when the arm is by the side, and passing from this neutral
position into that of pronation, when the dorsum of the hand is directed forwards, or
supination, when the palm of the hand occupies the similar position. We then observe
that in the normal individual there should be about 90° of pronation, and about the same
[  45   ] amount of supination. As the result of injury, it may happen that the whole of the range
of pronation is retained while all supination is 'lost, or vice versa. When this view of the
proper quality of forearm movement is appreciated, one can understand that in any
derangement of function such as results from fracture, restoration to normal cannot be
considered complete, unless a full range of pronation and supination is obtained.
Anatomy.
Consider first, the bones.
The ulna is practically the axis of the forearm. This is not mathematically a correct statement, but from the surgical point of view, it is substantially true. It means
that in the movements of pronation and supination, the ulna remains practically immovable, while the radius carrying the hand, rotates around it. Near the elbow, the ulna
is massive and strong; it alone bears the overwhelming proportion of the strain which is
transmitted from the forearm to the upper arm; the head of the radius1 is little more than
a passenger as far as accepting transmission of strain is concerned. At the distal end of
the bone, the condition is reversed. The lower end of the ulna is comparatively fragile;
it accepts none of the responsibility for the passage of strains from the hand to the forearm; the radius alone accomplishes this; the radius and the hand are one. The ulna does
not share in the function of the wrist and carpal region any more than the radius does in
the duties of the elbow joint. Between upper and lower extremities the shaft of the ulna
has a subcutaneous border and this enables us to make out by palpation a fairly trustworthy estimate of the condition of the bone.
The radius has a button-like upper end. This is retained in contact with the capitellum
of the humerus by a ring-shaped ligament. Below the head the shaft is constricted to
form the neck, and then the main length of the bone sweeps in a rounded curve towards
the distal end, the bulk of the bone becoming gradually greater as it is traced distally.
At the summit of the curve, there is a rough area to which is attached the pronator teres
muscle. The distal extremity itself merits a little attention. The dorsal surface is
grooved for the passage of tendons; the volar surface shows a fairly deep hollowing termination in a sharp ridge; the distal surface shows a curvature in both dorsi-volar and
transverse directions. The aspect of this double convexity is of great importance, especially
that from before backwards. A special prominence may be noted on the dorsal surface;
this is known as Lister's tubercle; note its relation to the distal aspect of the radius. It
lies exactly between the rather quadrangular area and the triangular one outlined on the
surface of the radius which articulated with the semilunar and scaphoid respectively;
this is a useful relationship to keep in mind in regard to injuries of the carpal region.
Between the shaft of the radius and the adjoining border of the ulna there stretches
an interosseous ligament. It is through this ligament that the transfer of strains is made
from radius to ulna in passing from the hand and wrist to the elbow. It must therefore be
obvious that in order to prevent the radius being pushed past the ulna, the fibres of this
ligament though they run in both directions, run mainly from radius obliquely downwards towards the ulna. These are the main outlines of the skeletal factors of the forearm.
We have spoken of the axial rotation of the forearm. Where does the axis lie? To a
small extent it passes through both bones, but for the most part it lies outside of them.
Its upper extremity may be taken as the centre of the head of the radius, while the lower
end corresponds to a small pit at the base of the styloid process of the ulna. The triangular discus articularis moves with the lower end of the radius.
In order to avoid misunderstanding, I shall not refer to the muscles as the axis powers;
this term has recently acquired a degraded significance. Let us see however, what forces
are available to carry out the movements of pronation and supination which are proper
to the forearm. There are two pronators and two supinators. One of these in each case
comes from the humerus to the radius; the other passes from the ulna. The pronators are
the pronator teres, passing from the medial epicondyle of the humerus to the rough area
previously noted on the summit of the curve of the shaft of the radius; and the pronator
quadratus, passing from a small area on the anterior face of the lowest quarter of the
shaft of the ulna to a large surface, (the radius is larger at this point) on the corresponding part of the shaft of the radius.   When these muscles contract, the radius is rotated
[ 46  ] around the axis into the position of pronation, and the shafts of the bones are approximated. The supinators are the Biceps coming from the humerus and inserted into the
bicipital tuberosity of the radius, a prominence situated far back on the deep side of the
shaft of the bone a little below the neck, and the Supinator coming from a triangular
area adjoining the upper part of the shaft of the radius and wrapping itself around a wide
area on the upper third of the shaft of the radius. The supinator muscle combination is
much more massive and strong than is the pronator combination; a fact known to the
makers of corkscrews.
After this preliminary survey of the mechanics of forearm movement, we are in a
position to appreciate how it is that forearm fractures may give serious trouble. If either
bone is broken, then the integrity of the pivotal or the fixation axis is broken; if both
bones are fractured, both the fixation and pivotal axes cease to exist as axes. This is
not all; the long supinator, (Biceps) and pronator (teres) have an oblique course relatively to their insertion; this means that there is a transverse as well as a longitudinal
component; in the case of the short supinator and pronator muscles, the action is almost
wholly transverse. The result of the transverse pull is that the bones tend to be approximated and this results in a loss of the special property of the forearm; pronation or supination, or both are diminished.
The displacement resulting from the original violence accompanied by the muscle
action may be of various kinds; there is generally shortening from the pull not only of the
proper muscle of the forearm but of those going to the hand. There may be angulation,
or rotation of the bones in opposite directions. Union may occur with shortening; this
in itself is of little moment; what really matters is that the interosseous distance should
be preserved throughout its whole length. If this is not obtained, here is certain to be
loss of pronation-supination. Hence the necessity for obtaining direct end-to-end contiguity in the reposition.
Ulna Alone.
This fracture is usually the result of direct violence, accordingly the bone gives way
at the point of impact as in warding off from the face a blow with a stick. Sometimes
there is little or no displacement; the amount of interference with the fixation axis is
proportionate to the amount of displacement and is generally less the closer the fracture
is to the distal end of the bone. When the bone gives way in the upper third, however,
there is almost invariably a complicating factor, viz., dislocation of the head of the radius.
The ulnar fracture is usually diagnosed at sight; it is treated secundum or tern, and after
union has occurred the discovery is apt to be made that the head of the radius is lying
in front of the capitellum. In this case the pivotal axis has retained its full length, but
has been shifted bodily in a proximal direction.
Radius Alone.
Fractures of the head of the radius may show as splitting of the articular cartilage
alone, or of the bone composing the head, or a fragment may be chipped off, or the head
may be shattered. In these cases the interosseous fibres have not been sufficiently tense
and strong to prevent slipping of the radius in a proximal direction past the ulna. The
head of the bone is driven with force against the capitellum and a fracture results. If
there is not much displacement, it is often feasible to leave the break to unite. Not
infrequently the patient by active movement gradually works the pieces into reasonable
relationship with one another and nothing further is necessary. More often the fragment
is so much out of alignment that the movements of pronation and supination are impossible, and in such a case there is nothing to be gained by waiting; the head of the radius
ought to be removed. If there is a stellate fracture with shattering of the head no alternative to removal exists.
The Shaft.
(a)  Above insertion of pronator teres.
When a fracture occurs in this situation, the forces acting on the fragments are
unequally distributed. On the upper piece the biceps and the supinator both exercise
influence, and accordingly it tends to assume the position of full supination.   On the
[  47   ] lower fragment the pronator teres and the pronator quadratus both are at work, and
hence it tends to become fully pronated. In this instance we must follow the invariable
rule that the distal segment must be brought into line with the proximal, and so such
a fracture should be put up with the elbow flexed to diminish the influence of the biceps,
and with the forearm in full supination. In this position of full supination the bones of
the forearm are at the maximum distance apart and thus, apart from the irksomeness of
the position, and the further consideration that it is never wholly satisfactory to subject
any joint to prolonged fixation in an extreme position, the result as regards retention of
pivotal action ought to be satisfactory.
(b)   Below insertion of pronator teres.
In this case action on the upper fragment if maintained by the two supinators with
the strong pronator teres making a pull in the opposite direction. The net result is that
the upper fragment is almost in the neutral position. The lower fragment is acted upon
especially by the pronator quadratus, and, theoretically at least, should be in a position
of slight pronation. As a matter of practice, it is customary to put up such a fracture in
the mid- or neutral position. One advantage of this is that as soon as the preliminary
reaction to trauma has passed off, the muscles are in an equal degree of tonus, they are as
nearly at rest as it is possible for them to be, and hence the position is comfortable, the
blood supply is presumably at its best, and the result is favourable.
Fractures of the lower end of the radius are generally classed in the group known as
Colles' Fracture; of these I shall say very little. In every case the potential displacement
is threefold, and the position in which consolidation is allowed to occur should take into
account each of these three factors. No position of retention is satisfactory which keeps
the hand in a position of strain. Remember that the callus is apt to be soft and yielding
long after the patient thinks the part good enough for him or her to resume work, and
an excellent result may terminate in unsightly deformity through unwise activity.
Fracture of Both Bones of the Forearm.
These constitute a real problem. They are very often approximately transverse. In
these cases, the two long sides of the triangular of fixation formed by articulation of the
ulnar notch with the trochlea of the humerous the articulation of the head of the radius
with the articular fossa on the upper end of the ulna, and the articulation of the head
of the ulna with the notch at the lower end of the radius, the two long sides of this
narrow triangle are broken and only the short base remains intact. There is bound to be
shortening, angulation of fragments may be extreme, and rotation of upper and lower
fragments relative to one another may be pronounced. The task of fitting the four
broken surfaces together as they were before the break occurred is one of extreme difficulty.   Reposition is difficult and retention is almost as difficult.
There is one variety of the fracture of both bones of the forearm which may secure
our interest for a moment. It is that of the green stick fracture in children. Why is it
that a Colles' fracture so common in the adult is almost never seen in children? To understand this it is necessary to keep in mind an axiom which we see manifested in many parts
of the body. In any mechanical system of which one part is fixed and another part is
movable, the point of maximum strain is in the neighbourhood of the fixed and the movable. In the adult the point of maximum strain is on the forearm side of the wrist, i.e.,
in the relatively fixed part. In children however, the bones of the forearm have much
more resilience than in the adult, and so the fixed, unyielding point is not reached so
speedily after the strain has passed the movable wrist; it is a short distance up the forearm. Hence the bones give way not within the first inch above the wrist but at a definitely higher level.
Complications.
1. Delayed Union. The causes of delayed union are reputed to be many, and perhaps
they are. From the point of view of the practitioner, there is one paramount cause of
delayed union, viz., movement. In my experience this has been more evident in cases
involving the lower third of the ulna than in any other situation. Fractures of the radius
unite with rare exceptions; the fragments are free at both ends and accordingly there is
less risk of movement at the actual site of the break.   When the ulna is fractured, the
[  48   ] proximal fragment must be fixed, and any activity involving movement of the distal
fragment is apt to take place at the fracture itself. Such activity is almost always axial
rotation.   Prevention of this will be discussed later.
2. Dislocation of the head of the radius. In such cases it is of the highest importance
to reduce the dislocated radial head. When it is restored to its normal position it assists in
retaining the fractured ulna in correct alignment.
3. Nerve injuries. The median nerve is not often injured. The radial is sometimes
involved in severe injuries about the upper end of the radius, as it winds around the
shaft through the substance of the supinator muscle. It is most seriously in danger during
the operation of excision of the head of the radius; it runs very close to the neck of the
bone; even if it is not severed in laying bare this part of the radius, it is apt to be
stretched, and put out of action for a number of weeks. With an adequate appreciation
of the exact position of the nerve, this accident shoulld not occur. The ulnar nerve is
injured in a fair number of cases especially towards the distal end of the bone.
4. Decalcification of the bones of the forearm and hand is not uncommonly met
with. The majority of cases are associated with compression by splints and bandages.
There is less risk of compression by the use of a plaster splint which surrounds the whole
part than by the use of a splint which h^s to be bandaged firmly in place. Pain is the
main subjective indicator and swelling of the hand in any patient particularly those over
middle age, ought to be a signal for immediate re-adjustment.
5. An extreme degree of compression leads to one of the most tragic phenomena in
surgical experience; the so-called ischaemic hand. Here again, pain and swelling are the
unmistakable indicators that something is wrong and the need for swift action cannot
be exaggerated.
6. Loss of substance. Fortunately this is not common. It is found at times in the
lacerated compound fracture. If healing occurs in the soft parts, it may be necessary
to devise a specially-shaped bone graft to fill the hiatus (Lang). Healing resulting in a
bone sufficiently strong for use by a labouring man may require very many months for
its completion.
Crest of ilium probably the best source for the graft.
Methods of Treatment.
Let us keep in mind the fundamental principles. SET. FIX. USE. How is the fracture
to be "SET." In the case of the greenstick fracture, it is as a rule, simple to bring the
parts into their normal relation by manipulation alone. In the adult, this method may,
upon occasion be successful, but for the most part, it is not so. The difficulty of engaging
four points end-to-end two by two is a feat beyond the skill of most of us. Mechanical
extension is increasingly employed in this machine age. In its simplest form it may take
the form of a plaster cuff around the arm to provide a fixed point for traction and then
by some device applied to the hand or the wrist, the bones are gradually pulled into
approximate alignment. Traction on the finger as by the "Banjo" type of splint is in
my opinion, never wise. The fingers joints are made for delicate movements; they never
recover from the prolonged traction to which they are apt to be subjected. Traction
from and through the wrist and carpal joints is only slightly less objectionable. To avoid
this, traction may be made by a Kirschner wire or a Steinmann pin through the lower
end of the radius and (the head of) the ulna, counter-traction being furnished by means
of a wire or pin through the upper end of the ulna about the base of the olecranon (Melny-
chuk) process. In using extension it should always be remembered that mechanical
devices employing screw traction give relatively powerful purchase, and it is not at all
difficult to overdo the process. If a fractured bone is maintained in the position of overextension, this is an invitation to non-union or at least delayed union. The bones of the
forearm do not possess a great deal of osseogenic power, whatever that may be, union is
easier and more certain if there is no gap to be bridged. A further criticism of the method
of mechanical extension is that the influence of a strictly longitudinal force upon stresses
which have a transverse or rotary component must of necessity be indirect and incompletely measured.  Mechanical extension is not ideal.
[  49   ] There remains the method of open exposure and adjustment by direct vision. By
this means it is possible to obtain the most accurate reposition. It is always possible to
expose any part of the radius or ulna without doing damage to muscles, or nerves, or to
blood-vessels of any importance. Other things being equal, open exposure undoubtedly
permits the best reposition or setting. The next part of the procedure is that of fixation.
If the broken ends have been exposed, it is quite reasonable to fix them by plating. This
may be a bone plate, a plate of stainless steel or ihje latest comer to the fijeld of surgical
hardware, Vitallium. This plate may be secured by screws, or it may be the angled plate
of Hawley. It may not be necessary to fix both bones. When one has been made stable,
the irregular fragments of the other may engage so as to remain secure without actual
plating. If only one bone of the forearm is to be plated, which should it be? Undoubtedly
the ulna. The ulna is the axis bone of the forearm, without stability of this, the forearm
is less than the best possible. When a plate has been applied, it is well to think of the
process as part of the setting, not part of the fixation. The metal plate, no matter how
many screws it may carry, should always be regarded as inadequate for the task of fixation. Fixation should be carried out by means of plaster. The first plaster will have to
be applied over the dressings and these are too voluminous to control movement entirely.
We have learnt much from Border's work on the unpadded plaster. After the lapse of
two weeks or so a fresh plaster should be applied without any padding: at all. This should
include the elbow and should extend down to include the hand as far as the necks of the
metacarpals. Fixation is incomplete as long as it is possible to promote or to supinate the
hand.
Axial rotation must be forbidden until bony consolidation is complete. If one remembers that the movement of pronation or supination means that the hand occupies an area
entirely medial or entirely lateral to the line of a fixed ulna, one can see that a plaster
which comes only as low as the wrist and does not inhibit this movement in its entirety
is bound to admit of axial movement within the confines of the plaster, and this movement can be attained only by lateral or medial displacement of the lower fragment of
the ulna. Fixation must include the second to fifth metacarpals for as long as may be
necessary.
The third member of the triad is active use. With a fixed elbow, wrist and metacarpals, what use is possible? The fingers can be and ought to be free, and should, be
encouraged to do all the light delicate work which is possible for fingers alone. Next,
the shoulder ought to be free. Light plasters are available which do not require the use
of a sling. Each day the shoulder joint ought to be put through a full range of move-!
ment. It will not then be necessary at the conclusion of the treatment! to spend weeks on
overcoming stiffness which should never have been allowed to develop.
ILLUSTRATIVE CASES.
Melynch.uk—Wire for traction and counter-traction.
Lang—Loss of substance.
Mill—Delayed union; abuse of pronation and supination.
Hathaway—Delayed union; insufficient fixation, Ulnar neuritis.
Torrance—Delayed union; insufficient fixation; osteoporosis, frozen hand.
Hein—Metal plate on ulna.
Richards—Metal plates on radius and ulna; very little loss of time.
ILLUSTRATIVE CASES.
M., boy, 16.
Date
4-12-37—Sustained fracture of both bones of left forearm.
8-12-37—Wire put through upper end of ulna and through lower end of both bones of forearm.   Plaster applied including  wires.
29-12-37—Wires removed.   Fresh plaster.
10-
11-
1-
7-
•78.
1-38—Plaster removed.   Nervous.
1-3 8—Fresh plaster.
2-3 8—Plaster off, seems solid.
3-38—Can finger violin strings.
4-38—Playing violin nearly as well
as  before.
50  ] **g»3WiMWHHWWiJWMija
IBEfl
H., 2
23-1
26-
26-
23-
5-
7-1
3-
5-
16-
28-
17-
13-
25-1
26-1
5-1
10-
21-
12-
5.
0-35-
2-3 6-
2-3 6-
3-3 6-
5-36-
0-36-
2-37-
2-37-
6-37-
9-37-
3-3 8-
7-3 8-
0-38-
0-38-
1-38-
1-3 9-
3-39-
7-39-
—Right arm caught in a pulley.   X-ray.
-Seen by me.   Operation graft and bone chips.   Plaster.
-Seen by me.   Operation.   Graft and bone chips.   Plaster.
—First plaster changed.
-Plaster off, tender, fresh plaster.
-Wore plaster until end of August.   Graft increasing in thickness.   Seems solid.   Wear
plaster collar.
-Has been exercising the hand.   Loss of bone at site of fracture.
-Regrafted.
-Plaster changed.   Clinically solid.
-Clinically solid plaster off, X-ray shows apparent union.
-Seems to be solid.   No work yet.
-X-ray shows improvement.
-Small sinus at lower part of scar. Local Dr. has been trying to increase axial movement.
-Sinus down to drill hole; no sequestrum.   Plaster.
-Plaster changed.
-Plaster changed.
-Plaster off.   Try light work.
-X-ray shows union apparently solid.
Return to full work.
3.
H, 25.
10-
10-
28-
15-
13-
5-
4.   T., 26.
1-3 8—Forearm wound into a cable.
2-39—Bone graft to ulna.   Radius united.
2-39—Fresh plaster.
4-39—Fresh plaster.
7-3 9—Clinically solid.
9-39—Clinically solid.   Try a little light work.
Bone graft of ulna.   Osteoporosis.
5.   A. H, 19.
_ 2- 9-39—Fract.  both bones left forearm.
* 2- 9-39—Ulna plated.
6.   B. R. R., 24.
27-  5-39
15-
3-
9-
11-
Struck on left forearm by rolling log.
6-39—Ulna and radius both exposed and plated.
7-39—Bones in good position.
9-3 9—Plates removed.   X-ray.   Clinically solid.   Has been at work in office throughout.
9-3 9—Fresh  plaster.
THE MECHANISM OF THE SPINE
Alexander Gibson, M. D.
We have it on the authority of a famous writer that every author has in his heart
of hearts a favourite child. In the same way I venture to think that every practitioner
has in his heart of hearts a favourite bugbear, and its name is Pain in the Back. The
alleged causes for this pain are extremely numerous, so manifold indeed that only a doctor
and a patient steeled to the prolonged tussle of a psycjho-analytic inquisition could make
the investigation a complete one. Those of us who are called upon to solve the spinal
problems of section-hands, coal-heavers or ditch-diggers are relieved from the necessity
of considering such possibilities as visceroptosis or uterine displacements. In most of our
cases, the trouble starts at work, and in many of the sufferers, the evil is mitigated or, it
may be, prolonged by a background of compensation for accident. It may be worth
while therefore to look a little more closely at the vertebral colum, to see how it is
designed, how it is constructed, and how it is meant to work.
It is hardly necessary to lay stress on the importance of the backbone. It is the distinguishing mark of that great section of the animal kingdom known as the Vertebrates.
Its purpose is two-fold. It is meant to give an axis of support for the trunk and head,
and to form a protective covering for the spinal cord. The upper limbs work from it as
a basis.
[  51   ] Upper Limbs.
Let us look at the design in the lower animals, especially the quadrupeds. Here the
analogy with a bridge is almost irresistible. Supported on front and hind piers is apparently
the truss that carries the weight of the animal. But this bridge is not like most bridges
which have above all things, to be rigid The vertebral column has to be rigid, it is true,
but it must also be flexible. It is only necessary to observe the domestic cat in the attitude of defiance to appreciate how great that flexibility must be. Again there are different types of bridges. The quadruped at once suggests a bridge made of a double cantilever, the front one resting on the forelegs, the rear one on the hind legs. The two are
in continuity but each carries its own proportion of weight. The arms of the front cantilever comprise the head and neck counterbalanced by a part of the trunk. The arms of
the rear cantilever are constituted by the remaining part of the trunk counterbalancing
the pelvis and tail. The proportion of weight borne by these two cantilevers varies a
great deal in different species. On the average, about two thirds of the weight is borne
by the fore limbs, about one third by the hind limbs.
Let us put it otherwise. The cantilever is like a double bracket. When weight is
placed on one or both of the arms, the lowest stratum is under compression strain, the
uppermost under tension. In between is an area where the strain is non-existent. This
is the area occupied by the spinal cord. We can now construct a qualitative diagram. In
this bracket arrangement the weak part is where the pier joins the bracket. At this point
both compression and tension strains will be greater, the greater the weight the bracket
has to support. Hence, to make the structure strong enough to withstand! the strains,
it would be necessary to increase the thickness of the bracket proportionately for compression and tension strains at the weakest point. In practice the engineer would prepare a graph of the "bending moments." This graph would correspond exactly to the
outline the cantilever would have to assume in order to be safe.
Now let us translate this into anatomical terms. It means that there is a gradual
increase in size of the vertebral bodies from the head end of the column to the point
overlying the forelimbs and after that a gradual decrease. This would be followed by a
corresponding variation for the remainder of the spinal column. In respect of the tension
member there would be an increase in the height of the spines, the maximum being
reached over the withers. How exact this diagram is, can be seen by inspecting the skeleton of quadrupeds, such as the elephant or the camel, with heavy head and neck. Perhaps
the most striking of all such demonstrations is seen in the skeleton of the extinct Titano-
there, an animal weighing many tons, most of the weight being carried by the fore limbs.
Now the actual tension is taken by soft parts, particularly by ligaments and by
muscles. The spines of the vertebrae correspond to the position of the diagonal of the
parallelogram of forces to which the vertebra is exposed. The spines tend to slope away
from the highest point. Apply the same reasoning to the region of the column overlying
the hind limbs and it will be seen that in quadrupeds in which trie loads on both piers
are approximately equal, there must be an "anticlinal" vertebra. It is also clear that there
cannot be an anticlinal vertebra in an animal which assumes the upright position. Neither
can an anticlinal vertebra be at all pronounced in those creatures, such as the buffalo,
where the hindquarters are comparatively small.
So much for the quadrupeds. What experiments has Nature made in the way of
progression on two limbs instead of four? In Cretaceous times some of the Dinosaurs
walked on the hind legs alone. In our own day the kangaroo progresses without the help
of the fore limbs. In each of these cases the enormous weight of the body was and is
counterbalanced by an exceedingly heavy tail. That means that these animals transformed
their vertebral column into a single cantilever. Their case is obviously different from
ours. Then there are the birds. They walk on the hind limbs alone, but they have solved
the problem of balance in still another way. The weight of the head and neck is counterbalanced by the weight of the greater part of the body and pelvis, and they have transferred the points of support, the hip joints, to a higher level. The hip joints are away
above the centre of gravity, so that the bird may be looked upon as a sort of animated
pendulum.  Obviously that is not the solution in the case of man.
52   ] HfifiBssSHEBEEBsHB ■ S^^^DB^Bwi
In raising himself to the upright position man has concentrated the weight right
over the points of support. He depends neither on cantilever action nor on being under-
slung. Man, therefore, presents an entirely novel procedure and it is not surprising that
in the half million or so of years occupied so far in working out the details, there may be
a good deal of variation. Let us omit consideration of these details and examine the design
as we see it in most of ourselves. Obviously an arrangement of this sort must demand
very fine co-ordination, for it is not so dependent on merely mechanical aids. Unlike the
birds we cannot sleep standing up. Co-ordination is bound up with the development of
the brain, an interesting subject which we must omit for the present.
Next, let us ask ourselves, is there an essential principle with which the design must
aonform, one common to quadrupeds and to other bipeds as well as to ourselves? This
principle is that during progression the head must move in a straight line avoiding up and
down as well as side to side motion.
This may be beautifully seen in a moving picture of a herd of giraffes on the run.
When the head is steady, it means that the owner of the head is a less conspicuous object
to his enemies and it also means that the field of vision undergoes less variation. That this
principle holds for ourselves may be seen in the compensatory scoliosis that develops in
cases of torticollis. The face may be asymmetrical, the neck definitely awry, but the
eyes are horizontal. So in cases of inequality of length of the two lower limbs, the individual may bring about quite a severe distortion of the vertebral column but the eyes
tend to be parallel to the ground.
It will be evident from the last consideration how very completely the properties and
movements of the spine are correlated with and are dependent on the lower limbs. Functionally speaking, the lumbar spine and the hip-joints are complementary. Any restriction of movement at the hip is immediately felt by the lumbar spine. Should the hip-
joint, as in cases of congenital dislocation, be outside the line of transmission of weight
the lumbar spine will compensate by increased lordosis, in the attempt to maintain the
head upright and the eyes directed horizontally forwards.
The essential mechanism used for this purpose is the spring. The action of springs
in the human body is perhaps seen at its best in the foot, where strength and delicacy
of adjustment are combined in a remarkable manner. In spite of this, most people, includ-
•ing medical men, and not excluding orthopaedic surgeons, speak of the "arches" of the
foot, and of "fallen arches," ignoring the obvious truth that while an arch may be a
very good support for stationary structures such as a bridge, a hotel or the Eiffel Tower,
it is not a suitable support for a body that moves about such as a wagon or a motor car.
Both arches and springs have in common the qualities of rigidity and flexibility, but in
the case of the arch, the flexibility is almost at vanishing point. If flexibility be entirely
absent the structure is still an arch. In the case of the spring, flexibility is the main theme
of the story. What are the characters of springs as we find them in the body? They may
be strong or weak with all gradations in between. The strong spring is short; its range
of deflection is small; it is composed of few elements; (it retains much stability). Thie
weak spring is long; its range of deflection is considerable; it is composed of many elements; (its "motif" is mobility). The contrast between strong and weak springs is seen
in the vertebral column if we compare the cervical with the lumbar region. The cervical
is relatively long, its deflection is great, it is composed of seven elements; in comparison
with the strong lumbar spine, it is relatively fragile. It does not have nearly so much
load to carry, merely the head, but it must arrange for the support of the head in any
position that the enquiring disposition of the owner may cause it to assume. The lumbar
spine is short in relation to its cross section; it has not so great a deflection as the cervical
spine; it is composed of five elements; it has to carry and maintain in equilibrium in
various positions, the weight, not merely of the head and neck and upper limbs, but also
of the whole trunk.  In this region stability must over-ride mobility.
We can thus look upon the vertebal column as composed of three main sections, a
lumbar spring whose keynote is strength; a region, the thoracic, which is almost rigid,
and a cervical spring of which the keynote is mobility. Why interpose a long rigid section
between two short springs?  Why not have the whole column one continuous spring?  In
[   53   ] the first place, the thoracic region gives shelter to the lungs and to the heart and great
vessels. Which ever of the bodily functions we may venture to interrupt or embarass for
a prolonged period, we dare not take chances in regard to respiration or circulation.
Again, by having this part of the column rigid, a tremendous saving of skeletal material
is possible. Even a small degree of flexibility would mean an added., mass of five or six
to one. This is in accordance with the mathematical formula known as Euler's Law which
is to the effect that the weight that a column liable to flexure is capable of supporting
varies inversely as the square of its length. By having the thoracic column with its convexity directed backwards, it is possible to provide a more roomy cavity for lodgment of
the thoracic organs. The backward convexity of this portion determines the forward
convexity of the cervical and lumbar portions. The combination of these three curves
imparts an innate springiness to the column as a whole quite apart from the individual
sections. If instead of a triple curve we had a single continuous curve stretching from
the promontory of the sacrum to the base of the skull, it would project so far forward
as to obliterate practically all the thoracic and abdominal space, and in accordance with
Euler's Law would have to be enormously massive. Taken as a whole, therefore, the
vertebral column is designed on the soundest engineering principles.
Now let us consider the material used in this remarkable column. It is composed of
bone and fibro-cartilage. There are materials stronger than bone for both compression
and tension stresses, e.g., steel or wrought iron, but these have biological drawbacks.
Bone is very much stronger than wood and it has the property of resisting crushing forces
almost as well as tearing ones, a valuable quality when one considers the infinitely variable
angles at which stresses may be brought to bear on the spine. Much might be said about
the fibro-cartilage, the intervertebral discs and the part they play in binding the many
elements of the column into one continuous whole. Suffice it for the present to note that
Nature has placed a highly efficient shock-absorber between each two vertebral bodies.
This minimises the amount of shock transmitted from one body to another, and ensures
that should such a shock be propagated from the lower end of the spine to the thoracic
region it is likely, unless excessive, to be dissipated through the thoracic cage by means of
the ribs. In this way the well known broom handle effect on the base of the skull is
generally obviated. Were not some such provision made it would be quite unsafe to step
off the kerb. It is therefore essentially in connection with compression stresses that the
fibro-cartilages play a leading role.
What mechanism is there to take up tension stresses? Here we must bear in mind
that the spring is movable in all directions from the upright position, forward, backward,
to either side, and in left or right rotation. There must be, therefore, what is practically
a cylindrical tension member. This can readily be distinguished.
In accordance with the comparatively fixed thoracic column we find little posteriorly
except suprapinous and interspinous ligaments. Laterally there are the ribs with limited
capacity for separation. Anteriorly there is the sternum with only the manubrio-gladiolar
joint in addition to the natural elasticity of bone. The whole region forms a resilient cage
with limited deflection in any one direction. In the movable regions of the spine the
tension members are very well developed. The muscles are very massive and complex.
Posteriorly there are supraspinous and interspinous ligaments, lumbo-dorsal fascia, and
ligamentum nuchas. Anteriorly there is the linea alba and the sheath of the Rectus abdominis muscle. But much more striking than fibrous and ligamentous bands is the presence
of muscle. Posteriorly there are two great tracts of deep muscles. In the neck region there
are specially well developed groups running for the most part longitudinally or only
slightly obliquely. These surround the cervical spine like a great muscular collar. In the
lumbar district as a strictly anterior tension member there is the paired rectus muscle
while the two oblique abdominal muscles and the transversus complete the cylinder. It
is of the utmost importance to emphasize the part played by muscle in acting as a tension
member. Indeed, throughout the body generally we are apt to undervalue, as a rule, the
use of muscle in limiting the excursion of joints. We are too prone to regard this as
determined by ligaments. Sometimes it is to ligaments that joints owe most of their
safety.   The most striking example is the knee joint where the cruciate ligaments are
r 541 KBS   BBSflnSi
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of paramouht importance. In general, however, muscles are much more important than
ligaments. It is muscle that provides the all-important factor of resiliency, elasticity and
control, the ability to return completely to the original position after deflection. Muscle
is the first and by far the most important line of defence. Ligament is the reserve and
should not be brought into use more than occasionally, just sufficient to keep it in working order, never as a routine. We recognize the part played by muscle in limiting joint
movement when we speak of an athlete as "muscle-bound", a term literally accurate. We
observe the inefficiency of ligament in the absence of muscle most notably in cases of
poliomyelitis where extreme degrees of—let us say—genu recurvatum are possible, or
where a small patient can excite the envy of his companions by putting his thigh at the
back of his neck. (Yet with strange inconsistency we decline to recognize the importance
of muscle in the case of a weak foot, where as a profession, even the leaders among us, we
deliver ourselves, lock, stock and barrel to the proponents of "arch supports", or in the case
of the vertebral column to brace-makers, corsetieres and even to surgeons who employ
bone grafts to give a final quietus to muscles which only await encouragement to do a
full measure of duty.)
The deep musculature of the vertebral column can be grouped in two divisions, a
medial tract, and a lateral tract. The former of these is of considerable mass in the lumbar
region (Multifidus Spinas) small in the thoracic region (Spinalis Thoracis, semispinalis
thoracis) and increases again in the cervical region. (Semispinalis capitis.) This bundle
is strictly a tension member corresponding to the mobility of the column, strong where
the mobility is great, weak where there is little movement. It controls the flexibility of
the flexible column. The lateral deep group is composed of the Ilio-costalis (lum-
borum, thoracis, cervicis) and the Longissimus, (thoracis, cervicis, capitis). It is broad
and strong below and is smaller and weaker above. It is obviously designed as a tension
member for the column as a whole, the power increasing proportionately with the strain
imposed on the lumbar region by the weight and leverage of the overlying parts. These
two deep systems are evidently complementary to one another. Together they demonstrate how tension stresses can be combated much more efficiently by the active exertion
of muscle than by the passive resistance of ligament.
Points of weakness in the system are not lacking. These are marked in any flexible
rod at a change in curvature. Here the bending moment changes its direction and this
change is abrupt, thus constituting what is virtually a jerk. In the vertebral column
where the rod is not flexible throughout, the principle may be expressed otherwise; in
any mechanical system consisting of a relatively fixed and a relatively movable part,
the point of maximum strain is in the region of the junction of the fixed and the movable. Sometimes the rupture occurs on the movable side of the junction as in the ordinary
sprained ligament, sometimes it occurs on the fixed side as in the "sprain-fracture". The
Colles fracture and the Pott's fracture are illustrations of this. What governs the exact
location of the break is not clear; in the last resort it must consist in the relative strength
of the parts in relation to the type and degree of the strain. In the vertebral column the
danger points are the cervico-thoracic region, and here the break is more often on the
movable (cervical) side; the thoracico-lumbar region where the twelfth thoracic and
first lumbar bodies show the result of excessive compression in almost equal proportions.
The third region is the lumbo-sacral. In this part of the column sudden excessive violence
does not usually make itself felt, but it is a region where innumerable small traumatisms
leave their mark. The amount of discomfort consequent on small sprains is not sufficient, it may be, to make the individual cease using the joint, thus leading to chronic
changes, comparable perhaps, to those which we see so frequently in the small joints of
the fingers.
Let us glance briefly at a few of the details of this bony column.
Cervical Region.
Here the typical body is roughly oblong on transverse section; it is short from before
backwards and relatively broad from side to side. Why is this? In this part of the column
the typical body is roughly oblong on transverse section; it is short from before backwards and relatively broad from side to side.   Why is this?   In this part of the column
[   55   ] the spinal cord is distinctly large; the vertebral canal must be correspondingly large to
accommodate it and to permit of free movement of the bones without impinging on the
cord. The back of the body is accordingly excavated, as it were, but as this would weaken
the column, the body is increased in breadth to guard against this danger. Notice too
the shape of the upper and under surfaces. The upper is concave from side to side, the
lower concave from before backwards. This makes a saddle-shaped joint. We notice also
that in this region the intervertebral discs are not the sole bond of union between the
bony bodies. The latter actually make contact with one another at the sides. What a
beautiful arrangement this is to obtain security with great freedom of movement. The
security is exactly like that of a hand-clasp. There are all the movements of a ball and
socket joint except circumduction. In addition to the muscular and ligamentous safeguards the great mobility of the head forms a factor of safety, especially for anteroposterior movements. For lateral movements the mobility is less and here the resistance
is increased by the raised lateral edges of the superior surface whichl resist displacement
and these again are strengthened by the double buttress of the transverse process. The
bodies themselves are not at all massive. They have to carry only the weight of the
head, i.e., compression strains are not as a rule at all severe. (It would be interesting to
see what results the systematic carrying of heavy weights on the head by natives of the
Orient may have had upon the cervical vertebrae. I know of no observations on the
subject.)
The strains in the cervical spine are mainly tension strains, and these are amply provided for by the muscle masses behind and at the side as well as to some extent in front.
The spines of the cervical vertebrae are short and bifid. The shortness is apparently an
adaptation to permit of free dorsiflexion; the bifid character, a character almost peculiar
to the human subject, gives more surface for muscle attachment. In animals in which
the head and neck form the anterior bracket of a cantilever, there is usually a very strong
fibro-elastic ligamentum muchae. In the gorilla the cervical spines are exceedingly long;
two to four inches. This animal has an exceedingly heavy skull, which, owing to the
position of the creature being only semi-upright, is carried in front of the line of support.
Thoracic Region.
In this portion of the column the body of the vertebra is heart-shaped; there is no
need to provide such a large vertebral canal inasmuch as the spinal cord is comparatively
small, and the amount of movement is less. There is practically no side to side movement, hence the strains are essentially compression strains. The arrangement of the main
mass of the bone along the ventral border is exactly what we observe elsewhere in the
body.  The thickest part of the shaft of a long bone is along the line of the concavity.
The spines of the thoracic vertebrae slope backward in a notable manner. The interpretation of this is that tension strains in this part of the column are not at all severe
and that they are associated with forward neck movements. The spines themselves are
of dense strong bone. In this part the spinal cord lies at no great depth from the surface;
the line of the spines forms as it were the ridge-pole of the roof of the vertebral canal.
The extensive overlapping of the spines forms an effective hindrance to backward movement. The size of the transverse processes in this region at once claims attention. These
are massive for they help to provide the ribs with a "two-point suspension." In the case of
the eleventh and twelfth vertebrae, the transverse processes are small and of little importance. They do not support the floating ribs. Structures that do not perform a useful
function become inconspicuous.   (Would it were so in the body politic!)
Next, take a look at the articular processes. They are placed so that the upper pair
look backwards and slightly outwards. They are as it were on the circumference of a
circle whose centre lies well in front of the vertebral canal. They, therefore, permit
a certain amount of rotatory movement. Contrast this with the lumbar articular processes. They face backwards and inwards; they lie on a circle whose centre is well behind
the vertebral canal.  In the lumbar region no rotatory movement is possible.
[   56  ] <^bnsvuiLPjjL,*i!i^^^^HP<w«m
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Lumbar Spine.
The bodjes of the thoracic vertebrae increase in size gradually from the fourth downwards. In the lumbar region these bodies are very massive. The vertebral canal has to
be massive for the lumbar swelling of the cord and for the cauda equina, so there is an
excavation at the back of the body which provides more room. Unlike the cervical
region, however,. the lumbar region is subject to great compression strains, it has to
carry all the weight of the trunk, head and neck, and upper limbs as well as any weights
which the individual may be transporting. Compression strains must be provided for,
and so the body must project forwards as well as laterally. The result is a body which is
kidney shaped.
The lumbar spines are large, giving wide attachment to muscle. They project straight
out from the bodies. The third is most massive, corresponding to the spot where the
tension strain is at a maximum. The fourth and fifth spines are definitely smaller.
Upwards from the third the spines continue massive to the twelfth thoracic. The eleventh
thoracic spine is abruptly smaller. This, then, is the area of maximum tension, opposite
the upper lumbar spine. The fifth spine is usually smaller than the fourth providing room
for a certain amount of backward movement between it and the sacrum. Proximity of
lower lumbar spines to one another means relatively little extension. This is a region of
the spinal column where the problem of the upright position would appear to be incompletely solved. The fifth lumbar vertebra is subject to a large number of variations; the
transverse processes are variable in size, direction, and relation to the ala of the sacrum;
the articular processes vary in the direction in which they face; the vertebral arch is frequently in two segments. It would seem as if Nature were still engaged in making experimental patterns, any or none of which will in the lapse of time become standard. With
the exception of the fifth lumbar, the transverse processes of this series are relatively
small. They have no ribs to support and are devoted entirely to muscle attachment. The
size and direction of the transverse processes in quadrupeds is subject to enormous variation, e.g., elephant, dog, jack-rabbit.
Muscle Action and the Vertebral Column.
Enough has been said to indicate that the vertebral column may be regarded as a
sort of flexible Maypole with guy-ropes attached to it on every side. It is important to
remember that muscle has a two-fold function: to contract and to extend, to pay out
the slack. We may take it that wherever a movement can be produced by a combination
of muscles, there is another combination that acts as its antagonist. Smooth, harmonious
action can result only if these muscles are balanced in tone and power. Continuous over-
action of one group must lead to deformity, and overstretching of the antagonists. Constant overstretching leads to permanent weakness, and thus the vicious circle is completed.
If the vertebral column is to move freely and safely it must act from a stable, fixed
base—the pelvis. From this it will be clear that attempted extension of the spine against
resistance, as in lifting a very heavy weight must be antagonized by the pull of the
Gluteus Maximus in the effort to keep the pelvis from tilting. If the pelvis be tilted the
gluteus maximus will tend to bring the trunk into the upright position. That is why
pain and tenderness after lifting strains are often referred to a point below the iliac crest,
corresponding to the attachment of the gluteus maximus muscle, generally in the neighbourhood of the posterior superior spine.
Next let us think of the action of the upper limb. For smooth movement it is necessary that the shoulder should be stable. Fixation of the scapula requires balanced contraction of the Trapezius, Rhomboids, and Serratus Anterior. The last named muscle
has a wide attachment to the upper eight or nine ribs. Its pull on these ribs must be
antagonized by a pull in the opposite direction and this must be done mainly by the
fibres of the external oblique of the same side and the fibres of the internal oblique of
the opposite side, the linea alba and fibrous sheath of the rectus intervening. Now a
powerful muscle like the serratus acting with the long leverage of the ribs must exert
a strong rotatory force upon the thoracic vertebrae. From this it is evident that weakness
of the flank muscles of either side in the presence of an unimpaired serratus anterior must
[   57  ] lead to rotation of the vertebrae, in other words to a scoliosis. That this can occur is seen
in severe cases of Poliomyelitis where pronounced scoliosis may develop although the
patient remains flat on his back in bed. There is no time to pursue in detail the action
of the muscles of the abdominal wall. Enough has been said to suggest the supreme
importance of symmetrically developed muscle power in all parts of the body. It also
suggests that exercises in the treatment of scoliosis must not neglect the muscles of
the abdominal wall.
It is not within the scope of this paper to discuss pathological changes or the treatment of disabilities. With a knowledge of the mechanism, its structure and its mode
of working, and a lively grasp of the fact that much more significant than the passive
bones and ligaments are the active muscles, many problems viewed hitherto imperfectly
understood become a little less obscure.
CARCINOMA OF THE CERVIX
W. G. Cosbie, M.D.
During the last ten years, 395 patients have been treated for carcinoma of the cervix
at the Toronto General Hospital and the Institute of Radio Therapy, Toronto. Since
the first patient was treated with radium in September, 1921, irradiation has gradually
come to be the only treatment used for carcinoma of the cervix. In 1929, a joint clinic,
diagnostic, therapeutic and follow-up was organized by the Departments of Radiology
and Gynaecology and since 1934 the work has been carried on in the Institute of Radio
Therapy under the direction of Dr. G. E. Richards with the association of certain members of the Department of Gynaecology.
It has always been recognized that the extent of the malignant disease is the greatest
factor to be considered in determining a basis for prognosis and for comparison between
reports from different treatment centres. Therefore a universal classification of four
stages is used which defines—
Stage 1.   As carcinoma entirely confined to the cervix.
Stage 2.   Where there is questionable extension into the vagina, into the parametrial
tissues or upward into the body of the uterus.
Stage 3.   When the extension to vagina, parametrium or body of uterus is very
definite.
Stage 4.   When the extension is extreme, e.g., the vagina massively involved, the
uteus fixed by heavy infiltration of the parametrium of the rectum or
bladder invaded, or metastases determined in more distant locations.
It is generally recognized that Stages 1 and 2 constitute a fairly broad conception of
so called operable carcinoma of the cervix.
TABLE 1.
Stage Number of cases % 3-yr. cures °/o 5-yr. cures
1.        „     40 89.3 92.3
2   121 49.4 43.4
3.           167 25.2 14.6
4 _      67
Total       -  395 37.7 30.8
Three-year cures 85 of 225 cases.
Five-year cures 3 8 of 123 cases.
This table presents an absolute cure rate as all untraced cases, deaths from extraneous
disease, and patients living with evidence of active or residual diseases are counted
against the cure rate.
It is felt that these results justify the form of treatment which has been followed.
It is interesting to compare them with the figures presented by Victor Bonney of London,
England in 193 5 before the American Gynaecological Society. He reported the result of
3 84 hysterectomies performed over a 22-year period. The immediate operative mortality
Was 20% in the first hundred cases, 14% for the whole series and 9l/z% for the last
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two hundred operations. The five-year cure rate was) 39%. Bonney claims to operate
on 63% of the patients whom he sees. The five-year cure rate from combined Stages 1
and 2 in our clinic has been 54%. If we were to include half of the cases classed as
Stage 3 to constitute 65% of all the patients coming to the clinic, the five-year^ rate
would be 44%, but this would certainly include many cases whom even the most sanguine
would have to admit as definitely inoperable.
It should not be forgotten that Bonney has averaged only 17 Wertheim hysterectomies a year and it is obvious that the number of operations falling to the lot of the
average operator in this country would be infinitely smaller and in all probability the
hope of cure correspondingly less. The cases which have come to the institute for post
operative irradiation after panhysterectomy have emphasized most tragically the point
one desires to make.
We have tried to form some ideas as to what factors determine the prognosis in carcinoma of the cervix. The earlier the diagnosis is made the greater is the hope of cure but
a review of our cases showed that no relationship existed between the duration of the
symptoms and the extent of the disease.
TABLE 2.
Duration of Symptoms
Stage                                         Under 3 mos. Under 1 yr. Over 1 yr. No. inf.             Totals
1             11                        16                        13 40
2.                  3 9                         47                         34 1 121
3.                  50                        81                        36 167
4                14                         27                         26 67
Totals       114 171 109 1 395
More surprising still are the figures presented in Table 3, which compare two definite
groups according to duration of symptoms, namley, patients with symptoms under 3
months and those with symptoms over a year. It is seen that the results of treatment are
the reverse of what might have been expected, e.g., the cure rate is much higher in patients
with a longer duration of symptoms.
TABLE 3.
3-year cure rate according to duration of symptoms.
Stage Under 3 months Over 1 year
1.         87.5% 90    %
2.        -  3 8.4% 57.1%
3   19   % 3 8.4%
4     — —
Total        33.8% 49   %
Total—115.
There is much food for thought in these two tables with the apparent paradox they
present.
1. Cancer is a silent disease in its early stages especially if its location does not readily
expose it to trauma. Tumours which are invasive rather than fungating and especially
those which grow primarily within the cervical canal may develop very considerably
before giving rise to symptoms. The involvement of the parametrium and the pelvic
glands, which is so difficult to control by treatment, occurs much earlier in some cases
than in others.
2. In multipara; carcinoma may develop in association with a long pre-existing cervical catarrh. The vaginal discharge of the benign condition tends to mask the onset of
discharge from the tumour.
3. Irregular bleeding is accepted by many as a normal condition at the menopause,
or if coming sometime after the menses have ceased is often thought to be a return of the
menstrual flow. The majority of patients only present themselves for treatment when
bleeding is profuse or has become almost continuous.
4. As nearly 30% of the patients waited until they had symptoms for over a year—
it may well be said that in many cases fear and ignorance tend to blind the patient to
the early danger signals.
[  59  ] Total
395
20-29,
12
TABLE 4.
Age Incidence.
30-39,        40-49, 50-59,        60-69,        70-79, 80-89
81 139 96 49 17 1
This table shows the age incidence of carcinoma of the cervix. The largest number,
approximately one third of the patients, were in the menopausal decade. It is interesting
to note that 67 patients were over 60 years of age. This is a greater number of patients
at that age than we have treated on the gynecological service and in the Institute for carcinoma of the body of the uterus, during" the last ten years.
It is generally believed that carcinoma of the cervix is more malignant in younger
patients.  This is shown in the next three tables.
Stage
1.
2.
3.
Total
TABLE 5.
3-year cure rate according to age.
Under 50
88.8%
45.6%
21.7%
Over 50
90
%
55.2%
32
%
%
43.5%
Number of cases analyzed—213.
The type of patient who presents herself with symptoms of short duration shows a
particularly high mortality rate when under fifty years of age as seen in Table 6.
TABLE 6.
Age Group Duration of Symptoms
50 over  : *j,     over 1 year
50" over  ..  under 3 months
50   under    ^       over 1 year
50   under under 3 months
Number of cases analyzed—115.
3-yr. cure %
52
41
46
29
The tragedy of carcinoma of the cervix in the young patient is further emphasized
by Table 7, which presents the record of thirteen patients 20-30 years of age.
Stage 2.
TABLE 7.
Duration of Symptoms
Result.
1 A. & W. 4 yrs.
2A.&V.9 mths.
1 D. D. 6 mths.
1 D. D. 1 yr.
1 D. D. 4 yrs.
f 2 D. D. 6 mths.
I   2D. D. 9 mths.
Stage 4.
1
5 months
1 D. D. 1 yr.
1 D. D. 18 mths.
D. D. 1 month.
Tl
iree-year cures-
-12.5%
No one has given a satisfactory explanation of the unknown biological factor that
determines the difference in rate of growth and malignancy in various patients. The
answer is probably closely associated with the actual cause of cancer. We have never been
convinced that the predominant cell type as presented by biopsy is of very great significance. Dr. D. N. Henderson drew attention to the massive invasion of the small lymphatics in the deeper portion of the tissue which featured the biopsy sections from seven
Stage 1 cases who failed to respond to treatment. This same rapid invasion by some
tumours is suggested by Bonney's observation of 40% glandular metastases in the cases
he operated upon without any constant relationship between the size of the primary
tumour and the metastatic tendency.
Since the treatment of these three hundred and ninety-five cases was undertaken,
many refinements in technique have been developed.   The trend has been toward more
[   60   ] 3ESECRS0V
thorough screening of radium and a more determined attack upon the parametrium.
Except in the most advanced tumour the primary lesion is readily destroyed but the
struggle is to control extra-uterine spread. Malignant tissue cells seem to acquire a
greater resistance to irradiation when transplanted.
Since 1934, high voltage therapy has followed the fractionated method of Coutard,
using 200 K.V. and since March, 193 8, new equipment has permitted 400 K.V. therapy.
Except in the earliest cases the high voltage treatment, extending over a period of six
weeks, precedes the application of radium. Radium treatment is given in a fractionated
manner also, small amounts of radium for a long period of time to build up the required
dose. The radium is applied first to the vaginal aspect of the cervix and finally the cervical canal is dilated and the radium placed within the uterine cavity. We feel that by this
routine of treatment it is possible to build up the heaviest dose in the parametrial tissues
and that traumatization of the primary tumour is minimal. After the completion of
treatment the destruction of normal tissue is apparently slight and the cervix, vaginal
vault and uterus regain to a considerable degree a normal conformation.
The not infrequent association of aerobic and anaerobic streptococcal infection with
carcinoma of the cervix must be kept in mind. In our experience it is the chief cause
of immediate mortality associated with the treatment of cervical carcinoma. The routine
of carrying out the high voltage treatment before local radium application permits time
for the eradication of infection.
Carcinoma has received so much publicity of late years that it might be expected
that the result would be an increasing number or early cases coming for treatment.  The
figures presented in Table 9 show that this is not the case.
TABLE 9.
Percentage of early cases according to years.
1929 - 45
1930 - 53
1931 - 48
1932 - 42
1933 - 52
1934 - 64
Neither the public nor the profession are sufficiently cancer-conscious. Occasionally
an early case will come for treatment, the result of a brilliant diagnosis when findings
are so meagre that only the microscope confirms the opinion. More often the patient
who comes, has been treated for a vaginal discharge or bleeding by means of douches
or drugs without even a vaginal examination being made.
Probably the time is not ripe for routine health examination to include a thorough
pelvic examination and thus to allow diagnosis while the tumour is in its incipient state.
It is encouraging however, to note the number of women one sees in private practice who
demand such an examination periodically during the menopausal years. Early diagnosis
is the result of constant watchfulness and the rational treatment of all cervical disease.
The casual cauterization of the diseased cervix or its repair without biopsy is unjustifiable.
The occurrence of irregular bleeding cannot be dismissed without a positive diagnosis
which invariably necessitates curettage or a section from the cervix for microscopic
report unless the disease is so advanced that even he who runs may read.
Showing the incidence of streptococcus haemolyticus and relationship to treatment
morbidity and mortality.
Showing the Incidence of Streptococcus Haemolyticus and Relationship to Treatment Morbidity and
Mortality.
Stage  of
Number of
Cases
Positive
Cultures
Morbidity
Mortal
ity
Remarks
' Disease
Number
%
Number          %
Number
%
1.
12
2
16.6
0                0
0
0
2.
45
5
11.1
4               9.2
3
6.6
rrl death—peritonitis
|[l death—pneumonia
3.
99
13
13.3
16              16.4
6
6.2
2 deaths—peritonitis
4.
29
4
13.8
7             23.9
1
3.4
Totals
185
24
12.8
27              14.4
10
5.3
[  61   ] NOTANDA.
1. The deaths were directly attributable to streptococcus haemolyticus in 3  cases, in all of which it
was imperative that treatment be proceeded with.   The patients were in very poor condition.
2. No special seasonal incidence was noted, other than in February and March, 193 8, when there were
also a larger number of cases than usual.
3. Treatment (local) is never proceeded with in the face of positive cultures aerobic or anaerobic, unless
considered imperative.
MATERNAL MORTALITY
W. G. Cosbie, M.D.
The problem to be discussed in this paper is based on the fact that the average
maternal death rate in Canada during the twelve years from 1926 to 1938, has been 5.3
per 1000 live births or in other words, 1230 women have died annually from the results
of pregnancy. This forms an unenviable comparison with the rate obtained in most other
civilized countries. When the Department of Health was established in 1919, a determined effort was made by Dr. Helen MacMurchy to stimulate a crusade against the high
maternal rate, and educational campaigns were inaugurated by the government and the
Canadian Medical Association. The beneficial results which might have been expected,
have been slow to develop and it has become more and more apparent that this end will
only be reached when the standard of obstetrical practice is raised and the public impressed
with the value of co-operation in aiding and demanding such care.
The most exhaustive and courageous attempt to study the causes and prevention of
maternal mortality is that which was conducted by the New York Academy of Medicine
in 1933. In this report an effort was made to determine the preventibility of death and
to ascribe the responsibility to either the physician or the patient. At the outset it was
obvious that the accuracy of the death certificates in a large number of cases was open
to question, the errors being close to 20%. As might be expected, the incorrect diagnoses
were most numerous when death was due to abortion or septicaemia. It was estimated
that if the care of the women had been proper in all respects, two-thirds of the deaths
would not have occurred. It is highly probable that a similar survey in Canada would
establish a comparable figure and that the lives of 800 women might be saved each year
by better obstetrical care.
Th£ chief causes of death in childbirth are puerperal sepsis, the toxaemias and puerperal
haemorrhage. Abortion is also a major factor in contributing to the maternal death rate.
It seems wrong that deaths from abortion and ectopic pregnancy should be charged
against a rate which should show the dangers of childbirth. It has been conservatively
estimated that two-thirds of the deaths from abortion follow criminal interference, and
it is therefore unfair that the physician or institution taking charge of such a case when
either sepsis or haemorrhage may have already determined the fatal outcome should
accept the responsibility for these deaths. Considerably more women die each year in
Canada from abortion than from puerperal haemorrhage and undoubtedly the number of
reported deaths is only a fair percentage of the actual number. The solution of this
problem lies in the education of the public as to the danger of criminal abortion.
Puerperal sepsis is the greatest cause of maternal mortality and is responsible for more
than a third of all deaths. Failure to control the incidence of this disease is the crowning
disappointment of modern obstetrical practice. True, the appalling death rate from childbed fever, which occured before the antiseptic era, has disappeared. But obstetrics has
fallen far behind surgical practice in reducing sepsis to the irreducible minimum. Failure
to recognize the common source of infection, indifferent aseptic technique and excessive
manipulation are the chief causes of a high septic incidence.
The work of Colebrook and his co-workers at Queen Charlotte's Hospital, London,
has clarified the view with regard to the bacteriology and control of puerperal sepsis.
The importance of the haemolytic streptococcus and its seasonal incidence corresponding
to the periodicity of respiratory tract infections had long been recognized. *But these
workers have proven the specificity of the type of streptococcus responsible for the great
r 62 ] majority of serious and fatal cases. It is the same type which causes tonsillitis and scarlet
fever and is found in many open septic lesions such as erysipelas, trivial finger infections
and impetigo. Sometimes symptoms resembling a common cold or influenza may be associated with its presence. About 7% of normal healthy persons are naso-pharyngeal carriers and it was cultured from the skin of the hands of 3% of persons selected at random.
Colebrook has shown by overwhelming evidence that haemolytic streptococcal puerperal infection is exogenous in origin, being derived in most instances from the nasopharynx of someone, often either doctor or nurse in attendance on the patient at the
time of delivery or during the puerperium. Occasionally the infection may come from the
naso-pharynx of the patient herself and more rarely from infection of some kind in the
home. He has further proven the air born nature of infection in some cases. Cultures
taken from the air about heavily infected patients were invariably positive. This observation is most valuable in accounting for the spread of infection in hospital wards, where
the making of a bed or the sweeping of the floor may be sufficient to carry infection from
patient to patient.
There is a second type of puerperal infection generally associated with birth trauma,
many times the result of "bad craftmanship." In the majority of cases the infecting
organism is one of the less pathogenic organisms, the anaerobic streptococcus, the colon
bacillus or the staphylococcus. If the infecting organism should be the haemolytic streptococcus then the course of the disease is much more severe. In the study made by the
New York Academy it was seen that the death rate from sepsis after operative delivery
was five times greater than after normal delivery. Table 1 shows the relationship between
non-intervention in delivery and a low septic mortality rate.
TABLE  1.                            Intervention Septic Mortality
Rate% Rate per 1000
Holland     1 .9
Denmark        4.5 1.1
Canada    ■—        ? 1.8
The prevention of puerperal sepsis is an involved problem. The danger to the mother
is present before, during and after delivery, from her environment: her family, her doctor,
and her nurse. It is obvious that a patient should not be confined in a home where there is
streptococcal infection. The attending doctor and nurse should be free of possible infection and the danger of transference of infection cannot be exaggerated should either have
been in contact with active infection elsewhere. During labour and delivery the patient's
only contacts should be with the doctor and the nurse. After what has been said it is not
too much to demand the wearing of masks and the frequent washing of hands by both
doctor and nurse, as the doctor may readily carry infection on his hands during abdominal
or other examination and the contact of the nurse is very intimate during the preparation
of the patient.
The progress of labour may be satisfactorily observed by careful abdominal examination, supplemented by rectal examination to ascertain the dilation of the cervix and the
level of the head in the pelvis. Vaginal examination will seldom have to be made, and
the patient is thus not exposed to the danger of the direct introduction of infection into
the vagina.
In all good hospitals, labour room technique is as rigid as that observed in the surgical
operating room. This entails the wearing of gown, masks and gloves by doctor and
nurses. How closely such an ideal may be followed in the home depends largely on circumstances. It was to overcome the unavoidable breaks in technique under unfavourable
conditions that the use of Dettol Cream was suggested for the sterilizing of clean surfaces, either the vulva and perineum, or the hands of doctor and nurse. Colebrook attributes to this practice, a 50% decrease in the puerperal sepsis rate at Queen Charlotte's
Hospital, both in-patient and on the district, in the last two and a half years.
It must be remembered that conscientious nursing technique must be maintained to
avoid danger of infection during the early days of puerperium. Prior to five years ago,
the nurses on the obstetrical service at the Toronto General Hospital did not wear masks
when attending patients at this time. Three cases of streptococcic sepsis occurred, one
ending fatally, and were traced to a nurse who had a positive throat culture. One epidemic
[ 63  ] was traced to septic infection introduced into a ward by a patient's husband, visiting during the puerperium, and prompts some thought regarding the probability of air-born
infection.
When infection occurs, an immediate bacteriological investigation should be made
and the patient and her nurse attendant isolated. At the present time much is heard of
the efficacy of sulfanilamide in the treatment of streptococcal infections. Time will tell.
Those of us who have been practicing obstetrics for some time have seen the rise and fall
of so many panaceas that we are not liable to lose our judgment by too hasty an opinion.
There is an increasing tendency toward confinement in hospital in Canada, the percentage having steadily risen from 29.9% in 1933 to 38.7% in 1937. It has often been
suggested that this would result in a higher mortality rate from more interference with
the normal course of labour and a greater danger of sepsis. A comparison, however,
between the mortality rate in Quebec where the hospital confinements have never been
above 15.5% and British Columbia where the hospital confinements have ranged from
72.1% up to 81% in 1937, shows that if anything, the reverse is true. During 1935,
1936 and 1937, in four of the five cities in.Ontario having over 100 births a year, three
times as many children were born in hospital as at home. The mortality rate in the fifth
city where the home and hospital confinements were approximately equal in number, was
the highest of all in each of the three years.
TABLE 3.
Resident
Births Maternal Deaths
1936 i '. 8477        40
1937 7931        3 8
193 8  8281 25
In Table 3 are presented figures from Toronto where 75% of the babies are born in
the hospital. Over one fifth of the mothers came into the city to have their children
and the death rate of the non-resident is more than twice that of the resident mothers.
In 1938, the city mortality rate was 3.8 per 1000 and excluding non-residents, would
have been only 2.9 per 1000. It is a reasonable deduction that the city hospitals take care
of a large number of complicated cases from the surrounding country and contribute
in no small way to lowering the maternal death rate. Probably the safest place to confine
a patient is a well-run maternity hospital. The danger comes from poor technique, the
mixing of obstetrical, surgical and medical patients or allowing the patients to be attended
by the same hospital staff. The ideal is a separate maternity building but this is not always
possible, and then a separate floor with an isolated delivery room should be available.
Facilities for prompt and absolute isolation of febrile and possibly infected cases is an
essential.
Table 4 shows what can be accomplished in hospital or in the home when good technique is followed.
TABLE 4.
Hospital Deliveries
T.G.H.,   Public  9729
T.G.H.,  Private  —*  7754
East End Maternity	
Hospital   (Colebrook) -lC  10376
Chicago Maternity i '•.    	
Centre     „*_—_:  11772
V.O.N.   Canada     15006
Compare this with Table 5, compiled from the Vital Statistics for Ontario,
1935, 1936 and 1937.
Non
Resident
Births
Maternal Deaths
1975
15
2037
23
2250
15
Sepsis Mortality Rate per  1000
1.2
.38
.03
.33
.2
TABLE 5.
Hospital Deliveries
City A   1  3136
City   B    ;  1239
City   C ;  1434
Town  A ;  457
Town   B     76
[  64  ]
Sepsis Mortality Rate per 1000
4.1
7.2
2.8
6.5
52.6 - ■ H7i£S * r J Ii WIJWS fffcs **TH?!
I i»*BWW'
EDHBKSflfa£B&m
"Although puerperal fever has practically become a thing of the past in our lying-in
hospitals, it is impossible to ignore the fact that there has not been a corresponding
diminution of mortality from puerperal fever in ordinary private practice. It was not to
be expected that those who had already been engaged for some time in practice would
at once assimilate the new ideas and adopt what appeared to many of them not only new,
but revolutionary and unnecessary methods. But as time wore on, and a younger race of
men came upon the scene, it was not unnaturally hoped that an improvement would take
place; that a mortality which had been conclusively shown to be preventable would show
some signs of diminution. How is it that this hope has not been realised? Either the profession is not convinced of the possibility of stamping out puerperal fever by the methods
that have been proposed, or it has failed to carry out those methods with the thoroughness
that can alone ensure success. As a responsible teacher of midwifery, I have often asked
myself the question: how far the teaching is at fault?
Do we teachers sufficiently impress upon the minds of our students the infinite importance of this subject?
Are we ourselves careful to show by our own example the importance of the precautions that we lay down in the lecture theatre?
Are we careful never to convey, by thoughtless word or careless act, the impression
that the rigid adoption of antiseptic measures is excellent in theory, but does not after
all matter so very much in practice?
If we are not, is it to be wondered at that when our students go into the world and
are released from the discipline of the school and hospital, they should forget how much
depends on attention to minute detail, and should discharge their consciences in this matter of antiseptics by pouring a few drops of carbolic acid or a drachm of tincture of
iodine into the water in which they wash their hands? I am not painting an imaginary
picture. The methods at present employed by many who, if questioned, would be quite
ready to proclaim their belief in antiseptic, and who glibly assure one they have used
'every antiseptic precaution' are often so crude and imperfect as to be a ludicrous travesty
of genuine antiseptic midwifery."
These are the words of the presidental inaugural address of the London Obstetrical
Society in 1895, and yet they say "Time Marches On."
The lives of the great majority of women who die from eclamptic toxaemia can be
saved by proper antenatal care.
TABLE 6.
Deliveries        Deaths from Eclampsia
Public  Clinic           6709 1
Private   Clinic           7754 0
Public, Non Clinic        2140 11
Table 6 is from the records of the Toronto General Hospital and is self explanatory.
The responsibility for the lack of supervision during pregnancy must lie for the most
part with the patients themselves, but the education of the public has been slow indeed.
One hesitates to believe that any physician today does not appreciate the necessity of
antenatal care. The question is, rather, how carefully is the patient watcjhed——this is a
matter of obstetrical conscience. Fulminating eclampsia is a rare condition and invariably
the danger signs are out for someone to see before disaster occurs.
Departure from the sound dictum that the treatment of eclampsia is to control the
convulsions without regard to the course of labour, is responsible for a surprising number
of deaths. Caesarean section is not performed for eclampsia in any good clinic today and
yet in 1933, one third of the patients dying from eclampsia in Ontario, were delivered
by caesarean section.
The most tragic cause of maternal death is haemorrhage. One never sees such a death
without feeling that something might have been done to avoid it. There is generally
some warning before the critical haemorrhage occurs in both types of Antepartum
haemorrhage. Instruction as to the gravity of disregarding what might appear to be trivial
bleeding and regular antenatal examination of the urine and blood pressure will allow
the hospitalization in time of all but the most exceptional case of placenta praevia or accidental haemorrhage.
[   65   ] Hospitalization, transfusion, and caesarean section for all major degrees of placenta
praevia has resulted in a lowering of the mortality rate from this condition. Table 7
shows the results of treatment at the Toronto General Hospital.
TABLE 7.
Deliveries Placenta Praevia Maternal Mortality
9130                                                       135 1.4%
Cxsarean Section Incidence Maternal Mortality
35 24% 3%
The feature of the treatment of accidental haemorrhage is to combat shock and
haemorrhage. The actual delivery follows conservative lines except in the most severe
form of concealed haemorrhage, where it has been felt that the uterine wall has been
damaged by haemorrhagic extravasation.
TABLE 8.
Accidental Hemorrhage P.W., T.G.H.
Deliveries Accidental Hemorrhage Maternal Mortality
9130                                                           82 4.9%
Caesarean Section Incidence Maternal Mortality
9 9.1% 11.5%
Practical experience teaches us that it is hard to dissociate shock and collapse from
difficult labour and post partum haemorrhage. Prenatal examination with an estimation
of the size of the pelvis and determining of a proper prognosis of labour will eliminate
many arduous deliveries. The proper conduct of labour with the avoidance of exhaustion
of the mother, a proper use of anaesthesia and above all, delivery with the minimum of
trauma have a real prophylactic value. The maintenance of uterine tone possibly using
an oxytocic immediately after the birth of the child without too hasty attempts at placental delivery is good obstetrics Failures in treatment when haemorrhage is severe may
be summed up under two headings:
1. Failure to realize the importance of conserving blood loss.
2. Neglect of transfusion.
The abuse of caesarean section undoubtedly contributes greatly to maternal mortality.
But it is not justifiable to hold the operation responsible for all the deaths which follow
it and not to consider the grave indications which often call for its performance. Nevertheless, the fact remains, that one fifth of all the deaths investigated by the New York
Academy of Medicine followed it, and what is more important, only one sixth of these
deaths were considered unavoidable. The chief cause of death was peritonitis and this is
attributed to an ill-chosen time for the operation. In the private wards of the Toronto
General Hospital, 12 of 25 deaths followed caesarean section. The incidence of peritonitis
was low but 5 deaths were due to pulmonary embolism.
There has been an increasing incidence of delivery by caesarean section during the
last 2 5 years. This has resulted from a great widening of the indications for the operation,
not always justifiable. It would appear that many times the desire of the patient dictates
the course to be followed or the easier road is taken to avoid possible fetal mortality, or
courage is lacking on the part of both patient and physician to face a more prolonged
and difficult method of delivery.
TABLE 9.
Private Public
N.Y.N. & C.      3.8 1.2
N. Y.L.I.     4.9 3.2
T.G.H.          7.4 2.7
The comparative incidence of caesarean section of private and public ward patients.
It is well to recall that Eden and Holland, after a nation-widje survey in England,
established a mortality rate of 1.6% for elective caesarean section, e.g., three times the
mortality rate for childbirth with all its complications. Ten years ago the incidence of
cxsarean section on our service was 5.78%, since then more conservative methods have
been applied in the treatment of complicated cases and the incidence has fallen to 1.9%
and 1.7% in 1937 and 1938 respectively without untoward effect on either the maternal
or foetal mortality rates.
[  66  ] Caesarean section has no place as a last resort in difficult labour. Twenty-four hours
is almost the limit of safety in a test of labour and if the membranes are ruptured, this
time limit is to be cut in half. The performance of caesarean section after repeated vaginal
examinations is dangerous and after any attempt has been made at delivery, only the
Porro type of operation should be performed.
All authorities are agreed that the lower segment operation has a much lower mortality
rate associated with it than has the classical high incision.
TABLE 10.
High Low
Chicago   L.I.      U-      4.76 1.26
Evanston        ;■  ; ■     5.2 .8
Cleveland  area  li Z     7.6 2.8
T.G.H., P.W.    -     2.5 2.5
Table 10 presents the relative mortality rate % for the high and low caesarean operation.
The figures from our service at the T.G.H. are interesting as the classical operation
has been reserved for operations of election and the lower segment operation largely for
patients who have received a test of labour and who are judged to be non-infected. The
Porro and extra-peritoneal operation has been used in potentially and actually infected
cases, which have all been neglected cases sent in as emergencies and the motality rate
has been 19.1% which has accounted for the difference in the mortality rate between public ward and private patients at the T.G.H., which, corrected, is 2.5% and 2.0% respectively.
The chief factors contributing to the high maternal mortality rate have been presented and it is obvious that conditions in Canada call for great improvement. The practice of obstetrics has not received the serious consideration it deserves by either the profession or the public. In 1935, the British Medical! Journal reported the result of a concentrated effort to lower the maternal death rate in Rochdale in the Black Country in
England. Refresher courses for doctors, special instruction for nurses and midwives and
the education of the public as to the value of antenatal care resulted in a drop from 10
to 3.9 per 1000 live births in two years. When the enthusiasm waned, the rate rose again
to 5 per 1000.  This epitomizes the whole story.
Those interested in the teaching of obstetrics realize the inadequacy of the practical
instruction which the undergraduate student receives. A major difficulty has been the
large number of students proportionate to the available clinical material, and obstetrics
has not held the place in the curriculum commensurate with its importance. Progressive
change is slow and only recently at the University of Toronto has the teaching of obstetrics been spread over the final three years of the course, and facilities made available so
that students are in residence for short periods of time during the fifth and sixth years.
The value of a specially trained nursing service is represented by the record of such
an organization as the V.O.N. Working under home conditions which have been far
from favourable and attending upward of 15,000 mothers in confinement annually, the
Victorian Order has maintained a mortality rate well under half that for the country as
a whole.
The rise of specialism in obstetrics is a recent development apart from teaching groups
in the university centres. The development of sane and logical, not spectacular and radical
practice will be more certain with a sprinkling of specially trained men throughout the
country. The vast majority of confinements will always remain in the hands of men
engaged in general practice but the value of trained consultants cannot be overestimated.
With the establishment of the Royal College of Obstetricians and Gynecologists it is a
hopeful sign to see the number of young men who are taking the examination of the
college and establishing themselves in their chosen specialty.
Lastly, it would appear that the education of the public has been neglected or else
has fallen into evil hands. On the one hand there is the ignorance and prejudice of the
type of woman who treats pregnancy and childbirth as one of the natural consequences
of married life and who merely calls her doctor when her labour has begun, and on the
[   67   ]
'     1 other hand there is that product of our modern civilization who, guided by sensational
journalism can think of nothing but "streamlined childbirth." Good obstetrics today
more than any other branch of medicine or surgery calls for persistent and unremitting
propaganda.
THE PRINCIPLES OF ARTIFICIAL FEEDING OF INFANTS
H. B. Cushing, M.D.
{Abstract.)
The speaker began by stating that he has been practising actively in Montreal for
forty years, in constant contact with those who are practising medicine.
If asked what was, in his opinion, the greatest advance in those forty years, the most
life-saving discovery, he would have no hesitation in saying it lies in the care of infants,
and particularly in the development of improved methods of infant feeding.
All the other great discoveries in medicine—insulin, sulphanilamide, etc., are of tremendous value of course—but not to compare with these improvements in the care of
feeding of infants.
Take the influence on mortality. In Montreal, for example, 25 years ago, 25% of
all infants died in the first year of life—now 6l/z% die in this year. Twenty-five years
ago, 57% of all burials in the cemetery were children under one year of age, now the figure
is less than 20%.
In a city like Montreal, this means a saving of 2000 to 3000 children yearly. Nor is
the saving of life the only result—equally, or perhaps more notable, is the effect on the
development and the health of the race, of improved methods of feeding.
Tables in textbooks of 3 0 or 40 years ago, giving standards of development, weight
and growth of children are ridiculous now, as compared with modern standards. Modern
children develop more and faster; are bigger, healthier, more immune to disease—when
we consider the effect of this on the race we can see the vital importance of this development in medical knowledge.
The Foundling Hospital in Montreal has a capacity of from 60 to 80 infants. These
are not sick children, but have nobody to care for or look after them. They are mostly
taken into the hospital shortly after birth and are cared for till they are two years of
age, if not placed sooner.  All these children, of course, have to be artificially fed.
Twenty-five years ago it required a staff of four medical men to look after these 60
to 80 children.
The attendants had to go and see them every day, to adjust their feeding chiefly—it
was a very arduous business.
Half of them died under one year of age. All who survived were marantic, rachitic,'
anaemic and miserable.
The hospital, which is used as a teaching hospital, always kept one baby breast-fed,
or supplied with breast milk. This served as a contrast and an example to the students of
the the urgent necessity for breast feeding if at all possible.
Things have changed completely here—so that now, with the same number of babies,
only one student interne, on duty all the time, is necessary, and one attending physician
visits once weekly.
No babies die, except from other causes—all gain weight progressively. There is no
breast-fed baby necessary for teaching purposes.
The explanation of this change, so miraculous and life-saving, that has so completely
changed the whole picture, may be found in the complete reversal of our ideas as to the
fundamental principles of infant feeding.
Thirty years ago there were three main principles laid down.
1. The only safe way was breast-feeding. This is the cheapest, easiest, safest method.
This latter is still true, but the first part of the statement is no longer true; it is not the
only safe method.
2. If this was impossible, the baby must have raw milk. We have completely discarded this.
[  68   ] 3. If we were to have any success, we must maternalize this cow's milk to exactly
the composition of mother's milk. Nobody believes this now. The old formulae were most
complicated, difficult to learn; changing continually.
Our modern principles, on the other hand, are very simple.   They are these:
1. A child will never develop properly unless you give it sufficient food. We used to
starve babies. We knew the exact size of the stomach, its capacity, etc., now we pay no
attention to this. We almost let the child feed itself—regulate its own amount of feeding
and so on. Children so treated do better.
In 100 cases of athrepsia analysed for etiology, 85 were found to have been not given
enough food; 10 were not getting enough nutrition for other reasons; only one was overfed.  27 is pretty hard to overfeed a child.
2. We must give food that is free from pathogenic organisms: as nearly sterile as
possible.
Milk is the most dangerous food used by man, it conveys so many infections.
It is the most easily perishable of all the foods we use.
The cause of the high mortality in the old days was the unprotected milk supply.
The control of the infant mortality in any community can only be effected by safeguarding the milk supply, and by boiling ft—in the first year of life.
3. The addition of sufficient vitamins to the diet must be regarded as a prime essential. These are an absolute necessity. The infant with its rapid growth requires far more
of these than an adult.
An infant who is not getting sufficient vitamins, even when the deficiency is only a
slight one, fails to gain, is more susceptible to disease, etc. We must start early to give
vitamins and must give enough of them.
Orange juice and cod liver oil are the two main sources of the required vitamins, vitamins A, C and D.
There is no such thing, in the opinion of Dr. Cushing, as a child who can't take these;
at least in hospital practice they all can, though in private practice we sometimes have to
make concessions to supposed idiosyncrasies.
To carry out these three principles of feeding, there are three ways of feeding children:
1. Adequate breast feeding, of course, fulfils all the three requirements and is easily
the best method.
2. Modified cow's milk can be used. There is no need for formulae. Just add water
and sugar and give vitamins, or lactic acid milk can be used instead of plain cow's milk.
3. Of late years, and more year by year, we are coming to use evaporated canned
milk, dried milk, etc. These are purer, safer, because practically sterile, uniform in composition, reasonably cheap and easily handled. Dr. Cushing thinks this is the method of
the future.
INDICATIONS FOR AND RESULTS OF REMOVAL OF
TONSILS AND ADENOIDS    |
Abstract of Address Given
by
H. B. Cushing, M.D.
As a paediatrician, if asked what was the most frequent question put to me, I should
say it was, "Should this child's tonsils and adenoids be removed?" Sometimes we are
bitterly criticised later because we advised against the operation: equally we may earn censure because we have advised removal.
All we can do is to try and get as clear ideas on the subject as we can.
Tonsils and adenoids are a constant problem and source of trouble to hospitals. They
are by far the commonest cause of admission of children to hospital—and their removal
is the commonest and most frequently done operation in children's hospitals—more than
[ 69 ] all other operations put together, in the experience of the Children's Memorial Hospital
in Montreal.
They constitute a source of grief to the administration, which has great trouble with
their admission. There is always a large waiting list of those whose patients and doctors
are eager to have them admitted. Another trouble is the question of records. The ordinary
records are of no value at all, as usually kept.
Is this enormous number of operations necessary or justifiable?
Let us view the anatomy of physiology of the tonsils and adenoids.
They are part of Waldeyer's ring of lymphoid tissue—are present in all mammals.
There is no evidence that they are vestigial remains—a statement we frequently hear made.
On the contrary, they are functioning and active organs during the first six years of life.
Normally, they gradually increase in size up to 5 or 6 years of age, then become smaller
and inactive.
There is no evidence of any endocrine function being exercised by them—there is no
loss to the system when they are removed—no effect on the growth, development, or
resistance to infection of the child.
The only reasonable function assigned to them is as sentinels against infection in early
life. This duty can be, and is, taken up by other glands if they are removed.
You cannot have enlargement of one part of Waldeyer's ring without other parts being
involved, so that if the tonsils enlarge, the adenoids also enlarge.
These organs share with other lymphoid tissue the ability to become rapidly hyper-
trophied. They may, in a few hours, grow to four times their usual size and recede to
normal as quickly.  They share this property with the spleen, thymus, etc.
Preliminary Remarks Regarding This Operation.
In the first place, certain postulates must be laid down.
The removal of tonsils and adenoids is absolutely unjustified unless they are thoroughly
and completely removed. It is a serious operation and should not be looked upon lightly,
or undertaken without a due sense of the importance of the operation.
We say it is a serious operation. This does not necessarily mean dangerous. Thus, in
the last 1000 consecutive cases done in the Children's Memorial Hospital, there have been
no deaths.
Many however, have been seriously ill; a few nearly died; some were ill for a long time.
There are certain dangers:
1. Danger of anaesthetic, shared with all operators.
2. Danger of serious haemorrhage.
3. Danger of pneumonia, which occurs in a certain number of cases.
4. Danger of lighting up of underlying conditions, e.g., T.B., endocarditis, etc.
5. Danger of secondary infections after operation. Thus scarlet fever or diphtheria
may supervene shortly after operation—these, if they occur, are apt to be very
severe and the outlook is poor.
6. Danger of psychic trauma to child. A thing not to be ignored.
Indications for Operation.
Out of one hundred cases that were brought for operation, we asked why they were
brought; analysis showed the following:
15 % were being done as a convenience. Others were being done, so these are included,
or it was holiday time and the best time to do it.
35% (the largest percentage in one group) were brought because the school nurse
or public health nurse had recommended that they be removed.
We do not believe that the nurse should dictate in this matter, and said so. We took it
up with these nurses. There were three Public Health nurses who denied that they recommended removal and stated that they had advised a visit to a doctor.
One third of the nurses consulted, we found, had an understanding of reasons for
removal; two thirds had only the size of the tonsil as a criterion, had no idea of the variations in size at different ages.
[ 70 ] h**ht«^4r»Nfctti$3y«<
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20% were brought on account of frequent sore throats; another 30% for frequent
colds. This latter is decidedly not an indication.
10% for various reasons, including enlarged glands in neck, snoring, mouth-breathing, dullness at school, etc.—one for epilepsy and two for bed-wetting.
There are three real indications; and first, we must thoroughly examine the tonsils
and throat in a good light.
(a) Enlargement—hypertrophy. Remember size varies to some extent with age.
The tonsils can be easily seen and examined; not so adenoids—but the adenoid facie is a
valuable indication.  Adenoids may be readily seen in a lateral X-ray of the nasal passage.
(b) If tonsil is diseased. We must carefully examine the tonsil itself. There may be
scarring round tonsils. We may be able to press pus from the tonsil. The anterior pillar
may be inflamed.   These all show on case and justify removal.
(c) Local effects. Repeated peritonsillar infections; adenitis, persisting where other
possible causes have been excluded or removed.
Otitis Media.
There is an improvement in general health from the removal of focal infection when
diseased tonsils are removed.
We must bear in mind the relation of the tonsil as port of entry to rheumatism and
diphtheria and the fact that disease carriers often have the disease confined to the tonsil.
Results.
Kiser in Rochester reports 4000 cases, and finds the results very disappointing. The
best results he found were elimination of mouth-breathing and a good effect on general
physical condition of child and improvement of the intelligence and mental outlook of
the child.
Otitis and adenitis were benefited, as were sore throat, occasionally, but not greatly.
As regards any effect on the medium of upper respiratory infections, this was nil—
and some think they are more common after removal. There is no increase of protection
against infectious disease.
As regards rheumatic fever in children—the removal of tonsils and adenoids, Kiser
feels, has been very disappointing, but if they are thoroughly removed before the child
has had rheumatism, we feel that the operation lessens the danger of involvement. If
rheumatism has been present, the results are slight, if any.
This operation has no effect on growth and development.
Our Own Conclusion.
1. The operation, a thorough and searching one, should not be lightly undertaken.
2. It is only to be advocated when a competent observer decides definitely, using
above criteria, that operation is clearly undertaken.
3. It should only be done by an experienced operator and proper after-care should be
available.
4. A general careful preliminary examination is absolutely necessary. While, as we
said, we have had 1000 cases with no deaths, we found the following on careful preliminary examination:
One had lymphatic leukaemia, one midantial?, two active tuberculosis, two had
recent active endocarditis.
Finally, we must never promise too much. Do not promise that there will be no snoring or sore throats—that there will be no more colds—no rheumatism or recurrences.
[ 71 ]   "■* .»,« «ltv.. .*.',: i-> .-!«:*-»   University of British Columbia Library
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