History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1940 Vancouver Medical Association Jun 30, 1940

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WANCOUVER
M E DI CAL A S S O dl AT IO N
Vol. XVI
JUNE,£1940
No. 9-
With Which Is Incorporated
Transactions of the
Victoria Medical Society
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Vancouver General Hospital
and
StWaul'^Oospital
In This Issue:\
Page
NEWS AND NOTES-i^^^^- - | jjjjp   ;|| __. 249
LOW BACK PATN|i[^g    lllt^ W&- W^S-: /Sfe IP2
PNEUMOCOCCIC MKNTTN^TTTS   :f^j, [ §SR      :^^S^ ^l^^^^^ft^0
DIAGNOSIS AND TREATMENT OF OI.AIJmMA||||:     ||' __>__:L. 264
THE DIAGNOSIS OF EARLY SYPHILIS^. ;:|p|---. W§j.  --S- 1 27y
VICTORIA MEDICAL SOCIETY jfe- 276
VANCOUVER MEDICAL ASSOCIATION
SUMMER SOEiOQLijUNE 25thlrO 28 th INCI*, 1940 Accidental
Wounds
Section through healing wound.
1. Dead cells and detritus.
2i Regenerating epithelium.
3. Regenerating connective tissue.
4. Budding new capillaries*
The combination of glycerine with iodine or boric
acid is considered by many physicians as ideal for
the dressing of wounds.
There are probably few products in which this
combination of ingredients is so well compounded
and proportioned and which so well fulfills the
desiderata for a satisfactory surgical dressing as does
It is bacteriostatic, decongestive and pain-relieving.
Sample on request
THE DENVERpHEMICAL^lFG. CO|f
153 Lagauchetiere St. W., Montreal
Made in Canada THE    VANCOUVER    MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
EDITORIAL BOARD:
Dr. J. H. MacDebmot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XVI.
JUNE, 1940
No. 9
OFFICERS,  1939-1940
Dr. D. F. Busteed Dr. W. M. Paton Dr. A. M. Agnew
President Vice-President Past President
Dr. W. T. Lockhart Dr. Murray Baird
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. C. McDiarmid, Dr. L. W. McNutt.
TRUSTEES
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. W. Lees
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS |
Clinical Section
Dr. Karl Haig Chairman Dr. Ross Davidson Secretary
Eye, Ear, Nose and Throat
Dr. W. M. Paton Chairman Dr. G. C. Large Secretary
lUediatric Section
Dr. R. P. Kinsman „  Chairman Dr. G. O. Matthews Secretary
STANDING COMMITTEES   f
Library:
Dr. F. J. Buller, Dr. D. E. H. Cleveland, Dr. J. R. Davies,
Dr. W. A. Bagnall, Dr. T. H. Lennie, Dr. J. E. Walker.
Publications:
Dr. J. H. MacDermot. Dr. D. E. H. Cleveland, Dr. G. A. Davidson.
Summer School:
Dr. T. H. Lennie, Dr. A. Lowrie, Dr. H. H. Caple, Dr. Frank Turnbull,
Dr. W. W. Simpson, Dr. Karl Haig.
Credentials:
Dr. A. W. Hunter, Dr. W. T. Ewing, Dr. A. E. Trites.
V. O. N. Advisory Board:
Dr. C. E. Riggs, Dr. T. M. Jones, Dr. R. E. McKechnie II.
Metropolitan Health Board Advisory Committee:
Db. H. Spohn, Dr. F. J. Buller, Dr. W. T. Ewing.
Greater Vancouver Health League Representatives:
Dr. G. O. Matthews, Dr. M. W. Simpson
Representative to B. C. Medical Association: Dr. A. M. Agnew.
Sickness and Benevolent Fund: The President—The Trustees. PREGNANCY...
greatly increases the requirement
for calcium. Viophate-D combines calcium, phosphorus and
Vitamin-D in therapeutically
useful proportions.
In pregnancy and lactation, the
calcium requirement is greatly increased. Since the normal diet
may verge on a deficiency in calcium, the calcium requirements of
pregnancy are very likely to be
insufficiently covered without a
diet supplement.
Viophate-D (Dicalcium Phosphate
Compound with Viosterol Squibb)
is a suitably balanced source of
calcium and phosphorus, with
sufficient Vitamin-D to ensure
their adequate utilization.
Tablets Viophate-D each contain
9 grains Dicalcium Phosphate and
6 grains Calcium Gluconate together with at least 660 Vitamin-D
International Units derived from
Viosterol. The ratio of calcium to
phosphorus is 1.625 (calcium 2.6
phosphorus 1.6 grains).
Two Capsules Viophate-D are
equivalent to one tablet in calcium, phosphorus and Vitamin-D
content, each Capsule containing
approximately 4.5 grains Dicalcium Phosphate, 3 grains Calcium
Gluconate, and at least 330 International Units of Vitamin-D
derived from Viosterol.
may demand increased intake of
Vitamin-E supplied in Zygon
(Squibb Wheat Germ Oil.)
When there is a deficiency of
Vitamin-E in the diet, it affects
the reproductive system. In
female animals fed a diet lacking
in this vitamin, the fertilized ova
are implanted in the uterus apparently in the normal manner. However, the fetuses die and are
resorbed. In the male animal,
there is a gradual degeneration of
the germinal epithelium.
In man the clinical application of
Vitamin-E has found its greatest
application in the prophylaxis and
treatment of habitual and threatened abortion and in some forms
of sterility.
For therapy the most abundant
natural source of Vitamin-E is
wheat germ oil. The House of
Squibb supplies wheat germ oil as
Zygon. Zygon is a cold-pressed
oil, rich and palatable, obtained
from fresh wheat germ.
Zygon is administered orally. The
fluid form of Zygon is useful
where comparatively large doses
may seem indicated. In less
severe deficiencies, the capsules
may be used in a suggested dosage
of 3 or more capsules several
times daily.
Zygon (Squibb Wheat Germ Oil—
Cold-Pressed—Rich source of
Vitamin-E) is supplied in 2-fluid-
ounce and 16-fluidounce bottles;
also in 3-minim capsules, in boxes
of 100 and 500.
For literature address : 36 Caledonia Road9 Toronto.
ER:Sqtjibb&.Sons of Canada,Ltd.
MANUFACTURING   CHEMISTS   TO   THE   MEDICAL   PROFESSION   SINCE   1858 VANCOUVER HEALTH DEPARTMENT
STATISTICS, APRIL, 1940
Total population—estimated 269,454
Japanese population—estimated 9,094
Chinese population—estimated 8,467
Hindu population—estimated        339
Rate per 1,000
Number Population
Total deaths  265 12.0
Japanese deaths  7 9.4
Chinese deaths  16 23.0
Deaths—residents only .,  233 10.5
BIRTH REGISTRATIONS:
Male, 210;  Female,  198 408 18.5
INFANTILE MORTALITY: April, 1940 April, 1939
Deaths under one year of age 12 11
Death rate—per 1,000 births    29.4 28.5
Stillbirths (not included in above 10 10
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
May 1st
March, 1940 April, 1940 to 15th, 1940
Cases   Deaths Cases   Deaths Cases Deaths
Scarlet Fever      18           0 15           0 6 0
Diphtheria           0           0 0           0 0 0
Chicken Pox     122           0 234           0 102 0
Measles         10           0 39           0 50 0
Rubella        7          0 10 0 0
Mumps         0           0 5           0 2 0
Whooping Cough      22           0 18           0 8 0
Typhoid Fever        0           0 0           0 0 0
Undulant Fever : ;        10 0           0 0 0
Poliomyelitis           0           0 0           0 0 0
Tuberculosis      26         14 32         16 14
Erysipelas        4           0 3           0 2 0
Meningococcus Meningitis         0           0 0           0 0 0
Paratyphoid Fever        10 10 0 0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
West North Vancr. Hospitals,
Burnabv   Vancr. Richmond Vancr. Clink- Private Drs. Totals
Syphilis j        0               0               0 0               16               25 41
Gonorrhoea        0               0               0 0               48               20 68
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Bioglan products differ in that they are derived from original material."
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
STANLEY   N.   BAYNE
Phone: MAr. 4027
1432 Medical-Dental Bldg.
Descriptive Literature on Request
Vancouver, B. C.
247 Professional Men  appreciate
the Value of being well-dressed
A Suit tailored to your measure by us is your assurance of
Quality British Woollens, fine hand tailoring
and correct style.
Our new Spring patterns are now ready and your early
inspection is invited.
British Importers of Men's and Women's Wear
MEDICAL-DENTAL BUILDING VANCOUVER, B. C.
Kellogg's ALL-BRAN
provides iron and
Vitimin 61 as well as
LAXATIVE BULK
Made by Kellogg9s
FLAVOREOW.THMAITSUBA«A«.MIT
Pi
G>H/dipatio*L
DUE TO DIET DEFICIENCY
OF-BUtK"
KELLOGG COMPANY OF CAMADA.lTD-AOH0ON.ONt
in London, Canada VANCOUVER MEDICAL ASSOCIATION
SUMMER SHOOL, 1940
HOTEL VANCOUVER
June 25th, 26th, 27th and 28th, 1940
PROGRAMME
Tuesday, June 25 th
9.00 a.m.—Dr. Magner: "Pathogenesis of Jaundice."
10.00 a.m.—Dr. Jeans: "Recent Advances in the Diagnosis and Treatment of Nephritis
and Nephrosis."
11.00 a.m.—Dr. Reichert: "Lymphcedema in Man."
12.30 p.m.—LUNCHEON, Cafe Room Hotel Vancouver.
Speaker: Dr. W. S. Middleton:  "Some Lay Contributions to Medicine."
(Illustrated by Slides.)
3.00 p.m.—CLINIC: Vancouver General Hospital.
Dr. P. C. Jeans: Pediatric Clinic.
8.00 p.m.—Dr. Wm. S. Middleton: "Idiopathic Hypertension."
9.00 p.m.—Dr. Farmer: "Burns and Their Treatment."
Wednesday, June 26th
9.00 a.m.—Dr. Reichert: "Neuralgias of the Head and Face."
10.00 a.m.—Dr. Middleton: "Protection of the Circulation in Surgery."
11.00 a.m.—Dr. Farmer: "Emergency Abdominal Surgery in Childhood."
2.30 p.m.—CLINIC: St. Paul's Hospital.
Dr. Reichert: Surgical Clinic.
8.00 p.m.—Dr. Magner: "Clinical Aspects of Jaundice."
9.00 p.m.—Dr. Jeans: "Nutritional Requirements of the Growing Child."
Thursday, June 27th
9.00 a.m.—Dr. Magner: "Pathogenesis of Anaemia."
10.00 a.m.—Dr. Jeans: "Calcium and Vitamin D Needs of the Child, with Reference
to Dental Caries."
11.00 a.m.—Dr. Reichert: "Anterior Scalenus Syndrome."
AFTERNOON—GOLF TOURNAMENT—Jericho Golf Club.
8.00 p.m.—Dr. Farmer: "Treatment of Avulsed Skin Flaps and Treatment of Angiomata."
9.00 p.m.—Dr. Middleton: "Post-operative Pulmonary Complications."
Friday, June 28 th
9.00 a.m.—Dr. Middleton:   "Rationalized Therapeutic Experiences."
10.00 a.m.—Dr. Farmer: "Acute Osteomyelitis."
11.00 a.m.—Dr. Jeans: "Congenital Syphilis."
2.30 p.m.—CLINIC: Vancouver General Hospital.
Dr. Middleton: Clinic on Internal Medicine.
8.00 p.m.—Dr. Magner: "Some Clinical Aspects of Anasmia."
9.00 p.m.—Dr. Reichert: "Regional Ileitis and Other Localized Lesions of the Small
Bowel."
248 Each fluid ounce of Dilaxol E.B.S. contains:
Bismuth Subsalicylate -------     4 grains
Digestive Enzymes   --------     I grain
Magnesium Trisilicate,
Carbonate and Hydroxide -   -   -   -   -   75 grains
Dilaxol is alkaline in reaction and, in contrast to the strong
alkalies, does not stimulate the secretion of surplus acid; yet it will
neutralize many times its volume of excess acid in the stomach.
This unique property of Dilaxol is akin to the buffer action of the
blood. Dilaxol neutralizes free acid and does not interfere with
the natural digestive process, nor does it cause alkalosis.
Indicated in Dyspepsia, Duodenitis, Flatulence, Hyperacidity,
Vomiting of Pregnancy and other gastro-intestinal disorders.
Palatable and Protective.
Also supplied in powder form.   Sample on request.
THE E. B. SHUTTLEWORTH CHEMICAL CO. LIMITED
TORONTO
MANUFACTURING   CHEMISTS
CANADA
STOCKS CARRIED AT
WINNIPEG, MAN.—CAMPBELL HYMAN LTD. VANCOUVER. B. C—J. P. SOUTHCOTT & CO. LTD.
SPECIFY     KB.   S.     ON     YOUR      PRESCRIPTIONS THE
TOR'S   PAGE
The Annual Summer School of the Vancouver Medical Association is with us again
this month, from June 25th to 28 th, inclusive. It hardly seems a year since the last one
—but our calendars attest the fact.
In these grim days of stress and strain one is tempted occasionally to allow oneself
to sag a bit—to feel that all is vanity, to pass things up. This we must recognise as a
most dangerous, even fatal, temptation. The one thing that counts is morale on the
home front. We can absolutely rely on the high morale on the fighting front: the least
we can do—perhaps the best thing we can do—is to maintain our own at a high and
steady level. We are living in times that will try the souls of men as, in our knowledge
at least, they have never been tried: but we shall live through these times, and come to
a safe and righteous ending, and meantime we must carry on: and do our regular work
live our regular lives, maintain the even tenor of our way.
So let us support the Summer School fully and heartily, and not allow it in any way
to fall below the levels of other years. The programme, which is repeated in this number of the Bulletin, is an excellent one, and there is particular emphasis this year on
paediatrics and the care of children's diseases. Clinics are to be held in both the big hospitals, and these promise to be excellent. One need hardly say that a Golf Tournament
forms an essential part of the programme. It is a matter of deep regret that we shall
miss, this year, the presence of our very dear friend, Joe Bilodeau, whose geniality and
joie de vivre have always made him the ideal Master of Ceremonies in these events; but
we have reason to believe that he will not be away for long, and his return will give
occasion for a very special sort of celebration.
The meeting is being held at the Hotel Vancouver. We all know by now what an
excellent place this is for meetings. Tickets and information can be obtained at the
Library of the Association.
NEWS    AND    NOTES
Capt. R. Scott-Moncrieff won the Gait Cup at the Victoria Golf Club, Oak Bay.
^ *$* *fr *£
Dr. D. E. Alcorn of Victoria attended a meeting of the North Pacific Society for
Neurology and Psychiatry in Tacoma, and gave a paper entitled "Some Prepsychoana-
lytical Concepts of the Unconscious."
5f 'C ?£" «Tf*
Dr. and Mrs. Lloyd W. Bassett of Victoria are receiving congratulations on the
arrival, on April 17th, of a son.
We are very glad to report that Dr. E. L. McNiven of Victoria is recovering from
a long and tiresome illness.
Doctors M. J. Keys and J. W. Lennox of Victoria attended the International Medical Golf Tournament in Seattle.
Dr. H. E. Ridewood gave a very interesting paper entitled, "Examples of Incomplete Surgery" before the last meeting of the Victoria Medical Society.
249 The Chilliwack Medical Society is entering upon its third milestone; Dr. R. McCaffrey was its first president and held office for two years. At their recent Annual Meeting
the following officers were elected: President, Dr. L. A. Patten; Vice-President, Dr. A.
R. Wilson; Secretary-Treasurer, Dr. G. A. C. Roberts.
The new Hospital, of which the community is justly proud, is partly the result of
the efforts of the Medical Society to draw to the attention of the Hospital.Board and the
citizens the need there was for just such a building. Now that this is nearing completion the Doctors of Chilliwack are helping with the furnishing by contributing the
cost of the sterilizing equipment.
All service and other organizations of Chilliwack and the surrounding district have
given generously to furnish the wards and operating rooms. The Hospital Board is
launching a Hospital Insurance Scheme for the surrounding district, as this has proved
very popular and successful in other districts.
5S» A *'- *•
Dr. and Mrs. R. H. Irish of Tranquille are receiving congratulations on the birth of
a son on May 7th.
* *       «■       *
We understand that Vanderhoof is to have a hospital.   Plans have been completed.
Congratulations, Dr. Stone.
A new X-ray apparatus has been installed in the Prince George General Hospital.
The Annual Meeting of the Fraser Valley Medical Society was held on May 9th, and
was largely attended by members not only from New Westminster but from the Lower
Valley. Following the Golf Tournament, the members had Dinner at the Vancouver
Golf and Country Club. A very successful year under the chairmanship of Dr. W. A.
Clarke was reported.
The following officers were elected for 1940-41: President, Dr. L. S. Chipperfield,
Port Coquitlam; Vice-President, Dr. A. N. Beattie, loco; Secretary, Dr. B. H. Cragg,
New Westminster.
Dr. G. H. Manchester gave a reminiscent talk on early days in New Westminster,
and following the meeting a social evening was enjoyed.
Dr. and Mrs. M. M. McPherson of Vancouver are receiving* congratulations on the
birth, on May 19th, of a son.
Dr. Neil Morrison of Nelson is in the! East doing post-graduate work.
*r »& *C •S"
Dr. J. Stuart Daly of Trail was in Vancouver during last week. He called at the
office to discuss certain arrangements for the Annual Meeting in Nelson.
Dr. G. E. L. MacKinnon of Cranbrook, recently elected Member of Parliament, is
now in Ottawa.  He will be no longer associated with Dr. F. W. Green in practice.
* *       *       *
Dr. W. O. Green has joined his father in practice and they will be assisted by Dr.
Melville Swartz.
* *      «•      *
Dr. R. R. Laird is visiting his home in Oliver and renewing acquaintances there and
elsewhere in the Okanagan.
*t A A A
*ST *r *s* *ir
Dr. A. L. Buell has taken offices in North Vancouver on Lonsdale Avenue.
Congratulations are extended to Dr. and Mrs. L. M. Green of Smithers on the birth
on April 9th of a son.
*t »t *& A
*T ^ *v •Sf
Capt. J. R. Ireland of Kamloops is at present absent on military duties.
Dr. H. Baker of Salmon Arm has disposed of his practice.
250 Dr. F. E. Pettman of Vernon is in the East doing post-graduate study.
sf" # f- t
Dr. M. G. Archibald is leaving shortly to visit his old home in Nova Scotia. He
will attend the Canadian Medical Association meeting in Toronto on June 17th.
The profession extends best wishes to Dr. C. P. Jessop of Tranquille on his marriage to Miss Helen Peterson of Copper Mountain on May 14th. Dr. and Mrs. Jessop
will reside in Toronto.
Dr. A. S. Underhill of Kelowna was a recent visitor to Victoria and Vancouver.
Dr. W. J. Knox of Kelowna was in Vancouver attending the Convocation exercises
at U. B. C, his son, William, graduating in Arts.
Medical Officers present at Vernon Militia Training Camp were: Major G. A.
Lamont, Camp Medical Officer; Major C. H. C. Bell, M.O., Army Service Corps; Capt.
Roy Huggard, Camp Sanitary Officer; Capt. J. A. Ireland, M.O., Rocky Mountain
Rangers, and Lieut. W. F. Anderson, British Columbia Dragoons.
Dr. G. W. Knipe'sf son is home on vacation from Alberta and will be stationed at
the emergency outpost at Port Essington under Dr. C. A. Armstrong of Port Simpson.
Dr. S. L. Williams of Nanaimo attended the last regular meeting of the Committee
on the Study of Cancer of the British Columbia Medical Association.
Dr. B. J. Hallowes of Alexis Creek has been in Vancouver for the past few weeks
and tells of big trout on small flies.
The Annual Meeting of the Council of the College of Physicians and Surgeons was
held on May 6th. Doctors W. E. Ainley and L. H. Appleby of'District No. 3, W. A.
Clarke of District No. 2, G. C. Kenning and Thomas McPherson of District No. 1,
Osborne Morris of District No. 4, and J. Bain Thorn of District No. 5 were in attendance at the meeting, which lasted the full day.
Dr. H. A. Whillans is relieving Dr. J. K. Kelley of Zeballos.
Dr. O. O. Lyons of Powell River is away on vacation.
A A A *t
Dr. W. B. Clarke is assisting Dr. J. Murison at Powell River during Dr. Lyons'
absence.
Dr. Hugo Emanuele is assisting Dr. J. H. Black at Wells.
BOOK REVIEW
PNEUMOCONIOSIS (Silicosis) : The Story of Dusty Lungs; by Lewis Gregory Cole
and William Gregory Cole, John B. Pierce Foundation, New York.
This book is a partial account of some research work done by Dr. Lewis Gregory
Cole and his son, William Gregory Cole. The work has received the support of the
John B. Pierce Foundation, and this volume is published and distributed by the Foundation.
The principal part of the work is a summary of the senior author's conclusions after,
as he states, some months' study of microscopic slides of lungs in varying stages of
pneumoconiosis.   Eventually there developed a picture of pneumoconiosis which was
251 quite at variance with previous conceptions.   Insofar as he presents his own observations
the work is very interesting though not altogether convincing.
There is no clear clinical description of the various types of silicosis and its complications met with in ordinary practice, and as the authors admit, the description and
theories given are quite unorthodox. The book will have considerable interest to the
research worker in the silicosis field, but to the average practitioner it will be of little
interest. (C. H. V.)
LIBRARY NOTES
The new book case has been installed in the Reading Room, and is now in use.
Attention is directed to the rearrangement of periodicals, which have been grouped
according to subject matter, insofar as possible, in place of the alphabetical order in
use before.
It is hoped that members will find this a satisfactory change, and that it will prove
to be a more convenient arrangement, after they have become accustomed to it.
New Books
Following are some of the new books which have recently been added to the Library:
Neurology, 2 vols., 1940, by the late S. A. Kinnier Wilson.
Textbook of Medical Treatment, 1940, by various authors.
The Dysenteric Disorders, 1939, by Philip Manson-Bahr.
■ Sterility and Impaired Fertility, 1939, by Cedric Lane-Roberts, etc.
Principles and Practice of Aviation Medicine, 1939, by Harry G. Armstrong.
Clinical Heart Disease, 2nd ed., 1940, by Samuel A. Levine.
Electrocardiograph Patterns, 1940, by Arlie R. Barnes.
Sclerosing Therapy, 1939, by Frank C. Yeomans.
Diseases of the Gall Bladder and Bile Ducts, 1940, by Waltman Walters and Albert
N. Snell.
Gonorrhoea in the Male and Female, 3rd ed., 1939, by Percy Starr Pelouze.
Vancouver Medical   Association
LOW BACK PAIN
Dr. H. H. Boucher
Read at the General Meeting of the Vancouver Medical Association, April 2, 1940,
It is proposed in this short paper to discuss the diagnosis and treatment of a few of
the more common causes of low back pain. Before doing so it might be well to mention the examination of the patient and review briefly some of the anatomy of the part.
The history is very important and should be taken personally. In a problem case of
long standing this may take half an hour or more. The way in which the accident
occurred is often indicative of the seriousness of the injury. The complaints may be so
numerous and so bizarre that a marked anxiety condition is obvious. Most patients
suffering from chronic low back strain show anxiety symptoms in some degree and
these are not infrequently overlooked. Their recognition and treatment will be found
to have a favourable influence on the progress of the case. The patient should be stripped
except for a loin cloth and examined in the standing and lying positions. The examination should be most complete, including as well as a general physical check-up, posture,
motion, length and size of limb, condition of the feet, and a brief but careful examination of the central nervous system. Sweating, coarse fibrillation of the muscles, congestion of the face and neck, shunting of power, prompt one to look for further signs
of anxiety such as dilated pupil, gross exaggeration of deep reflexes and absent pharyngeal
reflex.
252 Anatomy of the Lumbo-sacral Region
The lumbo-sacral joint represents the junction of the mobile spine and the immobile
sacrum and here a sharp change in the direction of the spine takes place, as the concavity
of the sacrum develops to form part of the posterior wall of the pelvis. The superior
surface of the sacrum is normally considered to form an angle of 42.5 degrees with the
horizontal, which would create a markedly sloping surface for the support of the last
lumbar vertebra, were it not lessened to a great extent by the shape of the intervertebral
disc which unites the fifth lumbar and the first sacral vertebrae. This strong fibrocartilaginous body is wedge shaped with its base forward and is firmly attached to the
surrounding interspinous ligaments. The thinness of the disc posteriorly diminishes its
value as a shock absorber and pre-disposes to injury. The fifth lumbar vertebra is
characterized by being considerably deeper in front than behind, by the small size of its
spinous process, by the wide interval between the inferior articular processes and by the
thickness of its transverse processes which spring from the body as well as from the
pedicles1. The sacrum is a wedge shaped bone formed by the fusion of the five sacral
vertebrae and is inserted between the two hip bones. Articulating with the base of the
last lumbar, it forms the sacro-vertebral angle. It is placed obliquely and curved longitudinally to increase the size of the pelvis. The bodies of the vertebrae bear the weight
of the trunk and upper extremities while the spinous and transverse processes together with
the laminae and their articular processes form the posterior column. This structure
protects and forms a canal for the spinal cord and affords surfaces for the attachment
of strong ligaments and muscles which hold the body erect. The articular processes
between the upper lumbar vertebrae are set fairly close together and lie in the sagittal
plane which allows flexion and extension and prevents rotation of the bodies. Those
between the last lumbar and the sacrum are powerful and set widely apart with joint
surfaces which face in an oblique sagittal direction resembling somewhat the frontal
type found in the dorsal region. This allows some degree of rotation which motion in the
lumbar spine occurs wholly in these joints. Some hold that this added movement of
rotation is a source of weakness as flexibility and strength are always opposed. However,
the oblique direction of the facets is an added factor of safey causing them to impinge
upon one another as the fifth lumbar tends to slide forward on the sacrum, and thus
act as buttresses preventing forward displacement. Therefore the added mobility is more
than compensated for by the gain in strength. The lateral intervertebral articulations
are true joints with hyaline cartilage, synovial membrane and capsule. As such they
are subject to the usual joint affections of static strain, trauma and inflammation. They
help in stabilizing the spinal column and allow certain special movements in respective
portions of the spine. Those of the lumbo-sacral junction are arranged specially to allow
flexion with some rotation. In certain instances the lower lumbar lateral articulations
are called upon to aid in supporting the superincumbent body weight. The lumbosacral joint is further supported by the anterior and posterior longitudinal ligaments of
the spinal column, by the ligaments connecting the vertebral arches and their processes,
of which the ligamentum subflavum is the most powerful, and by the sacro-lumbar and
ilio-lurribar ligaments, adding further strength to the structure and relief to the ligaments are the strong erector spinae and psoas muscles lying posteriorly and laterally,
while the anterior aspect which most needs protection is unsupported by muscles. Other
less powerful spinal muscles aid in binding the bones together.
Anatomical Variations
The lumbo-sacral region is generally understood to be undergoing evolutionary
changes as a continuation of the gradual adaptatation of the human skeleton to the
upright position. It is therefore morphologically unstable and the site of many anatomical variations.
Examples of these are:
1. Sacralization, where the enlarged transverse processes of the fifth lumbar vertebra are united to the body of the sacrum. The condition may be unilateral or bilateral
and the union may be complete or incomplete, in which case a pseudo-arthrosis is present.
253 Solid union would mean added strength, while fibrous union with a false joint predisposes
to strain. This is considered to be a further adaptation of the skeleton to the upright
position by shortening of the spine.
2. Abnormally long transverse processes.
3. Spina bifida.
4. Separate neural arch (which allows spondylolisthesis).
5. Horizontal sacrum.
The importance of these variations has been stressed by some more than others. They
are frequently seen in X-ray plates of the pelvis in patients who do not complain of low
back pain. The horizontal sacrum and other architectural deficiencies which tend
towards an unstable lumbo-sacral junction would seem at least to predispose to strain.
Dynamics of the Pelvis2
During motion in the sagittal and frontal planes, strain is transmitted through the
lumbo-sacral articulations while in the transverse plane strains caused by rotation of the
body about the perpendicular axis are received through the lumbo-sacral and sacro-iliac
junctions. The lumbar spine has practically no rotation such as there is occurring at the
lumlbo-sacral junction. If the impulse of rotation exceeds the rotatory range at this
junction the momentum is transmitted to the sacro-iliac articulation. It is evident that
a greater rotatory impulse will be taken care of by lumbo-sacral articulations which lie
in the antero-posterior plane than by those which lie in a sagittal plane. The sacro-iliac
joint supported by its ligamentous masses resists the rotatory impulses which thus pass
on to the hips, knees and ankles and may even cause the body to spin on the ball of the
foot. If the golfer stands firmly planted on the ground rotation will be less, due to a
resisting force in the opposite direction. If the rotating force is strong and the resisting
force inadequate then injury to the ligamentous apparatus will follow. The strong
muscles overlying the anterior and posterior aspects of the sacro-iliac joint offer much
help to the ligaments in stabilizing this region.
Posture
Lack of postural tone is a common cause of chronic low-back ache. The patient
stands with the head and shoulders forward and down, the abdomen relaxed and the
pelvis rotated forward. If the patient is thin the knees are usually slightly flexed, while
if stout they are extended, possibly as a bracing effect. A degree of flat-foot is often
present. In the presence of such relaxed musculature the ligaments alone offer support
and static strain follows. Correction of this condition is accomplished by the use of
braces, corsets, or remedial. exercises, possibly a combination of support and exercise.
The success of the treatment depends upon the co-operation of the patient as he cannot
be successfully "braced" into correct posture. A light brace of the Gbldthwait type
may be used in certain cases and in others a well-fitting full-length corset is more applicable. Unless the physical condition of the patient is a contra indication, remedial
exercises should be taken. The latter are by no means the usual exercises as taught in
the gymnasiums. A special group has been developed by Dr. Joel Goldthwait and are
based upon the use of correct abdominal breathing. It would probably be correct to say
that few of us breathe properly and if we do it is more by accident than by design. Dr.
Goldthwait has been more interested in posture than possibly any other orthopaedic
surgeon of his day and has established certain principles which he describes in his text
"Body Mechanics"3. You will probably not agree with some of his ideas as to the relation of posture to disease but you will find that his principles of treatment are sound.
They are being used in the physiotherapy department of the Vancouver General Hospital
for both out-patients and private patients and have produced good results .
Trauma
The sacro-iliac articulation is a diarthrodial joint between the articular surfaces of
the sacrum and the ilium. Each of these two surfaces is covered by cartilage which is
thicker on the sacrum than on the ilium. These plates of cartilage are closely approximated and in areas are united by soft fibrocartilage. There is no capsule and no synovial
fluid and the nerve supply is negligible and is not described in text books of anatomy.
254 The supporting ligaments are weak in front and strong behind. The chief bond of union
between the two bones is the interosseous sacro-iliac ligament which fills the space above
and behind the joint. Its short fibres connect the iliac and sacral tuberosities and lie
beneath the long and short posterior sacro-iliac ligaments. The fibres of the sacro-iliac
ligamentous mass cross each other at all angles, indicating that at this junction strains
and stresses are received and resisted from all sides. Motion in this joint is limited to a
very few degrees in any direction. This limitation is caused by the irregularity of its
surface, the binding effect of the short strong ligaments and the patchy areas of fibrocartilaginous union. Such motion as there is grows less with age and is considered to be
negligible in the male after the fourth decade. Degenerative changes appear later in
the female and motion is possible till later in life. During pregnancy the pelvic ligaments
relax and sacro-iliac motion is slightly increased. The most important mechanical function is to transmit the weight of the trunk and upper limbs to the lower extremities.
The sacro-iliac joints act as shock absorbers during changes of distribution of weight.
The sacrum is wedge shaped with its base upwards and forward. The weight of the
trunk transmitted to the sacrum at the lumbo-sacral joint has two components. One
tends to drive the sacrum downwards and backwards between the iliac bones and is
resisted posteriorly by the sacro-iliac and ilio-lumbar ligaments and anteriorly by the
ligaments of the symphysis pubic. The second component thrusts the upper end of the
sacrum downwards and forwards towards the pelvic cavity and is resisted mainly by
interlocking of the joint surfaces especially of the middle segment, a slight rotatory
movement resulting. Antero-posterior forces act particularly in the lumbo-sacral junction. Examples of these are falls upon the buttocks, violent hyperextension or gradual
strain as in malposture.. Lateral strain acts upon the lumbo-sacral region and excessive
lateral bending develops stresses in both the lumbo-sacral and sacro-iliac regions. Rotatory strain, being blocked by the limits of rotation in the lumbar spine is the one most
likely to involve the sacro-iliac ligaments, partciularly if the rotatory impulse is unable
to spend itself in motion due to some resistance or block. Any of these three types of
forces however may produce both lumbo-sacral and sacro-iliac strain.
The low-back represents an area of limited motion protected by strong binding ligaments and powerful supporting musculature. Strain is a common occurrence and may
involve fascia, muscle, ligaments and periosteum. The pain is acute, tenderness superficial and recovery in mild strain is generally rapid. More severe strains tend to become
chronic. Superficial pain disappears with areas of deep-seated tenderness remaining often
accompanied by leg signs. This would seem to be in the nature of a painful myofascitis
involving the soft tissues down to and including the periosteum which latter structure
is highly sensitive to pain stimuli. It has been the custom to classify the majority of
low back strains as sacro-iliac or lumbo-sacral or a combination of both and most ortho-
pcedic text books include a diagnosis. Certain well-known low-back tests have been
widely used and have been considered diagnostic when present. If energetically done
they will not infrequently cause pain in the absence of low-back strain. A sensitive
patient may anticipate discomfort and will sometimes acknowledge pain before the
manoeuvre is well under way, particularly in the presence of a robust examiner. That
this approach to the problem has not proven satisfactory is shown by the fact that some
ceased to attempt to classify the various lesions and merely described them as low-back
conditions. It is becoming more apparent that the precise soft tissue structures affected
are capable of recognition. Pain is centred in a certain area and palpation reveals
localized superficial tenderness. The tissues involved may be the sacro-iliac ligaments,
the aponeurosis of the sacro-spinalis, the muscles of the back or hip, or all of the soft
tissues of a certain area down to the periosteum. It is conceivable that even the latter
structure may be elevated from the bone over a small area with formation of a haematoma. That the sacro-iliac joint is not involved is suggested by the light touch required
to produce pain, by the absence of nerve supply to the joint and by the comparative
absence of pain following true dislocation of this joint after a severe crushing injury.
Treatment—Early and complete immobilization has been widely used as the basis of
treatment.   Bed rest promotes relaxation with disappearance of pain and spasm.   Others
255 advocate immediate mobilization of the spine by manipulation under deep ether or spinal
anaesthesia followed by massage and exercises and do not make use of bed-rest. Active
mobilization following strain in other parts of the body is commonly and successfully
used. No one form of treatment will be satisfactory in all instances of low-back strain.
Every patient should not be put to bed nor should immediate manipulation under anaesthesia always be done. Indeed many persons recover from low-back strain without
medical treatment. Bed rest should be for only a few days until the acute pain and
spasm have disappeared. If pain and spasm persist traction is applied to one or both
legs. If there is referred leg pain the hips and knees may be flexed as in balanced traction.
A fracture board is used if the mattress is not firm and a lumbar pad may be of value.
Moist or dry heat may be used and the bowels are opened and fluids forced. It is important to preserve the postural tone of the leg muscles and exercises for the quadriceps and
calf groups should be done for a few minutes of each hour of the day.
It would seem that the period of bed rest has frequently been much longer than
necessary apparently because complete absence of pain and spasm was insisted upon
before mobilization was begun. It has been the writer's custom to encourage the patient
to get up as soon as the actute symptoms have subsided, usually within a few days and
to begin moving his trunk within mild pain limits. Within ten days of the onset of
injury he may be doing remedial exercises under supervision and within a few weeks will
frequently have recovered full range of motion. If some pain and spasm persists with
limited motion, manipulation under general or spinal anaesthesia may be advisable.
Patients who have kept on walking after an ankle sprain usually have an excellent range
of motion free of pain and spasm. Tennis elbow responds well to manipulation and
continued active motion. The pain which follows strain in the neck from incoordination of muscle disappears within a few days if active motion is maintained.
Athletes who suffer sprains and contusions know that if they continue to exercise they
will usually recover more rapidly and with less eventual pain and discomfort than if they
sit on the sidelines. It may be that the lack of motion in the sacro-iliac region predisposes to painful fibrositis and that long periods of immobilization encourage this
predisposition. The writer does not use belts or braces for support after low-back sprain
but depends rather upon the preservation of postural muscle tone and the prevention of
atrophy. No occasion has arisen in several years where it has been found necessary to use
any manner of supportive apparatus in the absence of architectural deficiencies or degenerative bone changes. The various forms of support usually cause discomfort and limit
motion. Morevover, the amount of support given to the low-back by anything but
adhesive plaster or a full length form-fitting corset is questionable. Snug adhesive strapping may offer some relief in the early stages but frequently it aggravates the condition
and is removed by the patient.
Chronic low-back strain frequently responds well to manipulation and exercises.
The patient is kept in bed for a day or two until the soreness following manipulation is
less and then is asked to get up and begin active exercises. Arthrodesis of the sacro-iliac
joint or fusion of the lumbro-sacral region or a combination of both operations has been
a common form of treatment when all conservative measures have failed. However,
much less radical procedures are now being used with success and the more extensive
operations have become less popular.
Certain forms of acutely painful low-back strain occur from trivial causes. During
the simple manoeuvre of bending over as in making a bed or in reaching to pick up an
object, a sudden agonizing pain is felt usually in the lumbar region which frequently
completely incapacitates the patient. Muscle spasm is present to a marked degree and
any active or passive attempt to extend the spine causes the patient to groan or cry
aloud. Recovery is usually rapid following conservative treatment and may be complete
in a week or ten days. It is probable that the lesion has been in the muscle fibres and
aponeurosis following inco-ordination of movement. Another acutely painful injury
occurs in a simple manner. Stepping down unawares from a curb or jerking a tire off a
rim may cause sudden pain in the low-back.    The pain is usually moderate in amount
256 and the chief complaint is the inability to straighten up. Manipulation without anaes
thesia will frequently cause an immediate and complete disappearance of signs and symptoms and the patient walks out apparently well. This suggests that soft tissues have not
been involved and that a subluxation of a joint has occurred as in one of the lateral
articulations of the lumbar spine. X-ray examination before manipulation might be of
diagnostic value although minor degrees of subluxation are rarely demonstrated by this
means.
Lumbago
This condition is considered to be an inflammatory affection of the lumbar muscles
and may also involve the fascia. It frequently comes on after exposure to wet and cold.
One patient found that he would develop lumbago when lightly clothed if exposed to
even a mild breeze. On a warm summer day when golfing he found it necessary to wear
a light sweater when his back was to the wind. The onset is sudden and acute but is not
associated with injury and tenderness is not so localized as in acute back strain. The
disease is self-limited and is favourably influenced by conservative treatment. Some
years ago Dr. W. D. Patton of this city found that early full hyperextension of the
lumbar spine considerably shortened the period of convalescence.
Low-back Pain with Sciatic Radiation
Direct sciatic irritation occurs as a result of pressure upon the cord or sciatic nerve
roots when the lesion is in the spinal canal. Herniation of the nucleus pulposus, cord
tumour and thickening of the ligamentum subflavum are examples of such a lesion. The
signs and symptoms are suggestive and include clinical neurological findings of a peripheral neuritis frequently accompanied by a spinal block and an increase of total proteins
in the spinal fluid.
In the large majority of cases of low-back pain with sciatic radiation there is no
evidence of a peripheral neuritis. No satisfactory explanation of the mechanism of
referred pain which apparently arose from painful stimuli in the soft tissue areas in the
low-back had been made prior to the work of Steindler and Luck5. They found that
when pressure upon a painful area in the soft tissue caused sciatic radiation of pain,
this pain stimulus could be eliminated by novocaine injection at the tender spot. In a
recent article6 Dr. Steindler suggests that sciatic radiation in these cases is purely of
reflex origin. The motor and sensory nerve supply to the soft tissues of the back including muscles, ligaments, fascia and periosteum, is derived entirely from the posterior
primary division of the spinal nerve. There is no anatomical relationship between the
peripheral sensory nerves of the low-back and of the leg. The afferent branch of the
reflex arc is supplied by the sensory fibres of the injured soft tissues and the connection
with the sciatic nerve is made in the region of the spinal ganglion or possibly in the cord.
This phenomenon was noted in some thirty per cent of Steindler's cases of low-back pain
pain with sciatic radiation. The leg pain disappeared and with it the spasm so that all
leg signs were temporarily abolished. This seems to be a rather higher percentage than
usual. In most cases there are tender areas to be found and these seem to usually be in
the region of the posterior superior iliac spine and along the posterior third of the crest
of the ilium above the superior gluteal line corresponding to part of the origin of the
gluteus maximus. Occasionally pressure over these areas causes referred pain but more
often only a local tenderness and injection with novocaine fails to abolish the leg signs.
It would seem that these cases are probably of longer duration and ones in which a
condition of painful fibrositis had been followed by scar tissue contracture with the
mechanical factor predominating.
Various methods of immobilization have in the past constituted the most popular
form of treatment. They ranged from bed-rest with traction to a brace or plaster cast
or even to fusion of a painful joint which had resisted conservative treatment. Immobilization is generally considered as a conservative form of treatment. It can at times
be a very radical form. If the low-back is immobilized by rest in bed or by a cast or a
brace, muscle atrophy and loss of postural tone will follow. After immobilization of the
knee there is marked quadriceps and calf group atrophy and loss of tone.    If muscle
257 volume and tone are not restored (before the patient attempts to make full use of the
joint a recurrence of the strain frequently follows. The muscles of the back are most
important and necessary in providing support and their weakness following immobilization may be a factor in recurring back strain. Some form of treatment which will allow
the patient to resume early activity will be the one of choice. Sub-periosteal stripping
of the origin of the gluteus maximus from the ilium and of the interosseous ligaments
between the sacrum and the posterior spines of the ilium as described by Heyman seems
to be a satisfactory procedure7. It apparently relieves pain by releasing strain at the
site of muscular or ligamentous attachments. Spasm gradually disappears and with it
the limitation of leg motion. The patient is able to lie and sleep in comfort from the
beginning of the first post-operative day. One patient who had suffered continual pain
which had not been lessened by any of the usual methods of conservative treatment
including months of bed-rest remarked on the first post-operative day that as his pain
was so completely relieved he knew the operation would be a success. This has been
the usual response to the operation in these chronic cases. The operation of sacro-iliac
fusion whether done after the manner of Smith-Peterson or of Campbell frequently
gives the same dramatic relief from pain and it would seem that this immediate disappearance of symptoms could not arise as a result of the fusion alone, but is due rather
to the sub-periosteal stripping. In the Smith-Petersen operation the countersinking of
the bone block might possibly give early relief through stability but this could not be
the reason in the Campbell operation, as it is not one of fixation. Bone chips are laid
around the joint margin and fusion would not occur in less than several months. Dr.
Percy Roberts many years ago operated on a patient suffering from sciatic pain whose
X-rays seemed to show a pathological lesion in the ilium. The bone was exposed sub-
periosteally, no lesion was found and the wound was closed, but the patient was relieved.
He subsequently performed this stripping operation in sixteen other cases and relieved
all but one. Dr. Frank Ober of Boston described an operation in which he severed the
tensor fasciae latae at the upper level of the great trochanter for the relief of sciatic pain8
It became quite popular and was frequently successful, apparently relieving fascial pull
on the pelvic bones. The aponeurosis of the gluteus maximus muscle is inserted largely
into the ilio-tibial band and relief from pull on this muscle would follow such a section.
The operation was the more valuable because of its simplicity but unfortunately recurrence of symptoms was not infrequent possibly following restoration of continuity of
the band. The results of the operations of both Ober and Heyman may be shown by a
brief review of a few cases.
Fasciotomy:
R. A., male, age thirty-five.    Lineman.
Complaint: Low-back pain extending down left thigh and leg to the foot.  Gradual onset February, 1937.
Conservative treatment including bed-rest and traction and removal of tonsils failed to help. He returned
to work following manipulation wearing a sacro-iliac belt. Pain returned six weeks later. Examination
October 21st, 1937, showed a typical sciatic scoliosis with atrophy of buttock, diminished ankle jerk, normal
sensation, limited painful straight leg raising and positive Ober's sign due to a tense ilio-tibial band.
Operation: November 5th, 1937. There was early post-operative relief of pain and he left hospital walking in ten days.  He returned to work December 20th, 1937, feeling fit.
He came in by request a few days ago and has no complaint. There is still some bilateral hamstring
spasm with absent ankle jerk on the left and some atrophy of the left lower extremity including buttock,
thigh and calf. He has had an office job for some time now and it is quite possible that he might have had a
return of symptoms had he been doing heavy work.
Sub-Periosteal Stripping:
G. B., male, age thirty-three.   Longshoreman.
Complaint: Low-back pain accompanied by leg pain. Onset in June, 1936, following strain. Conservative treatment failed to help.
Examination in April, 1939, showed typical sciatic scoliosis of a very marked degree. Atrophy of buttock
and limb was noted with absence of ankle jerk and marked bilateral restriction of straight leg raising with
pain.   Sensation was normal.
Operation: May 2nd, 1939, consisted of very thorough sub-periosteal stripping of the origin of the right
gluteus maximus and of the ligaments attached to the posterior superior spine of the right ilium, and section
of the lumbo-dorsal fascia. Immediate relief of pain followed and he would have been out of bed in a few
days except for a haematoma which developed.  He left hospital three weeks after operation and returned to
258 work six weeks later, having no pain, no scoliosis and much increased range of leg motion. The wound sinus
healed soon after returning to work and recent letters from the patient and his physician state that he has
been perfectly well and has been able to continue at his former occupation of longshoring.
A similar type of lesion occurred in a female.
Mrs. O. J., age 30.   Stenographer.
Complaint: Low-back pain referred down left leg to heel. Onset four years ago, sudden, during gym.
exercises.  Referred down leg almost from the beginning.
Previous treatments Epidural injection and manipulation. Pain worse and spent several weeks in bed.
Three direct injections into the sciatic nerve did not help and there was no benefit from numerous chiropractic
.treatments. It was thought that an ovarian cyst might be pressing on the nerve so a laparotomy was done and
the cyst removed. At the same time, the sciatic nerve was stripped by a retroperitoneal approach. While in
bed she felt better but the pain returned immediately after getting up. She was now considered to have a
neurosis and no further treatment was given for a year, during which time she was almost totally disabled.
A corset was then tried for a month but this aggravated the pain so she was put to bed on a fracture board.
Injections of eucupin in oil helped for a short time but the pain returned overnight and she spent a further
ten weeks in bed with no improvement.
Examination: A well nourished healthy looking female. Typical sciatic scoliosis with pelvic list, hamstrung spasm, atrophy of buttock and limb and normal sensation. Tendterness in the region of the posterior
superior spine of the left ilium and over the sciatic nerve.
An anxiety condition was present.
Operation: September 5th, 1939. Sub-periosteal stripping of the gluteus maximus and of the posterior
spines of the ilium on the left side.
Progresss Immediate post-operative relief of pain. She was out of bed in seven days, left hospital on the
tenth day. Has been well since and resumed her occupation within a few weeks. A recent communication
from her attending physician states that she remains well, having no deformity, no pain and only slight
limitation of forward bending.
L. G., age 20.   Male.
Complaints (1)  Pain in the low-back and right leg down to heel;  (2) limited back motion.
Onset gradual two years ago. Pain first in the leg below the knee and did not appear in the back until
several months later. Conservative treatment including several months in bed gave no relief. Manipulation
did not help.
Examination: May, 1939, showed marked bilateral hamstring spasm with extremely limited back and
leg motion. Tenderness over both posterior and superior iliac spines. Ober's test for contracted fascia lata
positive on both sides.   Sensation and reflexes normal.
Operation: May 30th, 1939, bilateral stripping of posterior iliac spines and of the iliac origin of the
gluteus.   Transverse section of the lumbo-dorsal fascia.
Result: Apparently, the operation was of no immediate benefit. He said his pain was no less and there
was little clinical improvement. Subsequent examinations showed that hamstring spasm was less and motion
better but he still complained of pain. The operation was considered a failure. Examination April 2nd, 1940,
showed a marked improvement in appearance, the patient having gained in weight and colour. Apparently
he has been working in a knitting mill ever since he left the hospital. Motion in the left leg is almost normal
but there is hamstring spasm in the right leg and limited forward bending. His employer states that he has
noticed continual improvement and has not heard him complain of pain, whereas before he quit work to
attend the outpatient department of the Vancouver General Hospital he looked ill and was apparently suffering from continual pain.
In the summer of 1939 the writer attempted to strip the periosteum from the posterior portion of the wing of the ilium and from the region of the posterior iliac spines
by a closed method. The purpose was to find out if local relief from tension by mechanical release of the soft tissue through elevation of the periosteum would relieve the
pain and increase the range of motion. Two patients were selected, one from the outpatient department with a ten-year history of back-ache with referred leg pain and
limited motion as a result of an industrial accident and the other presenting similar
signs and symptoms of several months' duration following an accident in industry. Both
of these men had previous conservative treatment. Using a 0.5 per cent solution of
novocaine in saline, large quantities of this fluid were injected by needle and syringe
under the periosteum. This tissue was stripped with some difficulty and following it
a large subperiosteal lake could be distinctly palpated. Gradually it diffused into the
soft tissues and produced an oedema. Some post-operative pain was felt, one patient
staying in bed at home for several days and requiring a mild pain laxative. This was
the young man with the ten-year history. He came to the office recently in uniform and
is a sergeant instructor in a local unit. Apparently he became quite active after the
fi'-st few days and states that his pain and limited motion disappeared, within a fortnight, that he joined the army as fit a few weeks later and has felt perfectly well ever
259 since. Examination showed no clinical evidence of his previous disability. The second
young man also came to the office recently by request for examination and although he
still complains of some soreness across the low back there is no clinical evidence of low-
back strain. It is obvious that no conclusion can be drawn from these two cases. Having
noted their satisfactory progress the operation will be repeated as the opportunity arises.
Lantern slides were shown demonstrating the anatomy of the lumbo-sacral region and the various
anomalous conditions which predispose to low-back strain.
1.
2.
3.
.4.
6.
REFERENCES:
Gray's Anatomy.
"Mechanics of Normal and Pathological Locomotion in Man," by Arthur Steindler, M.D., F.A.C.S.
Publisher: Charles C. Thomas.
"Body Mechanics," Joel E. Goldthwait, M.D., LL.D., and Associates.   Publisher: J. B. Lippincott Co.
Personal communication by Dr. George Greaves, head of Physiotherapy Department, Vancouver General
Hospital.
Steindler and Luck: "Differential Diagnosis of Pain Low in the Back." Journal of the American Medical
Medical Association, CX, 106, 1938.
A. Steindler, M.D., F.A.C.S.: "The Interpretation of Sciatic Radiation and the Syndrome of Low-Back
Pain." Journal of Bone and Joint Surgery, Jan., 1940, p. 28.
Clarence H. Heyman, M.D.: "Thoughts on the Relief of Sciatic Pain." Journal of Bone and Joint Surgery, October, 1934, p. 8 89. "Posterior Fasciotomy in the Treatment of Back Pain." Journal of Bone
and Joint Surgery, January, 1936, p. 105.
V
ancouver
G
enera
Hospita
PNEUMOCOCCIC MENINGITIS
Report of Two Cases.
from the Sub-Department of Neurology and Neurosurgery, Vancouver General Hospital.
By T. F. H. Armitage, M.D., and,Frank Turnbull, M.D.
The introduction of Dagenan (sulphapyridine) has profoundly altered the treatment
of pneumococcic meningitis. There are several matters which are as yet unsettled,
notably the necessity, or otherwise, of combining anti-pneumococcus serum with
Dagenan therapy. Two cases are herein reported, one fatal, the other with recovery.
They illustrate some of the new therapeutic problems. Certain unusual aspects in both
cases seem to justify their publication.
Case I.—H. M., a logging truck operator, age thirty-one, referred by Dr. Ryall of
Alert Bay, was admitted to the Vancouver General Hospital on October 9th, 1939. On
October 5 th he was thrown from his truck and struck his head on the ground. He was
unconscious for several minutes. On coming to his senses he noted some blurring of his
vision and a mild epistaxis. Previous to his accident he had been in good health. Lumbar
puncture on October 5 th showed bloody cerebrospinal fluid and the next day cloudy,
pink fluid.   On October 7th the fluid was definitely purulent.
Examination.—On October 9th, the temperature was 99.2°, pulse 92, respirations
20. He was well oriented, though slightly drowsy. His neck was moderately stiff and
Kernig sign positive. There was slight deafness in both ears. The eardrums appeared
normal. There was blurring of the nasal margins of both optic discs. The Kahn test
was negative. Lumbar puncture (see Table 1) demonstrated purulent fluid with pneumococci of Type 10.
Progress.—Treatment with Dagenan along with soda bicarbonate was started immediately. Soludagenan was given intramuscularly the first three days and after that
Dagenan by mouth. He complained of headache and soreness of his neck intermittently
throughout his illness.  He was frequently irritable and occasionally confused.   In spite
260 of a blood Dagenan concentration of 10 mg. and over his condition by October 26th
was becoming poorer. A course of antipneumococcic serum (Lederle) Type 10 was
started (see Table 1).  He was given a blood transfusion of 500 cc. on November 1st.
Three days after admission he complained of a sore mouth. There were numerous
small white ulcers over the whole buccal mucous membrane which remained throughout
his illness. On October 25th, sixteen days after therapy was started, he developed a
diffuse morbilliform rash over his entire body except the face, scalp, hands and feet. It
was most marked on the abdomen and back. This rash faded away gradually in spite of
continuance of Dagenan, but it became quite pronounced again six days later. On
November 2nd, twenty-four days after admission, he was first noticed to have jaundice
of his conjunctivae and the spinal fluid was straw-coloured. In the face of this complication Dagenan was discontinued. A Van den Bergh test on November 4th was 8.75
mg. with immediate direct reaction. The jaundice increased rapidly and he died five days
after Dagenan was discontinued.
Post-mortem findings.—There was a fracture through the floor of the sella turcica
with slight separation of the edges in its midportion. There was some mucopus in both
sphenoid sinuses. (The meningeal infection presumably arose as a direct extension at this
site.)   The base of the brain was covered with an extensive thick purulent exudate.
The liver weighed 2160 gr. and was rather pale. On gross section it showed a marked
passive venous congestion. Microscopic sections showed a well-marked parenchymatous
degeneration but no evidence of necrosis or fatty change.
Table  1
Date
Oct.
Nov.
Total
Oct.
D
ose of Dagenan
each 24 hours
Serum Dose
9
60 grains (ir
4 hrs.)
10
90    I
11
90     '
12
90     '
13
180     '
14
180    '
15
158     '
y
16
135     '
y
17
135     '
9
18
112
>
19
135     j
i
20
180
y
21
180
i
22
150
y
23
135
ty
24
135
>
25
135
)
26
135
9
100,000 units
27
135
»J
100,000   "
28
135
ii
40,000   "
29
135
§
60,000   "
30
135
g
40,000   "
31
135
yy
1
135
»
2
135
n
3
4
100,000   "
5
6
7
33 80 gr
ains
440,000 units
Red Blood
Cells
Dagenan Concentration    Cerebrospinal fluid    Original Pressure
Blood    CerebrospinalWhite blood   Culture        Millimetres
fluid
cells
Cerebrospinal fluid
10.08 mg.
700
Positive
Positive
120
410
12.5   mg.
10.0
mg.
11.2   mg.       8.3 mg.
12.5   mg.
2,100
380
570
170
Positive
330
300
Positive
280
75
180
0
Negative
120
20
150
4
90
25
•
230
152
Positive
230
400
Positive
310
700
Positive
600
2,000
Positive
610
.0,000
Positive
500
Haemoglobin   White Blood
17      4,280,000 86
Oct. 24       4,060,000 81
Oct. 31  % \    3,300,000 66
Blood Kahn—negative.
Urine—negative except for occasional Dagenan crystals and, November 3, bile.
Cells
6,200
5,500
6,400
Polymorphonuclear Lymphocytes
Leucocytes
57 43
71 29
79 21
261 Comment.
When the cell count of the cerebrospinal fluid was reported as nil and its pressure
as normal on October 15th the outlook appeared bright. But culture of the fluid was
still positive for pneumococci. A sense of false security and too much regard for the
comfort of the patient prompted us to lower the dose of Dagenan. With a subsequent
increase in the dose of Dagenan and the addition of antipneumococcus serum intravenously, the cerebrospinal fluid findings became entirely normal on October 30th.
Discontinuance of Dagenan three days later, when jaundice became manifest, undoubtedly sealed his doom. In the light of post-mortem findings it is possible that the liver
damage was due to toxasmia rather than to Dagenan, and the wisdom of its discontinuance may be questioned. Demonstration of a fracture of the base of the skull at autopsy
confirmed our clinical impression that the meningitis was directly attributable to head-
injury and made his wife's claim for compensation unquestioned.
Case II.—W. B., a boy of six years, was admitted to the Vancouver General Hospital, under Dr. H. H. Milburn, on September 8th, 1939. He was seen in consultation
by one of us (F. T.) on September 15th and transferred to the Staff service under our
care on October 2nd.
Eight hours prior to admission he had fallen about twelve feet from a porch and
struck his face on the ground. He got up at once, walked into the house, and then fell
to the floor. He had a profuse epistaxis. He became drowsy but did not lose consciousness.  Previous to this accident he had always been healthy.
Physical examination on admission.—Temperature was 97.0°, pulse 120, respirations
20. Weight was 60 pounds. He was a well-developed, well-nourished boy, drowsy but
able to rouse enough to co-operate. His nose was flattened and palpation of the nasal
bones revealed crepitus. There was swelling and ecchymosis of both eyelids on the left
side and the lower lid on the right. There was clotted blood in^ both nostrils. The rest
of the general physical examination and neurological examination were negative. X-ray
examination showed displacement of the nasal bones but no evidence of fracture of the
base of the skull. He was started at once on moderate dosage of Dagenan as a prophylactic against meningitis.
Operation.—On September 11th, operation (by Dr. J. A. Smith ( was carried out
under ether anaesthesia. The nasal septum was straightened, the nasal bones elevated,
and the nares packed with vaseline gauze.
Progress.—Packing in the nose was removed September 14th. On this day he first
complained of headache. Temperature was 100° F. He became nauseated and vomited.
Next day the temperature was 104° F. rectally, the pulse 146 and respirations 38 per
minute. The right pupil was larger than the left. There was marked neck rigidity and
positive Kernig sign. Lumbar puncture showed an initial pressure of 220 mm. of cerebrospinal fluid. The fluid was cloudy and contained 7500 W.B.C. per cubic millimetre
and 100% polymorphonuclear leucocytes. Direct smear revealed no organism. Neoprontosil, 15 grains every four hours, was given for thirty-six hours but when culture
of the spinal fluid demonstrated pneumococci type 6 this was discontinued and Dagenan
therapy resumed (see Table 2). Soludagenan was given intramuscularly when Dagenan
was not tolerated by mouth.
On September 16th, a white ulcerated area, three-quarters of an inch in diameter,
appeared on the mucous membrane of the lower Up. On this day he developed an internal
strabismus from palsy of the left sixth cranial nerve. He was drowsy and quite confused at times. A transfusion of 250 cc. of whole blood was given. He was able to
take his medication orally and his condition improved in the next two days. His temperature became normal, he was bright and cheerful, the strabismus cleared up, and he
complained only of slight headache and slight rigidity of his neck. On September 18 th
he developed an internal strabismus of the right eye from palsy of the right sixth cranial
nerve. On October 6th his temperature had been normal for six days and he was quite
well. There was no neck rigidity and the palsy of the sixth cranial nerve had gone.
The Dagenan dosage was reduced. After two days the temperature rose to 103°, there
was marked rigidity again, and nausea and vomiting recurred.
262 There were remissions at times but his general condition became gradually worse.
The temperature rose, palsy of the right sixth nerve returned, and marked papillcedema
of both optic discs developed. On October 30th his condition was very poor. Antipneumococcus serum Type 6 was given intravenously after conjunctival and skin sensitivity tests had been done. There was a slight reaction to the first dose. Over a period
of eight days a total of 250,000 units of serum were given as well as two transfusions
of 250 cc. of whole blood.
From November 9th (sixty-three days after admission) onward he made a steady
recovery. His temperature dropped to normal. The spinal fluid culture and cell count
became negative.
During all the severe part of his illness the whole ulcerated area remained on his
lower lip. When he was very ill, in the latter part of October, this ulceration spread to
include nearly the whole buccal mucous membrane. His cheeks were markedly swollen
and painful and he made the lesions worse by chewing. These lesions all cleared up
concurrently with recovery from the meningitis.
He had about twenty-five intramuscular injections of Soludagenan, given when he
was unable to retain his medication orally. Probably as a result of one of these injections an acute right-sided sciatic neuritis developed on November 1st. This was treated
with heat, Buck's extension, physiotherapy, and vitamin B. He was able to be up, walking with a limp, by Christmas. His papillcedema had subsided, leaving slight pallor of
both discs but no gross defect of vision. Partly because his home conditions were very
unsatisfactory and partly to ensure a complete recovery he wag kept in hospital until
the middle of January.
24-hour dose of Dagenan
24-
Sept.    8
7Vz
grains
9-13
22-30
»»
16
11
»»
Sept. 17 to
Oct.   11
30-45
»
12
52
»»
13
75
atai
Oct.   14 to
Nov. 22
90
»»
23
60
»>
24-27
45
H
28
15
«
Total Dagenan,
5160
grains.
Cerebrospinal
White Blood
fluid
Cells
Sept.  15
7,500
23
200
Oct.     2
60
17
600
30
600
Nov. 13
20
23
0
Table 2.
Dagenan Concentration
hour dose of Dagenan
in Blood
2 mg.
Blood Counts.
Sept.
Oct.
Nov.
Red Blood
Cells
4,780,000
4,040,000
3,700,000
2,370,000
4,220,000
Haemoglobin
85%
82%
70%
54%
91%
Nov.
Polymorphonuclear
Leucocytes
100%
70%"
70%
90%
70%
0
0
Serum Dose
Oct.
Nov.
Total
Lymphocytes
50,000 units
40,000
40,000
40,000
40,000
40,000
250,000 units
Culture
White Blood
Cells
41,100
10,950
9,250
6,850
10,500
24,600
6,550
4,700
Polymorphonuclear
Leucocytes
0
Positive
30
Positive
30
Positive
10
Positive
30
Positive
100
Negative
0
Negative
npho-
Eosino
Mono-     Baso
ytes
phils
cytes       phils
4
1
44
2
1
17
2
1
37
2              1
32
2
1
12
23
5
26
4
5
263 Polymorpho
Red Blood
Haemo
White Blood
nuclear
Lympho
Eosino
Mono
Baso
Cells
globin
Cells
Leucocytes
cytes
phils
cytes
phils
Nov.   14
4,000
47
42
3
7
1
16
4,700
42
51
4
3
17
4,600
43
49
1
5
2
20
4,300,000
90%
5,200
39
59
2
Dec.    12
4,390,000
92%
6,700
52
41
3
4
Jan.       3
4,700,000
91.%
8,700
35
56
5
4
Urine
negat
ive throughout.
Comment.
The possibility of meningitis was foreseen from the day of accident and positive
measures taken for its prevention, namely, the administration of Dagenan (see Table 2)
in moderate dosage. The fallacy of regarding such treatment as "prophylactic" is
apparent. Later in his illness we were concerned about giving so much Dagenan to a
fifty-pound child. On two occasions in the first two months his clinical condition
improved remarkably and discontinuance of Dagenan was considered, but both times
he relapsed before a decision had been made. He was terrified of lumbar punctures, our
stock of serum was limited, and consequently Dagenan in full dosage as long as any
symptoms persisted was the only hopeful treatment. The total amount of this drug
that he received was very great, but did not seem to do him any permanent harm.
Delay in the establishment of an adequate concentration of Dagenan (10-12 mgm.) in
his blood we now regard as a mistake. Prolonged contact with sublethal amounts of the
drug may develop resistance or "fastness" of the pneumococci to it.
SOME REMARKS ON THE
DIAGNOSIS AND TREATMENT OF GLAUCOMA
By Dr. Meyer Wiener
Washington University, St. Louis, Missouri.
Delivered at the Annual Meeting of the Eye, Ear, Nose and Throat Association of B. C, March 30, 1940.
Whether glaucoma is on the increase, or whether we are recognizing cases which
were heretofore overlooked, the fact remains that the percentage of glaucoma cases
reported in the literature is on the increase. Of all pathologic conditions found in practice in a large city by the ophthalmologist, more than 3 per cent are cases of glaucoma.
We can realize, therefore, how very important it is for us to be on the qui vive for that
type of case which sometimes lies dormant and reveals few, if any, symptoms over
periods of time.
I am not going into the minute details of symptoms of the average case, but sound
a warning concerning those patients where a slip up can easily be made if we are not
constantly on the alert. One type which is not given enough attention, especially by
the man in small towns in general practice, is the case which comes to the country
doctor with failing vision asking when his cataract will be ripe for operation. Unfortunately, he is often told to wait until he can no longer see to read and get about. When
this happens, and he, at the same time has glaucoma, the case is indeed sad. All of us
have seen, and do see this type of case constantly. It is our duty to instruct the prac-
tioner how he may recognize a case of cataract complicated by glaucoma simplex. He
has no tonometer and the tension may be so slow that even an expert may not be able
to determine by the finger test that the tension is abnormally high. Warn him of the
most important, single, sign by which he may catch this case early: A large pupil. We
know that the pupil of the infant is extremely small. That of youth is very large. In
old age it reverts back to type. Whenever he sees a patient complaining of failing
vision with or without cataract, who has an unusually large pupil for his age, that person
is immediately under suspicion and will bear further investigation and watching.
Changes in the fields of vision are, to my mind, the most important single thing in
the early diagnosis of glaucoma simplex.    One may find a perfectly normal peripheral
264 field during the ordinary routine examination with the perimeter. If, however, in an
obscure case, we use a smaller target, we may find a slight indent in the upper nasal
field, or a partial or complete scotoma in this part of the field. By using the tangent
screen, we may find an early Roenne or Bjerrum defect before the peripheral field is
affected.  I do not believe that colours will help us out much.
We know only too well that one may have an acute or subacute attack of glaucoma
and the symptoms subside, or lie dormant, so that it is most difficult to state whether this
patient has glaucoma. I have such a case in mind where my former associate saw a
patient during a mild attack of acute glaucoma, which responded beautifully to treatment with pilocarpine. After being told of the diagnosis she consulted one of our most
prominent ophthalmologists in New York, who told her that she did not have glaucoma
and that he didn't believe that she ever had it. On her way home to Des Moines, Iowa,
she stopped at Washington, D.C., where she had a fulminating attack in one eye, and
on her arrival in St. Louis, the other eye had become involved. This happened early in
my career and taught me a lesson, never to say that a patient does not have glaucoma, but
that I can find no evidence of glaucoma.
We all know that the tension of the normal eye is higher in the morning than in
the afternoon and at night. The difference is very little normally; not more than 3 mm.
to 4 mm. of Hg. at the most. In glaucoma, it may run as high as 15 mm. or even 40 mm.
This is not always true, especially if the patient is using his eyes a great deal for close
work. In that case, unless you take the tension very early, before he begins to use his
eyes, you may find it down. The constant action of the ciliary muscle pumps the fluid
into the canal of Schlemm. For this reason I always encourage my glaucoma patients
to read and write and use their eyes a lot for close, as this tends to bring the tension
down. I have often listened to men admonish their glaucoma patients not to use their
eyes at all for close work.
Arnold Knapp observed that when a solution of 1-100 epinephrin was instilled in a
normal eye the pupil did not dilate, but that in a glaucomatous or preglaucomatous eye,
the pupil would dilate. This is a very valuable piece of knowledge in diagnosing suspicious cases, but it is not infallible. Using euphthalmine or a drop of homatropine as a
diagnostic aid for glaucoma is too dangerous a procedure and, in my opinion, should
never be followed.
Very little new has been brought out in the last few years as to the etiology of glaucoma. We know that certain people are predisposed to it. We also know that certain
shaped eyes have a tendency to develop glaucoma. On the other hand, one may have a
very small cornea associated with a very large lens and never develop glaucoma, even
with severe provocation. The symptoms may all be explained by the increase in pressure; but what causes this rise in pressure we are still seeking to learn. Focal infection
and arterio-sclerosis play little or no part.    Blood chemistry is of questionable value.
It has been shown that in edema, the sodium ion furnished by NaCl is an important factor in causing water to be retained in the tissues. In some patients with simple
glaucoma it is possible to reduce the tension to normal, providing it is not high, by regulating the blood chemistry. Sodium chloride is eliminated in these cases as in cases of
cedema. Baking powder and soda crackers are also withheld. Potassium chloride is given
as a substitute for table salt, while fruit juices are cut down and meat increased. Concentrated vitamins are prescribed to make up for the deficiency in vegetable diet. Coffee
is also withheld as it too, increases the tension. Redslop has demonstrated that the
vitreous shrinks with every slight increase in acidity.
There are many theories of glaucoma besides blocking of the angle. They may
explain certain phases, but none of them explains all of the conditions in a satisfactory
manner. Permeability of the capillaries, vaso-motor osmotic pressure of the blood and
its chemical composition have been brought forward by different authorities. Also the
action of the hormones. All of these factors have their influence on the formation of the
aqueous and vitreous from the capillaries. In the light of our present knowledge, they
must all be considered as accessories in the case of glaucoma. We know that in certain
cases the use of adrenalin, either by instillation or subconjunctival injection or suspender
265 in gum tragacanth, as suggested by Alvis, reduces the tension. It cannot be due to
contraction of the capillaries and consequent reduction of blood because the greatest
reduction in tension occurs 12 to 24 hours after its use, when the capillaries are dilated.
It may possibly be explained by a secondary hyperemia, flushing out the capillary bed
and carrying away some of the debris in the aqueous. This may account for some of
the favourable results reported by Walker and others from the use of short wave diathermy.
Koeppe considers the presence of pigment granules on the posterior surface of the
cornea, floating in the anterior chamber or deposited on the lens, to be pathognomic of
glaucoma simplex. This, while undoubtedly a valuable sign, cannot be taken as an infallible sign of glaucoma, since it is seen in other conditions.
We know that the normal average tension runs between about 18 and 25 mm. of Hg.
with the Schiotz instrument. There are some who feel that we may have glaucoma
simplex with an average tension of 22 to 24. That may be possible but I believe these
cases to be so rare that we need hardly even consider them, I have also heard it said by
prominent authorities, that one may have a tension of 33 nun. to 38 mm. of Hg. in
simple glaucoma without doing damage to the eye. My experience does not bear this
out. I cannot picture a patient with a tension ranging between 33 mm. and 3 8 mm. over
a period of time, without damaging effect on the fields of vision, nerve head and eventually, on the central vision. I have seen, in my office, a patient with tension measuring over 40 mm. of Hg. who had been told by his ophthalmologist in Chicago that his
was a case where this tension was normal and that he need not worry a bit about it. This
in spite of the fact that his field was greatly contracted, and his vision according to the
history slowly deteriorating. A sclero-corneal trephine operation brought tension down
to 20-.   His vision and fields have remained stationary for the last eleven years.
The gonioscope is one of the comparatively newer methods of examination which
promises to be of value in determining the extent of the adhesion of the base of the iris
to the sclera and cornea, and consequently enabling us to make a better choice in the
method of operative procedure as well as clearing, to some extent, the prognosis. I have
had no personal experience with the method advanced by Otto Barkan, so that I shall
have to refrain from expressing an opinion as to its worth at this time.
In discussing the treatment, we shall first take up the acute congestive glaucoma.
If one delves into the history he will find that there have been, in nearly every case, some
prodromal symptoms or signs. Unfortunately, the ophthalmologist seldom sees this sort
of patient in the very early stage. As a rule, the patient has sent for her family doctor
for the extreme headache and nausea, and the eye condition may not even be thought of
until the patient is blind beyond help. When we do see her, provided it is not too late,
we first try miotics to bring down the tension. The efforts must be heroic, and nothing
short of starting with 1 per cent eserine should be used. Pilocarpine is entirely too
weak to be effective. I do not think that one should wait longer than 48 hours for the
tension to come down, before operating. If we wait longer there is certain to be some
eventual loss of vision that might have been preserved had we not waited. The operation of choice, by almost universal agreement, is the old iridectomy of von Graefe. It
must be broad, and especially deep. Should the anterior chamber be so shallow that the
making of a proper incision is not probable, then a posterior sclerotomy will not only
reduce the tension temporarily, but deepen the chamber as well.
Gifford seems to think that the intravenous injection of 100 cc. of 50 per cent
glucose solution intravenously and waiting about 12 hours to see if the tension will go
down is valuable. Lately, he has substituted 50 per cent solution of sorbital solution
recommended by Puntenney, Bellows and Cowen. Duke-Elder, in one case, reported a
reduction of the tension from 95 mm. Hg. to 38 mm. following the injection of a
strong NaCl solution and in another from 58 mm. to 20 mm. He uses from 33 5 to 50
cc. of 30 per cent salt solution, injected intravenously; or 100 to 150 cc. of a 10 per cent
solution. He finds that the stronger solution is more rapid. Very few cases are affected,
however. The tension can be brought down by puncturing the anterior chamber, but
this does not deepen the chamber, like posterior sclerotomy.   As soon as the operation for
266 glaucoma is completed, a drop of atropine should be instilled. This applies to almost
every type of operation for glaucoma excepting iris inclusion. I have seen many good
operations for glaucoma ruined by not following this most important treatment. It
prevents adhesion of the iris to the lens, which sometimes results in complete posterior
synechia.
Calcium chloride by mouth, or afenil by injection has been recommended by Kleiber
and Rofe.    Its value is questionable.    I have had no personal experience with either.
Since Laquer first discovered the beneficial effects of miotics in glaucoma, little new
has been brought out other than the use of eserine and pilocarpine, until a short time
ago. They still seem to be the most dependable of all the drugs in the average run of
cases. In simple glaucoma, where the tension can be controlled by pilocarpine, it is to
be preferred for several reasons. It ordinarily produces no pain when instilled and very
little or no irritation of the conjunctiva. The mucosa seldom becomes sensitive to pilocarpine, whereas eserine almost invariably irritates after prolonged use; and often, to
such an extent that it has to be withdrawn and a substitute used.
Many of our confreres have become enthusiastic lately over the use of mecholyl and
prostigmine. These drugs are powerful para-sympathetic stimulators, and not without
danger. Besides, the number of cases which they benefit is limited. Clark reports a
series of 200 cases in which these new drugs were used with favourable effect. The
results of others have not been so promising.   .
They may be used as a substitute for eserine to bring down the tension, either by
instillation or by hypodermic injection. The prostigmine acts most probably, by neutralizing the esterase which normally inhibits the action of choline almost immediately. In
some cases, 20 mg. of mecholyl injected retrobulbarly, lowered the tension but required
the immediate injection of atropine, owing to unfavourable systemic effects. Even the
local instillation may produce dangerous symptoms. T. E. Saunders reported before the
St. Louis Ophthalmic Society, a case which almost terminated fatally from a few drops
of mecholyl instilled in the eyes. On the other hand, Dr. E. B. Alvis tells me that a few
brilliant results have been secured in the clinic of Barnes Hospital in acute glaucoma.
Several other cases in which these drugs were used, did not respond at all.
The use of spleen extract has recently been revived, chiefly through the reports of
successful cases by Goldenberg. E. B. Alva tested it out in the eye clinic of Barnes Hospital with unsatisfactory results. In these tests, 20 cc. of Armour's extract was injected
every day for a week; then every other day for two weeks. The tension, vision and
fields during this period were compared with similar periods before the spleen extract
was used, when the patient was on regular therapy, and on no therapy, when this was
possible. The results showed that the spleen extract, as used, had no appreciable effect
on simple glaucoma. It was used on two or three acute cases on private service with
inconsistent results.
Pituitrin has been recommended by Krogh to lower the tension in glaucoma. 0.3 to
0.5 cc. of the ordinary obstetrical preparation is said to lower the tension without dilating
the pupil.    It is injected subconjunctivally.
I must confess that my experiences with epinephrin have made me fear to use it in
any way but one form of glaucoma. I have seen it reduce the tension in acute glaucoma
like magic; at the same time, relieving the pain and other symptoms. In another, seemingly identical type of case, the eye would be made worse and not alone produce unbearable pain, but nearly result in loss of the eye. We have tried links-glaucosan as well as
Hamburger's other preparation of amine-glaucosan, 10 per cent solution of histamine.
This latter produces intense pain and severe chemosis of the conjunctiva. I have seen
it pull the pupil down to pinpoint size without lowering the tension materially. The
one type of case in which I have found the adrenalin preparation to be almost a specific,
is the increase of tension following discussion for cataract. In these cases, the tension is
nearly always brought down immediately with no bad effects. As a rule, atropine
may be resumed in a few days. I have also had a few satisfactory results from its use
in injury cases, without dislocation of the lens, where the tension is increased from blood
267 in the anterior chamber. If it does not respond immediately in these cases, then paracentesis should be performed.
Occasionally we come across a case of secondary glaucoma that will not respond to
operation or any sort of treatment. We have found a few such cases where we were
able to keep the tension under control with the use of ergotamine tartrate, which goes
under the trade name of gynergen. It is well worth trying. One of the chief objections
is the expense, as the drug is costly, and must be used over a long period of time. In
fact, as long as the patient fives. It is not necessary to use it constantly, but almost so,
and whenever the symptoms or signs appear, start it again. It contracts the uterus,
increases the blood pressure, and depresses the end organs of the sympathetic nervous
system, but, with a little care, may be used with safety. We have not found it necessary
to give it hypodermically. It comes in ampules for hypodermic use, the hypodermic dose
being 1/25Oth of a grain. It also comes in tablets of l/60th of a grain to be used by
mouth.   These tablets are given two or three times a day, as they are needed.
Some interesting experiments have recently been reported by Erlanger on the use
of iontophoresis in affecting the tension of the eye. Ordinarily, the galvanic current
has a tendency to increase the intra-ocular tension. This is the immediate effect, rising
at times as much as 50 mm. of Hg., then falling to 5 to 8 mm. Under the galvanic
current, certain drugs have a special action on the autonomic nervous system, developing,
under favourable conditions, characteristics which he terms electro-motor or electro-
kinetic effects.
(1) Miosis always sets in after iontophoresis, and is the expression of a temporary
reaction of the para-sympathetic nervous system.
(2) Prolonged duration of the specific drug.
(3) Changed balance between the para-sympathetic and sympathetic nervous system.
He experimented with atropine, acetylcholine, prostigmine and adrenaline.    Two to
three milliamperes of current, not to exceed three minutes, was used. Clinically, he finds
that 1-1000 or 1-10,000 adrenaline iontophoresis, or a mixture of calcium chloride
(1-300) with two or three drops of adrenaline, prepares the iris for a stronger action
of the subsequent atropine instillation. The prostigmine has the same action as acetylcholine: stimulation of the para-sympathetic nervous system. Experiments with acetylcholine and adrenalin show that one overcomes the effect of the other, but the effect of
the adrenalin predominates. If the pupil is widely dilated with atropine it can be brought
down with acetylcholine in a few minutes. This latter observation may prove of great
value in the treatment of obstinate glaucoma .
Many authorities debate as to what is the most favourable time to operate on glaucoma
simplex. Some feel that as long as the tension and fields can be kept down, pilocarpine
and eserine should be used and the danger of operation avoided. There are also those
who think that in old and very feeble individuals operation should be avoided. I do
not subscribe to these views, but agree with that outstanding authority on glaucoma,
La Grange. In his address before the Royal Qpthalmic Society some years ago on
"Glaucoma, its Surgical Hour," he closed with these words: "Whenever the diagnosis of
glaucoma has been firmly established, that is the surgical hour. If I had glaucoma, or
anyone near and dear to me, I would want to be operated upon, provided that I was
sure of my eye surgeon. A man may be a very good eye doctor and know what to do,
but unable to make his fingers do what his brain tells them to do. Unfortunately, this is
too often the case, and that is one reason why there is such a difference of opinion on
whether or not to operate."
Nor can I agree with certain authorities who maintain that, although chronic congestive glaucoma may develop into chronic simple glaucoma, the simple never becomes
chronic congestive. I am certain that I have seen the latter take place, and that they
were not cases of secondary glaucoma .
I have also known those who refused to operate in the face of tiny fields, with marked
pallor and cupping of the disc. I fail to see the logic of their argument that the operation will destroy the remaining vision. It is true, that in spite of the operation, the
vision may be lost, but I feel that the patient has a better chance with operation than
268 without, and that he most likely would have lost his vision had the operation not
been performed. This, of course, with the proviso that it was done skilfully. If the
increase of tension is the cause of the loss of vision in glaucoma, why not reduce it in
the fastest way possible where there is only a little left, as well as when there is a lot.
Another thing the reduction of tension does is to increase the circulation of the intraocular tissues, which is just the thing the atrophic nerve needs at this time. Of course,
if the connective tissue surrounding the axis cylinders of the nerve is so advanced in
contraction that it will go on squeezing out the nerve life anyway, then operation will
not help.    But who can tell this beforehand?    No one.
The choice of operation in glaucoma simplex is a well performed sclerc—corneal trephine. In over 90 per cent of the cases it should be successful in reducing the tension
to normal and allaying all the symptoms. A great deal has been said about the danger of
late infection. I have had only four cases of late infection, to my knowledge. And I
am sure that I would learn only too soon of bad results, should they occur. I know that
has been my experience throughout the practice of medicine. Only two of these cases
were lost. The others responded to the use of large doses of dead typhoid-paratyphoid
bacteria.
In old and feeble individuals, I can see no contra-indication to operation. I think
there is much less shock from operation than from the constant worry about not being
able to see. In these days, when operation, even for acute, congestive glaucoma, can be
done without pain with a local anaesthetic, we need concern ourselves very little about
the danger of shock. I have operated on a patient for cataract who was past 84 and
who insisted that she didn't want to live if she had to be blind. She had a heart attack
while being prepared for the operation and was immediately taken back to her room
after being given emergency treatment. Three days later, upon her insistence and against
the wishes of her family, she was successfully operated on for cataract, with no complication following.
While an iridectomy practically always helps in acute, congestive glaucoma, it is of
no value at all in the non-congestive form. Why, I do not know. Nor has my experience with iridectomy for chronic, congestive glaucoma been much better. I also prefer
sclero-corneal trephining for this type. When the tension is so high that I fear haemorrhage, I perform a paracentesis about an hour before; in the case of acute congestive,
where we require a deeper anterior chamber for the incision, porterior sclerotomy is
advisable.
Glaucoma following cataract extraction is one form that resists nearly all forms of
treatment. Most surgeons are in favour of cyclo-dialysis. I have not had much luck
with it. The only thing I have found to be helpful, and this in too small a percentage
of cases to satisfy me, is iris inclusion. The iris inclusion should be done without
cutting the pillar, because when left intact, the iris forms a natural wick when pulled
into the wound, whereas it lies flat if one or both pillars are cut. This is the only type of
operation where a miotic must be used immediately following the operation, and kept
up, along with massage of the eye for several weeks, or, until the tension comes down.
For the tension is not usually reduced immediately after this operation. In fact, it may
even rise higher than before for a while before it begins to go down. This is my choice
for most of the secondary glaucomas. Sometimes, where we have a case of iritis which
develops increased tension, a large, broad iridectomy will not only reduce the tension,
but quiet the iritis as well. I have seen my preceptor, Dr. Charles Michel, do an iridectomy in this type of case, even where the tension was normal, when the inflammation
was resistant to other forms of treatment.    They usually responded.
A word about prevention in doing a capsulotomy. Gifford warns not to put atropine
in an eye after capsulotomy. I heartily subscribe to this, as well as to the warning not to
pull on the zonule during the operation. This is one of the many reasons why I prefer
the Ziegler method over all others, because, when properly performed, there should be
no pull on the zonule, whatsoever.
Wheeler recommended cylodialysis combined with iridectomy. In the case of glaucoma following cataract operation, naturally ,this can be done.    I should think that a
269 cyclo-dialysis combined with an iris inclusion would be even better. I can recall Hofrat
Fuch's admonition not to do cyclodialysis for the reason that the iris, as he used to
demonstrate on the slides, would scar even heavier after the operation than before.
On his last visit to America when I asked him in consultation in a case of glaucoma
following an apparently perfect extraction in the capsule, with no vitreous in the chamber, he advised cyclodialysis. When I asked him how he reconciled this advice with his
previous teachings, he said, "I can't; I just know that this is an exception."
In the February number of the Archives of Ophthalmology, Troncoso published an
article which he read before the American Medical Association in St. Louis last June,
recommending cyclo-dialysis with the insertion of a strip of pure magnesium metal for
the treatment of glaucoma. The advantage claimed is that the metal remains long
enough to permit the iris and ciliary body to remain separated from the sclera, when it
absorbs, causing very little irritation. It may turn out to be a very valuable procedure,
but I am always fearful of placing any foreign material inside the eye for keeps, even if
it does disappear in time.
Arnold Knapp describes certain cases of cupping and optic atrophy of the optic
nerve, which he does not consider as being glaucoma, although he does state that these
cases may be a combination of low grade glaucoma plus a calcification of the carotid
arteries. In any event, if the tension were elevated and there were cupping present, I
would be inclined to operate for the glaucoma and do the best I could for the other
condition. There is no reason why glaucoma cannot be complicated by some other
disease, or accompanied by some other ailment.
I would be remiss if I did not mention, before closing, the masterly paper presented
before the same meeting, and published in the January Archives, on the role of the
states of anxiety in the pathogenesis of primary glaucoma. Not that all of us are not
aware of the close relationship of the body health to the eye and to the psychosomatic
inter-relations with their therapeutic implications in glaucoma. He points out that
there is abundant evidence to show that the two parts of the autonomic nervous system,
the sympathetic and the parasympathetic, are out of balance in glaucoma, and that states
of anxiety have a different effect on glaucomatous eyes than on normal eyes. He presents what he takes to be abundant evidence, to prove the fact.
[We are indebted to the Eye, Ear, Nose and Throat Section of the Vancouver Medical
Association for the opportunity to publish this excellent paper. It can be read with profit
by every medical man, whether ophthalmologist or not.—Ed. ]
AN UNUSUAL CASE OF "RETAINED MENSES"
From the Gynaecological Service of J. W. Arbuckle, M.D.
S. G. Baldwin, M.D.
A girl, aged sixteen years, was admitted to the Vancouver General Hospital on
January 6, 1940, complaining of severe pains in the lower abdomen and absent menstruation.
History of Present Condition: She began having pains in the lower abdomen about
two years ago, which were severe and would return every two months, lasting about
three days each time. The pains were crampy at first, later becoming a steady ache.
Appendectomy was done in 1937 with no relief. There has been no nausea, vomiting or
dysuria with these attacks. She has never menstruated. Otherwise, she has been well,
though never considered very strong.
Family History: Her mother and one sister did not menstruate until the age of
seventeen years.    Other family history negative.
270 Examination: She was a pale but well developed girl looking somewhat distressed.
She had a slight coryza but the throat was clear. The heart and lungs were normal.
Temperature on admission was 99.4 and the pulse 96 but during the next three days this
rose to a maximum of temperature 101 and pulse 110.
Laboratory findings: Haemoglobin, 85 per cent; Red blood cells, 4,320,000; White
blood cells, 14,000; Polymorphonuclears, 85 per cent; Sedimentation Rate, 36 mm. in
one hour; Urinalysis, negative; Kahn, negative.
The abdomen was flat, firm, and held tense on account of pain. Marked tenderness
was present all over the abdomen but more extreme in the lower half. A firm round mass
could be felt rising out of the pelvis in the midline about the size of a three and one-
half months' pregnancy. A vaginal examination revealed nothing as the virginal
introitus only admitted one finger with difficulty. On rectal examination a rounded mass
could be felt which seemed to fill the pelvis and was difficult to distinguish from the
uterus; it was extremely tender and seemed to fill the cul de sac.
A diagnosis of hematometra, with possibly hematosalpinx, was made. On January
eighth, she was taken to the operating room for examination and drainage of the uterus.
Under cyclopropane the hymen was dilated manually and a speculum was inserted. The
examining finger found a solid mass, 15 by 10 centimeters, smooth and round, and
partly fixed in the midline. There was a mass in the posterior cul de sac extending into
both fornices. A sound was passed into the uterine cavity without difficulty but no
blood was obtained.
For a few days she continued to have severe pain in the abdomen but gradually as
her temperature became lower the paid became less and in a week she was quite comfortable and much brighter. Apart from the nose-bleeds she seemed normal but the
tumour in the lower abdomen remained the size of a three months' pregnancy. An
Aschheim-Zondek test was negative. This was done as pregnancy had been suggested
although not considered possible unless in the remote possibility of a bicornuate uterus.
On January twentieth, a laparotomy was done and the condition found was bilateral
dermoid cysts of the ovaries. There was one large mass, thirteen (13) by six (6) centimetres, which had given the impression of an enlarged uterus. This had undergone
torsion about its pedicle and secondary inflammation and had probably been responsible
for the severe pain. The other was small and hard and was in the posterior cul de sac. Both
were typically dermoid and were removed. No normal ovarian substance was seen.
There was a normal post-operative course and the patient was discharged on February
fourth.
Discussion
The interesting point about this case was the difficulty in diagnosis. The fact that
at age sixteen she had never menstruated but was having severe abdominal cramps every
two months, associated with a pelvic tumour, pointed naturally to a haematoccele, but
when this was found to be absent it was not easy to be certain of the nature of the
tumour although a diagnosis of possible dermoids was made. Dermoids may occur
during childhood although they are usually encountered during the period of sexual
maturity. They are usually of slow growth and their origin is still subject to speculation. They frequently gravitate into the pouch of Douglas, and there is often torsion,
both of which occurred in this case.
Dermoids are teratomas consisting generally of tissues from all three germinal layers.
Ovarian teratomas occur in two forms: the complex dermoid cyst which is fairly common, and the solid teratomas which are very rare. The dermoid is usually a unilateral
pedunculated tumour which may greatly in size but may be bilateral or even multiple.
The outline may be smooth or somewhat nodular and the cyst wall may be thick or
thin with local areas of thickening. Upon cutting open the cyst is found filled with
an oily material which when cooled has the consistency of soft soap. This material is
probably secreted by sebaceous glands. It is made of glycerine or fatty acids, cholesterol
and other alcohols. Practically always a tangled mass of hair is mixed with the oily
material.   Most of the hair grows from a knob-like projection from the cyst wall.
271 \r
There may also be teeth and structures resembling jaw bone. Microscopically a wide
variety of tissues may be identified. Ectoblast may be represented by skin and its associated structures, mucous glands, teeth, etc. Mesoblast may be represented by bone,
muscle, etc., and endoblast may be shown by various glands and mucosa of the alimentary canal.    These are relatively mature tissues and malignant changes are rare.
Similar tumours may occur in other situations, more particularly in body fissures and
in the region of bronchial clefts of the neck.
Discussion
This paper was discussed by Doctors E. M. Blair, J. W. Arbuckle and W. L. Graham.
Dr. Graham inquired if the Aschheim-Zondek test was not frequently positive in these
cases. Doctor Gee, in reply said that no false positives had been obtained in dermoid
cysts of the ovary in her series of tests, but they had occurred in cases of cystic ovaries.
PAN-AMERICAN CONGRESS OF OPHTHALMOLOGY
IN CLEVELAND NEXT OCTOBER H
Plans for a Pan-American Congress of Ophthalmology to be held at the Hotel
Cleveland, Cleveland, Ohio, October  11-12, have been announced.
The congress will be sponsored by the American Academy fo Ophthalmology and
Otolaryngology, an organization of more than 2,500 specialists in diseases of the eye,
ear, nose and throat, which will hold its annual convention immediately preceding the
Pan-American gathering.
The U. S. Department of State has expressed its interest and the governments of all
the countries of the Western Hemisphere have been invited to send official delegates. It
is felt that the meeting will do much toward bringing about an entente cordiale among
scientific men of the two Americas, and it is expected that a permanent organization
will be effected.
The committee that is developing the congress has the following members: Drs.
Harry Gradle, Chicago; Conrad Berens, New York, and Moacyr E. Alvaro, Sao Paulo,
Brazil. The executive secretary of the American Academy of Ophthalmology and Otolaryngology, which will be host to the Latin-American eye specialists, is Dr. William P.
Wherry, 1500 Medical Arts Building, Omaha, Neb.
Under the direction of Dr. Berens, papers in Spanish or Portugueste will be made
understandable to English speaking ophthalmologists by the use of lantern slides projecting a synopsis of each paragraph translated into English. The reverse process will be
used with the English papers. Spanish and Portuguese stenographers will be present to
record the discussions in the language of the authors.
The congress is open to any ophthalmologist who wishes to register. Non-members
of the Academy of Ophthalmology and Otolaryngology may register regardless of
attendance at the Academy meeting proper. Individual invitations have been sent to
about 1,800 members of the ophthalmologic profession in the Latin-American countries,
as well as to the national societies of eye specialists and the universities. Individual
invitations were not sent to ophthalmologists in the United States and Canada, but
official invitations to them are being prined in he various journals of ophhalmology. A
fee of $5 has been set for membership in the congress.
Among the guests expected for the congress is Dr. Manuel Marquez y Rodriguez,
for many years a prominent eye specialist, teacher and writer in Madrid and now living
in Mexico City.
272 THE DIAGNOSIS OF EARLY SYPHILIS
(Continued from May Issue)
PRIMARY STAGE
The Diagnostic Maxims
Every medical student should be required to learn by heart the six diagnostic
maxims shown in figure 1. These maxims are sufficiently self-explanatory to require
no textual expansion. If they were generally applied, the proportion of patients coming
under treatment for primary  (especially seronegative primary)   rather than secondary
FIGURE 1.
1. Any genital sore in male or female is possibly primary syphilis until proved to be otherwise.
2. Any indolent lesion anywhere on the body  (especially lips, tonsils, fingers)  which fails to heal in two
weeks may be primary syphilis.
3. The diagnosis of primary syphilis is a laboratory, not a clinical, prcoedure.
4. Do not treat suspected primary syphilis locally until repeated dark fields are negative.
5. Do not give antisyphilitic treatment on suspicion; prove the diagnosis.
6. There is reason for urgent haste in diagnosis; hours count!
syphilis (i.e., when the chance of cure is 20 per cent greater than a few days later)
would be enormously increased. At present, in the five Co-operative Clinical Group
clinics only 10 per cent of patients with early syphilis have already developed seropositive
primary or secondary syphilis. This is not altogether due to delay in the patients first
reporting to a physician for diagnosis, but is in part—and large part—due to delay on
the physician's part in arriving at the diagnosis. Urologists and gynecologists are the
worst offenders.
FIGURE 2.
A LIST OF 13 DISEASES
Which Genital Primary Syphilis May Resemble
Gonorrhea
Primary syphilis may look like and must be  distinguished
from:
Chancroid
Herpe progenitalis or simplex
Scabies
Venereal warts
/ Carcinoma
K   Granuloma inguinale
Lymphopathia  venereum
Balanitis gangrenosa
Traumatic lesions
Pyogenic lesions
Secondary syphilis
^Late syphilis—gumma
V
Suspect Syphilis
Diagnostic Confusion in Primary Syphilis	
In figure 2 are shown a list of 13 conditions (11 of them nonsyphilitic and all of
them common) with which genital primary syphilis may be clinically confused. In
figure 3 appears a similar list of common diagnostic confusions in extragenital primary
syphilis.
273 Each of these conditions except gonorrhea implies the presence of a sore. With gonorrhea a special word of caution is necessary. Suspect all patients with gonorrhea of
simultaneous infection with syphilis (intra-urethral chancre, painless discharge masked
by gonorrheal pus), but particularly suspect those patients with painless, rubbery, discrete
inguinal adenopathy.
With the other genital conditions enumerated, the presence or absence of satellite
bubo is of little importance. In about 30 per cent of patients with primary syphilis, the
bubo is completely absent, and in most it does not appear until the chancre has been
present about a week. In extragenital primary syphilis, however, the bubo may be the
first "suspicion arouser."
The Diagnosis of Primary Syphilis
The necessary diagnostic steps in primary syphilis are stated in figure 4. They
should be applied whenever any of the diseases specified in figure 2 are thought to be
present.
To what extent these minimum modern diagnostic procedures are not applied, even
by experts, is shown by the League of Nations study of early syphilis. In the co-operative
clinics of the world, only 16 per cent of the cases diagnosed as primary syphilis had been
FIGURE 3.
A LIST OF 12 COMMON DISEASES
Which Extragenital Syphilis in its Commonest Locations May Resemble
Lip
Tonsil
Infected  fever blister
Trauma
Carcinoma
Tuberculosis
Acute follicular tonsillitis
Chronic tonsillitis
Vincent's angina
Neoplasm
Infected  hangnail
Paronychia
Onychia
kBone felon
Suspect Lesions Which Fail to Heal.   Look for Satellite Bubo.
Finger   (suspect doctors, nurses, and dentists)
verified by these laboratory procedures.   If the situation is thus bad among experts, what
must it be with the rest of the medical profession!
Urgent haste in reaching a diagnosis is essential:
1. For the protection of others.
2. For improved chance of "cure" for the patient himself.   Literally, hours count,
and days are all important.   Delay is inexcusable.
The dark-field microscope is the sine qua non of early diagnosis. Few physicians
possess this equipment or are experienced in its use. In most areas, however, there is a
syphilologic consultant, or a private clinical or health department laboratory which is
properly equipped, which the patient or a specimen may reach within a few hours. It is
not worth while, therefore, to describe the dark-field technic or the differentiation of
Treponema pallidum from other spirochetes. The inexperienced physician cannot learn
sufficient expertness by reading about it; the expert does not require written text but has
acquired his knowledge by actual practice .
Lacking this practice, the physician should not purchase a dark-field apparatus and
attempt his own instruction. He should on the contrary, whenever primary syphilis is
suspected, do one of two things:
274 FIGURE 4.
DIAGNOSE PRIMARY SYPHILIS BY-
1. Dark-field of surface serum; if negative, repeat at least three times on consecutive days before local
treatment.
2. If surface dark-field is negadve, do dark-field of aspirated serum from lesion's base,
OR
2.a Dark-field of aspirated material from lymph node.
3. If you have no dark-field microscope, send the patient at once to someone who has; or send a capillary
tube specimen  (see text) to nearest laboratory.
4. Do serologic test at first visit.
If any of these tests are positive, treat at once.
If all are negative—
5. Do serologic test follow-up for 3 months, weekly for first month, every 2 weeks thereafter.
1. Preferably, he should at once send the patient in person to a properly equipped
colleague or laboratory, where the dark-field of surface serum, and, if necessary
of serum obtained by aspiration of the base of the lesion or neighbouring lymph
node may be promptly carried out. Capillary tube outfits are furnished free
of charge by many State boards of health.
2. If no such colleague or laboratory is available in the neighbourhood, he should
at once prepare and send to the nearest health department laboratory (by air
mail special delivery if necessary, with a request for a telephoned or telegraphed
report), a capillary tube specimen obtained by the following technic.
If the lesion is covered with a crust or scab, remove it. Then wash the lesion
thoroughly with a gauze sponge wet with plain tap water (no soap) or normal salt solution, to remove gross surface infection. This should be dried off, and the surface of the
lesion abraded with a dry sponge sufficiently to provoke bleeding and exudation of serum.
As oozing occurs, gently wipe away the first few drops, especially if they contain much
blood, waiting for a drop of clear serum to appear. It is rarely necessary to squeeze the
lesion. It is desirable to obtain serum from the depth, not the surface, of the lesion. A
drop or two of clear serum is aspirated with the tiny rubber bulb furnished, or by capillary attraction, into the capillary tube. Seal both ends of the tube with beeswax (not
with heat), and mail at once in the provided container.
If it is necessary for the physician to aspirate the lesion or a lymph node (repeated
surface dark fields being negative) for capillary transmission to a laboratory, the technic
is as follows: There is required a sterile Record or tightly fitting Luer syringe fitted with
a stout needle of at least 20 gauge. A drop or two of sterile normal salt solution is drawn
into the syringe. The overlying skin is painted with iodine and alcohol and the gland (or
indurated base of the lesion) steadied between thumb and finger of the left hand. The
needle is inserted well into the gland, penetration of the capsule being indicated by the
ability to move the gland with the needle. The drop of salt solution is injected into the
body of the gland, the needle is manipulated in various directions to macerate the tissue
about its point,,and the injected salt solution and tissue juice aspirated. This is placed
in the capillary tube as above.
The presence of T. pallidum in serum from a suspected lesion makes a positive diagnosis of syphilis, and treatment should be commenced at once. Failure to find the organism does not mean that the lesion is not syphilis. Carry out the serologic follow-up for
3 months as directed in all such cases.
(To be continued.)
275 Victoria  Medical   Society
Officers, 1938-39.
President Dr. W. A. Fraser
Vice-President- Dr. A. B. Nash
Hon. Secretary  Dr. E. H. W. Elkington
Hon. Treasurer Dr. C. A. Watson
SOME SUGGESTIONS FOR THE MANAGEMENT OF
SOME COMMON FRACTURES |
(Read before meeting of Victoria Medical Society, January 8, 1940)
D. M. Meekison.
First, may I most sincerely thank you for the honour of being invited to address your
Society. I deem it a great privilege, and I only hope that in a small way I may be able
to pass on to you an occasional useful bit of information. As the years pass, one's fund
of axioms, tricks, ideas and what not accumulates. Some are discarded and others added.
Some are proven by experience to be good. Others are probably bad, and I hope that I
shall be able to keep my mind sufficiently open to cast out the bad as their failings
become apparent. On this occasion I shall try and give you only what I believe have
proven to be good. I have nothing original to offer, and what I give you has been culled
from the literature, the work of better men, and personal contact with their work, from
meetings, observations in distant clinics—all tried and proven by experience.
I have chosen as my subject something homely, simple and, I hope, practical: "Some
suggestions for the management of some common fractures." It is obviously impossible
to deliver an oration which would stand as a textbook on fracture treatment, so I propose to take you on tour of this frame of ours, starting at the hand, working up to the
shoulder, down the back and out by the toes. Certainly all fractures will not be covered, and while I may dwell for a moment or two on some, others will be dismissed with
a word. I am sorry that I have no slides, as Dr. Nash had advised me that the lantern
has only recently been overhauled, especially for the occasion. However, if I am ever
asked back after tonight, I shall try to do better.
So far I have said nothing. I had better get ahead with my tour. I shall start with
the fingers, and here we all have trouble. Terminal phalanges rarely go wrong and are
easily treated with criss-cross strips of adhesive, held in place with a one-inch bandage.
This makes a simple splint, effective and much easier to wear than the traditional tongue
depressor. Middle phalangeal fractures are uncommon, tend to angulate to the palmar
side, and may require traction. The proximal phalanx fractures, I find, are very common
and can produce more grief than a fracture of the femur. These practically always
angulate to the palmar side, and when they do invariably require traction, and the traction has to be applied with the wrist dorsi-flexed and the metacarpo-phalangeal joints at
a right angle. This is to relax the lumbricales, which are the muscles which produce the
angulation. It seems a tremendous amount to do for a fractured finger, but the result
is worth it. I find, as usual, that the simplest traction is obtained by means of a silkworm gut suture through the tip of the nail and a bit of he pulp, or the pulp only. A
cast is applied extending to above the elbow, with this joint at a right angle. A banjo
splint is incorporated, and a good idea is to place another piece of wire, suitably bent,
at the wrist, to prevent the plaster from breaking at this point. Little traction is necessary, using a common, widish, rubber band from silkworm gut to banjo splint. Reduction is usually good.   Three weeks is required, for consolidation.
Metacarpals are usually well taken care of by the time-honoured roller bandage
splint, unless the fracture is near the head, when the distal fragment tends to angulate
forward.   These may require open correction, as may also fractures of the shaft.
276 I shall omit discussion of the carpal fractures except for two points. I have made
reference in a previous talk to the possibility of the use of traction in fractures of the
scaphoid, but it is pure theory and, as yet, I have not had an opportunity to prove or
disprove its value. Incidentally, bone grafts of carpal scaphoids, technically rather
difficult, are proving of distinct value when this fracture results in non-union. I say
technically difficult, for in two of my series of now ten cases I have failed to engage
the proximal fragment with the graft. Needless to say, the results in those two cases
were indifferent.
Let me say a word about dislocation of the semilunar, a not infrequently overlooked
lesion. These almost invariably dislocate to the volar side and are easily seen in a lateral
radiograph. They can be reduced by closed methods up to two weeks after dislocation!
The secret—and it shouldn't be a secret—is my often stressed admonition—traction!
With general anaesthesia, an assistant holding the upper arm, the surgeon sits with a
watch by his side, and pulls on the hand in the long axis of the forearm—for ten minutes. When you are looking at a watch, this is a long time, but I believe that it is
essential. At the expiration of this time, without losing traction, the wrist is dorsi-flexed,
the semi-lunar "thumbed" back into position and the wrist acutely volar-flexed to hold
the bone in position. Three weeks' immobilization is all that should be necessary. A
complication to remember is Keinboch's Disease—aseptic necrosis—but I must not dwell
on this.  There is a lot of ground to cover in our tour and I must be on.
Colles' fractures have been previously discussed, but again I remind you—traction.
In the two days preceding Christmas I had three of these, and two of them required
traction.
As far as I am concerned, fractures of both bones of the forearm are no longer a
problem. I recommend open reduction of either or both bones and plating with a
Vitallium plate. Vitallium, by the way, is the answer to the orthopaedic surgeon's prayer
for a trustworthy metal that can be used in internal fixation. In personal experience,
after communication with others using it, and in the literature, I have not found one
case in which this cobalt chromium alloy appliance has had to be removed. It is unfortunately expensive, but it is pointed out that everything made of Vitallium has to be
cast. The metal is so hard that it cannot be turned on a lathe. Each individual screw is
cast and then polished. It is a pleasure to put home a screw whose slot does not cut.
All in all, Vitallium, although a proprietary product, is worth the investment, and has
proved a boon to those engaged in orthopaedic and fracture surgery.
I shall move on to the region of the elbow, observing in passing that fractures of
the radius or ulna not infrequently require open reduction and long immobilization.
The head of the radius.—This, I think, is one of the emergencies of fracture surgery.
If the head is completely dislocated, or is at all fragmented, I think it should be removed
forthwith, preferably within three or four hours, and usually an excellent functional
result is obtained. If treatment is delayed a tragic mess may be the result. I have seen
X-rays of improperly treated radial head fractures, taken a month later, which looked
as though a high explosive shell were bursting in the elbow joint. For some reason or
other, new bone production at the elbow is extremely rapid and profuse. I have a strict
rule for elbows: never forcibly manipulate; just as I have a strict rule for wrists: never
use diathermy. It decalcifies the region of the wrist very rapidly and often results in
what might be called a stiffish, painful, "diathermy wrist."
Lateral humeral condyle fractures practically all require open reduction and can
usually be retained in position by simple plain cat-gut suturing. The wrist and finger
extensor attachments nearly always turn this condyle upside down and nothing short of
open correction will reduce and maintain the reduction. On the other hand, supracondylar fractures in children can nearly always be treated by closed methods—and
reduce these immediately by traction. General anaesthesia again and the surgeon sits
again. A clove hitch around the wrist—using a factory cotton bandage for this purpose.
The loop can be passed over the operator's shoulder and under the opposite arm for good
steady pulling. An assistant steadies the upper arm and traction is exerted in the long
axis of the arm for at least five minutes by the watch, with the elbow fully extended.
277 At the expiration of this time, you may be amazed at the simplicity of reduction with
only the pressure of the thumb. If the elbow comes easily into flexion, the fracture is
reduced and will not tend to again become displaced. It can be retained by a posterior
moulded slab with the forearm in supination—the so-called "spit in the hand" position
—to avoid rotation of the distal fragment. There is not complete agreement with this
procedure, but supination tends to counteract the pull of the pronator radii teres.
Some brief observations on other fractures of the humerus. Transverse fractures in
the mid-shaft require rigid immobilization or non-union may result. This is the commonest site in the human body for non-union, and the most difficult site to obtain union
when non-union is established. Fixation may be made by means of Roger Anderson's
half-pin and plaster method, open reduction plating and spica, or possibly by a spica
alone. An adequate shoulder spica is difficult to apply, and even with the best applied
spica there is going to be some movement at the site of fracture. Recently there has
been described a "hanging cast" method, but it is difficult to see how this can provide
adequate immobilization. This is a good procedure, however, for long spiral fractures,
although long spiral humeral fractures, I believe, can be treated with the arm kept in
a sling and with the application of only coaptation splints.
It is surprising what amazingly good clinical and functional results can be obtained
in fractures of the surgical neck of the humerus, where the fracture is only indifferently
reduced or not reduced at all. This also is true of fractures of the cervical spine in
which there has been no nerve involvement. Surgical neck fractures of the humerus are
best treated by balanced traction suspension for three weeks, and then balanced suspension in abduction for another week or so, and in about three months the patient usually
has a normal shoulder.
Extension is necessary in clavicles—although non-union does occur (I had two last
year), it is very unusual. The clavicular cross is probably the easiest splint to apply.
I rather like the Anderson-Burgess suspension sling splint. ! have found it very useful.
vSayre's dressing is to be mentioned only to be condemned. Someone, I forget who, has
said: "If a Sayre's dressing is adequately applied, it cannot be tolerated by the patient.
If it can be tolerated, it is not adequate."
Cervical spine fractures—traction again. I prefer skeletal traction obtained by means
of short bent pins under the zygomata, attached to a horseshoe over the head. Cohn in
Montreal passes a Kirschner wire between the tables of the skull, but I haven't dared to
try this. Simple cervical halters may suffice. Recently, in the British Medical Journal,
an amazingly simple and astonishingly effective method of traction has been described.
Look it up.
For dorsal and lumbar spine compression fractures, I have a fairly well established
routine. Even up to six weeks after injury, these patients are placed on a curved Bradford frame (properly called the Whitman frame, I believe) for a week or so to get them
stretched, particularly the abdominal muscles. Then, using a portable Goldthwaite
frame, a body cast is applied in the hyperextended position. This device has recently
been resurrected following many years of oblivion after Goldthwaite's original idea at
least 30 years ago. By the way, the old man, famous for his brace, irons and frame, is
still hale and hearty and still practising in Boston. You can readily see how the plaster
cast can be moulded up under the chin by this means, better than by any other method,
—Davis, Watson-Jones, sling-table, or by the use of any of the commonly used fracture or orthopaedic tables.
There is a good deal of discussion concerning the time for recumbency following
compression fracture of the spine, ranging from immediate ambulation (Watson-Jones)
to 16 weeks (Ryerson).  For no reason at all, I keep mine recumbent for three weeks
and allow them up.   I haven't had any trouble yet.   The cast is worn for three months,
and a brace (Taylor, Goldthwaite, or just a firm corset)  for a further three months.
Results are usually good, unless the patient is on compensation and is aware of the fact
that he has a "broken back."
*      *      *      *
Much has been written and said about fractures of the hip. (I shall not discuss
fractures of the pelvis unless someone has some questions later.)   I believe that "nailing"
278 is the best answer to date, but I do not believe that it is the final answer. A few years
ago Kellog Speed called it "the unsolved fracture" in an article in S. G. & O. I think
he is right, but we know more about it today than we have ever known. I think we
can now prophesy union or non-union with reasonable certainty by an inspection of the
X-ray plates. A recent article by Gibson in the V.M.A. Bulletin describes this. However, whatever method of retention each individual here may employ, be it the time-
honoured Whitman method and cast, adequately applied, or nailing—using Vitallium
nails of the Watson-Jones, Smith-Peterson, Austin Moore, Johannsen, Venables, Morrison, Thompson, or what-have-you type, the necessity for adequate reduction is of paramount importance.
I firmly believe that the manoeuvre described by Guy Leadbetter of Washington,
D.C., some years ago, is the answer to complete reduction. Extension with flexed hip
and knee at 90° and adduction of the femur. Then 45 degrees internal rotation and
circumduction to extension, of hip and knee. I have used this method many times, and
if the palm heel test checks then reduction is adequate. I think this is most important
and, if I leave nothing else with you tonight, please make a note of this.
With the use of an adequate guide, that I think is foolproof, I have recently become
converted to so-called "blind-nailing." Heretofore, I have used the open method employed by Watson-Jones. On occasion I use the regulation Whitman method of reduction and spica, depending on the patient's condition.
Enough of hips. It is a fracture that can be discussed for hours and days,—and
likely no conclusions would be reached.
Intertrochanteric fractures—reduced—always get better, so I will not dwell on them.
Subtrochanterics are in a class by themselves and very difficult to handle. Fortunately,
they are uncommon. I think the solution may be found in a new type of pin now
available.
The shaft of the femur. At the risk of being considered a radical I am inclined to
say that open reduction in adults is likely indicated unless—to drag in Roger Anderson
once more—the Anderson frame and method are available. A word of caution—do not
put up any long bone fractures when using pin fixation in over-extension.
In children, fractures of the femur are extremely easily cared for. For many years
I have followed the same routine without any bad results. With the child under the influence of a quarter or sixth of Morphia, a Buck's extension and Thomas's splint is applied.
Weights may be used or the spreader tied to the splint and the split tied to the food of
the bed with the latter elevated 12 inches. The child's body weight is the counter
weight. This is maintained for four weeks and at the end of the first week position is
checked by X-ray. At the end of the four weeks period, a single spica is applied for a
further four weeks. The spica is then removed and the child kicks around in bed for
a final two weeks. Weight bearing is then allowed, and in no time the child is normal.
The foregoing obtains for children up to fourteen years of age, apart from those up to
three, who are put up in a gallows frame.
Supracondylar fractures of the femur are particularly beastly and, unless opened,
must be treated, preferably with Kirschner wire traction with the knee flexed to relax
the gastrocnemius. Preferably, open reduction with a Vitallium plate is the method
of choice.
I believe that the removal of the patella in comminuted fractures is now well justified by results. Some men remove only the distal fragment which is usually comminuted.   Those I have done have produced uniformly good results.
Hey-Groves added comment to the epoch-making article in the British Journal of
Surgery on excision of the patella in comminuted fractures of the patella, pioneered by
R. Brooke of Chichester, when he said that at first he didn't believe it. He went to the
trouble of having experimental work done at the University of Bristol, particularly in
anatomy, and, after he had proven to his satisfaction that (1) among other animals,
the deerhound has no patella while the hippopotamus has a very large one, and (2) that
growth of the patella from infancy to adult life is not commensurate with the growth.
279 of the individual, therefore the presence of the patella was not in keeping with the necessity of the individual's function or speed, et ergo it could be excised with advantage.
I usually treat my tibial fractures with pin fixation in the Anderson apparatus under .
fluoroscope control. These are not always easy, as I found out this morning. Some of
them cannot be made perfect and some of them require a lot of juggling to get them
into position. The main admonition is, once reduction is obtained, don't have overextension. Dr. Geo. Wilson of Toronto is very wise in advising reduction of fractures
of the lower third of the tibia and fibula by means of a flexed knee over the end of
the table and the foot in plantar flexion. This makes it much easier. After three or
four weeks, the plantar flexion of the foot is straightened out and the flexion of the
knee is decreased to nearly straight. I do all my ankle fractures with the knee flexed at
90° while I sit on a stool. In tri-malleolar eversion fractures, a plaster slab applied next
to the skin, followed by a posterior slab while the former is held in inversion, is, I
believe, a good procedure.
As far as fractures of the ankle and os calcis are concerned, I am experimenting
with "delayed reduction." I am doing this on good authority, although it is too early
to say anything about results. At the same time, I think we may be getting somewhere, particularly with regard to the os calcis. I have talked about this last to the
extent that I don't think that anyone can pre-empt my ideas. If anyone wants them,
they may have them.
As far as ankle fractures are concerned, I think that Ashurst's Classification is the
most valuable. This was published in the Archives of Surgery in 1922, vol. IV. It is
worth looking up.   It is very valuable, even for only description use.
I will not go into the rare and usually complicated fractures of the tarsus (unless
they are the common, ordinary sprain fractures, which simply require a cast for six
weeks) and I will dismiss the rest of the foot with, the comment that traction is frequently necessary in fractures of the toes or metatarsals and occasionally open reduction
in metatarsal fractures.
In spite of my promise at the onset of this verbal barrage, I am afraid that I have
delivered myself of a complete self-written textbook dealing with the treatment of
fractures. I started with meticulous care, fearing an inadequate supply of material, and
have finished at a gallop finding that there was a plethora. I find that many fractures
have been passed over, but surely you have had enough for one session. Some fractures,
such as the hip, are worthy of much longer discussion. Indeed, on two occasions I have
sat in on symposiums on fractures of the hip which lasted for from five to eight hours
and were contributed to by the representative crowned heads in fractures. No conclusions were reached except that—so far—nailing is the method of choice. Some of
these subjects are inexhaustible.
I hope I have not bored you and I am sorry about Dr. Nash's slides. I do hope that
you, individually, can take away maybe one small point that will help you in your daily
work and I wish you success in the treatment of your fractures.
MEMBERS of THE GUILDf
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Always Maintain the
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430 Birks Bldg*.   Phone Sey. 9000
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280 DEXTRI-MALTOSE
DEXTRI-MALTOSE is no ordinary carbohydrate.
Step by step, its manufacture is surrounded
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