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EARLY DIAGNOSIS OF COMPRESSION OF THE SPINAL CORD
49 consisted of 2 primiparse who were initially hyper(essential hypertension) and 3 multipart with initial hypertension and histories of having had previous toxaemia (i.e., patients who according to my theory had permanently retained a hostility to invading transplacental hormones). By the correct diet, eclampsia and severe toxaemia can nearly always be reduced in severity to little more than mild toxaemia. " Many cases of mild toxaemia " that still occur probably
patients tensive
include or
a
considerable number of
"
Dr. Schuurmans doubts my theory that mothers may react to the entry of foetal hormones because, he says, these do not differ in any respect from those of the mother. But this is not Steroid chemistry is complex enough in an established fact. the adult, but it has never been studied, and could probably never be studied, properly in the fcetus. Apart from the suspicion that the sex hormones of the foetus are probably produced by the adrenal cortex, instead of by the ovary in the mother, it is quite impossible to prove the truth of Dr. Schuurmans’ incautious statement about the hormones of the unborn baby, though it may well be possible to disprove it.
To predetermine the foetal sex by biochemical means, it is essential for the foetal sex hormones in the mother to differ from the maternal hormones, and for the presence or influence of the foetal hormones to be detected. I suggested in my article that it might be possible to predetermine sex before, but not after, the onset of toxaemia, because entry of foetal hormones into the mother would then be resisted. This suggestion, if confirmed, should dispel Dr. Schuurma,ns’s doubts concerning the possibility of maternal reaction to foetal hormones. K. D. SALZMANN. SALZMANK. Reading. EARLY DIAGNOSIS OF COMPRESSION SPINAL CORD
OF THE
would like to congratulate Mr. Rowbotham on his efforts to encourage early diagnosis of neoplasms causing cord compression, and endorse his views on the disastrous results of late diagnosis. Recently I have seen four such cases.
SiR,—I (Dec. 10)
One of these four patients had a ten-month history and bilateral palsy of the fifth, sixth, seventh, and eighth cervical and first thoracic nerve-roots, but no sensory changes. He At operation had been treated for cervical spondylosis. he had a pachymeningitis. The next patient had an eight-month history and a bilateral palsy of the fifth, sixth, and seventh cervical nerveroots, with sensory changes ; the plantar responses were flexor. He also had been treated as a case of cervical spondylosis. At operation a benign intramedullary tumour was removed, and he is doing well. The third patient had a four-month history and a unilateral palsy of the seventh and eighth cervical and first thoracic nerve-roots with sensory changes. There were no radiographic changes in the cervical spine, and there was no evidence of a Pancoast tumour (which may cause this type of palsy) ; but further radiographic examination showed the seventh cervical vertebra collapsing and by this time a supraclavicular gland was palpable, which biopsy showed to be malignant. The fourth case was in a young adult who had a sevenmonth history and a bilateral first sacral palsy, bladder symptoms, and sensory loss from the upper buttocks to the outer side of both feet, including the anal and perineal areas. Operation disclosed a tumour of the cauda equina. cases
had been
diagnosed
as
a
disc
lesion. I would like to add six criteria which of spinal tumours :
help
towards
early diagnosis
1. A history of increasing and intractable segmental pain. 2. Peripheral symptoms, starting distally and progressing proximally, in the upper limb. 3. Sensory changes in more than one dermatome. 4. Rapid increase in the palsy. This is common with disc lesions, but then only one nerve-root is affected. If more than one nerve-root is affected, then a spinal tumour should be
suspected.
R. BARBOR.
London, W.I.
INGUINAL HERNIORRHAPHY
aborted " severe toxaemias
eclampsias.
Each of these
5. Bilateral sensory or motor changes, especially if more than one segment is affected. 6. The plantar response is unreliable, since the response may not be extensor until late in the course of the disease.
SIR,-Mr. Doran (Dec. 24) argues that, since the
conjoined tendon forms the lower border of an inelastic aponeurosis, the " primary fixed point" remains equidistant from the anterior superior iliac spines, and the distance of this point from umbilicus and pubic crest remains fixed, no " shutter action " of the conjoined tendon is possible. While the clinical and experimental evidence adduced seems to support this hypothesis, the geometrical argument appears to be fallacious. In his fig. 1 Mr. Doran represents the primary fixed point the point of intersection of the diagonals of a quadrilateral whose apices are the umbilicus, the anterior superior iliac spines, and the pubic crest. Were this the case the argument would hold. In fact,, however, the geometrical representation of these points is an asymmetrical four-sided pyramid, with the primary fixed point at the apex. Theoretically this figure degenerates into a quadrilateral when all five points are co-planar, and the apex of the pyramid becomes the point of intersection of the diagonals of the quadrilateral. Even if this configuration were present in an individual it would only occur temporarily, since any change in intra-abdominal tension would alter the position of the primary fixed point in the sagittal plane. Once it is appreciated that the correct representation of these points is a pyramid it may be seen from geometrical considerations that the primary fixed point is only " fixed " in the coronal plane. In the sagittal plane it is able to occupy a wide range of positions without its relations to the other four points in the coronal plane being altered. Normally the primary fixed point lies anteriorly to the three bony points and the umbilicus. On increasing the intra-abdominal pressure, as in coughing, it moves more anteriorly. Bearing in mind that the tissues between the conjoined tendon and the primary fixed point are inelastic, if one accepts Mr. Doran’s hypothesis one would expect the conjoined tendon to become further separated from the inguinal ligament. The experiments with radio-opaque markers show that, in fact, the distance between the markers remains fixed. as
One is led to the inescapable conclusion that there be some mechanism which prevents further separation, and that this mechanism can only be the shutter mechanism of the conjoined tendon. I submit therefore that the argument against this action of the conjoined tendon is based on a too-literal interpretation of the word " shutter." The fact that apposition to the inguinal ligament or, indeed, any movement does not take place is not a valid argument against its action in maintaining the integrity of the inguinal canal. Failure of reparative operations based on this principle must be sought elsewhere. J. J. F. F. ROBINSON. ROBINSON. London, W.11. must
SiR,—Mr. Doran, in Anatomical
his paper which
Society, understandably
was read to the confined himself
to anatomical facts. The value of his observations would be enhanced for surgeons if he would state what incidence of recurrent hernia, if any, was noted among the 12 cases in which the conjoined tendon and Poupart’s ligament eventually parted company, and among the 25 cases in which these structures remained in apposition. The gratifying freedom from recurrence in my experience after operations similar to that performed in Mr. Doran’s series suggests that, even if the conjoined tendon and Poupart’s ligament separate, they yet remain joined by a sbeet of fibrous tissue strong enough to form an adequate posterior wall to the inguinal canal. When recurrence has followed suture of the conjoined tendon to Poupart’s ligament after making a relaxing’
patients tensive
include or
a
considerable number of
"
Dr. Schuurmans doubts my theory that mothers may react to the entry of foetal hormones because, he says, these do not differ in any respect from those of the mother. But this is not Steroid chemistry is complex enough in an established fact. the adult, but it has never been studied, and could probably never be studied, properly in the fcetus. Apart from the suspicion that the sex hormones of the foetus are probably produced by the adrenal cortex, instead of by the ovary in the mother, it is quite impossible to prove the truth of Dr. Schuurmans’ incautious statement about the hormones of the unborn baby, though it may well be possible to disprove it.
To predetermine the foetal sex by biochemical means, it is essential for the foetal sex hormones in the mother to differ from the maternal hormones, and for the presence or influence of the foetal hormones to be detected. I suggested in my article that it might be possible to predetermine sex before, but not after, the onset of toxaemia, because entry of foetal hormones into the mother would then be resisted. This suggestion, if confirmed, should dispel Dr. Schuurma,ns’s doubts concerning the possibility of maternal reaction to foetal hormones. K. D. SALZMANN. SALZMANK. Reading. EARLY DIAGNOSIS OF COMPRESSION SPINAL CORD
OF THE
would like to congratulate Mr. Rowbotham on his efforts to encourage early diagnosis of neoplasms causing cord compression, and endorse his views on the disastrous results of late diagnosis. Recently I have seen four such cases.
SiR,—I (Dec. 10)
One of these four patients had a ten-month history and bilateral palsy of the fifth, sixth, seventh, and eighth cervical and first thoracic nerve-roots, but no sensory changes. He At operation had been treated for cervical spondylosis. he had a pachymeningitis. The next patient had an eight-month history and a bilateral palsy of the fifth, sixth, and seventh cervical nerveroots, with sensory changes ; the plantar responses were flexor. He also had been treated as a case of cervical spondylosis. At operation a benign intramedullary tumour was removed, and he is doing well. The third patient had a four-month history and a unilateral palsy of the seventh and eighth cervical and first thoracic nerve-roots with sensory changes. There were no radiographic changes in the cervical spine, and there was no evidence of a Pancoast tumour (which may cause this type of palsy) ; but further radiographic examination showed the seventh cervical vertebra collapsing and by this time a supraclavicular gland was palpable, which biopsy showed to be malignant. The fourth case was in a young adult who had a sevenmonth history and a bilateral first sacral palsy, bladder symptoms, and sensory loss from the upper buttocks to the outer side of both feet, including the anal and perineal areas. Operation disclosed a tumour of the cauda equina. cases
had been
diagnosed
as
a
disc
lesion. I would like to add six criteria which of spinal tumours :
help
towards
early diagnosis
1. A history of increasing and intractable segmental pain. 2. Peripheral symptoms, starting distally and progressing proximally, in the upper limb. 3. Sensory changes in more than one dermatome. 4. Rapid increase in the palsy. This is common with disc lesions, but then only one nerve-root is affected. If more than one nerve-root is affected, then a spinal tumour should be
suspected.
R. BARBOR.
London, W.I.
INGUINAL HERNIORRHAPHY
aborted " severe toxaemias
eclampsias.
Each of these
5. Bilateral sensory or motor changes, especially if more than one segment is affected. 6. The plantar response is unreliable, since the response may not be extensor until late in the course of the disease.
SIR,-Mr. Doran (Dec. 24) argues that, since the
conjoined tendon forms the lower border of an inelastic aponeurosis, the " primary fixed point" remains equidistant from the anterior superior iliac spines, and the distance of this point from umbilicus and pubic crest remains fixed, no " shutter action " of the conjoined tendon is possible. While the clinical and experimental evidence adduced seems to support this hypothesis, the geometrical argument appears to be fallacious. In his fig. 1 Mr. Doran represents the primary fixed point the point of intersection of the diagonals of a quadrilateral whose apices are the umbilicus, the anterior superior iliac spines, and the pubic crest. Were this the case the argument would hold. In fact,, however, the geometrical representation of these points is an asymmetrical four-sided pyramid, with the primary fixed point at the apex. Theoretically this figure degenerates into a quadrilateral when all five points are co-planar, and the apex of the pyramid becomes the point of intersection of the diagonals of the quadrilateral. Even if this configuration were present in an individual it would only occur temporarily, since any change in intra-abdominal tension would alter the position of the primary fixed point in the sagittal plane. Once it is appreciated that the correct representation of these points is a pyramid it may be seen from geometrical considerations that the primary fixed point is only " fixed " in the coronal plane. In the sagittal plane it is able to occupy a wide range of positions without its relations to the other four points in the coronal plane being altered. Normally the primary fixed point lies anteriorly to the three bony points and the umbilicus. On increasing the intra-abdominal pressure, as in coughing, it moves more anteriorly. Bearing in mind that the tissues between the conjoined tendon and the primary fixed point are inelastic, if one accepts Mr. Doran’s hypothesis one would expect the conjoined tendon to become further separated from the inguinal ligament. The experiments with radio-opaque markers show that, in fact, the distance between the markers remains fixed. as
One is led to the inescapable conclusion that there be some mechanism which prevents further separation, and that this mechanism can only be the shutter mechanism of the conjoined tendon. I submit therefore that the argument against this action of the conjoined tendon is based on a too-literal interpretation of the word " shutter." The fact that apposition to the inguinal ligament or, indeed, any movement does not take place is not a valid argument against its action in maintaining the integrity of the inguinal canal. Failure of reparative operations based on this principle must be sought elsewhere. J. J. F. F. ROBINSON. ROBINSON. London, W.11. must
SiR,—Mr. Doran, in Anatomical
his paper which
Society, understandably
was read to the confined himself
to anatomical facts. The value of his observations would be enhanced for surgeons if he would state what incidence of recurrent hernia, if any, was noted among the 12 cases in which the conjoined tendon and Poupart’s ligament eventually parted company, and among the 25 cases in which these structures remained in apposition. The gratifying freedom from recurrence in my experience after operations similar to that performed in Mr. Doran’s series suggests that, even if the conjoined tendon and Poupart’s ligament separate, they yet remain joined by a sbeet of fibrous tissue strong enough to form an adequate posterior wall to the inguinal canal. When recurrence has followed suture of the conjoined tendon to Poupart’s ligament after making a relaxing’