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SCOLIOSIS
497
gonococcal urethritis. Cases of gonorrhoea at the clinics of England and Wales, which amounted to 47,343 in 1946, declined to 17,436 in 1954, but rose in each subsequent year to reach 33,756 in 1960; and the increase is known Cases of non-gonococcal to have continued in 1961. urethritis in males were first recorded in a separate category in 1951 when the total was 10,794 ; it has increased each year, and in 1960 there were 21,971 cases. On the other hand, the incidence of infectious syphilis, which reached a peak in 1946, when 17,675 cases were reported, fell to 808 cases in 1954 and to 704 in 1958. It increased to 984 in 1960; but this remains a small problem by all the standards of the past. ’Only in recent years has it been fully appreciated that vaginal infestation with Trichomonas vaginalis, which is extremely common in women in the reproductive years, is frequently transmitted sexually and that infestation, with few or no symptoms, is common in men. Modern methods of treatment are very effective, but reinfection is almost inevitable unless sexual partners are also treated. Neither patient nor partner should be treated without proper investigation, because of the possibility that other diseases may be
present. For those who undertake responsibility for potentially infected patients without the resources and experience available at venereal-disease clinics, the booklet gives some useful advice. It emphasises that the diseases may be clinically latent, and therefore anyone who has been exposed to possible infection should be examined to exclude it. Transmissible infection is by far the commonest cause of urethral discharge in the male and of vaginal discharge in the female. Symptoms of cystitis, rectal discharge, or lower abdominal pain in a woman may all be due to such a cause. Any genital lesion is suspect, and syphilis should always be excluded. Treatment should never be given before diagnosis, and tests to prove cure are essential. Latent syphilis is the commonest form of the disease and can be detected only by blood tests. Arthritis in young adults may be due to Reiter’s disease, which is believed to be a complication of one variety of transmissible non-gonococcal urethritis. Especially important is the tracing, investigation, and treatment of contacts of infectious patients; for without this any measures for the control of venereal disease must fail. Failure in this responsibility leads to spread of infection, and may lead to reinfection. Patients are often unwilling to assist in this matter, especially men whose wives ought to be examined. Such resistance should be overcome by careful explanation, by tactful insistence, and by perseverance. Some hospitals arrange for sessions to be conducted on other premises than those of the v.D. department, at which patients can have expert investigation while remaining unaware of an association with that department, which inevitably carries some stigma. Control of this serious spread of disease requires a concerted effort by all branches of the medical profession, and the general practitioner has an important part to play. Specialists in other fields also have a considerable responsibility, for patients with these infections commonly present in other departments. The booklet suggests that many problems are best handled by cooperation between the family doctor and a specialist. For those
practitioners who have a particular interest in the personal problems of their patients, clinical assistantships at special clinics offer opportunities for valuable work in this field.
SCOLIOSIS
THE management of any
deformity can be divided into phases-firstly prevention, and secondly correction. Prevention of progressive deformity, especially in growing children, is an important part of orthopaedics and much work has been done on the prevention of progressive scoliosis in children. Stilwell’casts fresh light on this subject because his experiments were performed on monkeys, whereas those reported hitherto have concerned quadrupeds. Stilwell resected the erector spinas muscles, interspinous ligaments, and ligamentam flava, and found that this caused progressive kyphosis and scoliosis, with adaptive changes in the growing bones and distortion of the intervertebral discs. Suppression of growth, or epiphysiodesis, followed in areas which were subjected to excessive compression, whereas where pressure was less than normal the growth of cartilage was accelerated. As a result there was wedging of the vertebral bodies. Stilwell divides the factors responsible for progressive idiopathic spinal deformity in children into the predisposing, the precipitating, and the perpetuating. Even if the predisposing and precipitating factors cannot be eliminated, the perpetuating factors can usually be controlled. An established deformity can be corrected either by direct attack on the primary curve or by creating secondary two
compensatory curves to mask it. Each of these may be attempted either by conservative means-i.e., by different types of splinting-or by operative intervention. Some years ago Allan2 described a spinal jack for the correction of lateral curvature of the spine. More recently Gruca3 described an ingenious system of springs to be inserted on the convex side of the curve in order to correct the deformity. Harrington4 has described his experiences with instruments of his own devising which combine jacking-up the concave side with compressing the convex side. This method has now been used in 129 patients over a period of eight years. He claims that, where his " " operation of spine instrumentation is combined with spinal fusion and long-continued immobilisation, there will be improvement in 84% of cases. Certainly, dramatic improvement can be produced in curves which are still mobile. There are certain technical problems in the introduction of straight rods where lateral curvature is combined with severe kyphosis. Moreover, Harrington gives no details of the aetiology of the various curves he has treated, of the exact types of curve (whether kyphoscoliosis, pure lateral curvature, or lordoscoliosis), or of their preoperative mobility. The procedure which Harrington recommends is fairly extensive, may be extremely difficult, and demands great technical skill. Whether it is applicable to the majority of spinal curvatures or only to a selected few is not yet known; but, in selected patients, it has certainly produced improvement unparalleled by purely conservative measures. The technique has already been employed in some centres in this country, but it should not be regarded as an easy short-cut to the correction of spinal deformity. Indeed, it should only be used by those who have very considerable experience of this type of spinal surgeryat any rate until its exact indications and contraindications have been firmly established. Meanwhile we must await a longer and more complete account of Harrington’s results, with details of the deformities best suited to this treatment. 1. 2. 3. 4.
Stilwell, D. L. J. Bone Jt. Surg. 1962, 44A, Allan, F. G. ibid. 1955, 37B, 92. Gruca, A. ibid. 1958, 40A, 570. Harrington, P. R. ibid. 1962, 44A, 591.
611.
gonococcal urethritis. Cases of gonorrhoea at the clinics of England and Wales, which amounted to 47,343 in 1946, declined to 17,436 in 1954, but rose in each subsequent year to reach 33,756 in 1960; and the increase is known Cases of non-gonococcal to have continued in 1961. urethritis in males were first recorded in a separate category in 1951 when the total was 10,794 ; it has increased each year, and in 1960 there were 21,971 cases. On the other hand, the incidence of infectious syphilis, which reached a peak in 1946, when 17,675 cases were reported, fell to 808 cases in 1954 and to 704 in 1958. It increased to 984 in 1960; but this remains a small problem by all the standards of the past. ’Only in recent years has it been fully appreciated that vaginal infestation with Trichomonas vaginalis, which is extremely common in women in the reproductive years, is frequently transmitted sexually and that infestation, with few or no symptoms, is common in men. Modern methods of treatment are very effective, but reinfection is almost inevitable unless sexual partners are also treated. Neither patient nor partner should be treated without proper investigation, because of the possibility that other diseases may be
present. For those who undertake responsibility for potentially infected patients without the resources and experience available at venereal-disease clinics, the booklet gives some useful advice. It emphasises that the diseases may be clinically latent, and therefore anyone who has been exposed to possible infection should be examined to exclude it. Transmissible infection is by far the commonest cause of urethral discharge in the male and of vaginal discharge in the female. Symptoms of cystitis, rectal discharge, or lower abdominal pain in a woman may all be due to such a cause. Any genital lesion is suspect, and syphilis should always be excluded. Treatment should never be given before diagnosis, and tests to prove cure are essential. Latent syphilis is the commonest form of the disease and can be detected only by blood tests. Arthritis in young adults may be due to Reiter’s disease, which is believed to be a complication of one variety of transmissible non-gonococcal urethritis. Especially important is the tracing, investigation, and treatment of contacts of infectious patients; for without this any measures for the control of venereal disease must fail. Failure in this responsibility leads to spread of infection, and may lead to reinfection. Patients are often unwilling to assist in this matter, especially men whose wives ought to be examined. Such resistance should be overcome by careful explanation, by tactful insistence, and by perseverance. Some hospitals arrange for sessions to be conducted on other premises than those of the v.D. department, at which patients can have expert investigation while remaining unaware of an association with that department, which inevitably carries some stigma. Control of this serious spread of disease requires a concerted effort by all branches of the medical profession, and the general practitioner has an important part to play. Specialists in other fields also have a considerable responsibility, for patients with these infections commonly present in other departments. The booklet suggests that many problems are best handled by cooperation between the family doctor and a specialist. For those
practitioners who have a particular interest in the personal problems of their patients, clinical assistantships at special clinics offer opportunities for valuable work in this field.
SCOLIOSIS
THE management of any
deformity can be divided into phases-firstly prevention, and secondly correction. Prevention of progressive deformity, especially in growing children, is an important part of orthopaedics and much work has been done on the prevention of progressive scoliosis in children. Stilwell’casts fresh light on this subject because his experiments were performed on monkeys, whereas those reported hitherto have concerned quadrupeds. Stilwell resected the erector spinas muscles, interspinous ligaments, and ligamentam flava, and found that this caused progressive kyphosis and scoliosis, with adaptive changes in the growing bones and distortion of the intervertebral discs. Suppression of growth, or epiphysiodesis, followed in areas which were subjected to excessive compression, whereas where pressure was less than normal the growth of cartilage was accelerated. As a result there was wedging of the vertebral bodies. Stilwell divides the factors responsible for progressive idiopathic spinal deformity in children into the predisposing, the precipitating, and the perpetuating. Even if the predisposing and precipitating factors cannot be eliminated, the perpetuating factors can usually be controlled. An established deformity can be corrected either by direct attack on the primary curve or by creating secondary two
compensatory curves to mask it. Each of these may be attempted either by conservative means-i.e., by different types of splinting-or by operative intervention. Some years ago Allan2 described a spinal jack for the correction of lateral curvature of the spine. More recently Gruca3 described an ingenious system of springs to be inserted on the convex side of the curve in order to correct the deformity. Harrington4 has described his experiences with instruments of his own devising which combine jacking-up the concave side with compressing the convex side. This method has now been used in 129 patients over a period of eight years. He claims that, where his " " operation of spine instrumentation is combined with spinal fusion and long-continued immobilisation, there will be improvement in 84% of cases. Certainly, dramatic improvement can be produced in curves which are still mobile. There are certain technical problems in the introduction of straight rods where lateral curvature is combined with severe kyphosis. Moreover, Harrington gives no details of the aetiology of the various curves he has treated, of the exact types of curve (whether kyphoscoliosis, pure lateral curvature, or lordoscoliosis), or of their preoperative mobility. The procedure which Harrington recommends is fairly extensive, may be extremely difficult, and demands great technical skill. Whether it is applicable to the majority of spinal curvatures or only to a selected few is not yet known; but, in selected patients, it has certainly produced improvement unparalleled by purely conservative measures. The technique has already been employed in some centres in this country, but it should not be regarded as an easy short-cut to the correction of spinal deformity. Indeed, it should only be used by those who have very considerable experience of this type of spinal surgeryat any rate until its exact indications and contraindications have been firmly established. Meanwhile we must await a longer and more complete account of Harrington’s results, with details of the deformities best suited to this treatment. 1. 2. 3. 4.
Stilwell, D. L. J. Bone Jt. Surg. 1962, 44A, Allan, F. G. ibid. 1955, 37B, 92. Gruca, A. ibid. 1958, 40A, 570. Harrington, P. R. ibid. 1962, 44A, 591.
611.