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 Halimah Badioze Zaman · Alan F. Smeaton ·
Timothy K. Shih · Sergio Velastin ·
Tada Terutoshi · Nazlena Mohamad Ali ·
Mohammad Nazir Ahmad (Eds.)
LNCS 11870

Advances in
Visual Informatics
6th International Visual Informatics Conference, IVIC 2019
Bangi, Malaysia, November 19–21, 2019
Proceedings
Lecture Notes in Computer Science 11870

Founding Editors
Gerhard Goos
Karlsruhe Institute of Technology, Karlsruhe, Germany
Juris Hartmanis
Cornell University, Ithaca, NY, USA

Editorial Board Members

Elisa Bertino
Purdue University, West Lafayette, IN, USA
Wen Gao
Peking University, Beijing, China
Bernhard Steffen
TU Dortmund University, Dortmund, Germany
Gerhard Woeginger
RWTH Aachen, Aachen, Germany
Moti Yung
Columbia University, New York, NY, USA
More information about this series at http://www.springer.com/series/7412
Halimah Badioze Zaman Alan F. Smeaton
• •

Timothy K. Shih Sergio Velastin

• •

Tada Terutoshi Nazlena Mohamad Ali

• •

Mohammad Nazir Ahmad (Eds.)

Advances in
Visual Informatics
6th International Visual Informatics Conference, IVIC 2019
Bangi, Malaysia, November 19–21, 2019
Proceedings

123
Editors
Halimah Badioze Zaman Alan F. Smeaton
Universiti Kebangsaan Malaysia Dublin City University
Bangi, Malaysia Dublin, Ireland
Timothy K. Shih Sergio Velastin
National Central University Carlos III University of Madrid
Taoyuan City, Taiwan Madrid, Spain
Tada Terutoshi Nazlena Mohamad Ali
Toyo University Universiti Kebangsaan Malaysia
Tokyo, Japan Bangi, Malaysia
Mohammad Nazir Ahmad
Universiti Kebangsaan Malaysia
Bangi, Malaysia

ISSN 0302-9743 ISSN 1611-3349 (electronic)

Lecture Notes in Computer Science
ISBN 978-3-030-34031-5 ISBN 978-3-030-34032-2 (eBook)
https://doi.org/10.1007/978-3-030-34032-2
LNCS Sublibrary: SL6 – Image Processing, Computer Vision, Pattern Recognition, and Graphics

© Springer Nature Switzerland AG 2019

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 Preface

The world is going through great economic and technological challenges in this digital
economy era. With the advent of the 4th Industrial Revolution (4IR) and Industry 4.0,
Visual Informatics has become a significant component in computer science. This
multidisciplinary field encompasses that of computer science and information
technology and engineering, integrating areas such as computer vision, image
processing, pattern recognition, computer graphics, simulation, virtual reality, data
visualization and analytics, cyber security, as well as social computing, which can all
be applied to various domains of knowledge such as education, medical and health,
finance, or security. The Institute of Visual Informatics (IVI) at the Universiti
Kebangsaan Malaysia (UKM), also known as The National University of Malaysia, is a
center of excellence (CoE) established as an outcome of the first Visual Informatics
Conference (IVIC) held in 2009. The institute, which conducts research in the basic
areas mentioned earlier, conducts Masters and Doctoral (PhD) Degree programs of
research, as well as short Professional Practical Certifications currently in the areas of
Data Science and Intelligent Visual Data Analytics. The institute has successfully
graduated more than 30 postgraduate students (Masters and PhD) since its inception in
2010. We are indeed indebted to the international fraternity from the last five IVIC
conferences (2009, 2011, 2013, 2015, and 2017), who have given us support for the
establishment of the institute. Our smart partnerships, through this conference, has
helped the institute to grow and enhance research in this area locally and
internationally.
The Visual Informatics Research Group and the Institute of Visual Informatics
(IVI) at UKM, once again hosted this 6th International Visual Informatics Conference
(IVIC 2019), with the objective to bring together experts to discuss and share new
knowledge and ideas in this research area so that more concerted efforts can be
undertaken nationally and globally. As in the previous IVIC conferences, this
conference was organized collaboratively by the Visual Informatics fraternity from
various public and private universities and industry from various parts of the world
(their names are listed in the proceedings). This sixth edition of IVIC was co-sponsored
by Malaysian Digital Economy Corporation (MDEC), National Council of Professors
(MPN), and Malaysian Information Technology Society (MITS). The conference was
co-chaired by five professors from the UK, Ireland, Taiwan, Japan, and Malaysia.
The theme of the conference, ‘Digital Innovation Towards Society 5.0’ reflects the
importance of digitalization in this fourth industrial revolution digital economy, where
disruptive technologies have caused technologies to integrate and result in fusion
technologies that bring about interesting emerging technologies such as autonomous
and semi-autonomous vehicles, Internet of things (IoT), and Blockchain that will
benefit society. The changing landscapes of Industry 4.0 require technologies that are
Artificial Intelligence (AI)-driven which will assist future Society 5.0 to make decisions
from more precise intelligent predictions that would result in an efficient decision
vi Preface

making and smart intelligent applications for the well-being of society and the
economy. Thus, the theme of the conference was relevant, apt, and timely.
The conference focused on four tracks:
– Visualization and Digital Innovation for Society 5.0
– Engineering and Digital Innovation for Society 5.0
– Cyber Security and Digital Innovation for Society 5.0
– Social Informatics and Application for Society 5.0
The tracks took place over the course of two days (November 19–20, 2019) and
ended with a one-day workshop (November 21, 2019). There were 4 keynote speakers
and 65 paper presentations based on topics covered by the 4 main tracks. The
reviewing of the papers was conducted by experts who represented the Program
Committee from Asia, Europe, Oceania, and the USA. Each paper was reviewed by 3
reviewers and the acceptance rate was 47%. The reviewing process was managed using
the EasyChair system.
The conference also included for the first time an exhibition portraying the theme
‘Symbiosis of Art, Science, and Technology for Society 5.0’ to show how scientific
and technological research can be presented in interesting art works that have a great
impact on public awareness on the seamlessness of knowledge in art, science, and
technology, and its effects on the civilization of societies.
On behalf of the organizing and Program Committee of IVIC 2019, we thank all
authors for their submissions and camera-ready copies of papers, and all participants
for their thought-provoking ideas and active participation in the conference. We also
thank the vice-chancellor of UKM (host university), and vice-chancellors and deans of
all IT faculties of the IHLs for their support in organizing this conference. We also
acknowledge the sponsors, members of the Organizing Committees, Program
Committee members, support committees, and individuals who gave their continuous
help and support in making the conference a success. It is our fervent hope that one day
IVIC will be held in different host countries such as Asia, Europe, Oceania, the UK or
the USA.

November 2019 Halimah Badioze Zaman

Alan F. Smeaton
Timothy K. Shih
Sergio Velastin
Tada Terutoshi
Nazlena Mohamad Ali
Mohammad Nazir Ahmad
 Organization

The 6th International Visual Informatics Conference (IVIC 2019) was organized by the
Visual Informatics Research Group and Institute of Visual Informatics, Universiti
Kebangsaan Malaysia (UKM), in collaboration with local public and private
universities in Malaysia, the Multimedia Development Corporation (MDEC), and the
ICT Cluster of the National Professors’ Council (MPN).

Local Executive Committee

Chair
Halimah Badioze Zaman (UKM)

Deputy Chair
Rosalina Abdul Salam (USIM)

Secretary
Nazlena Mohamad Ali (UKM)

Assistant Secretary
Norshita Mat Nayan (UKM)

Treasurer
Rabiah Abd. Kadir (UKM)

Assistant Treasurer
Ummul Hanan Mohamad (UKM)

Program Committee
Program Co-Chairs
Halimah Badioze Zaman
Alan F. Smeaton
Timothy K. Shih
Sergio Velastin
Terutoshi Tada
Universiti Kebangsaan Malaysia, Malaysia
Dublin City University, Ireland
National Central University, Taiwan
Queen Mary Univ. of London, UK
Toyo University, Japan
viii Organization

Technical Program Committee

Mohammad Nazir Ahmad (UKM) – Head
Halimah Badioze Zaman (UKM)
Nazlena Mohamad Ali (UKM)
Ely Salwana Mat Surin (UKM)
Norshita Mat Nayan (UKM)

Sponsorship
Azlina Ahmad (UKM) – Head
Halimah Badioze Zaman (UKM)
Rosalina Abdul Salam (USIM)
Wan Fatimah Wan Ahmad (UTP)
Bahari Belaton (USM)
Noor Afiza Mat Razali (UPNM)

Publicity (Web Portal)

Noor Afiza Mat Razali (UPNM) – Head
Ang Mei Choo (UKM)
Hanif Baharin (UKM)
Norshahriah Abd. Wahab (UPNM)
Mohamad Taha Ijab (UKM)
Nur Intan Raihana (USM)
Mohd Nadhir Ab Wahab (USM)
Dahlan Abdul Ghani (UNIKL)
Robiatul Adawiah Jamaluddin (IUKL)
Nizam Md Husen (UNIKL)
Noramiza Hashim (MMU)
Anusha Achuthan (USM)
Hajah Norasiken Bakar (UTEM)
Suraya Hamid (UM)
Dayang Rohaya Awang Rambli (UTP)
Prasanna Ramakrishnan (UiTM)
Nurul Amelina Nasharuddin (UPM)
Aslina Baharom (UMS)

Logistics
Riza Sulaiman (UKM) – Head
Mohamad Taha Ijab (UKM)
Syed Nasir Syed Zakaria Alsagoff (UPNM)
Dahlan Abdul Ghani (UNIKL)
Asama Kuder (UKM)
Azreen Azman (UPM)
Hafizhah Suzana Hussien (UKM)
Mohammad Haziq Mohd Johari (UKM)
 Organization ix

Zulkepli Mukhtar (UKM)

Mohamad Shahmi Shahril (UKM)

Workshop
Puteri Nor Ellyza Nohuddin (UKM) – Head
Amelia Ritahani Ismail (UIA)
Nur Intan Raihana (USM)
Joshua Thomas (KDU)

Conference Management System

Ely Salwana Mat Surin (UKM) – Head
Mohammad Nazir Ahmad (UKM)
Hafizhah Suzana Hussien (UKM)

Tour
Nurul Amelina Nasharuddin (UPM) – Head
Hajah Norasiken Bakar (UTEM)
Azreen Azman (UPM)

Exhibition
Mohamad Taha Ijab (UKM) – Head
Hanif Baharin (UKM)
Mohammad Haziq Mohd Johari (UKM)
Zulkepli Mukhtar (UKM)

Special Task
Norshita Mat Nayan (UKM) – Head
Siti NorazimahAhmat (UKM)
Nurulhuda Muhamad (UKM)
Anis Najwa Mohd Sharuddin (UKM)

Technical Committee
International
Alan F. Smeaton Dublin City University, Ireland
Timothy K. Shih National Central University, Taiwan
Sergio Velastin Queen Mary University of London, UK
Tada Terutoshi Toyo University, Japan
Emanuele Trucco University of Dundee, UK
Hang-Bong Kang Catholic University of Korea, South Korea
Marta Fairén Universitat Politècnica de Catalunya, Spain
Erich Neuhold University of Vienna, Austria
Theng Yin Leng Nanyang Technological University, Singapore
x Organization

Tony Pridmore University of Nottingham, UK

Neil A. Gordon University of Hull, UK
Hyowon Lee SUTD, Singapore
Jianguo Zhang University of Dundee, UK
Jing Hua Wayne State University, USA
Nick Holliman Durham University, UK
Qingde Li University of Hull, UK
Wenyu Liu Huazhong University of Science and Technology,
China
Malcolm Munro Durham University, UK
Huang Jiung-Yao National Taipei University, Taiwan
Li Kuan-Ching Providence University, Taiwan
Khider Nassif Jassim University of Wasit, Iraq
Kamal Badr Abdalla Badr Qatar Foundation, Qatar
Yunis Ali Simad University, Somalia
Furkh Zeshan University Islamabad, Pakistan
Kamarul Faizal Hashim University of Dubai, UAE
Omar Ahmed Ibrahim University of Mosul, Iraq
Sommai Khantong Mahasarakham University, Thailand

Malaysia
Azlina Ahmad (UKM)
Aliimran Nordin (UKM)
Amalina Farhi Ahmad Fadziah (UPNM)
Asama Kuder Nseaf (UKM)
Aslina Baharum (UMS)
Azreen Azman (UPM)
Ang Mei Choo (UKM)
Bahari Belaton (USM)
Bavani Ramayah (NOTTINGHAM)
Chiung Ching Ho (MMU)
Dahlan Abdul Ghani (UNIKL)
Dayang Rohaya Awang Rambli (UTP)
Ely Salwana Mat Surin (UKM)
Falah Y. H. Ahmed (MSU)
Fauziah Zainuddin (UMP)
Halimah Badioze Zaman (UKM)
Hanif Baharin (UKM)
Hajah Norasiken Bakar (UTEM)
Hoo Meei Hao (UTAR)
J. Joshua Thomas (KDU Penang)
Jamaiah Yahaya (UKM)
Kasturi Dewi Varathan (UM)
Khairul Shafee Kalid (UTP)
Mahadi Bahari (UTM)
Maizatul H. M. Yatim (UPSI)
Marwan D. Saleh (MSU)
Mohamad Taha Ijab (UKM)
Mohammad Nazir Ahmad (UKM)
Mohammad Adib Khairuddin (UPNM)
Mohd Afizi Mohd Shukran (UPNM)
Mohd Hafiz Faizal Mohamad
Kamil (UNIKL)
Mohd Nadhir Ab Wahab (USM)
Mohd Nizam Husen (UNIKL)
Mohd Rizal Mohd Isa (UPNM)
Mohd Nazri Ismail (UPNM)
Muhammad Reza Z’aba (UM)
Muslihah Wook (UPNM)
Nor Hidayati Zakaria (UTM)
Nazlena Mohamad Ali (UKM)
Nazmona Mat Ali (UTM)
Noor Afiza Mat Razali (UPNM)
Noor Azah Samsudin (UTHM)
Noor Hafizah Hassan (UTM)
Noor Hayani Abd Rahim (IIUM)
Noorminshah Iahad (UTM)
 Organization xi

Nor Asiakin Hasbullah (UPNM) Robiatul A’Dawiah Jamaluddin (IUKL)

Nor Zairah Ab. Rahim (UTM)
Norizan Mat Diah (UiTM)
Norshahriah Abdul Wahab (UPNM)
Norziha Megat Mohd. Zainuddin (UTM)
Nur Azaliah Abu Bakar (UTM)
Nur Fazidah Elias (UKM)
Nurulhuda Firdaus Mohd Azmi (UTM)
Noor Afiza Mat Razali (UPNM)
Norshita Mat Nayan (UKM)
Prasanna Ramakrisnan (UiTM)
Puteri Nur Ellyza Nohuddin (UKM)
Rabiah Abdul Kadir (UKM)
Rahayu Ahmad (UUM)
Rahmah Mokhtar (UMP)
Rasimah Che Mohd Yusoff (UTM)
Razatulshima Ghazali (MAMPU)
Ridzuan Hussin (UPSI)
Riza Sulaiman (UKM)
Rohayanti Hassan (UTM)
Roslina Ibrahim (UTM)
Rosmayati Mohemad (UMT)
Savita K. Sugathan (UTP)
Siti Nurul Mahfuzah Mohamad (UTEM)
Stephanie Chua (UNIMAS)
Suraya Hamid (UM)
Suzaimah Ramli (UPNM)
Suziah Sulaiman (UTP)
Syed Nasir Alsagoff (UPNM)
Ummul Hanan Mohamad (UKM)
Wan Fatimah Wan Ahmad (UTP)
Zahidah Abd Kadir (UNIKL)
Zarul Fitri Zaaba (USM)
Zeratul Izzah Mohd Yusoh (UTEM)
Zuraini Zainol (UPNM)
Zuriana Abu Bakar (UMT)
Zahidah Zulkifli (IIUM)

Strategic Partners
National Council of Professors (MPN)
Malaysia Digital Economy Corporation (MDEC)
Malaysian Information Technology Society (MITS)
Sistem Perintis Sdn Bhd

Co-organizers

Universiti Kebangsaan Malaysia (UKM)

Universiti Pertahanan Nasional Malaysia (UPNM)
Universiti Sains Islam Malaysia (USIM)
Universiti Teknikal Malaysia Melaka (UTeM)
Universiti Teknologi PETRONAS (UTP)
Universiti Sains Malaysia (USM)
Infrastructure University Kuala Lumpur (IUKL)
Universiti Kuala Lumpur (UniKL)
Universiti Teknologi Malaysia (UTM)
Universiti Malaya (UM)
Universiti Teknologi MARA (UiTM)
Al-Madinah International University (MEDIU)
International Islamic University Malaysia (IIUM)
University of Malaysia, Sarawak (UNIMAS)
xii Organization

Universiti Pendidikan Sultan Idris (UPSI)

Universiti Tenaga Nasional (UNITEN)
Universiti Utara Malaysia (UUM)
University of Nottingham, UK (Malaysia Campus)
KDU Penang University College
Sunway University
 Contents

Visualization and Digital Innovation for Society 5.0

Content-Aware Video Analysis to Guide Visually Impaired Walking

on the Street. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ervin Yohannes, Timothy K. Shih, and Chih-Yang Lin

Experts’ Feedback on DST Elements as Infused in Development Process

of Mobile Learning Apps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Hashiroh Hussain and Norshuhada Shiratuddin

Virtual Environment for VR-Based Stress Therapy System Design Element:

User Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Farhah Amaliya Zaharuddin, Nazrita Ibrahim, Azmi Mohd Yusof,
Mohd Ezanee Rusli, and Eze Manzura Mohd Mahidin

Factors to Consider When Designing a Virtual Environment

to Treat Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Farhah Amaliya Zaharuddin, Nazrita Ibrahim, Mohd Ezanee Rusli,
Eze Manzura Mohd Mahidin, and Azmi Mohd Yusof

Evaluation of a Virtual Reality (VR) Learning Tool for Fundamental

Turbine Engineering Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Hidayah Sulaiman, Siti Najiha Apandi, Azmi Mohd. Yusof,
Rubijesmin Abdul Latif, and Nazrita Ibrahim

Data Visualisation: World Happiness at a Glance! . . . . . . . . . . . . . . . . . . . . 60

Angela Siew Hoong Lee, Ammar Kudbuddin, and Phoey Lee Teh

Data Visualization of Supplier Selection Using Business

Intelligence Dashboard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Nik Nur Ayuni Nik Alwi, Noor Hafizah Hassan,
Ahmad Fazreen Baharuden, Nur Azaliah Abu Bakar,
and Nurazean Maarop

Comparison of User-Centered Design Antibiotic Resistance Awareness

App to Existing Antibiotic-Related Mobile Applications . . . . . . . . . . . . . . . 82
Ummul Hanan Mohamad

Realization of a 3D Gearbox Model Through Marker-Based

Augmented Reality for Edutainment Applications . . . . . . . . . . . . . . . . . . . . 91
K. Martin Sagayam, Julia Schaupp, Alex J. Timothy,
and Chiung Ching Ho
xiv Contents

Users’ Perception on Usability Aspects of a Braille Learning Mobile

Application ‘mBRAILLE’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Lutfun Nahar, Riza Sulaiman, and Azizah Jaafar

Early Intervention Through Identification of Learners with Dyscalculia

as Initial Analysis to Design AR Assistive Learning Application. . . . . . . . . . 110
Kohilah Miundy, Halimah Badioze Zaman, Aliimran Nordin,
and Kher Hui Ng

Gamifying Online Knowledge Sharing Environment:

A Motivating User Interface Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Prasanna Ramakrisnan

Ascertain Quality Attributes for Design and Development of New

Improved Chatbots to Assess Customer Satisfaction Index (CSI):
A Preliminary Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Nurul Muizzah Johari, Halimah Badioze Zaman,
and Puteri N. E. Nohuddin

Engineering and Digital Innovation for Society 5.0

Intrinsic Face Image Decomposition from RGB Images with Depth Cues. . . . 149
Shirui Liu, Hamid A. Jalab, and Zhen Dai

Haze Removal Algorithm Using Improved Restoration Model Based

on Dark Channel Prior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Dai Zhen, Hamid A. Jalab, and Liu Shirui

Initial Investigation on Affective 4D Mathematics Model for Low

Vision Learners (AM4LV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Nurulnadwan Aziz, Ariffin Abdul Mutalib, Siti Zulaiha Ahmad,
Sobihatun Nur Abdul Salam, and Nur Hazwani Mohamad Roseli

Virtual Reality Ideal Learning: A Look into Future Medical Classroom . . . . . 182
Mohd Yazid Bajuri, Kamarul Syariza Zamri, Mohammad Nazir Ahmad,
and Mohd Ismawira Mohd Ismail

Hybrid Requirement Elicitation Techniques with Lean Six Sigma

Methodology for an Enhanced Framework . . . . . . . . . . . . . . . . . . . . . . . . . 190
Narishah Mohamed Salleh and Puteri N. E. Nohuddin

Longevity Risk Profiling Based on Non-disease Specific Risk Factors

Using Association Rules Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Nur Haidar Hanafi and Puteri N. E. Nohuddin

Ensemble of Deep Convolutional Neural Network for Skin Lesion

Classification in Dermoscopy Images. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Ather Aldwgeri and Nirase Fathima Abubacker
 Contents xv

A Comprehensive Review Towards Appropriate Feature Selection

for Moving Object Detection Using Aerial Images . . . . . . . . . . . . . . . . . . . 227
Zainal Rasyid Mahayuddin and A. F. M. Saifuddin Saif

SUFID: Sliced and Unsliced Fruits Images Dataset . . . . . . . . . . . . . . . . . . . 237

Latifah Abdullah Bin Turayki and Nirase Fathima Abubacker

A Combined of Fuzzy TOPSIS with Z-Number and Alpha-Cut

for Decision Making Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Nurnadiah Zamri and Awajan Khaleel Yahia Ibrahim

Facial Recognition Adaptation as Biometric Authentication for Intelligent

Door Locking System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Ahmad Sufril Azlan Mohamed, Mohd Nadhir Ab Wahab,
Sanarthana Radha Krishnan, and Darshan Babu L. Arasu

Manufacturing Lead Time Classification Using Support Vector Machine . . . . 268

Zhong Heng Lim, Umi Kalsom Yusof, and Haziqah Shamsudin

iFR: A New Framework for Real-Time Face Recognition

with Deep Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Syazwan Syafiqah Sukri and Nur Intan Raihana Ruhaiyem

Algebraic-Trigonometric Nonlinear Analytical Inverse Kinematic Modeling

and Simulation for Robotic Manipulator Arm Motion Control . . . . . . . . . . . 291
Khairul Annuar Abdullah, Suziyanti Marjudi, Zuriati Yusof,
and Riza Sulaiman

Combining ARIZ with Shape Grammars to Support Designers . . . . . . . . . . . 305

Kok Weng Ng, Mei Choo Ang, Dong Theng Cher, Siti Azfanizam Ahmad,
and Amelia Natasya Abdul Wahab

Expert System for Dota 2 Character Selection Using

Rule-Based Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Mohammad Zaki Azim Zairil Aznin, Norizan Mat Diah,
and Nur Atiqah Sia Abdullah

Preliminary Simulation of Robot on Script Detection

from Camera Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Wydyanto, Norshita Mat Nayan, and Riza Sulaiman

Virtual Lower Limb Stroke Rehabilitation to Assess Post Stroke Patients . . . . 343
Lee Wei Jian and Syadiah Nor Wan Shamsuddin

Older Adults’ Number Entry Using Touchscreen

and Keyboard-Mouse Computers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Zaidatol Haslinda Abdullah Sani and Helen Petrie
xvi Contents

An Overview and Experiment on Wi-Fi Direct Connection Behaviour

with Network Analysing Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Thian Seng Lee, Paul Gardner-Stephen, Riza Sulaiman,
and Nazlena Mohammad Ali

Multi-word Similarity and Retrieval Model for a Refined Retrieval

of Quranic Sentences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Haslizatul Mohamed Hanum, Nur Farhana Rasip,
and Zainab Abu Bakar

Cyber Security and Digital Innovation for Society 5.0

Cyber Security Education Using Integrative Learning Module

for an Optimum Learning Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Noor Afiza Mat Razali, Khairul Khalil Ishak,
Muhamad Aliff Irfan Muhamad Fadzli,
and Nurjannatul Jannah Aqilah M. Saad

CMBlock: In-Browser Detection and Prevention Cryptojacking Tool

Using Blacklist and Behavior-Based Detection Method . . . . . . . . . . . . . . . . 404
Muhammad Amirrudin Razali and Shafiza Mohd Shariff

Systematic Literature Review of Prediction Techniques to Identify

Work Skillset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Nurul Saadah Zawawi, Ely Salwana, Zahidah Zulkifli,
and Norshita Mat Nayan

Prediction of Learning Disorder: A-Systematic Review . . . . . . . . . . . . . . . . 429

Mohammad Azli Jamhar, Ely Salwana, Zahidah Zulkifli,
Norshita Mat Nayan, and Noryusliza Abdullah

Identifying Fake Account in Facebook Using Machine Learning . . . . . . . . . . 441

Ahmad Nazren Hakimi, Suzaimah Ramli, Muslihah Wook,
Norulzahrah Mohd Zainudin, Nor Asiakin Hasbullah,
Norshahriah Abdul Wahab, and Noor Afiza Mat Razali

Internet of Thing (IoT) Smart Home Systems: Conceptual Ethical

Framework for Malaysian Developers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Hasnani Hassan, Robiatul Adawiah Jamaluddin,
and Fadimatu Muhammad Marafa

Social Informatics and Application for Society 5.0

iPassenger: Smart Passenger Analytics System . . . . . . . . . . . . . . . . . . . . . . 465

Mohd Nadhir Ab Wahab, Ahmad Sufril Azlan Mohamed,
and Kong Chee Chung
 Contents xvii

Investigating the Intentions to Adopt ICT in Malaysian SMEs

Using the UTAUT Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Anis Nur Assila Rozmi, Mohd Izhar A. Bakar, Abdul Razak Abdul Hadi,
and A. Imran Nordin

Encouraging Correct Tooth Brushing Habits Among Children in the B40

Community Through Gamification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Elavarasi Kuppusamy, Farinawati Yazid, Murshida Marizan Nor,
Chui Ling Goo, Muhammad Syafiq Asyraf Rosli,
Rohaya Megat Abdul Wahab, and A. Imran Nordin

App4Autism: An Integrated Assistive Technology with Heart Rate

Monitoring for Children with Autism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
Cheng Yee Yap, Kher Hui Ng, Yungen Cheah, Suk Yee Lim,
Jessica Price, and Marieke De Vries

Review on Preliminary Study on Student’s Motivation

in Learning History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
Muhammad Baderi, Wan Fatimah Wan Ahmad,
and Muhammad Ridhuan Tony Lim Abdullah

Factors in Personal Information Management Evaluation . . . . . . . . . . . . . . . 523

Mohammad Rustom Al Nasar, Masnizah Mohd,
and Nazlena Mohamad Ali

The Factors that Influence the Reading Habit Among Malaysian:

A Systematic Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Ahmed Sedik Hassan Mohammed, Zahidah Zulkifli,
and Ely Salwana Mat Surin

Student’s Perception on Entrepreneurial Education Programs for Graduate

Startups in Selected ASEAN Universities . . . . . . . . . . . . . . . . . . . . . . . . . . 550
Md. Sum Sarmila, Shamshubaridah Ramlee, Akmal Sabarudin,
Norhana Arsad, Murshida Marizan Nor, Zainebbeevi Kamal Batcha,
Nurul Asmaa Ramli, and A. Imran Nordin

Enhance Multi-factor Authentication Model for Intelligence Community

Access to Critical Surveillance Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
Wan Nurhidayat Wan Muhamad, Noor Afiza Mat Razali,
Khairul Khalil Ishak, Nor Asiakin Hasbullah,
Norulzahrah Mohd Zainudin, Suzaimah Ramli, Muslihah Wook,
Zurida Ishak, and Nurjannatul Jannah Aqilah MSaad
xviii Contents

Disaster Management Support Model for Malaysia . . . . . . . . . . . . . . . . . . . 570

Hasmeda Erna Che Hamid, Nurjannatul Jannah Aqilah MSaad,
Noor Afiza Mat Razali, Mohammad Adib Khairuddin,
Mohd Nazri Ismail, Suzaimah Ramli, Muslihah Wook,
Khairul Khalil Ishak, Zurida Ishak, Nor Asiakin Hasbullah,
Norshahriah Wahab, Norulzahrah Mohd Zainudin,
and Putri Nurshamiera Natasha Azizan Shah

Investigating Relationships Between Roads Based on Speed Performance

Index of Road on Weekdays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Bagus Priambodo, Azlina Ahmad, and Rabiah Abdul Kadir

Social Network Sites (SNS) Issues in Learning Landscape – Systematic

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592
Nani Amalina Zulkanain, Suraya Miskon, Syed Norris Syed Abdullah,
Nazmona Mat Ali, Mahadi Bahari, and Norasnita Ahmad

Proposed UX Model for Children Educational Mobile Application . . . . . . . . 601

Kiranjeet Kaur, Khairul Shafee Kalid, and Savita K. Sugathan

eRMS for Research Management and Monitoring at Universiti

Pertahanan Nasional Malaysia (UPNM) . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Syahaneim Marzukhi, Hasmeda Erna Che Hamid, Hafizah Ariff,
Mohd Hakimi Ahmad Zainudin, Nur Shazwani Abdul Latif,
Nurul Fatehah Roslan, and Ayuni Akmal Ramlee

The Importance of the Psychomotor Factors for Effective Learning

Management System Use in TVET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620
Nor Azlan Ahmad, Nur Fazidah Elias, and Noraidah Sahari@Ashaari

Identifying Suitable Icon Button for Museum Application Interface

Using Online Card Sorting Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
Fasihah Mohammad Shuhaili, Suziah Sulaiman,
Dayang Rohaya Awang Rambli, and Saipunidzam Mahamad

Understanding Instant Messaging in the Workplace . . . . . . . . . . . . . . . . . . . 640

Jason Ariel Rajendran, Hanif Baharin, and Fazillah Mohmad Kamal

Usability Evaluation of Heart Disease Monitoring Mobile Applications:

A Comparative Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
Muhammad Sobri, Mohamad Taha Ijab, and Norshita Mat Nayan

User Profiling to Overcome the Social Effects of Student Dropout . . . . . . . . 663

Justin Gilbert and Suraya Hamid

Usability Evaluation of Smartphone Gestures in Supporting Elderly Users . . . 672

Hasanin Mohammed Salman, Wan Fatimah Wan Ahmad,
and Suziah Sulaiman
 Contents xix

The Design Criteria of Product Label Assisting Purchase Decision . . . . . . . . 684

Mohd Hafiz Faizal Mohamad Kamil and Dahlan Abdul Ghani

Academic Writing for Higher Learning Institution Students:

Implications from User Needs Analysis for a Specific Plagiarism Module
in e-Learning Platform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694
Hafizhah Suzana Hussien, Fariza Khalid, Supyan Hussin,
and Dini Farhana Baharuddin

A Framework for Sustainable Eco-Friendly Product Development

Based on TRIZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704
Nur Syaza Zainali, Mei Choo Ang, Kok Weng Ng,
and Mohamad Taha Ijab

Computational Thinking (CT) Problem Solving Orientation

Based on Logic-Decomposition-Abstraction (LDA) by Rural
Elementary School Children Using Visual-Based Presentations . . . . . . . . . . . 713
Halimah Badioze Zaman, Azlina Ahmad, Aliimran Nordin,
Hamidah Yamat@Ahmad, A. Aliza, M. C. Ang, N. Azwan Shaiza,
S. Riza, C. M. Normazidah, J. Azizah, W. Wahiza, M. A. Nazlena,
K. Fauzanita, N. Puteri Nor Ellyza, H. Baharin, I. Mohamad Taha,
A. K. Rabiah, M. N. Norshita, M. Ummul Hanan, and M. S. Ely Salwana

E-Community Program: A Study on ICT Knowledge Transfer

to Labuan Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Wan Nooraishya Wan Ahmad, Ahmad Rizal Ahmad Rodzuan,
Khan Vun Teong, Nuraini Jamil, and Nooralisa Mohd Tuah

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741

Visualization and Digital Innovation for
Society 5.0
 Content-Aware Video Analysis to Guide
Visually Impaired Walking on the Street

Ervin Yohannes1, Timothy K. Shih1, and Chih-Yang Lin2(&)

1
National Central University, Taoyuan, Taiwan
2
Yuan Ze University, Taoyuan, Taiwan
andrewlin@saturn.yzu.edu.tw

Abstract. Although many researchers have developed systems or tools to assist

blind and visually impaired people, they continue to face many obstacles in
daily life—especially in outdoor environments. When people with visual
impairments walk outdoors, they must be informed of objects in their sur-
roundings. However, it is challenging to develop a system that can handle
related tasks. In recent years, deep learning has enabled the development of
many architectures with more accurate results than machine learning. One
popular model for instance segmentation is Mask-RCNN, which can do seg-
mentation and rapidly recognize objects. We use Mask-RCNN to develop a
context-aware video that can help blind and visually impaired people recognize
objects in their surroundings. Moreover, we provide the distance between the
subject and object, and the object’s relative speed and direction using Mask-
RCNN outputs. The results of our content-aware video include the name of the
object, class object score, the distance between the person and the object, speed
of the object, and object direction.

Keywords: Content-aware
Mask-RCNN
Visually impaired
Distance

Speed
Direction
Assistive technology

1 Introduction

The World Health Organization (WHO) reports that around 253 million people have
some form of vision impairment and 36 million people are blind. These populations
would benefit from navigation assistance to help them in their daily lives. In recent
years, Computer Vision (CV) has created opportunities to develop systems that can
enable the visually impaired to connect with, recognize, and search their surroundings
[1]. However, building such navigation tools is difficult, especially in complex situa-
tions. Many methods have already been tried, including inexpensive canes, guide dogs,
and electronic travel aids. The difficulties that all of these solutions are trying to solve
can be classified into three categories: identifying the position of the person, the per-
son’s desired destination, and the best way to get to that destination [2]. Traditionally,
the blind and visually impaired have used a cane-like stick to detect object/obstacles in
the way. But now, more advanced technology has led to many research papers about
smart sticks that can classify object/obstacles via embedded sensors [3]. Researchers
have even added GPS into these walking sticks to obtain accurate location information,

© Springer Nature Switzerland AG 2019

H. Badioze Zaman et al. (Eds.): IVIC 2019, LNCS 11870, pp. 3–13, 2019.
https://doi.org/10.1007/978-3-030-34032-2_1
4 E. Yohannes et al.

and ultrasound to detect obstacles and potholes when the user is walking indoors or
outdoors [4]. Another navigation solution uses a virtual dog [5], which is implemented
by combining AlexNet and GoogleNet network for activity recognition. It can help the
blind and visually impaired to “see” using audio output from activity recognition.
We propose a new way to help the visually impaired navigate their surroundings
through image classification, object detection, and segmentation, which are imple-
mented via deep learning methods. We employ Mask-RCNN, a well-known model that
has been widely used to handle such issues. It has already been successfully applied to
oral disease detection and segmentation [6]. Moreover, its model can automatically
segment nucleic using a microscopic image. A navigation system must be able to
perform detection, localization and instance segmentation of a natural image [7]. Mask-
RCNN has been applied to hand segmentation using the COCO dataset and combined
with Mean Shift to improve the tracking results. Moreover, it can be applied to
dynamic hand segmentation for even better accuracy [8].
Using artificial intelligence, computer vision, and pattern recognition for classifi-
cation, tracking, detection, and recognition can be handled by Mask-RCNN. We want
to leverage the advantages of this method to build content-aware video analysis for
blind and visually impaired people to classify, track, detect, and recognize
object/obstacles around them. We use the COCO dataset, which contains many classes
of object/obstacles, for training.
We improve upon the Mask-RCNN results with the distance between the person
and object, additionally calculating the object’s speed and direction. We obtain the
class and score of an object from the Mask-RCNN results and find the distance by
using the threshold of the bounding box perimeter between the person and object using
two conditions (“medium” and “near”) in our system. We then calculate the total
distance and frame to get the speed of the object. The direction of the object is found
using the origin coordinates, point, and angle, which automatically show the direction.
Our contributions are thus threefold. (i) Calculate the distance between the subject and
the object; (ii) Calculate the object’s speed; (iii) Identify the direction of the object.
The paper is organized as follows. In Sect. 2, we present related literature. In
Sect. 3, we describe the Mask-RCNN method and our proposed method. In Sect. 4, we
present the experimental results. We draw conclusions and propose future work in
Sect. 5.

2 Related Work

The rapid global development of technology has spurred innovative assistive tech-
nologies, especially for the blind and visually impaired populations. For instance,
recently developed technology can help blind people easily identify clothes using NFC
(Near Field Communication) [9]. This system was developed on a Web platform, and
clothing characteristics are input manually. Blind people can also recognize products
for daily needs using a camera [10] since combining K-means clustering and SIFT
method allows for the separation of background and foreground, as well as recognition
of product labels.
 Content-Aware Video Analysis 5

Today, deep learning has proven to be more powerful than machine learning
methods, especially in classification, tracking, detection, and recognition tasks [6, 7].
A deep neural network schema has been used to predict the future short-term speed
with a dataset consisting of a vehicle’s historic speed and acceleration, steering
information, area and driving time [11]. Positive results have shown promise for deep
learning methods. New deep learning models for object recognition (Faster-RCNN, R-
FCN, Mask-RCNN) and image feature extraction (InceptionResnet and Resnet) rely on
simple designs with better results. Mask-RCNN can be applied to synthetic images
only with the feature extractor frozen [12].
The latest event-recognition structure using deep local flow in fast region-based
convolutional neural network (Fast RCNN) is related to traffic violation recording,
monitoring, and control. The definition of the event varies in many aspects, but at its
core, an event in video detection is an object that manifests some behavior in the
scenes. So, in [13] event-recognition in the video consists of direction and speed of
object recognition, detection, and behavior. Content awareness also uses deep object
co-segmentation that segments a similar object from various images [14]. The work
compares three architectures, including channel-wise attention (CA), fused channel-
wise attention (FCA), and channel spatial attention (CSA) for classification between a
seen object and unseen object. Content awareness can additionally be implemented on
sports data to become a reference in context-aware research, especially sports videos
with respect to context-oriented groups, objects, and events [15].

3 Proposed Method

The general framework of our proposed method is shown in Fig. 1. It consists of four
main blocks. First, Mask-RCNN outputs name class and object score. Second, the
distance between the person and object is found using the bounding box perimeter
threshold. Third, the speed of the object is calculated using distance and frame total.
Lastly, we determine the direction of the object.

Fig. 1. Framework for the proposed method

6 E. Yohannes et al.

Fig. 2. The Mask-RCNN framework [17]

Fig. 3. Selected portions of a frame. Original image (left); after processing (right)

3.1 Mask-RCNN
Mask-RCNN is a popular deep learning model, especially for instance segmentation
[16]. It is derived from Faster RCNN and adds a mask for predicting segmentation on
every Region of Interest (RoI). The bounding box regression and existing branch
classification run in parallel. The technique applies a similar two-step procedure, with
an identical first stage, (which is RPN). The framework of Mask-RCNN is shown in
Fig. 2 [17]. For this research, we only take the important parts of an image to be
processed by Mask-RCNN. Those parts remain in RGB video, while other parts are
converted into the black by setting a value limit for the distance from the left and right
sides as shown in Fig. 3.

3.2 Distance Measurement

Distance between the person and object is based on thresholding of the bounding box
perimeter. We assume that the bounding box shape is a rectangle. So, we can get the
perimeter from the width and height of the bounding box using Eq. (1).

perimeter ¼ ð2 x widthÞ þ ð2 x heightÞ ð1Þ

Here, we have two conditions for the distance: “near” and “medium”. “Near” means the
perimeter value exceeds 400. “Medium” means the perimeter value is between 300 and
400. This is denoted by Eq. (2).
 Content-Aware Video Analysis 7

Fig. 4. Perimeter perspective (a) near distance (b) medium distance

300\perimeter\400; medium
distance ð2Þ
perimeter [ 400; near

We have a perspective on the distance of an object. If an object is far from the person,
the size of an object is small (the perimeter is small). In turn, if an object is close to the
person, the object’s size is large (the perimeter is large) as shown in Fig. 4.

3.3 Speed Perspective

We assume the speed of the object always moves based on the subject’s perspective.
So, when we refer to speed, we are referring to the speed at which the blind person is
moving from the object, and not the actual speed of the object. Many researchers have
calculated vehicle speed using static cameras in traffic lights [18, 19]. Besides using
simple line applying RoI to obtain the vehicle speed [20], gradient [21], infrared/
ultrasonic sensors [22], and fusion of visual and semantic features [23] have also been
used. However, little research about vehicle speed has been done in dynamic cameras.
Thus, we need to define the vehicle speed. We use the old coordinates and current
coordinates to get the distance by Euclidian distance. Afterward, we divide the distance
and frame total by time. Distance and speed are calculated using Eqs. (3) and (4)
respectively. The description of vehicle speed can be shown in Fig. 5.
8 E. Yohannes et al.

Fig. 5. Description of vehicle speed

qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
s¼ ð x1  x2 Þ 2 þ ð y1  y2 Þ 2 ð3Þ

distance ðsÞ
speed ðvÞ ¼ ð4Þ
time ðtÞ

3.4 Direction
The direction of a moving object is based on the center point, destination point, and
angle. The destination point is the same as the center point, and we add speed value
inside it so the length of the direction depends on the speed. We can find the angle by
calculating two coordinates (x, y) and then incorporating them with the cotangent
(tan−1) as shown in Eq. (5).
 
b 1
h ¼ tan ð5Þ
a

After we get the theta (h), we insert it into a trigonometric function that rotates a point
counterclockwise by an angle around the origin, which must be in radians. The
computation of the rotation is shown in Eq. (6), and the description of h is shown in
Fig. 6. R represents rotation, (i, j) represents the destination coordinates, (a, b) refers to
the center coordinates, and h is the angle.


x ¼ a þ cosðhÞ x ðiaÞ  sinðhÞ x ðjbÞ
R ð6Þ
y ¼ b þ sinðhÞ x ðiaÞ þ cosðhÞ x ðjbÞ
 Content-Aware Video Analysis 9

Fig. 6. The description of h

4 Experimental Results

4.1 Datasets
The dataset uses a common object in context (COCO). COCO is the largest image
dataset for object detection and segmentation purposes and can be applied in many
platforms, including MATLAB, Python, and Lua APIs. The COCO 2017 dataset
contains 123.287 images and 886.284 instances. We use this dataset without any edits.

4.2 Requirements and Results of Mask-RCNN

The computations in this model are complex, so we must use a computer with a lot of
memory. Moreover, deep learning implementation uses GPU to get faster results. The

Fig. 7. Mask-RCNN results

10 E. Yohannes et al.

software used Python 3, Keras, and TensorFlow. Furthermore, we had to install another
library that included numpy, scipy, pillow, cython, matplotlib, scikit-image, opencv-
pyhton, h5py, imgaug, and Ipython. Afterward, we could run the Mask-RCNN pro-
gram to obtain outputs for the name of the label class, score, mask and bounding box.
The original results of Mask-RCNN are shown in Fig. 7.

4.3 Distance Analysis

The average distance between the blind person and a detected object can be accurately
calculated, but some objects are not detected. This issue comes from the dataset used;
not all objects are available in the COCO dataset. One example of an object not
available in the COCO dataset in our research is a power pole shown in Fig. 8. It is
important for blind people to recognize objects surrounding them. In our work, nearby
objects are in red, and those that are a medium distance from the subject are marked in
green. The different colors are intended to create system alerts for the blind and visually
impaired.

Fig. 8. A missing object in the COCO dataset (Color figure online)

4.4 Speed and Direction Analysis

The speed and direction have the same functions in defining the length of the line. In
our research, the speed in each object detection has a different value and no object has a
zero value. The description of speed and direction is shown in Fig. 9. The circle
represents the center of an object and the circle depends on the width and height of each
object. Sometimes, the object’s width is greater than the height or vice versa. The arrow
represents the direction of each object and it is developed using the center point,
destination point, and angle.
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 Acute Spinal Meningitis.

SYNONYM.—Leptomeningitis spinalis acuta.

By the term spinal meningitis is usually meant inflammation of both

the arachnoid and the pia, the two being, as already stated, in reality
one membrane. In connection with meningitis of the brain it
constitutes a distinct disease which is usually epidemic, and
probably zymotic in its origin. (See EPIDEMIC CEREBRO-SPINAL
MENINGITIS.) Sporadic spinal meningitis is a rare disease. It may be
acute or chronic.

ETIOLOGY.—Among the causes of acute spinal meningitis are injuries

to the vertebral column, such as fracture and dislocation from falls,
blows, etc.; wounds by stabbing or shooting; violent bodily effort, as
in lifting heavy weights, etc. Other causes are local exposure to wet
and cold, as from sleeping on the wet ground or standing long in
water while at work. Like cerebral meningitis, it may complicate
constitutional diseases, as rheumatism, pyæmia, etc., but less
frequently than the former. Syphilitic inflammation of the spinal
membranes is, however, not unfrequently met with, but chiefly of the
chronic form. (See the article on SYPHILIS OF THE BRAIN AND SPINAL
CORD.) In tubercular meningitis of the brain the pia mater of the cord
is often implicated in the disease. Acute spinal meningitis is most
frequently met with in young persons, and is more common in men
than in women.

SYMPTOMS.—The onset of the disease is generally sudden, and it is

rarely preceded by the usual inflammatory symptoms of chilly
sensations, restlessness, headache, etc. A sharp rigor is the first
indication of disease in most cases. This is followed by fever, with
high temperature and a quick, full, hard pulse. Pain in the back
follows, either confined to a limited region or extending throughout
the whole extent of the spine, soon becoming acute, and aggravated
by any movement of the trunk or even of the limbs. There is usually
but little tenderness on pressure upon the spinous processes, and
often none at all. The pain extends around the body and throughout
the limbs. In the course of a few hours muscular contraction in the
region of the back, and also of the limbs, is observed. When the
disease is situated in the cervical region, the head is drawn
backward, and cannot be moved without severe pain. If it occupies a
considerable extent of the spine, the dorsal muscles become rigidly
contracted and the body is arched forward (opisthotonos), as in
tetanus, so that the patient may even rest upon his occiput and
sacrum. Owing to the implication of the muscles of respiration, more
or less dyspnœa is common, and may even cause death by
asphyxia. There is no paralysis of the limbs, unless there be
complication of myelitis, but the patient abstains as far as possible
from any movement from dread of pain. Reflex irritability is
exaggerated. Retention of urine and constipation are common,
probably for the same reason. Hyperæsthesia of the surface of the
body in limited areas is sometimes noticed, owing to the irritation of
the posterior spinal roots. Provided the extent of the inflammation be
comparatively limited, recovery is possible, though rare, at this stage
of the disease.

When the course of the disease is unfavorable, symptoms of

paralysis appear, from compression of the cord by the products of
inflammation. The hyperæsthesia of the skin gives place to
insensibility; the muscles lose their reflex function and their reaction
to electricity; the bladder and rectum become paralyzed. The
invasion of the medulla by the disease, which is announced by
paralysis of the muscles of the œsophagus and of the tongue, is a
fatal complication. The pulse and the respiration become rapid and
irregular from compression of the vagus, the temperature rises to
106° or 108° F., and death ensues through asphyxia or failure of the
heart.

The course of acute spinal meningitis is rapid. It sometimes

terminates fatally within two or three days, and the average duration
of fatal cases is about a week, but exceptionally the disease may last
for several weeks or even months. Even then complete recovery
may take place, though permanent effects are usually left behind,
such as paresis or paralysis of the lower extremities, muscular
contractions, muscular atrophy, etc., from injury to the nerve-roots or
the cord.

The mind is generally clear in the early stage; afterward there may
be delirium, especially along with cerebral complication.

MORBID ANATOMY.—It is rarely that the pia mater is the only tissue
involved in the inflammation. Frequently the inner surface of the dura
is the seat of a fine injection, with delicate false membranes, and the
cord itself—at least its exterior portions—probably always
participates more or less in the congestion. The pia is reddened and
thickened, the surface showing small bloody extravasations, and the
space between its two layers is the seat of a fibro-purulent deposit.
The spinal fluid is turbid and flocculent. The seat and extent of the
morbid appearances vary in different cases; they are always more
abundant in the posterior than the anterior part of the cord, and may
be confined to a limited space or extend throughout its whole length.
It is remarkable that the region of the medulla oblongata is generally
free or only slightly affected; but since bulbar symptoms are often
prominent in grave cases, Leyden6 accounts for it by supposing that
the exudation is washed away by the constant movement of the
cerebro-spinal fluid. If the cord be involved in the inflammation, it is
softened and injected, the nerve-sheaths are destroyed, and the
axis-cylinders swollen in places. The nerve-roots show hyperæmia,
infiltration of the interstitial tissue with round cells, and destruction of
the nerve-sheaths.
6 Klinik der Rückenmarks-krankheiten, von E. Leyden, Berlin, 1874, vol. i. p. 407.

DIAGNOSIS.—Spinal meningitis is easily recognized in most cases by

its sudden onset and the severity of its symptoms. The distinguishing
symptoms are sudden and acute pain in the back, extending around
the body and into the limbs, which is increased by every movement
of the trunk, rigidity of the back, hyperæsthesia of the skin, retraction
of the head, with difficulty of breathing and of swallowing. The
diseases from which it must be distinguished are muscular
rheumatism (so called), tetanus, and myelitis. In rheumatism of the
dorsal muscles the pain is confined to the back, does not extend to
the limbs, and is only excited by movement. The fever is moderate or
absent; there are no symptoms of spinal complication, such as
cutaneous hyperæsthesia, retraction of the head, paresis of the
limbs, etc.; and the result is uniformly favorable. Tetanus is almost
always due to some well-marked traumatic cause; the muscles of the
jaw are usually first implicated (trismus); and the attacks of general
muscular spasm are easily excited by peripheral irritation. Myelitis
can be distinguished by the absence of pain in the limbs and by
paraplegia, but it must be borne in mind that myelitis and spinal
meningitis may coexist.

PROGNOSIS.—Acute spinal meningitis is always a grave disease,

hence a guarded opinion should be given even in apparently
favorable cases. General mildness of the symptoms, with no
indication of extension to the medulla oblongata, would afford ground
for encouragement. The unfavorable symptoms are those showing
compression or inflammation of the cord, such as paresis, paralysis,
twitching of the limbs, muscular contractions, cutaneous anæsthesia,
etc. The extension of the disease to the medulla, as shown by
difficulty of swallowing, speaking, or breathing, is almost necessarily
fatal.

TREATMENT.—During the first stage of the disease an effort should be

made to reduce the hyperæmia of the membranes by the local
abstraction of blood. This is best effected by cupping along each
side of the spine and by the application of leeches to the anus; the
bleeding should be promoted by poultices. Free purging is likely to
be of service, and is best obtained by means of ten grains each of
calomel and jalap (for an adult), followed by saline laxatives.
Counter-irritation to the back may be induced by the application of
blisters or by painting the skin with a strong tincture of iodine (one or
two drachms of iodine to an ounce of sulphuric ether). After the
effusion of lymph and pus, as shown by symptoms of compression of
the nerve-roots and cord, absorbents should be tried, of which the
iodide of potassium, in doses of five to ten grains, four times daily, is
most likely to be of benefit. Pain must be relieved by opium or
morphia and chloral hydrate. The latter, either alone or combined
with hyoscyamus and bromide of potassium, will be useful to allay
spasmodic twitching, opisthotonos, or muscular contraction. The
patient should be enjoined to lie on each side alternately, or on the
face if possible, in order to equalize the hyperæmia of the
membranes and cord. Liquid nourishment must be freely
administered, such as milk, broths, gruel, etc., together with wine
and other stimulants in case of exhaustion and threatening of
collapse. During convalescence the patient should be carefully
protected against cold and fatigue, and the strength must be
supported by quinine and iron with suitable diet.

Chronic Spinal Meningitis.

SYNONYMS.—Chronic inflammation of the pia mater of the spinal cord,

Chronic spinal leptomeningitis.

Chronic spinal meningitis may follow the acute form, or it may arise
from chronic disease of the vertebræ or of the cord, especially
myelitis and sclerosis. It is most apt to accompany sclerosis of the
posterior columns, and it is often difficult to say in any particular case
whether the meningeal affection preceded or followed that of the
cord. Probably some cases of chronic myelitis, especially of the
disseminated form, owe their origin to chronic meningitis.7 It has
been thought to follow blows on the back, and also to arise from
general concussion without traumatism, and has been considered as
a frequent result of accidents from railroad collisions, etc. This view
has been disputed by Herbert W. Page,8 who says: “Of the
exceeding rarity of spinal meningitis as an immediate result of
localized injury to the vertebral column we are well assured.... And
we know of no one case, either in our own experience or in the
experience of others, in which meningeal inflammation has been
indisputably caused by injury to some part of the body remote from
the vertebral column.” Chronic alcoholism and syphilis, especially the
latter, predispose to the disease. In many cases no adequate cause
can be assigned.
 7 Leyden, op. cit., vol. i. p. 442.

8 Injuries of the Spine and Spinal Cord, without Apparent Mechanical Lesion and
Nervous Shock, in their Medico-legal Aspects, London, 1883, p. 128.

SYMPTOMS.—Gowers9 remarks that a large number of symptoms

formerly assigned to chronic spinal meningitis have nothing to do
with that pathological state, but are now known to be owing to
alterations within the cord which are frequently associated with it.
The symptoms which are really due to the meningeal inflammation—
namely, those arising from interference with the nerve-roots in their
passage through the thickened membranes—do not differ essentially
from those of chronic pachymeningitis of the spine; the principal are
pain in the back, especially on movement, extending to the trunk and
limbs, hyperæsthesia of the skin in various regions within the domain
of the irritated sensory roots, with diminution or loss of the knee-jerk,
and areas of anæsthesia due to their more complete compression.
The compression of the motor roots gives rise to symptoms which
are similar to those of disease of the anterior cornua, consisting
chiefly of muscular wasting, with impairment of motion in
corresponding regions, without fever.
9 The Diagnosis and Diseases of the Spinal Cord, by W. R. Gowers, M.D., 2d ed.,
Philada., 1881, p. 73.

The anatomical appearances, which are most pronounced in the

posterior aspect of the cord, and diminish from below upward, are
often of considerable extent. The membrane is thickened, opaque,
and often adherent to the cord. On the inner surface are seen
numerous small bodies composed of proliferating connective
tissue.10 These, according to Vulpian, are chiefly found in the lower
dorsal and lumbar region and on the cauda equina. The dura is very
frequently involved in the inflammation; it is thickened, and its inner
surface is adherent to the pia, often showing numerous miliary
bodies similar to those found in the pia.
10 Leyden, op. cit., vol. i. p. 144; A. Vulpian, Mal. du Syst. nerv., Paris, 1879, p. 126.
DIAGNOSIS.—Chronic spinal meningitis so rarely exists apart from
disease of the dura or of the cord that its separate diagnosis must be
mainly a matter of conjecture. Leyden justly says we must usually be
content to diagnosticate chronic meningitis without attempting any
further distinction, except in cases which originate in disease of the
vertebræ or of their neighborhood, and afterward penetrate into the
spinal canal, and which would probably give rise to pachymeningitis.
The diseases with which chronic meningitis of the spine is most likely
to be confounded are posterior sclerosis (locomotor ataxia) and
chronic degeneration of the anterior cornua (progressive muscular
atrophy).11 From the former it is distinguished by the absence of
ataxia; from the latter, by the irregular distribution of the symptoms;
and from both, by the existence of limited areas of anæsthesia and
of extensive spinal pain. It must be remembered that inflammation of
the cord complicating that of the meninges, or pressure upon the
cord by the thickened membranes may give rise to mixed symptoms.
The latter is especially observed in syphilitic cases.
11 Gowers, op. cit., p. 74.

PROGNOSIS.—Simple chronic spinal meningitis is rarely if ever fatal.

How far it is capable of amelioration or of cure is not, in the present
state of our knowledge, known. When complicated with disease of
the cord the prognosis will depend upon that of the latter. Syphilitic
chronic meningitis is to a certain extent amenable to appropriate
medication.

TREATMENT.—The treatment should have for its object (1st) to relieve

pain; (2d) to arrest the progress of the inflammation, and especially
to prevent it from extending to the cord; (3d) to promote the
absorption of the exudation. For the first object the internal or
hypodermic employment of morphia should be combined with
external applications, such as fomentations, liniments, ice, etc.
Counter-irritation by means of dry cupping, blisters, iodine, etc., with
leeches, shampooing, and douches of hot water, may be of some
use in retarding the progress of the inflammation, and should be
aided by the administration of mercurials and the preparations of
iodine. The biniodide of mercury would be useful for this purpose in
the dose of one-sixteenth to one-eighth of a grain three times daily,
its effect being carefully watched in order to prevent salivation. The
same means will also aid in favoring the absorption of lymph. In
syphilitic cases an appropriate specific treatment is indicated.

Spinal Meningeal Hemorrhage.

SYNONYMS.—Spinal meningeal apoplexy, Hæmatorrhachis.

Spinal meningeal hemorrhage may take place between the dura

mater and the walls of the vertebral canal, or between the dura and
the pia mater—i.e. into the arachnoid space.

ETIOLOGY.—Penetrating wounds, injuries to the vertebræ, fractures

and dislocations, and violent blows are apt to give rise to more or
less hemorrhage into the spinal canal. Violent convulsions, as in
tetanus, epilepsy, uræmic eclampsia, hydrophobia, may be followed
by meningeal hemorrhage, owing to the disturbance of the
circulation from asphyxia; and excessive muscular effort, as in lifting
heavy weights, etc., has been said to cause it. In cerebral meningeal
hemorrhage and in effusion into the substance of the brain the blood
sometimes escapes into the spinal canal. An aneurism of the aorta
has been known to communicate with the canal; such a case was
reported by Laennec.12 In certain diseases with hemorrhagic
tendency, as purpura and scurvy, spinal extravasation is occasionally
observed.13
12 Traité d'Auscultation médiate, 4th ed., Paris, 1837, vol. iii. p. 443.

13 A case of scorbutic spinal hemorrhage is reported in the British Med. Journal, Nov.
19, 1881.

SYMPTOMS.—These vary according to the conditions under which the

hemorrhage is produced and to the amount of bleeding. In traumatic
cases the signs of hemorrhage are often completely overshadowed
by those of the injury of the vertebræ, the membranes, or the cord,
and are undistinguishable. When a large amount of blood is
suddenly introduced into the spinal canal, it usually gives rise, by
pressure on the cord, to paraplegia, which, however, is sometimes of
only short duration. Thus in Laennec's case the bursting of an
aneurism into the spinal cavity was signalized by a sudden
paraplegia, but in half an hour the power of movement returned,
though sensation did not. The patient died in a few hours from
hemorrhage into the left pleural cavity. The amount of blood in the
spinal cavity is not stated, and, in fact, it would appear that the spine
was not opened. When the amount of blood is smaller the symptoms
indicate irritation of the spinal nerves and of the cord. Pain in the
back is always present, extending into the limbs, and is sometimes
severe. Its seat corresponds to that of the effusion. There may be a
feeling of tingling and numbness in the lower extremities, with
anæsthesia or hyperæsthesia of the skin and more or less paresis. A
feeling of constriction around the waist or the chest is sometimes
complained of. In slight effusions the symptoms may be limited to
numbness and formication of the extremities, with slight paresis.
There is rarely fever in the early stages, unless the amount of blood
is sufficient to give rise to inflammatory conditions of the cord or
membranes. If the extravasation be moderate it is generally
absorbed, with relief to the symptoms, although slight numbness and
paresis of the extremities may continue for a long time.

PATHOLOGICAL ANATOMY.—In hemorrhage outside the dura the loose

cellular tissue between the membrane and the bony canal contains
more or less coagulated blood according to the circumstances of the
case, especially in the posterior region of the canal and covering the
nerve-roots. The dura is reddened by imbibition of the coloring
matter of the blood. When the amount of the effusion is large, as in
traumatic and aneurismal cases, or where cerebral hemorrhage has
extended into the spine, the cord may be compressed by it.
Hemorrhage into the arachnoid sac, except in cases of violence,
etc., is usually of limited amount, sometimes only in the form of
drops of blood upon the surface of the dura or pia. When more
abundant it may surround the cord more or less completely, but in
most cases it is limited in longitudinal extent, being confined to the
space of one or two vertebræ. The cord may be more or less
compressed, reddened, and softened. In all cases the spinal fluid is
discolored and reddened in proportion to the amount of the
hemorrhage.

DIAGNOSIS.—When the complications are such that symptoms

attributable to hemorrhage are not observed, the diagnosis of spinal
hemorrhage is impossible. This may happen in the case of wounds
and injuries of the vertebræ and of the passage into the spinal canal
of blood from an apoplectic effusion of the brain. In the convulsions
of tetanus, epilepsy, etc. the amount of the hemorrhage is rarely
sufficient to give rise to distinctive symptoms. In idiopathic and
uncomplicated cases the chief diagnostic marks are suddenness of
the attack; pain in the back, usually at the lowest part; disturbances
of sensation in the extremities (anæsthesia, formication, etc.);
paresis or paralysis of the legs; the absence of cerebral or spinal
inflammatory symptoms; and, in many cases, the favorable course of
the disease. Sometimes an ostensible cause, such as scurvy,
purpura, suppressed menstruation, or hemorrhoidal flux, will aid in
the diagnosis. The disease for which spinal hemorrhage is most
likely to be mistaken is acute myelitis, but this is not sudden in its
onset, is accompanied with fever, and gives rise to paralysis both of
motion and sensation, and to loss of control over the sphincters, to
bed-sores, etc. Hemorrhage of the cord would be accompanied by
paraplegia and loss of sensation in the lower extremities and slight
tendency to spasmodic manifestations; it is fatal in the majority of
cases, or else is followed by permanent paralysis. Hysteria might be
confounded with spinal hemorrhage, but the history of the case and
the transient duration of the symptoms would clear up all obscurity.

PROGNOSIS.—In traumatic cases the hemorrhage is usually only one

element in the gravity of the situation, which depends chiefly upon
the character and extent of the original injury. In idiopathic and
uncomplicated cases the prognosis, which must always be doubtful,
will vary according to the severity of the symptoms as corresponding
to the amount of the effusion. The danger is greatest during the first
few days; if there should then be diminution of the more important
symptoms, an encouraging opinion may be given. The immediate
effects may, however, be less grave than the remote, such as bed-
sores, cystitis, etc. Except in the very mildest cases the patient is
likely to be confined to bed for several weeks. In more severe ones
the convalescence may be very protracted, and permanent
lameness, etc. may result.

TREATMENT.—In the early stage absolute rest in bed, with cold

applications to the back and moderate purging, should be employed.
Large doses of ergot are recommended, but there is little evidence of
benefit from this medicine. In traumatic cases no rules for treatment
of the hemorrhage can be laid down. If the extravasation evidently
depends upon a constitutional diathesis, as in purpura, scurvy, etc.,
the remedies appropriate for these diseases should be employed,
especially tonics and astringents, such as the tincture of the chloride
of iron, in doses of from fifteen to thirty drops three times daily,
quinine, and the vegetable acids. Should there be evidence of blood-
pressure from suppressed discharge, as in amenorrhœa, arrested
hemorrhoidal flow, etc., leeches should be applied to the anus, and
blood may be taken from the region of the spine by cupping. In the
later stages an attempt may be made to aid the absorption of the
effused blood by the administration of the iodide of potassium or the
protiodide of mercury, and by the application of blisters or strong
tincture of iodine to each side of the spine. Pain must be relieved
and sleep obtained, when necessary, by means of opium, chloral
hydrate, or other anodynes. Electricity, rubbing, bathing, etc. will be
useful for combating the paralytic symptoms which may remain after
the disease itself is relieved.
 SPINA BIFIDA.

BY JOHN ASHHURST, JR., M.D.

DEFINITION.—By the term spina bifida is meant a congenital

malformation of the vertebral column, consisting in the absence of a
part—commonly the spinous processes and laminæ—of one or more
of the vertebræ, and thus permitting a protrusion of the spinal
meninges, which, with their contents, form a tumor of variable size
and shape, usually in the lumbo-sacral region.

SYNONYMS, ETC.—Of the various names which have been proposed

for this affection, most are objectionable, as not expressing with
sufficient definiteness what is meant. Thus, hydrorachis (the term
generally employed by French writers), hydrorachitis, spinal
hydrocele, etc., convey merely the notion of an accumulation of fluid
within the spinal canal, and are as applicable to simple serous
effusions in that part, whether occurring as a complication of
hydrocephalus or as the result of injury, as to the special affection
under consideration. Again, myelochysis—pouring out or protrusion
of the spinal marrow—would imply that the cord itself was
necessarily involved in the tumor, which is certainly not always the
case. The terms schistorachis (cleft spine) and atelorachidia
(defective spine—a name suggested by Béclard) would be
preferable, and are really more accurate than the name spina bifida,
since, as a matter of fact, the spinous processes are, as a rule, not
bifid, but totally deficient. The latter term, however, has the
advantage of being more familiar, and may be retained simply as a
matter of convenience. It is said by Itard to have been first employed
by the Arabian physicians.
HISTORY.—Spina bifida does not appear to have been known to the
ancients, the earliest recorded observations of the affection being
found in the writings of Bauhinus (1560-1624), of Tulpius (1593-
1674), of Bonetus (1620-89), and of Ruysch (1638-1731). Good
accounts of the affection may be found in the Dictionnaire des
Sciences médicales (tome xxii., Paris, 1818), and particularly in
Holmes's Surgical Treatment of the Diseases of Infancy and
Childhood (2d ed., London, 1869), in Follin and Duplay's Traité de
Pathologie externe (tome iii.), and in Treves's article on
“Malformations and Injuries of the Spine” in the International
Encyclopædia of Surgery (vol. iv., New York, 1884).

ETIOLOGY.—There are two conditions essential to the formation of a

spina bifida: (1) an arrest of development, or at least a defective
closure, of the vertebral arches; and (2) a dropsical condition either
of the central canal of the spinal cord or of the subarachnoid spaces;
but which of these is the antecedent condition it is, as justly
remarked by Erb, impossible to decide. Spina bifida often occurs as
a complication of hydrocephalus, and is itself often complicated with
an atrophic and deformed condition of the lower extremities—a
circumstance which led Tulpius to suggest that the malformation was
caused by a malposition of the fœtus in utero, an explanation which
it seems hardly necessary to waste time in considering. Salzmann
observed spina bifida in two children born of the same mother, and
Camper noticed it in twins.

SYMPTOMATOLOGY.—Spina bifida forms a tumor—or, more rarely,

several tumors—in the region of the vertebral column, usually
discovered at birth, but occasionally not noticed until a later period.
Thus, Lancisi mentions a case in which the tumor first made its
appearance in a hydrocephalic child at the age of five years, and J.
L. Apin one in which the patient reached the age of twenty before
any swelling was manifested. If these records are accepted as
authentic, the only satisfactory explanation is that of Itard—viz. that
the bony deficiency existed from the time of birth, and that the
dropsical protrusion did not occur until afterward: this seems to me
more reasonable than the suggestion of the younger Andral, that the
vertebræ underwent a process of secondary softening and
absorption. The part most frequently affected is the lumbar region,
but cases are not wanting of the occurrence of spina bifida in the
cervical, dorsal, and sacral regions, and even, in at least one case
(Genga's), in the coccyx. The tumor almost invariably occupies the
median line, and projects directly backward: in at least four cases,
however, recorded by Bryant, Emmet, and Thomas, the tumor
protruded anteriorly from deficiency of the vertebral bodies.

The size of a spina bifida varies from that of a walnut to that of a

child's head, or even larger: in some rare instances, such as those
recorded by Lezelius and Richard, the whole spinal column has been
cleft, and the tumor has extended from nucha to sacrum; but cases
of this kind seldom come under the surgeon's observation, as
children with such extensive deformity usually perish shortly after
birth. The shape of the swelling is rounded, or more often oval; it is
commonly sessile, but occasionally pedunculated; and it is
sometimes lobulated, the lobules being separated by more or less
distinct sulci. The skin covering the tumor is in some cases normal,
with more or less fat in the subcutaneous connective tissue, but
more often thin, tightly stretched, red, shining, and occasionally
ulcerated; more rarely it is thickened and leathery, as in a case
referred to by Sir Prescott Hewett. Sometimes a navel-like
depression is found at some part of the surface, corresponding, as
pointed out by Follin and Duplay, and by Erb, to the place of
attachment, on the interior of the sac, of the terminal extremity of the
spinal cord. The cutaneous investment is sometimes altogether
wanting, the spinal dura mater itself forming the external covering of
the tumor. It is in these cases especially that ulceration and rupture
are apt to occur.

Spinæ bifidæ are usually soft and fluctuating, and occasionally

partially reducible; their tension and elasticity are increased when the
child is in the upright position or during the acts of expiration and
crying, and are diminished during inspiration or when the child is laid
upon its face. When the part is relaxed a bony prominence can be
felt on either side, and the aperture in the vertebral column can be
more or less distinctly outlined. The swelling is apt to be painful on
pressure. If the tumor is of moderate size and covered with healthy
skin, there are usually no constitutional symptoms, and, even where
ulceration and rupture occur, the opening may heal and a
spontaneous cure may possibly ensue. More often, as the tumor
increases in bulk—or at any time if pressure be made upon it—
various nervous symptoms are observed: drowsiness, muscular
twitchings, convulsions, and often paraplegia and paralysis of the
sphincters. Rupture is usually followed by the development of spinal
meningitis, or may prove directly the cause of death by the loss of
cerebro-spinal fluid which it causes; in other instances, however, if
the rupture be a small one, healing may occur (as already
mentioned) or a fistulous opening may persist; in rare cases the fluid
may escape by a process of transudation without rupture, as in an
example recorded by Laborie.

As may be inferred from what has already been said, the course of
spina bifida is usually rapid and toward a fatal termination. In some
instances, however, as in cases observed by Holmes, and more
recently by Lithgow, spontaneous recovery has followed the
obliteration of the channel which unites the sac with the cavity of the
spinal membranes; and in other instances, without a cure having
been effected, life has been prolonged for very many years. Thus,
Behrend reports a case in which a patient with spina bifida lived to
the age of fifty, and Holmes refers to another in which death resulted
from an independent disease at the age of forty-three. But a still
more remarkable case was recorded by Callender, the patient in this
instance having reached the age of seventy-four.

PATHOLOGY AND MORBID ANATOMY.—The most important points for

consideration in respect to the anatomy of spina bifida are the
relations which the spinal cord and spinal nerves bear to the sac,
and the nature of the contained fluid. It is ordinarily said that the
spinal cord itself commonly enters the sac of a spina bifida—the
report of the London Clinical Society's committee gives the
proportion of cases in which it does so at 63 per cent.—and Holmes
figures a specimen from the museum of St. George's Hospital,
London, in which this condition is obviously present; on the other
hand, Mayo-Robson in eight operations only once found the cord
implicated; and the late John B. S. Jackson of Boston—whose name
will be recognized as one of high authority in regard to all questions
of morbid anatomy—once assured me that he had made very many
dissections of spinæ bifidæ, and that he had invariably found that the
cord stopped short of the sac, and that only the nerves entered the
latter: this, as negative evidence, cannot of course contravene such
positive evidence as that of the specimen referred to by Holmes, but
it would seem to show that the condition was a less common one
than is generally supposed, and that in at least a fair proportion of
cases the cord itself did not form part of the sac contents. This
remark applies especially to those cases in which the fluid is
accumulated in the subarachnoid space, and in which, as pointed
out by Sir P. Hewett, the cauda equina or spinal nerves are pushed
by the vis a tergo into the sac; but when the dropsical effusion
occupies the central canal of the cord, this is apt to be flattened and
spread out like a thin lining to the sac, just as the brain is spread
over the inner wall of the skull in cases of internal hydrocephalus;
and, on the other hand, when the accumulated fluid fills the cavity of
the arachnoid the cord is apt to be pushed forward, and the sac may
be entirely devoid of all nerve-structures. Such, too, according to
Giraldès, is the case in spina bifida of the cervico-dorsal region.

The committee of the London Clinical Society classify cases of spina

bifida in three divisions: (1) Those in which the membranes only
protrude (spinal meningocele); (2) those in which the protrusion
involves both the cord and membranes (meningo-myelocele); and
(3) those in which the central canal of the cord itself forms the cavity
of the sac (syringo-myelocele). The last variety is the rarest, as the
second is the most common. In meningo-myeloceles the spinal cord
with its central canal is continued within the median, vertical portion
of the sac, and at this part there is no covering of true skin; the
nerve-roots which traverse the sac arise from this intramural portion
of the central nervous system.
Humphry of Cambridge, England, makes a somewhat similar
classification of spinæ bifidæ, recognizing as the most common
variety the hydrorachis externa anterior, in which the fluid occupies
the subarachnoid space in front of the spinal cord, and in which “the
cord and the nerves are stretched backwards and outwards upon the
sac, and are there confluent, together with the arachnoid, pia mater,
and dura mater, or their representatives, in the thin membrane which
forms the hindmost part of the wall of the sac;” rarer forms are the
hydro-meningocele, or hydrorachis externa posterior, in which the
fluid accumulates behind the cord, which does not enter the sac, and
the hydro-myelocele or hydrorachis interna, in which the fluid
occupies the central spinal canal.

The theory which, according to the Clinical Society's committee, best

explains the pathological anatomy of spina bifida is that which
assumes a primary defect of development of the mesoblast from
which the structures closing in the vertebral furrow are developed.

The fluid of spina bifida appears to be identical in character with the

cerebro-spinal fluid. Bostock found that it was very slightly clouded
by the application of heat, and that it contained, in 100 parts, 97.8 of
water, 1.0 of chloride of sodium, 0.5 of albumen, 0.5 of mucus, 0.2 of
gelatin, and some traces of lime. Five specimens more recently
analyzed by Hoppe-Seyler gave an average of 98.8 parts water, 0.15
parts proteids, and 1.06 extractives and salts. Turner found a
reaction somewhat similar to that of grape-sugar, as had been
previously found by Bussy and Deschamps in cerebro-spinal fluid
itself, but in two specimens analyzed by Noad for Holmes it was at
least very doubtful whether sugar was actually present. “The first
specimen was found to be completely neutral; its specific gravity was
1.0077; it contained phosphates, but no reaction could be obtained
resembling that of sugar. The second specimen ... did give a reaction
with copper like that of sugar, but no trace of fermentation could be
obtained.” Three analyses, however, made by Halliburton for the
London Clinical Society's committee showed uniformly a decided
trace of sugar, with a diminution in the quantity of proteids, which
appeared to consist entirely of globulin.
In some cases the sac of a spina bifida contains, besides nerve-
structures and cerebro-spinal fluid, both fibrous and fatty tissues.

DIAGNOSIS.—Ordinary fatty tumors have been mistaken for spinæ

bifidæ, but such an error could only be committed through
carelessness: more difficult is the diagnosis from certain forms of
congenital cyst, occupying the median line of the back, and still more
difficult the diagnosis from the several affections known as false
spina bifida. In the former case the distinction might be made by
noting the irreducibility, constant shape, and unchanging tenseness
of the cyst, and perhaps, as suggested by T. Smith, by tracing the
line of spinous processes beneath it; some information, too, might
perhaps be gained by chemical examination of the fluid obtained by
puncture. Under the name of false spina bifida Holmes includes
three distinct conditions: these are—(1) a true spina bifida, in which
the connection with the spinal membranes has in some way been
obliterated, the sac then communicating with the vertebral canal, but
not with the theca; (2) a congenital, cystic, or fatty tumor, taking its
origin within the vertebral canal, and projecting through an opening
caused by a gap in the laminæ; and (3) a tumor containing fœtal
remains, and properly regarded as an example of included fœtation.
In any of these cases a positive diagnosis might be impossible, and
the probable nature of the tumor could only be inferred by noting the
absence of one or more of the characteristic symptoms of true spina
bifida.

PROGNOSIS.—The prognosis of spina bifida is without question

unfavorable; at the same time the affection is by no means to be
considered, as it was formerly, one of an invariably fatal character,
for, apart from the fact already mentioned that several cases are on
record in which patients with untreated spina bifida have reached
adult life, and even old age, the modern method of treatment has
proved so much more successful than those formerly employed that
in favorable cases surgical interference affords at least a reasonable
prospect of recovery. The circumstances which especially furnish
grounds for an unfavorable prognosis are the rapid growth of the
tumor, the thinning or ulceration of its coverings, and the occurrence
of nervous symptoms, and particularly of paralysis or convulsions.

TREATMENT.—This may be either palliative or radical. If the tumor be

not increasing materially in size, the surgeon may properly content
himself with palliative measures—applying equable support and
perhaps slight pressure by the use of a well-padded cap of gutta-
percha or leather, an air-pad, or, as advised by Treves, a simple pad
of cotton smeared with vaseline, and a bandage; if the tumor be
small and covered with healthy integument, painting its surface with
collodion may be of service through the contractile property of that
substance. Radical measures are only indicated when the child,
otherwise healthy, seems to have his life threatened by the rapid
growth of the tumor, causing risk of ulceration and rupture, or giving
rise to convulsions or paralysis. The principal modes of treatment to
be considered under this heading are—(1) simple tapping or
paracentesis; (2) injection of iodine; (3) ligation of the neck of the
sac; and (4) excision.

(1) Paracentesis, a simple evacuation of the fluid contents of the sac,

is the only operation ordinarily justifiable in cases attended by
paralysis or other grave nervous manifestations. The puncture
should be made in the lower part of the sac and at a distance from
the median line (in the course of which the nerve-structures are
particularly distributed), and only a small quantity of fluid—a few
drachms or at most one or two ounces—should be removed at a
time, the instrument being at once withdrawn if convulsions follow,
and the wound being instantly closed with lint dipped in compound
tincture of benzoin. Either an aspirator-tube or a small trocar may be
used, and the operation may be repeated if necessary, pressure
being maintained during the intervals. Paracentesis has occasionally
though not often proved curative.

(2) Injection of Iodine.—This mode of treatment was introduced

about the same time by Velpeau and by Brainard of Chicago. The
latter surgeon's method consists in injecting, after only partially
emptying the tumor, a solution of iodine with iodide of potassium
(iodine, 5 grs.; iodide of potassium, 15 grs.; water, 1 fl. oz.), allowing
it to flow out again, washing out the sac with water, and finally
reinjecting a portion of the cerebro-spinal fluid originally evacuated;
and the former's, in completely evacuating the tumor, and then
injecting a mixture of iodine and iodide of potassium, each one part
to ten parts of water. Each of these plans has met with a fair
measure of success;1 but the modification introduced by James
Morton of Glasgow is a great improvement, and affords what is
actually the most successful mode yet devised for dealing with spina
bifida. Morton employs a solution of iodine in glycerin (iodine, 10
grs.; iodide of potassium, 30 grs.; glycerin, 1 fl. oz.), which has the
advantage of being less diffusible than the aqueous solution, and
therefore less liable to enter the spinal canal. The tumor is about half
emptied, and a small quantity—from fluid drachm ss to fluid drachm
iij of the solution—is then slowly injected, and allowed to remain. The
operation is repeated after a few days if necessary. Of 50 cases
known to Morton as having been treated in this way up to May, 1885,
41 were regarded as successful; but of 71 cases collected by the
London Clinical Society's committee, only 39 had been benefited by
the operation.
1 In a case recently recorded by Woltering, however, iodine injection was followed by
death within half an hour.

The introduction of iodine into the sac of a spina bifida is, according
to Morton, only justifiable in cases unattended by paralysis; under
opposite circumstances I should be disposed to try a plan recently
employed with success by Noble Smith in a case of meningocele—
viz. injecting the iodo-glycerin solution into the coverings of the sac,
and as close to it as possible without perforating it.

(3) and (4). Ligation and excision have each occasionally effected a
cure, but more often have but helped to precipitate a fatal issue. A
successful case of ligation followed by excision has been recently
recorded by Löbker. The elastic ligature, applied around the neck of
the sac (if this be pedunculated), has been employed by Laroyenne,
Ball, Colognese, Baldossare, Mouchet, and other surgeons, and of 6