syphilis. I have shown in every case, on making an injection and fell to the floor in a faint. When she awoke there was of tuberculous material into an animal, that the animal never a severe pain in the lower part of her back, but after a time, failed to develop tuberculosis. Among those cases which I with some assistance, she was able to walk home. For a call the hypertrophie, we found cases of inflammatory reac¬ week the pain continued, though less severe, and she was able tion, as well as the development of tubercle; and we believe to go to school, but on the eighth day her legs grew weak that these are cases of mixed infection. Dr. Fassett spoke and began to feel numb. A week later she was unable to concerning the rarity of the occurrence of tuberculosis in the walk at all. The pain radiated down the back of the thighs shaft, as a frequent occurrence in the epiphysis ; and he men¬ and legs, and for a time the family physician thought it tioned the work of Dr. Noyes of Edinburgh, who thinks that might be due to "sciatic rheumatism." As it did not respond it is entirely metaphyseal or epiphyseal. He does not believe to salicylates, a neurologist was called in consultation. that it occurs in the shaft. Yet it certainly does occur in the The knee-jerks were increased, a slight ankle-clonus was shaft. He does not say, however, that it is rare in the present, and the condition was one of spastic paraplegia. It epiphysis. That is the most common situation by far. He was thought that possibly a vertebral tuberculosis might be agrees that it occurs there. Dr. Steindler spoke of the work present, with pressure on the cord. A double Buck's extension of Friedländer on diaphyseal tubercle, and his classification, was applied to relieve the painful flexion of the knees. In including a purely periosteal form. If you search you will a few days the paralysis had disappeared, and the child was find in every case a central focus. Tubercle cannot occur sent to the orthopedic department of the Chicago Policlinic primarily in the periosteum. It used to be thought that it to have an artificial ankylosis of the vertebrae made by the occurred in the periosteum of the rib, but osteomyelitis occurs Albee method. in every such rib. Dr. Griffith spoke of the importance of Examination.—On examination, however, no evidence of eliminating bovine tuberculosis. That is the most important spinal tuberculosis could be found, and it seemed probable part of the work. If we can eliminate that we shall have that the condition was due to a mechanical cause rather than accomplished a great deal. Our system of milk inspection in to disease. An actual forward displacement of the fifth Edinburgh, at present, is shocking beyond words ; but we lumbar was not considered as likely as a protrusion of the hope to have this corrected. Dr. Griffith also asked how I intervertebral disk, although no history of a sideways bend¬ could explain the way in which, by retarding the blood¬ ing at the time of the accident could be elicited. stream, we can localize tubercle, and asked how I could Subsequent Course.—The patient was now apparently per¬ account for tuberculous infection without any interference fectly well, and after a week of observation in the hospital with the return circulation. I would ask him how he knows she was allowed to go home, in the belief that the trouble that retardation of the blood-stream does not occur in such would not recur without severe exertion. She was cautioned cases. The tubercle is always secondary to some focus in to avoid lifting any weights and to keep quiet for some the body; and with this primary focus you get a thickening weeks. For a week at home she remained well, but the next of the vessels, which produces a certain amount of retarda¬ day she stumbled over some obstacle on the floor and the tion of the blood-stream over the entire body. paralysis recurred. The Buck's extension once more rapidly relieved the paralysis and a plaster jacket was applied, fit¬ ting very low over the hips. A few days later an attack of and was RECURRENT WITH ptomain poisoning occurred, the jacket removed SPONDYLOLISTHESIS, by the family physician on account of the distention of the PARALYSIS; BONE-SPLINT abdomen. Now began a series of attacks of paralysis, aver¬ TRANSPLANTATION aging one every ten days, until January, 1914, when the child was confined to the bed all of the time. A small and ineffi¬ EDWIN W. RYERSON, M.D. cient commercial brace had been applied some time before, CHICAGO but it did no good. I saw her again Feb. 6, 1914, ten months after she had The fifth lumbar vertebra is subject to many abnor- passed from my observation. No paralysis existed, and the malities of development which may cause mechanical reflexes were normal. On bending her backward in bed, trouble. The most frequent anomaly is probably in exaggerating the lumbar lordosis, the spinous process of the the shape or size of the transverse processes. This fifth lumbar vertebra could be felt to move forward abnor¬ will not be considered here. mally far on the sacrum. This caused pain in the back and Next in is a variation in the articular a tingling and pricking sensation in the feet. On bending frequency the the lumbar processes, which may vary in size, in or in direc- body forward, obliterating lordosis, imme¬ shape, relief was tion. If the articulation be of the lumbar type, with diate felt and the child stated that this occurred the and the habitually on similar movements. She lies and sleeps with the long axis of joint antero-posterior, flat the spine in flexion for the sake of comfort. facets to the it is for the vertebra facing side, possible Treatment.—An opinion was now given that the trouble on sacrum is to slide forward the when the spine was due to the slipping forward of the fifth vertebra as a straight or extended, especially if the articular proc- whole, and that the best way to rectify it would be to implant esses be small and the ligaments weak. If the proc- a bone splint by Albee's method so as to immobilize the lower esses be of the dorsal type, and this is by no means lumbar spine. Accordingly, on March 11, 1914, this operation was rare, flexion of the spine, with violence, may cause performed at the Policlinic. A splint was cut from the left tibia, curved to fit the lumbar the facets to override; more easily, again, if these slightly lordosis and the facets be small and the be weak. sacrum, and long enough to reach from the third lumbar ligaments process to the third sacral. The lumbar The exhaustive work of Goldthwait1 and first two sacral explained spinous processes were readily split, but the third sacral was of class of but no clearly the mechanism this lesions, merely a small projection, so a groove was cut out lumbar vertebra bodily case of displacement of the fifth with in this region. The splint was sewed in with No. 12 braided paralysis has come under my observation until last silk sutures, boiled in mercuric chlorid solution and then in year: paraffin. These sutures were inserted deeply and strongly, CASE REPORT with large needles and a heavy needle-holder, and they were tied very tightly. A layer of the lumbo-sacral fascia was History.—In the latter part of February, 1913, a strong sewed over the whole both and silk and of 15 was another in her arms, splint, covering splint healthy girl carrying girl sutures. in the gymnasium, when she suddenly felt a pain in her back The girl was placed in an ordinary bed and kept recum¬ Read before the Section on Orthopedic Surgery at the Sixty-Fifth bent for three weeks, when against orders she began to Annual Session Medical Atlantic of the American Association, City, sit when the nurse was out the room. N. J., June, 1914. up of April 7 she 1. Goldthwait, J.: Boston Med. and Surg. Jour., 1911, clxiv, 365. went home, and April 21 began to walk about. Her back

Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015 felt perfectly well and strong and she remained in excel¬ «xposed and ultimately came out. As this was the thir¬ lent condition until June 4, a period of over six weeks. On teenth operation, it naturally would be expected to fail. this latter date something gave way in her back, causing That was the only graft that I lost in the twenty-six cases; severe pain but no paralysis. Examination June 11 showed and I think, from the experience I have had, that the attach¬ that the upper tip of the splint had become loosened from ing of the graft to the sacral region gives as good results as the third lumbar spinous process. The knee-jerks were nor¬ in any other region. Dr. Ryerson's paper is of immense mal, there was no ankle clonus and sensation and motion importance, as opening up a field for the treatment of that were undisturbed. There was easily perceptible grating and most troublesome of cases, the cases of spondylolisthesis. crepitus at the tip of the splint when the back was moved, In older patients, past 35 or 40, when it is possible by and the pain was said to be quite severe on such motion. posture or some other method to eliminate the exaggerated She was advised to keep perfectly quiet for a few weeks, in lordosis and replace the cast, we shall have, I think, entire the hope that union might again take place, but it will prob¬ control of cases which hitherto have been extremely trouble¬ ably be necessary to reattach the end of the splint by oper¬ some. ation, or to cut the end off to relieve the discomfort. The Dr. J. A. Nutter, Montreal, Canada : How does Dr. Ryer- lumbo-sacral joint remains perfectly fixed and there will son explain paraplegia from so low a lesion as slipping of apparently be no further trouble from this source. the fifth lumbar vertebra? I recently had occasion to exam¬ ine mortem a man with a broken at the Montreal Note.—Aug. 7, 1914. This patient was reoperated on July 1, 1914, post back, and the upper end of the splint firmly reattached by drilling both splint General Hospital, and found a marked traumatic spondylolis¬ and third lumbar spinous process and tying with silk. She is now thesis, probably hastened by congenital malformation of the sitting up in a plaster jacket without any symptoms referable to the original difficulty. The spine seems strong and the splint is apparently laminae; without, however, any narrowing of the vertebral firmly fixed. canal at that level. This man's paralysis was probably due 122 South Michigan Avenue. to a coincident injury to one of the intervertebral disks, three or four vertebrae up, causing pressure on the cauda equina. We could not, at that time, attribute any of his ABSTRACT OF DISCUSSION paralysis to the fracture of the fifth lumbar vertebra. There Dr. Fred H. Albee, New York City: There has been con¬ was no narrowing of the vertebral canal at that level, in siderable uncertainty about the result of the application of spite of the spondylolisthesis. I should like to have some bone splints in the lumbosacral region. In my experience, light on that subject. How can injury to the cauda equina the result has been as satisfactory when the graft has been at the level of the fifth lumbar vertebra cause paraplegia? placed in the posterior part of the sacrum as in other regions Dr. E. W. Ryerson, Chicago : It is quite true that it is of the spine. Although the spinous processes there are not easy to constrict the spinal canal at the level of the fifth small, as Dr. Ryerson has said, we are able by means of lumbar vertebra, but it can be done ; and I can think of no them, together with the splitting of the periosteum on the other method by which this little girl's paraplegia could have posterior part of the body of the sacrum and the scarifying been caused. I could put my finger on the fifth lumbar of the bone, to get good union and a good surface for the spinous process, and pinch it, and could then bend her back¬ application of grafts. I have had no trouble in getting union ward and feel it slip so far that I am afraid to tell you just of the grafts in this region. So far as fixation of the fifth how far I felt it slip. It certainly could constrict any spinal lumbar vertebra goes, the contrast of the results of this graft canal that I have ever seen, and I do not think that any fixation with that of external fixation by means of braces intervertebral disk higher up had anything to do with it. or plaster jackets, is very gratifying. In fact, it is difficult She was a sensible little girl and could locate it so accu¬ to fix this region by any external means. rately that, although I was at first doubtful of the cause, I Dr. Charles A. Parker, Chicago : One point is of prac¬ had to be convinced. With regard to the attachment of the tical anatomic interest in cases in which the operation might splint to the sacrum, the remarks made are pertinent; but not be successful. Fortunately, in the cases reported, it was when attachment is made there, it is not mechanically at as apparently very successful. This is with regard to the devel¬ great advantage as when it is made to the spinous process. opment of the lower half of the fifth lumbar vertebra. The The immobilization must be carried out for a longer' time gentlemen who have described that development have gone than I carried it out in this case. I should have insisted into the matter thoroughly. The portion of the arch contain¬ on a longer period of immobilization. I believe that we must ing the spinous process frequently develops from an entirely make every effort to prevent strains on the spine. There is different center from that of the upper half, and remains a terrific leverage at the third and fourth lumbar vertebrae, and it takes a separated, except for cartilage, throughout life ; so in the strong splint to make enough bone to gain As time we an to cadaver, the big body with the shortened arch is in one piece, security. goes on, may make attempt of the articular and the lower half, with the lower articular surfaces, in an produce ankylosis facets, rather than put in a entirely separate piece. That is the usual variation found. bone splint in this locality. It is united more or less firmly. Another variation is that the two halves of the spinous process may be quite separate. Results of Infant Welfare Campaign.—During 1914 infant One can conceive that, in a case of that kind, when the graft welfare work was carried on in twelve localities in New was into the of fifth implanted spinous process the lumbar York. During the summer there were thirty-two different there would be little control of the vertebra, vertebra. localities where such work was in operation. A comparison : attest Dr. J. Torrance Rugh, Philadelphia I want to the of the vital statistics of the two summers indicates the sav¬ value of the bone graft in this region. In a series of twenty- ing of many lives. During the four summer months of 1913 six cases I have had three in which the graft has been there were 4,387 deaths of infants under 1 year of age out¬ attached to the upper two sacral vertebrae, and the results side of New York City, while for the corresponding months have been as good as in any of the other sections of the of 1914 the infant deaths numbered 3,833, or an actual reduc¬ spine. In one of my cases, after a period of six months, tion of 554. The infant mortality, based on the ratio of was firm be when the fixation and the results all that could deaths under 1 year of age to 1,000 living births, in 1913 was desired, the patient on sitting down felt something give way. 141 for the summer months, June, July, August and Septem¬ Examination showed a fracture of the graft between the ber, while for the same period of 1914 it was 117. The State fourth and fifth lumbar spines. She was placed in a solid Bulletin of Health which presents these figures, states that plaster jacket and kept in the supine position for nine weeks, two factors might influence these statistics, the better regis¬ when firm union of the graft took place, just the same as tration of births and the mild summer, but a comparison with it would have taken place in the shaft of any bone. At a the statistics of New York City show that these are not subsequent operation, done for the purpose of attempting to responsible to any extent for the great drop in infant mor¬ reinforce this graft opposite the point of fracture, another tality. The figures show that the infant death-rate in the graft was inserted; but, through a surgical error on my part, city dropped twelve points in 1914 below the record of 1913, the flap of skin became devitalized, so that the graft was while the rate for the rest of the state dropped 23 points.

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