102 RUDIMENTARY SPINA BIFIDA. 



A differentiation is to be made between the type of defective arch in which there 

 is a medianly incomplete dorsal arch, as in these cases, and the condition studied 

 by Manners-Smith and Hrdlicka in the last lumbar vertebra, where the whole 

 vertebra was divided into two parts. In such instances the separation usually 

 occurs bilaterally, between the junction of the superior articulating processes of the 

 vertebra and laminae. Manners-Smith and Els attribute the condition chiefly to 

 mechanical factors, such as strain from flexion, occurring suddenly or of long dura- 

 tion. Hrdlicka regards it as congenital. In osteological collections the posterior 

 fragment is very easily lost, and thus a lumbar vertebra with a wide dorsal gap is 

 encountered fairly frequently. A wide posterior gap, however, was not once 

 observed throughout the 1,000 X-ray plates. Spina bifida of the other lumbar 

 vertebrae does occur in varying degree, and records of such cases appear from time 

 to time, usually in the clinical literature, but these are rather rare. A case of 

 Voelcker (1903) is in point. Here, in a woman of 23, spina bifida of L 2 is associated 

 with a fatty and ligamentous tumor and various motor and sensory disturbances. 

 George (1907) also gives a case of a child 2| years old, where L 3 and L,, as well as the 

 sacrum, are cleft in the midline and a dislocation of the left femur is present. 



As has been said before, considerable clinical interest is attached to certain 

 phases of lack of posterior vertebral union; i. e., when it forms spina bifida occulta 

 associated with neurological and other maldevelopments (Fuchs 1910, Krause 

 1911, Schulthess 1912, Els 1915, Findlay 1917). Among the maldevelopments, 

 when the defect is in the lumbo-sacral region, may be mentioned trophic, sensory 

 and motor disturbances of the lower extremities, bladder disturbances, uterine and 

 rectal prolapse, club feet, congenitally dislocated hip, and pelvic and spinal mal- 

 formations. Brickner (1918) has conveniently classified the abnormality into four 

 divisions for clinical purposes: (1) Spina bifida occulta, with external signs and 

 symptoms; (2) spina bifida occulta with external signs and no symptoms; (3) spina 

 bifida occulta with no external signs but with symptoms; (4) spina bifida occulta 

 with no external signs and no symptoms. 



Of the 8 cases in this study in which the sacrum was found to be involved, 6 

 showed more or less marked clinical manifestations : 



L.E., male, 27 years. Sacrum only bifid. Extreme pain in back after working in stooped position 



Slight scoliosis to left. No other suggestive physical findings. 

 A.M., male, 23 years. Sacrum only bifid. Bladder paresis, involuntary voiding as a child, later 



incomplete emptying of bladder. Depression and blind sinus over sacrum. Rt. foot 



supinated and varus position; large trophic ulcer under proximal end of rt. 5th metatarsal. 

 F.L., female, age 17 years, unmarried. Last lumbar and sacrum bifid. Congenital dislocation of 



right hip and well-marked congenital left-sided flat foot. 



M.R., female, age 55 years, nullipura. Sacrum only bifid. Pain in right leg and hip; pain in coccyx. 

 S.R., female, age 35 years. Four healthy children. L 4 , L 5 , and sacrum bifid. Hypertrichosis and 



ntevus over sacral region. Marked lordosis. Rt. foot showed mild hallux valgus and 



Schaeffer's non-deforming club foot. Congenital relaxation of bladder sphincter (w. 



plastic operation which did not cure). 

 E.S., female, age 26 years. Last lumbar bifid. Pain in lumbar region, began 1 year previous. 



Lumbar lordosis increased, and increased prominence of sacrum. Spine mobile. No 



tenderness. 



