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UNIVERSITY OF PENNSYLVANIA PRESS 
PHILADELPHIA, PA. 
Oreat Britain: Cassell and Company. London: 
MAY, 1894 
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A CASE OF PRIMARY TUBERCULOSIS OF THE LAMINA: AND 
SPINOUS PROCESSES OF THE VERTEBRAL COLUMN. 
By JOHN B. ROBERTS, M.D., 
OF PHILADELPHIA, 
Professor of Surgery in the Woman’s Medical College of Pennsylvania; Surgeon to the Methodist 
and the Jewish Hospitals. *A; CASE OF PRIMARY TUBERCULOSIS OF THE 
’ LAMINAE AND SPINOUS PROCESSES OF THE 
VERTEBRAL COLUMN. 
By JOHN B. ROBERTS, M.D., 
, OF PHILADELPHIA, 
PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE OF 
PENNSYLVANIA; SURGEON TO THE METHODIST 
AND THE JEWISH HOSPITALS. 
THIS case seems worthy of record because of the unusual 
situation of the tuberculous process, the diagnosis of 
which is substantiated not only by the clinical expression, 
but by bacteriological investigation. Even before an expert ex- 
amination of the specimen was made, I had no doubt of the 
tuberculous character of the lesion until I recently read the 
statement of Bradford and Lovett, that “ the transverse, articular, 
or spinous processes are rarely affected secondarily, and so far 
as is known never primarily, their structure of hard bone appar- 
ently protecting them from tubercular invasion.” 2 
The child, a girl of ten or twelve years, a native of Russia, was 
unable to give a very clear account of herself because of her igno- 
rance of German and English. She was admitted to the Jewish 
Hospital in July, 1892, with the statement that three months pre- 
viously she had fallen down two steps, and had subsequently expe- 
rienced pain in the side and the abdomen, for which she had walked 
to the Pennsylvania Hospital for treatment. She was admitted to 
that institution. The pain in the abdomen gradually left her, but 
she subsequently suffered from increasing pain in the legs. Two weeks 
later she had fever on a certain day, and on the following day was 
paralyzed from the hips downward. There was incontinence of 
urine and faeces, and bed-sores soon developed upon the hips. There 
1 Read before the Orthopaedic Section of the College of Physicians of Phila- 
delphia, January 19, 1894. 
2 Orthopaedic Surgery, p. 3. 2 
JOHN B. ROBERTS. 
was loss of sensation as well as motion below the brim of the pelvis. 
There was slight scoliosis in the dorsal region, with tenderness on 
pressure. No history of scarlet fever or diphtheria was obtained, and, 
according to the statements made, the patient had been well up to the 
time of injury. At the time of admission to the Jewish Hospital 
the child’s appetite was good, the tongue slightly coated, and the 
bowels regular. The urine had an alkaline reaction, contained no 
albumen, and no sugar. These notes I obtained from Dr. J. C. Knipe, 
the resident physician of the Jewish Hospital. 
After the death of the patient I applied to the Pennsylvania 
Hospital for an account of the condition of the girl while in the 
wards of that institution. The notes of the physician who had 
charge of her state that the child was brought in by the police patrol 
with the history of having been overcome with the heat. The patient 
was conscious and said that she had been feeling well until about 
three hours before admission, when she fainted while working in a 
hot room. Her temperature was F. in the rectum, 990 F. in 
the axilla, and her pulse 104, respiration 30. The following day her 
condition appeared normal, and she was discharged, the pulse being 
80, the respiration 24, temperature F. It will be seen, therefore, 
that no marked disease existed at the time she was admitted to the 
Pennsylvania Hospital. The discrepancy as to the character of the 
fall is probably due to the difficulty in obtaining an accurate history 
from the patient. 
She remained under treatment in the Jewish Hospital, being 
given potassium iodide and tonics. Electricity was also employed. 
Her temperature was very variable, and the complaint of pain in the 
feet and back was almost constant. Sometimes the pain was very 
severe, and accompanied by nausea and vomiting; and elevation of 
temperature amounting to two or three degrees occurred. 
When I first saw her, in October, 1893, I found a sickly-looking 
child, with bad bed-sores partially cicatrized, and a marked promi- 
nence in the dorsal region, which did not look like the ordinary 
kyphosis of Pott’s disease, because the bulging was more marked on 
each side of the spinous processes than over them. The testimony 
of the nurses and doctors seemed to be that there was little or no 
deformity in this region when the child was admitted. I presume, 
therefore, that the statement in the notes is correct; that there was 
appearance of lateral deformity or scoliosis only when she was 
admitted. I ordered a plaster-of-Paris jacket to be applied, and that, TUBERCULOSIS OF THE VERTEBRAL COLUMN. 
3 
if possible, extension and counter-extension in bed should be made. 
The latter seemed impracticable, but the jacket was worn for about 
ten days. The deformity in the back increased, and I thought I 
obtained a sense of indistinct fluctuation. The bed-sores, under 
careful nursing, though they were very deep and extensive, became 
healed. The patient presented marked swelling about the middle of 
the dorsal region of the back. It was evident that this was no 
ordinary kyphosis, because the swelling was most marked on each 
side of the median line, and there was a hollow over the spinous 
processes of the vertebrae. The tumefaction on the right side of the 
spinous processes was more marked than that on the left, and the two 
were divided by a groove due to the normal attachment of the integu- 
ment to the apices of the vertebral spines. This swelling had been 
gradually increasing for five or six weeks. It gave an elastic sensa- 
tion on palpation, and showed evidences of being a tubercular abscess. 
I believed that the case was one of tuberculosis of the middle 
dorsal region attacking the laminae of the vertebra and not the bodies, 
and that there was probably an abscess within the spinal canal causing 
the paraplegia present, which had developed early in the history of 
the case. The fact that no deformity, except some little deviation 
(lateral (?)) of the spine, was noticed when the child came into the 
hospital seemed to verify this conclusion. 
After watching the case for six weeks I concluded to make an 
exploratory incision with preparations for doing laminectomy. My 
friend, Dr. H. Augustus Wilson, agreed with me in the diagnosis and 
propriety of operative interference. A one-inch incision was made 
over the more prominent portion of the swelling,—namely, to the 
right of the median line, and when the skin and fascia were divided, 
an elastic swelling similar to a cystia tumor presented itself. This I 
believed to be an abscess-sac, and I had a basin brought to receive 
the fluid which would escape upon puncture. I incised the distended 
deep fascia and found it to consist of broken-down cheesy material 
and a considerable quantity of fluid blood. As I put my finger into 
the opening so made, I found some bone fragments, which were, 
however, very small. I bored my finger through the soft tissues to 
a considerable extent. There was no puriform fluid in the cavity, 
though there was some disintegrated bony material. The blood was 
dark in color and seemed to come from an active venous haemorrhage. 
I could stop the bleeding by pushing my finger into the bottom of the 
wound close to the laminae. In the endeavor to control this haemor- 4 
JOHN B. ROBERTS. 
rhage I enlarged the wound, while I held my finger upon the bleeding- 
point. When the parts were laid open there was general oozing, but 
no special vessels were found that needed ligation. 
The cavity was then packed with gauze, and an incision from 
three to four inches long was made on the other side of the spinal 
column into the second tumor.. This was connected with the first 
incision by a transverse cut across the median line. This enabled me 
to raise a large rectangular flap, and exposed thoroughly the spinal 
column and the swelling on both sides. The swelling on-the leftside 
consisted of a mass of tissue infiltrated with tuberculous deposit. As 
this was hard, it was quite different from the soft, moderately fluctu- 
ating tumor on the right side, which had been opened first.. Bleed- 
ing was quite diffuse from the vessels divided on raising the flap. The 
patient probably lost, through both incisions and from the hsemato- 
eele on the right side, from four to five ounces of blood. The sur- 
faces were pressed with sponges, but no vessels needed to be tied. 
The laminae were easily cut with an ordinary scalpel, except at 
the left side, where at the upper portion of the osseous incision a 
chisel was used. This, however, required very little force to 
push it through the soft bone. Two, or perhaps only one, verte-, 
bral arches were thus divided. The laminae' on the. right side 
of the spinous process in the same region had previously been 
divided. I had at first determined the position of the first solid 
spine and arch below, and of the first solid spine and arch above, 
before I cut into the softened bone. There was no -evidence of a 
bony spinal arch at all in the region of marked external swelling. I 
could pass my finger into the spinal canal below and above, but could 
see nothing in the bottom of the wound but the flattened spinal cord, 
which I at first mistook for the posterior common ligament of the 
spinal column. 
At this point of the operation the child’s condition became so 
serious that the wound was quickly closed. Two hypodermic injections 
of strychnine, g!_. grain each, were given, and about five ounces of 
water were injected into the subcutaneous tissue of the chest by means 
of a large hypodermic needle and a fountain syr.inge.- The patient 
was also inverted. No ether had been given for some time before 
this stage of the operation. Before the administration of ether a 
hypodermic injection of morphine, grain, and of atropine,, 
grain, had been given. 
The child became conscious and spoke a few words, but - died TUBERCULOSIS OF THE VERTEBRAL COLUMN. 
5 
just as she was taken from the operating-table. Death in this 
case was evidently due to shock and haemorrhage. The bleeding 
was not excessive, but was important in a case of such depressed 
vitality. 
The specimen removed shows that the disease was limited to 
the arches, and did not involve the bodies of the vertebrae. The 
evidence seems to support the idea that the destruction of tissue, due 
to tuberculous degeneration, had opened blood-vessels, the bleeding 
from which had converted the right swelling into a haematocele con- 
taining fluid blood. I cannot understand the free bleeding that 
occurred in any other way, for the tumor was dense when punc- 
tured with a knife, and seemed to give exit to little except fluid 
blood, which was venous in color, and which seemed to fill the 
cavity as far back as my finger could reach. The tumor or swelling 
did not resemble a spongy sarcomatous tumor, and had no charac- 
teristics of an aneurism. 
The portion of the spinal column removed consists of five 
vertebral bodies and a part of a sixth vertebra. The specimen shows 
no disease of the bodies, and the spinous processes and laminse of 
two vertebrae are absent. The gap is due to the removal of the soft- 
ened bone at the time of operation. The spinal cord which is seen 
in the foramen of the first and in that of the last vertebrae of the 
series appears normal, but at the point where the excision of the bone 
was made, it is so flattened by pressure that the membranes lie close 
to the posterior surface of the vertebral bodies, resembling ligament- 
ous tissue. An incision through the dura, however, shows the flat- 
tened cord within. There are two small openings in the dura at its 
upper and lower part in this same region, through which some reddish 
pultaceous fluid escaped when I recently examined the specimen, which 
had been in alcohol for nearly a year. On the front of the spinal 
column are two enlarged lymphatic glands. 
Pathologist's Report.—By Drs. W. M. L. Coplin and David 
Bevan. 
“After a thorough examination of the specimen (spine) which you 
sent us, we respectfully submit the following : The specimen consists 
of five vertebrae, all of which are dorsal; the lowest vertebra contains 
the extreme upper end of the cauda equina. The upper segment is 
apparently normal, the second, third, and part of the fourth are the 
seat of a well-marked pathological process. The laminae are destroyed, 
and the base of the spinous process is attacked. The muscular and 6 
JOHN B. ROBERTS. 
ligamentous structures of the morbid area are softened and evidently 
advanced in some degenerative condition. On the anterior aspect, 
slightly to one side over the body of one of the diseased vertebrae, 
are two tuberous masses,—presumably lymphatic glands; the larger 
is one and a quarter inches in its greatest diameter, by seven-eighths 
of an inch in its transverse measurement; it is ovoidal in outline, 
with a slightly-flattened anterior surface. On section it is caseous, 
the centres of caseation being disseminated at several points, although 
most marked near the middle. There is a moderately-firm capsule 
surrounding the mass which posteriorly becomes continuous by blend- 
ing with the anterior margin of the second glandular mass. The 
latter is largely caseous, and from its contour, the position of the case- 
ous points, and its general appearance, one is led to believe that only 
a part of the gland is present. 
Histology.—The infiltrated areas show a rich cellular exudate 
of varying age ; some points are recent, others old. Caseation is 
going on at nearly all points. The muscular, fibrous, ligamentous, 
and osseous tissues are involved. The glands are histologically typical 
of tubercle. 
Bacteriology.—The bacillus of tuberculosis is to be found in 
nearly all the surrounding structures of which we made sections. The 
glands are rich in bacilli.” 
The pathological report on this case shows, then, that my 
clinical diagnosis was a correct one. The only other possible diag- 
nosis, it seemed to me, was that of sarcoma of the laminae, which 
appeared to me a condition that did not agree with the clinical 
aspects of the lesion. Dr. William H. Ross1 gives an interesting 
discussion on the “ Symptomatology of Sarcoma and Massive 
Tuberculosis of the Spinal Cord.” His article, however, is one 
referring rather to tuberculosis of the cord than to tuberculosis 
of the bony arches of the spinal column. Mr. A. Parkin2 men- 
tions, incidentally, a case of “ Caries of the Spinous Processes in 
the Dorso-Lumbar Spine.” 
1 Medical Record, August 12, 1893. 
a Lancet, July 1, 1893, p. 22.