FUNCTIONAL TESTS OF HEARING.

must of necessity turn to more radical means. I have had no personal experience with 'the operation mentioned here, but am much impressed with the excellent results reported, and can only hope that like results may be obtained by those following the technic given. S. NICHOLAS JACOBS, M. D. (209 Post Street, San Francisco)-There is no doubt of the increasing importance as to the proper handling of cases showing abnormalities of the fifth lumbar vertebra and particularly those cases with sacralization, either unilateral or bilateral, showing symptoms. That it is a rather common condition, which heretofore has been quite generally overlooked, especially in those presenting themselves with symptoms of lower back strain, is well shown by the answers to several questions which I put to Doctor Howard Ruggles. He informs me that of all cases roentgenologically examined in their offices in which the lower spine appeared, regardless of the purpose for which the examination was made, over 10 per cent showed sacralization of the fifth lumbar vertebra, either partial or complete. Furthermore, about one-half of the cases showing sacralization are so-called "pick-ups," that is, accidental discovery of the condition during routine examination, and comprise many who have not shown any symptoms referable to the lower spine. He has found sacralization quite commonly present in children as well as in adults, the youngest at three years of age and with no evidence roentgenologically in these children of a previously existing rickets, which might be considered as an etiological factor in the production of sacralization as has been claimed by some authors. He has also found the sacralization as common or even more so in those other than working people, in whom we would more naturally expect to find, because of the nature of their work, chronic inflammatory changes in the lower spine; and this does not bear out the theory of the etiology, as claimed by other authors, as being associated with chronic inflammatory changes in the bony and articular surfaces of the lower spine. Taking the above into consideration, it leaves little doubt as to the congenital origin of these abnormal transverse processes. As to the indications for operation, time alone will tell us in just which type of cases we can expect relief of symptoms by operation. I wish particularly to emphasize the fact that in the presence of sacralization on one side, which produces fixation, there results an abnormal mobility on the opposite side and an abnormal susceptibility to injury which is very often the cause of a stubborn sciatica. In these cases removal of the sacralized transverse process relieves symptoms by re-establishing mobility. H. D. BARNARD, M. D. (2417 South Hope Street, Los Angeles)-Anyone who is called upon to struggle with the problems concerned in obtaining benefit in the treatment of patients suffering with low back pain will watch with interest the results obtained by the operative treatment of abnormalities of the fifth lumbar. The very complicated nature of the etiology of these low back syndromes and the exact role which is played by these so-called sacralized conditions of the last lumbar vertebra make the treatment far from an exact science in my judgment. Definite proof as to whether these sacralized fifth lumbar are entirely causative, or only contributory, or only predisposing; whether pain is produced by inflammatory reaction as result of trauma; just what the element of nerve pressure is; just what cases develop the inflammatory bursitis between the iliac crest and the transverse processes; what the relation is between a stabilized transverse process on one side, and the normal mechanism concerned in the joint action on the other; the relationship, if any, of the forward displacements of the fifth lumbar which are being demonstrated with much more frequency; whether these abnormalities of the fifth lumbar cause sacro-lumbar trouble or sacroiliac, or a combination of both-even these are not all of the questions which must be answered more definitely before this surgical proceduce can be put on a clear-cut status where the indications and contra-indications will be generally accepted. The percentage of cases is comparatively low where it is possible to accurately diagnose the exact location of the cause of the low back pain or sciatic irritation, whether it be sacro-iliac or sacro-lumbar, or a combination of both, either with or without the so-called sacralization of the fifth lumbar, partial or complete. The points of differential diagnosis, while comparatively definite as described by certain authors in the literature, are far from infallible. Certain cases obviously localized beyond a question of a doubt in the sacro-iliac joint, have, in our experience, done nicely after the arthrodesis operation described by Smith-Peterson. Likewise fusion of the last lumbar to the sacrum in certain types of lumbo-sacral trouble has proven equally satisfactory in our hands. To just what extent the resection of the transverse process of the fifth lumbar will stand the acid test of time is highly problematical in my judgment. This doubt is only made more profound when we consider the disconcerting data which each of us must encounter in our actual experiences of the variable results, both successful and otherwise, which accompany the different types of treatment for these low back conditions, a certain percentage of which must fall into the class of abnormalities of the fifth lumbar under special consideration in the above papers. DOCTOR GALLANT (closing)-In reviewing the criticisms of the men who were kind enough to discuss this paper, we admit that this operative procedure, for the correction of the conditions under consideration, is a difficult one and should only be done in properly selected places. We feel that after all conservative measures having been tried for a sufficient length of time and failing to obtain satisfactory results that such operative measures are justifiable. We are well aware that dire results can easily follow surgical measures, particularly in the region of the fifth lumbar vertebra and sacrum and feel certain that if the technique described in this article is carefully followed the results ought to be good. We know that it is a big problem and a difficult one, especially from an industrial standpoint, and if a small percentage of cases can be relieved we still feel justified in resecting these transverse processes. We know of one instance at the Los Angeles General Hospital in which all conservative measures were employed and failed to obtain good results. This patient had a unilateral transverse process resected and four days afterward was absolutely free of pain and able to walk about the ward. His post-operative recovery was uneventful and to date has had no return of symptoms. In closing, we wish to express our thanks to the men who have so kindly discussed this paper.