. Diseases of the nervous system . cralis) is usually lowerbut somewhat broader;transversely the interver-tebral spaces measure from18 to 20 mm., and vertic-ally 10 to 15 mm. Thethird intervertebral spaceis generally the best forpuncture since it is broad,is sufficiently distant fromthe conus medullaris, andthe space between the bi-lateral bundles of thecauda equina is here suffi-ciently large; but thefourth and fifth inter-vertebral spaces, also inadults the second, may be used for puncture. Hence, in the individual case,the choice must be made according to the palpable form of the bones, par
. Diseases of the nervous system . cralis) is usually lowerbut somewhat broader;transversely the interver-tebral spaces measure from18 to 20 mm., and vertic-ally 10 to 15 mm. Thethird intervertebral spaceis generally the best forpuncture since it is broad,is sufficiently distant fromthe conus medullaris, andthe space between the bi-lateral bundles of thecauda equina is here suffi-ciently large; but thefourth and fifth inter-vertebral spaces, also inadults the second, may be used for puncture. Hence, in the individual case,the choice must be made according to the palpable form of the bones, par-ticularly of the spinous processes. With repeated punctures it is generallybetter to vary the point of insertion of the needle. In the cadavers of eight children I found the end of the conus to be at the heightof the third lumbar vertebra up to the end of the first year; at the end of the thirdyear, at the height of the second lumbar vertebra, and only once, in a child four yearsold, at the height of the fourth lumbar Fig. 135. — Transverse Section through the LumbarVertebral, Column, the Puncture Needle in situ.(Two-thirds of natural size.) 242 LUMBAR PUNCTURE In thin people the lumbar spinous processes may be easily counted. Theyare broader and may be outlined more easily than the dorsal which some-times deviate laterally (although the twelfth dorsal vertebra frequently re-sembles those of the lumbar region). It must be remembered that the twelfthrib is joined to the upper margin of the twelfth thoracic vertebra. Thisis difficult to find in stout people, in whom also it is difficult to feel the fourth lumbar spinous process is in these cases a good landmark; it ison the same horizontal plane as the upper border of the iliac crest. Afterdetermining the height of the five spinous processes by palpation I have foundit of great assistance to outline these by five horizontal lines on the skin(compare Fig. 129 a.). In estimating the pressure, the behavior o
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