Medicine: The Role of the Turtle

When she was eleven, Margaret Bilotti, stage-struck elder daughter of a Manhattan construction worker, collaborated with another East Side youngster in writing a play, the proceeds to buy Christmas toys for underprivileged children (gross take from ticket sale: “over $2”). Soon afterward an uncle noticed that as Margie sat on a hassock she looked crooked, and her right shoulder blade protruded. The family doctor prescribed a corset, which soon broke and was discarded. Eventually a neighborhood hospital referred the Bilottis to one of the few places in Manhattan that specialize in treating conditions like Margie’s, the Hospital for Special Surgery.

The trouble with Margie was scoliosis, a sidewise curvature of the spine. As in 80% to 90% of cases, no cause for her condition could be found, and nobody knew when the trouble began. Neither Margie nor her mother had noticed it, and, like most victims, she had begun to compensate for it by shifting her body to achieve a comfortable balance.

Reverse Curves. At the Hospital for Special Surgery, doctors took X rays. The curvature, when looked at from behind, appeared like a reversed letter C; for no known reason most such curves are in this direction. Because it was a single curve it was certain to be deforming—many scoliosis cases have two curves, one right and one left like a letter S, which cancel each other out and leave a good balance, with no worse effect than a shortening of the trunk. And Margie’s case was severe. Special Surgery doctors grade cases by a technique developed by one of their leading scoliosis specialists. Dr. John R. Cobb; with a protractor, applied to the top and bottom vertebrae of the curve on the X ray, they measure the total deviation from a straight line. Up to 30° is rated mild, rarely needing operation; 30° to 60° is moderate, and beyond that, severe. Margie’s had reached 97° by the time she was admitted last fall.

Having decided that operation was unavoidable, the surgeons prepared for a long, complicated siege. Off came Margie’s long, glistening black hair. Her entire torso and part of one thigh, her shaved head and her neck were encased in a monstrous plaster cast known among doctors and nurses as a “turtle.” The cast was hinged in the middle. Joining the halves on the left, and spanning the spinal curvature, was a turnbuckle. Every day or two the doctors extended the turnbuckle by a couple of turns. As it was lengthened, it flattened and almost erased the curve. But unaided, the spine would not be able to maintain its restored straightness.

Fused Vertebrae. The surgeons cemented the two parts of the cast together and removed the turnbuckle. To make doubly sure of holding the shape, they affixed a curved iron bar to serve as a flying buttress on the right side. By this time they were about ready for a tricky piece of surgery they call “fishing through the ice.” Last week they interrupted Margie’s eighth-grade studies (a New York City schoolteacher keeps children in the hospital plugging at their work), used an instrument like poultry shears to cut a rectangular hole in the back of the cast, over the spot where the curve had been sharpest. More X rays showed the new position of the vertebrae, indicated how many would have to be fused.

This week, working with no room to spare through their “hole in the ice,” the orthopedists operated. They inserted wedges of bone (from a deep-frozen bone bank) between seven vertebrae, fixing this part of the spine so that it could not bend again. To allow time for the grafts to fuse solidly. Margie must spend at least six months in the rigid cast, though she can now enjoy the luxury of having her head free. Then there will be a “holding jacket,” reaching only to the hips, for four months; most of that time Margie, though at home, will still be lying in bed. After that, two more weeks in the hospital should see her up and about, walking straight in special shoes, with no more restraint than a snug jacket. Total treatment time: about 18 months.

Scolio Club. Each year the Hospital for Special Surgery handles 30 to 40 scoliosis cases—about half of them of unknown cause, most of the others resulting from paralytic polio. The polio cases tend to be more severe because other parts of the body are also weakened; usually a greater part of the spine has to be fused, often in a series of operations. But post-polio cases are already becoming markedly less common, thanks largely to the success of the Salk vaccine.

Comparable operations are performed at other U.S. orthopedic centers. Los Angeles’ Dr. Joseph C. Risser, though he pioneered the turnbuckle cast, has abandoned it in favor of a smaller, lighter cast, through which he operates after only one week. Patients, home after two weeks, can run and play while wearing the cast for only six months. Dr. Risser also favors operating in some cases that other orthopedists would leave alone. For Margie Bilotti, now 13½ and intent on an acting career, there was never any doubt about the operation’s necessity. Like most of the “scolio club,” she has played the part of a turtle smilingly and without complaint.