In cases like this, in which the cord and its nerves pass through the cavity of the Cy is gu

tumour, it is probable that the fluid was originally effused in the sub-arachnoid cellular tissue, after partial adhesions had formed between the cord and its nerves and the two layers of arachnoid covering its posterior surface. But in some cases the cord and its nerves are found spread out upon the posterior wall of the sac, without passing through its cavity; and in these most probably the fluid was effused into the sub-arachnoid cellular tissue after extensive adhesions had united the cord and its nerves to the two layers of arachnoid covering its posterior surface. Whereas, if the liquid be effused into the cavity of the arachnoid, before any adhesions form between the two layers of the membrane, no nerves will, in Mr. Hewett's opinion, be connected with the sac."-P.H.B.]

Hydrorachis is not always very marked at birth, and only becomes manifest at the end of some days. It is often complicated with hydrocephalus, which may be recognized by the size of the head and by the separation of the fontanelles, and by their protrusion on pressure of the spinal tumour.

Most children attacked by this disease lose flesh and dwindle away; some are paralysed in the lower extremities, in the rectum, and bladder. ut hub. Some have club feet, others have gangrenous phlyctenæ, and the skin is exceedingly sensitive. As the tumour increases in size, its wells

become thinned, fissures form, ulcerations appear, and the opening of Course

the tumour, followed by the gradual or rapid escape of the serum, often causes convulsions followed by death. I say often, in consequence of General, a rare exception. Maurice, Hoffmann, and Camper have, on the contrary, seen this followed by the collapse of the tumour and its cure. Hydrorachis is generally a fatal disease. Some children die before in dearte or very soon after birth; others live a month, and very few survive to the end of the first year. Bonn has seen one who lived ten years, Loue hai Varner another who lived to the twentieth year, Camper a third & Coorout who arrived at the twenty-eighth year, and Moulinié a fourth who prolonged his existence to the thirty-seventh year. Similar facts are excessively rare.

Prog. Bad Herge young woman, aged twenty-seven, in whom the tumour relieves itself when distended Sou live by the exudation of a watery fluid through a minute aperture.-P.H.B.]

[Druit mentions a case which came under his observation some time ago, of a

long witho When the children die, the examination of the vertebral column others.

furnishes the following information.

The division and separation of the vertebral laminæ sometimes exists in the cervical or dorsal region, but more frequently in the lumbar region. There may be two or three separate clefts, as well as the complete division of the spine from above, downwards.

Most Fre quent in The tumour is composed, 1st, by the thinned skin adherent to the subjacent tissues, reddened, bluish towards the centre, sometimes incom Jurbar pletely formed; 2nd, by a small quantity of indurated subcutaneous on

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SPECIAL PATHOLOGY OF INFANCY.

[Part III. cellular tissue; 3rd, by a fibrous membrane, forming the wall of the spina bifida, smooth internally, and prolonged in the vertebral canal as far as the dura mater, with which it becomes continuous above; Lund-4th, sometimes by the cord spread out in the sac; 5th, by the limpid cephalo-rachidian serosity, which becomes thick and bloody in cases of inflammation; 6th, by the orifice of the cleft vertebræ, which allows us to see the body of these bones intact; 7th, sometimes even by the division of the bodies of the vertebræ; 8th, lastly, by the presence of other deformities, such as anencephalia, encephalocele, hare lip, imperforation of the anus, ectrophia of the bladder, &c.

TREATMENT.

They formerly abstained from meddling with spina bifida, and it was left to its natural progress. This is often the best thing to be done. But in some cases, when the lesion is simple, and of small extent, we should endeavour to effect its disappearance. With this intention,

surgeons employ palliative or curative means.

1. Compression by means of a bandage, padded with horsehair, has been employed by Abernethy and Sir A. Cooper, but unsuccessfully, for the tumour reappeared as soon as the pressure was taken off, and which was, moreover, very painful.

2. Puncture with a very delicate trocar has been several times very successfully practised; if I were to have recourse to this means I should at least employ puncturation according to the method of M. J. Guerin, so as to avoid inflammatory complications; and after having emptied the tumour, I should exercise moderate compression by means of a well applied bandage.

Some surgeons prefer acupuncture to the subcutaneous puncturation. They follow the example of Sir A. Cooper, who, by puncturation with a sewing needle, repeated every four or five days, combined with compression, cured several children. MM. Robert and Rosetti, who have made use of this mode of proceeding in cases in which it appeared most likely to fail, in paralytic children, have succeeded notwithstanding. In the successful cases, the spina bifida and the paralysis have disappeared simultaneously.

[Abernethy punctured the swelling of a spina bifida every fourth day for six weeks. The wounds generally healed very well, but at last the plaster slipped off one of them, it ulcerated, the discharge became purulent, and the child died. Sir A. Cooper performed the operation with a fine needle, and applied pressure. In two of his cases the patients were alive and healthy, the one twenty-eight and the other twenty-nine years after this treatment.

The operation has several times been performed since without success. Dr. Sherwood tried it and failed. Otto punctured the tumour in a child also affected with hydrocephalus, and the tumour disappeared, but the child died three weeks afterwards. Pliny Hayes lost a child in two days after a single puncture. In 1819

Dr. Berndt failed in three cases; the first died twelve days after the operation, the second after three weeks, and the third after three punctures. Benedict Trompei performed the operation on a girl, six years old, with a cataract needle, and she died comatose thirteen days after. Dr. Churchill (Diseases of Children, p. 65) tried the same plan three or four years ago, and the tumour was becoming more solid, so as to give some hopes of success, when the child was seized with convulsions and died. Dr. Steevens's case (New York Journal of Medicine, September, 1843) was successfully treated by puncture alone. The tumour was about three and a half inches broad from side to side, and it was punctured three different times, and more than nine ounces of fluid escaped. After the last operation the sac inflamed, and the child became irritable and restless, but these symptoms soon subsided, and a year after nothing remained of the sac but a small bunch of indurated and corrugated integument. The child was eight months old. Professor Rugieri has also successfully employed the combination of puncturation and pressure.

If it is determined to try the effect of puncture, the two following rules, laid down by Mr. Hewett, should be strictly observed.

"1. The tumour should never be punctured along the median line, especially in the sacral region, for it is generally at this point that the cord and its nerves are connected with the sac. The puncture is to be made at one side of the sac, and at its lowest part, so as to diminish the risk of wounding any of the nervous branches.

"2. The instrument ought to be a needle or a small trocar; for if a lancet is used there will be a greater risk of wounding some important part contained in the cavity of the tumour."

Of thirteen males and fifteen females who died from spina bifida in London, in 1849, twelve males and fourteen females died during the first year of existence.-P.H.B.]

3. The use of the seton, recommended by Richter and Desault, finds no longer any partisans.

4. Excision followed by suture has been proposed and practised by M. Dubourg on three patients, and the operation has been twice crowned with success. This practitioner opens the pouch and closes the cleft in the spine with the finger, and then removes, by another Soc incision, what is superfluous in the walls, so as to enable them to collapse and unite perfectly together on the back, over the situation of the opening in the spine, by means of a twisted suture.

5. Circular ligature may be made use of if the tumour is pedicellate, but such an instance is very rare. M. Beynard has practised the linear ligature by means of two quills, retained on the two sides of the tumour by proper contrivance, and containing in the interior a thread, which is gradually tightened. M. Latil has modified this method of proceeding, and has replaced the quills by wooden rods, pierced with holes at certain distances for the passage of the thread. Under the influence of this lateral constriction, the above-mentioned physicians have seen the tumour mortify and become separated at the end of some days. Adhesion had taken place internally, at the situation of the compression, and the cure was thus obtained at the end of eight or ten days.

6. Adhesion. M. Dubois has proposed the combination of puncture, inflammation, and adhesion. He empties the tumour, then applies at the base two convex iron plates, having at their extremities a neck to receive the threads; he compresses the pedicle between the convexities of the plates, so as to produce the adhesion of the internal serous membrane; then two pins are introduced into the holes made in the middle of the plates, so as to transfix the tumour and cause adhesive inflammation. I much prefer the method of Beynard and Latil, which possesses the advantage over the above of reckoning some successful cases in its favour.

7. Puncture and injection. It has lately been attempted to treat spina bifida like hydrocele, by means of puncture and injection of iodine. Several children have died from it, but it appears that it has obtained some success. I here relate a successful case which M. Chassaignac reported to the Society of Surgery, and I add thereto the remarks to which it gave rise, and the opinions of several members of this society.

Case. Hydrorachis, in a child five months old, situated at the lower part of the vertebral column, at the sacrum; the effects of the hydrorachis radically cured by the iodine injection.

The following is briefly the history of this interesting case:

On January 14th this young child, then two months old, was brought to the St. Antoine Hospital. It had been taken to the Hôpital des Cliniques, to M. P. Dubois, who discovered the nature of the disease, but who was under the necessity of not admitting him into the wards, on account of the small number of nurses engaged for the children born in that hospital.

The child, emaciated and extremely weak, presented over the sacral region a tumour as large as a hen's egg, elongated in the vertical direction, very moveable, slightly pedicellate, having the appearance of a cyst; it was fluctuating and transparent; the skin, which was very thin, had, nevertheless, the appearance of ordinary skin. During the efforts which the child made in crying, the tumour became excessively distended, even to such an extent that a rupture was feared at the most attenuated portion of the skin. When the effort ceased, the tumour appeared less distended; pressure exercised on it caused convulsive movements of the lower limbs.

M. Chassaignac, in consequence of the importance of the disease, which threatened the child's life, and caused impending death, decided on attempting the radical cure by means of the iodine injection.

He first made a puncture with an ordinary trocar. About two spoonfuls of limpid yellow liquid escaped. When the pouch was thus emptied, he discovered the probable point of communication of this sac with the spinal cavity; and applying the thumb over this spot, he injected water and tincture of iodine in equal parts. This liquid was allowed to remain in contact with the internal surface of the sac for one minute, it was then emptied out in as complete a manner as possible, and compression applied by means of strips of adhesive plaster.

The operation was very well borne; there was no immediate convulsive movement. The child was then removed from the hospital, so that the progress of the disease could not be attentively watched. It is said to have had several attacks of convulsions. The symptoms assumed so serious an appearance, that the state of the patient appeared desperate. After the first day, the tumour resumed its primary size.

For fifteen days it thus continued enlarged, it then changed its appearance, and insensibly diminished. It was then discovered that indurated plates could be distinguished on various points of the walls.

At length the tumour disappeared, but slowly; since three weeks only it is entirely collapsed, there only remains a small painless projection, formed by folds of skin, like an old shrivelled apple. In its centre, the spot where the division of the sacrum existed can be distinguished. The general health of the child is considerably improved: he has become more plump. The movements of the limbs are free; in fact, the cure may be considered as quite complete.

Two months since, M. Debout assisted at an operation performed by M. Velpeau in a precisely similar case. The iodine injection did not give rise to any sort of bad symptom. Ten days after the operation, no change had taken place.

M. Lenoir considered the operation practised by M. Chassaignac as quite unique. He thought that it could not be very often applied. To give it really some chance of success, it should only be had recourse to in the case of very minute communication with the spinal canal. For his part, he admitted that he would never make use of iodine injections in the treatment of hydrorachis: in support of this opinion, he alluded to the accidents which sometimes occur when puncture and injection are practised in congenital hydrocele. In spite of the precautions taken to prevent the introduction of the liquid in the peritoneal cavity, the inflammation invades this membrane, and numerous facts prove that death may be the consequence of this operation.

M. Chassaignac appreciated the value of the objections made by M. Lenoir. Up to that time he was of the same opinion, and disposed to deprecate the treatment by puncture and injection, for the suppuration which followed injection appeared to him likely to be a cause of death, in consequence of the passage of pus into the spinal canal. But he has been encouraged in the path he has followed by the known harmlessness of iodine injections, which scarcely bring on inflammation.

M. P. Guersant attached great importance to this case; but that it should possess a complete value, he wished M. Chassaignac to promise to bring the little patient in some months time; for the cure was not, perhaps, permanent. As long as the cleft in the spine exists, so long may relapse be feared. In order to avoid this relapse, M. Guersant recommended the application of a small compressive bandage over the situation of the osseous cleft.

M. Danyau proposed several questions with the intention of discovering if the diagnosis had been sufficiently established. He inquired about the state of the skin over the tumour, if it was completely formed. Then, being struck with the mobility of this tumour, he asked if it was really a spina bifida, or only a simple cyst.

M. Chassaignac repeated the description of the tumour-we do

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