interference with the circulation leads to inflammatory changes in the neighbourhood of the pelvis or in the mucous membrane of the pelvis itself, as a result of which fibrous bands of adhesions may form between the sac and the upper part of the ureter, and may end by converting an intermittent into a permanent hydronephrosis. These alternating periods of fulness and emptiness of the pelvis, consequent upon the transitory obliteration of the ureter, manifest themselves clinically by paroxysms of pain, which occurring generally every month, and sometimes oftener, and following on a period of health more or less perfect, are almost characteristic of the affection. These paroxysms present three phases-onset, climax, and terminal phase-which are charac terised by pain, always severe and sometimes almost intolerable, and by the coincident appearance of a tumour-fluid but rarely giving rise to fluctuation-which is generally seated in the right loin, and is synchronous with a marked diminution in the quantity of urine passed. These are the results of the sudden kinking of the ureter which follows the displacement of a floating kidney. Each attack lasts for some hours, coming to a sudden termination when the kidney regains its normal position. The pain and swelling disappear, and there is a copious evacuation of urine, consequent on the emptying of the pelvis. Those cases which have been hitherto described as instances of acute strangulation of floating kidneys are in reality only an early stage of the condition of intermittent hydronephrosis.

In many of these cases the question of treatment does not arise. The attack lasts a day or two, and with the evacuation of the pelvic accumulation of urine all trouble ceases, and months of absolute comfort may succeed. But where the pain is excessive in degree, and the periods of intermission short, so that the patient is being rapidly worn out by the constant strain and loss of repose. then the question of operative treatment becomes of paramount importance. Moreover, the danger of a septic infection of the retained fluid, with the consequences of an infective pyelonephritis, must always be present in the mind of the surgeon, and adds enormously to the gravity of the case. Hence, in early stages. nephropexy-or the fixation of the kidney to the abdominal walloffers the best chance of success. But when the tumour is large and increasing in size more radical measures are needed, and especially if both kidneys are affected, the most promising mes sure is incision and drainage of the pelvis on the side which is

most engaged, with the view of establishing a pelvic fistula. But in other cases, when one kidney still remains sound, it is better to have immediate recourse to nephrectomy. It entails less suffering on the patient, and holds out better hopes of success, than the establishing of a urinary fistula, as many of these cases have required the subsequent performance of a secondary nephrectomy ander conditions much less favourable for the surgeon and for the patient.

As regards the operation of nephropexy-the name preferred by the authors instead of nephrorraphy, that given to it by its originator, Hahn—the kidney is exposed by a lumbar incision in the usual way, and fixed from above downwards by sutures of silk, which penetrate into the kidney-substance as well as the capsule, and are then passed through the aponeurosis of the quadratus lumborum. Mr. Morris, we may here remark, uses kangaroo tendon, and Mr. Treves silkworm-gut sutures, as Dr. Newman found the absorption of catgut to be more rapid in the kidney than in any of the other tissues. The authors entirely condemn the palliative Teatment by suspensory bandages and trusses, not only as being aseless, even when well applied, which is seldom, but also as allowing the condition to progressively develop, thus adding to the difficulties of future surgical interference. Aspiration of the

tumour or the establishment of a lumbar urinary fistula are equally ondemned; but a urinary fistula may be, in certain cases, estabished by lateral laparotomy, incision of the pelvis, and stitching of ts walls to the abdominal opening after the manner of dealing with hydatid cysts. This incision allows the extirpation of the kidney at the same time if found necessary.

IX.-SPINAL SURGERY.

The attention of surgeons has recently been drawn largely in this direction, and the brilliant results which have, in a few cases, been already attained seem to hold out the hope that, with larger experience and improved methods, the spinal canal and its contents will come within the legitimate range of practical surgery. In an important paper in the Revue de Chirurgie, T. XI., No. 7, 1891, M. Chipault deals with some new facts in connection with of Pott's caries, his first case being an example of a further adaptation of Mr. Treves' operation for lumbar abscess by direct incision and drainage. In this case-a boy aged nine years-no abscess could be detected, but there was severe sciatic

the

surgery

pain in the left side, considerable lordosis from contracture of the sacro-lumbar muscles, pain on pressing over the left transverse processes of the three lower lumbar vertebræ, and also marked tenderness on palpation of their bodies through the flaccid and emaciated abdominal wall. The diagnosis was tubercular caries of the bodies of the vertebræ with extension on the left side compressing the roots of the sciatic nerve. At the operation large fungous masses of tubercular tissue were found extending from the diseased bodies and compressing the nerves at the foramina of exit. These and the softened parts of the bodies were curetted away carefully, and in the anterior part of the cavity thus left the aorta could be felt distinctly pulsating. The operation was almost bloodless. A drain was passed across the vertebral cavity, coming out at the most dependent part of the wound. It was removed at the first dressing, and the wound was found completely healed at the second (the dates are not given). On the 15th day the pain and lumbar contracture had completely disappeared. In this case, to which we have referred at some length on account of its intrinsic interest, the spinal canal was not opened, but in the following cases M. Chipault has deliberately adopted a method for the treatment of ante-medullary lesions by trephining and drainage through the vertebral canal. In his three cases the patients were the victims of Pott's disease, and were paraplegic. The first, a boy, aged nine, who had suffered for some months from caries of the upper dorsal spine, suddenly became paralysed after falling down a staircase. He was treated by suspension and jackets, but without benefit. There was incontinence of urine but not of fæces; there was no cystitis. After a short interval the following operation was performed. An incision 10 c.m. long was made over the transverse processes of the 2nd, 3rd, 4th, 5th. and 6th dorsal vertebræ, the periosteum was reflected outwards, and the arches resected. The dura mater was found healthy, but at the 4th vertebra there was found a projection and a compres sion so marked that the spinal cord seemed to be altogether wanting. Numerous fungous projections into the canal were scraped away, a large abscess was opened, and the ridge of bone projecting was completely removed, and the cavities of the diseased vertebræ as far as possible cleaned out. The destruction of the bodies was enormous, and the removal of the disease certainly incomplete. Notwithstanding this the wound healed, and the progress was excellent for some time, but a month after the operation the

At the

child succumbed to an attack of broncho-pneumonia. autopsy the wound was found firmly closed by a mass of osteofibrous tissue, evidently developed from the periosteum that had been preserved; but a large cold abscess in connection with other diseased vertebræ was found. In the second case, a girl aged four and a half years, the same region of the spine was affected, but not so extensively. The paraplegia was one produced by a gradually increasing pressure, and not one suddenly developed by fracture or displacement. A similar but less extensive operation was performed. Numerous outlying fungosities were scraped away, and the principal focus of infection in the posterior part of the body of the 4th dorsal vertebra was thoroughly evacuated and cleansed. A drain was inserted into it and brought out across the vertebral canal between the 4th and 5th dorsal nerves; the muscles cut were sutured, then the skin, and the whole wound Irrigated until the boric solution returned clear. An immobile dressing was applied. An excellent recovery followed. On the second day motion returned in the toes, and on the fifth day she could lift the heel from the bed. In the third case, a child whose age is not given, a similar procedure gave similarly good results. In six hours after the operation the child lifted its two heels together off the bed to any height, and the paralytic club-feet had disappeared; and the following day the exaggeration of the knee reflexes was gone. So far it has continued to progress

favourably.

Striking as these cases undoubtedly are, though too little time has been allowed to elapse after the operations to formulate any decisive judgment on the permanency of their results, still M. Chipault must be congratulated on the skill and courage with which he has tackled a class of hopeless cases, and one too often allowed, hitherto, to glide unheeded from suffering to suffering till death brings a happy release. The conclusions which the author formulates from his experience are as follows:

1. The operation is anatomically possible; it requires skill, but it is easy to avoid injury of the meninges or of the spinal nerve roots. Drainage and irrigation of the diseased centres through the vertebral canal do not give rise to even transitory disturbances of the medulla.

2. By direct treatment of the tubercular focus we may hope to obtain a result not merely palliative but curative-a result impossible with the methods hitherto employed.

X.-SPASMODIC TORTICOLLIS.

Dr. Charles A. Powers has recorded (New York Medical Journal, March 5, 1892), a case in which he performed the operation recommended by Keen in cases of obstinate spasmodic wryneck, in which excision of portion of the spinal accessory nerve has failed to give relief—viz., resection of the posterior branches of the first three cervical nerves. This procedure was independently practised and advised by Mr. Noble Smith, and his case, in these countries, together with those of Dr. Keen and the author in America, constitute, according to Dr. Powers, the only three cases as yet recorded. Keen's patient was a woman, fifty-four years of age. who had suffered for some years from spasmodic movements of the head towards the left shoulder. In 1886, when the affection had persisted for over two years, Dr. Ashurst excised four inches (?) of the spinal accessory nerve; the spasms disappeared for a week and then returned as before. Some time after this the patient

came into Keen's hands, and excision of portions of the nerves supplying the posterior rotators was practised, with the result that though a slight amount of spasm returned the patient was much benefited by the operation. In Noble Smith's case, a lady, aged forty-one, had suffered for sixteen years from severe spasmodic wryneck, the result of a strain of the neck. Stretching, and subsequently resection, of the spinal accessory nerve were performed; but, the spasms continuing, a month later, in May, 1890. parts of the posterior divisions of the upper cervical nerves, as low down as the fourth, were excised. Recovery from the operation was complete, the spasms ceased, and eleven months afterwards there had been no recurrence. Dr. Powers' patient was a man of muscular build, thirty-seven years of age, in whom the spasms began two and a-half years previously, and had been increasing in severity ever since. Only the posterior rotators appeared to be affected; "the spasmodic movement seemed to be a rotation of the atlas upon the axis;" the trapezius and sternomastoid were apparently not implicated. Excision of parts of the posterior divisions of the upper three cervical nerves was performed, with the result that the patient is now free from pain, which before was intense; "the deformity is but slight, all movements of the head are quite free, there has been no return

a

* For a fuller account of this case, and description of the steps of the operation, ses "Spasmodic Wryneck and other Spasmodic Movements of the Head, Face, and Neck." By Noble Smith, F.R.C. S., Ed. London: Smith, Elder, & Co., 1891.