Cushing in 1908 proposed a method of retrope itoneal drainage by a combined laparotomy and laminectomy for hydrocephalus of the congenital, chronic and progressive type. He states the procedure was carried out in 12 cases with a considerable measure of success. Later, in 19148, he modifies the value of this suggestion, and says:

"In most of these cases (i.e. hydrocephalus accompanying spinal meningocele) it is possible to empty the ventricles as freely by a lumbar as by a direct ventricular puncture. It was in view of this finding that my early efforts to drain the spinal subarachnoid space into the loose

When the fluid is let

retroperitoneal tissues were undertaken.
out under the scalp, and probably also when it escapes into the loose retro-
p ritoneal spaces, the early widespread edema which occurs i; followed
by the gradual formation, about the primary area of outflow into the
tissues, of an endothelial cavity from which the fluid no longer is ob-
sorbed into the adjoining ymphatics."

Thus it is seen that even with good immediate operative results
the ultimate outcome of anything more than a simple meningocele
is most doubtful.

Most operators agree upon the following contraindications:

1. Demonstrable evidences of hydrocephalus.

2. Paralysis of legs or sphincters (except of the slightest degree).
3. The defect so extensive as to preclude the securing of good flaps
without tension.

The above recital of events is a dreary one and not altogether in accord with the reports of successful cases published in twos and

However, the reports of good justifiable to operate except in

threes at various times by other writers.
results in occasional cases makes it seem
the presence of the above described contraindications. If the structural
condition is then found hopeless, we have done no more than our
duty in making the attempt.

I take the liberty of quoting the description for the radical cure of spina bifida by Dr. J. W. Markoe of this Hospital, who has performed more of the operations in the series presented than any other single operator.

"It has been my custom to operate upon these cases as soon after the child is born as is possible with the belief that the sooner it is performed, the less likelihood there will be of infection taking place. It is true that in some instances the sac may be so resistant as to allow the child to live for years without rupture and consequent opening of the spinal canal. Yet in the vast majority of the cases, the sac is either already ruptured at birth or does so very shortly after, from the friction of the clothes or from overdistention from within the neural canal. Once the sac is ruptured, it has been found that it is almost impossible to keep the sac free from infection on account of the near

ness of the rectum and the constant restlessness of the child, and should the sac become infected, the death of the child from septic infection of the cord and brain is inevitable."

"In operating one must bear in mind that the sac with its thin wall must be replaced by tissues that will for all time protect the spinal cord from external injury. To accomplish this, it does not seem necessary to transplant bone to close in the defect in the vertebra, for by so doing there is apt to result a stiffening of the dorsal and lumbar spine that might be awkward in later life. It is believed that if the fascia and muscle are brought together over the canal and then covered with the fat and skin of the back that ample protection is given."

"The almost constant association of hydrocephalus in connection with this malformation makes the prognosis, even in the hands of the most skillful operator, always a questionable one."

"The operation is practically the same in all forms of spina bifida and involves the following steps:

1st: Strict asepsis in all manipulations of the sac and the surrounding skin, with disinfection where possible of the skin and sac wall before commencing to open the sac. If the sac has already ruptured, this will be all the more difficult, on account of the constant flow of spinal fluid and the restless motions of the child which make it so difficult to isolate the field of operation.

2nd: The opening of the sac at its upper portion and the separation of the nerve filaments that are so frequently spread out over its inner surface. In some cases, it will be necessary to leave a portion of the sac wall and replace it with the attached nerve filaments within the canal as these nerves may be so intimately adherent to the sac that it is impossible to detach them.

3rd: The closing of the canal by as many layers of tissue as is possible. This will differ in almost every case, some closing in with the greatest ease while in others the separation of the lateral bony processes makes it extremely difficult. The steps of the operation in general are as follows:

Replacing the nerve elements in the neural canal and closing the dura over them so that no spinal fluid escapes, except through the lowest point where a puncture is made into the gluteus muscle and two or three strands of silkwormgut tied together may be placed as a drain from the canal into the muscle as advocated by Mayo, in the hope that the excess of fluid will be taken up by the muscle and thereby reduce the amount of fluid in the ventricles of the brain. Of course, if there is already hydrocephalus which does not empty itself into the spinal canal, such drainage will be useless and one of the methods proposed by Cushing and others may be adopted. The next step in the operation is, if possible, to bend around the canal the cartilaginous processes of bone which lie on either side bringing these together and holding them in place by cutting through the erector spina muscles and fascia on either side and suturing them firmly together in the median line. Over this the superficial fascia and skin finish the operation; an occlusive dressing then completes the case."

REFERENCES.

1. Trans. London Clin. Soc., vol. xviii.

2. Zeitschr. f. Heilk. Berl. 1897, xviii, 405.

3. Inaug. Diss., Breslau, 1902.

4. Keen's Surgery, vol. ii, 1908.

5. Ann. Surgery, vol. 61, 1915.

6. Antenatal Pathology and Hygiene, vol. ii, 1904.

7. Keen's Surgery, vol. iii, 1908.

8. Jour. Med. Research, vol. xxi, No. 1, Sept. 1914.

OPEN-AIR TREATMENT IN SURGERY*.

BY

J. W. MARKOE, M. D.
Attending Surgeon.

THERE is, within the reach of all, air and sunshine sufficiently pure and constant to be of the greatest aid in the treatment of surgical cases, even where the surgeon's practice is in the crowded city or where the homes and climatic conditions are such that it would seem to be impracticable.

This subject has, therefore, been chosen for your consideration in the hope that a knowledge of the action of these agents will stimulate to their more frequent use, not only those who have the facility for open air treatment in properly equipped hospitals, but also those whose work is in private homes. It is to be regretted that in the comparatively few instances where it has been used that this treatment has been taken advantage of only in the more desperate cases and as a last resort, rather than as a routine, and also that it is but rarely though applicable to minor cases, where I feel sure much more rapid recoveries would be the outcome of its systematic use.

Among the ancients, the bath and the exposure of the human body to the elements was practiced extensively, and not infrequently for the cure of maladies, both medical and surgical; and now in modern times its employment in tuberculosis is general throughout the civilized world with incalculable benefit; yet its use in general surgery has not been universally adopted. Spallanzani, many years ago, showed that molds and fungi when exposed in the air to the direct rays of the sun, died in a very short time, and today our bacteriological workers have demonstrated by innumerable experiments that all microorganisms are inhibited in their development or totally destroyed by the rays of the sun. The effect of the sun upon protoplasm has as yet not been worked out so carefully that we are able to divide the spectrum into its component parts and use each of them as we see fit for its therapeutic influence. To be sure, we have the Rontgen ray and the gamma ray and others; but we cannot say just what action the solar rays really have. Dr. Bovie, in his article "Action of Light on Protoplasm," states that it is his belief that the physiological effect of light must be the result of photochemical reaction, inasmuch as only those electromagnetic waves that are absorbed are capable of bringing about physiological

*The address in Surgery, delivered at the 27th annual meeting of the Minnesota State Medical Association, at Rochester, Minn., September 30, 1915.

Appears also in the Journal-Lancet, Dec. 1, 1915.