In less severe cases the dis turbance is confined to palsies of the foot and of the sphincters.
The combination of spina bifida with other malformations is by no means rare. Thus we find reduplication of the spinal marrow, hydromyelia, dilatation of the fourth ventricle, hydro cephalus, defects in the skull, as well as ectopia of the bladder and congenital hernias.
The diagnosis of spina bifida presents no difficulties when the characteristic pi cture o f the tumor and paralysis are present. In the absence of these comitant symptoms distinction from liporna or teratoma may be quite difficult, particularly as these tumors exhibit a preference for the same situation and the ciation of spina bifida with tumors of this kind is by- no means rare. In general it may be said that spina bifida is translucent, only slightly movable. flaccid, covered with a delicate envelope and more or less compressible, the act being sometimes, although not regularly, panied by cerebral symptoms. If all these signs, which are not very pronounced. are absent, the presence of spina bifida ruay be established by means of an exploratory puncture with a delicate acupuncture needle. The X-rays have recently been employed in the examination of a few cases and are useful for the diagnosis of a cleft in the spinal cord, but are of no value for determining the kind of spina bifida that is present.
The prognosis in cases of myelocele with pronounced palsies is extremely grave. The ulcerated surface of the sac is prone to become the starting point of a purulent meningitis; if the tumor is very tense it may rupture or at least become permeable for fluid, in that way permitting infection of the interior to take place. Aside from the dangers of intraspinal suppuration. the children may be destroyed by catarrah of the bladder, sepsis following ulcers of the skin, diseases of the intestines, etc. Ifiedert lost 25 out of 32 cases in the first week. There is no prospect of the palsy disappearing spontaneously; indeed, paralytic symptoms may develop secondarily in cases in which the spinal hernia was at first unaccompanied by symptoms. These palsies are probably due to pressure or to maceration of nerves that pass through a layer of fluid.
It is therefore easy' to understand that the question of operative removal of spina bifida has for a long titne occupied the attention of pediatrists and surgeons. After the first primitive attempts, consisting
in clamping or ligation, or compression of the sac, puncture followed by the injection of iodine solutions was resorted to, the injected solution of iodine glycerin being removed soon after its introduction. In this way it was hoped to set up local inflammation and cause adhesions of the inner surfaces of the sac, with complete obliteration. The latest development in this treatment consists in the injection of paraffin saturated with iodine for the double purpose of setting up irritation in the meninges and closing the opening in the spinal marrow with a kind of tampon. At the present time more attention is given to the careful elaboration of operative methods, with the laudable object of avoiding as much as possible any' injury to the nerves contained in the spinal sae, although the details of the plastic operations for closing the open ing in the spinal marrow are somewhat exaggerated. This is not the place for a discussion of the technic of these operations, for which the reader is referred to text books on Surgery, and to the writings of Bayer, Bockenheimer and others. We shall merely emphasize Bayer's warning against too much operating in cases of this kind. If the patient is com pletely, paralyzed, he is very little benefited by a masterly surgical performance and the substitution of a beautiful scar for a tumor that is constantly exposed to infection; particularly if the paralysis is made worse by the operation, owing to the unintentional removal of large portions of nerves. It also appears that, when there is hydrocephalus, closure of the spinal sac has an unfavorable influence on its subsequent course. Bayer is therefore quite right when he insists on excluding from operation all cases characterized by extreme degrees of paralysis and the presence of hydrocephalus and other pronounced malformations. On the other hand, uncomplicated cases of spina bifida are favorable for operation, and the many statistics which have been collected indicate very good results (Hildebrandt, Nicoll, Sachtleben, Schirmer and others).