In spinal meningocele an early operation (Bottcher) would offer the greatest hope were it not for the dread spectre of hydrocephalus lurking in the background. I operated on a case of spina bifida (form 3) which healed satisfactorily; but after six months the child returned with an enormous hydrocephalus from which fortunately it was soon relieved by death. Since then I have followed a different method so as to obtain better information in regard to this risk.
Under careful observation I institute gradual compression upon the tumor; this can be carried out easily by means of a metal or celluloid cap. A mould is made to fit the growth; as it diminishes the cap can be reduced in size by inserting pieces of gauze. The cap is placed over the tumor and is strapped to the body with rubber bandages. A few days are sufficient to reduce the growth, and it is astonishing to sec the transparent skin begin to assume a normal appearance. When the growth has been reduced to half its size the child is discharged with instructions to gradually reduce the size of the cap and to keep the rubber bandages applied. In order to prevent any injurious pressure upon the abdomen a kind of bridge, made of cardboard, is placed over it as a protection.
If the cranial circumference should not increase during this syste matic reduction of the spinal sac the chances for appearance of hydro cephalus are unquestionably lessened. Two or three months are suffi cient for observation.
This method is, of course, only indicated if there is no imminent danger to life, or in the presence of other conditions that necessitate taking the risk of immediate operation. In regard to the operation, the remarks made about cephalocele, mutatis mutandis, hold good here, too.
The head should be lowered to prevent, as far as possible, the exuda tion of cerebrospinal fluid. The sac should be ligated, opened, and the nerve cords replaced. Fistula from the needle wounds should be avoided and the wound closed in the simplest and strongest manner, as in cephalo cele, with the child lying on its abdomen. In one instance (1906) I endeav ored, in a case that was complicated with hydrocephalus, to counteract the pressure of fluid by perforating the vertebra at the base of the opened cyst and inserting a hardened artery reaching to the peritoneal cavity. As the case was one with an exposed spina bifida, and infection was already present, the chances of success were small.
It might be possible to relieve the growth and the increase of pres sure from the operation by instituting drainage transperitoneally from the front before operation. As it is easier to approximate the abdominal
walls to the vertebral column in a child than in an adult, this procedure can be carried out by a small incision and the subsequent operation would be considerably simplified.
The results of operation in this deformity depend upon the kind of cyst, the vitality of the child, and the simplicity of operation. In osteo plastic procedures (Gorochow) to cover a cerebral defect, the danger of even a slight necrosis should never be disregarded, since even slight suppuration may lead to serious results. For this reason the French authors, among them Kirmisson, Piechaud, and Froehlich, prefer fascia and skin closure to all others on account of its simplicity (Henlc).
All attempts to remove the entire growth by ligation or by injections are objectionable because of their danger, and in the present status of surgical knowledge these procedures should be looked upon as antiquated.
If the parents of an otherwise normally developed child cannot bring themselves to consent to an operation, which in any case involves a risk, it is preferable to resort to the reduction of the growth by means of the protective cap above described and to trust to the elastic pressure it exerts.
Spina bijida occultu, being an aplasia of the central nervous system, is not amenable to surgical treatment at the present time, unless the existing paralysis can be symptomatically influenced by plastic and orthopaedic measures on nerves and tendons. It is just in these cases, however, that the enormous power of restitution and substitution of the central nervous system is frequently exemplified.
In a case of severe pelvic paralysis I observed progressive improvement from year to year, the uppermost segment always showing the improvement first. This slowly extended downward, so that the child after nine years has the full use of the muscles of the thighs and legs, while the small muse]es of the foot, bladder, and rectum are still paretic. This auto-cure can be explained only by the erection of new centres or channels. I have never observed in anv of my eases anv increase of trouble from pulling the retracted spinal cord (Katzenstein).
The operations upon other growths at the lower end of the vertebral column, coceygeal and sacral tumors, are carried out according to gen erally accepted surgical procedure.