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—The principal reason for attack upon this nerve is spasmodic torticollis, or wryneck It is exposed through an incision along the anterior border of the sternocleidomastoid muscle, extending two inches downward from the ear. The nerve is found a little above the level of the hyoid bone; or, again, it may be found by an incision along the outer border of the muscle, opposite its centre, just above which it will be detected (Fig. 405).
The Deep Posterior Cervical Plexus.
—When operation upon the spinal accessory has failed to relieve long-standing and serious spasmodic torticollis, Keen has suggested to divide the first, second, and third cervical nerves The operation is difficult and not always successful; still it is worth trying. A transverse incision is made below the level of the lobe of the ear, the trapezius being divided and dissected up until the great occipital nerve is found. It is followed after the necessary division of the complexus until its origin from the posterior division is reached. The suboccipital or first cervical nerve, which lies in the triangle close to the occiput that is formed by the two oblique muscles and the posterior rectus, is excised. The exterior branch of the posterior division is found lower down, and should be divided close to the bifurcation of the main nerve (Fig. 406).
405
Exposure of the spinal accessory nerve alone: a, digastric; b, jugular veins; c, sternomastoid muscle; d, spinal accessory (Marion )
F 406
Incisions through which the various nerves in the neck may be sought: a, facial; b, facial and hypoglossal; c, facial and sp acces ; d, spinal accessory; e, cervical plexus; f, brachial plexus (Marion )
The Cervical Sympathetic.—The cervical sympathetic is a most complicated nerve trunk, furnishing fibers of various functions to the skin, and to the deeper parts fibers which are vasomotor, vaso-inhibitory, pilomotor, and secretory in function. It supplies the various glands, the upper viscera, the heart and bloodvessels, and connects with nerves below, which supply even the genital organs and the non-striped muscles of the body. The upper part has a very important oculopupillary function, as it supplies the dilator pupillæ, the non-striped part of the elevator of the upper lid, and the orbital muscle of Müller, i. e., a small bundle of non-striped muscle which lies behind the globe and projects across the sphenomaxillary fissure at the back of the orbit. (By contraction of this muscle the eye may be pushed forward.) It also supplies the submaxillary gland, the cutaneous bloodvessels, and the sweat glands of the head and neck. The pupil dilating fibers arise in the medulla, run backward in the lateral columns of the cord to the
ciliospinal centre, emerge through the anterior roots of the first and second dorsal segments, and enter the inferior cervical ganglion, thence passing upward through the sympathetic trunk to the orbit. Therefore ocular and other symptoms are produced not only by lesions of the external trunk, but also by lesions within the cord at the level of the upper dorsal segments. These nerves may be injured anywhere in the neck, or compressed by inflammatory deposits or new-growths, or even by cicatricial tissue at the apex of a tuberculous lung. Many cases of phthisis show inequality of the pupils. One nerve may be injured in operations on the neck, the result being slight drooping of the lid and flushing of the face, as well as excessive perspiration on the injured side; the corresponding pupil being smaller than the other because of paralysis of the dilators, but contracting to light, as the third cranial nerve which supplies its sphincter is unaffected. The eye will then sink back somewhat, owing to paralysis of Müller’s muscle, and thus permit a nearer closure of the lids. These oculopupillary symptoms are pathognomonic of paralysis of the cervical sympathetic. Cocaine will not dilate a pupil whose dilator has thus been paralyzed. The area of skin supplied with sweat fibers by the cervical sympathetic includes the corresponding side of the head, neck, shoulder, and upper part of the trunk (Fig. 407).
When the cervical sympathetic is unduly stimulated we have dilatation of the pupil, exophthalmos, widening of the palpebral aperture, delayed descent of the upper lid when the patient looks downward, all of which can be imitated or produced by dropping into the eye a solution of cocaine, which stimulates the nerve.[47]
[47] Stewart, Some Affections of the Cervical Sympathetic, The Practitioner, February, 1905.
The surgical sympathetic is attacked surgically for three widely variant conditions: epilepsy, glaucoma, and exophthalmic goitre—the first, because of its vasomotor control of the vascular supply of the brain; the second, because of the relation of the nerve to the orbital circulation and nutrition; and third, because of its relations to the thyroid and the heart. In the latter case it is especially desirable to remove the lower cervical ganglion and the first dorsal, if it can be reached, although the procedure here is exceedingly difficult.
The tachycardia of Graves’ disease is due apparently to irritation of the accelerator nerves of the heart, which come from the sympathetic, or else to paralysis of the regulator (pneumogastric) supply. The former spring from the lower part of the cervical cord and the upper dorsal segments, and pass to the third cervical ganglia and to the first dorsal, terminating in the cardiac plexus.
The operation described below is practically that advised by Jonnesco, more or less modified by other operators, and may be varied to some extent to meet the exigencies of particular cases. Thus whether it shall be done through one or two incisions will depend on the will of the operator It is made about as follows: A long incision is made along the posterior border of the sternomastoid. The latter may be either retracted forward or its fibers separated, in order that the fascia on its inner side may be reached and separated from the deeper muscles. This fascia should be divided as high as the base of the skull. The upper ganglion of the cervical sympathetic lies on the inner side of the anterior tubercle of the transverse process of the second and third vertebral processes, resting upon the muscles covered by this fascia. The ganglion, being recognized by its shape, and the sympathetic trunk being thus identified, the nerve should be divided and made free, as high as possible and just beneath the base of the skull. (See Fig. 408.)
Diagram to illustrate the relations of the cervical sympathetic and the mechanism of the various disturbances following lesions of its trunk (Stewart )
The lower end is to be exposed by continuation of the first incision, or by another beginning 1 Cm. above the clavicle and extending along the posterior border of the sternomastoid for 4 or 5 Cm. The platysma should be entered and the tissues separated upward until the fingers can meet in a channel thus made by connection with the upper incision. The tissues should also be loosened downward until a point has been reached behind the clavicle. They then should be widely retracted and the inferior thyroid artery sought. The middle cervical ganglion is found inside of its curve. Occasionally this ganglion is replaced by a plexus, or the main trunk may pass behind the artery. At this level it is to be seized and its upper divided end pulled down and out through this opening. The nerve trunk should then be followed downward. The artery should be freed from any plexus of sympathetic fibers around it, all of which should be destroyed, and especially those fibers which constitute the middle cardiac nerve, which pass to the inner side. The main trunk is to be drawn down beneath the artery and then followed downward and outward to the lower ganglion, where it lies behind the clavicle, on the neck of the first rib, between the scalenus anticus and the longus colli. The ganglion and the trunk should be separated from the efferent and afferent branches which connect with it, as well as from the vertebral artery; being thus made free it is again drawn outward. Here one should divide especially the cardiac branches which form the lower cardiac nerve, as well as the vertebral branches which have so much to do with controlling the supply through the vertebral artery. The ganglion, after being identified, should be finally removed. The nerve should be traced still farther down to the first thoracic ganglion, which has much to do with supplying the heart, and this also should be separated and destroyed (Fig. 409).
408
Sympathectomy. Exposure and removal of middle and upper ganglia (Marion )
F 409
Sympathectomy. Seizure and removal of inferior ganglion (Marion )
It is rarely necessary to provide for drainage after the operation, unless the retraction and laceration of tissues have been very great. My own preference is to make one long incision along the posterior border of the sternomastoid, by which the dissection is facilitated and the operation made less complicated and difficult. When done for glaucoma on one side it will be sufficient to attack one nerve, but when for epilepsy or for exophthalmic goitre the operation should be bilateral. When for epilepsy or glaucoma it is not so necessary to remove the lower cervical ganglion; this is indicated rather in those cases where it is desirable to control the accelerator nerves to the heart. The operation has given good results in all three affections named, yet it is one of considerable difficulty. It would be made extremely difficult by the presence of a large goitre, and in such case it would probably be better to extirpate the thyroid rather than to attack the nerve. (See Glaucoma, Epilepsy, and Exophthalmic Goitre.)
CHAPTER XXXVIII.
THE SPINE, THE SPINAL CORD, AND THE PERIPHERAL NERVES.
SYRINGOMYELIA.
The term syringomyelia implies irregular dilatation of the central canal of the spinal cord, having a congenital origin, tending to relative increase later in life, with corresponding disturbance of function, the latter including paresthesiæ, loss of sensibility to heat and cold, more or less motor impairment and disturbances of nutrition, more noticeable in the region of the joints than elsewhere, the latter having been already considered in the chapter on the Joints. The dilatation is by no means regular, may occur in various regions of the cord, and attain a size permitting encroachment upon, and even atrophy of, the structures of the cord itself. When functional disturbance, especially paralytic, has become very pronounced a few surgeons have ventured to expose the cord by a laminectomy, and endeavored to make a more or less permanent opening with drainage of the dural cavity. Thus Keen has operated twice, Abbe once, and Munro three times, including twice on the same patient. Only in this last instance was any permanent relief obtained, and this was at the expense of a second operation. It is doubtful if any of the peculiar joint lesions of this disease will be in any way affected by operation for this purpose.
TUMORS OF THE SPINAL CORD.
Tumors of the spinal cord may be classified as follows (Krauss):
1. Tumors springing primarily from the envelopes of the cord: (a) Tumors of the vertebral column, and (b) tumors of the meninges, the latter including those arising from the external surface of the dura, or from the periosteum of the spinal canal, i. e., extradural tumors, and those from the inner surface of the dura and the other membranes, that is, intradural tumors.
2. Tumors developing in the cord proper, intramedullary These are generally gliomas and do not present so much the symptoms of cord tumors as of syringomyelia.
Vertebral tumors may be carcinoma (secondary), endothelioma, sarcoma, osteosarcoma, as well as the non-malignant and cartilaginous or osseous tumors, and parasitic cysts, i. e., echinococcus. The sarcomas are the most common of all.
Symptoms.
—The symptoms of tumor of the spinal cord depend upon the part involved and differ according as it involves the cervical, thoracic, or lumbar portions or the cauda equina. They are to be classed as root symptoms and cord symptoms. Root symptoms include pain, paresthesia, and hyperesthesia. The pain is usually persistent, burning, and severe, affecting one side or the other, if the tumor be laterally placed, or both sides if central. The pain follows the distribution of the spinal roots rather than the course of the intercostal nerves, i. e., is more horizontal and less oblique. These pains persist and have the characteristic feature of not presenting painful points on pressure. They are commonly referred to the abdomen, and may thus give rise to serious mistakes in diagnosis, e. g., they have been regarded as due to hepatic colic, dry pleurisy, appendicitis, etc. Pain may assume the girdle character, which is usually accentuated by movement, and is frequently accompanied by herpes zoster. The greater the involvement of the posterior roots the more painful the condition. When the anterior sensory roots are involved pain may be wanting and the disturbance assume a type of paresthesia, with final anesthesia, in which case the patient would at first complain of numbness and prickling sensations. There is sometimes noted a zone of hyperesthesia on the proximal side of the anesthetic area, or this zone, if not hyperesthetic, may be replaced by a condition of uncertainty of sensation.
The cord symptoms are the reliable ones, varying according to the segment involved. The portions of the cord where lesions can be best localized are, for instance, the third to the fifth cervical, including the origin of the phrenic nerve; the fifth to the seventh cervical, where the posterior thoracic nerve comes off; the seventh to the eighth cervical and first thoracic segments, where originate the dilator nerves of the pupil. The upper border of the anesthetic area points to a lesion of the next or second higher spinal segment than the level really represents. The lowest level of the lesion corresponds to the highest level of the sensory disturbance. The level of the segment area of the skin of the back does not correspond to the level of the spinal segment involved, the latter being higher up. The point of greatest sensitiveness over the spine is in many cases a good guide to the segment involved, but is applicable only where the lesion is posteriorly placed. The absence of pain or tenderness along the spine means little or nothing, but their presence has great significance.
Diagnosis.
—The diagnosis of a cord tumor covers, according to Krauss, a first or subjective period, indicative of irritation along the posterior roots, and is characterized by pain and paresthesia. This is followed in time by a second or objective period which points to invasion of the spinal cord, characterized mainly by weakness and later by paralysis, with disturbed tendon reflexes. Diagnosis early is extremely difficult, for pain and disturbances of sensation are produced in many ways.
Treatment.
—The treatment of spinal-cord tumors is purely surgical and should be instituted promptly so soon as diagnosis has been
made. Only in tumors of syphilitic origin will internal treatment be of any avail. The therapeutic test having been made, should it seem wise, and proved futile, the case should be regarded at once as surgical. According to Krauss’ statistics nearly 40 per cent. of all operated cases have resulted in recovery, while in 35 cases of sarcoma 8 have resulted in recovery and 6 in improvement. This is really a more gratifying statement than can be made with regard to brain tumors, and should be regarded as lending encouragement to surgical procedure.
The operative details will be discussed later in this chapter.
THE PERIPHERAL NERVES.
The remarks made concerning the surgical affections of and operations upon nerves contained in the previous chapter, pertaining to the cranial nerves, will apply equally well to the peripheral nervous system.
Constant pressure as well as contusions of nerves will cause more or less paralysis. The surgeon occasionally sees manifestations of this kind in the socalled “crutch paralysis,” due to pressure upon the brachial plexus by the use of crutches, and in another form so generally associated with administration of an anesthetic as to be called “ether paralysis.” It is another form of pressure paralysis due to indifference in letting the arm, for instance, hang over the edge of an operating table during anesthesia or operation. It does not call for operation so much as for electricity, massage, and similar measures. Extreme consequences of nerve and vessel injury are portrayed in Fig. 410
Tumors of nerves are both benign and malignant, the former assuming the fibromatous type oftener than any other, and frequently involving more than one nerve trunk, attaining also considerable size and impairing or destroying function by pressure. In addition to the true fibroma of nerve sheaths we have the peculiar type of fibromas of nerve stumps seen after amputations, and the multiple neuromas, again largely of the fibromatous type, which involve many and in rare instances nearly all the peripheral nerves. Cases are on record where as many as 1600 small and large tumors have been found, strung like beads upon wires, along all the peripheral nerves throughout the body. Another variety of fibromas of nerves involves those of the skin and produces small painful subcutaneous nodules, although these may attain a considerable size. Within the past few years there has been a much better familiarity with that form of growth known as plexiform neuroma, in which entire nerve trunks are involved, so that they become elongated, thickened, and tortuous, and resemble a varicose condition of the veins. The plexiform neuromas are found in any part of the body; they produce little or no pain, but lead to disturbances of function, as well as to peculiar irregular swellings that may be mistaken for lymphangioma, and which are often accompanied by pigmentation of and growth of hair upon the overlying skin. (See chapter on Tumors.)
For the various purposes already mentioned different nerve trunks and plexuses are made accessible for operation by the following methods.
The Brachial Plexus.
—The brachial plexus is reached through an incision similar to that for ligation of the subclavian artery. After opening the deep fascia the nerves are sought and found behind the subclavian vein and lying around the artery. This plexus is stretched especially for the relief of choreiform spasm or painful nervous affections. The various nerves of the upper extremity, after leaving the brachial plexus, are made accessible to operations for grafting or suture as below. (See Fig 406.)
The Median Nerve.
—The median nerve lies in front of the brachial artery and is exposed through an incision as if the artery were to be tied in its course. It may also be found on the inner side of the tendon of the palmaris longus, where it lies beneath the deep fascia.
The Ulnar Nerve.
—The ulnar nerve is reached through practically the same incision as the median, when it is sought in the middle of the arm, but is farther back. It lies near the surface, just behind the inner condyle, between it and the olecranon, and at the wrist it is on the radial side of the tendon of the flexor carpi ulnaris.
Gangrene (mummification) of arm resulting from injury to nerves and vessels (Preindlsberger )
The Musculospiral Nerve.
—The musculospiral nerve is found between the heads of the triceps, where it lies in the groove which winds obliquely around the humerus.
The Radial Nerve.
—The radial nerve lies to the outer side of the radial artery, three inches above the wrist. Should any of the nerves of the arm or forearm have been cut by an accident which has produced an incised wound they should be sought for in the wound if fresh, and in the neighborhood of the scar if older, and should be reunited by suture, as already described.
The Great Sciatic Nerve.
—In the lower extremity it is the great sciatic nerve which is usually made the subject of operation. An incision midway between the great trochanter and the tuberosity of the ischium, by which the lower border of the gluteus muscle is exposed, will enable the surgeon to identify the
F . 410
biceps, to divide the deep fascia, and find the sciatic nerve at the outer border of the muscle. It is sought for the purpose of nerve stretching, and it may be pulled completely out of the wound, while the entire weight of the limb may be suspended by it.
The Tibial Nerve.
—The tibial nerves may be exposed through incisions identical with those indicated for ligation of the tibial arteries.
The Anterior Crural Nerve.
—The anterior crural nerve lies in Scarpa’s triangle, near Poupart’s ligament, on the outer side of the femoral artery.
Tetanus should be treated by injecting antitoxin into the main nerve trunks, as well as into the spinal canal. The individual nerve trunks of the brachial plexus may be exposed in the upper arm, where the point of the hypodermic syringe needle may be inserted into their substance. The same expedient may be employed with the sciatic or anterior crural trunks, through the incisions just described. The same measures may be used in cocainizing the nerve trunks, as suggested by Crile and others, and described in the chapter on Alterations of Blood Pressure (p. 181).
Abbe has suggested to treat certain cases of inveterate neuralgia of the peripheral nerves by an intraspinal division of the posterior nerve roots. There has been added to the standard operations on nerves another measure. This consists of grafting by means of foreign material; using a section of nerve trunk removed freshly from some animal, or inserting catgut loops between nerve ends which shall serve as trellises upon which the growing nerve tissue may arrange itself. Powers, of Denver, has, for instance, reported the implantation of four inches of the great sciatic nerve of a dog into the external popliteal of a man. The results seemed to be good so far as sensation was concerned, but negative as regards motion. Probably no method of nerve grafting will give so good results as the utilization of a part of the nerve itself to be operated upon, by partially detaching and turning back a portion of its central end and uniting it to a similar flap made from the other end. Various operators have made use of different materials for the purpose of forming a tube around the nerve ends, and thus excluding other tissues. For this purpose cargile membrane is perhaps as serviceable as any. When all other measures fail the method by long catgut sutures may be adopted.
DISLOCATION OF NERVES.
A few of the nerve trunks may be displaced by injury in such a way that they are liable to subsequent redislocation. The condition is recognized by the mobility of the nerve trunk under the skin, by peculiar sensations when the trunk is irritated, and often by tingling sensations referred to its distribution. The condition is most common in connection with the ulnar nerve, just behind the inner condyle. Should nothing else give relief the trunk should be cut down upon and retained in place by suture or by fixation of other structures around it.
WOUNDS OF THE SPINE AND CORD.
Penetrating Wounds.
—Penetrating wounds of the spine occur both in military and in civil practice. Sometimes the vertebræ alone are injured; occasionally the spinal canal will be opened, with little injury to the bone, only the cartilage suffering. All such injuries are serious in proportion as the cord itself may be injured. Such injuries may be direct or indirect. Should a large vessel have been divided the cord may suffer from pressure of clot, and should this injury occur high in the spine, death may be caused by pressure. The severity of such an injury is generally estimated by phenomena pertaining to the nerve supply of parts below the wound. Should anything indicate partial or complete division of the cord, or that a single nerve trunk has been divided, then an operation is indicated for relief of symptoms, and for nerve or cord suture except in those instances where destruction seems to be too complete to warrant it.
Gunshot Injuries.
—Gunshot injuries vary from small punctures and penetrating wounds to extensive laceration. The lower the injury the lower the mortality, other things being equal. Such injury to the cervical region generally proves quickly fatal. The symptoms here are not essentially different, save that the bullet may have done still more harm by passing beyond the cord, and that to the signs of a penetrating wound may be added those of a traumatic hemothorax or some other serious complication. It is necessary to distinguish between mere stiffness of the back and disinclination to use certain groups of muscles and absolute loss of motility. The former may indicate contusion and the latter severance or pressure. After some perforations cerebrospinal fluid will escape. In one instance I opened a spinal canal for perforating gunshot wound with complete paralysis, and found not only that the bullet had divided the cord but had passed through the vertebra into the lung beyond. A very curious phenomenon presented in this case is that when the passage was well opened air passed backward and forward through the spinal wound, the patient thus partly breathing through his back.
PLATE XLVI
Intraspinal Hemorrhage,
mostly Subdural, with Minute Subpial Ecchymoses.
The effect of pressure from hemorrhage is practically the same whether it be intradural or extradural, or occurring within the structure of the cord itself. The presence of blood in the spinal canal is known as hematorrhachis, and when occurring within the cord itself is termed hematomyelia. The typical symptoms of sensory and motor paralysis, which serious pressure upon the cord always produces, occur when produced by mere presence of fluid more slowly than when due to the introduction of a foreign body or to comminution of the bone. Diagnosis is then much facilitated if by the personal history it can be learned that there was an interval after the reception of the injury and before the occurrence of paralysis, during which the patient had reasonable use of the parts later paralyzed. This interval may be one of but a few minutes’ duration or may have extended over several hours.
When, on the other hand, such an interval lasting several days has been noted, then the intraspinal lesion must be either one of acute degeneration or of suppurative character (See Plate XLVI.)
The question of operation in spinal hemorrhages will frequently be raised, and is to be decided in part by the intensity of the symptoms and in part by the character of the injury Incomplete paralysis would indicate a lesser degree of pressure and justify a hope that the outpoured blood may be resorbed. This hope may be further encouraged should symptoms improve. On the other hand symptoms of complete paralysis, indicating serious and extensive pressure upon the cord, would justify a laminectomy, and make it even more encouraging than though it were done for a crushing injury. The more serious cases, then, of spinal hemorrhage would seem to justify exploration.
Until very recently it has been held that a complete cross-division of the spinal cord must necessarily be followed by a hopeless paralytic condition, plus the changes due to ascending degeneration of the upper segment. The results of laboratory experiments have made this quite plain, and therefore it was a startling innovation in surgery when Harte could report an experience contradicting all that we had learned to believe in this regard. In spite, then, of the fact that experimental suture of the cord after its division had not been successful in animals we are now confronted by three more or less successful cases reported by American surgeons, Estes, Harte, and Fowler, where the spinal cord was sutured after division, with at least partial recovery of function. In Harte’s case the operation was done three hours after injury; in Fowler’s case ten days had elapsed. Fowler used chromicized catgut sutures in the cord
itself, with separate sutures of the dura with the same material, the principle here being the same as in nerve suture, and the effort being to do as little harm as possible with the needle and the suture material. After a simple division there is but little tension, and the ends of the cord are easily approximated.
It has thus been proved that there is at least some possibility of regeneration of the cord after such destructive lesions; but the cases which permit of or justify this measure will be rare, although it is gratifying to learn that there has been so much encouragement afforded by experiences reported.
THE SPINAL COLUMN.
SPINA BIFIDA; SPINAL MENINGOCELE.
Spina bifida is the result of a congenital defect in the construction of the spine with incomplete closure of the spinal canal. The defect lies in the posterior arches of the vertebræ; the bodies are rarely involved. For this reason these lesions are centrally placed, i. e., in the middle line. The essential feature of a spina bifida is protrusion of the spinal membranes, and they are, to all intents and purposes, spinal meningoceles. These tumors sometimes have only the thinnest of skin coverings; at other times they will be covered by considerable masses of overlying fat or fibrous tissue.
These congenital tumors when more definitely described should be classified as—
1. Meningocele, where there is simply a protrusion (hernia) of the dura, which may be lined with some branches of the vertebral nerves;
2. Meningomyelocele, where some portion of the spinal cord proper is included within the sac;
3. Syringomyelocele, where the central canal of the cord is dilated into a cyst of some size, over which the structures of the cord proper are more or less thinly spread out, the whole being covered with the spinal dura.
The first form is by far the simplest and most amenable to treatment. The other forms are much more serious, and the third form is hopeless so far as operative surgery is concerned.
The greater proportion of these cases occur in the lumbar region, at least 70 per cent. being met with in the lower region of the spine, including the sacrum. It occurs occasionally in the neck and in the mid-dorsal region.
Fig. 411 illustrates the general appearance of such a tumor The opening of communication may be very small or may involve the arches of several vertebræ. So with the tumor itself, it may be small and almost imperceptible, or it may attain almost the size of a child’s head. The overlying skin is rarely absent; it is usually covered with a growth of hair, and its presence in the region
of the spinous processes, coupled with the presence of any perceptible tumor, should cause suspicions of the so-called spina bifida occulta
F 411
Spina bifida (Bradford )
These tumors are situated in the middle line or very near to it, and are compressible in proportion to the thinness of their coverings. When small they can be collapsed by pressure, the same not infrequently causing pressure symptoms, as the fluid is forced into the cranial cavity, such as coughing, vomiting, vertigo, etc. If the fluid can be easily expressed from the sac the opening may be regarded as relatively large. If pressure makes no alteration in the size of the growth the case should then be regarded as one where the small original communication has been closed by natural processes. Some of these tumors have more or less of a pedicle and others are broadly sessile. The tendency is ever toward increase in size, being rapid or slow according to the thickness of the protecting membranes and the size of the opening. While spontaneous occlusion may occur there is practically no spontaneous repair of the bony defect. The surgeon should beware of a tumor of congenital origin situated in or near the middle line, anywhere from the root of the nose, over the head, and down to the tip of the coccyx. Such a tumor should be regarded with suspicion until shown to be harmless. Many cases of spina bifida are accompanied by other congenital defects, such as club-foot, or hydrocephalus. Symptoms may or may not be present. When present they will be of the paralytic type and affect those parts of the body below the level of the growth. They are due to the involvement of the cord or the nerves. The ever-present danger in such cases is of rupture with escape of the contents, with its proportionate reduction of intraspinal pressure, and the possibilities of infection, with rapid death from meningitis. Inasmuch as some of these cysts have such thin walls that transillumination is possible it will be seen how great may be this danger
Treatment.
—Treatment should be made to meet the indications. Only in cases which are deemed inoperable should some protection be relied upon and worn. This may be afforded by a common surgical dressing or by means of a plaster-of-Paris or waxed gauze. A molded shield may be prepared and so arranged upon a band or girdle as to protect the cyst from external harm. Efforts to reduce the size of the tumor by pressure are futile and useless. The skin may be protected by covering with collodion.
The radical treatment of spina bifida should only be attempted in favorable cases, but in such instances can be made exceedingly satisfactory and successful. A tumor with a small pedicle may be treated by ligation, the skin being divided by elliptical incisions, the pedicle proper being surrounded by a chromicized or silk suture and the sac then excised. When the pedicle is too large to be treated in this way and yet not very large, it may be closed by sutures after removal of the sac, and dropped downward into the spinal opening, and the adjoining tissues made to close over it by buried and superficial sutures. It is the larger and more sessile sacs which give rise to the greatest difficulties. The attempt may be made to excise a greater portion of the sac, to fold in its edges and to approximate these with sutures of fine chromic
catgut. The fold thus formed may be laid downward and upon the spinal groove, the aponeurotic and other firm fibrous tissues in the neighborhood being loosened sufficiently so that they may be brought together by buried sutures, and the balance of the wound closed. I have a number of times been able to introduce either strips of metal foil or thin pieces of celluloid, or, better still, ivory trimmed to fit the bony defect, and so arranged as to be sprung into grooves made on either side of the osseous canal. If ivory be used for this purpose the thin small sheets which are used by miniature painters should be procured.
Such operations should be made at the earliest practical moment; in infants especially, but probably with all young patients, the head being maintained at a much lower level than the sacrum in order that only the smallest quantity possible of the cerebrospinal fluid may escape. I have also used a small amount of weak cocaine solution after exposing the cord in the spinal canal, in order that reflex impressions may be avoided so far as possible and shock thus prevented. With a young patient the amount of cocaine to be thus used should not exceed more than 2 or 3 Mg.
Osteoplastic methods have also been devised for the purpose and may be practised in cases permitting them.
Many of these cases do not come to operation until the skin is excoriated or ulcerated. It is exceedingly difficult under these circumstances to make an aseptic operation. The subsequent difficulties of maintaining asepsis should also be foreseen, especially when lesions are located low in the spine and in little patients, as soiling from diapers and discharges is so easy After such operations oiled silk, or gutta-percha tissue should be fastened around the pelvis by rubber cement, in such a way as to make a water-tight covering for the deep surgical dressings, and this line of junction should be scrutinized frequently. These operations often give satisfactory results.
CYSTS AND COCCYGEAL TUMORS.
Many congenital tumors are met with about the region of the sacrum and coccyx, some of which have the essential characteristics of meningocele, while others are rather of the dermoid or embryonal variety. Tumors of great size develop from the region of the coccyx, and many are of interest to the pathologist.
True dermoids often begin to develop within the pelvis and then escape therefrom in this vicinity, some of them containing soft epithelial products, others being dense and hard. (See Figs. 72 and 73, p. 266.)
