—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].)
Fig. 412
