PROGNOSIS.—The prognosis of spina bifida is without question unfavorable; at the same time the affection is by no means to be considered, as it was formerly, one of an invariably fatal character, for, apart from the fact already mentioned that several cases are on record in which patients with untreated spina bifida have reached adult life, and even old age, the modern method of treatment has proved so much more successful than those formerly employed that in favorable cases surgical interference affords at least a reasonable prospect of recovery. The circumstances which especially furnish grounds for an unfavorable prognosis are the rapid growth of the tumor, the thinning or ulceration of its coverings, and the occurrence of nervous symptoms, and particularly of paralysis or convulsions.
TREATMENT.—This may be either palliative or radical. If the tumor be not increasing materially in size, the surgeon may properly content himself with palliative measures—applying equable support and perhaps slight pressure by the use of a well-padded cap of gutta-percha or leather, an air-pad, or, as advised by Treves, a simple pad of cotton smeared with vaseline, and a bandage; if the tumor be small and covered with healthy integument, painting its surface with collodion may be of service through the contractile property of that substance. Radical measures are only indicated when the child, otherwise healthy, seems to have his life threatened by the rapid growth of the tumor, causing risk of ulceration and rupture, or giving rise to convulsions or paralysis. The principal modes of treatment to be considered under this heading are—(1) simple tapping or paracentesis; (2) injection of iodine; (3) ligation of the neck of the sac; and (4) excision.
(1) Paracentesis, a simple evacuation of the fluid contents of the sac, is the only operation ordinarily justifiable in cases attended by paralysis or other grave nervous manifestations. The puncture should be made in the lower part of the sac and at a distance from the median line (in the course of which the nerve-structures are particularly distributed), and only a small quantity of fluid—a few drachms or at most one or two ounces—should be removed at a time, the instrument being at once withdrawn if convulsions follow, and the wound being instantly closed with lint dipped in compound tincture of benzoin. Either an aspirator-tube or a small trocar may be used, and the operation may be repeated if necessary, pressure being maintained during the intervals. Paracentesis has occasionally though not often proved curative.
(2) Injection of Iodine.—This mode of treatment was introduced about the same time by Velpeau and by Brainard of Chicago. The latter surgeon's method consists in injecting, after only partially emptying the tumor, a solution of iodine with iodide of potassium (iodine, 5 grs.; iodide of potassium, 15 grs.; water, 1 fl. oz.), allowing it to flow out again, washing out the sac with water, and finally reinjecting a portion of the cerebro-spinal fluid originally evacuated; and the former's, in completely evacuating the tumor, and then injecting a mixture of iodine and iodide of potassium, each one part to ten parts of water. Each of these plans has met with a fair measure of success;1 but the modification introduced by James Morton of Glasgow is a great improvement, and affords what is actually the most successful mode yet devised for dealing with spina bifida. Morton employs a solution of iodine in glycerin (iodine, 10 grs.; iodide of potassium, 30 grs.; glycerin, 1 fl. oz.), which has the advantage of being less diffusible than the aqueous solution, and therefore less liable to enter the spinal canal. The tumor is about half emptied, and a small quantity—from fluid drachm ss to fluid drachm iij of the solution—is then slowly injected, and allowed to remain. The operation is repeated after a few days if necessary. Of 50 cases known to Morton as having been treated in this way up to May, 1885, 41 were regarded as successful; but of 71 cases collected by the London Clinical Society's committee, only 39 had been benefited by the operation.
1 In a case recently recorded by Woltering, however, iodine injection was followed by death within half an hour.
The introduction of iodine into the sac of a spina bifida is, according to Morton, only justifiable in cases unattended by paralysis; under opposite circumstances I should be disposed to try a plan recently employed with success by Noble Smith in a case of meningocele—viz. injecting the iodo-glycerin solution into the coverings of the sac, and as close to it as possible without perforating it.
(3) and (4). Ligation and excision have each occasionally effected a cure, but more often have but helped to precipitate a fatal issue. A successful case of ligation followed by excision has been recently recorded by Löbker. The elastic ligature, applied around the neck of the sac (if this be pedunculated), has been employed by Laroyenne, Ball, Colognese, Baldossare, Mouchet, and other surgeons, and of 6 cases collected by Mouchet, 3 ended in recovery. Another success has been recently recorded by Turretta. The écraseur has been used, but its employment cannot be recommended. Compression by clamps is advised by Schatz of Rostock. Ligation is best adapted to cases occurring in the cervical and dorsal regions, in which, as pointed out by Giraldès, nerve-elements are less likely to be involved. Excision, supplemented by transplantation of a strip of periosteum from a rabbit, has been successfully resorted to by Mayo-Robson and by R. T. Hayes of Rochester, N. Y.; and simple excision, with suture in separate lines of the sac and integuments, by Mayo-Robson, Atkinson, and Jessop. The Clinical Society's committee in all refers to 23 cases treated by excision, 16 of which are said to have been successful.