CHAPTER IT. (Part 15)

between it and a spina bifida may be impossible. Such a cyst may cause death by obstructing labor, or by the develop- ment of a gangrenous inflammation after birth. As a rule, operations for their removal have not resulted successfully when undertaken during the first three years of life. One operation practised at a later date has, however, been crowned with success. Spina Bifida. — Concerning this variety of cyst little need be said ex- cept as regards its diagnosis. It should be borne in mind that a tumor due to a deficiency of the spinal bones may be entirely within the pelvis, in which case it would present great difficulties in diagnosis. Such a case is the following.* Case XVII. — ^Woman, aged 36, single. The patient stated that ten years before, she^detected a swelling as large as a goose egg in the right iliac region, her attention having been called to it by shooting pains through the abdomen starting from this point. The size of the tumor increased slowly, had once caused retention of urine, and now caused oedema of the right leg. The patient was cachetic and emaciated. . . . The abdomen was uniformly enlarged and tympanitic. On making a vaginal examination, the cervix uteri could be scarcely reached, situated as it was above the pubes, while a mass was felt behind in the cul-de-sac, extending to the right, apparently an ovarian cyst. But from a digital examination in the rectum it was evident that the rectum was pushed forward by a large, soft, fluctuating tumor behind it, which filled up the hollow of the sacrum to within a short distance of the anus. . . . J Exmnet: Prin. and Prac. of Gynaecology, 1st ed., p. 773. 156 DISXA8B8 OF THB BBOTUM AND ANUB. The patient was placed under ether, and a fine trocar was introdnced into the sac, about three inqhes beyond the anus, by which an oiince or more of its contents were aspirated by Dieulafoy's pump. This fluid was serous in character, perfectly clear and limpid, resembling hysterical urine. It contained no albumen, and the microscope revealed nothing more than a few oil globules, which had, beyond question, been attached to the instrument before its introduction. Autopsy nine and a half hours after death. On opening the abdomen, the colonwas so much distended as to fill the whole cavity, and reached to a level of the fourth rib, being filled with flatus and faeces. ... A cyst which contained some three quarts of fluid was found behind and to the right of the rectum, filling completely the cavity of the pelvis, and extending up to a line with the second lumbar vertebra. . . . The rectum was greatly constricted in its upper portion. . . . In attempt- ing to discover the attachments of the cyst m the hollow of the sacrum it was ruptured. The sacrum was removed, and a spina bifida found, the three lower bones of the sacrum being deficient on the right side. A funnel-shaped opening communicated directly with the spinal canal, from which projected portions of the cauda equina an inch or more in length. . . . Although the posterior portion of the bones were wanting, no external bulging of the sac could take place posteriorly in consequence of the dense ligamentous structures bridging it over. The diagnosis of spina bifida can generally be made by the reduci- bility of the tumor, the signs of pressure on the brain and spinal cord which are produced by pressure on the tumor, the fluctuation at the fon-^ tanelles, and the chemical character of the fluid which may be withdrawn for the purpose of diagnosis. The fluid of a spina bifida contains both sugar and urea as does that of the cerebro-spinal canal, and though both these substances may be found in cysts entirely independent of the cere- bro-spinal canal, they will always be found in spina bifida. There still remains a class of congenital cysts which are neither con- nected with the spinal canal (spina bifida), nor parasijiical (containing foetal remains). These are often of large size at the time of birth, and may consist of a single cyst or be multilocular. They are generally attached by a pedicle near the tip of the coccyx, though the cyst or cysts may have prolongations in the perineum or the ischio-rectal f osssb. The cyst- wall in these cases is fibrous, and when many cysts are present, it sends prolongations between them. The integument covering it is thin and generally marked by large veins. The cyst is filled with a yellowish, tenacious, gelatinous fluid, transparent to light as is a hydrocele. It will be seen at once that the great difficulty in diagnosis lies between this form of cyst and a spina bifida, and though the diagnosis may not always be possible, it will generally turn upon the presence or absence of the signs of communication with the spinal canal when pressure is made upon the tumor. KON-MAUGKANT GROWTHS OF THE SEOTUM AND ANUS. 157 The treatment of these growths is by extirpation. Injections of iodine^ etc., have in them the element of danger from prolonged and ex- tensive suppuration. When extirpation is attempted it should be com- plete; and where the cyst is mnltilocular it should be followed into the perineum and ischio-rectal f ossaa if necessary, in order that no parts of it may remain to undergo subsequent development. These cystic forma- tions, unless of sufficient size to cause death during labor, are not incom- patible with life. > Bnneau: Bull, de la Soc. M6d. de la Suisse romande (Molli^re). This look is the property of COOPER MEDICAL COLLEGEi SAN FRANCISCO. CAL. a)t(l is //('/ /" hi' rr»}orrd from thn J/-',).' ,j t'\ ' f If <"■// y^C^A'O/^ 01* 1' ' ' ' t I • ' • ' ' •''/'• 158 DISBABES OF THE BECTUM AND AKUS^