Lines of removal of bone as practised by the author, by Lannelongue, and by others.
Fig. 384
Defective cerebral development. (Buffalo Clinic.)
The operation is usually described as craniotomy or craniectomy, and is apt to be successful in many cases of microcephaly combined with idiocy. An acquired form will give a better prognosis than will the congenital condition. The danger of the operation is often great, and especially so since it is called for in puny, ill-nourished, and badly cared-for children. To be successful it ought to be extensive. It should vary in character and degree—from simple division of the skull along the middle line, from near the root of the nose to the occiput on one or both sides, to the formation of large bone flaps by cutting away a wide groove of bone so as to relieve pressure upon the hemispheres. [Fig. 383] presents the various ways of performing the operation.
It can usually be made bloodless, or nearly so, by an elastic tourniquet around the skull. The incision in the skin should not correspond to the groove in the bone, but should overlap it some little distance. For my own part I prefer to do most of these operations in two sittings. I would advise, as a rule, to prepare the scalp carefully for operation, to divide the skin along the proposed line, separate it from the pericranium and check all oozing; then, after opening the skull with the trephine, to cut away with proper forceps (rongeur) along the desired line, or, if provided with it, to remove the bone by some surgical engine or revolving saw operated by electricity. The strip of bone thus removed should be at least half an inch wide, and the overlying periosteum should be removed with it, as only in this way can the undesirably rapid regeneration of bone be prevented. By this means the dura is exposed, but not opened. In some cases this will be sufficient.
In many others, however, it will be insufficient; and, could this be foreseen, it would be well to combine the above measures in one as a first operation, and then, a few days later, to open the dura as the second procedure—this, however, only on the discovery by careful inspection that the wound is absolutely free from possibility of infection. Could infection be prevented, this is certainly the safer procedure, since in weak, puny young children to make a long scalp incision, to remove a long strip of bone, and then to widely open the dura is more than can safely be done in the majority of instances.
It should have been carefully explained to those interested in the case that improvement will in all probability be extremely slow, and that little or nothing is to be expected at first, even if prompt recovery from the operation ensue. Neither would I advise any one to perform the operation unless parents are willing to assume all risks and abide by the results.