Читать книгу The Surgery of the Skull and Brain - Louis Bathe Rawling - Страница 61

The baby would be well wrapped up and, after shaving and cleansing of the scalp, the scalp-tourniquet applied. Babies stand these operations exceedingly well so long as hæmorrhage is but slight. A scalp-flap is turned down and a small trephine (¹⁄₂-inch diameter) applied immediately to one side of the depression, the trephine circle including the outer margin of the depressed area. The dura is stripped away and a flat periosteal elevator introduced so that its apex corresponds to the apex of the depression. An attempt is then made to lever the depressed area in the outward direction. If that result be attained, well and good. The flap is replaced and dressings applied. In many cases, however, the elevated region promptly assumes its original depressed position as soon as the elevator is removed, and, in other cases, all attempts at rectification of the deformity are of no avail. Under these circumstances, it is advisable to carry out the method advocated by Nicholl—adopted in the case described above—the whole of the depressed area being cut out with blunt-pointed scissors, reduced to a more normal curvature by manipulation between layers of gauze, and replaced in the inverted position, the original dural surface becoming now external. This inversion is requisite, as it is usually quite impossible—even under considerable pressure—to reduce the depression to a permanently satisfactory degree.

Nicholl reports on 23 cases, the ages of the patients varying from 3 weeks to 8 years. The first 13 cases were treated by elevation. The results obtained were most unsatisfactory, complete reduction of the deformity seldom being attained, whilst recurrence, of a greater or lesser degree, was the rule.

In the last 10 cases the inversion method was carried out, with, in all cases, satisfactory results. Bony union was present in 10 days.

Four cases of depressed birth-fractures have come under my own care. In two cases the depression was elevated—in both cases with considerable difficulty—whilst in the other two cases, after failure of leverage, Nicholl’s method was carried out, in both cases with eminently satisfactory results.