Surgery Saved the Day

The doctors c*aII it hyilrot:ef)halus-"wutrr on the
brain"-and, in the past, it has killed ninety per
cent of its tiny victims before they were two years
            ,
old. Now a dramatic new surgicxl idea is making
well c:hildren of a majority of such cakes.

But iho, ca~i of perfnrmws on this day was an
unuw;\lly large one. Crowded mto the fifteen-foot
awna wrw live surgeons. 111~ee nursex, an anee
t hrt isc and R general-purpose technician-ten per-
ROIIX in all--end each with a specific assigned tmk.
By contr;%Ht, the focus of thrir organized activity
was untwlievably amall. it haby girl three wee&
old and no longer than R doctor's forearm. She lay
on H qw'cial operating table the size of a footstool,
which had teen placed on top of the regular table.
Already m an anesthetic sleep, the tiny patient,
whom we'll call Nancy, had been propped on her
right Hid<, with drips of adhesive tape acro8~ her
left shoulder and thigh to keep her from rolling.
The position was important.. For this w&4 to be no
ordinary operalion. The baby was on her Hide HO
that two major operation8 could proceed at one
time upon her small body.

What had brought Nancy here to the Children's
HospXal of Philadelphia vvab we of sever4 iilbom
defects which, if not corrected, usually result in
mental rrtardation, blindness. crippling or death.
Her particular condition had been diagnosed aa
hydrocephalus, often called "water on the brain."
It con&ts of an abnormal accumulation of spinal
fluid, the increased prellsure of which squeezes the
brain and distorts the head. Fortunately, hydro-
cephalw iH not too common, but neither is it very
raw. And to the parents of a baby m afflicted it
has nearly always been a heartbreaking tragedy.
Until very recently almost 90 per cent of the infants
horn with hydrocephalus died before they were two
years old. Most of thoRe who survived were seriously
handicapped, mentally or physically or both. Usu-
ally their heeds were greatly enlarged.

This small patient on the miniature operating
table was, however, to have a much better chance
at normal life and health than is indicated by the
above statistics. For the two teams of surgeons,
one workmg on the spine and the other on the
abdomen, would carry out, the two phases 01 a re-
markable new procedure, designed to pipe off the
excess spinal fluid and prevent the damaging rise
in pressure within the skull and spinal canal.

The operation, developed in its present form by
Dr. Eugene B. Spitz, neurosurgeon, and Dr. C.
Everett Koop, chief surgeon, both of the Children's
Hospital staff, is one of the most effective solutions
yet offered for a problem that. has challenged the
best surgical efforts for more than fifty years. And
it i part of a concentrated preventive attack which
the Philadelphia Children's Hospital doctors and
othrr tealw, notably Dr. Frwnc I). Ingraham and
his awciaten in Boston, are making against certain
anatomical CRUH~ of mental retardation.


In Nancy's case the first signs of trouljle had heen
fcrding difliculties and a fever when she was only
five days old. Her doctor at the Northern New
Jersey hospital where she was horn immediately
began a search for the cause. First he found I~lood
in the spinal fluid. Then he noticed the baby's head
was beginning to enlarge, an observation he con-
firmed with a tape measure. Finally, when a needle
puncture revealed intracranial pressure and a thin-
ning of the brain, the doctor suspected hydro-
cephalus and sent Nancy to Philadelphia.

Following the operation, which involved insert-
ing a plastic drainage tube between the spinal canal
and the abdominal cavity, she began almost at once
to improve. The "soft spot.," or fontanel, where the
bones of the forehead are joined, had previously
tw2n taut and bulging. As soon as drainage was
established it flattened out. The head lost its
swollen appearance and slowed down to a normal
rate ot growth, so that over a period of months the

rest of Nancy's Iwdy was able to catch up with it
and eliminate any disproportion in size. She began
t.o eat normally, and to laugh and smile like any
well and happy h&y. Her mental development, hy
all tests, is proceeding at, a good pace, showing that
the operation was done in time to prevent any
serious brain damage.

The urgent necessiiy for prompt, action is a point
which all physicians working on this problem feel
has not been fully understood or strongly enough
emphasized. Errors of two types have lxen made,
hoth resulting in tragic loss of precious time. Some
parents, although recognizing an ahnormality, have
done nothing about it, hecause they have been
advised the situation was hopeless and nothing
could he done. Others have hecn t.old t,hat the
odd shape of t,he baby's head or some slowness in
sitting up, walking or talking was "nothing to

worry allout " and that t,he child would "grow
out of it.."

It is a doctor's business to worry ahout theBe
things, asserts Doctor Spitz; it takes only a few
minutes for a physician to determine, by feeling
the hones of a baby's head. whether there is really
anything 10 worry ahout and whether a more de-
tailed and extensive examination is called for. It
is also a mistake t,o assume that convulsions or
other neurological disturbances are simply due to
psychological factors or to a fever. Convulsions
aren't normal, whether the child has a fever or not,
and they should always be investigated to deter-
mine the underlying cause.

Appreciation of the need for earlier recognition
and treatment of neurological conditions in children
is what prompted the heads of several departments
at the University of Pennsylvania School of Medi-
tine-Dr. I. S. Ravdin, of surgery; Dr. Francis C.
Grant, of neurosurgery;


and Dr. Joseph Stokes, Jr., of pedi-
atrics- to set up the special pediatric-
neurosurgery unit at the Children's
Hospital. Doctor Spitz, assistant pro-
fessor of neurological surgery, was
placed in charge, and Doctor Koop,
chief surgeon at the hospital and asso-
ciate professor of pediatric surgery,
works closely with him. Through co-
ordinated study of the large number of
cases brought to this center it is also
hoped to accumulate information that
may lead to improved methods of
treatment.

Of course, it would be misleading to
suggest that operations will prevent
more than a fraction of the cases of
mental deficiency. The factors reapon-
sible for a large proportion of casss
have not even been identified and could
not therefore be expected to yield to
surgery. But "brain-crowding" condi-
tions of the type we are discussing here
occur so often that it is possible to save
thousands of lives and   .
alertness and prompt fo ow-through
       Y ds through

on the part of parents and physicians.

  One such life was that of Betty, a
chubby, bright-eyed little girl who, at
--t+&m+we saw her, was nine msntb.s
i    . .
old. What had rescued her from death
or mental retardation was her parenta'
refusal to accept a discouraging med-
ical prognosis as the f&d word.

The third child in the family, Betty
had had a normal birth and had
seemed all right in every way until .+he
was three weeks old.

"Then one day, when I cuddled the
baby against my cheek," her mother
said, "1 noticed her head was unusually
soft, high up on her forehead. Of
course that's where all babies have a
soft spot, but Betty's head was softer
than I thought it should have been."

The mother consulted a pediatrician,
who looked the child over carefully,
expressed concern about the condition,
and referred her to a brain specialist
in a small Eastern city. The brain
specialist kept the baby in a hospital
for five days for a ssriea of examina-
tions, and during this period the
mother and father were sleepless with
worry over the outcome of the tests.

"We tried and tried to get informa-
tion about what was going on and
what they thought was wrong with the
baby," the mother related, "but we
could never get hold of the doctor. I
guess he just hated to give us the bad
news. Finally I was notified to come
and get the baby and take her home,
but I still wam&+.o&what was U-
done for her. Then the brain specialist
sent his assistant to tell us that Betty
had hydrocephalus. He explained what
it was and said there was no effective
treatment for it.

"We asked if there wasn't some-
thing that could be done for her, and
the doctor said, `I'm afraid not. You
could take her all over the world and
you wouldn't find anyone who could
help your daughter."'

This was a bitter blow, and the
parents were heartsick. By now the
infant's head was beginning to look
abnormally large. "It was so notice-
able that I was sensitive about it," the
mother said, "and I would never take
the baby's bonnet off when she was
out in her carriage. But we did feel
that surely, somewhere, something
might be done for her."

Betty's parents have always be-
lieved in the power of prayer. Ap
propriately, it was the pastor of their
church who told them about the opera-
tions being performed at Children's
Hospital, of Philadelphia, to help in-
fants with this distressing condition.

They took the baby to the surgeons
there, who performed the operation
when she was eight weeks old. Betty's
improvement since then has been re-
markable. She sat up alone when she
was eight months old and was able to
stand on her feet when given support.
Although her head is slightly wider and
higher at the back than normal, there
is every indication that she will develop
properly in every other respect.

Sometimes it is not easy to diagnose
hydrocephalus in its very early stages,
but there may be other difficulties
that cause the doctors to keep an eye
on the child. This was the story in the
case of Billy M., who was born early
in 1951, after a long and difficult labor,
and who had so much trouble breath-
ing that he was placed in an incubator
and given oxygen. On the second day
he was transferred to the Children's
Hospital, where doctors found that in
addition to his respiratory troubles he
was slightly spastic in his arms and
legs. And there were certain abnormal
reflexes. However, he improved in a
few days and was sent home, with a
request that the family doctor keep a
clpae watch on him and bring him back
to the hospital in three months, or
sooner if his condition changed.

It was soon noticed that Billy's head
was becoming larger than normal. His
mother recalls that caps and bonnets
didn't fit him.

"But you know how babies' heads
often are," she said. "Lots of babies
seem to have large heads at first. I
didn't think too much about it."
Her doctor did, however. He also
noticed that Billy's upper eyelids were
stretched in a peculiar manner, typical
of hydrocephalus. He lost no time in
getting Billy back to Children's Hospi-
tal, where the diagnosis was quickly
made, and the situation and the opera-
tive procedure carefully explained to
the parents. They were told that with-
out an operation the baby's chances of
life were not good, and that if he did
live there was a strong likelihood that
he would be impaired mentally.
"There was never any hesitation in
our minds about having the opera-
tion," Billy's mother said.
"And just look at him now," his
father added.

No parents were ever prouder. And
it would be hard to find a cuter two-
and-a-half-year-old than Billy. He is a
completely charming little fellow, with
blue eyes, an engaging smile and a
-wt alert -*er. The perfeet best,
he dashed into the bedroom to get his
toy dog, which he pulled out through
the slats of his crib and brought to
show the visitors. He gave the right
answers to the standard questions
about what the dog and cat and cow
say, and he made an amusingly realis-
tic "eek" for the bird. He had re-
cently visited the Philadelphia Zoo,
where he said he had seen "tigers, wota
of tigers, and wions-and how about
the hippopotamus?" His father chuck-
led. "He always says it that way-
`How about the hippopotamus?`"

To understand how operations in
the vicinity of the waistline can reduce
Billy could count up to six and could
pick out and identify the pennies,
quarters, nickels and dimes in a hand-
ful of change-and without asking for
any. In brief, Billy showed that he is
a perfectly normal little boy, better
behaved than many. No one would
suspect that his brain had ever been
threatened by a treacherous rise of
spinal-fluid pressure. All Billy knows
about "my opewation" is the incisions
in his abdomen and back.

brain-squeezing pressure in the head
it is necessary to consider a few points
of anatomy, specitically the distribu-
tion of the spinal fluid. This clear,
watery liquid occupies the ventricles,
or hollow spaces, inside the brain. It
also bathes the outside surface of the
brain and it surrounds the spinal cord
within its bony vertebral canal. In the
normal individual and in those with
hydrocephalus of the type with which
we are concerned, these chambers and
channels connect with one another to
form a continuous but closed system.
Therefore, withdrawing fluid from a
lower level of the spine will decrease
the pressure of the whole system, in-
cluding the brain.

The increased pressure in hydro-
cephalus is usually brought about by
an excess of spinal fluid. Whether the
excess in turn is due to an overproduc-
tion of fluid, an underabsorption of it,
or both, is not always clear. In some
cases of hydrocephalus the situation is
complicated by-or even caused by-
blockage somewhere in the cerebro-
spinal-fluid system, and in most of
these cases tapping the spine would
not lower pressure in the brain. To
obtain relief through the procedure we
are discussing here it is necessary that
the patient's hydrocephalus be of the
so-called communicating type, in which
there is free flow of fluid between the
brain ventricles and the spinal canal.
Other. techniques may eventually be
worked out for the obstructive cases,
but to date only communicating hydro-
cephalus has been corrected by the new
operation. Between 1948 and 1952 a
little less than half of the hydrocephalus
patients coming to Children's Hospi-
tal-87 out of 184-had the communi-
cating type, but of the first fourteen
seen in 1953, all but two were of this
variety.

Most of the surgical efforts in hydro-
cephalus have been aimed at providing
an overflow through which to drain
off the excess spinal fluid and keep the
pressure down. Various ways of doing
this have been attempted over the
course of the past half century, but
most of them met with failure or in-
different suck Dr. Harvey Cuehing,
the famous bram surgeon, placed a sil-
ver tube between the spinal canal and
the abdominal cavity in fifteen pa-
tients. This was in the early 1900's, and
though his results were promising, they
were not consistently good and the
method was discontinued. A German
mrgecm, Dr. B. He&z, developed sev-
era1 techniques, one of which, in 1925,
involved removing a kidney and hook-
ing up a rubber tube from the spinal
canal to the kidney end of the ureter,
thus draining off the excess spinal fluid
through the urinary tract.

Doctor Spitz and Doctor Koop
therefore returned to the older prin-
In 1948 Doctor Inpaham and his
associates, and Doctor Spitz, inde-
pendently, tried this procedure, with
newer plastic tubing; and a number of
patients so operated on are still doing
well. This method may still be used
under certain circumstances, but it has
bad two drawbacks. First, there was
the danger of a urinary-tract infection
spreading upward to the membranes
around the spinal cord or brain and
producing a meningitis. Second, because
a kidney had been removed and a di-
rect hookup made between the spinal
fluid channels and the bladder, a great
deal of body salt was lost which would
normally have been conserved by that
kidney. It became difficult to main-
tain adequate salt levels in these pa-
t.ifmts.

ciple of draining the spinal fluid into
the abdominal cavity, wh&e it would
be absorbed into the general circulation
of blood and lymph. They used a plas-
tic tubing for this purpose, as we have
already mentioned, inserting one end
into a small incision in the spinal canal
and placing the other end in the ab-
dominal area-or peritoneal space, to
use a more specific term.

But in several cases the tubing be-
came plugged by the omentum, a fatty
tissue which hangs between the loops
of large intestine. That the omentum
should get in the way was only natural.
For, as Doctor Koop remarked, "Older
surgeons used to call the omentum the
policeman of the belly because of the
way it would wrap itself around a
foreign body or an infected area and
wall it off." In the hydrocephalus cases,
however, it was a nuisance and a
serious obstacle to the success of the
operation.

Now the best way to combat a nui-
sance that has no compensating virtues
is to remove it. That is precisely what
Doctor Koop decided to do with the
troublesome omenturn. And while he
was working out that modification of
the hydrocephalus operation, Doctor
Spitz was designing a little plastic tip,
or nozzle, further to improve the drain-
age from the end of the flexible plastic
tubing.

Simple as these innovations sound,
to employ them successfully against
the brain-destroying pressure of hydro-
cephalus requires much careful pre-
liminary study of the patient, a high
degree of surgical judgment and skill,
and smooth teamwork on the part of
every one of those ten people in the
operating room-the surgeons, anes-
thesiologists, nurses and technicians.
The surgeons feel that credit for an
important assist should also go to the
chemical companies which developed
the nonirritating plastic tubing and
which co-operated with the doctors in
finding the proper type-and size for the
delicate job in hand.

In the preoperative examination
the doctor pays close attention to the
baby's head, noting whether or not the
fontanels-soft spots at the junctions
of the skull segments-are bulging. He
asks the mother about the child's gen-
eral physical development an& its be-
havior, and makes his own observa-
tions concerning these matters. He
then inserts a needle through one of
the soft parts of the skull to determine
the thickness of the brain and thus
obtain an indication of how much the
fluid pressure has already compressed
the brain tissue. Finally, a dye is in-
jected into one of the ventricles of the
brain and a few minutes later a small
amount of fluid is removed through a
spinal puncture. If dye appears in the
sample of spinal fluid, this is evidence
that there is free communication be-
tween the brain and the spinal canal,
and that the baby has a good chance
of being helped by surgery, other fac-
tors being favorable.

For a close-up look at what takes
place during the operation itself, let's
go back to the scene with which this
article opened, the green-tiled oper-
ating room in Philadelphia Children's
Hospital,  where the three-week-old
baby, Nancy, was the patient. We
were sitting in the small gallery as
Nancy was carried into the room in
the arms of an attendant. A nurse was
holding the bottles of blood and glucose
which had already been connected by
plastic transfusion tubing to veins in
the baby's foot. She was placed on her


side, as we havL said, to permit both
teams of surgeons to operate simul-
taneously. A surgical assistant now
swabs the back and belly with bright
orange antiseptic solution. As the
nurses begin to drape sheets over the
baby, Doctor Koop, helping in this
procedure, feels the fabric between
thumb and finger and shakes his head.
"This one is too hot and heavy," he
says, throwing it aside; and to the
visitor in the operating-room gallery,
"You don't realize how much these
things weigh on a little body."

A flat plate in the shape of a pancake
turner with a wire attached is placed
between the baby's knees. This is one
terminal of the electric-cautery ap-
paratus to be used in sealing off small
blood vessels. A copper chain is looped
over the infant's wrist as an electrical
ground to guard against sparks that
might ignite anesthetic gases.

Meanwhile the anesthesiologist, Dr.
Margery Deming, has inserted a tube
into the child's throat and windpipe,
and through this the anesthetic is now
being administered. For a few mo-
ments the baby's skin becomes bluish
and Doctor Deming pumps the rubber
anesthetic bag to assist the breathing.

"When a child takes anesthesia
poorly," Doctor Spitz explains, "it is
often a sign that some brain damage
has already been produced by the
hydrocephalus. We hope there hasn't
been too much and that we're not too
late with the operation."

Now the skin is a healthy pink
again, Doctor Deming nods reassur-
ingly to the surgeons, and they begin.
Doctor Spitz, having first felt the
spine with his fingers and marked with
purple dye the site of the proposed
incision, makes a two-inch cut. This
exposes the ridge of the spine, and with
a bone nipper he removes parts of two
vertebrae in the lumbar, or "small-of-
the-back," region. He is now close to
the tough membrane that forms the
wall of the spinal canal. Through thu
membrane he makes a tiny nick am!
immediately inserts one end of the
special plastic tubing, anchoring it in
place with two stitches taken into but
not through the thickness of the tubing.

Meanwhile Doctor Koop, on the
other side of the operating table, has
made a two-inch incision just above
the infant's navel, and through it he
has gently pulled the colon, or large
intestine. Clinging to the colon and
lying between it and the stomach is
the omentum. At this age it contains
very little fat. It is just a membrane,
but it is as stringy as wet cheesecloth
and it is easy to see how it could plug
the end of a tube lying near it. The
surgeon carefully strips the omentum
away from the intestinal wall with the
blunt end of an instrument, sometimes
the handle of a scalpel. This blunt
dissection technique is used, where pos-
sible, to avoid bleeding.

"The major blood vessels enter the
omentum from the stomach," Doctor
Koop says, "and we'll get those by
ligation." This means first clamping
each vein or artery, then cutting, and
finally tying off with thread. It is
clamp, cut, clamp, cut, for eight or ten
vessels. "Sometimes as many as twenty
vessels must be tied," the surgeon re-
marks, "and you have to do them all
carefully, because you don't want any
of them to leak blood into the peri-
toneal space. It would promote ad-
hesions. In fact, we do this omentum
removal outside of the abdominal
cavity so that any blood escaping dur-
ing surgery will fall outside and not in."

After he has finished this part of

the operation and has tucked the loop
of colon back into place, Doctor Koop
tunnels through the side of the infant's
body with a long, blunt-nosed clamp,
passing it between layers of muscle and
fat, to grasp the plastic drainage tube.
Doctor Spitz has already connected
one end of the tube to the spinal cad.
Doctor Koop draws the fres end back
through to the front of the body,
fastens the special plastic screw tip
onto the end and drops it into the
abdominal cavity. Before closing Up
the two incisions the surgeons irrigate
the tissues with fluid containing the
enzymes, streptokinase and strepto-
donmae, which discourage clots and
adhesions. They also squirt some of
the fluid directly into the plastic tubing,
having found that otherwise a long clot
may form in the tube itself and defeat
the very purpose of the operation.

"This is one of the places in surgery
where small details of technique really
make a tremendous difference in the
final result," one of the doctors BBYS as
he completes the enzyme irrigation.

During the past three and a half
years at Children's Hospital forty-five
babies with congenital communicating
hydrocephalus have had the spine-to-
abdomen drainage tube installed in the
manner just described. Thirty-eight
have survived, with apparent relief of
the condition, and the surgeons at the
hospital believe they can continue to
expect success in approximately 80 per
cent of the patients with this type of
abnormality. In a number of other ba-
bies examined, the hydrocephalus had
already caused such serious brain dam-
age that surgery could not have helped
and was therefore not attempted.

Even today, however, subdural he-
matomas may at first be mistaken for
something else. There was the child of
a bomber pilot and his wife, born in
the hospital at an air base. The baby
looked normal, but something was ob-
viously wrong, for he screamed almost
twenty-four hours a day. The doctors,
not used to seeing such casas in an
Army hospital, told the mother it was
"only colic," and suggested she bring
the baby back every week or two.
When, at the age of three months, the
baby was still extremely fretful, could
take only a little food without crying
and seemed a little dull, his mother
took him back home to Pennsylvania,
where her pediatrician referred her to
the Children's Hospital, of Philadel-
phia. There the condition was found to
be a hematoma, and two operations
were performed during the baby's
fourth month, in September, 1952.

There was little change in the baby's
behavior until Christmas. Then the
effects of the operation suddenly began
to be apparent. "He blossomed out
wonderfully," his mother related, "and
on New Year's Day he pulled himself
up in his play pen for the first time.
When my husband, who bad gone to
Korea in November, came home in
March, the baby's improvement was
so great he could hardly believe it."
On the day I saw the child, then thir-
teen months old, he was as bright as a
new toy, with sparkling brown eyes
and plenty of well-directed energy. He
was scrambling about the doctor's
waiting room, toddling a few steps and
then dropping to hands and knees for
faster locomotion, as many babies do
while learning to walk. Although he
had been definitely retarded before the
operation, the physicians were now cer-
tain that he will be mentally normal.

In this condition, as in hydroceph-
alus, the shape of the baby's head is
frequently what first causes parents or

friends to become concerned. A New
Jersey infant was brought to the hos-
pital at the suggestion of a neighbor
who had noticed that the back of his
head was quite flat. The neighbor had
faced a similar problem with her own
child and was therefore alert to such
signs. The baby's own parents, on the
other hand, had assumed the flatness
was merely the result of lying so much
on his back. So it was. But the Chil-
dren's Hospital doctors soon found that
the reason he lay on his back was that
he was too dull and lethargic to roll
over, and the lethargy was in turn due
to brain pressure from a hematoma.
He was operated upon when nine months
old; and today, at three and a half,
with the threat of mental retardation
removed, he is talking, walking, run-
ning and riding a tricycle like any other
normal child of his age. He is neither
quiet nor dull.

This experience illustrates how easy
it is for a parent to misinterpret an
infant's behavior. It is not uncommon
for a mother, upon learning that her
child has a neurological condition, to
protest that it can't be so because,
"he's such a good baby, doctor; he
never cries." The too-good baby that
never cries may, like the one who
cries too much, have something wrong
with him.

The surgery for releasing the brain
from the bonds of a subdural hema-
toma is carried out in the skull itself,
which is first pierced with a needle
to confirm the diagnosis. Prelimiiary
drainage is then established via half-
inch-diameter burr holes drilled with a
stainless-steel brace-and-bit.

"YOU can't use much pressure'on an
infant's skull," Doctor Spits remarks
as he completes the boring of a burr
hole, "or it will break like an eggshell."

Draining the hematoma may be all
that is required. Often, however, the
baby must return to the operating
room, after an interval of observation,
for a more extensive operation. At that
time a segment of the skull is tem-
porarily lifted off and the tough mem-
branous hematoma sac is cut away.
For this membrane alone, even when
empty, can bind and hamper the de-
velopment of the underlying brain
tissue. The sac sometimes extends over
two thirds of one hemisphere of the
brain, and in many casee it partially
overlies both the right and left hemi-
spheres.

Of all the things that can interfere
with the development of a baby's brain
few are as strange and tragic as the
premature closing of the seams of his
skull, a condition known as cranio-
stenosis. It may occur before birth and
in some instances it is probably heredi-
tary. The brain, striving to grow at a
normal rate and finding certain of the
cranial suture lines, or "expansion
joints," firmly closed by bony fusion,
pushes out in other areas, where the
bone is softer. This produces a variety
of bizarre skull formations, one of the
commonest of which is the one called
a "tower skull," with a high, flattened
forehead. The eyes bulge out. Pressure
on the optic nerve often causes blind-
ness Parts of the brain atrophy under
the excessive pressure, with resulting
mental retardation. The high intra-
cranial pressure may also cause head-
ache, vomiting and convulsive seizures.

Craniostenosis was recognized in an-
tiquity and was menMoned by Homer
and Hippocrates. Not until recent
years, however, have neurosurgeons
achieved consistent success in treating
it. A good operative procedure was
worked out in the 1890's by two sur-

geons named Lannelongue and Lane,
but, unfortunately, it fell into dis-
repute because of poor results obtained
by other doctors who, through wrong
diagnosis, employed the operation in
cases of microcephalic idiocy. In that
condition the brain fails to grow, no
matter how much room it has, and
surgical easing of the skull bones could
not be expected to improve mental
development. Failure to distinguish
between microcephaly, which was hope-
less,andtruecraniostenosis,whichcould
have been helped, thus led to the tem-
porary abandonment of the operation.

A number of neurosurgeons have
been responsible for its revival within
the last two or three decades, and for
improvementa which have made it
more effective in saving the vision and
mentality of those unfortunate young-
sters born with their head bones pre-
maturely fused. The procedure is per-
haps the most drastic of all skull opera-
tions performed on children. The sur-
geon makes several cuts clear through
the skull alongside the normal suture
lines and then sews strips of polyeth-
ylene-plastic film over the cut edges
to delay their reunion. The bone seg-
ments eventually grow together again,
leaving the plastic imbedded, but in
the meantime the brain has been given
a chance to reach its normal size. In
some cases the cranial distortion is so
extreme that it is ne cessary to cut an
arsa of the skull into many small
squares and remold them into a more
normal contour. This technique, be-
cause of the morsels of bone involved,
is called morcellation.

The amount of surgery which these
small infants can tolerate never fails to
astonish those not familiar with the
truly phenomenal advances which have
been made in this area of children's
medicine. The youngeat craniostenosis
patient at Children's Hospital was only
eighteen days old when he was opsr-
ated upon. Another child, born with
three deformities - craniostenosis, a
pushed-m, or "funnel," chest, and a
"blue-baby" heart-had all three sur-
gically corrected during one hospitali-
zation, when he was only two years
old. An unusual aspect of his case was
that even though the skull bones had
fused together prematurely, they had
been so poorly nourished because of
the heart condition that they remained
thin and allowed the head to expand
with the growth of the brain. At the
age of two, however, the skull had be-
gun to tighten up and the resulting pres-
sure was already affecting the boy's vi-
sion. The operation was just in time to
restore his sight and save his brain.

It should be emphasized again that
success can be achieved in all of these
casea only if the affected infants are
brought to the neurosurgeon as soon
as an abnormality is suspected. A sec-
ond factor important in the saving of
these threatened lives and minds is the
presence of nemosurgical teams trained
in children's problems, teams that in-
clude not only surgeons but anesthe-
tists and nurses. Unusually vigilant
nursing is required by infants with
brain troubles, for, as the physicians
point out, "They can go from good to
bad and bad to worse much faster than
youngsters with other types of illness."
Through the training efforts of such
centers as the unit at the Children's
Hospital, surgical groups capable of
carrying out these brain-saving opera-
tions should soon be within reach of
children everywhere.