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BATTLE WOUNDS OF THE HEAD
149
likely ]4owpvor,, that iniobilisation by splinting is an imperfect biological method of preventing the stretching of paralysed muscles, and that the influence of muscular
pain has not been properly appreciated. It may well be that advances in physical therapy, springing from Miss Kenny’s enthusiasm will outlast her theory and terminology.
to deal
properly with the wound must have a suction apparatus which provides the only way to keep the operation field clear : a foot-pump suction apparatus, at least, should be available for every surgical team. Cushing clips should be provided, for electrosurgical apparatus is rarely available. ’ Pentothal Sodium’ as
preliminary anaesthetic allows thorough shaving and cleaning of the scalp, the operation being then continued THE HOWELL- JOLLY BODIES under local anaesthesia. Thorough excision of the wound THE Howell-Joily bodies are small refractile granules is essential. The scalp flaps are freely mdbilised to about 1µ in diameter that are sometimes found in red facilitate closure; bone edges are excised by sharp blood-cells ; they are usually eccentrically placed and rongeur forceps; soiled dura is removed with scissors, may be single or multiple. They have not attracted haemorrhage being controlled by silver slips or an undermuch attention, in spite of their cheerful name ; they are suture. When no endotherm is available the running classed with Cabot’s rings and other nuclear remnants, red-hot of a probe is useful to seal small bleeding tip and hsemato.logical textbooks still find them a place on on the dura. The brain wound is cleaned by points their colour-plates. They have however a long and gentle suction until a clear field is obtained. history, irrigation and in continental literature particularly they are associArtery forceps are of course never applied to the brain, ated with the spleen. Some 3a years ago, Howell-Jolly and swabbing is avoided except for the application of a bodies were noticed in the red cells after splenectomy, small moist wool slab to points. Haemorrhage and have been reported to persist in the blood for as long from venous sinuses is bleeding controlled by a stamp of as 11 years after; they have also been noted in the bloodmuscle. Deep foreign bodies are left severely temporal cells ofpatients who were afterwards found to have those which can be gently dislodged are alone, and atrophic spleens. This connexion between the Howell-. removed. only Glancing gunshot wounds may cause local Jolly bodies and atrophy of the spleen has recently been contusions of’ the underlying brain with resulting reviewed by Boveri.1 The number of published cases he temporary hemiplegia. This is sometimes misinterpreted quotes is small; he describes two cases of his own-in as a sign of intracranial haemorrhage requiring operation, only one was the atrophy of the spleen confirmed at but in these glancing wounds there is usually no impairautopsy-and gives a few facts about 7 more cases found ment of consciousness and this serves to exclude proamong hæmatological records covering 5 years ; in 5 of gressive cerebral compression requiring surgical reliefs these the state of the spleen was not known, in the remainThe sulphonamides have greatly reduced the risk of ing 2 it was fibrotic but not atrophied. The evidence meningitis and brain abscess. Regular examination of thus obtained is admitted by Boveri to-be poor, but a fewthe cerebrospinal fluid is performed in cases of infection. interesting facts emerge. Nearly all the patients had The fluidintake must be well maintained, if necessary by disturbed absorption from the alimentary tract, such as intravenous infusion. There is usually little or no con. achlorhydria or excess fat in the stools ; and such cussion of the brain as a whole, and treatment consists disturbances have been linked-again by continental essentially in dealing with the area of local injury to the writers-with atrophy of the spleen. They are only scalp, skull and brain. really significant if they persist in the red cells of patients HOME TREATMENT OF PNEUMONIA who are- not anaemic, in whom the proportion of affected cells is of the order of 1-5 per 1000 ; if the patient is THE Boston Dispensary, which has been running since anæmic, there should be many affected cells-5% have 1796,provides a free pneumonia service for poor patients. been found after splenectomy-and they should persist The aim is to give them treatment in their own homes, at the 1-5 per 1000 rate even ifthe anaemia is successfully so- lessening the burden on overcrowded hospitals, and treated. In these circumstances a diagnosis of atrophy avoiding the psychological disturbance of moving them of-the spleen may be made,. and this seems to be specially from familiar surroundings, the risks of transport in true of cases of non-tropical sprue. There is no evidence ambulance, and possible delays in starting treatment that Howell-Jolly bodies always connote a disorder of Against these advantages may be set poor homes- and the spleen. Except as’a help to complete the pathoinadequate nursing and the possible lack of medical logical picture, the knowledge that a patient’s spleen is equipment or of immediate medical attention in an emeratrophied is neither thrilling nor helpful ; nevertheless, gency. Rosenthal, MacColl and Pratt,l in a report since Boveri has reminded us that they have some of 132 cases treated by the dispensary staff, suggest that significance, it is likely that the Howell-Jolly bodies will with the proper use of sulphonamides, the death-rate of continue to be allowed, their, quiet corner in the colourpatients treated at home may be as low or lower than that of patients in hospital.- During the winter of plate and their few propitiatory lines in the textbook. 1940-41 four physicians undertook treatment and the BATTLE WOUNDS OF THE HEAD patients ranged in age from 2 months to 86 years, 17% ONE of the most useful functions of specialised surgical of them being above the age of 50. As a rule treatment units in war is to formulate a policy for the guidance of could be started within 48 hours of the onset of the illness, the general surgeon who under war conditions must be and the usual initial delays over hospital admission were prepared to treat all types of wound. Major Miller,2 who of course eliminated. In all cases the sputum was was in command of a neurosurgical unit in. the Middle examined, pneumococci being found in 53% ; bloodEast, tells the general surgeon exactly what he wants to counts were done and the urine examined regularly. know about the treatment of gunshot wounds of the Sulphathiazole was given by mouth, an initial dose of head. He points out that the practice of leaving battle 4 g. being taken in the presence of the physician. The wounds unsutured has no place in head wounds. All average total dosage given was 37 g. for adults, and 12 g. head wounds should be treated by scrupulous debride- for children. For patients not showing pneumococci a
"
ment and closure. In the Western Desert this could be successfully carried out even three or four days after the injury. " Nothing is more fraught with danger," he says, " than partial interference with such wounds in forward field units from which an early and exhausting evacuation will have to be made." The surgeon who has 1, Boveri, R. M. Guy’s Hosp. Rep. 1942, 91, 81. 2. Miller, D. Med. J. Aust. 1942, ii, 207.
"
in the sputum the average dose was 23 g.. for adults and 10 g. for children. The temperature dropped to normal in about 48 hours in almost all cases and the average duration of sulphathiazole treatment was 4 days for adults and 3’6 days for children. A low white-cell count was not regarded as a contra-indication to the treatment, 1.
Rosenthal, J., MacColl, W. 1942, 226, 845.
A., Pratt,
J. H. New Engl. J. Med.
’
likely ]4owpvor,, that iniobilisation by splinting is an imperfect biological method of preventing the stretching of paralysed muscles, and that the influence of muscular
pain has not been properly appreciated. It may well be that advances in physical therapy, springing from Miss Kenny’s enthusiasm will outlast her theory and terminology.
to deal
properly with the wound must have a suction apparatus which provides the only way to keep the operation field clear : a foot-pump suction apparatus, at least, should be available for every surgical team. Cushing clips should be provided, for electrosurgical apparatus is rarely available. ’ Pentothal Sodium’ as
preliminary anaesthetic allows thorough shaving and cleaning of the scalp, the operation being then continued THE HOWELL- JOLLY BODIES under local anaesthesia. Thorough excision of the wound THE Howell-Joily bodies are small refractile granules is essential. The scalp flaps are freely mdbilised to about 1µ in diameter that are sometimes found in red facilitate closure; bone edges are excised by sharp blood-cells ; they are usually eccentrically placed and rongeur forceps; soiled dura is removed with scissors, may be single or multiple. They have not attracted haemorrhage being controlled by silver slips or an undermuch attention, in spite of their cheerful name ; they are suture. When no endotherm is available the running classed with Cabot’s rings and other nuclear remnants, red-hot of a probe is useful to seal small bleeding tip and hsemato.logical textbooks still find them a place on on the dura. The brain wound is cleaned by points their colour-plates. They have however a long and gentle suction until a clear field is obtained. history, irrigation and in continental literature particularly they are associArtery forceps are of course never applied to the brain, ated with the spleen. Some 3a years ago, Howell-Jolly and swabbing is avoided except for the application of a bodies were noticed in the red cells after splenectomy, small moist wool slab to points. Haemorrhage and have been reported to persist in the blood for as long from venous sinuses is bleeding controlled by a stamp of as 11 years after; they have also been noted in the bloodmuscle. Deep foreign bodies are left severely temporal cells ofpatients who were afterwards found to have those which can be gently dislodged are alone, and atrophic spleens. This connexion between the Howell-. removed. only Glancing gunshot wounds may cause local Jolly bodies and atrophy of the spleen has recently been contusions of’ the underlying brain with resulting reviewed by Boveri.1 The number of published cases he temporary hemiplegia. This is sometimes misinterpreted quotes is small; he describes two cases of his own-in as a sign of intracranial haemorrhage requiring operation, only one was the atrophy of the spleen confirmed at but in these glancing wounds there is usually no impairautopsy-and gives a few facts about 7 more cases found ment of consciousness and this serves to exclude proamong hæmatological records covering 5 years ; in 5 of gressive cerebral compression requiring surgical reliefs these the state of the spleen was not known, in the remainThe sulphonamides have greatly reduced the risk of ing 2 it was fibrotic but not atrophied. The evidence meningitis and brain abscess. Regular examination of thus obtained is admitted by Boveri to-be poor, but a fewthe cerebrospinal fluid is performed in cases of infection. interesting facts emerge. Nearly all the patients had The fluidintake must be well maintained, if necessary by disturbed absorption from the alimentary tract, such as intravenous infusion. There is usually little or no con. achlorhydria or excess fat in the stools ; and such cussion of the brain as a whole, and treatment consists disturbances have been linked-again by continental essentially in dealing with the area of local injury to the writers-with atrophy of the spleen. They are only scalp, skull and brain. really significant if they persist in the red cells of patients HOME TREATMENT OF PNEUMONIA who are- not anaemic, in whom the proportion of affected cells is of the order of 1-5 per 1000 ; if the patient is THE Boston Dispensary, which has been running since anæmic, there should be many affected cells-5% have 1796,provides a free pneumonia service for poor patients. been found after splenectomy-and they should persist The aim is to give them treatment in their own homes, at the 1-5 per 1000 rate even ifthe anaemia is successfully so- lessening the burden on overcrowded hospitals, and treated. In these circumstances a diagnosis of atrophy avoiding the psychological disturbance of moving them of-the spleen may be made,. and this seems to be specially from familiar surroundings, the risks of transport in true of cases of non-tropical sprue. There is no evidence ambulance, and possible delays in starting treatment that Howell-Jolly bodies always connote a disorder of Against these advantages may be set poor homes- and the spleen. Except as’a help to complete the pathoinadequate nursing and the possible lack of medical logical picture, the knowledge that a patient’s spleen is equipment or of immediate medical attention in an emeratrophied is neither thrilling nor helpful ; nevertheless, gency. Rosenthal, MacColl and Pratt,l in a report since Boveri has reminded us that they have some of 132 cases treated by the dispensary staff, suggest that significance, it is likely that the Howell-Jolly bodies will with the proper use of sulphonamides, the death-rate of continue to be allowed, their, quiet corner in the colourpatients treated at home may be as low or lower than that of patients in hospital.- During the winter of plate and their few propitiatory lines in the textbook. 1940-41 four physicians undertook treatment and the BATTLE WOUNDS OF THE HEAD patients ranged in age from 2 months to 86 years, 17% ONE of the most useful functions of specialised surgical of them being above the age of 50. As a rule treatment units in war is to formulate a policy for the guidance of could be started within 48 hours of the onset of the illness, the general surgeon who under war conditions must be and the usual initial delays over hospital admission were prepared to treat all types of wound. Major Miller,2 who of course eliminated. In all cases the sputum was was in command of a neurosurgical unit in. the Middle examined, pneumococci being found in 53% ; bloodEast, tells the general surgeon exactly what he wants to counts were done and the urine examined regularly. know about the treatment of gunshot wounds of the Sulphathiazole was given by mouth, an initial dose of head. He points out that the practice of leaving battle 4 g. being taken in the presence of the physician. The wounds unsutured has no place in head wounds. All average total dosage given was 37 g. for adults, and 12 g. head wounds should be treated by scrupulous debride- for children. For patients not showing pneumococci a
"
ment and closure. In the Western Desert this could be successfully carried out even three or four days after the injury. " Nothing is more fraught with danger," he says, " than partial interference with such wounds in forward field units from which an early and exhausting evacuation will have to be made." The surgeon who has 1, Boveri, R. M. Guy’s Hosp. Rep. 1942, 91, 81. 2. Miller, D. Med. J. Aust. 1942, ii, 207.
"
in the sputum the average dose was 23 g.. for adults and 10 g. for children. The temperature dropped to normal in about 48 hours in almost all cases and the average duration of sulphathiazole treatment was 4 days for adults and 3’6 days for children. A low white-cell count was not regarded as a contra-indication to the treatment, 1.
Rosenthal, J., MacColl, W. 1942, 226, 845.
A., Pratt,
J. H. New Engl. J. Med.
’