REPAIR OF DURAL DEFECTS WITH GELATIN FILM

943 average of 36-5 calories, the divergence is equal to the standard deviation of 2-5 calories ; hence the patient’s test result lies within the limits of normal variation. Only if the output were greater than 41-5 or less than 31-5 would we suggest, on this evidence alone, that the patient’s B.M.R. was abnormal in the sense here used. These standards are based upon observations made on These were nurses, apparently healthy volunteers. medical students, and members of the staff of the Middlesex Hospital, children attending welfare clinics and on tonsillectomy waiting-lists, and members of the public who came in response to newspaper appeals. In so far as these " normal people " are typical of the British

REPAIR

DURAL DEFECTS GELATIN FILM

OF

WITH

WYLIE MCKISSOCK O.B.E., M.S. Lond., F.R.C.S. NEUROLOGICAL SURGEON, NATIONAL HOSPITAL, QUEEN AND ST. GEORGE’S HOSPITAL, LONDON

SQUARE,

DEFECTS in the dura mater remaining after the removal of certain intracranial tumours or the excision of cortical scars have always presented a problem to the neurological surgeon because adherence of the brain to overlying structures, with subsequent formation of fibrous scar tissue, may give rise to epileptic attacks. In attempts to prevent adhesion of the brain many different tissues have been used to close these dural defects, including fascia lata, periosteum, temporal fascia, and muscle. Likewise, the dura remaining in the wound has been split into two layers so as to bridge the defect with the extra area of membrane so produced ; but though this can be done with small defects and a thick dura, it may not be possible in the frontal region, where the dura is closed thin : the larger defects provide problems insoluble by such a process. Various foreign substances have also been used, among them’Cellophane,’ amniotic membrane, tantalum foil, fibrin foam, andGel-foam’ film. From the multi. plicity of methods it is evident that the ideal substance has not yet been discovered. The use of gelatin film was reported by Busch et al. (1949) but it was considered unsuitable for repairing dural defects. Weisel et al. (1950) gave a detailed account of gelatin film implanted into chest wounds as a temporary closure for pleural defects, and found that the implants were completely absorbed between the eight and fourteenth days : tissue reaction was minimal, and the normal pleural regeneration did not seem to I be hindered by the presence of the gelatin film. compare here the results achieved with tantalum foil and with gelatin film in relation first to the postoperative convalescence and secondly to the incidence of ‘

TABLE

III-EXPECTED

MEAN

HEAT

OUTPUT

AND

-

LIMITS

OF

VARIATION

(Calories

per square metre

body-surface

area

per

hour)

-

subsequent epilepsy. PRESENT INVESTIGATION

these tables of their heat output at different ages, measured by the technique described, should form a useful standard for clinical work on basal metabolism in this country.

population,

Our thanks

due to Prof. E. C. Dodds, in whose departbegun, and to Mr. A. V. Bridgland, Chairman of the Trustees of the London Clinic, where it was completed; to Sir Alan Daley, Mr. Somerville Hastings, and the press for their help in enlisting the cooperation of suitable people ; and above all to the volunteers themselves. are

ment this work

was

This series of cases dates from 1945, and in the first few years tantalum foil was used to close almost all the dural defects. Then, however, Messrs. Allen & Hanburys produced a gelatin film large enough to close the largest defects. This film is a thin transparent membrane, supplied sterilised in tubes, which closely resembles cellophane until it is moistened with saline solution, when it immediately becomes soft and is easily tucked in beneath the edges of the dural defect. No fixation of the implant appears necessary, because it sticks quite easily to the underlying brain. The series consists of 60 cases of intracranial meningioma after the removal of which duraldefects remained, 30 being treated with tantalum-foilimplants and 30 with gelatin film. The series is consecutive except for half a dozen cases in which fibrin foam or film was used ; these have been excluded as providing too small - a -number of cases to give data comparable with those of the gelatin or tantalum groups. TABLE I-SITE

REFERENCES

Aub, J. C., DuBois, E. F. (1917) Arch. intern. Med. 19, 823. Barrett, J. F., Robertson, J. D. (1937) J. Path. Bact. 45, 555. Boothby, W. M., Berkson, J., Dunn, H. L. (1936) Amer. J. Physiol. 116, 468. DuBois, D., DuBois, E. F. (1916) Arch. intern. Med. 17, 863. Pearl, R. (1940) Introduction to Medical Biometry and Statistics. 3rd ed., Philadelphia. Robertson, J. D. (1937) Lancet, ii, 815. — (1944) Brit. med. J. i, 617. Tanner, J. M. (1949) J. appl. Physiol. 2, 1. Vogelius, H. (1945) Basal Metabolism of Girls, 1, 617. Copenhagen.

OF MENINGIOMAS

944 TABLE II—POSTOPERATIVE

this tissue. In 3of the 6 cases a low-grade osteomyelitis of the bone ilap had developed, and the bone flaps had to be removed, In spite of this a good new duralment. brane had formed beneath the tantalum, and no patient had an infection of the iutracranial. contents deep to this membrane. The gelatin series provided no example of sepsis, osteomyelitis of the bone flap, or need for removal of the

COMPLICATIONS

The size of the defect varied considerably, but none was smaller than 4 × 4 cm. ; so, if an implant had not been made, quite a large area of brain would have been exposed to the risk of adhesion to overlying bone,

galea. meningiomas is shown in table I. Postoperatively there were no deaths in the tantalum series but there were 3 in the gelatin group. In none of the fatal cases was there any suggestion that the implant was at fault, for there was no evidence of infection, death being due to other causes. An attempt has been made to assess differences in the postoperative course in the two groups by considering such items as leaks of cerebrospinal fluid (c.s.F.), late healing, and extrusion or removal of the implanted substance (see table II). There was nothing noteworthy in the temperature charts. Late healing indicates that a given wound was not healed and dry forty-eight hours after operation, when all the sutures are normally removed. In most of these cases of late healing the wound continued to discharge a little fluid, old blood, or c.s.F., for several days. In the gelatin series all were healed within a week. periosteum,

or

The site of the

It seems the gelatin TABLE

evident,

implants

from such small numbers, that gave much less trouble than did the

even

III—SITUATION

OF

OPERATIVE AND

TUMOUB.

IN

RELATION

TO

PRE-

POSTOPERATIVE EPILEPSY

implant. Epilepsy is, of course, a common symptom in the supratentorial meningiomas, particularly where the tumour lies over the convexity of the brain or along the superior longitudinal sinus. A comparison has been made of the incidence of preoperative and postoperative epilepsy im the two groups (table III) and of recurrent and acquired epilepsy after operation (table IV), and these results liave been contrasted with those described and Eisenhardt (1938) (table v).

by Cushing TABLE

IV-INCIDENCE

OF

RECURRENT AND ACQUIRED

EPILEPSY

Cushing

and Eisenhardt

to close dural defects

covering

the

raw

(1938) rarely used an implant although they mention occasionally

brain surface* with

a

delicate film of

gutta-percha. There is a small but probably significant decrease in both recurrent and acquired epilepsy in the present series where tantalum or gelatin have been implanted, which would suggest that some useful purpose is served by the implants. In the series of Cushing and Eisenhardt (1938) 45% of patients surviving operation continued to sufbr from epilepsy, whereas the present series showed an incidence of of continued seizures. The follow-up in these cases is as yet too short for a final assessment of the continued-epilepsy rate to be made. That this is an imperfect result all will agree, and no doubt further refinements in surgical technique may be looked to in the hope of reducing this figure.

29%

’

SUMMARY

of gelatin film for repairing 30 dural defects after excision of meningiomas is reported. remaining The rate of healing of the wounds and the incidence of continued epilepsy in these 30 cases are contrasted with the results in a similar series of 30 cases where tantalum foil was used to close the dural defect. No untoward effects were observed in the gelatin series, 6 cases in the tantalum series required further operation for removal of the foil, 3 patients also losing the bone flap from low-grade osteomyelitis. Comparison of this series with that of Cushing and Eisenhardt (1938) suggests that the closure of dural The

use

.

tantalum

implants. No fewer than 6 patients required subsequent operation for removal of the tantalum because of persistent discharge from their wounds or

because of breakdown weeks or months later from lowgrade infection. In each of these 6 cases the operation revealed a mass of soft greyish granulation tissue containing pockets of pus, with the tantalum crumpled among

TABLE V-INCIDENCE OF PREOPERATIVE EPILEPSY IN PARASAGITTAL AND CONVEXITY MENINGIOMAS

945

defects with tantalum

or

with

gelatin

film leads to

a

lower incidence of continued epilepsy. REFERENCES

Buseh, E., Bing, J., Hansen, E. H. (1949) Acta chir. scand. 97, 410 ; abstr. J. Amer. med. Ass. 140, 1302. Springfield, Ill. Cashing, H., Eisenhardt, L. (1938) J.Meningiomas. Wis. M., Wood, (1950) Arch. Weisel, W., Ross, W. B., Lubitz, Surg. 60, 87.

XERODERMA PIGMENTOSUM AN ATTEMPT AT CANCER PROPHYLAXIS

D. W. SMITHERS M.D. Camb., F.R.C.P., D.M.R. THE

ROYAL

J. H. WOOD M.P.S. CHIEF

PHARMACIST,

THE ROYAL

CANCER HOSPITAL

IN November, 1946, an 8-year-oJd schoolgirl was sent She was suffering from to us by Mr. Alan Small. xeroderma pigmentosum and had developed a small squamous-e-ell carcinoma on the vermilion border of her upper lip (fig. 1). Her mother and father were first cousins ;

.

her brother,

two years older than

herself,

freckled. An account of the family has already been published was

moderately

(Koller 1948).

"

"

OF THE RADIOTHERAPY DEPARTMENT, CANCER HOSPITAL, LONDON

DIRECTOR

Skin sunburn is due to a comparatively narrow band of wave-lengths in the ultraviolet spectrum. Hausser and Vahle (1922) found a maximum effect at a wavelength of 2975 A°, dropping off to almost no erythema at 2800 A° on one side and 3130 A° on the other. A second region producing erythema less efficiently was found with a maximum at 2540 A°. There is no reliable information about the range of wave-lengths to which the skin is particularly sensitive in xeroderma pigmentosum, but some suggestion that those longer than If 3000 A° might be the most important (Zoon 1938). xeroderma pigmentosum is caused by one of the known sensitisers to light, and if this is a haematoporphyrin, even wave-lengths longer than 4000 A° might be important. In the absence of information on this it was necessary to provide for protection over as wide a range of wave-lengths as possible. The substance with the best covering power was titanium dioxide, and after our first tests with skin partly covered with various preparations and then exposed to ultraviolet light it was decided to use this substance in the final covering cream. Most of the creams tested fell short of our requirements in one or more particulars, the best being one of those advocated by Giese and Wells (1946), in a restricted report made in 1943 to the committee on medical research of the Office of Scientific Research and Development which we were privileged to see and which was published three years later. This cream included titanium dioxide as its mechanical screening and light-dispersing ingredient, and magnesium stearate and butyl stearate for their water-resisting and adhesive properties. Menthyl salicylate was included as an absorber screen to act a.s the continuous phase of the case some defence in mechanical screen should crack. The vanishing-cream base consisted of stearic acid, cetyl alcohol, and triethanolamine, and the pigment base was made with various salts of iron. The resulting product fulfilled all

’

This child when we first her was wearing long black stockings covering her knees, long black gloves over her arms, and a large Her parents black hat. had been given a most gloomy prognosis by dermatologists,- who had warned that she must always Fig. [-Patient with xeroderma be kept out of the sunlight pigmentosum and a squamousand should not- go out of cell carcinoma of the upper lip doors at all during the before treatment in November, middle part of the day 1946. in summer. The problem presented was the comparatively simple one of dealing with a small early malignant tumour, and the much more difficult one of calming agitated parents and trying to arrange a more normal life for the child. The tumour of the lip was treated with low-voltage X rays in December, 1946, and has shown no sign of recurrence in the subsequent five yearns. An attempt was then made to find the best way of protecting her skin from further damage by sunlight, while a close watch was kept to see that any further tumour that developed as a result of the damage already done would be treated immediatelv. We studied the literature on the protection of the skin from sunlight and wrote to a number of organisations for advice, receiving helpful suggestions from several sources, including the American Naval Medical Research Institute through the American Embassy and the Medical Research saw

point

them

Council.

A

PROTECTIVE

CREAM

We laid down the following requirements for any to be used for our purpose :

preparation (1) (2) (3) (4) (5) (6) (7)

Good

screening power. Easy apply. Good covering power. to

Moderately

water-resistant. Allow, but not be removed by, perspiration. Not easily rubbed off but not too difficult to remove. A finish which would be cosmetically acceptable.

Protective cut-out ; b, Protective cut-out after c, Skin 6 hours after 3 minutes’ exposure to ultraviolet light from biosol mercury-vapour lamp 18 in. away. d, Same skin 24 hours after exposure.

Fig. 2-Skin

application

test.

of

a,

creams.

KEY: (1) Officially issued protective

(2) Royal Cancer Hospital

cream.

cream

prepared

in

pharmaceutical

’department.

(3) (4) (5)

’-

C ontrol. Tannic acid 5% in vanishing-cream base. Elizabeth Arden modification of Royal cream.

(6) A proprietary sunburn

cream.

Cancer

Hospital