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SIMPLIFIED MANAGEMENT OF HEAD INJURIES
505 life in hospital because of the ravages of dermatitis and diarrhoea. The condition responds, though tardily, to breast milk and diodoquin, but relapses readily. For 26 months there has been complete absence of hair on the head, eyelashes, and eyebrows. In the last attack the diarrhoea was controlled with diodoquin, but skin lesions persisted. Diodoquin was therefore discontinued, and treatment was begun with penicillamine, 150 mg. daily. Within 10 days some growth of hair on the head became visible! After 2 months the child has a good growth of hair and eyelashes which curl spontaneously. The eyebrows are scanty, and there is no growth of hair elsewhere on the body. The dermatitis, which initially cleared quickly, relapsed after 6 weeks but hair continues to grow. The stools have remained normal throughout. The child’s new toy is a hairbrush.
He does state that there are two forms of service: the first is provided by the neurosurgeons, and apparently forms about 10%; the rest is provided either by general surgeons or by
orthopxdic surgeons. Surely the neurosurgeons should campaign for many more neurosurgeons and neurosurgical centres by putting pressure on the Ministry, the regional boards, the hospital management committees. There is, I believe, only about one neurosurgeon per million population in this country, which is obviously very inadequate, particularly in view of the increase in head injuries resulting from road accidents.
G. P. ARDEN.
CHROMOSOME DAMAGE AFTER X-RAY THERAPY SiR,-The striking finding by Dr. Court Brown and Although the cause of acrodermatitis enteropathica is his colleagues1 of acentric chromosome fragments persistunknown, its occurrence in siblings suggests a genetic ing up to five years after exposure to X rays raises once disorder, possibly of the enzyme-deficiency type. The again the question of how chromosome pieces lacking a success of penicillamine in Wilson’s disease and cysticentromere are maintained for prolonged periods of time. nosis2 prompted its use in our patient. Whether its hair- In the patient recorded2 by us not a single normal diploid stimulating propensity is here also related to the thiol cell was found although the blood-cultures were set up group is conjectural. Obviously, further trials must be fifteen and twenty months after the last X-ray treatment. undertaken. A patient with alopecia totalis is now under Moreover, these cultures contained a high proportion empirical treatment with penicillamine. of chromosome types which are not usually perpetuated Transvaal Memorial Hospital for Children, in a series of mitotic cycles. Acentric fragments were S. N. JAVETT. Johannesburg, South Africa. exceedingly common in these cultures-up to six in 1 cell. In addition six chromatid breaks were observed UNDE VENIS? among 54 cells cultured twenty months after the last SIR,-Professor Maegraith, in his fascinating address radiotherapy. Acentrics and chromatid breaks are generally (Feb. 23), underlines two aspects of clinical history- accepted as evidence of recent breakage events. Unless taking of great importance-namely, careful and skilled damaged nuclei are able to remain " dormant " for years interrogation and a global outlook, in these days of rapid and subsequently enter a mitotic phase, these aberrations world travel. cannot be considered as the immediate result of X-ray The police officer, the attorney, and the security officer rely treatment. We therefore suggest that the mammalian very largely upon skilled interrogation for their information, organism may occasionally maintain factors inducing conbut all too often the doctor can hardly wait to get his hands and tinuous chromosome breakage. Such factors may be gene his stethoscope upon the patient. Moreover, we must be ever virus infections, or chemical compounds proready to use the vital evidence which can be. given only by mutations, duced irradiation, or by leukaemic conditions. A by relatives, friends, workmates, and other eye-witnesses. We vulnerability of chromosomes to breakage of the type must also be prepared to go back over the history when the fog of acute pain, distress, breathlessness and impaired con- visualised by us appears, for example, in some tissue sciousness have cleared, for, if we are honest, many a true cultures of the Chinese hamster3 and in the Jensen rat sarcoma cultured on certain media.4 diagnosis is made in retrospect. All this may seem rather mundane and obvious, but I doubt Dr. Court Brown writes that we have misquoted his whether enough attention is paid to it in medical schools or in group in our discussion of manifold chromosome anomalies the clinical world bevond. found in a case of leukaemia. He states that the report5 of his DENIS M. FREEMAN. unit contained no information implying " that recovery from radiation-induced damage is quite rapid ". In our opinion SIMPLIFIED MANAGEMENT OF the text, tables, and chi-square calculations of this report indicate that indeed a large fraction of the chromosome HEAD INJURIES caused by radiation was eliminated fast. The proPoland Mr. .Potter SIR,-In John recently (Feb. 16) damage of modal cells in both patients tended rapidly towards portion deal to sort out the wheat from the chaff helped a good the pre-exposure level. The proportion of cells with structural in methods of treating head injuries. But in the section abnormalities declined from 40% to 18% within about a on extradural haemorrhage he suggests that a general or month (patient A) and from 41 % to 9% within less than an orthopaedic surgeon should do a craniectomy rather two weeks (patient B). The decline in frequency of damaged than a craniotomy. In fact it is not necessary for them to cells is stressed: " By the fifth day, however, the percentage do either. May I suggest once again3 that the proper way of modal cells (in patient B) has returned to within normal to treat depression of the dura is to elevate it ? This can limits and remained so for the rest of the period of observation. be done with a J-shaped needle through a burr hole. The fifth day also marked a decline in the number of cells with structural abnormalities, but even on the last two days What could be simpler ? of observation these were present in 9 to 10% of the cells Brook General Hospital, London,
SIR,-As
J. R. GIBBS.
S.E.18.
orthopaedic surgeon treating a considerable number of these head injuries, I find Mr. Potter’s interesting article very helpful. I was, however, disappointed an
that he made
no
mention of the fact that there facilities in this country.
inadequate neurosurgical
1. Walshe, J. M. Amer. J. Med. 1956, 21, 487. 2. Clayton, B. E., Patrick, A. D. Lancet, 1961, 3. Gibbs, J. R. ibid. 1960, ii, 727.
ii,
909.
are
(italics ours).
A second publication 6-quoted by us but not mentioned in Dr. Court Brown’s letter-emphasises the fact that patients 6-9 displayed structural anomalies of the chromosomes after having been " treated by radiotherapy for their leukaemic 1. Lancet, 1962, i, 1242. 2. 3. 4. 5. 6.
ibid. p. 1098.
Tjio, J. H., Puck, T. T. J. exp. Med. 1958, 108, 259. Hsu, T. C., Manna, G. K. Amer. Nat. 1959, 93, 207. Lancet, 1960, ii, 849. ibid. 1961, i, 411.
He does state that there are two forms of service: the first is provided by the neurosurgeons, and apparently forms about 10%; the rest is provided either by general surgeons or by
orthopxdic surgeons. Surely the neurosurgeons should campaign for many more neurosurgeons and neurosurgical centres by putting pressure on the Ministry, the regional boards, the hospital management committees. There is, I believe, only about one neurosurgeon per million population in this country, which is obviously very inadequate, particularly in view of the increase in head injuries resulting from road accidents.
G. P. ARDEN.
CHROMOSOME DAMAGE AFTER X-RAY THERAPY SiR,-The striking finding by Dr. Court Brown and Although the cause of acrodermatitis enteropathica is his colleagues1 of acentric chromosome fragments persistunknown, its occurrence in siblings suggests a genetic ing up to five years after exposure to X rays raises once disorder, possibly of the enzyme-deficiency type. The again the question of how chromosome pieces lacking a success of penicillamine in Wilson’s disease and cysticentromere are maintained for prolonged periods of time. nosis2 prompted its use in our patient. Whether its hair- In the patient recorded2 by us not a single normal diploid stimulating propensity is here also related to the thiol cell was found although the blood-cultures were set up group is conjectural. Obviously, further trials must be fifteen and twenty months after the last X-ray treatment. undertaken. A patient with alopecia totalis is now under Moreover, these cultures contained a high proportion empirical treatment with penicillamine. of chromosome types which are not usually perpetuated Transvaal Memorial Hospital for Children, in a series of mitotic cycles. Acentric fragments were S. N. JAVETT. Johannesburg, South Africa. exceedingly common in these cultures-up to six in 1 cell. In addition six chromatid breaks were observed UNDE VENIS? among 54 cells cultured twenty months after the last SIR,-Professor Maegraith, in his fascinating address radiotherapy. Acentrics and chromatid breaks are generally (Feb. 23), underlines two aspects of clinical history- accepted as evidence of recent breakage events. Unless taking of great importance-namely, careful and skilled damaged nuclei are able to remain " dormant " for years interrogation and a global outlook, in these days of rapid and subsequently enter a mitotic phase, these aberrations world travel. cannot be considered as the immediate result of X-ray The police officer, the attorney, and the security officer rely treatment. We therefore suggest that the mammalian very largely upon skilled interrogation for their information, organism may occasionally maintain factors inducing conbut all too often the doctor can hardly wait to get his hands and tinuous chromosome breakage. Such factors may be gene his stethoscope upon the patient. Moreover, we must be ever virus infections, or chemical compounds proready to use the vital evidence which can be. given only by mutations, duced irradiation, or by leukaemic conditions. A by relatives, friends, workmates, and other eye-witnesses. We vulnerability of chromosomes to breakage of the type must also be prepared to go back over the history when the fog of acute pain, distress, breathlessness and impaired con- visualised by us appears, for example, in some tissue sciousness have cleared, for, if we are honest, many a true cultures of the Chinese hamster3 and in the Jensen rat sarcoma cultured on certain media.4 diagnosis is made in retrospect. All this may seem rather mundane and obvious, but I doubt Dr. Court Brown writes that we have misquoted his whether enough attention is paid to it in medical schools or in group in our discussion of manifold chromosome anomalies the clinical world bevond. found in a case of leukaemia. He states that the report5 of his DENIS M. FREEMAN. unit contained no information implying " that recovery from radiation-induced damage is quite rapid ". In our opinion SIMPLIFIED MANAGEMENT OF the text, tables, and chi-square calculations of this report indicate that indeed a large fraction of the chromosome HEAD INJURIES caused by radiation was eliminated fast. The proPoland Mr. .Potter SIR,-In John recently (Feb. 16) damage of modal cells in both patients tended rapidly towards portion deal to sort out the wheat from the chaff helped a good the pre-exposure level. The proportion of cells with structural in methods of treating head injuries. But in the section abnormalities declined from 40% to 18% within about a on extradural haemorrhage he suggests that a general or month (patient A) and from 41 % to 9% within less than an orthopaedic surgeon should do a craniectomy rather two weeks (patient B). The decline in frequency of damaged than a craniotomy. In fact it is not necessary for them to cells is stressed: " By the fifth day, however, the percentage do either. May I suggest once again3 that the proper way of modal cells (in patient B) has returned to within normal to treat depression of the dura is to elevate it ? This can limits and remained so for the rest of the period of observation. be done with a J-shaped needle through a burr hole. The fifth day also marked a decline in the number of cells with structural abnormalities, but even on the last two days What could be simpler ? of observation these were present in 9 to 10% of the cells Brook General Hospital, London,
SIR,-As
J. R. GIBBS.
S.E.18.
orthopaedic surgeon treating a considerable number of these head injuries, I find Mr. Potter’s interesting article very helpful. I was, however, disappointed an
that he made
no
mention of the fact that there facilities in this country.
inadequate neurosurgical
1. Walshe, J. M. Amer. J. Med. 1956, 21, 487. 2. Clayton, B. E., Patrick, A. D. Lancet, 1961, 3. Gibbs, J. R. ibid. 1960, ii, 727.
ii,
909.
are
(italics ours).
A second publication 6-quoted by us but not mentioned in Dr. Court Brown’s letter-emphasises the fact that patients 6-9 displayed structural anomalies of the chromosomes after having been " treated by radiotherapy for their leukaemic 1. Lancet, 1962, i, 1242. 2. 3. 4. 5. 6.
ibid. p. 1098.
Tjio, J. H., Puck, T. T. J. exp. Med. 1958, 108, 259. Hsu, T. C., Manna, G. K. Amer. Nat. 1959, 93, 207. Lancet, 1960, ii, 849. ibid. 1961, i, 411.