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TREATMENT AND PROGNOSIS OF COLLES' FRACTURE
663
rapid bleeding. The volume of blood returned than 50 ml. and usually 10-12 ml. was sufficient to restore the pressure to its previous level of 40 mm. Hg. 4. Volume of Blood Lost During Infusion The volume of blood lost during the infusion was always very nearly equal to the volume of fluid infused. If any variation did occur it was in the region of 10% above or below because of
too
was never more
this volume. 5.
Sequence of Experiments
The control experiments were not all performed in a single initial group. When it was found that six animals suffered no tissue damage after infusion with sodium bicarbonate and a further three treated with hypertonic saline were similarly unaffected, and that the animals survived so easily and recovered so quickly as long as they were not over-transfused, we returned to the control experiments and performed a further three. None of the animals had, up to that time, been treated with antibiotics. Further control experiments with animals which had received antibiotics were performed later when infection appeared in the kennels late in the series.
Our experience with profound hypothermia at the Westminster has made us aware of the importance of environmental temperature, its effect upon metabolism, and the changes it produces in biochemistry.2-4 The experiments were conducted in a particularly wellventilated room kept warm in winter and by referring to the factors used to calculate TC02 on the Van Slyke apparatus in the same room at the same time as the experiment, we see that the ambient temperature did not vary from between 25°C and 20°C and was mainly in the region of 23°C to 21 °C. Of greater importance is, of course, the temperature of the animal itself which in the infused animals did not fall below 36-2°C but there was generally a fall from 38°C to usually just above this figure. In the untreated animals the lowest rectal temperature recorded was 35°C, except those artifically ventilated. As indicated in the paper, the rectal temperature of these animals fell to 32°C just before death. As is true of all animal experiments, it may well be that they have no immediate application to man but we feel that we can foresee a somewhat wider clinical application than that which has been suggested by Dr. McGowan. People who have experienced major trauma involving such conditions as ruptured spleen, extravasation of blood into muscles, and multiple fractures are often hypotensive for considerable periods of time and require transfusion, and sometimes their condition is not improved during anaathesia, manipulation, and treatment. Patients undergoing major vascular surgery lasting four or five hours are sometimes subjected to periods of hypotension and haemorrhage, even when the greatest care is taken to replace blood as soon as it is lost. Procedures such as these may increase the degree of damage to vital tissues, especially the kidneys, that has already occurred. Our hope is that further damage may be prevented, in these and many other conditions which require resuscitation of the patient. While it is ideal to replace blood immediately, this is sometimes not possible. Even when adequate replacement has apparently been achieved, patients still die, and this may be because of the failure to correct biochemical changes that have occurred. If in fact this work is of no value to man then the successful management of natients who are ahnnt tn clie -
2. Brooks, D. K. in Modern Trends in Anaesthesia; p. 102. 3. Brooks, D. K. Chir. thorac. Cardiovasc. 1962, 1, 593. 4. Kenyon, J. R., Ludbrook, J., Downs, A. R., Tait, I. B., Pryczkowski, J. Lancet, 1959, ii, 41.
London,
1962.
Brooks,
D. K.
from the effects of haemorrhagic shock will have to await further knowledge based on clinical evaluation alone. Department of Experimental Surgery, Westminster Hospital, London, S.W.1.
Brompton Hospital, London, S.W.3.
D. K. BROOKS. W. G. WILLIAMS.
THE NEUROLOGICAL SERVICES OF ENGLAND AND WALES SIR, Your issue of March 2 contains an excellent leading article on Where to be Treated for a Brain Tumour and a letter from Mr. Arden on the subject of head injuries. I need scarcely say that I am in entire agree-
with all that is implied. My purpose in writing, however, is to draw notice to the fact that the scarcity of neurosurgeons in England and Wales is perhaps not so serious as their uneven distribution. In 1959 I made a survey1 of the neurological services in England and Wales, in which the distribution of neurologists and neurosurgeons in the Metropolitan regions and in the provinces was calculated. From this it was evident that there was not only an uneven distribution of both neurological physicians and surgeons, but also in a few places an impossibility for these two classes of specialist to work in close proximity. Moreover, it seems to me absolutely essential, not only for the proper treatment of neurological patients, but also for the advancement of neurology, that the country shall be given a sufficiency of centres each of which shall include consultants in neurology, reurosurgery, neuroradiology, electrophysiology, and neul1ûpathology, with appropriate junior staff. Such a policy will undoubtedly be expensive to implement, but, without it, patients with organic disease of the nervous system can never be properly cared for. National Hospital for Nervous Diseases, DENIS BRINTON. London, W.C.1.
ment
TREATMENT AND PROGNOSIS OF COLLES’ FRACTURE
SIR,-Mr. Golden (March 9) is to be congratulated, I feel, on his lucid exposition of the treatment and prognosis of Colles’ fracture. For too long it has been accepted, as he points out, that this is another kind of case for the casualty officer to have a bash " at, and it leads to a fair amount of disability when not treated correctly. "
I have, for a number of years, treated selected Colles’ fractures by long-arm plasters in pronation and a degree of flexion at the wrist. I have confined this form of treatment mostly to those with comminution of the lower radial articular surface and subluxation of the inferior radio-ulnar joint, and also when there is a fair amount of dorsal comminution. In practically all cases of this type, the results were excellent compared with the results of a short plaster. Like Mr. Golden, I did not find the patients had any difficulty in regaining full elbow movements later. I feel that every Colles’ fracture, irrespective of age or should be reduced. In my view, there is can be general, regional and, although I do not like it very much, occasionally local. Unlike Mr. Golden, however, I have found that, providing extreme ulnar deviation and some flexion are present, a dorsal short plaster slab for three to four days, to be followed by a long-arm plaster, gave as good a result as a long-arm plaster from the beginning. Lastly, it amazes me how often I see cases from other hospitals which have never had what I consider a must-that is, a check X-ray at the end of seven days, and, if the fracture has slipped, a further reduction.
general health, no
excuse, for the anaesthetic
W. LAURENCE. 1. Proc. R. Soc. Med.
1960, 53, 4.
rapid bleeding. The volume of blood returned than 50 ml. and usually 10-12 ml. was sufficient to restore the pressure to its previous level of 40 mm. Hg. 4. Volume of Blood Lost During Infusion The volume of blood lost during the infusion was always very nearly equal to the volume of fluid infused. If any variation did occur it was in the region of 10% above or below because of
too
was never more
this volume. 5.
Sequence of Experiments
The control experiments were not all performed in a single initial group. When it was found that six animals suffered no tissue damage after infusion with sodium bicarbonate and a further three treated with hypertonic saline were similarly unaffected, and that the animals survived so easily and recovered so quickly as long as they were not over-transfused, we returned to the control experiments and performed a further three. None of the animals had, up to that time, been treated with antibiotics. Further control experiments with animals which had received antibiotics were performed later when infection appeared in the kennels late in the series.
Our experience with profound hypothermia at the Westminster has made us aware of the importance of environmental temperature, its effect upon metabolism, and the changes it produces in biochemistry.2-4 The experiments were conducted in a particularly wellventilated room kept warm in winter and by referring to the factors used to calculate TC02 on the Van Slyke apparatus in the same room at the same time as the experiment, we see that the ambient temperature did not vary from between 25°C and 20°C and was mainly in the region of 23°C to 21 °C. Of greater importance is, of course, the temperature of the animal itself which in the infused animals did not fall below 36-2°C but there was generally a fall from 38°C to usually just above this figure. In the untreated animals the lowest rectal temperature recorded was 35°C, except those artifically ventilated. As indicated in the paper, the rectal temperature of these animals fell to 32°C just before death. As is true of all animal experiments, it may well be that they have no immediate application to man but we feel that we can foresee a somewhat wider clinical application than that which has been suggested by Dr. McGowan. People who have experienced major trauma involving such conditions as ruptured spleen, extravasation of blood into muscles, and multiple fractures are often hypotensive for considerable periods of time and require transfusion, and sometimes their condition is not improved during anaathesia, manipulation, and treatment. Patients undergoing major vascular surgery lasting four or five hours are sometimes subjected to periods of hypotension and haemorrhage, even when the greatest care is taken to replace blood as soon as it is lost. Procedures such as these may increase the degree of damage to vital tissues, especially the kidneys, that has already occurred. Our hope is that further damage may be prevented, in these and many other conditions which require resuscitation of the patient. While it is ideal to replace blood immediately, this is sometimes not possible. Even when adequate replacement has apparently been achieved, patients still die, and this may be because of the failure to correct biochemical changes that have occurred. If in fact this work is of no value to man then the successful management of natients who are ahnnt tn clie -
2. Brooks, D. K. in Modern Trends in Anaesthesia; p. 102. 3. Brooks, D. K. Chir. thorac. Cardiovasc. 1962, 1, 593. 4. Kenyon, J. R., Ludbrook, J., Downs, A. R., Tait, I. B., Pryczkowski, J. Lancet, 1959, ii, 41.
London,
1962.
Brooks,
D. K.
from the effects of haemorrhagic shock will have to await further knowledge based on clinical evaluation alone. Department of Experimental Surgery, Westminster Hospital, London, S.W.1.
Brompton Hospital, London, S.W.3.
D. K. BROOKS. W. G. WILLIAMS.
THE NEUROLOGICAL SERVICES OF ENGLAND AND WALES SIR, Your issue of March 2 contains an excellent leading article on Where to be Treated for a Brain Tumour and a letter from Mr. Arden on the subject of head injuries. I need scarcely say that I am in entire agree-
with all that is implied. My purpose in writing, however, is to draw notice to the fact that the scarcity of neurosurgeons in England and Wales is perhaps not so serious as their uneven distribution. In 1959 I made a survey1 of the neurological services in England and Wales, in which the distribution of neurologists and neurosurgeons in the Metropolitan regions and in the provinces was calculated. From this it was evident that there was not only an uneven distribution of both neurological physicians and surgeons, but also in a few places an impossibility for these two classes of specialist to work in close proximity. Moreover, it seems to me absolutely essential, not only for the proper treatment of neurological patients, but also for the advancement of neurology, that the country shall be given a sufficiency of centres each of which shall include consultants in neurology, reurosurgery, neuroradiology, electrophysiology, and neul1ûpathology, with appropriate junior staff. Such a policy will undoubtedly be expensive to implement, but, without it, patients with organic disease of the nervous system can never be properly cared for. National Hospital for Nervous Diseases, DENIS BRINTON. London, W.C.1.
ment
TREATMENT AND PROGNOSIS OF COLLES’ FRACTURE
SIR,-Mr. Golden (March 9) is to be congratulated, I feel, on his lucid exposition of the treatment and prognosis of Colles’ fracture. For too long it has been accepted, as he points out, that this is another kind of case for the casualty officer to have a bash " at, and it leads to a fair amount of disability when not treated correctly. "
I have, for a number of years, treated selected Colles’ fractures by long-arm plasters in pronation and a degree of flexion at the wrist. I have confined this form of treatment mostly to those with comminution of the lower radial articular surface and subluxation of the inferior radio-ulnar joint, and also when there is a fair amount of dorsal comminution. In practically all cases of this type, the results were excellent compared with the results of a short plaster. Like Mr. Golden, I did not find the patients had any difficulty in regaining full elbow movements later. I feel that every Colles’ fracture, irrespective of age or should be reduced. In my view, there is can be general, regional and, although I do not like it very much, occasionally local. Unlike Mr. Golden, however, I have found that, providing extreme ulnar deviation and some flexion are present, a dorsal short plaster slab for three to four days, to be followed by a long-arm plaster, gave as good a result as a long-arm plaster from the beginning. Lastly, it amazes me how often I see cases from other hospitals which have never had what I consider a must-that is, a check X-ray at the end of seven days, and, if the fracture has slipped, a further reduction.
general health, no
excuse, for the anaesthetic
W. LAURENCE. 1. Proc. R. Soc. Med.
1960, 53, 4.