705

THE NURSE IN CHARGE

THE LANCETLONDON: : SdT Z1RD.Y, DEC.E1BE 4, 1943

NEUROSURGERY IN AFRICAN WARFARE

DOCTORS at work are not often members or leadersof teams. In student days, the unit or firm of clerksor dressers, house officer, registrar and chief, doesadmittedly take some of the rough edges off ourindividuality. But though the chief may chastenthose he loves, registrar and house-surgeon are

usually sweet-tempered. And the team is temporary;students move on after three months, and even thestay of registrars is limited. Most doctors, then,never experience life in a rigid hierarchy from whichthere is no escape unless armed with a testimonialfrom the man on top. In other walks of life howeverthe team is a common working unit, and its happinessand efficiency depend on the recognition that obliga-tions are incurred by those invested -with leadership.The Army officer who is worth his salt does not eator sleep until he is satisfied about the comfort of hismen. The superintendent of the telephone exchangemust watch over the health and* happiness of hergirls with a quasi-maternal eye. And the factorywelfare officer is a symbol of the recognition by thebosses that contented workers work best.Nursing is as rigid a hierarchy as is to be found in

democratic society. The conduct and behaviour ofthe nurse, at each stage of her career, is reported on byher superior, and on these reports the matron mustbase her assessment and her testimonial. Ordersare issued from which there is no appeal. " Her’snot to reason why " is still the general rather than theexceptional attitude forced on the probationer. Asa result, girls with individuality and initiative tendnot to find their way into nursing, while those whodo so lose something in their passage throughthe mill. There are many sisters and matrons whoretain their humanity in their journey to authority ;but there are others who do not. A sister has twofamilies to, care for, her patients and her nurses, notto mention her doctors, and the kindness lavished onthe sick may leave little for the subordinate. Then,again, the charming manners which impress the laycommittee are sometimes only one facet of a per-sonality which seeks power by the easy road ratherthan lasting satisfaction by the hard path of serviceto all. At all events, there are few hospitals whichcannot claim at least one sister whose ward is abyword.One of the unhappy results of the exaggerated

respect enjoyed by the nurse in charge is the fearwhich many junior nurses have about reporting sick.A feeling of malaise and fatigue, unaccompanied bya spectacular rise in temperature, is all too liable tobe treated as a trifling disorder, unworthy of anurse, and certainly unworthy of medical attention;yet it’is precisely these symptoms which may bethe earliest sign of tubercle. Moreover it is a short-sighted tradition, for patients no less than staff,which counts it creditable to carry on with a heavycold. The problem is- to know how the nurse incharge can be converted into someone who cares for

her staff no less diligently than for her patients.There are hospitals where the nurse who does not eather breakfast is forbidden to go on duty, and the onewho looks seedy on duty is sent off again forthwith.But this is the exceptional viewpoint and a difficultone to maintain when patients must be nursed on astarvation ration of staff, and by a team in which theraw student nurse counts as a unit and not as a super-numerary. Present standards of hospital staffing,which work everybody to capacity all the time, andmeet extra claims by achieving the impossible, needrevising before a nurse can report sick without uneasi-ness. Probably there is no simple solution. Commit-tees of junior nurses, staff nurses, and sisters, withpower to make representation to hospital boards, arelikely to infuse something of the new spirit that isneeded. Careful psychiatric selection, both of proba-tioners and sisters, would offer a second line of approach.A return of the married woman to nursing, not neces-sarily as a subordinate, but as a sister working regulardaily hours and living out, might help to ventilate thecloistered atmosphere ; and ’indeed the atmosphereitself might change if all qualified nurses had theoption of living out. Finally, there is much to besaid for a short course in staff management for allnurses who aspire to take charge of others. Then atleast those who inspire fear because they do not knowhow to inspire respect will have the opportunity todispel their ignorance.

NEUROSURGERY IN AFRICAN WARFAREINAPOLEON was lond ot saying, JJon tight your

enemy too long, he will begin to understand war."Last week at the Royal Society of Medicine BrigadierHUGH CAIRNS unfolded a remarkable story of theevolution of the neurosurgical services in response tothe -changing needs of mobile warfare. Considerablecredit for such triumphs is due to the Army medicaldirectorate for their vision and alert pliant control. Atthe beginning of this war it was realised that there wasno place for the " gipsy " specialist roaming fromhospital to hospital, and segregation of head injurieswas decided on. The neurosurgeon insisted that hewas but a poor thing unless equipped with his fullarmamentarium. He had to have a sucker, diathermyand adequate lighting, otherwise the surgery degener-ated into a higgledy-piggledy affair. Special vehiclesthus equipped were planned and constructed ; but inFrance they were captured before their worth hadbeen tested. AsCROFT,l fully equipped, was now sentto the Middle East. At first he worked in the forwardareas, but he soon found that, owing to the difficulty ofsegregating casualties in the very forward areas, only10% of those reaching him had head injuries. Itwas therefore decided to base the neurosurgical teambehind the general hospital ; this meant a delay in theprimary operation of quite 48 hours, but even so theresults appeared to make it well worth while for thepatient to wait for such special services. AmongASCROFT’S cases, the fatality-rate where the dura hadnot been pierced was 1-5% ; where the dura had beenpierced it was 15%. But a disquieting feature wasthat one out of four (75 out of 293) of the penetratingwounds developed brain abscess.With the break-through at El Alamein, the lines of

communication became so long that KENNTH EDEN,1. Ascroft, P. B. Brit. Med. J. 1941, i, 739.

706 CORONER AND DOCTOR

who was now in charge, split his neurosurgical team °

and himself went forward. To the original teamequipment he added an operating-theatre built withina captured Italian motor coach, as described in his post-humous paper on our opening page. It says much forthe general medical organisation that EDEN was ableto operate on 188 out of the 293 head injuries within 24hours of injury, and that only in 34 were the woundsmore than 3 days old. Primary healing was thusobtained in over 90 % of cases. The lowered incidenceof infection as a result of getting such cases early iswell reflected in the fall of serious complications.CAIRNS gives 3’4% as the incidence of intracranialinfection in EDEN’S cases. In AsCROFT’S " late "cases the case-mortality due to infection was 10’8% ;in the last war CuSHiN&’s case-mortality due to infec-tion was 36’5% and death was then usually due to arapid meningitis rather than to late abscess forma-tion. This lowered incidence of sepsis, CAIRNS points

out, is important not only from the point of view ofimmediate complications but because of its effect onthe subsequent development of traumatic epilepsy.ASCROFT,2 after a thorough study of Ministry ofPensions records of the last war, concluded that long-continued wound sepsis, whether the dura was pre-served or penetrated, favoured, and was closely relatedto, the onset of traumatic epilepsy. It is an importantfact, therefore, that EDEN obtained 97% primaryhealing in a series of.139 scalp wounds. EDEN foundno place for first-aid operations, but there is probablya need to sterilise such external wound surfaces early ;for CAIRNS brought bacteriological evidence to showthat in most brain wounds infection starts in the super-ficial layers of muscles and then spreads inwards.Staphylococcu8 aureus was the predominating in-

fecting organism, and sulphonamides alone will notcontrol this, though it is reasonable to give themcredit for the relative absence of streptococci. TheRussians too, CAIRNS recalled, found their brainwounds infected-only 2 out of 300 were sterile.CAIRNS and others have used penicillin in woundsover 72 hours old, and the results were encouraging.Penicillin is the most powerful bacteriostatic agent thatwe have against the infecting Staph. aureU8; very littleis required in the head cases and it is hoped that it willsoon be fully available. As FLOREY 3 has pointed out,its correct place is in the wound early, in the formof a penicillin and sulphonamide powder ; a first-aidoperation to get the penicillin into the very depths ofthe wound may become necessary. CAIRNS also

reports that, contrary to Russian experience, clinicalgas-gangrene of the brain has not been seen in theMiddle East, though clostridia had been found disport-ing on the surface.The immediate postoperative mortality in the

penetrating wounds reported by EDEN was 25 outof 102 cases ; 18 out of the 25 died within 24 hoursfrom the initial brain damage. Coma came to be

regarded as a serious prognostic sign, and it is to benoted from his<figures that of the patients who diedhalf were in coma. A third of all the head injurieshad others associated injuries, and cooperation withthe general surgeon and ophthalmic surgeon was

important. The orbital injury often had an associatedbrain lesion, and EDEN recommends suturing of the

2. Lancet, 1943, ii, 211.3. Florey, H. W. see Lancet, Nov. 20, 1943, p. 638.

lids after removal of orbital contents. In the sinusbrain injury (with, its grave risk of meningeal infec.tion) he repaired the dural defect with a free fasciagraft. This however usually necessitates an extensiveoperation, and CAIRNS reported that SCHORSTEIN (whowas attached ,to the First Army) has obtained goodresults by packing with - soft-paraffin gauze. Thedura was not closed, which is rather diflbrent from theGerman practice 4 of cutting " postage stamps "’fromthe external dural layer or turning in pericrania1 flapsto close the defect. Where the sagittal sinus had beeninjured EDEN was able to control the haemorrhage bysilk suture over muscle grafts ; CAIRNS gave the veryuseful tip of raising the head (sitting the patient up).The neurosurgeons prefer sulphadiazine by mouth orits sodium salt intravenously. EDEN regularly dustedthe brain with sulphathiazole, and CAIRNS reportsthat this was not followed by epileptiform seizures asdescribed by WATT and ALEXANDER.1i EDEN insistson full closure of the entire scalp wound, and makesuse of extensive nap-sliding incisions. His cases wereevacuated by air within 2-3 days and they all travelledwell. With the.poet the patient may well say " Nowthat the work is smoothly done, I can fly and I canrun." All men with scalp wounds were back on dutyin from 10 days to 3 weeks ; the rest of the follow-upis not yet complete, but we learn from AsoBOTT’sfigures that quite 70% of head wounds (516 cases)returned to full duty.

Will the few neurosurgeons at present available beable to deal with all the casualties expected in thefuture ? 1 The essential function of the neurospecialist,AsoROFT declares, is to deal with the difficult case.The technique of acute traumatic brain surgery iswell within the competence of the general surgeon,and it is to be regretted that it is the fashion of thehour to make a scapegoat of him: no general surgeonwould deliberately leave locks of hair, bricks and otherdebris within a wound. - Neurosurgery, however, hasdeveloped a very specialised technique, and its

thoroughness and leisureliness appear to the generalsurgeon somewhat pernickety; he does not see theneed for all the fiddle-faddle. For answer the neuro-

surgeon can point to his own results. There is onlyone way to learn this technique and that is at theoperating-table. It is to be hoped that the EMS andother Services will make such practical teachingpossible.

CORONER AND DOCTORWE published last week a summary of an authorita-

tive legal opinion on the important question of thepossible obligation of medical practitioners to reportto the coroner the death of a patient.. That doubtsshould have existed is the natural result of theincredibly untidy condition of the law, whereof anoptimistic maxim forbids us to plead ignorance. The

layers of statutes governing the recording of births,deaths and marriages go back to 1836 and have longcried aloud for simplified restatement. It is not

surprising that popular understanding should be

tempted to confuse the registrar’s duty to reportcertain deaths to the coroner with the practitioner’sduty to certify the cause of death. It is reassuringthat solid authority should confirm the statement, set4. See Cairns, H. and Guttman, E. Bull. War Med. 1943, 9,

477.5. Watt, A. C. and Alexander, G. L. Lancet, 1942, i, 493.