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.

707CHEMOTHERAPY IN ACUTE OSTEOMYELITIS

out in 1927- in the v’onduct of Medical Practice, thatneither under the act of 1926 nor any other act isthere any legal obligation upon the medical man toinform the coroner. The earliest operative words inthe Coroners Act of 1887 are " When a coroner isinformed " ; the coroner is not put upon inquiryuntil he is informed of the death. The existence ofa legal duty may be tested by the evidence of itsenforcement. Isthore any precedent for the prosecu-tion of a practitioner for the supposed common-lawmisdemeanour of failing to report a death to thecoroner ? 1Deaths in certain particular circumstances-e.g., in

prisons, asylums or inebriate homes-cast a specialstatutory duty upon persons in charge. Otherwiseit is clear that Parliament deliberately made notifica’-tion the responsibility of the registrars of deaths. Asis well known, the registration regulations of 1927require the registrar to tell the coroner of the followingdeaths before registering them : those where thedeceased was not attended by a registered medicalpractitioner during his last illness or where a dulycompleted medical certificate in the prescribed formis not forthcoming ; those reasonably believed to beunnatural or due to accident, violence or neglect, orattended by suspicious circumstances, or due to somecause apparently unknown ; those due to abortionand certain specified diseases, particularly variousforms of poisoning ; those occurring after " an opera-tion necessitated by injury or occurring under anoperation or before recovering from the effects of theanaesthetic " ; those where the deceased was appar-ently not seen by the certifying doctor either afterdeath or within 14 days beforehand ; and lastly thosealleged stillbirths where there is reason to think thechild was born alive. Notification of the coronerin these instances does not, of course, mean that aninquest will inevitably follow.

Coroner and practitioner alike desire that allnecessary inquiries should be undertaken and com-pleted with the least possible discomfort to thepublic. The coroner may request, though he cannotrequire, that certain deaths (for example, those

taking place in hospital within 24 hours of admis-sion or within 24 hours of administration of anansesthetic) be reported to him by the medicalauthorities ; but he generally does this because he isaware that it is the relatives who suffer by uncertaintyand delay. Prompt reports from hospitals may spareanxiety to the family of the deceased; the relativesare occasionally pained by the coroner’s interruptionof their arrangements for the funeral. As was wellstated in the letter published last week, medicalpractitioners .(like other members of the community),have social, public and moral duties, not enforceableby law, to assist the coroner. * In the past they havecollaborated harmoniously for the public good. The

very existence of the uncertainty lately emphasised isremarkable evidence of the reasonable spirit mutuallydisplayed between the medical profession and thatancient office of coroner which the profession at largehas as little desire as the rest of the community to see,abolished.

Mr. BASIL GRAVES will talk on the cult of the eye andthe quest of reality at the Royal Eye Hospital ClinicalSociety on Friday, Dec. 17, at 4.30 PM.

Annotations

CHEMOTHERAPY IN ACUTE OSTEOMYELITISSiNCE sulphathiazole was introduced there have been

a good many isolated case-records of acute haemato-genous osteomyelitis treated with this drug, but untilrecently no adequate series has been published. Toassess the effects of chemotherapy in osteomyelitis isdifficult because there are generally two separate con-ditions to be considered-the staphylococcal septic-semia and the bony lesion. A drug may affect the oneand not the other. Butler,t reviewing 500 cases un-treated by chemotherapy, found a mortality of 25%.The cause of death was always staphylococcal septic-semia and the death-rate was uninfluenced by the typeof operation ; but of 31 cases in which no operation wasperformed, because the patient was considered too illfor it, 26 were fatal. To lower the mortality of thisdisease sulphathiazole must be able to deal with a severeblood infection. The severity of the infection, and theprognosis, can be judged on. the results of repeatedquantitative blood-cultures: Valentine and Butler 2

showed that of 17 patients whose colony counts rose toover 30 per c.cm. of blood only 3 lived; 5 of the 17received sulphathiazole, but all died save one. Of12 patients whose colony counts were under 20, all but2 recovered, though only 2 had sulphathiazole. Similarfigures are given by McLellan and Goldbloom.3

Robertson 4 now records 89 cases of acute hsemato-genous osteomyelitis with only 4 deaths. Blood-cultureestimations are not given, so it is impossible to assess theseverity of the infections, but the series provides one ofthe lowest death-rates yet recorded for the disease.Robertson believes that operation is hardly ever requiredand supports this claim with an account of 25 casestreated with sulphathiazole alone, despite the fact thatsome of them developed sinuses. He does not approveof immobilisation and uses no splinting of any kind saveextension where the joint is infected. In his experiencesulphathiazole given early in the disease and in adequatedosage (8-10 grammes daily) not only lowers the mor-tality, but also limits the bone infection. McKeown,5who has concentrated on the effects of sulphathiazoleon the bone’lesion, found in a small series of 25 cases thatthe best results came from adequate chemotherapyreinforced by drilling the infected bone. He maintainsthat with this treatment he was able to out short theillness and to get a better final result than with casesuntreated by chemotherapy. Like Robertson, he em-phasises the necessity for using sulphathiazole soon.

If it is given when infection is well established in thebone no clinical improvement can be expected.

DETENTION BARRACKSAFTER the trial of two warrant officers for the man-

slaughter of Rifleman Clayton, the Prime Ministerappointed Mr. Justice Oliver, the Bishop of Readingand Lord Moran, rBCP, to inquire into the treatmentof men under sentence in naval and military prisonsand detention barracks. The committee, on whichDr. H. E. A. Boldero served instead of Lord Moran,have issued a frank and useful report which admits-deficiencies, especially earlier in the war, but expressesthe opinion that men in detention are not now exposedto calculated brutality. A certain amount of shouting," chasing," and bad language is still encountered, andthe committee discuss the awkward problem of findingthe right kind of staff. The present medical arrange-ments on the whole impressed them very favourably.In some places separate accommodation for the mildly1. Butler, E. C. B. Brit. J. Surg. 1940, 28, 261.2. Butler, E. C. B. and Valentine, F. C. O. Lancet, 1943, i. 194.3. McLellan, N. W. and Goldbloom, A. Canad. med. Ass. J. 1942,

146, 136. 4. Robertson, D. E. Ann. Surg. 1943, 118, 318.5. McKeown, K. C. Brit. J. Surg. 1943, 31, 13.