Develop. Mrd. Child Ncurol. 1915, 17, 5 17-526

Annotations

A DANGEROUS WAY TO TREAT SUBDURAL HA EM ATOM A APPLYING suction with a syringe and needle is a dangerous method of treating infantile subdural haematomas, yet the practice is widespread. Recently there has been renewed interest in the conservative management of infantile subdural haeniatoma, hence a renewed interest in subdural tapping. It is difficult to say who first described this condition. During the second half of the nineteenth century, adult pachymeningitis haemorrhagica interna was recognised and it was known that a similar condition occurred in infants. The first series of infantile subdural haematomas was reported by ROSENBERC in 1913l; a medical classic, one of those in which a previously unknown syndrome was fully described in the first paper written about it. In the first quarter of this century the infantile form was regarded as a variety of adult subdural haematoma and was treated in the same way, by craniotomy and removal of the clot and membranes2. Subsequently, greater conservatism in the management of adult haematomas was advocated3 when it was realised that washing out the cavity from burrholes was often all that was needed. I N G R A H A M and H E Y L ~followed , by MATSON', opposed this conservative treatment in children and continued to advocate the removal of the membranes by craniotomy, on the grounds that the membranes stopped the brain growing. In general, this approach has held sway for the last 30 years. Recently a number of people have again advocated the conservative approach for infantile subdural haematomas, using repeated subdural tapping without removal of the The advice given is that the fluid should be allowed to drip out until the pressure in the skull is atmospheric. The temptation is strong for a busy Houseman o r Registrar t o attach a syringe and speed up the process, and in fact the practice is widespread. Nowhere in the literature is the firm injunction given 'thou shalt not suck'. The benefits of a conservative approach may be lost if suction with a syringe is used. MARTIN (recording his conversion t o the practice of not sucking), with WALLACE and ROSS!' showed that when suction was used there were two possible ill-effects. Firstly, a proportion of the circulating blood volume (of the order of 7 per cent) was suddenly diverted from the systemic arterial and capillary bed to fill the venous system in the skull, passively dilated by the sudden removal of intracranial fluid. Secondly, suction could start fresh bleeding into the cavity and cause the haematonia to persist. It is common oral teaching, though rarely mentioned in the literature"', that if too much fluid is taken off the infant may die, either at the time o r subsequently, and also that aspiration by syringe should be terminated if the infant becomes pale and stops crying. The stopping of crying, and pallor, and the occasional death, are usually explained as being due to 'brain-stem shock', produced by suddenly changing the pressure on the brain. It 517

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NEUROLOGY. 1975, 17

seems likely that these events are due simply to ordinary acute hypovolemic shock from the amount of blood needed to fill the suddenly dilated vascular bed in the skull. When one considers that a quick blood-loss of 15 per cent of the blood volume in an infant may be fatal, and that many of these infants are ill and dehydrated, it is surprising that more do not die. There does not seem to be any need to invoke a mysterious ‘brain-stem shock’ as the cause of death. Blood-volume loss of the order observed would be sufficient to explain the shock and occasional death. Thus, using suction is unnecessarily risky and may well help to perpetuate the subdural haematoma. The description of the treatment as ‘aspiration’ suggests that a syringe should be used, as in aspirating a pleural effusion. Perhaps the term ‘needle drainage’ should be substituted, as it would better describe the treatment and discourage suction. GRA HAM MARTIN J . C . WALLACE JAN Ross Departments of Neurosurgery and Nuclear Medicine, Wellington Hospital, Private Bag, Wellington, New Zealand. REFERENCES 1. Rosenberg, 0. (1913) ‘Die Pachymeningitis haemorrhagica interna im Kindesalter.’ Bertiner Klinische Wochenschrift. 50,2272. 2. Putnam, T. J., Cushing, H. (1925) ‘Chronic subdural hematoma, its pathology, its relation to pachymeningitis hemorrhagica and its surgical treatment.’ Archives of Surgery, 11, 329. 3. Horrax, G., Poppen, J. L. (1937) ‘The frequency, recognition and treatment of chronic subdural haematomas.’ New England Journal of Medicine, 216, 381. 4. Ingraham, F. D., Heyl, H. L. (1939) ‘Subdural hematoma in infancy and childhood.’ Journal of the American Medical Association, 112, 198. 5 . Matson, D. D. (1969) Neurosurgery of Infancy and Childhood. Springfield, Ill.: Charles C Thomas. 6. Rabe, E. F., Flynn, R. E., Dodge, P. R. (1968) ‘Subdural collections of fluid in infants and children.’ Neurology, 18, 559. 7. Yashon, D., Jane, J. A., White, R. J., Sugar, 0.(1968) ‘Traumatic subdural haematoma of infancy: long-term follow up of 92 patients.’ Archives of Neurology, 18, 370. 8. McLaurin, R. L., Isaacs, E., Lewis, H. P. (1971) ‘Results of non-operative treatment of 15 cases of infantile subdural haematoma.’ Journal qf Neurosurgery, 34, 753. 9. Martin, G. T., Wallace, J. C., Ross, I. (1975) To be published. 10. Guthkelch, A. N. (1953) ‘Subdural effusions in infancy.’ British Medical Journal, 1, 233.

TEACHING MEDICAL STUDENTS ABOUT EPILEPSY To increase the general public understanding of epilepsy, the International Epilepsy Bureau makes instructional tours around the world. But how far is comparable progress being made in the education of medical students? After all, epilepsy is a powerful example of the inter-relation of physiological, behavioural and socio-cultural issues. Because of lack of competence and confidence, epilepsy creates feelings of unease in many general practitioners, school doctors and paediatricians. Hospital notes contain entries such as ‘known epileptic’ from which large implications about behaviour are thought to follow automatically and reference is still being made, even in psychiatric circles, to ‘the epileptic personality’. The experience of the Special Centres for Epilepsy has suggested that virtually every section of the medical fraternity needs help and advice concerning seizure disorders. That this applies no less to recently graduated doctors implies a deficiency in current medical education. Epilepsy has many sides. It is, of course, inaccurate to refer to ‘epilepsy’ as if it were a disease entity in its own right. I t is a symptom of diverse aetiology often associated with a 518

A dangerous way to treat subdural haematoma.

Develop. Mrd. Child Ncurol. 1915, 17, 5 17-526 Annotations A DANGEROUS WAY TO TREAT SUBDURAL HA EM ATOM A APPLYING suction with a syringe and needle...
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