Medicine: Head Wounds

During two years of fighting in the Middle East, Major Peter Byers Ascroft, a surgeon with the Eighth Army, and his Scottish surgical unit handled 516 head-wound cases. Last summer Major Ascroft summarized the clinical results of this experience in the British medical journal, The Lancet. Last week the New England Journal of Medicine declared Major Ascroft’s article required reading for every U.S. military and civilian surgeon. Reasons: 1) “the conclusions differ so fundamentally from those previously authorized for publication by the [U.S.] War Department, which were largely reached shortly after World War I”; 2) the article settles a long debate among surgeons about when & how to deal with compound skull fractures.

Most important point in Major Ascroft’s paper: “We believe it is better not to operate in forward areas [on patients with head wounds], provided that the patient can reach a fully equipped base hospital within 48 to 72 hours of injury.” This agrees with the late, great Dr. Harvey Cushing’s World War I finding that “incomplete operations were more dangerous than a few more hours of delay.” But Major Ascroft points out that “in this war most casualties have not reached a base hospital under 48 hours or more.”

Major Ascroft’s chief reason for operating at a base hospital: there the surgeon can use 1) the X-ray (which is not always available in forward zones); 2) a suction apparatus to remove injured brain tissues and debris and an electric cautery to stop bleeding. Neither device is obtainable near a swiftly moving front.

Wide-Open Wounds. Major Ascroft finds only three valid reasons for treating head-wound cases at the front: 1) severe shock (but “shock is seldom severe in head wounds”), which makes it impossible to move a patient at once; 2) need for immediate surgery to relieve pressure on the brain; 3) no possibility of reaching a base hospital in 72 hours. For such cases he recommends “an operation of expedience”—a cleanup after which the wound is left wide-open, protected only by a plaster-of-paris bandage. A diagram of the wound may be drawn on the bandage to guide the base-hospital surgeon who completes the operation.

Other Ascroft ideas:

> “Local anesthesia can be used less often than might be expected; many patients are too restless, while others have wounds elsewhere unsuitable for local anesthesia.” The alternative is sodium pentothal by vein.

> Whenever an X-ray plate or the bone itself shows any sign of damage to the skull’s outer shell, a small, exploratory burr hole should be made at that spot. Reason: a blow which causes a slight bruise on the skull’s outer shell often causes a serious fracture of the inner shell. In one case, where only a threadlike crack showed on the surface, a bit of the skull’s inner shell had been driven almost an inch into the brain.

Major Ascroft’s statistics set a new record for successful treatment of head wounds, prove that few cases are hopeless. He reduced mortality in scalp wounds to zero. Only one out of 85 scalp-wound cases failed to return to duty. Of 139 skull fractures with the brain covering in tact, two died, 130 returned to duty. Of 292 whose brains were penetrated, 44 died — mortality 15%, compared with Cushing’s 28% (before Gushing, mortality from such wounds was 60%) — and 124 returned to duty.