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Typhoid Admissions in Childhood

DISCUSSION We believe that these results are acceptable. Only two of the deaths could probably have been avoided, and it is doubtful whether referral would have prevented either of them. In Case 1 an error of judgement was made in operating on a malnourished child with scalp sepsis, omitting antibiotics and leaving the dura mater unsutured. In Case 5 the underlying bony injury was not diagnosed until too late, when referral was unlikely to have helped. The survivors included a number with severe injuries and nine with macroscopic damage to the brain at operation. We believe that a more liberal referral policy would have resulted in more deaths. At the time of this survey Chogoria hospital was situated 40 miles from a tarmac road. This made referral difficult and also meant that road accidents mostly occurred at relatively low speeds. A new tarmac road has now reached the hospital, but the nearest neurosurgeon is still three hours away in Nairobi. Although it is beyond the scope of this paper to present a systematic discussion of management and operative technique, we would like to make a few practical recommendations we think important for the inexperienced surgeon who may have to deal with a serious head injury: (1) Special head injury observation charts will already be in use in most hospitals, for frequent observations of the vital signs and pupil sizes. Try to get one nurse assigned to this patient only. (2) Most textbooks state that torn dura mater should be repaired using grafts from temporalis fascia or fascia lata if necessary. However, we found this often technically difficult. In 12 patients in our series, the dura was left unrepaired, and 11 of these recovered with no signs that could be ascribed to the unsutured dura. We therefore think that the surgeon should not feel too concerned when he decides, for whatever reason, not to repair the dura. (3) Control of bleeding is a major problem. We used bone wax for the bone edges and laid pieces of temporalis muscle on bleeding brain itself. Diathermy was not available. (4) Drilling a series of burr holes in an unconscious patient's skull is unlikely to be very harmful, whereas referring a patient far with an extradural haemorrhage will usually prove fatal. Tropical Doctor, April 1988