Postgrad. med. J. (September 1967) 43, 574-581.

Head injuries today

JOHN M. POTTERM.A.(Cantab.), D.M.(Oxon.), F.R.C.S.

Consultant Neurosurgeon, United Oxford Hospitals

IT is interesting that recent advances in themanagement of head injuries - the essentiallypractical aspect of the subject - have come ratherfrom a re-orientation and re-emphasis of existingknowledge than from much direct application ofthe fruits of basic research. Nevertheless, a greatdeal of experimental work on fundamental prob-lems is being pursued, particularly in the U.S.A.where, for example, large sums of money andtechnical resources support efforts to elucidatethe mechanism of concussion and problems con-nected with the physical protection of the headsof motorists and aviators, and where a vastresearch programme in connection with the ex-ploration of space has enabled American scientiststo overcome many difficulties that arise when manis subjected to great acceleratory forces. A rep-representative picture of much recent Americanresearch can be found in Head Injury ConferenceProceedings (Caveness & Walker, 1966).

In Britain, however, the work being done ismore appropriate to this country's incomparablysmaller budget for this sort of activity, and itsemphasis has been more on attempts to try toimprove, on a wider basis of applied knowledgethan hitherto, the standards of service and treat-ment for patients sustaining head injury, for itis certain that there is still much room forimprovement. In this, as in many fields of medi-cine where new techniques, drugs and other ad-vances arrive at bewildering speed, there is acorrespondingly urgent need for their evaluationand consolidation at regular intervals, for thegap between discovery and full application appearsto be widening. What is new can be overlookedwhile, even during our preoccupation with whatis newer still, we are being jostled by the newestof all.

Historical perspectiveIn order to appreciate better today's situation,

it may be helpful to consider briefly what hashappened in the past, for the basic causes ofhead injury have not changed greatly throughoutthe ages. Of these, personal violence is presum-ably the oldest, some form of warrior's protective

helmet having been in use for approximately3000 years. The head injuries of modern warfareare mostly caused by high-velocity missile frag-ments and, being compound, they almost in-variably require surgical attention against infec-tion. (In contrast, the head injuries of peacetimeare commonly blunt and closed and, apart fromthe suture of scalp lacerations, demand surgeryonly if there is a complication, such as intra-cranial haemorrhage.) Besides premeditatedassault, personal violence can, of course, causeunintentional head injury during competitivegames, and the distinction between these twocircumstances is blurred nowadays only in respectof boxing. In this sport, the intention appears tobe to damage the brain only enough to producewhat is called in the ring a 'knock out', but theresult may be clinically indistinguishable fromcerebral concussion and sometimes, as seen occa-sionally at autopsy, from cerebral laceration orintracranial haemorrhage. Two hundred years agothere were other hazards of this kind, and thesewere even more serious because of the muchgreater liability to, and the danger from, infectivecomplications of injury.Man's desire to get about faster than his two

legs can carry him has always been a prominentcause of head injuries: the horse, the chariot andthe carriage were merely the slower and lessnumerous predecessors of the motorcycle, themotorized bicycle and scooter and the automobileitself, but, unlike its formidable mechanical suc-cessors, the horse also kicked and threw its riders- and, indeed on occasions, still takes this activepart in the production of quite unpleasant headinjuries.

Alcohol has over the centuries never been farfrom the head-injury scene, acting as an incite-ment to personal violence and as a factor exposingpoor horsemanship and driving, by augmentingany natural or latent tendency to aggression, torashness and foolhardiness; and also by the wayin which it facilitates falls through impairmentof mental judgement and locomotion. A Limericksurgeon, Sylvester O'Halloran, writing at the endof the eighteenth century, when cheap spirits,

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recently abolished in England, continued as theresult of Irish revenue policy, observed that, 'fairs,patrons and public meetings begin with festivityand end with broken skulls'; and, 'I have hadno less than four fractured skulls to trepan on aMay morning' (Lyons, 1959).

Falls from heights comprise another age-oldcause of injury to the head, but it is important torealize that when walking or standing, healthyadults only rarely fall with sufficient clumsinessto cause significant injury to the head, and thatwhen, for example, one is told that a young man'just fell down', it will often be found that hewas either intoxicated with alcohol at the time,or subject to some form of epilepsy-the 'fallingsickness' of our ancestors. In the very young andvery old, however, this is, of course, not neces-sarily so: gait may be ataxic and the posturalreflexes inefficient.Nowadays, the causes of head injury vary

somewhat in their proportions in different hos-pitals. In the wilder, heavily populated parts ofour cities, where life itself is faster and looserthan the vehicle traffic, more injuries due toassault are seen than one would expect to find inhospitals situated near the main highways, towhich the more familiar toll of the roads isbrought. Elsewhere, one may see a higher propor-tion of industrial or mining injuries, and indifferent parts of the world there are injuriespeculiar to the locality.

But the present-day problem is, of course,largely that of road-traffic accidents, which mightperhaps be regarded as the latest manifestationof natural selection at work. And in even thisbrief phase of evolution, the situation can be seen

TABLE 1

Oxford road accidents (head injuries) in 1954 and 1964

Lewin (1954) Potter (1964)(each series from 1000

consecutive head injuries)

Car 125 322Motor cycle (and scooter) 224 142Pedal cycle 233 113Total vehicle accidents 582 577Pedestrians 163 98Total road accidents 745 675

to be changing all the time: Table I shows com-parable figures from the Radcliffe Infirmary, Ox-ford: those compiled in 1954 by Lewin and thoseby the author 10 years later, in 1964. Approxi-mately 70%/,, of head injuries at this hospital arefrom road accidents. In 60-70% of fatal road

accidents there are head injuries (Gissane, 1963;Lewin, 1964; London, 1964) and from Lewin's(1964) estimates we have some idea of the size ofthe problem posed by head injuries of all kindsthroughout the country. Approximately 100,000are admitted to hospitals yearly; at least another100,000 treated in casualty departments and senthome; and others are dealt with by generalpractitioners, factory nurses, etc. Two hundredand fifty thousand is perhaps too conservativea grand total, which is one person in 200 per yearneeding some treatment for a head injury of somekind. The vast majority of these will be mild,even trivial, and uncomplicated, but-and it isthis that will always invest the subject with anaura of unease-even what is apparently a verytrivial head injury, without necessarily any sig-nificant brain damage, may on rare occasions becomplicated by some alarming turn of eventsleading to death. Intracranial haemorrhage mayresult from a torn blood vessel; meningitis canfollow a little tear of the meninges from thesharp splintering of the fractured inner wall ofone of the air sinuses; and severe epileptic fits,even status epilepticus, may on rare occasionsbe the reaction, to even the mildest trauma, of abrain which is probably predisposed in this way.These are the cases that tend to get the headlinesin the newspapers; but for every one of thesefortunately rare events, numerous mild head in-juries expose a great many people to disability,both mental and physical; to anxiety and frankneurosis, and this situation can be mitigated oreven prevented by judicious management. In asense, therefore, the minor head injuries are moreimportant than the severe ones, in that they aremuch more numerous and that there is greaterscope for effective treatment. The problem of the'vegetable', the severely brain-damaged and dis-abled person, can easily be exaggerated; thesepatients are obtrusive and stay around in hospitals,perhaps for months, to reproach us, either forhaving saved them for such mere survival or fornot having been able to do more to help them.But the great majority of those who survive braininjuries make reasonable recoveries, so that asense of proportion must be kept.Advances in the treatment of head injuries may

be regarded as having come about in three mainphases of medical history. First, surgeons openedthe skull to evacuate complicating collections ofblood or pus in order to prevent death fromcerebral compression. The Arab surgeons wereat least attempting to do this centuries ago, butrecorded successes from such intervention appearto have been few until Pott (1790) and his Frenchpredecessors 200 years ago started the wave of

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John M. Potter

skull trephining that has fluctuated in intensityright up to the present time. The greatly increasedaccuracy of clinical, particularly neurologicallocalization during the past 100 years and, muchmore recently, radiological aids have better enabledsurgeons to know where to operate on the head,although the answer to the question when? remainsless clearly defined except in the face of theclassical syndrome of extradural haemorrhagefollowing a 'lucid interval'.

Moreover, greatly improved surgical and anaes-thetic techniques have in recent years resulted inthe actual operations themselves carrying littlerisk. This has been particularly so since, in thesecond phase, there has been the overcoming ofthe complication of intracranial sepsis as a causeof death. As for the present-day treatment ofcompound wounds of the skull and brain, it isinteresting that the actual surgical technique usedis one which could have been practised centuriesago: that of early and thorough excision of con-taminated tissue and careful closure of the woundwhich is a much more important prophylaxisagainst infection than any supporting antibioticadministration, whatever may be the colours ofits spectrum. Nor should the same care beneglected in the case of simple scalp wounds,from which the occasional spread of infectionintracranially may still cause death. Even shouldinfection become established, it is now usuallypossible to combat it with appropriate systemicand/or intrathecal antibiotic therapy, togetherwith the still useful but half-forgotten drug, sul-phadiazine, which, alone among the few sulpho-namides remaining in use, enters the cerebrospinalfluid in sufficiently high concentrations after ad-ministration by mouth.

So, with infection largely preventable, and withthe means to relieve the relatively uncommoncomplication of clot-compression of the brain,we are left with some other causes of death anddisability, and it has been the fuller recognitionof these factors and the understanding of howthey operate and by what means they can be pre-vented that constitute the third and latest phaseof advance in treatment. This has been facilitatedby the removal of the mystique of undue neuro-logical emphasis which had made the subjectseem difficult for the non-specialist; by concen-trating more on the whole patient than on hishead and brain; and by distinguishing essentialpractical techniques from the sophistications ofspecialist neurosurgical practice (Potter, 1963a).In short, the aim has been Head Injuries forEveryman, who has to deal with most of them,rather than for the few on the touchlines.

TodayPrevention

Careful analysis of the different types of headinjury and their causation, and research into theirmechanisms, are essential if effective preventivemeasures are to be devised; but intense propa-ganda appears then to be necessary before thepublic will avail themselves of such protection.One need mention only the slow acceptance ofsafety helmets and seat-belts in cars to illustratethis, although accident-prevention in the homeand in factories and the part played by alcoholare gradually being forced on the attention andthe conscience of the public. Moreover, the obtru-sion of more and more disabled persons, salvagedbecause of more efficient treatment, is bringinghome the truth that a major head injury can bea disaster not only to the victim but also to hisfamily and dependents, as well as being a heavycharge on the community and its overstrainedhospital services.That the epidemiological situation is changing

all the time was seen in Table 1, and the researchto make available these sorts of figures must goon continually if preventive measures and theplanning of accident services (which take a longtime to implement) are to be appropriate ratherthan obsolescent.Principles of treatmentAn injury to the brain causes damage that is

irreparable in the sense that, so far as is known,there is no regeneration of neurones of the centralnervous system. However, the recovery of functionthrough neurones that have survived can be sur-prising, and, because we have as yet no methodof determining early the quantity of this potentialfor recovery in an individual case, the manage-ment should normally be based on the expectationof recovery and the patients' relatives never leftbereft of hope, however guarded a prognosis isentertained. Treatment is prophylactic againstcomplications and definitive.

Prophylactic treatment. It follows from thisthat, if the injured brain is to be given the bestchance to recover the most function, it shouldbe jealously guarded against further damage thatmay threaten it continuously for some time afterthe actual head injury. Apart from intracranialhaemorrhage, infection and seizures, the durationof this danger from complications depends mostlyon the severity of the injury and therefore onthe duration of the ensuing coma. This guardingagainst the now well-recognized complications ofunconsciousness is part of the prophylactic treat-ment that has resulted from the third phase inthe advance of head-injury treatment alreadymentioned.

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This has really come about in the last 15 yearsor so through the realization that the commonestmechanism of death in those who survive aninitial severe trauma to the brain is through somekind of respiratory insufficiency - often frankasphyxia which stops the heart. The term 'cardiacarrest' has unfortunately become a cliche-as ifit were a condition sui generis-which is a pitybecause this may preclude thought as to how thearrest occurred and, more important, in whatway it could have been prevented. In these patients,unconscious from a head injury, it can be pre-vented very simply-by ensuring adequate pul-monary ventilation through a free airway. Thisis really the first and most urgent thing to ensureafter a head injury has occurred. For, althoughan episode of airway obstruction or apnoea mayhave been insufficient to stop the heart, a periodof hypoxia may have been sufficient in itself todamage the brain, which of all organs has a highdemand for oxygen and which, it should be re-membered, has already been damaged by theinjury.When a road accident throws a man out of his

car or off his motorcycle on to the road, uncon-scious, chance determines whether he ends up onhis back or in a prone position. Even if he hasbeen only midly concussed, it is quite possiblethat his return of consciousness will be usheredin by vomiting and, if he is on his back, andparticularly if his stomach is full of food anddrink (and statistics tell us that it is likely to be)then he may drown even before the ambulancearrives. Moreover, provided a person has hadenough alcohol to drink, he does not even needto have had a head injury in order to die in thisway-by drowning in his own vomit.

Fig. 1 shows one of the most important methodsof treatment of head injuries-the almost-proneposition for all patients who are unconscious andwhose cough and swallowing reflexes are at alldepressed; for those who have complicated jawfractures or much bleeding in the mouth or

FIG. 1. The almost-prone position.

nasopharynx. The prone, semiprone, three-quarterprone, tonsil position, coma position or the almost-prone position-it matters not what it is called-some form of prone position will diminish therisk of inhaled vomit and blood. The offputtingthing about this position is that it does not allowproper examination of the patient, but this canwait until he gets to hospital, where nowadaysa cuffed endotracheal tube is usually passed as atemporary safeguard, if this should still be neces-sary.

All this is of fundamental importance, and itwas a mistake of the past to pay overmuch atten-tion to the injured part, the head, and too littleto the patient whose respiratory function dependson his brain function and whose brain functionis very much dependent on adequately oxygenatedblood. Twenty-five years ago, stertorous respira-tion was to most people just stertorous respira-tion: a sign of deep coma or of a deep plane ofanaesthesia. Now it is an alarming sign and oneto be remedied immediately, for it means simplythat the airway is obstructed.The danger here is of further brain damage

from hypoxic hypoxia and Table 2 shows thevarious ways in which this can occur and howit can be prevented and overcome. The additionof an injury to the chest, interfering with therespiratory mechanism peripherally, makes thesituation very much worse, and the combinationof a chest injury and a head injury used always tocarry a very grave prognosis, but now there aregrounds for believing that this no longer needbe so. And it should be remembered also thatin surgical shock, in loss of blood and in anaemia,there can also be hypoxia: the blood circulationmay be too sluggish to bring enough oxygenatedblood to the brain cells (stagnant hypoxia), andthere may not be enough red cells to carry suffi-cient oxygen (anaemic hypoxia). Therefore, theroutine treatment of shock by blood replacementis as relevant to the treatment of the head injuryas to the patient as a whole-indeed, it may beliterally vital.There are three other ways in which patients

used to die, but now do so only occasionally;although any of these factors that are being men-tioned may contribute or combine to cause thedeath of someone who is capable of recovery.

Bedsores can now usually be prevented bygood practical nursing: regular turning and atten-tion to the skin over pressure points. There is sofar no substitute for the hard work that thisentails; mechanical beds and mattresses are notreally enough-yet.

Dehydration used to occur before enough wasknown about water and salt metabolism and

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TABLE 2

Hypoxic hypoxia('Anoxaemia not only stops the machine, but wrecks the machinery')

Chance determines whether someone rendered Correct posturing later should always ensureunconscious by a head injury is thrown on to his that the risk of inhalation complications is reduc-back or face downwards ed to a minimum

What may be inhaled? Effects Prevention

Vomitus (gastric juice irritates; Hypoxia Correct posturingsolid food may obstruct) from Suction

Collapse of the lung (Avoid morphine which mayPneumonic consolidation aggravate anoxia)

Drinks (unwisely given) 1. Chemical (gastric juice) Treatment2. Bacterial Correct posturing

Blood Pulmonary oedema SuctionThe injured brain may thus Frequent turning from side to side

Saliva and other secretions suffer further damage PhysiotherapyIn severe cases Endotracheal tube, tracheostomy

Cerebrospinal fluid Asphyxia and cardiac arrest oxygen, assisted respirationmay occur Antibiotics and chemotherapy

when prolonged dehydrating measures werefashionable to try to remove water from a brainthat was often never really waterlogged, a prac-tice that probably contributed to many deaths.Now, adequate fluid balance is the aim, and ifthis is done, even with simple intelligent empiri-cism, it is very uncommon for serious metabolicdisturbance to occur.Hyperpyrexia occasionally follows a head in-

jury where there has been derangement of thethermostatic mechanism, and very high bodytemperatures may occur. It is known that thebrain is particularly sensitive to high temperatures,and it is therefore considered important to tryto prevent possible further brain damage fromthis cause. The body temperature is kept usuallybelow 101°F (38-5'C) but it is, of course, alwaysimportant to be sure that the fever that one issuppressing is not the natural and perhaps bene-ficial response to an infection of some kind. Diag-nosis is more important than treatment, in thatit has to come first. This lowering or preventionof an unusually high fever should not be confusedwith the purposeful lowering of body temperaturebelow normal, 'artificial hypothermia', which doesnot seem quite to have fulfilled its early promise-at least as an important method of treatment.The foregoing account has perhaps given some

idea how the understanding of the mechanismsof death and disability following a head injuryhas increased and how this new orientation ofour knowledge has led to active and at timesvigorous prophylactic measures being taken toprevent all these complications, particularly therespiratory ones occurring in the unconsciouspatient. Indeed, although the emphasis in this

paper is on the conservative management ofhead injuries, on the things that any doctor cando about them, it should be stressed that the term'conservative treatment' is very much more thana euphemism for just doing nothing.

Observation as prophylactic treatment. Theplace of the present-day practice of intensiveobservation in the care of a patient who has hada head injury is best illustrated in the contextof the complication of middle meningeal (extra-dural) haemorrhage-the 'thief in the night'. Itwill be recalled that the surgical prevention ofdeath from cerebral compression was the first ofthe three phases of effective treatment of headinjuries. The opzrative steps to be takeni will notbe recounted here, because the essentials of thetechnique at present in use have been known andwell described in surgical textbooks for at least100 years and can be found in them today (e.g.Lewin, 1966; Potter, 1964). During the past cen-tury, therefore, it has been theoretically possibleto save the life of everyone developing this com-plication after an injury which did not also causeserious brain damage. Yet, the general mortalityfrom this complication probably remains at about50%, owing chiefly to the operation being per-formed too late or not at all. There are severalreasons for this state of affairs and, if these arerecognized, it can be readily seen how the mortalityrate could be reduced very considerably, as ithas been in some hospitals where attitude andorganization are more important than specializedtechniques or facilities.

First, there is the failure to heed the warningof Hippocrates that no head injury should beregarded lightly. His lesson is one of the many in

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medicine that have to be learnt and relearnt overand over again, often from bitter personal ex-perience which, as best defined by Oscar Wilde(1893), is 'the name everyone gives to their mis-takes'. If, as it is sometimes said, the scientificmethod must always be the basis of medical prac-tice, then every medical man would have to seea death following a mild head injury before satis-fying himself that what Hippocrates said wastrue. There is still a small place for dogma.So commonly, the possibility of extradural

haemorrhage, complicating what appears to be amild concussion from a bump on the temple, isjust not considered, and by the time it is, eventshave often moved rapidly-too rapidly. A childmust be got to hospital, and if he is still alivewhen he gets there, there must be someone whocan operate on him immediately (which often thereis not), and there must be the tools for the job(which often there are not). Patients with headinjuries are still taken to hospitals where thereare no proper facilities for this type of case,sometimes because the ambulance men are toldto go to the nearest hospital regardless whetherit is an appropriate one-and the coroner mayeven have something harsh to say if they do not.So the first thing that can be done is to have

as many of these patients as possible admitted toa hospital where the complication can, first, beanticipated; second, spotted early when it isoccurring, so that, thirdly, the cerebral compres-sion can be relieved before it is irreparable.Obviously, every case of trivial head injury can-not be admitted-the line has to be drawn some-where. As a ready rule, it is advisable to admit,for at least the first night (the most- dangeroustime for this complication):

(1) All who have been concussed; that is tosay, those who have any traumatic amnesia.

(2) All with skull fracture.(3) All children brought to hospital (the

seriousness of their injury can often be difficultto assess).

(4) All others who cause anxiety on accountof undue headache, vomiting or other unduesymptoms which might be referable to the headinjury.Some hospitals may say that all this just

cannot be done, and this may be so; but if it isnot done, the mortality from this complication willcontinue to be higher than it need be. Once inhospital, after X-rays of the skull have been takenand the wound dealt with, intensive observationis instituted, and this is designed to detect com-plications as early as possible. This is activeprophylactic management and is another exampleof the new type of conservative treatment that

has replaced an older one of mere laissez-faire.This intensive observation is carried out by

the nurses who note at i-hourly- intervals, ormore frequently if necessary, the level of res-ponsiveness; the pupils; the pulse rate, systolicblood-pressure and the respiration rate and tem-perature. These observations are recorded on thetype of chart shown in Fig. 2. If this is done care-fully, and with a knowledge of what is beinglooked for, an extradural haemorrhage is likelyto be detected in plenty of time. The chief signsof this are a progressive lowering of the level ofresponsiveness, a progressively dilating pupil onthe side of the clot, a progressively slowing ofthe pulse and perhaps of the respirations, and arising systolic blood-pressure. Not all these signsare usually present: there is nearly always somecombination of them which makes the diagnosispretty clear, but the examination must have beenrepeated again and again.

If the patient is already unconscious, the nursesshould be carrying out other forms of activetreatment to prevent the complications which havebeen mentioned earlier: keeping the- airway clearby suction, turning the patient from side to side,preserving the skin and, later, feeding the patientby tube and checking the body's fluid balance-active, but conservative treatment.

Definitive treatment. It is believed that thereis also a more positive benefit in admitting thesepatients with mild head injuries to hospital. Thereis still a good deal of anxiety and often barelyconcealed superstition about head injuries, and ifthese patients and their relatives are left to fendfor themselves, they will often act inappropriately.Residual headache is fairly common and somepatients will stay much too long in bed on accountof this, while others will try to shake it off bygetting up too early and hurrying back to work,only to relapse later for a longer period of dis-ability than need have occurred. An anxiety stateor frank neurosis may even supervene, and it maybe difficult to decide whether there is anythingseriously the matter or not. There seems littledoubt that neurotic sequelae are very much lesslikely to occur in patients who have been admittedto hospital right from the start. These patients areusually impressed that their injury has been takenseriously, and they are reassured when they havebeen gradually sat up and got out of bed beforebeing sent home, after being told that all is welland that within a week or two they should beable to get back to work. They are warned notto be surprised if they have some headache for alittle while, and the relatives are told to encouragea gradual return to normal activities and not tofuss the patient or put him back to bed at home.

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Name _ Age Date of admisson _Level ofconsciousness Pupils Temp. Resp. B.P Pulse

(and other observations:e.g.fits, (equality and reactions) Isystolicincontinence,vomiting, etc.)

1' i I

FIG. 2. Head injury observation chart.

In doubtful cases, it is a good practice to see thepatient again in a week or so to make sure thatall is well and to give further reassurance.In addition to this active and necessary psycho-

logical treatment, other forms of definitive treat-ment may be required: scalp wounds must beproperly excised and sutured and contaminatedtissue removed from all layers of a compounddepressed fracture before the scalp is carefullyclosed. Details of the appropriate surgical tech-niques can be found in the books already referredto, and these contain also accounts of the treat-ment of meningitis and epileptic seizures whichcan be carried out by any doctor.

Organization for the treatment of head injuiMes(Potter, 1965a)

If approximately one in every 200 of us peryear must expect to have some sort of a headinjury, we may wonder when this is going tohappen, and where we are likely to be taken ifwe are involved in a road accident, say on ourholidays, and who will be there to look after us.

The chances are that we will be seen first by acasualty officer from one of the commonwealthcountries, and if it were not for the presence ofthese doctors and compulsory for candidates forthe FR.C.S. to undertake a period of casualtywork, it might be difficult to get casualty officersat all. For, apart from this being very hard, exact-ing and responsible work that goes on round theclock, it is a fact that accident surgery, an obviousand topical specialty directed at the great epidemicof our age, is not officially a specialty at all andnormally offers no career unless achieved throughan orthopaedic training and practised in nearlyall cases in conjunction with orthopaedic surgery.This would be appropriate if accidents consistedsolely of fractures and dislocations, but there arealso numerous head injuries, severe and lethalchest injuries, injuries to the abdomen and com-plicated combined injuries which call for morethan the skills of one specialty. The newlyappointed orthopaedic surgeon certainly hasspecialist knowledge of fractures, but his specialexperience of other types of trauma will vary very

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much indeed according to where he has beentrained or how much enterprise he himself hasshown in choosing his training programme.

Ninety per cent of cases of head injury in thiscountry are cared for by general or orthopaedicsurgeons, and only about 10% by neurosurgeons.In at least one hospital, anaesthetists have the mainresponsibility for these injuries; and in one teach-ing hospital, cases of head injury enter a medicalward under the care of the physician on duty. Itis not, however, necessary-nor is it ever likely tobe possible-to have neurosurgeons with theirexpensive and specialized facilities at every 'acute'hospital to deal with all the head injuries, oreven the majority of them. It will have beenseen from what has been said already that good,active conservative management, which is all thatit required for the vast majority of cases, canbe perfectly well carried out by any good doctorwho is prepared to apply certain general principlesrather than to try to learn complicated specialtechniques. There are neurosurgical units fairlywell placed throughout the country in relationto the chief population needs (though generallynot near the main roads), and most of them giveat least some sort of advisory service by telephone,although the amount of practical help that theyare able to give varies considerably.

This appears to be a situation where specializa-tion has gone awry, and it is probably everybody'sfault that this has been allowed to happen. Whenthe general surgeons handed over the fracturesto orthopaedic surgeons, this did not make ortho-paedic surgeons into accident surgeons; and thewhole trauma-baby has in most places now beenlet out with the fracture bath-water, so thatgeneral surgeons deal only with those injuriesrelated to what is really their specialty, abdominalsurgery. Nor is it easy for general or orthopaedicsurgeons during their training to get the right sortof experience of head injuries, even if they takean appointment in a neurosurgical unit, becausemost of these units admit only relatively few,highly selected and complicated cases of headinjury at second-hand-often the kind of cases infact that the non-neurosurgeon is not going to beexpected to deal with anyway.So one can read in the British Medical Journal

and in the Lancet advertisements for Accidentand Emergency Officers and for Casualty Officers

and Registrars, but to find Consultant posts, onehas to turn to vacancies under the heading ofOrthopaedic Surgery. Although this is disputedby orthopaedic surgeons, there does seem to be astrong case for abandoning the notion that thereis something wrong about training people properlyand specifically to deal comprehensively withaccidents (Potter, 1963b), as is done at the momentin very few centres. The need is obvious andoverwhelming; there are young men who wantthis type of training, but only a few are reallygetting it at present. There will, of course, alwaysbe a place for the centrally based specialist; butwhat is needed now is not the specialist-ortho-paedic-surgeon, the specialist-neurosurgeon, chest-surgeon, abdominal surgeon and maxillo-facialsurgeon at every hospital which admits accidents,but rather a new race of really general surgeons,well distributed and capable of dealing at leastcompetently with all aspects of injury. This wouldcreate a renaissance of general surgery to meetthe challenge of the new epidemic that is trauma.

ReferencesCAVENESS, W.F. & WALKER, A.E. (Eds.) (1966) Head Injury

Conference Proceedings. Lippincott, Philadelphia.GISSANE, W. (1963) The nature and causation of road injuries.

Lancet, ii, 695.LEWIN, W. (1954) The management of acute head injuries.

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