POSTGRAD. MED. J. (i963), 39, 709

THE MANAGEMENT OF HEAD INJ URIESP. R. R. CLARKE, M.B., B.S., F.R.C.S. G. F. ROWBOTHAM, B.Sc., L.R.C.P., F.R.C.S.

From the Regional Neurological Centre, Newcastle upon Tyne

IN the early stages after head injury, continuousand unremitting care is essential. This is demand-ing in terms of time and facilities but can be asource of great interest and satisfaction to thesurgeon. For treatment to be correct it is necessaryfor the aims of management constantly to be bornein mind (Gurdjian and Webster, 1958; Potter, I96I).Most patients with head injuries will recoverwithout operative intervention. In this firstgroup the surgeon's task is to provide the condi-tions that will be conducive to a speedy and fullrecovery. At the opposite end of the scale arethose whose condition is deteriorating, eitherfrom the direct effects of the injury or from second-arily developing states. Here the problem is torecognize the cause of deterioration and, whenpossible, to reverse the unfavourable trend withoutdelay. The third group consists of patients whoneither improve nor become worse and here toothe surgeon must make a diagnosis and institutesuitable treatment.When the patient first comes under medical

care an accurate history should be obtained, ifnecessary from eye-witnesses, family membersand those who have brought the patient to hospital.Past medical history and the state of health at thetime of the accident must be investigated, forthese may have a bearing on -the cause of theinjury and the actual physical state of the patient;illnesses such as coronary artery disease anddiabetes mellitus are relatively common amongstthose admitted to accident units. The time of theaccident and any alterations in conscious stateor behaviour should be entered clearly on thecase record. From the time of arrival at hospitalcontinuous observation must be maintained anda thorough examination of the patient in a goodlight is required. Examinations of the centralnervous system, abdomen and thorax are essentialand the blood-pressure, pulse rate, respirationrate and temperature, with details of the size andreactions of the pupils, should be recorded atleast as often as every half-hour at first. Thevalue of accurate, legible, concise and completerecords cannot be overstressed.

Care of the Unconscious PatientProvision of Airway

Obstruction of the upper respiratory passagesfrom the tongue, blood, vomit or secretions isvery apt to occur when consciousness and coughreflexes are depressed (Maciver, Frew and Mathe-son, 1958; Maciver, Lassman, Thomson andMcLeod, 1958). To the injured brain even slightdegrees of anoxia are dangerous and should beavoided by early attention to the airway. Thepatient should be placed in the three-quartersprone position so that the tongue will fall forwardand fluid matter flow from the open mouth.Gentle suction is used to clear the air passages.It may be possible to use a mouth tube but thiswill need careful supervision to ensure that itdoes not become blocked or displaced. Shouldthese simple measures not suffice, endotrachealintubation using a laryngoscope is indicated.If the jaws are tightly clenched, relaxant drugs canbe used, provided that apparatus for pulmonaryinflation is in readiness. An intratracheal tubeshould not be used for more than 36 hoursbecause of the danger of laryngeal ulcerationand infection. In certain circumstances tracheos-tomy should be considered but it must be bornein mind that this procedure carries its own risksand demands very high standards of nursing.The trachea harbours many organisms and thedanger of dissemination of infection from atracheostomy is great (Clarke, I963). The typeof patient who really benefits from a tracheostomyis the one who would normally be expected torecover from his brain injury were it not for theadverse effects of associated injuries or diseases.Examples of these are chest injuries, lung diseases,jaw injuries and fractures of the femur or pelviswhere immobilization causes difficulty in themaintenance of a clear airway. Prolonged statesof deep unconsciousness are often treated bytracheostomy but in our view the operation isbetter avoided whenever possible in these circum-stances because of the danger of cross-infectionand the undesirability of prolonging hopeless anddistressing situations.

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In the prevention of lung complications skilledphysiotherapy is invaluable and antibiotic covershould be provided in every case.

The Control of RestlessnessPatients may be restless for many reasons.

W; ile cerebral irritatipn and confusional statesmey make'control of; the patient difficult, thedi comfort, of a disten.ied bladc4er or the pain ofa hea*che may be co9tributory causes of restless-ness. 'In the early stages after head injury sedative-drugs are best avoided and they should be givenonly when one feels absolutely sure that extraduralor subdural hlmatoipas are not present. Suitabledrugs for use in these circumstances are eitherparaldehyde or a combination of a phenothiazinewith pethidine.Mpre important than the use of drugs is the

provision of really well-padded cot sides for thebed. A net is a useful device for restraining thepatient who might otherwise climb over the bedsides or ends. Extreme restlessness may necessitatenursing on mattresses placed side to side on thefloor.

Care of the SkinHere the aim is to avoid chafing and the develop-

ment of pressure sores. Care must be takenwhenever the patient is moved. In practice thismeans that adequate man-power is available forlifting purposes. The skin should be kept clean,dried carefully and treated with barrier cream.The position of the patient in the bed should bechanged hourly.

The BladderIncontinence of urine is usual but retention

sometimes occurs, necessitating continuouscatheter drainage and the use of a suitable sulphon-ami4e to keep the urine sterile. A careful watchshould be kept for bladder infection.

The BowelsIf these are not being moved satisfactorily

an enema will be required every three days.

Temperature Control(Cooper and Ross, i96o)The aim here is the maintenance of normother-

mia. If the temperature rises above ioo0F. (380C.)measures should be taken to reduce it. To startwith, the patient's clothing is removed and heis left with a sheet as the sole covering. If thisis not enough, tepid sponging may be applied.Should the temperature continue to rise, air isblown across the naked body by electric fans.Any ter~dency to shiver may be controlled by theuse of intramuscular injections of the 'lytic

cocktail' (chlorpromazine, phenergan andpethidine).

Mouth, Eyes and NoseIn states of prolonged unconsciousness these

will need regular toilet and the application oflocal antibiotics.

Decerebrate RigidityThis commonly occurs in spasms, associated

with hyperpncea and often in response to peripheralstimulation. It may be brought under controlwith 'lytic cocktail' but care must be exercisedin the use of these drugs lest a dangerous fall inblood pressure is produced.

FeedingIf the patient is unable to swallow, a fine

plastic stomach tube is passed and left in position.There is, however, no need in the first I2 hoursto administer fluids other than those requiredto compensate for blood loss. During the secondI2 hours 2 OZ. of water are given hourly and onthe second and third days mixtures of 3 pints ofwater with 3 pints of milk and 300 g. of glucoseare administered during each 24 hours, giving acalorie value of 2,250 with 50 g. of protein. Later,the diet is gradually enriched and made more solid.

This basic scheme may require modification inthe light of biochemical examination of the blood.When possible, daily estimations are made of theblood urea, sodium, potassium, chloride, andbicarbonate.

If the gastro-intestinal tract will not absorbthe quantities of fluid recommended, intravenousfeeding will be necessary.

The Complications of Head InjuriesWhen damage to the brain has been over-

whelmingly severe, recovery is impossible and thepatient must sooner or later succumb to hisinjuries. With lesser injuries there may besecondary occurrences that cause deteriorationor failure to recover consciousness. Some of theseare amenable to treatment but early diagnosisand prompt treatment are essential if lives areto. be saved. The following lesions should beborne in mind.

Extradural Hatmorrhage(Hooper, I959; McKissock, Taylor, Bloom andTill, I96o)

In the early stages extradural hImorrhage isprobably the most important complication. Itmay follow a relatively minor injury. Leftuntreated it will certainly lead to death. Bleedinginto the extradural space usually occurs in thesupratentorial portion of the head, generally

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in one temporal region. It can, however, takeplace in the posterior cranial fossa. The hxmor-rhage is usually the result of a tear in a meningealartery but it can follow injury to one of the duralvenous sinuses or be the result of bleeding fromthe diploic venous channels. The clinical pictureshould be familiar to all (Lewin, 1949). Typicallythe patient is unconscious for a short while,recovers and then gradually loses consciousnessagain. Variations in this picture are not un-common. For instance, the patient may not loseconsciousness in the beginning but may graduallybecome drowsy and later unconscious. Alterna-natively, he may never recover full consciousnessafter the blow has been received. The first signthat all is not well may be a convulsion. Neuro-logical signs that may occur are weakness of oneside of the body with an extensor plantar response.The classical alterations in the pupils described byHutchinson may also be seen. When a pupil isdilated and does not contract on direct or consen-sual exposure to light a tentorial pressure cone ispresent. In the early stages of cerebral compressionby extradural hbmorrhage the blood pressurerises and the pulse rate falls; the respirationbecomes deep and slow. If the condition is notrelieved by surgery the blood pressure falls, thepulse rate rises and the respirations becomerapid and shallow. A rising temperature is anominous sign. The most important indication ofcerebral compression due to extradural hamorrhageis an alteration in the level of consciousness; onthis sign alone the diagnosis can be made. Theposition of a hbmatoma may be deduced fromthe presence of surface bruising, radiologicalevidence of a fracture, and from the neurologicalsigns. Once extradural bixmorrhage is suspectedan immediate burr-hole exploration should bemade. The site of the first burr-hole is determinedby the physical signs. If the first explorationdoes not reveal a hamatoma, further burr-holeswill have to be made; thus both sides of the skullmay have to be explored and in as many as fourplaces. Should. a hiematoma be found it is rapidlyexposed by a large craniotomy or craniectomy.After removal of the hiematoma careful hiemo-stasis must be secured and the wound closed withdrainage..

Subdural Hamorrhage(McKissock, Richardson and Bloom, I960)

This may present in an acute, a subacute or achronic form. It occurs as a result of a lacerationof the surface of the brain, or the tearing ofveins that run from the surface of the brain to thevenous sinuses. When a h.ematoma follows abrain laceration it is naturally situated over thearea of torn brain. When it results from rupture

of a vein blood usually collects posteriorly overthe occipital and parietal regions. Subduralhaxmatomas are often bilateral. In the acute forma hlimatoma is nearly always associated with asevere brain injury. With subacute and chronicbleeding a patient's initial condition is much lessserious. The presence of a subdural hlimatomashould be suspected when a patient's conditionfails to improve with simple remedies or when thelevel of consciousness deteriorates. As in the caseof extradural haemorrhage, convulsions may occur.Should a patient remain conscious despite subduralbleeds he will often complain of severe headacheand show signs of raised intracranial pressure-papillcedema, sixth nerve palsies, raised bloodpressure and a slow pulse rate. Focal neurologicalsigns such as hemiplegia are uncommon. Diagnosisis made by burr-hole exploration, which shouldalways be carried out on both sides of the skull.The dura mater is opened and the hlumatoma isallowed to drain away. It is nearly always possiblein this way to obtain satisfactory evacuation of thehiematoma. Exceptionally a bone flap may haveto be raised to permit a wide opening of the duramater and evacuation of an adherent solid clot.However, such cases are rare and usually associatedwith severe brain damage.

Subarachnoid H&emorrhageBleeding into the subarachnoid space may

occur from any vessel on the surface of the brain.Blood is then carried in the cerebrospinal fluidthrough the subarachnoid space and into thecisterns. Irritation of the meninges by blood causesvascular congestion, more bleeding and cerebraledema. Arterial spasm may be provoked bysubrachnoid himorrhage. Clinically, the conditionis shown by headache, neck stiffness, Kernig'ssign and, in the later stages, papillcedema. Thediagnosis is made by lumbar puncture andexamination of the cerebrospinal fluid. Subarach-noid hrmorrhage after head injury is treated byrest and analgesics.When blood is found by lumbar puncture he

history of the case should be reviewed and, if it isthought that the subarachnoid haemorrhage mayhave preceded the injury, the patient should betransferred to a neurosurgical unit for angiography.

Cerebral H&-morrhageCerebral hiemorrhage may be caused by surface

laceration of the brain with an extension ofhiemorrhage into the deeper structures, or byrupture of a deeply placed cerebral vessel. It isusually a complication of a severe brain injuryand the prognosis here is bad. Very occasionallyan isolated hiematoma may develop within thebrain without any serious accompanying brain

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damage. Such a hematoma is susceptible totreatment. Clinically the picture is that ofdeterioration in the level of consciousness withlocalizing neurological signs and evidence of raisedintracranial pressure. In many ways it mimics anextradural liemorrhage. The treatment is burr-boleexploration over the suspected site and aspirationof the hxmatoma through a brain cannula.

Cerebral (EdemaCEdema is usually a complication of contusion

of the brain and may occur early or late. It causesa deterioration in the level of consciousness andsigns of raised intracranial pressure. It isimpossible to diagnose the condition clinicallywith any certainty. Therefore, in the managementof this condition the first essential is to carry outburr-hole exploration on each side. If noextradural or subdural hlimatoma is found, acannula is passed into the brain through eachburr-hole to determine whether an intracebralluematoma is present; if none is found and thebrain appears to be swollen, a diagnosis of rcdemacan be made. The condition is treated firstlyby the avoidance of overhydration of the patientand secondly by the application of dehydrationmethods. The most powerful dehydratingsubstances are urea (Stubbs and Pennybacker,I960) which may be given intravenously in adose of ig/kg. of body weight, and mannitolwhich can also be administered as an intravenousinfusion in the same dosage (Shenkin, Goluboffand Haft, I962)

MeningitisThis condition can be fulminating in its onset,

causing death within a few hours if not detectedearly and treated energetically. Its presence maybe suspected if there is a source of infection suchas an open wound, a septic lesion or a cerebro-spinal fluid fistula into the nasal passages or ear.Meningitis usually causes neck stiffness, a positiveKernig's sign and a deteriorating level ofconscious-ness. The diagnosis is made by lumbar puncture,which should never be omitted when meningitisis suspected. It is justifiable to give a generalanaesthetic if this is necessary to perform thelumbar puncture and obtain a specimen ofcerebrospinal fluid. The fluid must be sent tothe laboratory for identification of the causalorganisms and the performance of antibioticsensitivity tests. When the fluid obtained bylumbar puncture appears turbid, an intrathecalinjection of 5,ooo to io,ooo units of penicillinshould be given and systemic treatment withantibiotics and chemotherapeutic agents is startedat once. Penicillin should be given in largedoses; if an adequate fluid intake can be ensured,

a sulphonamide should be given as well becausethis freely passes the blood-brain barrier. Modi-fications in the antibiotic treatment may have tobe made in the light of response to treatment andthe information obtained from the bacteriologylaboratory. In serious cases daily intrathecalinjections of penicillin will be required andstreptomycin may also be given by this route ifconsidered necessary. Failure of the patientto respond to these measures is an indicationfor intraventricular antibotic treatment.

Epilepsy(Jennett, I962)

Epilepsy may occur in the acute or intermediatestages or as a late sequel to head injury. In somepatients a past history or a family history ofepilepsy may be obtained. As already mentioned,fits may be a symptom of cerebral compressionor of meningitis. They may, however, indicateactual brain damage. The fits must be broughtunder control rapidly if deterioration is to beavoided but unfortunately most of the drugswhich may be given for this purpose also depressthe level of consciousness. Should drug treatmentfor epilepsy be necessary a doubly careful watchmust therefore be kept for the development ofother conditions that depress consciousness.Phenytoin does not depress the level of conscious-ness and can be given by the intramuscular orintravenous route. If this is not effective in bring-ing the fits under control the best drug to use isparaldehyde; this can be given by intramuscularinjection in doses up to io ml. and the dose canbe frequently repeated.

Cerebral AnoxiaAnoxia often occurs when head injuries are

associated with chest injuries and lung infections.Chest injuries of the flail or sucking type areespecially liable to aggravate the cerebral conditionby reason of anoxia; the shallow breathing associ-ated with simple fractures of the ribs may alsodo so. Lung infections causing cerebral anoxiaare particularly liable to occur in patients whohave pre-existing pulmonary disease such asbronchiectasis, asthma or chronic bronchitis. Thediagnosis is based on the clinical picture and onradiographic examination of the chest. In thisgroup of complications early tracheostomy canbe life-saving. The treatment of flail injuries isalso of great importance; paradoxical respirationis treated by the use of a cuffed tracheostomytube in connection with a respiratory pump afterparalysis of the muscles of respiration withcurare-like drugs or by operative fixation of theinjured parts of the chest wall. In these cases theadvice of a thoracic surgeon is of great value.

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The administration of oxygen is helpful and allcases should be under full antibiotic cover.

Special InvestigationsX-raysGood radiographs of the skull should be taken

as soon as possible after injury. It is usually mostconvenient for the patient to be examined radio-graphically on the way from the admission unitto the ward. Anteroposterior, Townes' andlateral views are required in every case. Theparticular points for which one should look inthe radiographs are depressed fractures, fracturelines crossing the grooves in the skull producedby meningeal vessels, and fractures into theparanasal sinuses. If the pineal body is calcifiedits position in the A-P view should be noted,lateral displacement being indicative of a space-occupying lesion on the opposite side.

In the presence of signs of severe cerebralcompression, immediate burr-hole explorationmust be performed without delaying for radio-logical investigations unless these can be madewithin a few minutes.

Burr-holesAs already mentioned, burr-holes should be

made when the patient's condition is deterioratingor is unsatisfactorily static, and particularly whena massive surface or intracerebral hiemorrhageis suspected. By means of inspection holeshlimatomas and cedema can be diagnosed withcertainty. Specimens of cerebrospinal fluid maybe obtained by cannulation of ventricles andpenicillin or streptomycin can be injected intoventricles if the fluid is found to be purulent.The value of burr-hole exploration cannot beoverstated; surgeons in charge of patients withhead injuries should be prepared to perform theoperation on the slightest suspicion of cerebralcompression. Many lives which would otherwisebe lost can be saved if this policy is adopted.

Lumbar PunctureLumbar puncture is seldom indicated in the

acute phases of head injury and may indeed bedangerous for it can precipitate the developmentof a tentorial or cerebellar pressure cone. However,it should be performed if there is evidence ofmeningeal irritation. Should blood be found in thecerebrospinal fluid this indicates subarachnoidhaimorrhage but it by no means excludes thepresence of other pathological states such asextradural or subdural bsematomas.

X-rays, burr-holes and lumbar puncture arethe only special investigations essential for theproper management of head injuries. ContrastX-ray studies (Alexander, I96I; Hancock, I96I),

electroencephalography and echoencephalography(Jefferson, 1959) have their place in specializedunits but, in our opinion, they are no more thanadjuncts.

Points in General Operative Technique(Rowbotham, 1949; Rowbotham and Hammersley,I953)AncesthesiaA free airway at all times is essential in order

to avoid congestion of the scalp and brain. Endo-tracheal anxsthesia with minimal doses of anesthe-tic drugs and relaxants is advised. When goodfacilities for general anaesthesia are not available,local anasthesia with liberal quantities of ligno-caine for infiltration of the scalp should beemployed.Scalp PreparationThe head should be meticulously shaved, care

being taken to avoid injuring the skin. The scalpis then washed with soap and water, swabbedwith perchloride solution and finally treated withchlorxylenol (e.g. Dettol). Spirit and iodineshould be avoided as they are apt to scale orburn the skin.

PositioningThe head is supported on sandbags or firm

pillows so that it is raised above the rest of thebody. Obstruction to the veins of the neck mustbe avoided. If local anasthesia is being used thepatient's wrists should be loosely secured andsheets should be pinned round the body.

ApparatusGood lighting, efficient suction and diathermy

are necessary. Without them the surgeon willsooner or later encounter unsurmountabledifficulties.

HemostasisHemostasis must be perfect before the head

is closed since bleeding within the skull willlead to cerebral compression.The points set out above may seem trivial but the

margin between success and failure in headsurgery is extremely narrow. Success dependson meticulous attention to detail.

Cerebrospinal Fluid RhinorrhceaC.S.F. rhinorrhcea is caused by fistule from

the subarachnoid space through the cribriformplate or into the paranasal sinuses. The patientshould be instructed not to blow his nose. Acream of chlorhexidine and neomycin (e.g.Naseptin) is placed in the nostrils six-hourly anda sulphonamide should be administered. Although

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the C.S.F. leak will cease spontaneously in manycases, the danger of meningitis will remain;repair of the dura at a suitable time should becarried out. This is an operation requiring specialskill and experience and is best not attemptedunless it can be performed in a NeurosurgicalUnit.

Cerebrospinal Fluid OtorrhoeaAs in the case of C.S.F. rhinorrhcea the danger

here is of meningitis or brain abscess; sulphona-mides should be given. The external auditorymeatus is cleaned carefully and a sterile pad is keptover the ear. Dural repair is rarely needed forthis condition. Once the escape of fluid has ceasedmeningitis is unlikely to develop.

Closed Fractures of the SkullAlfracture of the skull without depression of

bony fragments requires no surgical treatmenton its own account. In children, indented frac-tures, often without demonstrable fracture lines,may be seen. Here, the indications for surgicaltreatment are:

(i) At birth-large indentations associated withsigns of cerebral compression.

(2) At three months-disfiguring indentationsoutside the hair line, indentations over themotor cortex and indentations associated withneurological deficits.

(3) At three years-all indentations more thanone inch in diameter.

When elevation of an indented fracture isindicated it should be carried out by leveringup the depressed bone with a curved dissectorinserted through a trephine hole at the peripheryof the indentation.

Closed depressed fractures are often unassoci-ated with signs of brain damage and in suchcases it may be wise to leave well alone, particularlyif they are situated over large dural sinuses.

Indications for operation on depressed fracturesare:

(i) Evidence of cerebral compression in anunconscious patient.

(2) Signs of underlying brain damage orpersistent headache and giddiness.

(3) Penetration of the dura. Judgment on thiscan be based only on X-ray appearances oftheshape of the fragments, angle of tilt andamount of depression.

(4) Cosmetic considerations.If operation is performed, the fracture should

be exposed by means of a scalp flap. Bonyfragments must not be rocked out but shouldbe picked out with bone forceps. When the frag-ments are tightly interlocked it may be bestfor a burr-hole to be sunk at the periphery of

. -:r- h

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xs ;a. 4 |sE

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a

.. V. . , .. . . S .:.;:.

FIG. i.-Closure of scalp with interrupted silk sutures.

the fracture and for the bone to be nibbled awayuntil a portion of the fracture is loose. Alterna-tively, a quadrilateral block of bone bearing thefracture may be cut out by means of Gigli sawcuts linking four burr-holes. The bone blockcan then be remodelled manually before replace-ment.

Open Wounds of the HeadScalp Wounds

Excision of skin edges is unnecessary 'andliable to cause difficulty in wound closure. If thescalp tissues are dirty, they should be cleanedby scraping with a scalpel. During wound closure,the epicranial aponeurosis should first be suturedwith silk. The skin is then brought together withinterrupted sutures of the same material (Fig.i). If the wound is contaminated or infectedthe layer of buried sutures is best omitted.

Compound FracturesLoose fragments of bone are lifted out (Fig.

2) and the underlying dura is carefully inspectedfor tears. If the bone is absolutely clean oninspection it may be replaced but, if there is anydoubt regarding its cleanliness, it is best discardedand a jcranioplasty performed at a later date.

Dural TearsStay sutures are placed through the edges and

used to retract them so that the underlying brainmay be inspected. If access is inadequate thedural wound is extended. At the end of the opera-tion the dura should, in our opinion, be closed bysuture (Fig. 3). If there is any difficulty inapproximating the edges, a graft of fascia cati beused to fill the gap. This fascia may be takenfrom the temporal regions or from the thigh.

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December I963 CLARKE and ROWBOTHAM: The Management of Head Injuries 715

FIG. 2.-Removal of depressed bone fragment.

Cerebral WoundsHere the aim is the removal of blood clots

and dead tissue, the extraction of foreign bodies,and the arrest of haemorrhage. All manceuvresmust be made with the utmost gentleness; careshould be taken to avoid damage to healthytissue by heavy retraction or unnecessarily vigoroussuction. Brain retractors applied over lintineswabs are used to expose the depths of brainwounds and debridement is performed by suction,using a fine glass tube as a nozzle (Fig. 4). Aforeign body in a deep situation difficult ofaccess should not be disturbed. It will onlyrarely lead to abscess formation or epilepsy.Hwemorrhage is arrested by electro-coagulation,the application of silver clips to vessels, musclegrafts or gelatine sponge.When a dural venous sinus is torn, hemorrhage

may be torrential. Should the sinus be dividedthe ends must be clamped and ligated. A smalltear can sometimes be closed by suture. Mostinjuries, however, will be large later*l tears and

FIG. 3.-Dural closure with interrupted silk sutures.\\\\\S

v b' ' \'1-

FIG. 4.-Debridement of brain wound.

these are best repaired by muscle grafts or packsof gelatine foam. The repair material is placedfirmly on the sinus tear and a swab is laid overit. Suction is then applied to the swab untilbleeding stops.

Finally, it must be reiterated that successdepends on attention to detail. General surgicalprinciples should be followed throughout. Bloodfor transfusion must be readily available wheneveroperation is performed for any wound extendingdeeper than the scalp.

We wish to thank Dr. Robert Blowers for help withthe manuscript and Mrs. V. L. Robinson for secretarialassistance.

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7I6 POSTGRADUATE MEDICAL JOURNAL December I963

REFERENCESALEXANDER, G. L. (I96I): Extradural Hmmatoma at the Vertex, J. Neurol. Neurosurg. Psychiat., 24, 38I.CLARKE, P. (I963): Observations on the Use of Tracheostomy in the Management of Cases of Head Injury, Excerpta

med. (Amst.), 6o, 107.COOPER, K., and Ross, D. (i960): 'Hypothermia'. London: Cassell.GuRDJIAN, E. S., and WEBSTER, J. E. (1958): 'Head Injuries, Mechanisms, Diagnosis and Management'. London:

J. & A. Churchill.HANCOCK, D. 0. (I96I): Angiography in Acute Head Injuries, Lancet, ii, 745.HOOPER, R. (1959): Observations on Extradural Hmemorrhage, Brit. J. Surg., 47, 71.JEFFERSON, A. A. (1959): Some Experiences with Echo-encephalography, J. Neurol. Neurosurg. Psychiat., 22, 83.JENNETT, W. B. (I962): 'Epilepsy After Blunt Head Injuries'. London: Heinemann.LEWIN, W. (1949): Acute Subdural and Extradural Hematoma in Closed Head Injuries, Ann. roy. Coll. Surg. Eng.,

5, 240.MACIVER, I. N., FREw, I. J. C., and MATHESON, J. G. (1958): The Role of Respiratory Insufficiency in the Mortality

of Severe Head Injuries, Lancet, ii, 390., LASSMAN, L. P., THOMSON, C. W., and McLEOD, I. (1958): Treatment of Severe Head Injuries, Ibid., ii, 544.

McKissocK, W., TAYLOR, J. C., BLOOM, W. H., and TILL, K. (I960): Extradural Haematoma: Observations on 125Cases, Ibid., ii, 167., RICHARDSON, A., and BLOOM, W. H. (I960): Subdural Hoematomas, Ibid., i, 1365.

POTTER, J. M. (I96I): 'The Practical Management of Head Injuries'. London: Lloyd Luke.ROWBOTHAM, G. F. (1949): 'Acute Injuries of the Head'. Edinburgh and London: E. & S. Livingstone.

, and HAMMERSLEY, D. P. (1953): 'Pictorial Introduction to Neurological Surgery'. Edinburgh and London:E. & S. Livingstone.

SHENKIN, H. A., GOLUBOFF, B., and HAFT, H. (I962): The Use of Mannitol for the Reduction of Intracranial Pressurein Intracranial Surgery, Y. Neurosurg., I9, 897.

STUBBS, J., and PENNYBACKER, J. (I960): Reduction of Intracranial Pressur ewith Hypertonic Urea, Lancet, i, 1094.

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