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HÆMORRHAGE FROM THE MIDDLE MENINGEAL ARTERY
750
tion-misfortunes which have not been noted in the children whose E.E.G.s were normal throughout. Of the infectious diseases f childhood measles is the likeliest to causeencephalitis. Instances in both children and adults of encephalitis due to Asian influenza were described in these columns two years -ago. 25-28 Since then Olivarius and Fog 29 have reported 12 cases showing neurological complications of Asian influenza, in 5 of which epilepsy developed during the illness or in the ensuing months. It therefore seems possible that, when more is known of the incidence of subclinical encephalitis from all causes, further inroads will be made on the " diagnosis of idiopathic epilepsy " and perhaps of other neurological and psychiatric disorders of uncertain origin. HÆMORRHAGE FROM THE MIDDLE MENINGEAL ARTERY
No year passes without a few tragic paragraphs in newspapers reporting the death of a child or a sportsman who, between a few hours and a day or so after sustaining
apparently trivial injury to the head, has died of an extradural hxmatoma. At different hospital centres the mortality-rate from this lesion differs widely-from 20% or less to 50% or more.3o In an article in this issue, Mr. Gibbs insists that the general surgeon should play an important part in these emergencies. He rightly declares that attention should be given to organising the treatment of casualties and emergencies, not simply at isolated points, but over areas. Many of our civilian casualties receive treatment that would not have been tolerated in a forward surgical unit in battle; and some of the defects in this service are made clear by the report of the Nuffield Provincial Hospitals Trust which we reviewed last week.31 In general, the measures proposed by Gibbs would certainly help to save lives; but his condemnation of subtemporal decompression is perhaps debatable. Admittedly an extensive clot extending right up to the sagittal line may require an osteoplastic flap to stop continued venous oozing after the arterial bleeding-point has been coagulated; but not all critically ill patients will withstand the operating-time and blood-loss involved in this procedure: the modest aim of preserving or even restoring spontaneous breathing may be the primary goal. an
McKissock
et
all reporting
an
impressively large
series of extradural hxmatomas, point out that the lucid interval-that well-known feature of the lesion-was found in only a minority. Of their 125 cases 10 were always conscious, 17 were initially conscious but became unconscious, 35 were initially unconscious and became conscious, and 30 were never conscious; only 33- had a lucid interval. Diagnosis is helped by the finding clinically of ipsilateral dilatation of the pupil and contralateral hemiparesis (and, less often, of papilloedema, dysphasia, and visual-field defects), and radiologically of a fracture with swelling of the overlying subcutaneous tissues; but occasionally all such signs are absent. On the other hand, headache and vomiting-sheet-anchors in the detection of intracranial compression-are almost invariably present. McKissock et al. declare that, if a haematoma is suspected but is not found by burrhole exploration, ventriculography 25. Flewett, T. H., Hoult, J. G. Lancet, 1958, ii, 11. 26. McConkey, B., Daws, R. A. ibid. p. 15. 27. Bental, E. ibid. p. 18. 28. ibid. p. 32. 29. Olivarius, B. de F., Fog, M. Danish med. Bull. 1959, 6, 248. 30. See Lancet, 1959, ii, 604. 31. Casualty Services and their Setting. London, 1960. See Lancet, Sept. 24, 1960, pp. 689, 698. 32. McKissock, W., Taylor, J. C., Bloom, W. H., Till, K. ibid. July 23, 1960,
p. 167.
angiography is essential; and, even in their experienced hands, failure to follow this precept has resulted in or
death. The work of McKissock and his colleagues on intracranial harmorrhage 32 33 has shown what may be expected when treatment is undertaken by neurosurgeons prepared in mind, equipment, and administration to treat these emergencies as they arise. How many of our larger hospitals without neurosurgical teams have the resources to deal with such emergencies in the night, except at an exorbitant cost in sleep of a staff that has already worked all day and will work again all next day ? And is such an arrangement really satisfactory for the surgery of the coming twenty years ?If Gibbs’ advice is to be followed, many more hospitals receiving casualties must have surgeons who are prepared to undertake emergency burrholes, and with them should work radiologists prepared to undertake angiography. But though not all may agree with the remedy proposed by Gibbs, he has done well to point to the need for definition of responsibility, and for which treat or admit these speedy action, in hospitals " There are," as he says, " still pressing emergencies. too many deaths from extradural haemorrhage." CHILD NEUROLOGY AND CEREBRAL PALSY
A POST-WAR innovation that seems to be working well is the hiring of Oxford and Cambridge colleges for conferences in the vacations. Those who attend these meetings undoubtedly gain much from the subtle effects of the intellectual environment, even if they have to do without some of the amenities of a modern hotel. The second biennial international study group of the National Spastics Society was held at St. Edmund’s Hall, Oxford, on
Sept. 11-17.
In the two years since the first of these gatherings, the society has greatly extended its research efforts and has become very active in child neurology and developmental medicine, notably by setting up a pxdiatric research unit at Guy’s, with a professorship endowed by the society. This tendency was reflected at the conference in, for example, the discussion on parietal-lobe function, opened by Dr. W. Ritchie Russell and Dr. E. A. Carmichael, and in the whole morning devoted to the neurological examination of newborn infants. This does not mean that the " society is losing interest in spastics "; but there is a growing feeling that the quickest route to the prevention of cerebral palsy is a roundabout one. The aim is to open up, so far as possible, the whole field of child neurology, in the hope that some useful clues will emerge. The gathering was truly international and multidisciplinary. But when the society holds its next study group, probably at the same place in 1962, it is likely to include more educationists and to discuss more educational problems-a side of cerebral-palsy research that has hitherto been relatively neglected.
Sir ARTHUR GEMMELL, a past president of the Royal College of Obstetricians and Gynaecologists, died at his home in Liverpool on Sept. 24 at the age of 67.
Dr. A. M. KENNEDY, emeritus professor of medicine in the of Wales, died in Cardiff on Sept. 24.
University
33. McKissock, W., Richardson, A., Walsh, L. ibid. 1959, ii, 683. McKissock, W., Richardson, A., Walsh, L. ibid. 1960, i, 1203. McKissock, W., Richardson, A., Bloom, W. H. ibid. p. 1365.
tion-misfortunes which have not been noted in the children whose E.E.G.s were normal throughout. Of the infectious diseases f childhood measles is the likeliest to causeencephalitis. Instances in both children and adults of encephalitis due to Asian influenza were described in these columns two years -ago. 25-28 Since then Olivarius and Fog 29 have reported 12 cases showing neurological complications of Asian influenza, in 5 of which epilepsy developed during the illness or in the ensuing months. It therefore seems possible that, when more is known of the incidence of subclinical encephalitis from all causes, further inroads will be made on the " diagnosis of idiopathic epilepsy " and perhaps of other neurological and psychiatric disorders of uncertain origin. HÆMORRHAGE FROM THE MIDDLE MENINGEAL ARTERY
No year passes without a few tragic paragraphs in newspapers reporting the death of a child or a sportsman who, between a few hours and a day or so after sustaining
apparently trivial injury to the head, has died of an extradural hxmatoma. At different hospital centres the mortality-rate from this lesion differs widely-from 20% or less to 50% or more.3o In an article in this issue, Mr. Gibbs insists that the general surgeon should play an important part in these emergencies. He rightly declares that attention should be given to organising the treatment of casualties and emergencies, not simply at isolated points, but over areas. Many of our civilian casualties receive treatment that would not have been tolerated in a forward surgical unit in battle; and some of the defects in this service are made clear by the report of the Nuffield Provincial Hospitals Trust which we reviewed last week.31 In general, the measures proposed by Gibbs would certainly help to save lives; but his condemnation of subtemporal decompression is perhaps debatable. Admittedly an extensive clot extending right up to the sagittal line may require an osteoplastic flap to stop continued venous oozing after the arterial bleeding-point has been coagulated; but not all critically ill patients will withstand the operating-time and blood-loss involved in this procedure: the modest aim of preserving or even restoring spontaneous breathing may be the primary goal. an
McKissock
et
all reporting
an
impressively large
series of extradural hxmatomas, point out that the lucid interval-that well-known feature of the lesion-was found in only a minority. Of their 125 cases 10 were always conscious, 17 were initially conscious but became unconscious, 35 were initially unconscious and became conscious, and 30 were never conscious; only 33- had a lucid interval. Diagnosis is helped by the finding clinically of ipsilateral dilatation of the pupil and contralateral hemiparesis (and, less often, of papilloedema, dysphasia, and visual-field defects), and radiologically of a fracture with swelling of the overlying subcutaneous tissues; but occasionally all such signs are absent. On the other hand, headache and vomiting-sheet-anchors in the detection of intracranial compression-are almost invariably present. McKissock et al. declare that, if a haematoma is suspected but is not found by burrhole exploration, ventriculography 25. Flewett, T. H., Hoult, J. G. Lancet, 1958, ii, 11. 26. McConkey, B., Daws, R. A. ibid. p. 15. 27. Bental, E. ibid. p. 18. 28. ibid. p. 32. 29. Olivarius, B. de F., Fog, M. Danish med. Bull. 1959, 6, 248. 30. See Lancet, 1959, ii, 604. 31. Casualty Services and their Setting. London, 1960. See Lancet, Sept. 24, 1960, pp. 689, 698. 32. McKissock, W., Taylor, J. C., Bloom, W. H., Till, K. ibid. July 23, 1960,
p. 167.
angiography is essential; and, even in their experienced hands, failure to follow this precept has resulted in or
death. The work of McKissock and his colleagues on intracranial harmorrhage 32 33 has shown what may be expected when treatment is undertaken by neurosurgeons prepared in mind, equipment, and administration to treat these emergencies as they arise. How many of our larger hospitals without neurosurgical teams have the resources to deal with such emergencies in the night, except at an exorbitant cost in sleep of a staff that has already worked all day and will work again all next day ? And is such an arrangement really satisfactory for the surgery of the coming twenty years ?If Gibbs’ advice is to be followed, many more hospitals receiving casualties must have surgeons who are prepared to undertake emergency burrholes, and with them should work radiologists prepared to undertake angiography. But though not all may agree with the remedy proposed by Gibbs, he has done well to point to the need for definition of responsibility, and for which treat or admit these speedy action, in hospitals " There are," as he says, " still pressing emergencies. too many deaths from extradural haemorrhage." CHILD NEUROLOGY AND CEREBRAL PALSY
A POST-WAR innovation that seems to be working well is the hiring of Oxford and Cambridge colleges for conferences in the vacations. Those who attend these meetings undoubtedly gain much from the subtle effects of the intellectual environment, even if they have to do without some of the amenities of a modern hotel. The second biennial international study group of the National Spastics Society was held at St. Edmund’s Hall, Oxford, on
Sept. 11-17.
In the two years since the first of these gatherings, the society has greatly extended its research efforts and has become very active in child neurology and developmental medicine, notably by setting up a pxdiatric research unit at Guy’s, with a professorship endowed by the society. This tendency was reflected at the conference in, for example, the discussion on parietal-lobe function, opened by Dr. W. Ritchie Russell and Dr. E. A. Carmichael, and in the whole morning devoted to the neurological examination of newborn infants. This does not mean that the " society is losing interest in spastics "; but there is a growing feeling that the quickest route to the prevention of cerebral palsy is a roundabout one. The aim is to open up, so far as possible, the whole field of child neurology, in the hope that some useful clues will emerge. The gathering was truly international and multidisciplinary. But when the society holds its next study group, probably at the same place in 1962, it is likely to include more educationists and to discuss more educational problems-a side of cerebral-palsy research that has hitherto been relatively neglected.
Sir ARTHUR GEMMELL, a past president of the Royal College of Obstetricians and Gynaecologists, died at his home in Liverpool on Sept. 24 at the age of 67.
Dr. A. M. KENNEDY, emeritus professor of medicine in the of Wales, died in Cardiff on Sept. 24.
University
33. McKissock, W., Richardson, A., Walsh, L. ibid. 1959, ii, 683. McKissock, W., Richardson, A., Walsh, L. ibid. 1960, i, 1203. McKissock, W., Richardson, A., Bloom, W. H. ibid. p. 1365.