Volume 2 Number 3

diagnosis and treatment concerned. The result is that the subject is covered thoroughly but in a way that leads to a fair amount of repetition and includes lists of causes and differential diagnosis that are not always of much practical importance. Some of the chapters are no more than a few paragraphs long. There is a useful chapter that deals briefly with the diagnosis and management of the abdomen as one of several injured parts of a single patient, and a particu- larly wise one dealing with selectivity in operating on stab and other penetrating wounds of the abdomen. The chapter on iatrogenous injuries (the author explains and justifies this word) is hardly relevant to the subject.

In summary, there is much of value in this book but there are some irrelevancies and trivialities, there are spelling mistakes and either typographical errors or malapropisms, and at £4 it is expensive, even these days.

P. S. LONDON

Peripheral Arterial Disease. By R. L. RICHARDS, M.D. , F .R.C.P. (Edin.), F .R.C.P . (Glas.), Physic- ian, Wes te rn Inf i rmary, Glasgow. 8½× 5¼ in. Pp. 1 2 6 + x , with 40 i l lustrat ions. 1970. E d i n b u r g h : E. & S. Liv ings tone Ltd. 50s. THE subtitle of this book is ' A physician's approach' but no surgical reader should be deterred by this. In his preface Dr. Ricbards pays tribute to his teachers and to Sir Thomas Lewis, whose classic Vascular Disorders of the Limbs he habitually recom-

ABSTRACTS 249

mended as a small book on vascular diseases until it went out of print. The present work is his attempt to fill the gap, which he has done admirably. His writing is clear and succinct, and the illustrations are helpful. Dr. Richards has concentrated on the clinical appraisal of vascular disorders and their treatment by medical means; while he leaves the reader in no doubt about what surgical treatment can achieve, he raises proper doubts about some claims that have been made. The information in this book should be known by all those that have to deal with patients with peripheral arterial disease, and if a first reading can be managed during the final year of a student's clinical studies, so much the better.

P. S. LONDON

New Safety and First Aid. By A. WARD GARDNER, M.D., D.I .H. , and P. J. ROYLANCE, R.D. , M.B., Ch.B. , 8¼×7 in. Pp. 96, wi th 69 i l lustrat ions. 1970. L o n d o n : Pan Books Ltd. 6s. DR. GARDNER and Dr. Roylance have taken their characteristically straightforward approach to first aid a step further by setting out for children not only how to set about dealing with the effects of an acci- dent but how to try to prevent accidents from happen- ing. One may wonder how many careless persons will either read or heed this book and how many careful ones will need it, but it deserves a place in junior schools and, perhaps, among the books of teachers in children's wards as a source of much useful information.

P. S. LONDON

ABSTRACTS

H E A D I N J U R I E S

Management of Head Injuries The number of excellent recent monographs avail-

able in the English language might be a good excuse for refusing any further articles on this subject. Yet here in the span of only three pages we have distilled wisdom and guidance from an acknowledged expert on the management of a head injury in the acute phase. To paraphrase the content of this paper would be an impertinence if not an impossibility.

The last three paragraphs, on the psychological effects of a head injury, put into correct perspective the difficulties and dangers of making this kind of assessment. They bring a breath of common sense to discussion of a topic to which so much nonsense is still being contributed by qutte distinguished neuro- logists, psychiatrists, and some members of the legal profession.

POTTER, J. M. (1970), ' The Management of Head Injuries ', Br. J. hosp. Med., 3, 909.

Early Post-conenssional Headache The authors studied 200 consecutive male patients

over 13 years of age who were admitted to the

Radcliffe Infirmary after being rendered unconscious by head injury. The headache suffered was graded from 0 to 3 according to whether the patient had no headache, admitted to one only if questioned, com- plained spontaneously of headache, or required anal- gesic drugs for it. Concussion was graded as mild, moderate, or severe, according to whether post- traumatic amnesia lasted for 1 hour, 1-2 hours, or more than 24 hours. Two-thirds of the patients had no headache at all and 10 per cent of these had p.t.a. of 1-24 hours. Only 3 patients needed analgesia and all had p.t.a, of less than 1 hour. Only one patient that had p.t.a, of more than 24 hours had a headache, which did not require analgesia.

TtmBS, O. N., and POTTER, J. M. (1970), 'Ear ly Post Concussional Headache ', Lancet, 2, 128.

Intracranial Pressure Changes after Head Injury Ventricular catheters were inserted through burr-

holes in 32 victims of severe head injury to allow the ventricular pressure to be compared with systemic arterial pressure. Ventricular pressures fell into three groups: normal, moderately, and much increased, all of which showed high mortality-rates. There was no constant or reliable correlation between arterial and ventricular pressure and neither mannitol nor surgical decompression could be relied on to lower ventricular pressure. Removing ventricular cerebrospinal fluid was very effective.

Clinical evidence could not be relied on to indicate the intracranial pressure after severe head injury,

250 INJURY" THE BRITISH JOURNAL OF ACCIDENT SURGERY Injury Jan. 1971

which makes it all the more desirable to have certain knowledge of the ventricular pressure and the means of lowering it by aspiration when other methods fail.

JOHNSTON, I. H., JOHNSTON, J. A., and JENNETT, B. (1970), 'Intracranial-pressure Changes following Head Injury ', Lancet, 2, 433.

Intracranial Pressure Monitoring The report is based on a total of 1500 hours of

recording in 11 patients with cerebral tumours and 3 with head injuries. The particular value after head injury lay in the fact that paralysis and artificial ventilation no longer made it impossible to recognize that intracranial pressure was rising. In one case it was found that over-ventilation succeeded in lowering intracranial pressure when urea had failed to do so. The authors had the impression that accurate know- ledge of intracraniai pressure improved the results of treatment but stated that to prove this would require many more cases.

RICHARDSON, A., HIDE, T. A. H., and EVERSDEr4, J. D. (1970), 'Long- term Continuous Intracranial- pressure Monitoring by Means of a Modified Sub- dural Pressure Transducer ', Lancet, 2, 687.

Treatment of Whiplash Injuries by Nerve-block At the 119th Annual Convention of the A.M.A.,

Dr. Tenicela told the Section of Anaesthesiology of his experience with nerve-block in the treatment of 81 persons whose whiplash injury symptoms had failed to respond to accepted forms of treatment. In the first place isotonic saline was injected into the stellate ganglion. I f this failed another injection using mepi- vacaine was performed. If pain continued cervical nerves or brachial plexus blocks were used. Seventy- five per cent of these patients were relieved of all (40 per cent) or nearly all (35 per cent) of their pain.

TENICELA, R., and CooK, D. R. (1970), ' T h e Treatment of Whiplash Injuries by Nerve-block ', J. Am. reed. Ass., 213, 212.

Fracture-dislocation of the Zygoma A review is made of 196 patients with fracture of

the zygoma treated over a period of 20 years. Wire- pin fixation was used in 24 per cent of these cases by means of a Kirschner wire inserted across the face with a power drill. Several pins may be required to gain full stability and the maxillary antrum may need internal support by packing. In all the cases treated with Kirschner wires solid union was obtained.

FRYER, M. P., BROWN, J. B., and DAVIS, G. (1969), ' Internal Wire-pin Fixation for Fracture Dislocation of the Zygoma ', Plastic reconstr. Surg., 44, 576.

Supraorbital and Glabellar Fractures In acute injuries of the face with supraorbital and

glabellar fractures surgical exploration was performed as an emergency if significant depression of the contour was suspected. No great reliance was placed on radiographs which were found to be unusually misleading. Bone fragments were preserved, replaced under direct vision, and fixed if need be by interosseous wires. Bone-grafts and foreign-body implants were never inserted primarily, but reserved for secondary reconstructive repairs. The author 's experience of 36 patients with this type of injury is given in detail.

SCHULTZ, R. C. (1970), ' Supraorbital and Glabellar Fractures ', Plastic reconstr. Surg., 45, 227.

T E N D O N S A N D L I G A M E N T S

Prevention of Boutonnitre Deformity The authors advocate early (if not immediate)

repair of the severed middle slip of the extensor mechanism in those cases in which primary suture of the middle slip is eitherimpossible or impracticabledue to the condition of the tissues. If the middle slip is avulsed or absent, no attempt is made to repair it. The two lateral bands are dissected free from the oblique and transverse retinacular ligaments, slit longitudinally for about 2 cm., and their middle seg- ments sutured together over the middle phalanx with 5/0 silk. Satisfactory results have followed this method of treatment in the few cases (no number is given) in which it has been tried.

AIACHE, A., BARSKY, A. J., and WEINER, D. L. (1970), ' Prevention of the Boutonniere Deformi ty ' Plastic reconstr. Surg., 46, 164.

Rotator Cuff Tears The results of repair by several surgeons of 71

rotator cuff tears are recorded by two Toronto surgeons. Seventy-seven per cent had significant relief from pain; 4 out of 5 complained that the operation had not improved shoulder movement and that the shoulder was weak; 20 of the shoulders were classified as grossly unsatisfactory; over half the patients could not abduct the arm to 90 ° or maintain this position against weak resistance. The authors conclude that the poor results are partly due to the poor state of nutrition of the rotator cuff and suggest that the supraspinatus muscle advancement technique of Debeyre, Patte, and Elmelik should theoretically give better results. Since the patients studied were all compensation minded, the reader feels that this may have at least some bearing on the results.

WEINER, D. S., and MACNAB, I. (1970), ' R o t a t o r Cuff Tears ', Can. J. Surg., 13, 219.

INJURY proposes to publish a series of invited contributions under the general heading of 'Accident Services Today '. Comment and correspondence on this subject will be published concurrently as appropriate.