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The need for specialists cannot be adequately assessed on the basis of current practice and an estimated case-load (based on prevalence/population ratio). Specialists should declare which patients can or cannot be expected to benefit from their treatment, and they should consider the consequences of underprovision of specialist services. Specialists should also decide how much of what they normally do might equally well be carried out by generalists using the knowledge of specialists. Only then can the appropriate level of provision for various specialties be assessed, and effective deployment of the resources provided ensured.

A survey was made of all patients in general surgical, urological, and orthopaedic and accident wards in Glasgow on one day in June 1975. Its purpose was to define features of acute surgical practice of relevance to the future planning of resources, particularly bed numbers. Over 40% of the patients in both surgical and orthopaedic wards were over 65 years. Most patients had serious conditions and could not have been treated other than by admission to an acute surgical ward. But a substantial minority no longer needed such facilities and could have been transferred to second-line beds, although many still required skilled nursing care. Delay in the discharge of elderly patients from acute surgical wards as a consequence of non-surgical (often medical or social) problems results in a proportion of acute surgical beds fulfilling a second-line function. Unless arrangements for the earlier discharge of these patients are made any reduction in acute surgical beds is likely to restrict elective surgery, especially in orthopaedics.

Clinical data available in the first few days after severe head injury have been collected prospectively on 600 patients from Glasgow and the Netherlands and stored on computer; the patients in the two countries were similar in initial severity and in their outcome on a defined scale at 6 months. Calculated predictions of outcome were made in 200 randomly selected cases, using Bayesian statistics to compare the data from each patient with those from the 400 remaining cases whose outcome was known. Confident predictions (greater than 0-97 probability) were made in 44% of cases within the first 24 hours of coma, and in 52-61% when data up to 3 days were available. The higher confidence-rate occurred when prediction was limited to two outcomes (death or survival). Comparison of predicted with actual outcomes showed that 96-98% of confident predictions were correct. More logical clinical decisions should be possible when these predictions are available.

Cerebral blood flow (CBF) measurements were carried out in two groups of anaesthetized normocapnic baboons. In the first group of five animals the effect of hypoxia on the CBF before and after ipsilateral carotid artery ligation was studied. The results showed that, although after ipsilateral carotid ligation there was little change in the CBF at normal PaO(2), at hypoxia there was only 20% rise in the CBF as compared with an 80% rise before the carotid ligation. In the second group of 10 animals, effects of haemorrhagic hypotension on the CBF after ipsilateral carotid artery ligation were estimated. The results indicated impairment of autoregulatory response of the cerebral circulation.

Universities, especially those with medical schools whose academics engage in clinical research, have a vital role in shaping the way in which medical technology is used. Academic clinicians are a bridge between laboratory research, where new technologies are developed, and clinical practice, where these technologies are applied in treating patients. Academic clinicians are particularly suited to doing clinical assessment of medical technologies, and academic clinical departments should devote more time to the assessment and application of technology on a broad scale.

The relationship between clinical features of brain dysfunction in the first week after severe head injury and outcome 6 months later has been analyzed for 1000 patients. Depth of coma, pupil reaction, eye movements, and motor response pattern, and patient age prove to be the most reliable predictors. The degree of brain dysfunction changes markedly soon after injury, and more reliable predictions of outcome result when assessment is based on the best level of functioning recorded in each early epoch. Predictions based on very early assessment are, therefore, often unduly pessimistic. Individual predictions of outcome, based on a large data bank, provide a powerful tool for assessing the relative efficacy of alternative treatments.

To find the incidence of the various types of head injury that occur in the community separate yearly rates (per 10(5) population in Scotland) for deaths, admissions to hospital, and attendance at accident and emergency departments were estimated and compared (when possible) with rates in England and Wales and the United States. Hospital admissions provide the best data for comparing incidences in different geographical areas and rates of attendance at accident and emergency departments the most reliable guide to incidences in the community. Admission rates, however, vary with local facilities and policies, and these also determine the proportion of patients referred to regional neurosurgical units. Such epidemiological data must be sought both for planning health care for head injury and for monitoring the effectiveness of services.

Prognosis depends on establishing a relationship between the patient's state in the early stages and the ultimate outcome. Both the severity of the initial damage (including early complications) and the degree of recovery need to be defined, but practical and statistical considerations impose a limit on the number of variables which can be manipulated. Variables chosen should be those likely to be relevant, and pilot studies are more reliable than intuition in indicating which items should be included. Data chosen should be of a kind likely to be readily available for most patients and should not therefore depend on complex laboratory investigation. The most reliable indicant of initial severity appears to be the depth and duration of coma or altered consciousness, and a scale has been devised for measuring these. Measures of outcome should include separate assessment of mental and physical disability as well as the overall social consequence of the brain damage. Prognosis should be expressed as the probability (mathematically expressed) that a patient will reach certain defined outcome categories, five of which are recognized in the present study. Predictions should begin only after initial resuscitative measures are complete (say six hours after ictus); they need not be limited to the early stages but can include estimates of the degree of further improvement expected in the light of progress in the early weeks after injuries. New methods of management cannot be critically assessed unless factors influencing prognosis are reliably identified and can be matched in comparative patient groups. An estimate of prognosis is also required for the selection of patients for intensive treatment, both in the acute and in the rehabilitation stage. Without such data there is a tendency to deploy an unduly high proportion of scarce resources on patients who have little prospect of recovery; this may deny the best chance of recovery to patients with severe, but less overwhelming, brain damage.

We reviewed 116 patients, known to have talked before dying after head injury, to discover factors which had contributed to death but which might have been avoided. All the patients were admitted to a neurosurgical unit and had a neuropathological post-mortem examination. One or more avoidable factors were identified in 86 patients (74%); an avoidable factor was judged certainly to have contributed to death in 63 patients (54%). The most common avoidable factor was delay in the treatment of an intracranial haematoma; others included poorly controlled epilepsy, meningitis, hypoxia, and hypotension. Changes in the management of patients with head injuries which reduce the incidence of avoidable factors should decrease mortality from this condition.

EEGs from 722 patients with injuries associated with a high risk of late traumatic epilepsy were analyzed. Although abnormal records were more common in patients who developed epilepsy, they reflected the more severe brain damage in these patients, which was already evident from clinical features. In individual patients the EEG does not improve the accuracy of the prediction calculated from clinical data. Patients with persisting or newly developing EEG abnormalities may never have a fit, while 20% of those with late epilepsy had at least one normal record in the first 3 months after injury. The conclusion that the EEG does not contribute usefully to the prediction of traumatic epilepsy appears to reflect a consensus among recent writers on the subject.

Criteria for transferring head injured patients to a regional neurosurgical unit were changed to enable a larger proportion of patients admitted to primary surgical wards to have a CT scan. The yearly number of transfers doubled, more intracranial haematomas were detected, and mortality from this complication was reduced. To operate such a policy requires seven neurosurgical beds per million for head injuries, given the Glasgow practice of early return of patients to primary surgical wards.

The review examines the variations in surgical practice and assesses the value of surgical audit in quality control and allocation of surgical resources.

Acute intracranial haematoma significantly increases the incidence of traumatic epilepsy, both early (first week) and late. Early epilepsy can cause diagnostic and management problems, while late epilepsy may produce persisting disability.

Ranking of head injuries by severity is an essential part of clinical management, of prognosis, of treatment trials, and of legal assessment for compensation. Various methods of assessing severity are reviewed. No one scale is appropriate for all types of injury, or in all circumstances. A check list is provided which should enable every injury to be assessed; its use would facilitate comparison between individual cases of head injury, and between reports from different studies.

Carotid endarterectomy and EC/IC bypass grafting have been widely adopted for patients considered at risk from stroke, without good evidence of efficacy. Unjustified claims for surgery usually derive from overestimating the dangers of the disease without surgery, while perioperative risks are underestimated. Inadequate follow-up and choosing irrelevant outcome measures often add to the confusion. All these factors apply to surgery for stroke. A trial of EC/IC bypass in 1,377 patients from three continents took 8 years to complete and showed no benefit in patients randomized to surgery. Reluctance to accept this result led to detailed critiques of this trial in several journals, largely based on the discovery that many patients had been operated on in some centers without having been randomized. In reply, the investigators showed that these cases did not affect the "resounding negativity of the results." Lack of good data about the prognosis of patients with TIAs or minor strokes was the fundamental reason for so much misplaced surgical effort. This applies equally to carotid endarterectomy, for which large trials are currently being completed. Had there been a reliable data base of patients at risk of stroke, prospectively collected and followed, the efficacy of these two operations could have been determined much sooner, and inappropriate diffusion might have been prevented.

The features of 3500 patients with head injury who attended accident and emergency departments in Scotland during 1974 are described. These represented 10 per cent of all attenders at these departments. Recent alcohol consumption was noted in 25 per cent of adult males; this was commonest amongst those who were victims of assault or pedestrians involved in traffic accidents. Forty-one per cent of patients had scalp wounds; 58 per cent had radiographs of the skull taken and of these 2.7 per cent had fractures of the skull. Although 20 per cent of patients had altered consciousness at some time, only 5 per cent showed any evidence of impaired consciousness when seen at hospital. Twenty-three per cent of those attending were admitted to hospital. Criteria which are important when assessing whether a head-injured patient should be admitted to hospital are listed.

Methods for assessing early characteristics and late outcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarity between the initial features of patients in the three series; in spite of differences on organisation of care and in details of management , the mortality was exactly the same in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.

Mechanical ventilation frequently saves lives that are threatened by temporary respiratory failure; but when breathing stops due to irreversible brain damage ventilation only prolongs the process of dying, as organs serially cease to function. The possibility of extending from a few minutes to many days the interval between final failure of the brain and ultimate cardiac asystole emphasises that death is not an event, but a process.

The Glasgow Coma Scale, based upon eye opening, verbal and motor responses has proved a practical and consistent means of monitoring the state of head injured patients. Observations made in the early stages after injury define the depth and duration of coma and, when combined with clinical features such as a patient's age and brain stem function, have been used to predict outcome. Series of cases in comparable depths of coma in Glasgow and the Netherlands showed remarkably similar outcomes at 3 months. Based upon observations made in the first 24 hours of coma after injury, data from 255 previous cases reliably predicted outcome in the majority of 92 new patients. The exceptions were patients with potential to recover who later developed complications: no patient did significantly better than predicted.