THE AUSTRALASIAN SOCIETY FOR INFECTIOUS DISEASES

scanners (per million population) are similar in Australia to those in most developed countries (except for U.S.A. and Japan, which have many more of both). What is different in Australia is the greater distance between many primary surgeons and the specialist units. What evidence is there for the assertion that head injured patients frequently sustain a second episode of brain damage after the impact-and that this can often be prevented by more expeditious medical care? The Glasgow studies have shown that onethird of patients dying after head injury in a neurosurgical unit talked at some time since injury-evidence that the impact damage was not overwhelming. ' In two-thirds of these cases (and in half of all neurosurgical deaths) it was considered that one or more potentially preventable factors had contributed to death. ' 4 These factors related to intracranial complications in two-thirds of cases-usually delayed or inappropriate management of intracranial haematoma, of intracranial infection or of status epilepticus. Extracranial factors were related either to multiple injuries and their complications, or to the consequences of the comatose state; these included hypoxia, hypotension, anaemia and hypercarbia. An American study has confirmed the frequency of these factors" 6 and has emphasized that they threaten to aggravate the brain damage already caused by head injury. War is a stern teacher, and doctors learn much about the management of trauma on the battlefield. Too often these lessons fail to be adapted and adopted in civilian life. What was found with combat injuries of the head was that results were much better when front-line care was limited to first aid, and every effort was then made to ensure early evacuation to neurosurgical units in base hospitals. In Australia a disproportionate number of head injuries (and of deaths from such injuries) occur in rural areas, where general practitioners and surgeons have a commendable independence, on the basis that distance often makes transfer to specialized regional units impractical. However, it may be timely, in the light of improved methods of retrieval and transportation of the severely injured, to reconsider the policy of "going it alone" with those head injured patients whose chances of survival, and of recovery without disability, may be greater if they are treated by specialists. Information about the frequency and geographical distribution of injuries of varying severities is needed before plans for their care can be made. Epidemiological surveys of head injuries have recently been initiated in several countries, as it has been realized that head injuries constitute a major health problem. A nationwide study in Scotland (with a population of five million) has set the style for such studies;7·' a similar ones are now being carried out in selected populations in the U.S.A. and one is being completed in New South Wales under the auspices of the Australian Neurological Foundation. What is striking about the comparison between the preliminary results of these studies is how similar the pattern of head injuries is in such different geographical settings; most local variations depend more on differences in the organization of care than on biological factors. Such surveys provide a proper basis for initiating discussions between neurosurgeons, primary surgeons, general practitioners and administrators about planning for the care of head injuries. Much could be done to reduce mortality and morbidity by the reorganization of existing facilities, without the need for major expenditure or new facilities. What is required is definition of the problem, agreement about the way to deal with it, and then education and exhortation to ensure that everyone concerned knows the rules of the game. The aim is to identify soon after injury those patients who have risk factors for secondary complications, and then to have such patients transferred rapidly to centres able to cope with the investigation and treatment of these