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cerebrate or decorticate posturing, hypertension, bradycardia have appeared The use of decompressive craniectomy in patients with progressive and intractable traumatic brain swelling has been a subject of renewed interest in recent years, after having been practically abandoned several decades ago Guerra and colleagues have reported on 57 such patients, mostly young adults, who underwent wide frontotemporal craniectomy, unilateral in 31 and bilateral in 26 Of these, 11 patients died, 5 remained in a persistent vegetative state, and 6 survived in a severely damaged condition; however, 33 patients (58 percent) attained surprisingly good states of rehabilitation These authors were of the opinion that these results represented a signi cant improvement over the expected outcome in this particular group of patients Similar results in children have been reported by Polin et al The few cases with which we have been involved, mostly children operated late, have not been as encouraging, but the procedure deserves further evaluation, especially in younger patients The treatment of other problems attendant on protracted coma has been outlined in Chap 17 Each patient presents unique problems that must be dealt with individually

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In respect to severe head injury, as has been intimated, the outcome is particularly discouraging Some aspects of prognosis have been mentioned earlier but the following general comments serve to frame the problem In the survey of the large European Brain Injury Consortium, comprising 10,005 adult patients, the injury proved fatal in 31 percent; 3 percent were left in a persistent vegetative state, and 16 percent remained severely disabled neurologically (Murray et al) Data from the extensively analyzed Traumatic Coma Data Bank are comparable (Marshall et al) The signs of focal brain disease, whether due to closed head injuries or to open and penetrating ones, tend always to ameliorate as the months pass A hemiplegia is often reduced to a minimal hemiparesis or to an ineptitude of voluntary motor function with exaggerated re exes

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and an equivocal Babinski sign on that side, and an aphasia is gradually transformed into a stuttering or hesitant paraphasia or dysnomia that is not disabling except to a professional person, speaker, or writer Many of the signs of brainstem disease (cranial nerve dysfunction and ataxia) improve also, usually within the rst 6 months after injury (Jennett and Bond) and often to a surprising extent Most patients who had been in coma for many hours or days ie, those with severe brain injuries are left with memory impairment and other cognitive defects and with personality changes These may be the only lasting sequelae According to Jennett and Bond, these mental and personality changes are a greater handicap than focal neurologic ones as far as social adjustment is concerned In open head wounds and penetrating brain injuries, Grafman and coworkers found that the magnitude of tissue loss and location of the lesion were the main factors affecting the outcome The prognosis of head injury is in uenced by several other factors The age of the patient is the most important of these (Vollmer et al) Increasing age reduces the chances of survival and of good recovery Older patients often remain disabled, especially when compensation is involved Young and middle-aged ones do better, particularly if they are not entitled to compensation Russell has pointed out that the severity of the injury as measured by the duration of traumatic amnesia is a useful prognostic index Of patients with a period of amnesia lasting less than 1 h, 95 percent were back at work within 2 months; if the amnesia lasted longer than 24 h, only 80 percent had returned to work within 6 months However, about 60 percent of the patients in his large series still had symptoms at the end of 2 months, and 40 percent at the end of 18 months Of the most severely injured (those comatose for several days), many remained permanently disabled However, the degree of recovery was often better than one had expected; the motor impairment, aphasia, and dementia tended to lessen and sometimes cleared Improvement could continue over a period of 3 or more years Children seemed to recover more completely than adults.

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Although a closed-formsolutioncan be developed this case,thereare other funcfor tions that may be difficult or irnpossible differentiate to analyticallyFurther,suppose that there was some way to measurethe jumper's position at various times during the fall Thesedistances along with their associated times could be assembled a table of discrete as valuesIn this situation,it would be usefulto differentiate discrete the datato determine the velocity and the acceleration both theseinstances, In numericaldifTerentiation methods are availableto obtain solutions This chapterwill introducevou to someof thesemethods

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of Calculusis the mathematics change Because engineers scientists and must continuously deal with systems and processes clrange that calculusis an essential tool of our profession Standingat the heartof calculusis the mathematical conceptof differentiation According to the dictionary definition, to dffirentiate means"to mark off by differences; distinguish; to perceive difference or between"Mathematically, derivetthe in the tive, which servesasthe fundamentalvehicle for diff-erentiation, represents rate of change the variablewith respect an independent to of a dependent variable depicted Fig 19l, the As in mathematical definitionof the derivativebeginswith a difference approximation: Ay Ar