The Sequelae of Head Injuries*
FROM THE MIDDLESEX HOSPITAL, LONDON
THE DIAGNOSIS AND treatment of head injuries is Sequelae of Organic Neurological Defects
directed not only to the immediate manifestations These deserve consideration. Amongst the most
of injury but also towards the prevention of important are
sequelae. (1) those due to damage to the brain or the pro-
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It is true that the majority of patients ultimately
make a complete recovery, although this is often (2) permanent loss of function of one or more
at the cost of prolonged morbidity and occasion- cranial nerves,
ally of partial or complete incapacity. (3) post-traumatic convulsions.
About 35,000 individuals are admitted to hos-
pital in the United Kingdom each year on account Permanent Damage to the Brain
of head injuries; 75 per cent result from road The result of this naturally depends on the area
accidents, the rest from accidents at work, at home involved. From the patient's point of view the
or at play. Consequently cases of brain injury, most serious effects are :
for that is, as has already been stressed, the im- (a) weakness or spasticity of one side of the
portant aspect of these cases, are widely dis- body, always associated with abnormal re-
persed. We, who are charged with the privilege flexes and often with some sensory disorder,
of teaching, have only ourselves to blame if there (b) ataxia and cerebellar incoordination,
are doctors less aware than they should be of the (c) speech defects which are rarely as circum-
diagnosis and management of acute brain injuries scribed as in vascular lesions and consequently
and of the recognition of complications needing more likely to make a slow and incomplete
surgical intervention. recovery.
Sepsis Permanent Loss of Function of Cranial Nerves
In mentioning this I would note that the most Damage to the olfactory nerves or bulbs may
simple head wound may be deceptive and, especi- occur in the absence or presence of cerebro-spinal
ally when there is a fracture, may result in osteo- rhinorrhoea after injury to any part of the head :
myelitis of the skull, an extra- or subdural abscess, it is most common in occipital and frontal
localized or generalized meningitis or a brain injuries, which are usually severe as judged by
abscess. The danger of these is minimised, of the length of post-traumatic amnesia and the
course, by. the proper care that goes with under- length of time in hospital, followed often by pro-
standing of their possibility. In this respect, refer- longed ill-health and permanent disability to be
ence must be made to Cairns' (1937) and Calvert's ascribed to the accompanying frontal lobe injury
(1942) work in relation to fractures of the cranial (Leigh, 1943). Associated loss of taste is in-
wall of the frontal and ethmoidal sinuses. In constant (Leigh, 1943). Recovery of smell is not
some of these there is slight and fleeting rhinor- common and only occurs within the first six
rhoea so that repair of the dural tear that exists months. If we say little of the loss of some of
is regarded as unnecessary; these workers con- life's savour from anosmia and aguesia, we must
sidered this policy indefensible for they recorded remember the increased hazards to life for
the development of brain abscess or meningitis ordinary people unable to smell and more especi-
months or years after the cessation of evanescent ally for chemical workers.
rhinorrhoea. Furthermore, in some of their Blindness may occur at the time of the injury,
cases, there was no such history nor was there usually of slight severity; visual loss may be
radiological evidence of air within the skull and partial. In the majority of cases the cause is
yet two-thirds of the cases in this group died from damage to the vessels supplying the optic nerve
abscess or meningitis. The need here is for special or chiasma, but when the onset of traumatic
x-rays designed to demonstrate the sole indication blindness is delayed it may be that there is a
for repair. fracture of the optic foramen with pressure on the
* Read to a Joint Meeting with the A.I.M O of Ireland in
nerve by callus; fibrous tissue or progressive
Dublin, on 12th July. 1955. arachnoiditis may produce the same effect. In
these cases decompression of the nerve should be gical complications which call for further investi-
done early for little improvement can be expected gation and sometimes for surgery.
once optic atrophy has occurred and certainly Late epilepsy appears after apparent recovery
none after a month. and is due to cerebral or meningo-cerebral scars,
Diplopia as an early symptom but without de- to traumatic cysts, to abscess, foreign bodies or
monstrable weakness of the 3rd, 4th or 6th occasionally to a chronic subdural haematoma.
cranial nerves is probably caused by circulatory Post-traumatic epilepsy is not frequent in peace-
disturbances in the brain-stem causing incoordina- time for the obvious reason that dural penetration
tion of eye movements. It is usually of short and gross cerebral damage with the added risk
duration. When a squint, not previously present, of infection are so much less common. Whether
is obvious the trunks of the nerves have been in- in peace or war inadequate surgery increases the
jured and recovery is doubtful if it has not begun incidence.
within three months. This is a serious disability Doubt has been thrown (Garland, 1942) on the
especially in precision work and in that needing common conception of traumatic epilepsy as a
appreciation of speed and distance. focal phenomenon. Recent work by Penfield
Permanent injury to the main branches of the (1954) has, however, brought many more cases of
trigeminal nerve is rare ; intractable pain may, generalized epilepsy into the focal category, a
however, develop in the maxillary division after a finding of immense significance in treatment.
basal fracture and requires an alcohol injection to The prognosis in post-traumatic epilepsy is not
control it. The supra-orbital nerve may be simi- always gloomy but becomes worse the longer the
larly affected, but numbness over its distribution latent period.
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is more common and resolves with time. The treatment of post-traumatic epilepsy is
The facial or auditory nerves may be damaged primarily medical, by advice as to conditions
by fractures through the petromastoid: there is known to favour or inhibit attacks, by suitable
haemorrhage into the middle ear. Immediate employment and by appropriate drugs. Surgery
facial paralysis is rare as is recovery from it, in should be. considered where there is a surgical
contrast to the more common delayed paralysis lesion or where medical treatment has failed :
appearing one to four days after injury and it should only be undertaken where special facili-
usually recovering in one to three weeks. ties for investigation exist. Absolute contra-
Degeneration of the nerve is very rare and when indications are extensive neurological involve-
it occurs regeneration takes three to four months. ment, mental deterioration, chronic infection and
The cause is probably compression of the nerve general debility.
by haemorrhage in the facial canal. In those
cases where no recovery takes place, anastomosis Skull Defects
with the 12th nerve should be considered. In the absence of dural defect or sepsis, these
Deafness is an important sequel: loss of hear- are not serious. They can easily be remedied by
ing may be partial or, when the inner ear is in- simple repair with tantalum, acrylic resin or auto-
volved, complete and permanent, together with genous bone. This needs to be done when a
vestibular disturbances. True vertigo is rare and man's life is made incomplete on account of
is probably due to haemorrhage into the labyrinth. deformity or a sense of insecurity. It is a very
An audiogram is necessary to determine the type different matter where wounds are not soundly
and- degree of deafness, and caloric tests and healed or have not done so by first intention,
objective evidence for appreciation of vestibular for to re-open them may activate latent infection.
dysfunction. In older people it is necessary to
confirm statements about their hearing before the Mental Disturbances
accident. It is well known that these, and rarely malinger-
ing, occur after head injuries. The subject of
Post-traumatic Convulsions post-traumatic psychotic states has become very
These may occur at any time after a head important with the increase of industrial and road
injury and because the pathological state of the accidents, the development of industrial compen-
brain is entirely different, according to the time sation and of laws tending to place the responsi-
of their appearance, it is convenient to divide bility for the accident and the ensuing injury.
cases into immediate, delayed or late. Observations about the mental state before the
In the immediate group, convulsions occur accident are usually missing so that it might be
from 12-24 hours after injury and are due to con- well if all new employees had a careful neuro-
tusions or lacerations, to haemorrhage outside or logical and psychological examination.
within the brain, to pressure from depressed frac-
tures or irritation from penetrating fragments, to Post-contusional State
oedema and to the beginning of sepsis. It is I intend to give most attention to this " no-
interesting to record that in a series of 362 cases man's land", and I am at one with Symonds
of simple, uncomplicated concussion at Montreal (1942) in opposing the division of the features in
there was not a single case with fits (Penfield this condition into organic and functional. The
1941). patients have a variety of complaints with little
Delayed convulsions occur in 2-4 weeks and are in the way of signs. More than one observer
to be related to the healing process or to patholo- (Symonds, 1942; Strauss and Savitsky, 1937) has
commented on the inherent difficulties of this prob- results as is seen with the patients in the second
lem and their aggravation by lack of thorough group, who have made a reasonable recovery and
clinical examination in the early stages, and of returned to useful work : later they break down
adequate records. and complain of persistent headache. In these
The case should be regarded as a new one and cases it is assumed that the psychological factors
more attention paid to the pre-traumatic per- which precipitated the headache had been mini-
sonality and intellectual level and to inherited or mised by correct medical and surgical treatment
latent predisposition to mental disturbance than in the acute stage and during convalescence, by
to a protracted neurological overhaul. In con- early settlement of worries and reassurance as
sidering the post-contusional state the individual's well as by appropriate rehabilitation.
adjustment, responsibilities, plans and ambitions There are clearly two variables: the nature of
before the accident must be compared with the the pain and the mental stature of the patient.
changes in his living conditions, work and pros- It is quite wrong to disregard these subjective
pects thereafter. complaints, which have a physiological basis, and
Rowbotham (1949) has drawn a beautiful and to do so may retard the patient's recovery. In
sympathetic clinical picture of the man who com- forestalling these problems we are torn between
plains of the results of a head injury, with liti- an adequate rest period and the desirability of
gation at stake. He describes the slow and hesi- early return to normal activity, knowing well that
tant entry of the patient into the consulting-room, to prolong inactivity unduly serves only to create
his aimless attitude and indifferent expression in an abnormal mental attitude on the part of the
the presence of a wife, as profoundly unhappy as patient towards his injury.
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himself, but who, in becoming the initiator of The electro-encephalogram is of considerable
action and the mouthpiece for them both, stresses value in determining the rate of recovery and
the profound mental and physical change and the possibility of sequelae. In all cases of significant
loss of interest and memory. The patient is con- brain injury abnormalities are invariable: in mild
vinced that nothing can, be done for him and can injuries, they are fleeting. The severity and per-
only be persuaded to define his difficulties reluc- sistence of dysrhythmic activity depends on the
tantly. Emotional episodes and expressions of severity of the injury. Improvement in successive
despair punctuate the slow and easily interrupted electro-encephalograms usually runs parallel with
process of undressing. The gait is deliberately clinical improvement. If, however, improvement
slow. There is caution in turning and often stops or the abnormality increases, prognosis for
tremor. In short, mental and physical sluggish- recovery is poor and permanent sequelae are
ness and changes in disposition dominate the find- likely.
Although no sex or age is immune, this state Conclusions
is most common in young and middle-aged adults. When we consider the mechanism of head in-
The outstanding features are headache, dizziness, jury, it is not surprising that there is such a rich
inability to concentrate, fatigue, changes in dis- variety of sequelae. At one end of the scale are
position, loss of zest, insomnia and mental retar- those due to organic structural changes, at the
dation, usually without any abnormal neuro- other the purely psychological, with the post-con-
logical findings. tusional state lying in between. It is, therefore,
Rowbotham (1949) recognizes two groups. In essential that these patients be cared for by en-
one the patients are incapacitated by headache lightened people aware of the complex nature of
and remain so from the time when consciousness their disabilities. Amongst these are already in-
is recovered, although it is as rare for them to be cluded those employers in industry who have had
explicit about its character as for the headache to the wisdom to appoint medical men and women
be unaccompanied by other symptoms. The with such qualities of heart and head that each
problem is complicated by the fact that many of individual who has suffered injury is assured of
these patients are awaiting some kind of com- all the help and understanding that go to re-
pensation under the Workmen's Compensation establishmerit in the work-a-day world.
Act, at civil law or by private arrangement. It
is a problem that demands considerable expendi-
ture of time if we are to arrive at correct diag- References
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is important that the doctor understands the illness GARLAND, H. G. (1942). Proc. R. Soc. Med., 35. 773.
and has his patient's confidence, that there is early LEIGH, A. D. (1943), Lancet, i. 38.
PENFIELD. W. AND ERICKSON. T. (1941). Epilepsy and
and satisfactory settlement of litigation, that a Cerebral Localization. Springfield. 111.: Chas. C. Thomas.
subdural haematoma or hygroma be eliminated, PENFIELp, W. AND JASPER. H. (1954). Epilepsy and the
Functional Anatomy of the Human Brain. Boston: Little,
that the patient be removed from surroundings Brown and Co.
tending to perpetuate his symptoms and that he ROWBOTHAM, G. F (1949). Acute Injuries of the Head.
Edinburgh: E. and S. Livingstone. '
has correct rehabilitation. These principles are STRAUSS, I. AND SAVITSKY, N. (1937). N.Y.SUMed.. 37.
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