Head Injuries

NZMJ, 1926

By Carrick Robertson, M.B., F.R.C.S.

With the remarkable increase in motor traffic, there has been a coincident increase in the number of head injuries. At the Auckland Hospital during the last year over 100 cases have been admitted.

But these head injuries are not only occurring in the larger towns, they must be occurring in the practice of all of us, and as they are of such serious import, not only in their immediate mortality, but in the remote effects on those that recover, it would seem to be of no small importance that at our Annual Meeting we should discuss the ways and means of dealing with these cases. Moreover, a considerable amount of work has been done during the last few years in working out the problems presented by these cases.

Although our profession has always taught and recognised the inherent possibilities of catastrophe in every case of head injury, it would seem that in the past this type of case has received too much of what we are pleased to term “expectant” treatment ; with the result that if they recover, an almost worse fate is in store for them.

How often, when an epileptic is brought to us, does the mother relate a history of “concussion” as being the predecessor of the fits, and as there are often some years between the accident and its alleged effect, we have been inclined to sweep these histories aside, more especially when we remember how common such accidents are in the life of every child. Surely these histories should receive more consideration—not that they will help us to cure this particular patient—but that it may impress on us the importance of seeing that our next “concussion” patient shall have the fullest investigation, for, any so-called concussion which lasts for more than a few minutes is due to brain laceration with effused blood, the unconsciousness being then caused by compression, and requires more treatment than a few hours in bed and a dose of castor oil. The old term “concussion” should be kept for those cases which show only a minute or two of unconsciousness. Concussion is the same thing as shock—the shock being caused by the sudden compression of the cranial components (the brain being incompressible) the force causes a displacement of the blood and cerebro-spinal fluid—resulting in a sudden acute anaemia of the medullary centres with instantaneous suppression of all vital processes. In a mild case the medullary centres soon re-establish themselves and consciousness quickly returns.

The old theory of concussion being due to a series of punctate haemorrhages is not now generally held. It is not unlikely that, in some of these cases of so-called concussion, a careful radiological examination would have revealed a fracture of the skull, and although I am fully aware that a fracture of the skull is only important when it can be demonstrated that the cranial contents themselves have been injured, it is at least a guide as showing that what may have appeared a trivial fall from an apple tree is really a serious accident.

In trying to find some statistics as to the frequency of epilepsy and other psychoses after cranial injury in the literature at my disposal I have found most conflicting results—in epilepsy, for example, it varies from 2 per cent. (Neuhof) to 12 per cent. (Frazier) up to 70 per cent. (Villandre). In a series of 52 cases of Coleman’s, 31 per cent. had epilepsy or epileptoid condition, and he notices that there was noticeably less epilepsy in these cases which were operated on. This agrees with my own impressions that the subsequent psychoses are less when the patient has been treated by operation or lumbar puncture than when they have been allowed to recover with rest alone. Cases of injury in the fronto-parietal region are much more liable to epilepsy than those having injuries in other regions of the skull. It is also strange that an apparently slight injury—viz., one with no fracture and only a passing hypertension—may develop a permenant cerebral affection.

Eagleton, a recognised authority, gives it as his opnion that traumatic epilepsy is generally preventable by early operation.

Before dealing with a few of the points in the management of head injuries, we must not forget that all these cases are liable to develop an increased intracranial tension, which may be cause by intracranial haemorrhage, such as ruptured meningeal artery, or more commonly, by an oedema of the brain from contusion. The gravity of any heady injury case depends upon the amount and duration of this increased tension, for it produces cerebral compression. It is, therefore, necessary to have a clear understanding of the effects of this on the patient before we are in a position to deal with a case of cranial injury.