National Academies Press: OpenBook

Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon (1961)

Chapter: Electroencerphalography, Pneumoencephalography, and Psychometry

« Previous: The Chronic Neurological Deficit
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 77
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 78
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 79
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 80
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 81
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 82
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 83
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 84
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 85
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 86
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 87
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 88
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 89
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 90
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 91
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 92
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 93
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 94
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 95
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 96
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 97
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 98
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 99
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 100
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 101
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 102
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 103
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 104
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 105
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 106
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 107
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 108
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 109
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 110
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 111
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 112
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 113
Suggested Citation:"Electroencerphalography, Pneumoencephalography, and Psychometry." National Research Council. 1961. Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon. Washington, DC: The National Academies Press. doi: 10.17226/18529.
×
Page 114

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Chapter IV ELECTROENCEPHALOGRAPHY, PNEUMOENCEPHALOGRAPHY, AND PSYCHOMETRY A. INTRODUCTION The functions of the brain are commonly described in terms of the results of observations of nervous activity, psychological reactions, or cerebral morphology. Although none of these special examinations may indicate the degree of specific functioning of the brain, each or all may be disturbed by injuries of the head. It is recognized that these diagnostic procedures do not analyze or measure the same or even similar properties of cerebral function. Those most commonly employed are the electroencephalogram, the pneumoencephalogram, and psychometric examinations. In this chap- ter it is planned to analyze the influence of the neurological deficit on these yardsticks and to determine, as much as possible, the sensitivity of these criteria in evaluating the neurological deficit. Having done that, it is pro- posed to examine the factors which may influence recovery and which may give certain prognostic indications as to the amount of recovery which might be expected from a neurological deficit. B. ELECTROENCEPHALOGRAMS AND NEUROLOGICAL DEFICIT 1. Variability in Interpretation The electroencephalograms have been read by independent examiners in the four centers. That the interpretation of an electroencephalogram is not entirely objective but is influenced to a variable extent by the reader's subjective impressions which are not always based upon tangible clues, is generally recognized. When the study was organized, the desirability of having all tracings in- terpreted uniformly (possibly by several readers independently) was not fully appreciated. However, analysis of the results of examination revealed obvious gross differences between readers at the several centers. Thus, the proportion of tracings which were considered to manifest generalized ab- normalities varied between 10.1 percent and 27.1 percent at the four centers. At one center, no less than 88.2 percent of the tracings which were called "generalized abnormality" were diagnosed paroxysmal slow, while the highest such percentage in any of the other three centers was 34.1 percent and the lowest 22.2 percent. Similar differences, fortunately of smaller magnitude, were seen in the diagnoses of types of focal abnormalities. It was considered desirable, in the face of these findings, to have all trac- ings interpreted by a single reader, but this proved to be impossible since many of the records had been destroyed. However, in order to gain some idea of the amount and nature of the variability between different readers, 140 tracings obtained from other than the Baltimore center were independ- ently reread by Dr. Curtis Marshall and the results were compared. These 77

findings are presented here for their general interest and as background for the discussion of correlations between electroencephalograms and other observations. In table 86 data are presented for the comparison of the summary diagnoses. Here generalized and focal abnormalities are considered in- dependently, so that tracings judged to show both kinds of abnormalities are counted under both headings. Of the tracings considered by reader B to show generalized abnormality, reader A considered 60 percent to be nor- mal or borderline. Correspondingly, of the 12 that reader A considered to have generalized abnormality, reader B called 5 normal. The situation with respect to focal abnormalities was a little better: The proportions of each such reader's diagnoses called normal by the other reader were 46.2 percent and 26.9 percent, respectively. The types of generalized abnormalities diagnosed were, not surprisingly, somewhat different. Reader A observed 2 instances of dysrhythmia and 10 of slow waves. Reader B saw no generalized abnormalities in half of these tracings. There were but six tracings which both readers thought to show generalized abnormalities, and the comparative diagnoses were: Reader A Reader B 4 cases Slow Slow. Slow Dysrhythmia Types of focal abnormalities were as inconsistently diagnosed by the 2 readers even in the 18 tracings for which they agreed that focal abnormalities existed. Diagnoses were identical in seven cases: two of asymmetry, three of paroxysmal slow waves, and one each of asymmetry combined with paroxysmal slow waves and of slow waves. The other 11 were quite varied: Reader A Reader B 1 case Irregular Asymme try . 1 case Irregular Asymmetry plus other unspecified Paroxysmal slow Asymmetry. 1 case Paroxysmal slow 1 case Paroxysmal slow Asymmetry plus slow. 1 case Spikes Paroxysmal slow plus spikes. Asymmetry. The findings presented above indicate that the art of interpretation of electroencephalographic tracings is quite subjective. Without decrying the usefulness of such tracings in the clinical management of patients, or even in diagnosis, it seems clear that the state of the art is not entirely satisfactory for the purposes of general surveys, since there is apparently wide disagree- ment as to interpretive criteria. Nevertheless, affected as they are by sub- jective considerations, it turned out that correlations did exist between the 78

e .s e co I I "z & ooo O O"S fit o a a •o-n tl B n n o 8 § £OfK a f2

interpretations originally reported by the four centers and certain other observations. 2. Characteristic* of the Wound In the following discussion the EEG results are presented in three classes: those electroencephalograms which were normal or borderline, those which showed a generalized abnormality, and those which showed a focal abnormality. The last two groups are not mutually exclusive, and men with both generalized and focal abnormalities are, except in table 87, counted in both classes. Slightly more than half of the patients examined had a normal electro- encephalogram, and 9 percent had an electroencephalogram which was borderline (table 87). In terms of age of the patients, it is apparent that older men were more likely to have normal electroencephalograms than younger men, the latter having more of both focal and generalized abnor- malities (table 88). Statistically this is significant, and possibly may be correlated with a certain instability of the younger nervous system, which would appear to be more easily disturbed by the stress of a head injury. Table 87.—General Characteristics of Follow-up Electroencephalogram Interpretation of follow-up EEG Number Percent Normal 333 56.0 Borderline 54 9.1 73 12.3 98 16.5 Generalized and focal abnormalities 37 6.2 Total with EEG 595 100.1 No EEG at follow-up 144 739 Table 88.—Relation of EEG at Follow-up to Age at Injury Age at injury Number done Normal or borderline EEG at follow-up Generalized abnormality Focal abnor- mality Number Percent Number Percent Number Percent Total 595 387 65.0 110 18.5 135 22.7 18-20 107 157 131 90 65 45 67 87 84 66 48 35 62.6 55.4 64.1 73.3 73.8 77.8 21 37 27 13 8 4 19.6 23.6 20.6 14.4 12.3 8.9 28 46 30 15 10 6 26.2 29.3 22.9 16.7 15.4 13.3 21-23 24-26 27-29 30-32 >33

The severity of wounding, which may be examined in terms of a number of factors, obviously influences the electroencephalogram in a very positive fashion (table 89). It is worthy of note that the proportion of men with generalized abnormalities is much less affected by the overall severity of the injury (as measured by the R-I group) than the proportion with focal abnormalities. Groups 1 and 2 (which are alike in injury score but differ as to source, whether from Army hospital admissions or VA disability rosters) were quite similar with respect to electroencephalographic results. These groups have, therefore, been combined to examine in more detail die nature of the EEG abnormality in relation to severity of injury. Table 89.—Abnormalities of Follow-up EEG in Relation to R—I Group Interpretation of follow-up EEG Total 1 and 2 R-I group 3 4 Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total done 595 100.0 234 100.0 285 100.0 76 100.0 Normal or borderline 387 110 27 65.0 18.5 4.5 182 32 77.8 13.7 3.0 175 56 17 61.4 19.6 6.0 30 22 3 39.5 28.9 3.9 Generalized abnormality . . Irregular (dysrhythmia) . Slow (including parox- ysmal) 7 Other, including fast or spiky 88 14.8 29 12.4 39 13.7 20 26.3 20 135 6 62 4 65 12 15 14 3.4 3 24 1.3 10.3 .4 4.7 .4 3.4 1.7 1.3 .4 12 77 4 35 2 37 6 7 3 4.2 27.0 1.4 12.3 .7 13.0 2.1 2.5 1.1 5 34 1 16 6.6 44.7 1.3 21.1 1.3 26.3 2.6 6.6 Focal abnormality 22.7 1.0 10.4 .7 10.9 2.0 2.5 .7 Irregularity 1 11 Hypersynchrony Paroxysmal slow waves . . Paroxysmal fast waves. . . Spikes, spikes and waves . Other 1 8 4 3 1 1 20 2 15 It is also apparent from table 89 that to the extent that generalized abnormalities are more frequent in severely injured men, the cause is an increase in the frequency of slow waves (including paroxysmal slow waves) and in patterns characterized as fast or spiky. The types of focal abnor- malities which are more frequent in the severely injured men are asymmetry and paroxysmal slow waves, which are almost wholly responsible for the increased number of focal abnormalities previously noted. Focal spikes, or spike and wave complexes, are also increased, but the total frequency of these abnormalities is small. Irregularity, hypersynchrony, and paroxysmal fast waves are apparently not altered in frequency by the severity of injury, and it is perhaps justified to conclude that these abnormalities do not result from trauma to the brain. It is apparent that men with penetrating wounds have a much higher percentage of abnormal EEC's than other men (table 90). This difference •1

is quite significant. The penetrating and perforating wound groups have an excess of men with generalized abnormalities, but the really impressive difference is in the high proportion of focal abnormalities—only 5.8 percent for uncomplicated fractures but 30.1 percent for compound comminuted fractures, and 42.9 percent for perforating wounds. The region wounded does not seem to be highly correlated with the electroencephalogram. There is a suggestion that wounds of the parietal and occipital regions are somewhat more likely to produce focal abnor- malities than wounds of other regions. That the electroencephalographic abnormalities coincide with the site of wounding is not entirely correct, since it is apparent that the electroencephalographic abnormalities may be present in sites both adjacent to and some distance from the actual site of wounding. Table 90.—Relation of EEC at Follow-up to Type of Wound Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal abnormality Type of wound Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 595 387 65.0 110 18.5 135 22.7 Uncomplicated fractures . . 52 41 78.8 8 15.4 3 5.8 Compound comminuted fracture, penetrating wound 345 21 199 8 139 57.7 38.1 78.5 75 5 22 21.7 104 9 19 30.1 42.9 10.7 Perforating wound 23.8 12.4 Other, excluding fractures 177 The fact that the severity of injury, as reflected in the R-I groups, was strongly correlated with EEG abnormalities leads one to expect that the specific observations from which the injury score was built would also show close relationships with the EEG, and this is, in fact, true. The size of the cranial defect and the depth of the head wound (table 91) are both well reflected by the EEG results. Superficial wounding (of the scalp), penetra- tion of the cranium, or even of the dura mater, are relatively similar in the proportions attended by EEG abnormalities, but the brain waves of men in whom there was penetration of the brain are distinctly worse than those of men with more superficial wounds, while those of men with penetration to the ventricles seemed still worse. The difference between the last 2 groups mentioned is not statistically significant (only 22 men were coded as having penetration to the ventricles), but the first difference mentioned is highly significant. Complications of wounding which would tend to aggravate the damage to the brain might be expected to increase the proportion of abnormal elec- troencephalograms, but such is not the case with the possible exception of fungus cerebri. Men with ulcerating cerebral herniations have a 56-percent 82

incidence of EEG abnormalities, chiefly (46 percent) focal. The period of unconsciousness, which indicates only roughly the severity of wounding, as has been noted in chapter III, is but weakly related to the changes in the electroencephalogram. Men unconscious more than 1 day do have a sta- tistically significant, albeit small, excessive frequency of abnormality as compared with men unconscious 2 hours or less . There is, however, no significant difference between the EEG abnormalities in the men who did not show any impairment of consciousness and those who showed even consid- erable impairment (2 to 24 hours of unconsciousness). Table 91.—Relation of EEG at Follow-up to Depth of Head Wound Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal ab- normality Depth of wound Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 588 381 64.8 109 18.5 135 23.0 Scalp. . . ............ 179 109 16 262 22 138 83 11 141 77. 1 76.1 68.8 53.8 36.4 24 14 3 62 6 13.4 12.8 18.8 23.7 27.3 20 14 2 88 11 11.2 12.8 12.5 33.6 Cranial Dural Brain 8 50.0 Men who had an immediate neurological deficit of any character have significantly more abnormal EEG's than men with no deficit (table 92). All deficits are accompanied by elevation of the proportions, especially of focal abnormalities. Men with hemianopsia seem even worse from the standpoint of EEG abnormalities than men with other deficits, and with respect to men with aphasia the difference is statistically significant. The presence of intracranial foreign bodies is also an indication of the severity of wounding as reflected in the EEG (table 93). In the classes in which a foreign body was present before debridement there was a higher proportion of abnormal EEC's than in the class in which there were no bone or metal fragments. The differences are all significant except for the class of incomplete removal of metal, where the difference is relatively small. This class (in which metal only remained) differs significantly from the class in which both bone and metal remained. In summary, then, remaining bone fragments seem to be of greater significance than remaining metallic foreign bodies. It is possible that the reason for this lies in the greater average severity of the wound in men with remaining bone fragments. Complications after debridement also apparently aggravate the severity of wounding, for those men who had complications were more likely than men without complications to have abnormal EEG's at follow-up (table 94). In particular, frank infection, fungus cerebri, and cerebrospinal fluid

Table 92.—Relation of EEC at Follow-up to Immediate Neurological Deficit Num- ber done Normal or borderline EEC at follow-up Generalized abnormality Focal Neurological deficit at time of wound abnormality Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 589 382 64.9 110 18.7 134 22.8 None 336 122 42 80 96 250 58 15 46 52 74.4 47.5 35.7 57.5 54.2 47 33 12 19 22 14.0 27.0 28.6 23.8 22.9 48 45 21 23 30 14.3 36.9 50.0 28.8 31.2 Hrrnianopsia Other Table 93.—Relation of EEC at Follow-up to Intracranial Foreign Bodies EEC at follow-up Foreign bodies Num- ber done Normal or borderline Generalized abnormality Focal ab- normality Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 484 308 63.6 88 18.2 120 24.8 Complete removal bone and metal. 167 147 54 66 126 87 28 45 75.4 59.2 51.9 68.2 23 29 9 12 13.8 19.7 16.7 18.2 21 42 23 14 12.6 28.6 42.6 21.2 Incomplete, bone and metal re- 50 22 44.0 15 30.0 20 40.0 leaks seem to be associated with a relatively high probability of abnormal EEG. Men who have had cranioplasty tend to have fewer normal EEC's than men without cranioplasty, and the abnormalities tend to be of the focal type, but the time of cranioplasty relative to the injury seems to be unrelated to the probability of EEG abnormalities (table 95). In large part, the correlation between cranioplasty and EEG abnormalities is related to the greater average severity of wound in those who had cranioplasty. Whether the patient had one or two or more cranioplasties seems to have virtually no effect upon the EEG. 84

Table 94.—Relation of EEG at Follow-up to Complications After Debridement Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal abnormality Complication Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 496 314 63.3 94 19.0 121 24.4 None 424 19 19 10 14 23 280 5 10 4 4 16 66.0 26.3 52.6 40.0 28.6 69.6 76 6 6 3 4 5 17.9 31.6 31.6 30.0 28.6 21.7 94 8 22.2 42. 1 36.8 50.0 50.0 21.7 Meningitis 7 5 7 5 Other 3. Neurological Deficit The neurological deficit as indicated both by the subjective complaints of the patient and the objective findings at the time of discharge definitely seems to be related to abnormality in the electroencephalogram. The symp- toms of impaired memory and impaired mentation in particular are signifi- cant in correlation with the abnormalities of the electroencephalogram, while the other symptoms are not apparently reflected by the electroen- cephalogram (table 96). Most of the objective neurologic findings at the time of discharge from service appear to have significance with respect to the follow-up EEG find- ings (table 97). Exceptions are personality changes and the miscellaneous Table 95.—Relation of EEG at Follow-up to Cranioplasty EEG at follow-up Num- ber done Normal or borderline Generalized abnormality Focal ab- normality Time of cranioplasty after injury Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 595 387 65.0 110 18.5 135 22.7 No cranioplasty 355 59 122 59 264 29 66 28 74.4 49.2 54.1 47.5 48 16 29 13.5 27.1 23.8 28.8 52 21 39 23 14.6 35.6 32.0 39.0 ^3 months 17 85

findings grouped under the heading "other and unknown." In particular the men with field defects (chiefly hemianopsia) show a high frequency of focal abnormalities: 25 of 42, or almost 60 percent. On the other hand, men with cortical sensory disturbances seem to have generalized EEC Table 96.—Relation Between EEC at Follow-up and Neurological Symptoms at Discharge From Service Neurological symptoms at dis- charge from service Num- ber done Normal or borderline EEC at follow-up Generalized abnormality Focal abnormality Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent 595 387 65.0 110 18.5 135 22.7 None 252 192 79 173 124 47 68.7 64.6 59.5 38 42 19 15.1 21.9 24. 1 54 40 20 21.4 20.8 25.3 Impaired mentation, lack of con- 14 22 19 5 4 13 35.7 18.2 68.4 7 9 2 50.0 40.9 10.5 6 13 5 42.9 59.1 26.3 Impaired memory Tinnitus Irritability, fatiguability, insom- nia etc 36 97 21 67 58.3 69.1 9 16 25.0 16.5 7 18 19.4 18.6 Table 97.—Relation Between EEG at Follow-up and Neurological Abnormalities at Discharge From Service Neurological abnormality at discharge from service Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal abnor- mality Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent All men 595 387 65.0 110 18.5 135 22.7 None 267 85 4 54 24 42 32 17 13 202 188 35 2 21 11 11 15 11 7 141 70.4 41.2 50.0 38.9 45.8 26.2 46.9 64.7 53.8 69.8 46 23 1 17 5 12 12 4 1 32 17.2 27.1 25.0 31.5 20.8 28.6 37.5 23.5 7.7 15.8 44 38 1 22 8 25 8 3 5 40 16.5 44.7 25.0 40.7 33.3 59.5 25.0 17.6 38.5 19.8 Paraparesis Field defect Cortical sensory disturbances Personality changes Visual disturbances Other and unknown 86

abnormalities more frequently than men not so afflicted, although the dif- ference is not statistically significant. This group is rather noteworthy in that it is quite exceptional in this material for a group of men to exhibit an increased frequency of generalized EEG abnormalities in the absence of an increased frequency of focal abnormalities of even greater magnitude. 4. Pneumoencephalogram Among the 595 men for whom EEG results at follow-up were available, only 88 pneumoencephalograms (PEG) were reported in the Army clinical records for the hospital admission directly following occurrence of the head wound. These were not done at a uniform time, but almost all (86 of 88) were within a year of injury; 30 were within 3 months and another 44 within the period 3 to 6 months, so that five-sixths were within 6 months of injury. It seems plain (table 98) that early PEG abnormalities of unilateral or local type (ventricular dilatation or absence of air) are fairly well reflected by focal EEG abnormalities several years later, at follow-up. Unfortu- nately, the samples are so small that the differences do not achieve statis- tical significance; however, the probability (one-tailed) comes to between .05 and .10, and in view of the low power of the significance test (because of the paucity of cases) we may regard the data as quite consistent with the existence of a moderately strong relationship between early local PEG abnormalities and late focal EEG abnormalities. Table 98.—Relation Between Follow-up EEG and Pneumoencephalogram in Army Hospital Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal ab- normality Pneumoencephalogram in Army hospital Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total done 88 44 50.0 20 22.7 33 37.5 Normal 26 62 17 27 65.4 43.5 5 15 19.2 24.2 6 23.1 43.5 Generalized ventricular dila- 27 Unilateral ventricular dilata- 21 12 6 10 57. 1 35.3 45.5 4 4 4 19.0 23.5 18.2 6 8 28.6 Local ventricular dilatation on side of lesion or over cortex. . Local absence of air in sub- arachnoid space 17 22 10 47.1 45.5 8 11 13 4 5 4 50.0 45.5 30.8 1 3 4 12.5 27.3 30.8 4 50.0 36.4 53.8 Inadequate filling of ventricle . Other abnormality 4 7 880802—62

5. Early Electroencephalograms It has been seen that the correspondence between independent readings of the same tracings is far from good; it is, therefore, not surprising that the correlations are quite low between the readings of EEG's made and in- terpreted in Army hospitals within 6 months of injury and those made and interpreted at follow-up (table 99). Of 80 men called abnormal at follow-up, 50 were called abnormal at 6 months, while of 104 normal at follow-up, 41 were abnormal at 6 months. Table 99.—Correlation of EEC Findings at 6 Months After Injury and at Follow-up Electroencephalogram within 6 months of injury Total Normal or borderline EEC at follow-up Generalized abnormality Focal abnormality Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 184 104 56.5 44 23.9 56 30.4 Normal or borderline 93 53 62 63 23 26 67.7 43.4 41.9 18 15 19 19.4 28.3 30.6 18 24 19.4 45.3 43.5 Generalized abnormalities Focal abnormalities . .... 27 Similarly, if the EEC findings at 6 to 12 mondis, 12 to 24 months, and more than 24 months after injury are compared to the findings at follow-up, the relationships are not very strong. Table 100 shows the correlation of the follow-up EEG and those made at varying times after injury. The numbers of readings are not very large, but plainly the correlations between early and late EEG's are disappointingly small. Admittedly, the men chosen for repeated early EEG examination were probably highly selected. It is concluded that the variation of interpretation of tracings by different electroencephalographers is probably so great as to interdict any attempt to follow temporal changes utilizing the different interpreters at different times, even if the interpretation be described simply as normal or abnormal. 6. Rehabilitation An examination of the electroencephalogram in terms of rehabilitation does not show impressive relationship. The men who were not regularly employed exhibited a significant excess of focal abnormalities over those who were employed. Similarly, men coded for "regression" in general work progress were significantly more likely to have focal abnormalities than men coded "no work progress" or "school and advancement" (table 101). Both the home and social adjustment seem to be uncorrelated with the electroencephalogram.

• +•» +•* I gg 1 H N in Tt Al CM Pi t in i*^ •2, ** .H* h 4 months c a 3J (L) § y O •s (j SJ •d CN J* j"* ,-' B O .^^^-' 1 I ™ SS f 1 1*3 1 *-> *-. c gg e 3 § && .a. "8 CM CO i-t I S V* o i n i n i n en o § 10 <N .>-' [£ § •** O £ ^^^ o | g g .§ § S V u p^ ^5 p CN en ON c -O ^O v~*' 1 VI oo CO T-l in .^- 1 o<* « CO O JQ h O g H — C o ] 1 £ II C u J3 0

Table 101.—Relation Between EEG and Vocational and Social Rehabilitation Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal abnormality Adjustment Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total . . 595 387 65.0 110 18.5 135 22.7 Work status: Unemployed or occasional jobs 94 35 458 56 23 304 59.6 16 6 85 17.0 17. 1 18.6 30 7 96 31.9 20.0 21.0 Employed 65.7 66.4 Work progress: None 165 121 114 68 69.1 26 23 15.8 19.0 29 17.6 36.4 Regression 56.2 44 Advancement (including school) 300 69 133 200 66.7 66.7 63.2 59 8 23 19.7 11.6 17.3 60 20.0 21.7 26.3 Home adjustment: Depressed, restless, unhappy. . Social adjustment: Has difficulty 46 84 15 35 7. Clinical Abnormalities The relation between the EEG and clinical symptomatology is not strong. None of the various symptom groups exhibits a significantly high percent- age of focal abnormalities (table 102). However, men with abnormal Table 102.—Relation Between EEG and Clinical Symptomatology at Follow-up Symptom Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal ab- normality Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent All men 595 387 65.0 110 18.5 135 22.7 Headache 55 154 40 56 40 99 30 72.7 64.3 75.0 66.1 8 29 4 10 14.5 18.8 10.0 17.9 9 36 6 13 16.4 23.4 15.0 23.2 Irritability or nervousness 37 Impaired memory, mentation, concentration 37 30 333 2 18 14 214 1 48.6 46.7 64.3 13 11 60 1 35.1 13 10 35.1 33.3 Easy fatiguability or insomnia .... Posttraumatic syndrome 36.7 18.0 75 1 22.5 Not stated 90

findings upon neurological examination (table 103) have a significantly high proportion of abnormal electroencephalograms. Every specific neuro- logical abnormality is accompanied by a significantly increased frequency of focal abnormalities on EEG. For men with hemianopsia, the most ex- treme class, the proportion with focal abnormalities is almost 60 percent, nearly four times the incidence in men without neurological abnormalities. On the other hand, generalized abnormalities are much less closely corre- lated with the neurological findings. The elevations of the proportions of generalized EEG changes in men with neurological abnormalities are always smaller, usually considerably, than the corresponding elevations in the proportions of focal abnormalities. Moreover, in only four instances do the elevations above the incidence of generalized EEG changes in normal men prove to be statistically significant at the 5-percent level: for men with hemiplegia, with hemianopsia, with cortical sensory impairment, and with mental impairment. It is perhaps significant that this last class shows the greatest elevation in the proportion with generalized abnormalities on EEG. Table 103.—Relation Between EEG and Neurological Status at Follow-up Num- ber done Normal or borderline EEG at follow-up Generalized abnormality Focal ab- normality Neurological finding Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 595 387 65.0 110 18.5 135 22.7 Normal 280 128 52 128 48 79 142 4 13 207 63 15 64 24 36 86 1 10 73.9 49.2 28.8 50.0 50.0 45.6 60.6 25.0 76.9 41 32 15 31 11 24 23 1 2 14.6 25.0 28.8 24.2 22.9 30.4 16.2 25.0 15.4 44 48 31 15.7 37.5 59.6 35.9 35.4 36.7 26.1 75.0 7.7 Aphasia 46 17 29 37 3 1 Mental impairment Cranial nerve palsy Other 8. Epilepsy The electroencephalograms made at the time of follow-up seem to correlate reasonably well with epilepsy (table 104). In each of the injury groups, the men with fits are much more likely to have focal EEG abnormal- ities than those without fits; in group 4—the most severely injured men— fits are also accompanied by an increased proportion of generalized abnormalities. This increase is caused by a relatively large number of tracings characterized as slow or paroxysmal slow. On the other hand, even in those group 4 men who had epilepsy, nearly one-third were classed as having normal or borderline EEC's. 91

Abnormalities in no single area seem to be associated with epilepsy. The most frequent alteration in all groups with or without epilepsy are asym- metry and paroxysmal slow waves. The type of focal abnormality does not seem to be related to an epilepsy. Spikes, commonly considered as related to seizures, were noted in only 10 of 168 men who had epilepsy, or 6.0 per- cent. Among men who did not have seizures, the relative frequency was 5 in 427, or 1.2 percent. This difference, although statistically significant, is not impressive. Neither is there any abnormality characteristic of epilepsy induced by hyperventilation. The correlation between the EEG and type of epilepsy (table 105) em- phasizes the high ratio of focal abnormalities to generalized abnormalities Table 104.—Correlation of EEG With Epilepsy Num- ber done EEG at follow-up R— I group and presence of epilepsy Normal or borderline Generalized abnormality Focal abnormality Group 3: Epilepsy absent Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent 192 125 65.1 53.8 35 21 18.2 22.6 45 32 23.4 34.4 Epilepsy present 93 50 Group 4: Epilepsy absent 26 50 14 16 53.8 32.0 5 17 19.2 34.0 9 25 34.6 50.0 Epilepsy present Table \OS.-Correlation of Type of Epileptic Attack and EEG at Follow-up Normal or borderline EEG at follow-up Generalized abnormality Focal abnormality Type of attacks Total Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total with fits 168 80 47.6 44 26.2 63 37.5 Minor attacks . 32 29 68 9 5 29 8 7 15 10 34 5 3 12 4 3 46.9 34.5 50.0 55.6 60.0 41.4 50.0 42.9 10 9 17 3 31.3 31.0 25.0 33.3 11 14 27 1 2 11 3 2 34.4 48.3 39.7 11.1 40.0 37.9 37.5 28.6 Focal attacks Psychomotor Focal and general attacks 10 1 2 34.5 12.5 28.6 General and minor Other combinations and unknown. 92

for most types. This is true not only of the group having focal attacks but also of those having generalized attacks. The differences between men having different kinds of fits do not attain statistical significance. If the type of epilepsy is a determinant factor in the electroencephalographic ab- normality, its influence is little reflected in these data. The groups categorized by aura seem relatively homogeneous with respect to abnormalities of the brain waves. For a further study of the sensitivity of the electroencephalogram rela- tive to epilepsy, a comparison was made between men who continued to have attacks and those whose attacks ceased. No difference could be dis- cerned in the electroencephalograms made at 6 months or at follow-up between men whose fits were controlled for at least 2 years prior to follow- up and those who were continuing to have attacks. This is true for all aspects of the brain waves—generalized abnormalities, location or type of focal abnormalities, and alterations induced by hyperventilation. 9. Intelligence Finally, the Wechsler-Bellevue IQ seems to have little relationship to the EEC's, although the deterioration as indicated by this test does seem to be so related in that men with abnormal deterioration tend to have ab- normal EEC's more frequently than men with no deterioration (table 106). Moreover, the excess of abnormal EEC's is wholly confined to the category of focal abnormality. The statistical test of significance applied to the difference in the proportions with focal abnormality shows this difference to be significant at the 5-percent (one-tail) level. Table 106.—Relation Between EEC and Wechsler-Bellevue Intelligence Test Num- ber done Normal or borderline EEC at follow-up Generalized abnormality Focal abnormality Wechsler-Bellevue tert Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent Total 562 366 65.1 101 18.0 129 23.0 Intelligence scale: < 89 78 388 96 51 65.4 66.2 60.4 14 65 22 17.9 16.8 22.9 17 90 22 21.8 23.2 22.9 90-119 257 58 >120 Abnormal deterioration: 121 441 70 296 57.9 67.1 24 19.8 17.5 36 93 21.1 29.8 77 10. Discussion Electroencephalography was heralded as a means of determining and, to some degree, of measuring the function of the brain. While experience has shown the fallaciousness of this as an exact principle, it has demonstrated 93

that abnormalities of the brain waves do correlate with cerebral damage in a general way. Because the electrical potentials are related to functional rather than purely anatomical substrata, it should be understandable that a brain, damaged in one area, may have a normal electrical pattern assuming that: a. The area is not so large that a diminution of potentials will be reflected in the total picture. b. The area is electrically relatively silent and not giving rise to abnormal discharges. c. The cortical margins of the area are functioning in an electrically normal fashion. d. The area is not essential in the activation of subcortical structures which may influence the focal or general activity of the cerebral cortex. That these conditions are met in 20 percent of cases of penetrating head wounds is apparent from an examination of table 107. Moreover, Wil- liams' (138) serial examinations of head-wounded men indicate that there is a tendency for the electrical patterns of the damaged brain to revert to normal over a period of months. In the present series, this tendency is not so apparent; at 6 months after injury 52 percent of men had normal EEC's, and at follow-up, 6 or more years later, this had only increased to 57 percent. Allowing for some variation due to different readers, this can indicate only mild improvement. Perhaps this result should be expected since Williams reports rather rapid reversion to normal hi 3 to 6 months; at later times the record may change little. Dow et al. (37) likewise found that the records of patients with closed head injuries returned to normal within a few weeks. Puech et al. (99) also found that the EEC's of head- injured (both closed and open) patients tended to become normal in about 3 months, with little change in die percentage of normal records (80 per- cent) after that time. They indicate a rather slower return to the normal state for patients developing epilepsy, but since their series is small (19 cases) and the factor of severity of the injury is not controlled, the differ- ences are probably not significant. In cases of cerebral contusion char- acterized clinically by focal neurological signs after a closed head injury, Table 107—EEC Findings After Dural Penetrating Head Wounds Author Year Number Perce ntage of cases Normal Abnormal Laufer and Perkins (76) 1946 81 19.7 80.3 Aita (2) 1947 100 10 90 Busse (26) 1947 103 19 81 Cramer et al. (31) 1949 442 21 79 Kaufman and Walker (70) 1949 i 83 22. 9 77.1 Hilterhaus and Bayer (64) 1955 1241 300 8.7 14 91.3 86 i Without convulsions. * With epilepsy. 94

Meyer-Mickeleit (88) states that the diffuse EEG abnormalities disappear in 6 months, at which time the alpha, previously slowed, regains its normal frequency. Focal alterations may persist for 2 years (25 percent of cases) or more (5 years in 15 percent of cases). The prediction of posttraumatic epilepsy is generally admitted to be difficult and uncertain. Only a few authors have asserted that an epilepsy can be prophesied on the basis of electroencephalograms. Roseman and Woodhall (102) suggested that the development of spike foci over a period of time might be correlated with an impending convulsive diathesis. But Williams (138) observed such changes to occur over a period of 3 to 6 months in patients who did not develop seizures. Jasper and Penfield (69) similarly conclude that "the EEG cannot be depended upon, however, to predict the development and course of a potentially epileptogenic lesion of the brain, since regressive as well as progressive lesions are encountered." Assuming that clinical manifestations of an epilepsy have occurred, does the EEG give information as to the posttraumatic origin of that convulsive state? There is more evidence concerning this point, although much of it is poorly controlled or uncontrolled. Williams (138) found that there was a sharp decline in the percentage of EEG abnormalities of an unselected group of head-injured patients (both open and closed) in the first 2 months. The length of posttraumatic amnesia was found to correlate closely to the percentage of abnormal records—those men being unconscious for 1 week or more have 67 percent of abnormal records. The EEG was abnormal in 55.4 percent of the men with posttraumatic symptoms and in 8 percent of those symptomless. Williams concluded that the character of the changes seen in the EEG in traumatic epilepsy appear to be the same as in idiopathic epilepsy, and prediction of traumatic epilepsy does not appear possible by electroen- cephalographic examination during the period of recovery from a head injury. Moreover, he noted that clinical recovery is followed closely by improvement in the EEG. Clark and Harper (29) while noting a pronounced change from "normal" to "focal" EEG changes as one moved from "closed" to "open penetrating head wounds," admitted that the EEG did not reveal with any degree of certainty those patients who had had convulsions. Based on a comparison of 2 series—one of 102 cases of severe head injury (both open and closed) in both children and adults, and one of 175 post- traumatic epileptic patients, the criteria for which is not clearly defined, Gibbs et al. (52) conclude that focal paroxysmal disturbances are 21 times as common among posttraumatic epileptics as among head-injured men without epilepsy. Because of these generalities in the population, the rather specific conclusions drawn by the authors require considerable reservation. This is particularly true since Heppenstall and Hill (63) have demonstrated that children and adults respond differently to head injury. Roseman and Woodhall (102) reported on serial EEG studies of 75 men with brain laceration, stating that in 4 cases the onset of the convulsive state was predicted following the gradual alteration from delta activity into "one or more characteristic types of epileptogenic encephalographic foci," but admit that similar findings were present in 15 cases who did not develop 95

seizures. They concluded that certain broad predictions could be made regarding the resolution of cerebral damage or its metamorphosis into a focus of epileptic activity. Jasper and Penfield (69) state that in posttraumatic epilepsy the elec- troencephalogram revealed (in 90 percent of cases) a focal area of random spikes or sharp waves usually upon a background of random delta waves. Slow waves alone were not considered a reliable guide to an epileptogenic focus. They conclude that the EEG cannot be depended upon to predict an epilepsy. Similarly, Puech et al. (99) state that posttraumatic epilepsy does not have a constant electrical record. Kaufman and Walker (70) in 1949 showed that in comparable wounds the EEG findings were essentially the same in patients sustaining penetrating head injuries with and without complicating seizures. Finally, the question has been raised regarding cerebral trauma as a causative factor in petit mal. Most authors [Williams (138), Gibbs (52), Hilterhaus and Bayer (64), and Kaufman and Walker (70)] whose ma- terial has been composed largely of adults, have not seen a typical three per second spike and wave pattern as a sequel of a head injury. Kellaway (71) believes that such a pattern requires considerable time to develop, and concludes "if generalized spike wave patterns are seen in the acute phase of head injury or without antecedent abnormality of other type, the chances are that they predated the injury." Jasper and Penfield (69) report three cases of petit mal or petit mal variant in their posttraumatic series. In their discussion the authors admit that all patients having this type of abnormality were under 14 years of age, and that "until such posttraumatic lesions (at the base of the brain or large areas of contused cortex) have been shown to be present in cases with these EEG findings, one may assume that the prob- abilities are greatest that they are essential rather than posttraumatic epilepsy." Meyer-Mickeleit and Schneider (89) also report that "three confirmed posttraumatic epilepsies of childhood showed three per second bilateral symmetrical spike and wave discharges with clinical 'absences'." These authors believe that the age of the injured patient is more important in the type of epilepsy than the etiology. It would seem that in children no positive statement can be made regarding the role of trauma in petit mal, but in adults there is no evidence that cerebral injuries cause such a convul- sive state. One may conclude that the evidence of a single EEG is not very sub- stantial whether positive or negative, but a series of tracings, especially if one of them antedates the trauma, is of great value both from the diagnostic and prognostic standpoints. Since EEC's are so commonly done, in the future it may not be difficult to obtain records made before a head injury occurred. C. PNEUMOENCEPHALOGRAPHY 1. Findings The results of air studies were originally classified as normal, generalized ventricular dilatation, unilateral ventricular enlargement, localized ventric-

ular dilatation at site of lesion, abnormal air over cortex, absence of air in subarachnoid space, inadequate ventricular filling, and combinations of these and other abnormalities. However, so few PEG's were performed during the original Army hospitalization that, for the purpose of analysis, it seemed necessary to combine the findings into fewer categories as: a. Normal. b. Generalized abnormality, including generalized ventricular dilata- tion, with or without localized ventricular dilatation, and abnormal air over cortex. c. Localized abnormality, including unilateral ventricular dilatation, localized ventricular dilatation. d. Other, including abnormal air over cortex, absence of air over cortex. As might be expected, air studies were more frequently done on the more seriously injured men. Of the total of 128 men with PEG's, 46 were in R-I group 4. Only 3 of the 99 men in R-I group 1 had PEG's as contrasted with 48 percent of those in R-I group 4. In R-I groups 2 and 3 the proportions with PEG's were 5 and 15 percent, respectively. The frequency of abnormal findings might be expected to be affected by factors relating to greater severity of wounding, such as increasing neuro- logical disability, high incidence of epilepsy, etc., but since the number of men in groups 1 and 2 for whom PEG's were reported is so small, such correlations cannot be well demonstrated in this material. Only the wounds of the temporal region seem to have a significantly larger percentage of normal air studies (44 percent) than those of other regions. Degree of severity of wounding, in terms of size and depth of the wound correlates with the pneumoencephalographic abnormalities (table 108). The immediate complications did not seem to influence the abnor- malities of the PEG except for the cases with fungus cerebri, of whom only 1 person in 20 had a normal air study. Localized abnormalities in patients having cerebral fungi were almost twice as common as in the total group. The criterion of unconsciousness following injury correlates with the presence of abnormality: Few men unconscious more than 2 hours had normal air studies. The neurological deficit at the time of wounding, too, was related to PEG abnormalities in that men with hemiplegia had less than half as many normal air studies as the entire group, and had a corresponding increase in localized abnormalities. Except that the absence of intracranial foreign bodies was likely to be associated with a high percentage of normal air studies, the presence of intracranial bone or metal seemed to influence the air studies little. Those patients whose cranial defects required repair had more ventricular distortions than those whose heads did not require cranioplasty; while 77 percent of the first group had abnormalities, only 50 percent of the latter were so recorded. The abnormality was usually a localized ventricular distortion. The pneumoencephalographic findings bear a direct relationship to the subjective complaints of the patient at follow-up, by which time few men were asymptomatic and three-fifths had a traumatic syndrome (table 109). 97

Table 108.—Correlation of PEG and Characteristics of Wounding Total number of men Normal (per- cent) General- ized abnor- mality (percent) Localized abnor- mality (percent) Other abnor- mality (percent) Characteristic Total 129 31.8 21.7 26.4 20.2 Mean diameter of cranial de- fect: No cranial defe*ct 15 53.3 26.7 20.0 <2 cm 20 40 0 10 0 30.0 20.0 2-4 cm. >4cm 52 23 36.5 13.0 23.1 26. 1 23.1 43.5 17.3 Other (including gutter wounds) and unknown. Depth of wound: Scalp, cranium, or dura. . 17.4 19 15.8 21.1 31.6 31.6 35 94 51.4 24 5 20.0 14.3 30 9 14.3 22.3 Period of unconsciousness: None 22 3 19 52.6 15.8 21. 1 10.5 <2 hours 22 50.0 22.7 4.5 22.7 >2 hours 32 12. 5 25.0 31.3 31.3 56 28.6 21.4 33.9 16.1 Table 109.—Correlation of PEG and Clinical Symptomatology at Follow-up Total number of men Normal (per- cent) Generalized abnor- mality (percent) Localized abnor- mality (percent) Other ab- normality (percent) Symptom Total 101 29.7 22.8 23. 8 23.8 60 26 7 26 7 21.7 25.0 Other symptoms 33 27 3 18.2 27. 3 27.3 8 62 5 12 5 25 0 A neurological deficit of almost any type decreased the probability of a normal air study, and increased the chances of a localized ventricular distortion. It is noteworthy, however, that of the men having no detectable neurological abnormalities, almost half were recorded as having pneu- moencephalographic abnormalities. No one category of defect was par- ticularly apt to be accompanied by PEG abnormalities (table 110). With regard to employment at follow-up, perhaps the most interesting point is that of the 67 men who were working, only 40.3 percent had a normal pneumonecephalogram. The occurrence of epilepsy was likely to be associated with abnormalities of the pneumoencephalogram. Only 12 percent of men who had multiple fits were recorded as having normal air studies (table 111). Finally, although general intelligence, as measured by the Wechsler- Bellevue test, did not seem to be correlated with morphological changes 98

in the brain, abnormal deterioration was associated with pneumoencephalo- graphic changes (table 112). 2. Discussion That both closed and open head injuries will produce ventricular changes easily demonstrable by pneumoencephalography has been recognized for decades (34). Such changes in the ventricular size and shape may occur within 10 days of a head injury and continue to become more pronounced over a period of months. Browder and Hollister (23) made serial exami- nations after head injuries, noting not only progressive ventricular dilatation but also that such changes might go on during clinical recovery from a hemiplegia. Troland et al. (126) also emphasized the early occurrence of ventricular alterations. Even mild head injuries may produce dilatation of the ventricles; Klaue (73) reported that 46 percent of concussed patients had slight ventricular enlargement. The late changes in the ventricular system, noted early in Foerster's clinic in Breslau, were described as "the wandering ventricle"—a dilation and deviation of the ventricle toward the side of the lesion. Schwab (115) and Bielschowsky (17), in papers from this clinic, emphasized not only the Table 110.—Correlation of PEG and Neurological Abnormalities at Follow-up General- ized ab- normality (percent) Localized abnor- mality (percent) Other abnor- mality (percent) Abnormality Total number of men Normal (per- cent) Total 101 29 7 22 8 23 8 23 8 None 28 53.6 28.6 3.6 14 3 Hemiparesis or hemiplegia .... Hemianopsia 40 17.5 17. 6 20.0 17.6 45.0 35 3 17.5 29 4 17 Cortical sensory impairment. . . 36 20 19.4 10 0 16.7 20 0 41.7 35 0 22.2 35 0 Mental impairment 24 16.7 20.8 33. 3 29 2 Cranial nerve palsy 33 12. 1 30.3 27.3 30.3 3 66 7 33 3 Table 111 .—Correlation of PEG and Epilepsy Total number of men Normal (per- cent) General- ized ab- normality (percent) Local- ized ab- normality (percent) Other ab- normality (percent) Epilepsy since injury Total 101 29.7 22.8 23.8 23 8 None 55 38.2 20.0 20.0 21 8 One definite attack 3 66 7 33 3 >1 definite attack 41 12. 2 26.8 31 7 29 3 Borderline attacks only 2 100.0 99

Table 112.—Correlation of PEG and Intelligence Total number of men Normal (per- cent) General- ized ab- normality (percent) Local- ized ab- normality (percent) Other ab- normality (percent; Wechsler-Bellevue test Total 101 29.7 22.8 23.8 23.8 Intelligence scale: <89 14 28 6 28 6 14.3 28.6 90-119 61 36 1 18.0 23.0 23.0 >120 18 22. 2 38.9 22.2 16.7 Unknown or not done 8 12.5 50.0 37.5 Abnormal deterioration: Present 22 13.6 27.3 22.7 36.4 Absent 79 34.2 21.5 24. 1 20.3 ventricular enlargement, but also the sulcal prominence and in some cases, the failure of the ventricles to fill. Each noted that although there was an obvious correlation between the clinical and pneumoencephalographic findings in many cases, in some this did not hold. Subsequent authors (48, 62, 121) considered that air studies allowed a differentiation be- tween patients with organic and patients with functional brain disturbance. However, most authors deprecated this view because of the many cases of ventricular abnormality without clinical concomitants and of abnormal neurological findings with a normal ventricular system. This study, too, finds little correlation between posttraumatic findings and degree of ventric- ular abnormality. Since the early descriptions, many authors have discussed and illustrated the ventricular distortions. There is much emphasis upon the changes noted but little effort expended upon the proof that the changes were secondary to the injury and not due to some other factor. True, a few authors such as Fischer (46) and Kennedy (72) sound this warning, observ- ing that similar changes can be found in patients without a history of head injury. To control this factor, Falk and Silfverskiold (44) compared the ventricular changes in a series of patients with cephalalgia and with trau- matic encephalopathy. Although they found a much higher proportion of abnormal pneumoencephalograms in their posttraumatic group than in the headache series (52/72 vs. 19/58), they noted that the percentage was almost as high in the cases which had no loss of consciousness (14/22) as in those insensible for some period of time. It must be admitted that pneumoencephalography is not an accurate measure of either pathological alterations or normal functioning of the brain. As an indicator of function, it is particularly unreliable, and sensi- tive only in the sense that function correlates to some extent with morphology. D. PSYCHOMETRY The mental processes may be subjected to analysis in many ways. For the purpose of this study two formal tests were employed—the Wechsler- Bellevue and the Minnesota Multiphasic Personality Inventory. It was 100

hoped that the first of these tests might give evidence not only of the immediate intelligence of the individual, but an indication of deterioration which might have resulted from cerebral damage. The evaluation of the personality was considered of particular pertinence because of the pre- sumed "functional" elements which enter into posttraumatic cerebral phenomena. 1. Intelligence as Determined by the Wechsler-Bellevue Test "Intelligence" as discussed in this section is based upon the formal IQ obtained from the Wechsler-Bellevue test. This test is not a measurement of the native endowment of men with brain injuries, since such factors as aphasia, apraxia, and even hemiplegia, may influence the scores of certain categories. Emphasis will be placed upon these changes wrought by the brain injury—the deterioration score. From the simple breakdown into low, intermediate, and high IQ, little data of clinical significance is obtainable (table 113). It will be noted that while half of the men widi IQ under 90 were abnormally deteriorated, the proportion was less than 2 percent for men with IQ of 120 or more. This might be interpreted as showing either that low intelligence at follow-up was often caused by abnormal deterioration, perhaps as a result of the head wound, or alternatively, that "abnormal deterioration" only in part measures what its name implies and that the scoring rules are such that persons with low IQ often tend to be scored as having abnormal deteriora- tion simply as an artifact of the way the test is constructed. Table 113.—IQ as Determined by Wechsler-Bellevue Test Abnormally deteriorated IQ Number Percent Number Percent <89... ... 88 470 125 12.9 68.8 18.3 44 99 2 50.0 21.1 1.6 90-119 >120 Total 683 100.0 145 21.2 In order to learn more about the meaning of the "abnormal deteriora- tion" score, military records were searched for results of the Army General Classification Test (AGCT) administered to most recruits during their first few weeks of training. This test has much in common with the Wechsler-Bellevue. Unfortunately, it turned out that the majority of the records had been destroyed, but it was possible to obtain AGCT scores for 153 men for whom Wechsler-Bellevue test results were also available at follow-up. A gross comparison of the AGCT prior to trauma and the Wechsler-Bellevue, made several years later, is presented in table 114 and discloses several interesting features. First, the correlation between the two scores is reasonably good: The correlation coefficient is + .65 and the mean Wechsler-Bellevue IQ increases regularly with increasing AGCT for 101

the whole sample and also for the subgroup of 102 men in whom no ab- normal deterioration was noted. Of the 60 men with AGCT score less than 100, 25 (41.6 percent) were scored by the Wechsler-Bellevue for ab- normal deterioration for age, while only 26 (28.0 percent) of the 93 men wida AGCT scores of 100 or more were so scored. This clearly implies that the deterioration noted by the Wechsler-Bellevue, whatever it may be, was often at least implicit at the time of the soldier's entry into service, and, hence, cannot be considered a measure of deterioration from that point of time forward. Table 114.—Relation Between Wechsler-Bellevue IQ at Follow-up and Army General Classification Test at Entry Into Service Abnormal deteriora- tion Abnormal deteriora- tion AGCT Total Total Absent Present Absent Present Number of scores Mean Wechsler-Bellevue score at follow-up <69 . . 9 4 10 9 12 5 3 7 10 13 8 4 1 90 93 98 106 108 112 117 119 94 95 98 107 112 113 119 121 86 87 97 104 103 108 104 104 70-79 13 16 22 30 26 28 9 80-89 90-99 . . 100-109. . . . 17 18 24 8 110-119 120-129.. 130+ Total 153 102 51 107 110 101 On the other hand, clearly the relation between the AGGT and the Wechsler-Bellevue was affected by the head wound. An analysis of co- variance in terms of the four R-I groups showed significant differences be- tween the regressions of the Wechsler-Bellevue scores on the AGCT scores within groups. The correlation coefficients for the four groups were: group 1, +.72; group 2, +.86; group 3, +61; and group 4, +.45. It also seems significant that if attention be resricted to men whose AGCT scores were 90 or more, then, within the subgroup of those who were scored as having ab- normal deterioration, there was no apparent relation between the AGCT and the Wechsler-Bellevue IQ. This would at least be consistent with the idea that for these men an extraneous influence (perhaps the head wound) was disturbing the relation between the AGCT and the Wechsler-Bellevue, and was being recognized by the latter test as "abnormal deterioration." This rather complicated situation may be understood a little more clearly by reference to table 115. Here it can be seen that among those men whose original AGCT scores were 100 or more, abnormal deterioration was scored on the Wechsler-Bellevue almost entirely among men with wounds that penetrated the brain (15 out of 18). On the other hand, men with low 102

AGCT scores were equally likely to be scored for deterioration whether the wound extended to brain substance or not. It can be concluded that abnormal deterioration may be attributed to the head wound with con- fidence only for men whose AGCT scores were 100 or more. Table 115.—Relation Between Army General Classification Test Score, Wechsler-Bellevue Deterioration, and Depth of Wound AGCT score Scalp, cranium or dura or not shown Depth of wound Brain or ventricle Total number With abnormal deterioration Total number With abnormal deterioration Number Percent Number Percent Total 77 13 16.9 76 24 31.6 <79 14 6 15 14 12 16 4 2 4 2 1 28.6 33.3 26.7 14.3 8.3 8 10 7 16 14 21 1 4 4 7 3 5 12.5 40.0 57.1 43.8 21.4 23.8 80-89 90-99 100-109 110-119 120 + A glance through the correlations of the Wechsler-Bellevue with factors of wounding reveals two main tendencies: a. The relative independence of the IQ itself to all factors. b. The close relationship between increasing deterioration and most factors contributing to the severity of injury. Although the type of wound changes the proportions of the classes of intelli- gence only moderately, it reflects itself strongly in the abnormally deterio- rated (table 116). The proportion of men abnormally deteriorated in- creases slowly as diameter of defect increases, but the effect is not strong. There is little apparent correlation with the IQ itself. The probability of deterioration also increases with increasing depth of wounding; little rela- tionship to the IQ itself is seen (table 117). There is a tendency for men having a second wound to be deteriorated more frequently than men with but a single head wound. This difference, although it seems natural enough, is not statistically significant. Men who were unconscious more than 2 hours are more frequently deteriorated than men never in coma or who were so for less than 2 hours. Moreover, there seems to be a definite shift in the proportions of low and high IQ's between men who had long unconsciousness and those who had little or none. However, within the group of men in coma for more than 2 hours, duration of unconsciousness seems not to affect the scores on the Wechsler-Bellevue (table 118). 630802—62 8 toa

Table 116.—Correlation of Intelligence and Type of Wound Wechsler-Bcllevue Num- ber tested IQ Abnormally deteriorated Type of wound Number Percent Num- ber Per- cent <89 90-119 >120 <89 >120 Total 683 88 470 125 13 18 145 21 Perforating wounds 22 419 7 41 12 294 3 84 32 10 14 20 10 45 Penetrating wounds 93 22 Wounds with no overt evi- dence of brain damage. . 246 42 166 38 17 15 43 17 Table 117.—Relation of Intelligence to Depth of Wound Wechsler-Bellevue Num- ber tested IQ Abnormally deteriorated Depth of wound Number Percent Num- ber Per- cent <89 90-119 >120 <89 >120 Total 683 88 470 125 13 18 145 21 Scalp 185 130 19 314 25 10 29 18 3 29 8 1 127 81 10 233 13 6 29 31 6 52 4 3 16 14 16 9 32 10 16 24 32 17 16 30 30 21 4 80 9 1 16 16 21 25 36 10 Dural Ventricle Unknown It is clear that "hemiplegia or hemiparesis" or "aphasia" at the time of the wound is of considerable prognostic significance both for deterioration and for the general IQ. However, hemianopsia seems not to have the same influence. Men with combinations of deficits of different kinds do worse on the Wechsler-Bellevue than men with single deficits, and they also have a higher probability of exhibiting abnormal deterioration (table 119). There seems little doubt that men with intracranial foreign bodies at the time of wounding are more frequently deteriorated than men without, but the significance of the type of foreign body and its removal on the intelligence is less clear (table 120). The only neurological symptom at discharge which was significantly correlated with the Wechsler-Bellevue score was "Impaired Memory": 104

Table 118.—Relation of Intelligence to Period of Unconsciousness Wechsler-Bellevue Num- ber tested IQ Abnormally deteriorated Unconsciousness Number Percent Num- ber Per- cent <89 90-119 >120 <89 >120 Total 683 88 470 125 13 18 145 21 None 141 151 52 40 35 15 249 13 15 94 104 33 22 29 7 181 34 32 9 5 2 1 42 9 10 24 21 21 23 16 10 9 8 58 15 15 31 25 26 53 23 <2 hours ^>2-24 hours 10 19 33 17 13 6 >l-3 days 13 4 7 26 >3-7 days 11 47 10 ^1 week 7 17 More than half (57 percent) of the 23 men so coded were abnormally deteriorated as opposed to 23 percent for men with no symptoms. More- over, not a single one of the 23 men with this symptom had a general IQ of 120 or more, although 18 percent of men generally were so scored. Many neurological abnormalities at discharge are associated with a significantly increased proportion of men who are abnormally deteriorated at follow-up: Hemiplegia or hemiparesis, aphasia, and sensory disturbance are all marked by a highly significant elevation of the proportion abnormally Table 119.—Relation of Intelligence to Neurological Deficit at Time of Wounding Wechsler-Bellevue Num- ber tested IQ Abnormally deteriorated Neurological deficit Number Percent <89 90-119 >120 <89 >120 Num- ber Per- cent Total 683 88 470 125 13 18 145 21 Hemiplegia or hemiparesis . 385 83 35 40 57 116 41 13 3 7 12 17 262 60 26 28 38 81 82 10 6 5 7 18 11 16 9 18 21 15 21 12 61 24 3 12 21 36 16 29 9 30 37 31 Combination of 2 or more . Other and unknown 17 13 12 16 10S

deteriorated. Spasticity and hemianopsia are characterized by elevations which are significant, although not highly so. Men with personality changes exhibit an elevated proportion with deterioration, but the number of cases is not large enough to achieve significance (table 121). Table 120.—Relation of Intelligence to Intracranial Foreign Bodies at Time of First Debridement Wechsler-Bellevue Num- ber tested IQ Abnormally deteriorated Intracranial foreign bodies Number Percent <89 90-119 >120 <89 >120 Num- ber Per- cent Total 683 88 470 125 13 18 145 21 No intracranial foreign bodies 173 28 119 26 16 15 23 13 Foreign bodies, all re- moved 179 68 17 10 8 122 40 14 15 9 22 21 20 39 17 12 22 25 16 Retained bone fragments. Retained metal fragments . Retained bone and metal fragments . 74 44 51 15 11 Other and unknown 57 132 7 18 45 89 5 25 12 14 9 19 24 30 42 23 Table 121.—Relation of Intelligence to Neurological Abnormalities at Discharge Num- ber tested Wechsler-Bellevue IQ Abnormality Number Percent Abnormally deteriorated <89 90-119 >120 <89 >120 Num- ber Per- cent Total 683 88 470 125 13 18 145 21 None 299 101 5 60 30 24 21 200 69 3 40 20 75 11 2 5 5 8 21 25 11 40 8 17 48 16 Hemiplegia or hemiparesis. Paraparesis 38 1 28 11 38 20 47 37 Aphasia 15 5 25 Spasticity 17 Hemianopsia or other field defect ... 48 37 22 17 235 7 11 4 5 38 35 22 14 11 167 6 4 4 1 30 15 30 18 29 16 13 11 18 6 13 15 15 7 3 52 31 41 32 18 22 Sensory disturbances Visual disturbances Other and unknown 106

On the other hand, certain factors of wounding or repair appear to have no relationship to either the IQ or deterioration. The region wounded, complications of the wound, or time of occurrence of cranioplasty have no apparent relationship to the IQ or the degree of deterioration. The intelligence as determined by the Wechsler-Bellevue test seems to have similar relationships to the findings at follow-up as to those at the time of wounding. The intelligence per se in the groups is little affected, but the deterioration bears a significant relationship to factors indicating neurological dysfunction. The complaints referable to the nervous system at the time of follow-up are more numerous than at discharge. The significant variations in the fractions of men deteriorated are the elevations for those with impaired mentation or memory and with posttraumatic syndrome. The fact that the fraction of asymptomatic men who were deteriorated is lower than the corresponding fraction of men with headache, dizziness, irritability, or ner- vousness is suggestive, but the differences are not significant (table 122). Almost every neurological abnormality is marked by a corresponding ele- vation of the fraction with deterioration, sometimes of large degree. The only statistically nonsignificant elevations are those for men with cranial nerve palsy and cerebellar syndrome. It seems anomalous that mental im- pairment should have been coded in 4 patients having an IQ of 120 or more. All neurological abnormalities (except the small group with cerebellar syn- drome) were accompanied by significantly high proportions of men with quite low IQ, that is, under 90 (table 123). Table 122.—Relation of Intelligence to Neurological Symptomatology at Follow-up Num- ber tested Wechsler-Bellevue IQ Symptom Number Percent Abnormally deteriorated <89 90-119 >120 <89 >120 Num- ber Per- cent Total 683 88 470 125 13 18 145 21 58 177 45 61 22 20 26 9 389 1 1 12 4 7 4 3 2 1 66 36 117 24 38 21 48 17 16 3 3 7 2 45 2 36 27 38 26 14 15 27 22 12 4 26 7 7 11 9 3 2 102 7 15 16 11 50 45 12 22 26 Dizziness 7 9 11 18 15 8 11 17 Irritability or nervousness. 15 14 17 6 Insomnia Posttraumatic syndrome. . . 278 1 107

Table 123.—Relation of Intelligence to Neurological Abnormalities Wechsler-Bellevue Num- ber tested IQ Abnormally deteriorated Abnormality Number Percent <89 90-119 >120 <89 >120 Num- ber Per- cent Total 683 88 470 125 13 18 145 21 Normal 320 144 61 25 32 14 218 95 40 77 17 7 8 22 23 24 12 11 47 47 20 15 I f em i paresis or hemiplegia. Hemianopsia 33 33 Cortical sensory impair- 142 51 93 161 6 13 29 16 31 25 1 2 98 30 58 116 5 10 15 5 4 20 20 31 33 16 11 10 4 12 48 21 51 34 1 6 34 41 55 21 17 46 Aphasia Mental impairment Cranial nerve palsy Cerebellar syndrome . . 17 15 Other and unknown 1 8 2. Minnesota Multiphasic Personality Inventory Unlike the Wechsler-Bellevue test, the personality inventory seems little related to the degree of organic neurological deficit (table 124). Perhaps this was to be expected since the two examinations measure quite distinct aspects of an individual's mental functions. The personality inventory, unaffected by the factors related to severity of wounding—diameter of de- fect, depth of wound, neurological deficit, presence of epilepsy, electro- encephalographic abnormality—does, however, correlate with certain fac- tors, which will be presented in detail. By examination of the first row of table 124, the proportion of elevated scores can be seen for each scale in the whole group with valid tests (485 men). Substantial proportions (about one-third) were elevated above the norms on Hs, D, and Hy; Pt and Sc were elevated for about one-sixth of the men, while small fractions (at most 6.6 percent) were elevated on the remaining form scales. There appears to be a moderate correlation with the type of wound (table 125). It seems noteworthy that the Hs scale is elevated for men with scalp lacerations and closed wounds and for men with fractures without brain penetration as compared with men having penetrating wounds. This may be related to the fact that, of scalp lacerations and closed wounds, a dispro- portionate number came from compensation rosters. On the other hand, although their differences test as statistically significant, this may not be clinically significant for there are a great many other possible comparisons in this table, none of which seems remarkable. It must be remembered that a certain fraction of comparisons even in homogeneous data can be ex- pected to turn out to be significant by chance.

Table 124.—Relation of Personality Inventory and Neurological Deficit at Time of Wounding Number of men Minnesota Multiphasic Personality Inventory Deficit Hi D Hy Pd Mf Pa Pt Sc Ma Percent with elevated scores Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 No deficit 289 77 32 45 42 39.4 33.8 21.9 24.2 36.4 28. 1 37.8 35.7 30.8 32.5 18.8 31. 1 42.9 6.6 9.1 6.3 4.4 4.8 2.4 3.9 2.1 1.3 14.9 20.8 3.1 22.2 11.9 12.8 24.7 6.3 4.2 5.2 9.4 6.7 4.8 Hemiplegia or hemiparesis Hemianopsia 35.6 38.1 26.7 23.8 Other and unknown 4.8 4.8 Table 125.—Relation of Personality Inventory and Type of Wound Number of men Minnesota Multiphasic Personality Inventory Type Ht D Hy Pd Mf Pa Pt Sc Ma Percent with elevated scores Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 Closed head wound without fracture, scalp laceration . . . Fractures, not penetrating. . . . 130 39 43.1 53.8 31.5 50.0 26.2 33.3 36.2 38.5 28.1 35.7 6.9 .8 5.1 2.6 7.1 3.1 2.6 1.3 15.4 13.8 25.6 15.6 3.1 10.3 5.0 7.1 302 14 28.8 35.7 7.7 6.0 14.3 17.9 15.2 14.3 35.7 The period of unconsciousness seems to bear some relationship to the MMPI (table 126). The Hs, D, Hy, and Sc scales are elevated more fre- quently for men unconscious 2 hours or more than for men not unconscious or only briefly so (under 2 hours). Social maladjustment bears a relationship to certain elevations in the personality inventory. Those individuals classified as depressed, restless, or unhappy have generally high scores in all categories of the personality inventory. Similarly, the men who consider themselves social misfits have elevated scores (table 127). Perhaps as a corollary of this, those who have not advanced or have regressed in their work have higher scores in most factors than those men who advanced. In the follow-up examinations organic abnormalities such as cranial nerve impairment, motor, sensory, or reflex abnormalities had little or no influence upon the elevations in the personality scores, whereas subjective neurological 109

Table 126.—Relation of Personality to Period of Unconsciousness Unconsciousness Number of men Minnesota Multiphasic Personality Inventory Hs D Hy Pd Mf Pa Pt Sc Ma Percent with elevated scores Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 None 116 124 31.9 37.1 48.9 33.8 25.9 29.0 43.2 22.3 23. 3 29.8 43.2 31.8 7.8 8.1 8.0 3.8 3.4 3.2 3.4 0.6 1.7 1.6 2.3 1.9 19.0 14.5 22.7 9.6 12.9 14.5 1.7 4.0 8.0 6.4 ^>2 hours 88 157 27.3 14.6 Table 127.—Relation of Personality to Home, Social, and Work Adjustment Number of men Minnesota Multiphasic Personality Inventory Adjustment Hs D Hy Pd Mf Pa Pt Sc Ma Percent with elevated scores Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 Unsatisfactory home adjust- ment (depressed, restless, 37 51.4 56.8 43.2 32.4 8.1 5.4 32.4 56.8 16.2 Unsatisfactory social adjust- ment (feels out of place, asocial, antisocial) 80 189 50.0 43.8 38.6 43.8 12.5 9.5 6.3 1.6 5.0 2.6 28.8 20.6 33.8 24.3 7.5 6.3 Unsatisfactory work progress, (no progress, regression). . 47.6 36.5 complaints were associated with high scores generally (table 128); only in the Mf scale did this not hold. It is interesting to note that men with low intelligence as measured by the Wechsler-Bellevue tests tended to have elevations of most scales of the personality inventory. On the contrary, those with supranormal intelli- gence had few elevated scores. Along the same line it should be noted that intellectual deterioration was associated with elevation of the Hs, D, Hy, and Sc scales of the personality inventory—precisely those elevated in men with prolonged unconsciousness (table 129). It seems on the basis of this study that the deterioration indicated by the Wechsler-Bellevue test is particularly related to the severity of organic brain damage, although it is also associated with high scores on most of the scales 110

Table 128.—Relation of Personality to Clinical Symptomatology at Follow-up Symptom Number of men Minnesota Multiphasic Personality Inventory Hs D Hy Pd Mi Pa Pt Sc Ma Percent with elevated scores Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 No symptoms 48 6.2 8.3 14.1 21.2 13.7 10.4 24.2 30.3 17.6 4.2 5.4 3.0 3.9 6.2 i.3 3.0 2.1 9.4 18.2 3.9 4.2 9.4 12.1 7.8 2. 1 .7 3.0 2.0 Headaches 149 33 51 26.8 33.3 23.5 2.7 3.0 2.0 Dizziness Irritability or nervousness .... Impaired mentation or mem- ory . 31 30 32.3 30.0 51.6 19.4 23.3 43.4 12.9 9.7 3.3 7.8 3 ? 17 Q 22.6 16.7 23.4 6.5 6.7 Easy fatiguability, insomnia . . . Posttraumatic syndrome . . 244 30.0 43.0 3.3 1.6 '2.9 6.7 23.4 7.8 Table 129.—Relation of Personality Inventory to Intelligence Number of men Minnesota Multiphasic Personality Inventory Wechsler-Bellevue test Hs D Hy Pd Mf Pa Pt Sc Ma Percent with elevated scores Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 Intelligence scale: <89 35 323 112 60.0 37.5 29.5 48.6 30.3 19.6 42.9 32.5 26.8 8.6 7.4 3.6 2.9 2.2 .9 31.4 31.4 16.1 14.3 5.7 5.6 3.6 90-119 2.2 3.6 14.6 15.2 >120 Abnormal deterioration for age . . 75 53.3 37.3 44.0 8.0 2.7 1.3 18.7 21.3 5.3 of the personality inventory. The Minnesota Multiphasic Personality Inventory, on the other hand, is only slightly affected by organic brain damage, but is significantly elevated in almost all scales by aspects of neuro- logical affections generally considered to be "functional." Although these differences acquire statistical significance, it must be admitted that, in an isolated case, the criteria may not be entirely reliable. 3. The Goddard Form Board Test To investigate sensory motor performance in the absence of exteroceptive clues, the Goddard Form Board was used in those patients having sufficient motor and sensory abilities to carry out the test. Only a few correlations 111

will be examined. The presence of neurological symptoms is related to this performance task. The test does not seem to be very specific, but in all symptomatic categories the performance is impaired as compared to the groups having no clinical symptoms (table 130). The memory score in this analysis would seem to be somewhat more sensitive than the other com- ponents of the test although the differences are not impressive. A neuro- logical deficit is correlated with impaired scores in this examination. The performance test is definitely deficient in those patients having motor, Table 130.—Goddard Test in Relation to Clinical Symptomatology Total Domi- Reces- Boths Mem- Loca- Total time nant sive hands ory tion number >16 hand hand >6 score score Symptom of men minutes >6 >6 minutes <4 <4 tested (per- minutes minutes (per- items items cent) (per- (per- cent) (per- (per- cent) cent) cent) cent) Total 576 29.5 44. 1 29.3 7.5 17.0 70.3 None 48 20.8 i 27. 1 16.7 4.2 6.2 1 52. 1 Posttraumatic syndrome . . 329 31.6 i 47.4 32.2 9.4 19.8 »76.6 Other symptoms or un- known 199 28.1 i 42.7 27.6 5.0 15.1 »64.3 i Variation is statistically significant at the P < .05 level. 1 Variation is statistically significant at the P < .01 level. Table 131.—Goddard Test in Relation to Summary of Neurological Abnormalities Total Domi- Reces- Boths Mem- Loca- Total time nant sive hands ory tion number >16 hand hand >6 score score Abnormality of men minutes >6 >6 minutes <4 <4 tested (per- minutes minutes (per- items items cent) (per- (per- cent) (per- (per- cent) cent) cent) cent) Total 576 29 5 44.1 29. 3 7. 5 17.0 70.3 None 302 24 8 39 1 24 8 6.0 15.2 67.2 Hemiparesis or hemi- pleeria. 68 1 50.0 i 52.9 1 50.0 i 14.7 23.5 77.9 Hemianopsia f ^6"»' ••_••' 42 31 0 52 4 31.0 7. 1 23.8 71.4 Cortical sensory impair- 71 i 40.8 50.7 i 40. 8 8.5 23.9 66.2 Aphasia 23 1 56 5 i 65 2 52. 2 i 21.7 30.4 82.6 Mental impairment 61 s 55.7 1 68.9 1 49.2 i 14.8 24.6 '82.0 Cranial nerve palsy 130 25 4 42 3 26 2 10.0 16.9 72.3 Cerebellar syndrome .... 5 20 0 40.0 20.0 20.0 40.0 80.0 Other and unknown 9 55.6 77.8 55.6 11. 1 22.2 77.8 i Percentages differ significantly from the percent in normal men at the P<.05 level. * Percentages differ significantly from the percent in normal men at the P<. 01 level. 1ll

sensory, or mental impairment (table 131). The poor scores in the aphasic group are probably related to the coincident motor or sensory disturbance in most of these patients. Other neurological defects do not seem to influence the performance scores significantly. Intelligence seems definitely related to the ability to manipulate the form board. In all components of the performance test lower intelligence is associated with significantly impaired scores, being perhaps reflected most sharply in the memory score. As further confirmation of the effect of intelligence on the performance test is the finding that abnormal deteriora- tion is associated in all categories with decreased performance, although statistical significance is reached only in three components (table 132). In summary, one might conclude that the Goddard Form Board serves as an additional check on general neurological function, and that it seems to fluctuate with other measures of neurological abnormality. Table 132.—Correlation of Goddard Test and Intelligence Total Domi- Reces- Both Mem- Loca- Total time nant sive hands ory tion number >16 hand hand >6 score score Wechsler-Bellevue test of men minutes >6 >6 minutes <4 <4 tested (per- minutes minutes (per- items items cent) (per- cent) (per- cent) cent) (per- cent) (per- cent) Total . . . 576 29 5 44 1 29 3 7 5 17.0 70 3 Intelligence scale: <89 61 1 47 5 1 57 4 1 47 5 i 13. 1 » 52 5 • 90.2 90-119 391 1 30.2 1 46.8 1 30.9 i 8.2 1 15. 9 1 74.4 >120 113 1 17.7 1 26. 5 1 14. 2 i 1.8 » 3.5 1 43.4 Unknown 11 27 3 54 5 27 3 9. 1 .0 90.9 Abnormal deterioration for age 100 M5.0 1 63.0 »42. 0 8.0 24.0 75.0 i Statistically significant at the P<.05 level. 1 Statistically significant at the P<.01 level. 4. Discussion There has been much discussion of the sensitivity of psychometric tests in differentiating organic from functional alterations of the nervous system. The present study, in line with previous investigations, suggests that, as a group, people with predominant neurotic disturbances react differently in mental tests than people with predominant organic deficits. Individual cases may not always be differentiated. Sands and Price (112) believe that the digit span and symbol test of the Wechsler-Bellevue test is sensitive to organic deficit as contrasted to epileptic and functional groups. Halstead (60) relies upon his category tests for such differentiation. Many psycholo- gists prefer the Rorschach responses as a basis of judgment. However, Lynn et al. (81) believe that a battery of tests is necessary to cover the complete range of potentially deviant cerebral responses in late head injuries. 113

It is of interest to consider that cerebral function may be impaired both by the elimination of cerebral substance and by the abnormal activity of damaged cortex. Dailey (33) has examined the thesis that continued inter- ference with normal brain function by pathological tissue may have more adverse psychological effects than those produced by the elimination of that tissue. In head-injured patients, psychological testing indicated that the performance was not reduced and might be improved by such excisions. 114

Next: Epilepsy »
Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon Get This Book
×
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF
  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!