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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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