Chapter 9

The multi-facetted nature of the sequelae after TBI has been studied for many years. Some of the milestones will be briefly reviewed in the following: In 1932, Russell (31) published the results of a study based on two hundred head injury patients consecutively admitted to the Edinburgh Royal Infirmery. The severity was graded according to the duration of unconsciousness, determined by the patient’s subjective memory of when he woke up. 80 patients were unconscious for less than one hour, 57 for between one and 24 hours, 47 for more than 24 hours, and 16 died. Thus, a wide range of severities was covered. Russell stated as compatible with prior knowledge already at that time that at follow-up six months of injury, the principal sequelae were headache, dizziness, inability to concentrate, disturbances of memory and behaviour, nervousness, disturbances of sleep, and epilepsy. Physical examinations at follow-up usually elicited no abnormal signs. Anosmia and deafness were occasionally present, as were slight motor disturbances. In particular, Russell drew the attention to the complete change of character not uncommon in children even after moderate head injury, as occurring by falls. It should be mentioned here that only 23% of the injuries comprised by this study were due to motor vehicle accidents. These high energy accidents are known to cause very severe diffuse injuries, with a high liability of both neurophysical and mental sequelae. Such injuries are probably underrepresented in the said study, compared to most more recent studies. In 1936, Goldstein (224) made the important but not always recognized observation that the performance of a person with a brain lesion depends not only on the specific lesion but also on the struggle of the personality changed by the lesion, with the task confronting it. Goldstein found by painstaking observations that mental parameters like attention, interest, memory, fatigue, etc. varied according to whether the individual succeeded or failed in solving a given problem. This is fundamental not only for the interpretation of psychometric test results, but also for the rehabilitation process. It means that especially for this group, the possibility of benefit from therapy of physical and mental functions will depend on the level of insight in these mechanisms among the personnel involved in the therapy. In particular, Goldstein pointed to the so-called catastrophic reaction, the flight from problems too difficult for the damaged brain. One of these flight mechanisms is complete self-exclusion from the external world. In 1969, after a considerable increase in the occurrence of head injuries during the two prior decades, the late effects of head injury and rehabilitation in this field were described in a monography edited by Walker et al. (225). Already at this time, it was established that there were at least two syndromes after head injury. One is the so-called postconcussional syndrome, illustrated by the person who performs normally by neurological examination and by simple psychometric tests, but who complains of headache, dizziness and tiredness and demonstrates a reduction in the ability to cope with life that often seems out of proportion with the apparently modest trauma. The other is the syndrome following a severe head injury followed by prolonged amnesia or otherwise reduced consciousness, and where deficits in mental and in some cases also in neurophysical performance are obvious. Since the latter is the topic of the present study, attention will be paid only to this syndrome in the following. The study from 1969 by Zwan (226) on 27 TBI patients surviving after at least three week’s unconsciousness showed that at follow-up six years of trauma, even in this severely injured group, subjective symptoms and objective findings concerning mental dysfunctions were about twice as frequent as neurophysical sequelae. Thus, while five patients were hemiparetic and 14 had gait disturbances, 20 had memory and abstraction problems, and 21 felt emotionally labile. In 1970, the results of additional studies covering a wide spectrum of head injury aspects were collected in the Proceedings of an international symposium (227). One of the contributions was from Lecuire et al. (228) who studied 55 patients with coma of over a month’s duration and found that while the neurological (= neurophysical) se-