Medical and literary sources have described head injury and its effects from early Egyptian times. Though milder injury - concussion - must have been familiar, there was little specific written about it until the latter part of the 18th century. Descriptions of persisting symptoms appear in the 19th century, and discussion of their origin and management has continued and intensified since then. There have been several major issues. How does mechanical trauma produce a temporary loss of neurological function and is there some lasting damage? When symptoms persist do they follow a pattern which we recognise as occurring with structural lesions, or are the symptoms a functional reaction to the injury and other life events? Are they both?Over the last 50 years these issues have been debated, often with heat. Whatever the final judgment the present task would seem to be to provide a service to deal with the clinical situation.

AIMS:To define mild head injury and determine its incidence and that of persisting symptoms.METHODS:Analysis of an eight week sample of all patients with head injury passing through the Emergency Departments of the four Auckland Hospitals, and of a five year sample of patients attending a clinic for management of symptoms persisting after head injury.RESULTS:Mild head injury was defined by the acute management needed--care out of hospital or not more than 48 hours admission, corresponding reasonably with a definition using post-traumatic amnesia. Incidence in those seen at hospital was 437/10(5) whole population/year for ages 15 and over, and 252/10(5) for ages under 15. Age specific incidences were 1769/10(5)/year for 15 and over, and 2920/10(5) for ages under 15, the major causes being road accidents (RTA) and falls, respectively. For 100 cases seen at hospital approximately 60 were treated by general practitioners alone. Referrals in patients 15 years and over because of persisting symptoms occurred in 5% (95%, CI 3-7), 69% in the first four months and 6% after a year. Referrals were equally likely after RTA, sports injuries and assaults, more frequent after objects striking the head. Older people were marginally more likely to be referred and the probability was significantly greater in women injured in sport and in minor RTA not needing admission to hospital.CONCLUSIONS:Mild head injuries are economically important and deserve efficient management.

This article examines the evidence that the effect of head injury on young children may differ from that in adults, in that while in the latter the pattern is of deficits that recover with time since the accident, this is not necessarily the case with very young children. In this group, there may be no evidence of any deficit in the early days or weeks after injury, but the children may fail to develop some skills as quickly as children who have not had a head injury. Results from a series of studies of MHI in preschool children carried out over a more than 10-year period from Auckland Hospital and recently published studies of pediatric MHI from other groups are reviewed. It is concluded from a comparison of these data that there is a need for long-term prospective studies designed within a developmental framework to clarify the issue.

This study describes the effect of mild head injury in preschool children on aspects of their cognitive performance in the year after injury and at the age of 6.5 years, with particular reference to the development of reading skills. Mild head injury was defined by diagnosis at a hospital emergency department of a head injury which was not severe enough to need admission for observation. Seventy eight such children were compared with a group of 86 with a minor injury elsewhere. The groups had similar developmental, family, and socioeconomic status. There were no differences in cognitive tests soon after the injury, but at six months and one year children with mild head injury scored less than controls on one test, solving a visual puzzle (visual closure); they were also more likely to have had another mild head injury. At 6.5 years of age they still scored less than controls, reading ability was related to their visual closure score at one year, and they were more likely to have needed help with reading. Mild head injury seems to be able to produce subtle but significant changes which can affect school performance.

Survival and clinical status in 105 acromegalic patients followed for up to 24 years after surgery is assessed against serum growth hormone (GH) levels and other factors. Primary treatment was at first 90Yttrium implants or craniotomy, later transsphenoidal operation. GH levels were similar for each method, and the results were combined.

OBJECTIVE The extent to which treatment modifies the excess in morbidity and mortality in acromegaly remains uncertain. This study investigates the determinants of final outcome following therapy for acromegaly.DESIGN A retrospective analysis of patients treated at the Departments of Endocrinology and Neurosurgery, Auckland Hospital, New Zealand.PATIENTS One hundred and fifty-one patients (63 females and 88 males) with acromegaly or gigantism treated between the years 1964 and 1989. The mean duration of follow-up was 12 years (median 11 years).MEASUREMENTS Patients had their age, estimated duration of symptoms preceding diagnosis, serum GH at diagnosis, presence of diabetes mellitus, cardiovascular disease, hypertension and/or osteoarthritis at diagnosis and the last known serum GH documented. The final outcome at the time of study was graded under three classes: dead (n = 32), those with major complications (n = 47) and those with minor/no complications (n = 67).RESULTS The mean age at diagnosis of acromegaly was 41 years and the average estimated duration of symptoms prior to diagnosis was 7 years, with older patients showing longer duration of symptoms preceding diagnosis (P = 0.0002). Final outcome (dead, alive with major complications, alive and well) was significantly worse in those with older age at diagnosis (P = 0.008), longer duration of symptoms before diagnosis (P = 0.03) and higher GH at last follow-up (P = 0.0001). In multivariate analysis, survival was significantly influenced by the last known GH (P = 0.0001), presence of hypertension (P = 0.02) or cardiac disease (P = 0.03) at diagnosis, and duration of symptoms prior to diagnosis (P = 0.04). Survival in the acromegalic group, irrespective of treatment, was reduced by an average of 10 years compared with the non-acromegalic population.CONCLUSIONS Acromegaly has a significant adverse effect on well-being and survival. The predominant determinant of outcome is the final serum GH level following treatment.

Twenty-six patients were subjected to temporal lobectomy for complex partial seizures resistant to anticonvulsant control. The criteria for selection were simple. There should be EEG evidence of epileptiform activity arising predominantly in one temporal lobe. It was desirable that psychometric tests should confirm the localisation by showing defects of function in this lobe, and necessary that they should demonstrate normal function in the other. There should be no radiological evidence of a gross structural lesion. Twenty-four patients have been followed for 5 to 17 years, two being lost at 3 and 4 years. After operation, 50% were completely free from seizures, and in a further 38% seizures were reduced in frequency by at least 75%. There was no mortality, and the only morbidity was a minor quadrantic hemianopia, usually unnoticed by the patient. A significant improvement in mental state was noted in many patients. It is concluded that to use simple criteria for selection of patients for temporal lobectomy gives worthwhile results. There are many patients in the community who could be selected for surgery on these criteria with a high probability that their condition would be improved.

A retrospective analysis was made of the natural history and treatment of 44 patients with syringomyelia, followed for a median interval of 10 years after diagnosis. Twenty-four patients were treated surgically. Four of 12 patients who had a laminectomy with aspiration of the syrinx or syringostomy, and 7 of 15 patients who underwent decompression and exploration of the cervicomedullary junction, showed sustained improvement or stabilisation of their neurological deficits. When symptoms had been present for more than 2 years, when there was a moderate or severe neurological disability, and when the patient was more than 40 years old, the long-term outlook of posterior fossa surgery was usually poor. Of the 20 patients who did not have an operation, 7 had no further progression in symptoms after presentation and prolonged survival was usual. It is concluded that in many cases syringomyelia is compatible with prolonged survival, and although improvement can follow surgery, its influence on the disease in the long-term is uncertain.

A 49-year-old man with acromegaly underwent the apparently complete removal of a pituitary microadenoma by the transsphenoidal route. There was complete remission of the biochemical abnormalities for 2 1/2 years, with basal plasma growth hormone (GH) levels of less than 1 ng/ml and normal somatomedin levels. The patient then died after the rupture of a cerebral aneurysm. Serial sections of the pituitary fossa showed persistent tumor with a volume of about 6% of the remaining normal gland. It is concluded that current endocrine tests are limited in their ability to detect residual GH-secreting tumor. Their sensitivity is likely to depend on the mass of tumor and on the GH secretion rate. Predictions of long term cure based on these tests are only tentative.

A carefully controlled prospective study was made of 66 men aged 17 to 48 with minor head injuries. The mean time off work was 4.7 days, range 0 to 26 days. Time off work was longer: in older patients; after road traffic accidents compared with sports injuries; in patients who had taken alcohol and in 5 patients who had needed admission to hospital. Post-traumatic amnesia alone did not relate to time off work but was longer in these groups of patients. Sixty per cent of patients had symptoms on return to work and 46 per cent could not do their job as well as usual for a mean time of 14 days. Leisure activities were affected for a similar period and fatigue was common. Ninety days after the accident 20 per cent still had symptoms, mostly defects of memory, concentration and work capacity. Four patients still had symptoms 2 years later. Though describing symptoms, all patients were back at their usual work and none had any claim for compensation outstanding.

A case of pituitary gigantism occurring in a 31 month old female child is reported. Growth records indicate that the disorder began early in the second yr of life. Apart from her size and history of excessive sweating, there were no characteristic clinical features of endocrinopathy. Elevated and autonomous secretion of GH (60–109 μg/I) and prolactin were corrected by the removal of an eosinophilic pituitary adenoma. In the subsequent 6 yr, despite the presence of immunoreactive GH (4.6–17.3 μg/l), plasma somatomedin was subnormal and the patient showed growth failure which responded normally to exogenous GH therapy. This case, which appears to be the youngest example of verified pituitary gigantism on record, illustrates that a successful outcome can be achieved by surgical ablative therapy.

The relation between duration of post-traumatic amnesia (PTA), performance on memory tests, and the Paced Auditory Serial Addition Task (PASAT) was examined in two samples of young adult closed head injury patients. Three different effects were isolated: (1) an attention and concentration factor, related to PASAT scores, (2) a deficit in the ability to place material into long-term memory storage, related to PTA durations, and (3) an impairment in the ability to retrieve material once it has been stored, which was not predicted by either PTA or PASAT.

Sixty-three men aged 17 to 48 who had been concussed were asked 90 days later if it had affected them, if they knew of others who had been affected, and if they would take action to prevent further injury. Twenty percent still had symptoms, mostly impairment of intellectual function. Sixty percent expressed concern about the injury, though only 19 percent intended realistic measures to prevent recurrence, such as giving up football or selling their motorcycle. Concern was commoner after sports than road accidents. Sixty percent had friends who had been concussed, and a third of these had given up sport because of the effects. It is concluded that there is considerable awareness, particularly amongst sportsmen, of the effects of concussion, and that sports administrators would find considerable support for rules to reduce the risk of brain damage from repeated concussion.

Ten university students who had recovered from minor head injury between one and three years previously were given vigilance and memory tests at a simulated altitude of 3,800 metres. Their performance was significantly below that of a matched group of students who had never had a head injury. The finding supports the proposition that even minor head injury has persisting effects, though they may be subtle and only emerge under the effects of stress.

Sixty-seven adult males with minor head injury were examined soon after arrival at hospital. Orientation and post-traumatic amnesia (PTA) were assessed every 15 minutes until the patient was discharged, and the sequence and times of events after the accident recorded. Five matched groups were formed and duration of PTA checked at intervals ranging from one week to three months after injury. Distributions of PTA estimates were significantly different from final PTA estimates made before the patient left hospital, but this was independent of the time when the follow-up was made. Thirty-six subjects were questioned a second time after they had recovered. Changed estimates were recorded in four of these cases, but again the change was not related to the length of time between the two interviews. “Islands” of memory were recorded in the early part of the amnesia in more than one third of the cases. No significant correlation was found between the period of disorientation and the period of PTA.

Operation by the trans-sphenoidal route allows removal of small pituitary adenomata with conservation of normal gland. Histological examination of tissue obtained at operation and necropsy in 73 cases showed that surgical methods at present in use are likely to leave tumour behind in the pituitary gland and in the dura mater of the pituitary fossa. The clinical significance of these findings will only become evident after following patients for an extended period, but there appears to be a strong indication for routine postoperative radiotherapy.