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Malingering after brain injuries
Abstracts
Cervical spinal fusion Details are given concerning the use of a stereotaxic head holder to achieve accurate reduction of fracturedislocations of the cervical spine. This is a preliminary to spinal fusion. MCFADDEN,J. T. (1971), ' Stereotaxic Realignment of the Dislocated Cervical Spine ', Surgery Gynec. Obstet., 133, 262. Malingering after brain injuries This article is adapted from a chapter on the subject that the authors contributed to a book. They pursue the line of argument presented by the senior author in the Milroy Lectures of 1961 and give a detailed account of one example of exaggeration and malingering. They recognize the difficulty of distinguishing malingering from unconscious motivation in some cases but express the opinion that the lack of a history of psychological disturbance before the accident is evidence in favour of a diagnosis o f ' accident neurosis '. They give several other pieces of evidence that they consider helpful and they comment on how an expert witness should best seek to give such facts as he can and such opinions as are sought. There is an acknowledgement that signs and symptoms can occur without there being any prospect of financial gain, but there is no reference to the possibility that in some instances the infliction of head injury may expose the vulnerability of a personality that had previously gone unrecognized, and that the repetition of the story that the legal processes necessitate is hardly likely to diminish complaints while it continues. The article deserves reading in full, it has much valuable comment but it could be a little more sympathetic in some respects. MILLER,H., and CARTLIDGE,N. (1972), ' Simulation and malingering after injuries to the brain and spinal cord ', Lancet, 1, 580. Detecting intracranial pressure waves lntracranial pressure was found in 12 of 22 patients to rise and fall either with the form of a plateau lasting half an hour or more or in a series of low spikes lasting for a minute or so each. Continuous recording of ultrasonic echoes showed a fall in the amplitude of the tracings coinciding with a rise in intracranial pressure. There was no change in the wave-form of the echoencephalogram unless there was a change in intracranial pressure. Continuous and reliable recording of the echoencephalogram requires care, particularly in restless patients. RICHARDSON, A., EVERDEN,J. D., and STERNBERGH, W. C. A. (1972), 'Detecting intracranial pressure waves with ultra-sound ', Lancet, 1, 355. Head injury and multiple fractures Aufranc's fracture of the month clinic brings out some interesting features in the case history of a child followed for 12 years. Dr. Wilson described the injuries to a 7-year-old girl as cerebral contusion,
91 closed comminuted fracture of the femoral shaft, compound fractures of radius and ulna, dislocation of hip, and contusion to intestines and kidneys. The child was unconscious for 7 weeks and was subjected to craniotomy, tracheostomy, and conservative treatment of the fractures. There were three interesting features. At 3 weeks the radial shaft was protruding 1 inch through an infected wound and was treated by excision of the projecting portion. The result 12 years later was a nearly perfect functioning forearm because the lower radial epiphysis with some metaphysis survived. Although the femoral shaft fracture was not compound, osteomyelitis developed 16 months after injury. It failed to respond to conservative treatment and sequestrectomy was required 6 months later. The final result was 1 inch lengthening of this leg. A peroneal paralysis which persisted was satisfactorily treated by extra-articular fusion of the subtaloid joint with transfer of the peroneus brevis tendon to the second cuneiform. WILSON, J. C., and AUFRANC, O. E. (1971), ' Headinjured child with multiple fractures ', J. Am. med. Ass., 217, 1847.
Infantile depressed skull fractures Drs. Hendrick and Hoffmann from the Hospital for Sick Children in Toronto report their method of elevating depressed skull fractures based on their experience with 70 children under 1 year of age over a period of 15 years. Instead of drilling a burr hole, the elevator is inserted through the coronal of lambdoid suture line. By opening up this cartilaginous suture line there is less trauma produced and the procedure is safer than the burr-hole technique. When the fracture is more than 10-14 days old it may be necessary to score the underside of the bone before applying outward pressure with the elevator. In particularly difficult cases the depressed area can be excised with scissors and the flap reversed. HENDRICK, E. B., and HOFEMAN, H. J. (1971), ' Coronal suture line used to repair skull fractures ', J. Am. reed. Ass., 218, 1372. Penetrating wounds of the neck ' A l l neck wounds penetrating the platysma should be explored '. The authors present an analysis of 211 cases, justifying this axiom, indicating the few exceptions, tabulating the lesions found, discussing the mortality, and recommending the surgical approaches. WEAVER, A. W., FROMM, S. H., and WALT, A. J. (1971), ' The management of penetrating wounds of the neck ', Surgery Gynec. Obstet., 133, 49.
THROMBO-EMBOLISM Peripheral venous scanning Seventy-two persons with strong clinical and radiological evidence of pulmonary embolism but no signs
Cervical spinal fusion Details are given concerning the use of a stereotaxic head holder to achieve accurate reduction of fracturedislocations of the cervical spine. This is a preliminary to spinal fusion. MCFADDEN,J. T. (1971), ' Stereotaxic Realignment of the Dislocated Cervical Spine ', Surgery Gynec. Obstet., 133, 262. Malingering after brain injuries This article is adapted from a chapter on the subject that the authors contributed to a book. They pursue the line of argument presented by the senior author in the Milroy Lectures of 1961 and give a detailed account of one example of exaggeration and malingering. They recognize the difficulty of distinguishing malingering from unconscious motivation in some cases but express the opinion that the lack of a history of psychological disturbance before the accident is evidence in favour of a diagnosis o f ' accident neurosis '. They give several other pieces of evidence that they consider helpful and they comment on how an expert witness should best seek to give such facts as he can and such opinions as are sought. There is an acknowledgement that signs and symptoms can occur without there being any prospect of financial gain, but there is no reference to the possibility that in some instances the infliction of head injury may expose the vulnerability of a personality that had previously gone unrecognized, and that the repetition of the story that the legal processes necessitate is hardly likely to diminish complaints while it continues. The article deserves reading in full, it has much valuable comment but it could be a little more sympathetic in some respects. MILLER,H., and CARTLIDGE,N. (1972), ' Simulation and malingering after injuries to the brain and spinal cord ', Lancet, 1, 580. Detecting intracranial pressure waves lntracranial pressure was found in 12 of 22 patients to rise and fall either with the form of a plateau lasting half an hour or more or in a series of low spikes lasting for a minute or so each. Continuous recording of ultrasonic echoes showed a fall in the amplitude of the tracings coinciding with a rise in intracranial pressure. There was no change in the wave-form of the echoencephalogram unless there was a change in intracranial pressure. Continuous and reliable recording of the echoencephalogram requires care, particularly in restless patients. RICHARDSON, A., EVERDEN,J. D., and STERNBERGH, W. C. A. (1972), 'Detecting intracranial pressure waves with ultra-sound ', Lancet, 1, 355. Head injury and multiple fractures Aufranc's fracture of the month clinic brings out some interesting features in the case history of a child followed for 12 years. Dr. Wilson described the injuries to a 7-year-old girl as cerebral contusion,
91 closed comminuted fracture of the femoral shaft, compound fractures of radius and ulna, dislocation of hip, and contusion to intestines and kidneys. The child was unconscious for 7 weeks and was subjected to craniotomy, tracheostomy, and conservative treatment of the fractures. There were three interesting features. At 3 weeks the radial shaft was protruding 1 inch through an infected wound and was treated by excision of the projecting portion. The result 12 years later was a nearly perfect functioning forearm because the lower radial epiphysis with some metaphysis survived. Although the femoral shaft fracture was not compound, osteomyelitis developed 16 months after injury. It failed to respond to conservative treatment and sequestrectomy was required 6 months later. The final result was 1 inch lengthening of this leg. A peroneal paralysis which persisted was satisfactorily treated by extra-articular fusion of the subtaloid joint with transfer of the peroneus brevis tendon to the second cuneiform. WILSON, J. C., and AUFRANC, O. E. (1971), ' Headinjured child with multiple fractures ', J. Am. med. Ass., 217, 1847.
Infantile depressed skull fractures Drs. Hendrick and Hoffmann from the Hospital for Sick Children in Toronto report their method of elevating depressed skull fractures based on their experience with 70 children under 1 year of age over a period of 15 years. Instead of drilling a burr hole, the elevator is inserted through the coronal of lambdoid suture line. By opening up this cartilaginous suture line there is less trauma produced and the procedure is safer than the burr-hole technique. When the fracture is more than 10-14 days old it may be necessary to score the underside of the bone before applying outward pressure with the elevator. In particularly difficult cases the depressed area can be excised with scissors and the flap reversed. HENDRICK, E. B., and HOFEMAN, H. J. (1971), ' Coronal suture line used to repair skull fractures ', J. Am. reed. Ass., 218, 1372. Penetrating wounds of the neck ' A l l neck wounds penetrating the platysma should be explored '. The authors present an analysis of 211 cases, justifying this axiom, indicating the few exceptions, tabulating the lesions found, discussing the mortality, and recommending the surgical approaches. WEAVER, A. W., FROMM, S. H., and WALT, A. J. (1971), ' The management of penetrating wounds of the neck ', Surgery Gynec. Obstet., 133, 49.
THROMBO-EMBOLISM Peripheral venous scanning Seventy-two persons with strong clinical and radiological evidence of pulmonary embolism but no signs