Introduction to 'The after effects of head injuries'

The paper by Sir Crisp English, reproduced here by kind permission of Mr Veryan Herbert and the Lancet, was the ®rst of three abstracts of his Hunterian lectures to the Royal College of Surgeons in 1904. The work is remarkable because of the author’s knowledge of head injury and its consequences. There are many references to the e ects of head injury in childhood throughout the three lectures, but I have chosen the ®rst one because of English’s particular reference to the question of age and recovery, the so-called Kennard Principle [1] or the question `Is it really better to have your brain lesion early? ’ [2]. English considered age among the main conditions in ̄uencing progress after head injury. He draws attention ([3], p. 487) to the dichotomy of opinion regarding age and recovery that has persisted to date [4, 5]: `It is usually stated that children recover remarkably well from injuries to the head, but my experience has not borne out this statement . ’. One may speculate to what extent he may have been aware of earlier reports of age-related di erences in response to brain damage [6, 7]. However, it is evident that English was fully aware of the need to adopt a developmental perspective on the consequences of head injury [8]. English quali®ed in medicine in 1900 and in 1902 was awarded the Jacksonian Prize for an essay on head injury. Unfortunately, it seems that English’s work in this area was interrupted by public interest in a lower organ, the appendix, and subsequently he became preeminent in that branch of medicine. There is perhaps more than a little irony in that transition, in view of his opening remarks ([3], p. 485), `The rapid and almost startling advance of abdominal surgery during recent years has exerted a retarding in ̄uence upon other branches of surgery, it has overshadowed cerebral surgery . ’. It seems that abdominal surgeons may have been two-a-guinea, as it were, whilst there was just a handful of neurological specialists. Given his astute observations and thinking on head injuries, it is likely that clinical and experimental neuroscience today would be far more advanced than it is if English had chosen to remain one of the few. In the late 19 th and early 20 th centuries, the common mechanisms of head injury would have been very similar. The literature contains references to children being run over by cartwheels or thrown from dogcarts, for example, as well as the usual assaults and falls. Consequently, the general pathology is likely to have been very similar, particularly deceleration insult to the prone frontal and temporal lobes, but without the high velocity acceleration injury caused by modern vehicular accidents. Acute medical and surgical care has advanced in recent times, such that we now have a greater number of survivors and consequently higher morbidity. Attempts at measuring outcome may seem to be more sophisticated now, but it is likely that return to work or education have remained the main classi®cations since English’s time. One invariant factor is the biological make-up of the immature brain [9, 10]. The vulnerability of immature structures to the e ects of insult will have been as great then as now. Aberrant development of the brain after early insult would have been the same, whatever the time or cause, with perhaps greater awareness of the behavioural sequelae [11]. It follows that the prevalence of disability, handicap and associated needs caused by head injury in children should be correspondingly greater now than 100 years ago. The consequences of head injury have always been detrimental to the individual’s functioning. Then, as now, the bene®cial e ects resulting from head injuries were considered almost entirely con®ned to the imaginations of novelists. However, there are rare examples where brain damage has the paradoxical e ect of