A third-year law student's car is rear-ended by a tractor-trailer truck. The student experiences a brief period of dizziness, overwhelming fatigue, and vision problems. The student later finds that he cannot concentrate or retain information from his case books. He begins to experience mood swings and depression.

• During a car collision, a 62-year-old sculptor hits her head on the car roof. She later finds out that she can no longer conceptualize or finish a sculpture.

• In a head-on collision, a bartender is thrown against the dashboard. He sustains facial bone fractures and loses consciousness. Later he discovers that he cannot remember patrons‘drink orders, although before the collision he had been able to keep track of 20 at a time.

• Another auto accident victim, a 25-year-old computer programmer, now finds that she gets lost driving to work. She can no longer do her job without making lists of every task to be completed and taking notes on every conversation she has. She begins to have heated arguments with her husband.

The personal injury lawyer who has had no prior experience with head-injury cases might dismiss the vague, seemingly unrelated symptoms in any one of these cases as the complaints of a hypochondriac. That lawyer could easily focus only on a soft-tissue neck injury claim and miss the much more important brain-injury claim.

Plaintiffs' lawyers are well aware of the epidemic of orthopedic injuries (fractures) and soft-tissue injuries (torn or bruised ligaments, muscles, and nerves) caused by accidents involving transportation vehicles, construction equipment, or falls. Both types anatomical damage can easily be recognized and diagnosed, often by a lay person. But mild to moderate brain damage associated with the same accidents frequently goes undiagnosed even by medical experts.

Each year, head injuries cause 100,000 deaths in this country, and an estimated 1.5 million Americans sustain head injuries that require medical attention. Roughly half these are minor and do not require hospitalization. The other half involve moderate to severe brain injury. Each year, 700,000 people with head injuries are admitted to hospitals. Each year, between 50,000 and 90,000 of them are unable to resume normal life. In 1983, more than $10.5 billion was spent on the care, treatment, and rehabilitation of people who have suffered head injuries.

An even larger number of brain-injured people are undiagnosed. They may be seen in emergency rooms by doctors who tell them that they will recover from brain-trauma-related complaints or they may never get medical attention. Thus, these people may not realize that they have sustained brain injuries and that their ensuing cognitive problems are real and have a definite cause. They are the victims of what experts call "a silent epidemic."

Many of them will seek legal counsel to obtain compensation for more obvious but far less significant injuries, such as fractures or cervical strain or sprain. Personal injury lawyers when recognize signs of brain injury can provide invaluable assistance to these clients by referring them to medical care providers skilled in the diagnosis and treatment of mild to moderate brain injuries. Getting them medical help is a satisfying adjunct to fulfilling the more traditional lawyer's role of helping them obtain full and fair compensation for all their injuries-head injuries included.

Signs of Damage

Brain injury causes physical, cognitive, and psychosocial impairment. Physical effects can include headaches; lack of coordination; muscle spasticity; paralysis; seizures; and speech, hearing, vision, tactile, and olfactory dysfunction. On a cognitive level, there maybe memory deficits; concentration problems; slowed thinking; and problems with perception, sequencing, judgment, and communication, including impaired reading and writing skills. Possible psychosocial consequences include behavioral and emotional dysfunction; lack of motivation; and emotional lability (volatility), including excessive laughing or a general difficulty in relating to others.

Many personal injury attorneys have accident-victim clients who complain of problems with organizing their thoughts, keeping track of things, selecting the right word in speaking, doing their jobs as well as before, getting along with family and friends, learning new things or retaining information, or finding their way from place to place. They may complain of headaches, dizziness, double vision, hypersensitivity to light or sound, or fear and confusion when in crowds. Many of these symptoms come under the diagnostic catch-all of "post-concussion syndrome." Their presence makes it likely that a brain injury evaluation will prove fruitful.

Brain injury can be present in a person who never lost consciousness. In such cases, the alteration of consciousness caused by the blow to the head may have taken the form of a period of feeling dazed, confused, or agitated. The client who did not lose consciousness is less likely to have had the brain injury correctly diagnosed. This person will suffer severely because no one recognized that there is a physical basis for the deficits.

People with mild to moderate brain injury are beset by residual problems that usually escape detection in ordinary medical examinations. Because these problems are undefined or improperly defined, they become more frightening and debilitating. These victims may simply decide that they are going crazy for reasons unrelated to the original trauma. Often they are misunderstood by their families, co-workers, and communities. Often they are accused of malingering.

Mechanics of Damage

How can a client have brain damage without having sustained a skull fracture, coma, or loss of consciousness? It is important to know some basic facts about brain anatomy in order to understand this type of injury. The brain lacks rigidity and strength, and is easily crushed or torn. Brain tissue is made up of billions of fine thread-like nerve fibers. It has the consistency of oatmeal or gelatin. The brain is protected externally by the rigid skull and internally by a cushioning bath of cerebrospinal fluid, which surrounds it and in which it floats. Most of this fluid is between the brain and the skull; the rest is in the ventricles (natural cavities in the brain).

The skull offers considerable protection because of its strength, but it does not protect perfectly due to its inner contours. The skull's interior is not smooth, but characterized by sharp, bony protuberances. When something hits the head, the brain may be flung against these protuberances and torn or bruised.

Much of the early research on the type and Iocation of damage to the brain that results from its movement within the skull was conducted by a physicist, A.H.S. Holbourn, during the mid-1940s. Using gelatin models of the brain encased in a skull, Holbourn delivered blows of measured intensity to specific points on the skull. He reported that the irregularities in the internal contour of the skull-its ridges and dural partitions-play a decisive role in determining the distribution of forces on the brain resulting from blows to the head. As the brain is moved within the skull, the tips of the frontal and temporal lobes are especially vulnerable to bruising due to their location within the skull.

Holbourn found the shearing effect caused by sliding brain tissue over bone to be responsible for much of the localized damage that occurs in both closed and open head injuries. When external forces cause rotational movement of the brain, as in a severe whiplash, wide-spread damage can also result.

U.S. government studies further documented such injuries in experiments with rhesus monkeys. The monkeys were placed in an automobile that was subjected to rapid acceleration and deceleration forces. The monkeys' brains were later dissected to determine the extent of the injuries. In evaluating rotational and translational rigid body motions of the head after impact, this study proved that concussion, visible hemorrhages, and contusions of the brain surface can be produced without direct head impact.

In trauma to the brain, rotational and shearing effects may also case injury to the blood vessels (bruising). When the blood supply carried by capillaries to brain tissue is obstructed by injury, the brain cells are deprived of nourishment and die. In addition, coup contra coup injuries can occur when the brain bounces off one side of the skull’s interior and then strikes the opposite side-even without a blow to the head.

Control of different physical functions and mental operations may be quite localized. Injuries to small areas of the brain may have very specific and limited effects, while larger injuries affect more functions. The forebrain or frontal lobes control many intellectual abilities.

Injuries to the frontal lobes are specifically associated with poor judgment of the consequences of one’s actions; difficulties in planning, sequencing, and decision making; diminished awareness of social propriety; and loss of inhibition. The frontal lobes organize and regulate behavior necessary for accomplishment. They are critical to the "executive functions"-anticipating, selecting goals, self monitoring, using feedback, and completing purposeful activities.

The frontal lobes coordinate attention, memory, language, perception, motor functions, and social behavior. When their function is impaired, all other cognitive systems-even those that remain individually intact - are affected. People with frontal-lobe injuries may appear to lose all ambition. They may have trouble starting routine tasks; following a sequence of directions; and maintaining attention to tasks or situations that involve judgment, social reasoning, and inventive problem solving.

The brain is also divided into right and left hemispheres, each with specialized functions. Injury to the left hemisphere can cause difficulty with language, verbal and nonverbal communication, logic, calculation, and moods. It can also cause right visual-field neglect- impaired ability to register or process information from the right eye, even if the eye itself is undamaged. With damage to the right hemisphere, the injured person may experience poor vigilance, scanning and spatial-orientation problems, indifference and apathy, loss of inhibition, or left visual-field neglect.

Temporal-lobe damage diminishes the ability to recognize, process, and remember information that is heard-words, voices, and numbers. The injured person may also suffer from sound discrimination problems, temporal-lobe epilepsy, or language disturbance.

Detecting Damage

The diagnosis and evaluation of mild to moderate brain damage require special training and specialized diagnostic tools. Counsel should not rule out a possible brain injury simply because a neurologist, a neurosurgeon, or even a neuro-radiologist has not made such a diagnosis. These medical specialists use sophisticated diagnostic tools like computerized axial tomography (CAT) scanners, nuclear magnetic resonance imaging (called MRI, NMR. or simply "the magnet"), and electroencephalography (EEG). But they can only identify grand mal epileptic seizures or major anatomical injuries- macroscopic (as opposed to microscopic) injuries- for example, subdural hematomas and hemorrhages.

CAT scans cannot identify subtle or microscopic tissue damage. Nearby bone produces false readings, making defects in the frontal and temporal lobes difficult to visualize. MRI is often inadequate. In some cases, it cannot be used to identify even acute subarachnoid hemorrhaging, much less microscopic damage to axons and neurons. A substantial population of patients who appear normal in CAT or MRI studies actually have focal abnormalities-localized injuries to discrete parts of the brain-or severe neurological disability.

EEGs record gross brain activity. They often show normal readings on a patient with only moderate damage unless the patient actually has a seizure during the test. Many clients undergo standard neurological examinations and are advised that nothing is wrong because the only objective tissue damage is on a microscopic level and a brain autopsy would be necessary to reveal it.

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