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Assessment of Coma and Impaired Consciousness - A Practical Scale

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81
significant
correlations between surface area or
weight
and B.T.T.
Discussion
Japanese
migrants
to
Hawaii-especially
their
families,
the
second-generation Nisei--develop
dis-
ease
patterns
similar to Caucasians. 6 The Hawaii-
Japanese
lose the
high gastric-cancer
risks of
Japan
and
acquire "Western" malignancies
such as those
of
prostate, breast,
and colon. The
Hawaii-Japanese
have more colonic
polyps
and diverticuloses than
Japanese living
in
Japan.8
It would be
expected, then,
that the more tradi-
tional Issei would have a faster B.T.T. than the Nisei
and that the
Hawaii-Japanese
would have transit-
times similar to those of Caucasians. We were sur-
prised
to find no differences between the Issei and
Nisei,
and the
Hawaii-Japanese
had
rapid
transit-
times
comparable
with those in rural Africans a
2
The
B.T.T. differences between the
Japanese
and Caucasians
could not be
explained by education, occupation,
body-weight,
surface
area,
or the number of bowel
movements
per day.
With
respect
to the
Hawaii-Japanese experience,
B.T.T.S do not seem to be related to the
pathogenesis
of colonic disease.
We thank Mr
Harry
Ito of Kuakini
Hospital
for
engineering
the stool-collection
equipment;
and Dr
Edgar Childs,
Dr
Donald
Ikeda,
and Dr David Sakuda of the
Department
of
Radiology,
Kuakini
Hospital,
for their technical assistance.
This work was
supported
in
part by
National Institutes of
Health contracts E-71-2170 and PH-43-65-1003-C.
Requests
for
reprints
should be addressed to the
Japan-
Hawaii Cancer
Study,
Kuakini
Hospital,
347 North Kuakini
Street, Honolulu,
Hawaii
96817,
U.S.A.
REFERENCES
1.
Burkitt,
D. P.
Cancer, 1971, 28,
3.
2.
Burkitt,
D.
P., Walker,
A. R.
P., Painter,
N. S.
Lancet, 1972, ii, 1408.
3.
Worth,
R.
M., Kagan, A. J.
chron. Dis.
1970, 23, 389.
4.
Hinton, J. M., Lennard-Jones, J. E., Young,
A. C.
Gut, 1969, 10,
842.
5.
Pryke,
E.
S., White,
H. M. ibid.
1970, 11,
966.
6.
Stemmermann,
G. N. Archs envir.
Hlth, 1970, 20, 266.
7.
Doll, R., Muir, C., Waterhouse, J.
Cancer in Five
Continents;
vol.
II.
Berlin,
1970.
8.
Stemmermann,
G.
N., Yatani, R., Cancer, 1974, 31,
1260.
ASSESSMENT OF COMA AND IMPAIRED
CONSCIOUSNESS
A Practical Scale
GRAHAM TEASDALE BRYAN
JENNETT
University Department of Neurosurgery,
Institute
of Neurological Sciences,
Glasgow
G51 4TF
Summary
A clinical scale has been evolved for
assessing
the
depth
and duration of
impaired
consciousness and coma. Three
aspects
of
behaviour are
independently
measured—motor re-
sponsiveness,
verbal
performance,
and
eye opening.
These can be evaluated
consistently by
doctors and
nurses and recorded on a
simple
chart which has
proved practical
both in a
neurosurgical
unit and in a
general hospital.
The scale facilitates consultations
between
general
and
special
units in cases of recent
brain
damage,
and is useful also in
defining
the dura-
tion of
prolonged
coma.
Introduction
A WIDE
range
of conditions
may
be associated with
coma or
impaired
consciousness.
Apart
from acute
brain
damage
due to
traumatic, vascular,
or infective
lesions,
there are metabolic disorders such as
hepatic
or renal
failure, hypoglycaemia
or diabetic
ketosis,
and
also
drug
overdose. In
gauging
deterioration or im-
provement
in the acute
stage
of such
conditions,
as
well as in
predicting
the ultimate
outcome,
the
degree
and duration of altered consciousness
usually
over-
shadow all other clinical features in
importance.
It
is therefore vital to be able to assess and to record
changing
states of altered consciousness
reliably.
Need for a Clinical Scale
Impaired
consciousness is an
expression
of
dys-
function in the brain as a whole. This
may
be due to
agents acting diffusely,
such as
drugs
or metabolic
imbalance;
or to the combination of remote and local
effects
produced by
brain
damage
which was
initially
focal. Such focal brain
damage may
affect some of
the
responses
which are used to assess the level of
consciousness,
and
any
scale devised for
general
use
must allow for this
possibility.
A
simpler
scale
might
suffice for metabolic or
drug coma,
when the likeli-
hood of structural brain
damage
is
small,
but in an
emergency
there
may
be insufficient information to
assign patients confidently
to a
particular diagnostic
category. Moreover,
coma of mixed
origin
is not un-
common,
as when head
injury
is
suspected
of
being
associated with
ingestion
of
drugs
or
alcohol,
or with
a vascular accident. These seem
good
reasons for
devising
a
generally applicable
scheme of assessment.
Existing Systems
The
development
of
equipment
for
monitoring
various functions in
critically
ill
patients
has not
altered the need for doctors and nurses to assess the
level of consciousness. There is an abundance of
alternative terms
by
which levels of coma or
impaired
consciousness are described and recorded.
Systems
for
describing patients
with
impaired
consciousness
are not consistent 1-14
Indeed, many
clinicians retreat
from
any
formal scheme in favour of a
general
description
of the
patient s state,
without clear
guide-
lines as to what to describe and how to describe it.
In
practice,
such unstructured observations com-
monly
result in
ambiguities
and
misunderstandings
when information about
patients
is
exchanged
and
when
groups
of
patients
treated
by
alternative
methods are
compared,
or
reported
from different
centres. There is no
general agreement
about what
terms to
use,
nor are those in common use inter-
preted similarly by
different workers. Almost
every
report
of
patients
in coma offers
yet
another classifica-
tion. Most divide the
spectrum
of altered conscious-
ness into a series of
steps,
which in the
reports
we
reviewed
ranged
from 3 to 17 and were often des-
cribed in terms which defied clear definition.
Many
assume the existence of constellations of clinical
features which are
unique
to
each " level ",
whilst

82
others
distinguish
between coma and consciousness
on the basis of
only
one
aspect
of behaviour.
The
importance
of careful and
complete
neuro-
logical
examination in
determining
the nature and
site of the lesion
causing
coma has been described
at
length by
Fisher and Plum and
Posner,13
who
emphasised
that tests of brainstem
function,
not
usually
included in routine
examination,
can be use-
ful in the
diagnosis
of
stupor
or coma.
Neither,
how-
ever,
was
primarily
concerned with
repeated
bedside
assessment of the
degree
of conscious
impairment,
which is the
subject
of our
paper.
Glasgow
Coma Scale
To be
generally accepted,
a
system
must be
prac-
tical to use in a wide
range
of
hospitals
and
by
staff
without
special training.
But the search for
simplicity
must not be the excuse for
seeking
absolute distinc-
tions where none exist: for that reason no
attempt
is
made to define either consciousness or coma in
absolute terms.
Indeed,
it is
conceptually
unsound to
expect
a clear watershed in the continuum between
these states. What is
required
instead is an effective
method of
describing
the various states of
impaired
consciousness encountered in clinical
practice.
More-
over,
this should not
depend
on
only
one
type
of
response
because this
may,
for various
reasons,
be
untestable. The three different
aspects
of behavioural
response
which we chose to examine were motor
response,
verbal
response,
and
eye opening,
each
being
evaluated
independently
of the other. These
feature in
many previous reports
on coma but not in
the formal
system
we
propose.
This
depends
on
identifying responses
which can be
clearly defined,
and each of which can be
accurately graded according
to a rank order that indicates the
degree
of
dys-
function.
Motor
Responses
The ease with which motor
responses
can be
elicited in the
limbs, together
with the wide
range
of
different
patterns
which can
occur,
makes motor
activity
a suitable
guide
to the
functioning
state of the
central nervous
system. Indeed, every
one of the
reported
scales which we reviewed included some
aspect
of motor
responsiveness
as a criterion.
Obeying
commands is the best
response possible,
but the observer must take care not to
interpret
a
grasp
reflex or
postural adjustment
as a
response
to
command. The terms "
purposeful "
and " volun-
tary "
are avoided because we believe that
they
cannot
be
judged objectively.
If there is no
response
to
command,
a
painful
stimulus is
applied.
The
significance
of the
response
to
pain
is not
always easy
to
interpret
unless stimulation
is
applied
in a standard
way
and is maintained until a
maximum
response
is obtained.
Initially pressure
is
applied
to the
fingernail
bed with a
pencil;
this
may
result in either flexion or extension at the elbow. If
flexion is observed stimulation is then
applied
to the
head and neck and to the trunk to test for localisation.
In brain
death,
a
spinal
reflex
may
still cause the
legs
to flex
briskly
in
response
to
pain applied locally ls
For this
reason,
and because the arms show a wider
range
of
responses,
it is wise
always
to test
them,
unless local trauma makes this
completely impossible.
A
localising response
indicates that a stimulus at
more than one site causes a limb to move so as to
attempt
to remove it.
A
flexor response may vary
from
rapid withdrawal,
associated with abduction of the
shoulder,
to a
slower,
stereotyped assumption
of the
hemiplegic
or decorti-
cate
posture
with adduction of the shoulder.
Experi-
enced observers
may readily distinguish
between
normal and abnormal
flexion,
but for
general
use in
the first few
days
after brain
damage
has been sus-
tained it is sufficient to record
only
that the
response
is flexor.
Extensor
posturing
is
obviously
abnormal and is
usually
associated with
adduction,
internal rotation of
the
shoulder,
and
pronation
of the forearm. The
term " decerebrate
rigidity "
is avoided because it
implies
a
specific physioanatomical
correlation.16
No
response
is
usually
associated with
hypotonia
and it is
important
to exclude
spinal
transection as
an
explanation
for lack of
response;
and also to be
satisfied that an
adequate
stimulus has been
applied.
When
recording
motor
response
as an indication of
the functional state of the brain as a
whole,
the best
or
highest response
from
any
limb is recorded.
During
a
single
examination some
patients give
variable
responses,
these
usually becoming
better as the
patient
becomes more
aroused; responses
from the
right
and
left limbs
may
also differ.
Any
difference between the
responsiveness
of one limb and another
may
indicate
focal brain
damage
and for this
purpose
the worst
(most abnormal) response
should be noted. But for
the
purpose
of
assessing
the
degree
of altered con-
sciousness it is the best
response
from the best limb
that is recorded.
Verbal
Responses
Probably
the commonest definition of the end of
coma,
or the
recovery
of
consciousness,
is the
patient s
first understandable
utterance; speech figured
in
nearly
all the
reported
scales which we reviewed.
Certainly
the return of
speech
indicates the restoration
of a
high degree
of
integration
within the nervous
system,
but continued
speechlessness may
be due to
causes other than
depressed
consciousness
(e.g.,
tracheostomy
or
dysphasia).
Orientation
implies
awareness of the self and the
environment. The
patient
should know who he
is,
where he
is,
and
why
he is
there;
know the
year,
the
season,
and the month. The words " rational " and
"
sensible " are
avoided because
they
cannot be
clearly
defined.

Confused
conversation is recorded if attention can
be held and the
patient responds
to
questions
in a
conversational manner but the
responses
indicate
varying degrees
of disorientation and confusion. It is
here that verbatim
reporting
of the individual
patient s
responses
can be useful.
Inappropriate speech
describes
intelligible
articula-
tion but
implies
that
speech
is used
only
in an exclama-
tory
or random
way, usually by shouting.and
swear-
ing ;
no sustained conversational
exchange
is
possible.
Incomprehensible speech
refers to
moaning
and
groaning
but without
any recognisable
words.

83
Eye Opening
Spontaneous eye opening,
with
sleep/wake rhythms,
is most
highly
scored on this
part
of the scale and it
indicates
that the arousal mechanisms
in the brainstem are active. But
arousal does not
imply awareness,
and
we believe it is
unwise
to
try
to decide
whether a
patient
is attentive on the
basis of
eye
movements. Patients in
the
persistent vegetative state,"
who
are
subsequently
shown to be struc-
Practical
Applications
of the Scale
Different
observers
were able to elicit the
responses
in this scale with a
high degree
of
consistency,
and
the likelihood of
ambiguous reporting appears
to be
small. This was demonstrated
by having
several
doctors and nurses examine the same
group
of
patients.
Disagreements
were rare,18 This was in
pronounced
contrast to what
happened
when the observers were
asked instead to
judge only
whether
patients
were
conscious or
unconscious;
one in five observers then
disagreed
with the
majority opinion.
This
20%
dis-
agreement-rate compared
with rates of
20-35 %
which
have been
reported
in various different clinical situa-
tions,19
whilst in one
study
extensor
plantar responses
showed
only 50% consistency
when observations were
repeated."
One or other
components
of this scale
may
be
untestable,
and this fact can be recorded. Limbs
may
be immobilised
by splints
for
fractures, tracheostomy
may preclude speech,
and
eyelid swelling
or bilateral
third-nerve lesions make
eye opening impossible.
In
the rare " locked-in
syndrome,"
a
patient
with
totally
inactive limbs
may obey
commands to move the
eyes
and
may
even be able to
signal
his needs.21
The nurses in our intensive-care unit have
willingly
adopted
this method of
formalising
observations which
they previously
used to record as a
descriptive
com-
ment.
They
now
plot
them on a chart
(see
accom-
panying figure)
somewhat similar in
format,
but not
content,
to one
proposed by Bouzarthl
and which
also
provides
for conventional
recording
of
tempera-
ture, pulse
and
respiration,
of the
pupil
size in
mm.,
and of focal motor
signs.
This method has
already
been
adopted successfully
for
making
observations on
head
injuries
in a
neighbouring general hospital.
In
such
hospitals patients
with head
injuries
form a
considerable
proportion
of acute
surgical admissions,
and observations there
depend
on medical and
nursing
staff who have no
special experience
of
neurology
and
neurosurgery.
s
! n n n n n
Chart for
recording
assessment of consciousness.
Discussion
Apart
from its
practical
use in the
management
of
recently brain-damaged patients,
this scale allows
the duration of coma to be defined more
precisely,
in
terms of how
long
different levels of
responsiveness
have
persisted.
There is evidence that this is a
crucial criterion when it comes to
predicting
the ulti-
mate outcome of
coma, particularly
after head
injury.22
It would make it
possible
also to examine
critically
claims for
good recovery
after weeks or months "in
coma," by enabling
the
alleged
coma to be more
accurately
assessed. In such cases as we have scrutin-
ised,
it has been
clear,
even
retrospectively,
that there
had been evidence of much earlier
recovery,
on at
least one
component
of the coma
scale,
than had been
recognised. By resolving
the
problem
of
defining
"prolonged
coma" the scale also makes it
possible
to
distinguish
between the various states which this
term
embraces,
such as akinetic mutism and the
per-
sistent
vegetative
state.17
Some
may
have reservations about a
system
which
seems to undervalue the niceties of a full
neurological
examination. It is no
part
of our case to
deny
the
value of a detailed
appraisal
of the
patient
as a
whole,
and of
neurological
function in
particular,
in
reaching
a
diagnosis
about the cause of
coma,
or in
determining
the
probable
site of brain
damage. However, repeated
observations of conscious level are
usually
made
by
relatively inexperienced junior
doctors or
nurses;
these staff are not
only few
in number but
they change
frequently
even
during
the course of a
day.
There
are therefore
good
reasons for
restricting
routine
observations to the
minimum,
and for
choosing
those
which can be
reliably
recorded and understood
by
a
range
of different staff.
We are
grateful
to
many colleagues
for their assistance in
developing
this
scale; particularly
Dr Fred Plum of New
York,
Dr Reinder Braakman of
Rotterdam,
and Dr David
Shaw of Newcastle
upon Tyne,
in whose units its
practical
value has also been confirmed. We thank the consultants of
the division of
neurosurgery, Glasgow,
for their
cooperation.
This scale was devised as
part
of a
study
of severe head
injuries supported by
the National Fund for Research into
Crippling
Diseases.
Requests
for
reprints
should be addressed to B.
J.
REFERENCES
1.
Bouzarth,
W.
F. J. Trauma, 1968, 8,
29.
2. Bozza
Marribini,
M. L. Acta neurochir.
1964, 12,
352.
3.
Bricolo,
A. Minerva neurochir.
1965, 9,
150.
4.
Fischgold, H., Mathis,
P.
Electronecephalogr.
clin.
Neurophysiol.
1959, suppl.
11.
turally decorticate,
have often been
believed
by relatives, nurses,
and even
by
doctors to be
reacting visually
to
people
aroun(
them; probably primitive ocular-following
reflexe
may
be executed at subcortical level.
Eye opening
in
response
to
speech
is a
response
t(
any
verbal
approach, whether spoken
or
shouted,
no
necessarily
the command to
open
the
eyes.
Eye opening
in
response
to
pain
should be teste(
by
a stimulus in the
limbs,
because the
grimacinl
associated with
supraorbital
or
jaw-angle pressure
may
cause
eye
closure.

84
5.
Fisher,
C. M. Acta neurol. scand.
1969, suppl.
36.
6.
Mansuy, L., Lecuire, J., Jouvet,
M. Proc. 3rd int.
Congr.
neurol.
Surg.: Excerpta
med. int.
Congr.
Ser.
1966,
no.
110, p. 411.
7.
Matthew, H., Lawson,
A. H. H.
Q. Jl
Med.
1966, 35,
539.
8. Medical Research Council. A
Glossary
of
Psychological
Terms
Commonly
Used in Cases of Head
Injury.
H.M.
Stationery Office,
1941.
9.
Mollaret, P., Goulon,
M. Rev. Neurol.
1959, 101,
3.
10.
Rowbotham,
G. F. Acute
Injuries
of the Head.
Edinburgh,
1964.
11.
Ommaya,
A.
K., Sadowsky,
D.
J. Trauma, 1966, 6,
605.
12.
Overgaard, J., Christensen, S., Haase, J., Hvid-Hansen, O., Hein,
O., Land,
A.
M., Pedersen,
K.
K., Tweed,
W. A.
Lancet, 1973,
ii, 631.
13.
Plum, F., Posner, J.
B. The
Diagnosis
of
Stupor
and Coma. Phila-
delphia,
1972.
14.
Powiertowski, H., Huber,
Z. Proc. 3rd int.
Congr.
neurol.
Surg.:
Excerpta
med. int.
Congr.
Ser.
1966,
no.
110, p.
209.
15.
Ivan,
L. P.
Neurology, 1973, 23,
650.
16.
Feldman,
M. H. Archs Neurol. 1971, 25,
501.
17.
Jennett, B., Plum,
F.
Lancet, 1972, i,
734.
18.
Teasdale,
G.
M., Knill-Jones,
R. P.
Unpublished.
19.
Conn,
H. O. New
Engl. J.
Med.
1965, 272,
830.
20.
McCance, C., Watt, J. A., Hall,
D.
J. J.
chron. Dis.
1968, 21,
369.
21.
Feldman,
M. H.
Neurology, 1971, 21,
459.
22.
Jennett,
B. Clin.
Neurosurg. 1972, 19,
200.
SEASONAL VARIATION OF HISTOLOGICAL
OSTEOMALACIA IN FEMORAL-NECK
FRACTURES
J.
E. AARON
J.
C. GALLAGHER
B. E. C. NORDIN
Medical Research Council Mineral Metabolism
Unit,
General
Infirmary,
Leeds 1
Summary
In a series of 134 iliac-crest
biopsies
from unselected cases of fracture of
the
proximal femur,
the
proportion
with evidence
of osteomalacia varied with the season. The
highest
frequency
of abnormal calcification fronts
(43%)
was
observed in
February
to
April
and the lowest
(15%)
in
August
to October. The
highest frequency
of
abnormal osteoid-covered surfaces
(47%)
was
observed in
April
to
June
and the lowest
(13%)
in
October to December. The overall
frequency
of
osteomalacia in femoral-neck-fracture cases in
Leeds seems to be about
37%.
It is concluded that
variation in hours of sunshine is
responsible
for a
seasonal variation in osteomalacia in these cases
and,
possibly,
in the
elderly population
as a whole.
WE have
previously reported 1 histological
evidence
of osteomalacia in about 25
%
of
patients
with femoral-
neck fractures in the Leeds area. In view of the
reports
of a seasonal variation in
plasma
concentrations
of
25-hydroxycholecalciferol (25-H.c.c., 25-0HDs)
in
the United
Kingdom,2,3
we have now re-examined this
material for evidence of seasonal variation in histo-
logical
osteomalacia.
The material
comprises
134 unselected iliac-crest
biopsy
specimens
from cases of fractured neck of femur admitted
to the
orthopaedic department
of the General
Infirmary,
Leeds,
in the
years
1969-73. The
biopsied
cases
represent
about
20 %
of the admissions
during
this
period.
The
histological procedures
have
already
been
described.1 We
simply grouped
the
biopsy specimens
according
to the month in which
they
were
taken, usually
at
operation
or
very shortly
after the fracture. Our
criteria of
normality
were
up
to
24%
osteoid-covered
surfaces and over
60%
osteoid surfaces with calcification
fronts.
Preliminary
examination of the data showed that
Fig. 1-Frequency
of excessive osteoid-covered surfaces
grouped
in
3-monthly periods.
The three lines are based on three different
upper
normal limits
for the
percentage
of osteoid-covered surfaces. The number of
specimens
in each 3-month
period
is
indicated. The
p values
refer to the difference between the second and fourth
quarter.
the
largest proportion
of
specimens
with excess osteoid-
covered surfaces were seen in
April, May,
and
June,
and
the
largest proportion
with a subnormal
percentage
of
calcification fronts were observed in
February, March,
and
April.
The data were then
analysed
in
3-monthly
periods, starting
in
January
for osteoid surfaces and in
November for calcification fronts.
With osteoid-covered surfaces
(fig. 1),
there is a
clear seasonal trend. In the second
quarter
of the
year,
17 of 36
biopsies (47%)
showed more than
24%
of osteoid-covered
surfaces,
whereas in the fourth
quarter
this
abnormality
was
only
observed in 4
out of 31
(13%).
In the first and third
quarters
the
frequencies
were 12 of 39
(30%)
and 8 of 28
(28%),
respectively.
This difference is
highly significant.
This
seasonal variation is
not
influenced
by lowering
the
upper
normal limit of
percent
osteoid-covered sur-
faces to
20%
or
raising
it to
28%.
The calcification-front data are shown in
fig.
2.
With a lower normal limit of
60% of,
calcification
Nov. Feb.
May Aug.
Dec. Mar. June
Sept.
Jan.
Apr. July
Oct.
(30) (35)
(42) (27)
Fig. 2-Frequency
of deficient calcification fronts
grouped
in
3-monthly periods.
The three lines are based on three different lower normal limits
of
percentage
calcification fronts. The number of
specimens
in each 3-month
period
is indicated. The p values refer to the
difference between the
second
and fourth
quarter.