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SECTION III
NEUROSURGERY
CHAPTER IV
NEUROLOGICAL ASPECTS OF THE EFFECTS OF GUNSHOT WOUNDS OF THE HEAD a The subject matter of this chapter is based on some general observations made in a series of 200 cases of wounds of the head, after their return to the United States, in practically all of which there were symptoms of injury to the brain. The 200 patients referred to represent practically all of the cases of this type under observation at General Hospital No. 11, Cape May, N. J..from October, 1918, to June, 1919. Of these parents, 163 suffered from wounds associated with demonstrable defects, and 13 with fractures of the cranial bones; 24 presented brain symptoms without demonstrable cranial injuries.
It may be seen that the greater majority of these patients presented cranial defects, which, with a few exceptions, were the results of gunshot wounds of the head, treated almost universally by early operation.
The associated brain injuries varied greatly, some being severe. In 68 patients the cerebral symptoms were slight or could not be demonstrated when the patients were admitted to the hospital. In 12 per cent of the cases there was no definite history or evidence of cranial injury, but either general or focal symptoms of cerebral origin following traumatisms of the
head seem to justify their inclusion in this series.
SYMPTOMATOLOGY
For present purposes the manifestations of disturbed action of the nervous system have been classified into general and focal symptoms, in much the same sense that the symptoms caused by brain tumors are so classified; focal symptoms representing lesions of definite areas of the brain, and general symptoms those resulting from the effects of diffuse forces, such as concussion or pressure.
EARLY GENERAL SYMPTOMS
Among the early general symptoms of importance, according to the clinical records, and to the histories as given by the patients themselves, were disturbances of consciousness, amnesia, delirium and confusion, choked disc, slow pulse, headache, and vertigo. While obviously incomplete, these histories, considered collectively, have a certain value.
DISTURBANCES OF CONSCIOUSNESS
Data concerning the state of consciousness immediately following the injury were available in 132 cases. In 22 there was no loss, while in the
a This chapter is from "A Review of the Effects of Gunshot Wounds of the head. Based on the Observation of Two Hundred cases at U. S. General Hospital No. 11, Cape May, N. J.," by Lieut. Col. Charles II. Frazier, M. C., and Capt. Samuel D. Ingham, M. C. Archives of Neurology and Psychiatry, Chicago, 1920, iii, No.1, 17.
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remaining 110 there resulted from the injurv immediate unconsciousness which lasted from a few minutes to several weeks. The period of unconsciousness, by number of cases, was as follows: Less than 1 hour, 51: 1 to 24hours, 21: 1 to 6 days, 22; 6 days, 16.
Since there was such a wide variation in the manifestation of this sympton is of interest to consider the factors active in its production. These factors include the degree of concussion, or sudden force transmitted to the brain by the blow; the amount of brain tissue traumatized, and the secondary effects of the injury, including hemorrhage, edema, and infection.
To facilitate the analysis the patients as a whole may be divided into three groups: (1) Those in whom there was no loss of consciousness, (2) those unconscious from a few minutes to 24 hours, and (3) those in whom this symptom was prolonged.
Group 1 included 22 patients with cranial defects who were not rendered unconscious by their wounds. Many of these had severe injuries, and 15 exhibited permanent focal brain symptoms. It is well known that a blow on any part of the head may produce unconsciousness by Concussion, but it is apparent that this factor was insufficient to cause this symptom in the patients of this group. In explanation it may be suggested that the force of the injury was apparently exerted over a small area, and even when the cranial bones were fractured and the bran itself traumatized locally, the diffuse concussion must have been relatively slight.. An illustration of this principle is furnished by the manner in which an egg may be broken-a quick, sharp blow producing a local fracture, while a slower but heavier blow results in extensive cracks in the shell. In tile latter case the diffusion of tile force is evidently greater than in the former.
Group 2 included 72 patients who were unconscious from a few minutes to 24 hours. It may fairly be assumed that cerebral concussion was the immediate cause of unconsciousness in this group, and that other factors were relatively unimportant in their effect on consciousness. Early surgical operations in many cases effected decompression, removed blood clots, pulped tissue, foreign bodies and bone fragments, and controlled infection. It is probable that the character of the wounds themselves, in some instances, hand the effect of automatic decompression, thus preventing prolonged unconsciousness.
Group 3 included 38 patients who were unconscious for more than 24 hours. In many of these patients the effects of trauma (hemorrhage. edema, infection) were important factors. Several of this group, with residual focal symptoms indicating severe brain injury, had had early operations in which the dura was not opened, hence decompression was not effected. Some had deeply penetrating foreign bodies, and others severe wound infections and hernia cerebri. In this class were also included 10 patients with cranial fractures, not decompressed. Even from the fragmentary records available, the large proportion of injuries not relieved by decompression was striking in this group, injuries which must have produced severe secondary effects and high intracranial pressure. In none of the cases was there evidence that prolonged unconsciousness resulted from concussion alone. While it is at times difficult
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in differentiate cases of uncomplicated concussion from those in which intracranial hemorrhage and edema are also present, it is apparent that prolonged unconsciousness resulting from simple concussion is rare. On the other hand, conditions producing increased intracranial pressure, such as hemorrhage and edema not relieved by decompression, must be considered as important factors in prolonging the unconsciousness primarily induced by concussion in head injuries.
Incomplete loss of consciousness, dazed and stuporous states, delirium, and mental confusion were common in the early histories, one or more of these conditions frequently following the period of unconsciousness or replacing it as the immediate effect of the trauma. These symptoms Were regarded as results of the same factors that caused unconsciousness, concussion standing in relation to the earlier and the secondary effects of trauma to many of the more prolonged manifestations. In this connection it should be stated that, definite symptoms apparently resulting from simple concussion occasionally persisted for several months.
AMNESIA
Amnesia, was present in practically all of the patients exhibiting the symptoms mentioned, and the memory blank frequently antedated the injury. In two instances patients who were injured in France had no memory of having been out of the United States. Those who were dazed or delirious for a long time often retained a fragmentary or dream-like memory of isolated occurences, or of their subjective mental processes at times fantastic and curiously related to actualities.
HEADACHE, VERTIGO, CHOKED DISC, AND SLOW PULSE
These symptoms were recorded with varying frequency, and were all more or less closely related to the secolndary effects of injuries.
LATE GENERAL SYMPTOMS
When coming under observation in General Hospital No. 11, two months "or more after receiving their head wounds, many patients still manifested cerebral symptoms of a general character. These included loss of memory, slow cerebration, indifference, mild depression, inabilitv to concentrate. fatigability, nervous irritability, vasomotor and cardiac instability, general convulsions, fine tremors. irritable reflexes, headache, vertigo, and restricted visual fields, but their manifestations varied in different patients as regards grouping, intensity, and persistence. Some of them were present in most of the cases of severe head wounds, many of them were present in some of the cases, and, exceptionally, a combination of these late general symptoms constituted the principal disability of the patient.
Almost without exception these symptoms himinished gradually, and ultimate recovery, apparently complete, occurred in from three to nine months after injury, where gross damage to the brain was absent. The tendency to recover from the symptoms both general and focal resulting from brain injuries of all degrees of severity deserves special emphasis. Since it is fairly well
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established that regeneration does not occur in the central nervous system, it is evident that any nervous tissue may be affected to the extent of suspended function without suffering permanent damage, and recovery from the symptoms of brain lesions signifies returning function in injured but not devitalized neurons.
FACTORS CAUSING RESIDUAL GENERAL CEREBRAL SYMPTOMS
So far as could be determined the following factors were operative in causing the late general symptoms in the series of cases under discussion:(1) Loss of cerebral tissue; (2) injury to the brain without destruction of tissue;(3) cranial defects; (4) cicatrices; (5) psychoneurosis.
LOSS OF CEREBRAL TISSUE
Symptoms resulting from the loss of cerebral tissue should properly be classified as focal, but these symptoms at times included intellectual impairment, or dementia, of which we have no definite knowledge in cerebral localization. Reference will be made, under the discussion of focal symptoms, to several instances in which the dementia apparently bore some relation to the location of the cerebral lesion.
INJURIES TO THE BRAIN WITHOUT DESTRUCTION OF TISSUE
These injuries include the effects of concussion and pressure, and also those of disturbed cerebral circulation and nutrition. Although, from the standpoint of pathology, changes of this nature are but imperfectly understood, it should be emphasized that they are common and important. Most of the late general symptoms of head wounds are best explained on the basis of such disturbances. These symptoms include memory loss, slow cerebration, indifference, incapacity for sustained effort, annl vasomotor and cardiac instability.
CRANIAL DEFECTS
Cranial defects, particularly those large enough to permit fluctuation and pulsation, are commonly accompanied by vertigo, throbbing in the head, and a feeling of insecurity, all of which are accentuated by active exercises and bending movements of the body. Headache, on the contrary, was noticeably unusual in the patients with cranial defects.
CICATRICES
These sometimes act as irritating foci, causing nervous and reflex irritability, at times apparently precipitating general or focal convulsions. Headaches often were traced to pericranial and dural adhesions.
PSYCHONEUROSIS
As an element in the symptomatology of this series this condition was comparatively unimportant. With three or four exceptions, anxiety and neurasthenic symptoms were present only to a degree commensurate with the nature of the injury. Conversion hysteria was not encountered in any of the cases.
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Summarizing briefly the general cerebral symptoms resulting from wounds in relation to the etiologic factors, they may be divided into four groups: Those due to (1) the immediate effects of the trauma; (2) the secondary effects of the trauma; (3) nondestructive injuries to cerebral tissue; (4) destructive injuries to cerebral tissue. The first two of these groups of symptoms appear early, the latter two coming into prominence as the earlier symptoms subside.
The immediate manifestations consist mainly in disturbances of consciousness and in dazed, delirious, and stuporous states, the principle causative factor being concussion.
The secondary effects of trauma (hemorrhage, edema, infection) add the symptoms of pressure to those of concussion.
Injuries to the brain tissue, not destructive in character, complicate all sorts of lesions and cause symptoms which last for weeks or months but which tend toward complete recovery. The syndrome of cerebral concussion (early disturbances of consciousness and prolonged mental symptoms including loss of memory, indifference, incapacity for sustained effort, and mental slowness) probably has its pathologic basis in changes of this character.
FOCAL SYMPTOMS
TRANSIENT FOCAL SYMPTOMS
Although the records were incomplete, they indicated that a considerable proportion of the patients suffered from focal symptoms of a transitory character, which disappeared completely or almost completely within one or two months following the injuries. Symptoms of this nature are to be explained by local injuries to the brain of a degree insufficient to cause tissue destruction. Twenty-four patients gave a history of early hemiplegia which later disappeared entirely or left an insignificant remnant. In contrast, there were 60 patients with definite residual cerebral paralysis. Fourteen gave a history of aphasic disorders of a transitory character, while in 16 some degree of aphasia persisted as a residual symptom. Four patients described symptoms evidently due to cerebellar disturbance, all of which recovered entirely. In no case was there evidence of a destructive wound of the cerebellum, a fact to be accounted for by the highly fatal nature of wounds involving the posterior cranial fossa.
Data concerning early sensory symptoms were for the most part unreliable, as patients usually fail to note any but perceptual losses and are even liable to confuse motor paralysis with anesthesia. In 10 instances, however, there was a fairly consistent history of superficial anesthesia of unilateral distribution and of temporary duration.
RESIDUAL FOCAL SYMPTOMS
Under this heading are considered the focal symptoms which persisted while the patients were under observation, in most cases six months or more after the injury.
MOTOR SYMPTOMS
Of the entire series of 200, 60, or 30 percent, of the patients suffered permanent motor symptoms of cerebral origin. Of these, 43 were hemiplegic,
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9 were monoplegic, and 8 were parlaplegic. The paralysis was of a severe degree in 10 hemiplegics and 3 paraplegics, while in the remaining 47 the residual motor disability was comparatively slight when the patients were last examined.
A striking feature of these cases was the marked degree of recovery which invariaby occurred. Probably without exception the patients, immediately following the injury, were completely paralyzed in the limbs affected. Twenty of them were admitted to General Hospital No. 11 as litter patients; but when last examined they were all ambulatory and many of them had a very fair amount of function in the paralyzed limbs. Notwithstanding this improvement, there remained, in patients having destructive lesions in the motor areas, an irreducible minimum of paralysis.
The residual motor disabilities consisted of disturbances of voluntary motion of the arms and legs, and to a slight degree of the face. Complete paralysis of a limb was never permanent. The functions of motility most disturbed were those of highly specialized and intricate character. Individual finger movements were uniformly most affected; finger flexion invariably returned in some measure, but extension was weaker and in two cases failed to reappear at all. All movements involving bilateral groups of muscles were normal or showed insignificant disturbances.
Exaggeration of the tendon reflexes and hypertonicity of the muscles of the affected limbs was the invariable rule, although there was considerable variation in the degree of these conditions. Articular relaxation or increase range of movements in the joints as compared to the normal side was occasionally noted, and was demonstrable by the greater latitude of movement on passive manipulation after overcoming the hvpertonicity of the muscles.
Incoordination constituted factor in the disability of many of the paralytics, especially those showing a large mnasure of improvement though actual muscular strength was very fair.
RESIDUAL SENSORY SYMPTOMS
Permanent impairment of cutaneous sensory perceptions of touch, pain. and temperature was found in only eight cases, and in none was it present as a complete hemianesthesia. On the other hand, 30 patients showed impairment of ability to localize sensory stiumll accurately, to recognize dual contacts, and to appreciate passive movement and position in the extremities. In the same patients there was disturbance of the stereognostic sense. The constant association of impaired sensory discrimination with astereognosis indicates that the latter condition may he considered as a manifestation of the former.
Sensory and motor symptoms frequently were associateil in the same case, and those having sensory symptoms almost invariably had motor impairment. The converse was not true. Only 50 per cent of the motor cases had demonstrable sensory symptoms. This relationship of motor and sensory symptoms may in part be explained by the dependence of normal movement, especially its coordination, on the discrimiminatory element of sensation.
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RESIDUAL APHASIA
In 16 patients disturbances in the use of language remained six months or more after the wounds were received. Of these, 10 were of the motor or dysarthric type, 3 of the sensory type with alexia as the most prominent symptom, and 3 were of the mixed type, manifesting disturbances both in the depression and in the interpretation of language. In none of the patients were the residual asphasic symptoms of severe degree, and all were able to carry on simple conversations fairly well. The patients with alexia were ultimately able to recognize letters and many words, but did not regain the ability to read understandingly to any practical extent.
RESI DUAL VISUAI. SYMPTOMS
Cerebral wounds were associated with defects in the visual fields in 18 cases, 12 of which were more or less complete homonymous hemianopsia, 3 were quadrant anopsias, 2 were symmetrical paracentral scotoinas, and 1 almost completely blind. Comparatively slight improvement was noted in the vision of these cases dutring the period of observation.
MENTAL SYMPTOMS
The occurrence of mental disturbance has been mentioned in connection with the general symptoms of cerebral injuries. Aside from the mental symptoms of cerebral concussion and the mild dementias of indeterminate type associated with many brain injuries, a few of the patients showed late psychic symptoms which evidently resulted from cerebral wounds, and apparently bore some relation to the injured areas of thie brain. This was true in four cases in which penetrating wounds involved both hemispheres. In three of these both frontal lobes were affected, and in the fourth a foreign body entered the right frontal region, penetrating to the left posterior parietal region near the cortex. Mental symptoms were pronounced in all of these patients and consisted of disorientation, loss of memory , emotional indifference and disregard of environment and personal appearance. In some measure they resembled the simple dementia of general paresis. Of the many patients with unilateral frontal lesions, some of them extensive, none showed characteristic psychic symptoms. These circumstances indicate the seriousness of bilateral brain lesions, and suggest the theory that either cerebral hemisphere may functionate in a way to minimize the effect of a lesion in the other.
CONVULSIONS
Convulsions occurred in 28 patients. eitiler before adlmission or while under observation at General Hospital No. 11. In 4 of these the attacks were focal without general involvement, 11 had local spasms initiating general attacks, and in 13 the convulsions were general so far as observations were recorded, although it is probable that some of these were preceded by unobserved focal symptoms. Attacks were observed in patients having lesions in the motor area and hemiplegia in which focal signs were definitely absent.
In 3 of the cases of this group it wias found that attacks had occurred prior to military service, leaving 25 in which there was evidently a close relationship between the war wounds and the convulsions. In 22 of these the wounds
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involved the parietal region, and in 21 there was motor paralysis. In the remaining 3 cases the wounds were in the frontal, occipital, and temporal regions. It is thus apparent that not only focal but general convulsions were associated with motor areas of the brain in the great majority of the cases, and that irritation of these areas is more productive of general convulsions than of other parts of the cerebrum.
Eighteen of the twenty-five patients were free of attacks for several months prior to the cessation of the period of observation; three others had but a single attack each. Four had repeated convulsions over a prolonged period, thus evincing a tendency to chronic epilepsy; these were all hemiplegic, and the attacks were the type which begin as focal convulsions, then become general with loss of consciousness.
The most frequent period for the occurrence of the attacks was soon after the wound had been received or after some operation on the head. About one-half of this group of patients had isolated convulsions at such times without later recurrences.
It should be stated that, as a routine measure, bromides were given in10-grain doses three time a day to all patients having convulsions and to all those subjected to operations on the head, a measure which no doubt reduced the incidence of the attacks while the patients were under observation.
PATHOLOGY
The degree of injury to the brain varied from insignificant lesions to extensive losses of cerebral tissue. In 23 cases intracranial foreign bodies were demonstrated by the Roentgen ray, some of them having almost traversed the cranial cavity. Small, indriven fragments of bone were common and were usually located in the vicinity of the cranial defect. In 26 cases the wounds were unhealed on admission, most of these having sinuses extending beneath the dura to fragments of dead bone or foreign bodies. One patient, who died four days after admission, had a large temperoparietal abscess and hernia cerebri. This patient was one of the two fatalities in the entire series of head wounds at General Hospital No. 11. The second fatality resulted from a complicating pneumonia and internal hydrocephalus, occurring after the wound had healed and the patient was convalescent.
During cranioplastic operations evidences of cerebral injury were at times noted. In such operations the dura was not usually opened, but occasionally it was necessary and several times in this way cystlike cavities filled with cerebrospinal fluid were exposed. In one notable case of this kind the operating surgeon opened such a cavity in the occipital lobe which communicated with the posterior horn of the lateral ventricle.
In estimating the area and extent of the cerebral lesions resulting from war wounds it may be stated as a rule that, in the absence of penetrating foreign bodies, the area of destruction of brain tissue conforms quite closely to the cranial defect, and extends but a few centimeters beneath the cortex. Foreign bodies may penetrate to almost any part of the cerebrum, even traversing the ventricles without causing death. The course of foreign bodies can be estimated bv careful Roentgenl-ray studies. comparing their location with the wound of entrance.
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TREATMENT
Besides the surgical treatment, special courses of treatment were given to practically all of the patients with the object of increasing their general efficiency, and of reducing to a minimum the effect of the disabilities from which they suffered. School, occupational, and workshop courses were prescribed, according to conditions.
Patients with hemiplegia and paraplegia received daily treatments consisting of special massage, passive movements, and electricity, also active exercises, employing the affected limbs to a maximum extent on gymnasium apparatus, and in recreational exercises in which handballs and footballs were found to be especially valuable. The results of this treatment were evident in reducing the spasticity and preventing contractures in paralyzed muscles and inprocuring a maximum return of function. The training of the unaffected muscles to compensate as far as possible for those of impaired function gave the patients greater freedom of action, and the general poise, self-confidence, and morale were noticeably improved.
Aphasics constituted another group that received special attention. Trained teachers gave the members of this group daily individual instruction and exercise in conversation, reading, and writing adapted to the needs of the patient and the character of his language disturbance. Although no evidence of the development of new language centers on the normal side of the brain was seen, improvement was marked in every patient of this group, the aphasic symptoms of some of whom had previously remained stationary for several months.
