CHAPTER XVIII
Neurology
William H. Everts, M.D.
COORDINATION OF NEUROLOGY ACTIVITIES
Neurology and psychiatry in the Army had always been coordinated within the single administrative purview of neuropsychiatry.1 Neurology, along with psychiatry, was thus the responsibility of neuropsychiatrists either directly or in a consultatory manner. Since psychiatry was by far the heavier part of the workload, neurologists were submerged by the mass of psychiatric cases. However, wherever competently trained neurologists were stationed-and there was a marked paucity of such officers-they performed most creditably in this dual role. In general, however, many psychiatrists lacked adequate neurological training, and many neurologists lacked adequate psychiatric training. As the ever-increasing volume of neurological problems became manifest during 1942 and 1943, it became imperative that better coordination of neurology and psychiatry be facilitated. To attain this end, a neurologist was assigned to the Neuropsychiatry Branch in the SGO (Surgeon General's Office), in October 1943.
When the Neuropsychiatry Branch was elevated to a division, on 1 January 1944, Neurology was designated as one of its branches, with Maj. (later Lt. Col.) William H. Everts, MC, as its chief. Later, in conformity with directions from The Surgeon General that officers not having had oversea service be given the opportunity for such service, Major Everts was relieved, on 2 July 1945, by Maj. Alexander T. Ross, MC, who had returned from the European theater.
In broad outline, the duties of the Neurology Branch were to coordinate the practice of neurology in the Army, to set policies for diagnosis and treatment, to procure personnel and equipment necessary to maintain high standards, to prepare neurological memorandums and technical bulletins, to collect and collate material of neurological significance, to stimulate research, and to effect a constructive, collaborative liaison with neurosurgery as it pertained to neurology.
In order to develop these policies in the most effectual fashion, it was considered advisable to enlist the services of two outstanding civilian
1Thanks are due to Drs. James L. O'Leary and Alexander T. Ross whose contributions have been incorporated in this chapter.-W. H. E.
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neurologists as consultants. Accordingly, on 10 May 1944, Dr. Edwin Zabriskie was appointed Consultant in Neurology, and on 24 June 1944, Dr. Frederick A. Gibbs was appointed Consultant in Neurology to advise especially in electroencephalography. These civilian consultants in neurology and their counterparts in psychiatry, Drs. Edward A. Strecker, Arthur H. Ruggles, Frederick W. Parsons, and Alan Gregg, all gave advice, time, and effort, unstintingly. They were called in consultation on frequent occasions and aided in the formulation of policies, some of which later appeared in technical medical bulletins and pertinent Army regulations.
DISQUALIFICATION FOR NEUROLOGICAL REASONS
The neurological standards for acceptability into the military service that governed during World War II were those published in MR (Mobilization Regulations) 1-9.2 In essence, the methods of routine neurological examination and the criteria of acceptability and rejection for military service are outlined and formulated in these regulations.
It has been estimated that, as of August 1945, some 277,300 selective service registrants were classified as IV-F (unfit for military service) for neurological disorders, on the basis of these neurological standards. These disqualifications constituted 5.7 percent of all disqualifications. Expressing it differently, some 1.7 percent of the examined registrants in World War II were disqualified for neurological reasons. (See appendix A, table 5, columns 3 and 4, and table 7.) World War II disqualification data for neurological disorders indicate that most of these disqualifications were for residuals of cerebral or spinal concussion (35.7 percent of the neurological disqualifications) and next was epilepsy (23.1 percent). About 7.0 percent of these disqualifications were for peripheral nerve diseases, and the remainder (34.2 percent) consisted of miscellaneous neurological disorders. (These data are limited to those specifically listed under the neurological diagnostic category, excluding such nonspecific neurological defects as neurosyphilis, et cetera.)
Compared with World War I experience, it seems that at least twice as many were disqualified in World War II for neurological defects. (See appendix A, table 7, last column.)
ORGANIZATION IN ZONE OF INTERIOR
Neurological Centers
With the anticipation of D-day in the European theater and with the increasing activity in other theaters, it was urgent that medical facilities be established to cope with expected neurological-neurosurgical casualties.
In World War I, relatively few cases needing definitive neurosurgical
2Mobilization Regulations No. 1-9, 31 Aug. 1940, and 15 Mar. 1942. (See appendix B, pp. 777-791.)
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care arrived from overseas, most having already been operated upon and with their status being changed from surgical to neurological patients. As a consequence, patients were admitted to geographically separated general hospitals and received treatment on general surgical services to which were assigned such neurosurgeons and neurologists as were available. This was not altogether a satisfactory clinical arrangement from the standpoint of adequately utilizing the specialties of neurology and psychiatry. With knowledge of this past experience, it was deemed advisable to keep neurology separate from neurosurgery and yet effect a close liaison between them. Since 19 strategically located hospitals specializing in neurosurgery had already been established,3 it was obvious that maximum efficiency and closest collaboration would be obtained by designating these same hospitals as specializing in neurology. This was effected by WD (War Department) Circular No. 347, issued on 25 August 1944, which designated the centers and indicated the types of patients to be referred into them. Initially, each center had an authorized capacity of 200 neurological beds, although this could and did vary as the need arose with some sections carrying, at times, over 400 neurological patients.
In order to utilize the full advantages of specialized hospitals located as close as possible to the patients' locality of preference, to save transportation facilities, and to maintain high morale, ASF (Army Service Forces) Circular No. 284, issued on 30 August 1944, directed that patients arriving at debarkation hospitals from overseas be promptly reported by code to the Medical Regulating Office. For neurological disorders, the symbol was 'SF' and included the following types of cases:
(1)Epilepsy of any cause.
(2)Encephalopathies.
(3)Encephalitis or meningitis residuals or complications.
(4)Disseminated sclerosis.
(5)Inflammatory disorders such as encephalomyelitis, myeloradiculitis, Guillain?Barr? syndrome, etc.
(6)Migraine.
(7)Myelopathies of degenerative vascular and traumatic causes (exclusive of obvious spinal fracture cases).
(8)Neuritis and polyneuritis of any cause.
(9)Muscular dystrophies and atrophies.
(10) 'Ill-defined' disorders affecting the central or peripheral nervous system.
To these later were added closed head injuries and sciatica (ASF Circular No. 89, 10 March 1945).
Relationship with neurosurgery
The organization of centers proved to be most effective for the definitive care of neurosurgical disorders, facilitating an optimal working relationship with neurosurgery so that there was minimal duplication of
3War Department Circular No. 235, 12 June 1944.
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diagnostic effort. Further, the previously common confusion of admitting nonsurgical patients to surgical wards was avoided. In this manner, the neurological sections became the primary diagnostic units of the centers so that more and more of the surgeon's time could be spent on strictly surgical activities. This was of no little importance since, as the war increased in tempo, the surgical load became increasingly great and taxed all neurosurgical personnel and facilities to the utmost.
The collaboration between neurosurgeon and neurologist was thus a natural one. The neurologist assumed a much greater role in screening all patients with disease or trauma of the nervous system and in carrying out all basic neurological studies short of surgery. The desirability of making this a uniform procedure throughout all the hospitals specializing in neurology and neurosurgery was recognized by The Surgeon General. Accordingly, the Surgeon General's Office, in a letter of 28 January 1945, brought this matter to the attention of each service command surgeon, the professional consultants, and the commanding officer of each center. In this letter, also, was stated that total authorized beds for neurosurgery would be increased from 9,250 on 29 December 1944 to 21,887 on 16 January 1945 and that two new centers would be established by transfer. The center at Walter Reed General Hospital, Washington, D.C., was ordered moved to Halloran General Hospital, Staten Island, N.Y., and the one at Brooke General Hospital, Fort Sam Houston, Tex., to McGuire General Hospital, Richmond, Va. Objection was raised to the assignment of a neurologist to each neurosurgical ward, and consequently, a followup letter dated 14 February 1945 clarified the issue by stating: 'A review of the total available number of neurologists discloses that there is an insufficiency to permit the assignment of a neurologist to neurosurgical wards. Neurologists are to be regarded as consultants to surgery and not assigned to that section.'
This then was the final organization of neurology which proved most effective and capable of coping with any caseload anticipated from the European and Pacific theaters, the latter at the time having taken on increased intensity and proportions.
The establishment of these neurological centers did not preclude study and treatment of neurological patients in regional and general hospitals where competently trained personnel and proper equipment were available. However, where specialized attention, prolonged observation, or definitive treatment were entailed, these patients were transferred to the nearest neurological center.
In order to increase uniformity in neurological procedures, War Department Technical Bulletin (TB MED) 76 was prepared and issued on 28 July 1944. Also, a new neurological form (WD, AGO Form 8-49, 1 August 1944) was provided which made possible orderly reporting and also served as a guide to less experienced medical officers.
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Location
The general hospitals at which neurological centers were established during World War II, together with the medical officers who served as chiefs of the neurology sections or as neurologists, are as follows:
| Number of beds | Medical officer | |
First Service Command: | ||
| Cushing | 125 | Maj. (later Lt. Col.) Frederic H. Lewey |
Second Service Command: | ||
| England (Thomas M. England after 14 Nov. 1944) | 300 | Capt. (later Maj.) Robert L. Craig |
| Hollaran | 200 | Maj. Waldemar C. Rasmussen |
Third Service Command: | ||
| McGuire | 200 | Capt. Philip K. Arzt |
Fourth Service Command: | ||
| Kennedy | 250 | Maj. Kurt Adler |
| Lawson | 200 | Capt. Charles L. Yeager |
| Northington | 112 | Capt. Frederick C. Redlich |
Fifth Service Command: | ||
| Ashford | 100 | Capt. Ralph W. Barris |
| Baker | 150 | Capt. Henry V. Agin |
| Nichols | 200 | Maj. (later Lt. Col.) Samuel Rebach |
| Wakeman | 200 | Capt. Charles H. Richards |
Sixth Service Command: | ||
| Percy Jones | 150 | Maj. D. Bernard Foster |
| Mayo | 100 | Capt. John A. Aita |
Seventh Service Command: | ||
| O'Reilly | 200 | Capt. (later Maj.) Samuel C. Little |
Eighth Service Command: | ||
| McCloskey | 190 | Maj. Francis Reisenman |
Ninth Service Command: | ||
| Bushnell | 216 | Maj. Samuel M. Schindelheim |
| DeWitt | 100 | Capt. (later) Maj. Manuel Sall |
| Hammond | 250 | Capt. (later Maj.) Charles W. Sult, Jr. |
| McCaw | 100 | Maj. Frederick D. Geist |
Personnel
With the establishment of neurological centers came the need to staff and equip them. This problem presented considerable difficulties as neurologists and psychiatrists were grouped together under the same MOS (military occupational specialty) number. It was necessary to examine the qualifications of all members of both specialties in order to select those who had sufficient training to supervise a neurological section. This was a tedious task and led to later proposals that neuropsychiatric officers be more specifically classified according to their field of specialized training. Most qualified neurologists were selected on the basis of personal knowledge of their capabilities; others, on their recorded qualifications. These officers
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were assigned to head the neurological sections in the centers and were assisted by officers who had had considerable postgraduate neurological training. This group, however, was insufficient to cope with the caseload. Therefore, arrangements were made with the Army School of Military Neuropsychiatry at Mason General Hospital, Brentwood, Long Island, N.Y., and with Columbia College of Physicians and Surgeons and New York University School of Medicine, both in New York City, N.Y., whereby student medical officers who had completed the established 90-day course in neuropsychiatry and had neurological aptitude would be given an additional 30 days' training in clinical neurology and electroencephalography at Mason General Hospital. Upon conclusion of this training, these officers were assigned to the various neurological centers where, under the continued guidance of their section chiefs and with experience, they became proficient assistants and proved of great value.
Despite the accelerated training program to produce young neurologists, the shortage continued, particularly in the staffing of station and general hospitals. For this reason, service command consultants in medicine and neuropsychiatry requested permission to place qualified internists in neurological centers for a period of training. This was discussed and approved by the Divisions of Medicine and Neuropsychiatry in the SGO. On 13 August 1945, Col. (later Brig. Gen.) William C. Menninger, MC, Director, Neuropsychiatry Consultants Division, submitted a letter to The Surgeon General giving the recommended procedure and detailed suggested course of instruction. These suggestions were favorably received, and centers for training were designated by the respective service commands. It was emphasized that the internists with this training in neurology were to function within their capabilities and to refer patients presenting special diagnostic problems to the appropriate neurological center. However, with the cessation of hostilities with Japan, with the gradual decrease in patient census, and with the projected closing of many of the hospitals, this program never materialized.
Electroencephalography
Development
The use of electroencephalography by the Army Medical Corps commenced shortly after 18 July 1942 at which time the Grass Instrument Co., of Quincy, Mass., shipped the first 4-channel model II instrument to Walter Reed General Hospital where the first electroencephalography laboratory was established by Capt. (later Maj.) Ephraim Roseman, MC. Somewhat later, the second instrument was installed at Darnall General Hospital, Danville, Ky.; in January 1943, another electroencephalography laboratory was started at Lawson General Hospital, Atlanta, Ga.
By April 1944, the widespread need for reliable diagnostic electro?
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encephalography had become evident. Because the specialty was so new, technicians for maintenance and operation and medical officers capable of supervision and interpretation of tracings were practically nonexistent. Earlier sporadic training had been attempted at Walter Reed General Hospital as an on-the-job endeavor, but the personnel so trained were used locally and there was at that time no official recognition of the specialty. Somewhat earlier, Major Everts had commenced a systematic attack upon the problem of providing enlisted personnel trained for maintenance and operation, and medical personnel trained for interpretation and supervision. Since that time electroencephalography has been linked to neurology as an important subspecialty.
Dr. Frederick A. Gibbs, the civilian consultant in electroencephalography, with Major Everts, furnished information on electroencephalography which was published as TB MED 74 and issued on 27 July 1944. This publication described the uses and limitations of electroencephalography and gave a lucid description of what was adopted as the standard procedure for taking the tracings and for their interpretation. Before the issuance of TB MED 74, there had been no standards for electrode positions or combinations, and tracings taken in one hospital were rarely understood by qualified physicians of another hospital to which a patient might be sent.
Training
Technicians.-The training of noncommissioned personnel at the same school at which medical neurologists were also being trained also proved to be a wise decision. The limited size of the classes in electroencephalography at the School of Military Neuropsychiatry permitted the blending of objectives. In some cases, a supervising officer and the technician who was to serve with him were trained simultaneously. The technician trainees were principally drawn from radar technician schools of the Signal Corps, which were operating at full capacity and could release the overflow of candidates. The enlisted personnel so selected easily adapted themselves to servicing the Grass equipment then in use and, ordinarily, were competent for maintenance work within a month of the start of training. Training in the application of electrodes and in the sequence of electrode combinations required for the standard tracing consumed more time. It was conducted mainly by WAC (Women's Army Corps) technicians previously trained in the School's laboratory. Upon completion of training, ordinarily 3 months, the trainees were assigned to Zone of Interior or oversea posts where laboratories were most needed.
Officers.-Medical officers selected were given 4 weeks' intensive training. The electroencephalographic material presented under the tutorship of Maj. James L. O'Leary, MC, was divided into four parts, as follows:
1.Survey of the rudiments of electronics with emphasis upon the prin?
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ciples of electronic amplification and upon the construction of the Grass Encephalograph, maintenance of this machine, and potential field theory.
2. Review of the developments of knowledge of bioelectric potentials as applied to the understanding of cortical rhythms.
3. Practical training in obtaining standard 4- and 6-channel EEG's in accordance with the procedures given in TB MED 74.
4. The method of classification of records adapted by the Army, practical experience in the diagnosis of records, and the writing of concise meaningful reports.
The essential material available for the program included two skulls, a 6-channel electroencephalograph, and illustrations, reprints, and other materials pertaining to the subject. A set of 106 record strips prepared for the Army by Dr. Gibbs was studied intensively by each student, and this served the purpose of introducing the classification system which had been adopted. The principles of localizing foci of abnormal activity by phase reversal and triangulation were taught, using an artificial brain within which a movable source of electrical potential was placed. When electrodes were applied to this model and connected to the machine, actual recording conditions were simulated, and test problems were given the students. This expedient made up for the lack of sufficient cases which could be used to study localization procedures.
By the war's end, the School of Military Neuropsychiatry had graduated 56 medical officers and 23 enlisted men and women who had been trained in electroencephalography. From three other courses which had been established at Walter Reed, DeWitt, and Brooke General Hospitals, a smaller number of trainees were graduated.
A total of 41 electroencephalographs were installed in medical treatment facilities in the Zone of Interior-35 in ASF hospitals and 6 in AAF (Army Air Forces) installations-as follows:
Installation | Location |
General hospitals: | |
| Ashford | White Sulphur Springs, W. Va. |
| Baxter | Spokane, Wash. |
| Birmingham | Van Nuys, Calif. |
| Borden | Chickasha, Okla. |
| Brooke | Fort Sam Houston, Tex. |
| Bruns | Santa Fe, N. Mex. |
| Bushnell | Brigham City, Utah |
| Crile | Cleveland, Ohio |
| Cushing | Framingham, Mass. |
| Darnall | Danville, Ky. |
| DeWitt | Auburn, Calif. |
| Fitzsimons | Denver, Colo. |
| Halloran | Staten Island, N.Y. |
| Hammond | Modesto, Calif. |
| Hoff | Santa Barbara, Calif. |
| Kennedy | Memphis, Tenn. |
| LaGarde | New Orleans, La. |
| Lawson | Atlanta, Ga. |
| Letterman | San Francisco, Calif. |
| Lovell | Ayers, Mass. |
| Mason | Brentwood, Long Island, N.Y. |
| Mayo | Galesburg, Ill. |
| McCaw | Walla Walla, Wash. |
| McCloskey | Temple, Tex. |
| McGuire | Richmond, Va. |
| Newton D. Baker | Martinsburg, W. Va. |
| Nichols | Louisville, Ky. |
| Northington | Tuscaloosa, Ala. |
| O'Reilly | Springfield, Mo. |
| Percy Jones | Battle Creek, Mich. |
| Thomas M. England | Atlantic City, N. J. |
| Tilton | Fort Dix, N.J. |
| Valley Forge | Phoenixville, Pa. |
| Wakeman | Camp Atterbury, Ind. |
| Walter Reed | Washington, D.C. |
AAF installations: | |
| Convalescent Hospital | St. Petersburg, Fla. |
| Convalescent Hospital | Fort Logan, Colo. |
| Regional Hospital | Maxwell Field, Ala. |
| Regional Hospital | Coral Gables, Fla. |
| Regional Hospital | Army Air Field, Lincoln, Nebr. |
| Regional Hospital | Hammer Field, Fresno, Calif. |
Five machines were sent to the European and Mediterranean theaters and six to the Pacific areas. Others were later sent to Japan to serve postwar purposes with the army of occupation.
Posttraumatic epilepsy center
In October 1945, a posttraumatic epilepsy center was established at Cushing General Hospital.4 For 1 year, this center was concerned with the specialized aspects of head injury, after which it transferred to the VA (Veterans' Administration). It is important to record that Metrazol (pentylenetetrazol) activation was first introduced at this center in the fall of 1945. Electrocorticography, with particular emphasis upon afterdischarge from cortical stimulation, was also developed during a study upon the posttraumatic epileptics.
Statistical data
The following data, tabulated by Major Everts and Major Ross in October 1945, were reported by 18 of 19 Zone of Interior special neurological centers:
4Medical Department, United States Army. Surgery in World War II. Neurosurgery. Volume I. Washington: U.S. Government Printing Office, 1958, pp. 279-317.
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Number | Percentage abnormal tracings | |
Total EEG's performed | 21,247 | 49 |
Posttraumatic encephalopathy | 6,144 | 55 |
Total epilepsies | 2,697 | 60 |
Total expanding intracranial lesions | 165 | 70 |
ORGANIZATION OVERSEAS
Hospitals
There were no neurological centers in oversea theaters similar to those established in the continental United States. Tables of organization for station and general hospitals provided for one to three officers on the neuropsychiatric staff. Because there were so many hospitals overseas, the available neurologists and psychiatrists were distributed sparsely. Usually, however, in hospital centers, a neurologist was assigned, as were specialists in other fields, to be consultant to the center hospitals and, thus, was called upon for the more severe neurological problems.
As a rule, neurological cases were admitted to hospitals caring for diseases and injuries in general. There were a few station and general hospitals in the European, Mediterranean, and Pacific theaters which had been designated as special neuropsychiatric centers. But in these installations there was such a heavy preponderance of psychiatric cases that neurological conditions, for the most part, continued to be cared for in the general hospitals.
Electroencephalography
European theater.-Information concerning oversea operations in electroencephalography was scattered and difficult to substantiate. The first EEG instrument known to have been officially sent overseas for American military use arrived in June 1944, at the 96th General Hospital, Malvern, England. Maj. Alexander Ross, MC, the assigned neurologist, appears to have had the only functioning electroencephalography laboratory in the European theater before the close of World War II. He was aided by Capt. James H. Lasater, MC, and an EEG technician. Their EEG machine was later turned over to Maj. Ephraim Roseman, MC, who had been sent overseas with two technicians in April 1945. Because of delays, Major Roseman was unable to have his laboratory in Paris operational until the war in Europe had ended.
Mediterranean theater.-Lt. Cols. Theodore J. C. von Storch, MC, and Benjamin Boshes, MC, had EEG equipment operating in Italy and North Africa. Colonel von Storch, chief of the Neuropsychiatry Section, 33d General Hospital, had the EEG equipment mounted on an ordnance truck for field use in the Italian campaign. His team, which studied blast con-
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Africa. Colonel von Storch, chief of the Neuropsychiatry Section, 33d General Hospital, had the EEG equipment mounted on an ordnance truck for field use in the Italian campaign. His team, which studied blast concussion cases, consisted of a neuropsychiatrist, a psychologist, two technicians, and a driver. Initially the team functioned at the 8th Evacuation Hospital, during the Apennines campaign, on Route 65 south of Bologna; later, they followed the Fifth U.S. Army offensive into the Po Valley. The team's findings from their study of blast concussion are given on pages 542-544.
Colonel Boshes operated his electroencephalography laboratory at the 12th General Hospital. Electroencephalographs were taken on head injuries of various types, for 'exhaustion' (neuropsychiatric casualties), in followup studies on electroshock therapy, and on a large number of seizure cases. Colonel Boshes carried out a standardized hydration experiment with electroencephalography upon those seizure cases in which the etiology was in question.
The studies of Colonels von Storch and Boshes placed emphasis upon the importance of obtaining EEG studies early, particularly in traumatic conditions.
ADMISSION AND DISPOSITION
On the whole, neurological diseases encountered in the Army were not much different from those observed in the civilian population. They comprised 1.1 percent of all admissions for disease. There were some 174,422 admissions for neurological disorders in World War II, indicating an overall admission rate of 6.9 per 1,000 mean strength per year, The largest admission rate was in 1943, the lowest, in 1945 (8.3 and 6.0 for these years, respectively). As may be seen from table 60, the specific diagnoses exclude neurosyphillis, infectious meningitis, and others alike, not considered by established policy within the proper province of neurology. Of the specific diagnoses, neuralgia, neuritis, and polyneuritis indicate the highest admission rates, followed by those for epilepsy, trauma of the central nervous system, and herniated nucleus pulposus. (See chapter IX, table 7 and chart 2 for neurological admissions in World War II, by month.)
While most of these conditions rightfully come within the province of the neurologist, established policy dictated that some, notably infections of the nervous system such as neurosyphilis and the infectious meningitides, be supervised by the appropriate medical specialist with the neurologist functioning as a consultant.
Disposition of patients with neurological disorders depended upon severity, degree of disability, response to therapy, existence of the disease before service or occurrence after induction, prognosis, potential incurrence of Government liability, and functional capacity on a limited duty status or by change of environment. These factors were also governed by prevailing administrative directives, an example of which was WD Circular No. 212, of 29 May 1944, prohibiting the return to duty of patients without special qualification who could not do a reasonable day's work.
Some 52,200 persons were separated in World War II from the Army
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| Diagnosis | Total 1942-45 | 1942 | 1943 | 1944 | 1945 | |||||
Number | Rate | Number | Rate | Number | Rate | Number | Rate | Number | Rate | |
Degenerative | ||||||||||
| neurological diseases | 2,736 | 0.1 | 678 | 0.2 | 1,053 | 0.2 | 505 | 0.1 | 505 | 0.1 |
Infections of nervous system | 7,688 | 0.3 | 1,141 | 0.4 | 3,017 | 0.4 | 1,890 | 0.2 | 1,640 | 0.2 |
Peripheral nervous system disorders: | ||||||||||
| Neuralgia, neuritis, and polyneuritis | 56,311 | 2.1 | 6,730 | 2.1 | 14,406 | 2.1 | 20,575 | 2.7 | 14,600 | 2.1 |
| Herniated nucleus pulposus | 11,523 | .5 | 710 | .2 | 3,348 | .5 | 3,510 | .5 | 3,955 | .5 |
| Paralysis | 8,252 | .3 | 1,073 | .3 | 1,884 | .3 | 2,055 | .3 | 3,240 | .4 |
| Other peripheral nerve diseases | 996 | .0 | --- | 0 | 1 | .0 | 505 | .1 | 490 | .1 |
| Total | 77,082 | 3.0 | 8,513 | 2.6 | 19,639 | 2.9 | 26,645 | 3.5 | 22,285 | 3.1 |
Paroxysmal disorders and disturbances of consciousness: | ||||||||||
| Epilepsy | 18,077 | 0.7 | 4,115 | 1.3 | 6,542 | 1.0 | 4,465 | 0.6 | 2,955 | 0.4 |
| Other | 36,716 | 1.5 | 5,184 | 1.5 | 15,882 | 2.2 | 8,345 | 1.0 | 7,305 | 1.0 |
| Total | 54,793 | 2.2 | 9,299 | 2.8 | 22,424 | 3.2 | 12,810 | 1.6 | 10,260 | 1.4 |
Trauma of central nervous system | 11,855 | 0.5 | 491 | 0.2 | 4,749 | 0.7 | 3,310 | 0.4 | 3,305 | 0.4 |
Miscellaneous disorders of the nervous system | 20,268 | 0.8 | 2,337 | 0.7 | 6,296 | 0.9 | 5,385 | 0.7 | 6,250 | 0.8 |
| Total neurological disorders | 174,422 | 6.9 | 22,459 | 6.9 | 57,178 | 8.3 | 50,545 | 6.5 | 44,240 | 6.0 |
1The diagnostic nomenclature and classification used for the presentation of World War II data on morbidity, separation, and mortality are those adopted by the Army in 1944 and used for 1944 and 1945 records. Therefore, the data for diseases which in 1942 and 1943 were differently named or grouped, or both, were renamed in equivalent or closely equivalent terms of the 1944-45 diagnostic nomenclature and regrouped accordingly. (For further details see footnote 1 to table 6, chapter IX.)
NOTE.-The entry .0 indicates a rate of less than 0.05.
for disability due to neurological disorders; 50,105 of these persons were enlisted men discharged on CDD (certificate of disability for discharge) (table 61). In general, the principal causes of admissions were also the principal causes of the disability separations. Epilepsy was the leading cause of separation (28.9 percent of the disability separations for neurological disorders), followed by encephalopathy and other posttraumatic conditions of the central nervous system (16.4 percent), and by herniated nucleus pulposus (10.8 percent) (table 62).
It is of interest to note that in World War II discharge rate for neuro?
535p logical disorders was identical to that of World War I. The discharge rate was 2.2 per 1,000 mean strength per year in both World War II and World War I. (See appendix A, table 10.)5 (The discharge rates for neuro?
| Diagnosis | Total (1942-45) | 1942 | 1943 | 1944 | 1945 |
Total U.S. Army Personnel | |||||
Epilepsy | 15,103 | 2,589 | 5,398 | 3,940 | 3,176 |
Encephalopathy and other posttraumatic conditions of the central nervous system | 8,565 | 208 | 3,025 | 2,514 | 2,818 |
Herniated nucleus pulposus | 5,658 | 188 | 1,412 | 1,167 | 2,891 |
Neuralgia, neuritis, polyneuritis | 5,201 | 275 | 1,562 | 1,143 | 2,221 |
Paralysis of part or all of one or both upper extremities | 1,752 | 93 | 124 | 622 | 913 |
Paralysis of part or all of one or both lower extremities | 868 | 41 | 77 | 374 | 376 |
Hemiplegia | 651 | 89 | 215 | 176 | 171 |
Paraplegia | 346 | 37 | 89 | 147 | 73 |
Facial paralysis | 428 | 23 | 85 | 95 | 225 |
Paralysis, other and unspecified | 1,864 | 29 | 435 | 199 | 1,201 |
Neurological diseases, other | 11,764 | 1,231 | 4,584 | 2,739 | 3,210 |
| Total | 52,200 | 4,803 | 17,006 | 13,116 | 17,275 |
Enlisted Men | |||||
Epilepsy | 14,633 | 2,559 | 5,258 | 3,735 | 3,081 |
Encephalopathy and other posttraumatic conditions of the central nervous system | 8,317 | 205 | 2,990 | 2,389 | 2,733 |
Herniated nucleus pulposus | 5,386 | 186 | 1,384 | 1,113 | 2,703 |
Neuralgia, neuritis, polyneuritis | 4,991 | 270 | 1,523 | 1,077 | 2,121 |
Paralysis of part or all of one or both upper extremities | 1,709 | 92 | 124 | 606 | 887 |
Paralysis of part or all of one or both lower extremities | 848 | 40 | 76 | 370 | 362 |
Hemiplegia | 630 | 89 | 214 | 163 | 164 |
Paraplegia | 341 | 37 | 89 | 143 | 72 |
Facial paralysis | 412 | 22 | 84 | 92 | 214 |
Paralysis, other and unspecified | 1,824 | 28 | 426 | 186 | 1,184 |
Neurological diseases, other | 11,014 | 1,193 | 4,418 | 2,432 | 2,971 |
| Total | 50,105 | 4,721 | 16,586 | 12,306 | 16,492 |
5Discharges for psychosis were also similar in both World War I and World War II, which might indicate that these conditions (neurological and psychotic) are unaffected by external conditions (stress).-A. J. G.
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Diagnosis | Percent | |
Total Army | Enlisted men | |
Epilepsy | 28.9 | 29.2 |
Encephalopathy and other posttraumatic conditions of the central nervous system | 16.4 | 16.6 |
Herniated nucleus pulposus | 10.8 | 10.7 |
Neuralgia, neuritis, polyneuritis | 10.0 | 10.0 |
Paralysis of part or all of one or both upper extremities | 3.4 | 3.4 |
Paralysis of part or all of one or both lower extremities | 1.7 | 1.7 |
Hemiplegia | 1.2 | 1.3 |
Paraplegia | .7 | .7 |
Facial paralysis | .8 | .8 |
Paralysis, other and unspecified | 3.6 | 3.6 |
Neurological diseases, other | 22.5 | 22.0 |
| Total | 100.0 | 100.0 |
logical disorders are shown in chapter IX, table 3 and chart 1, by month.)
Apparently there is a stability about neurological disturbances which permits a certain amount of predictability.
COMMON CLINICAL DISORDERS
Trauma to the Central and Peripheral Nervous Systems
No stereotyped system of management of all types of nervous system trauma was considered feasible since each case required individual discrimination. However, in general, the wounded soldier with neurosurgical or neurological complications received care and treatment through the usual evacuation chain. These patients presented problems of neurosurgical, neurological, and psychological importance, and while ideally it would have been desirable to have all three services complementing each other from the beginning, this was impractical. There was a shortage of personnel in each specialty, and in the early phases of treatment, the neurosurgeon often had to be neurologist and psychiatrist as well. This was not ideal, particularly from the psychological standpoint, for being under the care of only the neurosurgeon unwittingly placed emphasis upon severe and perhaps irreparable injury. This was particularly true in cases of closed head injury where psychogenic symptoms were so prone to occur.
Differentiating cases with so-called posttraumatic encephalopathy
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from those with psychogenic reactions to trauma was not always easy. Generally, the wounded person with organic defects had a nonrecoverable, retrograde amnesia; expressionless facies; memory and concentration defects; impaired abstract thinking; defective judgment and insight; impulsive and, sometimes, explosive behavior; and decreased intellectual function. Electroencephalography often lent support to the clinical impression. On the other hand, patients with psychogenic reactions were more complaintive, their faces were anxious, their symptoms radiated into multiple somatic spheres, and their memory defects were related to inattention and preoccupation. They were tense, showed autonomic instability, 'resisted' improvement, and posed real problems in management.
Results of treatment in these questionable closed head injuries depended upon the attitudes, concepts, and interpretations of the hospital personnel. In some hospitals, there were rigid and biased reactions on the part of either the surgical or medical services-the patient's symptoms being considered entirely organic or entirely psychogenic. In others, the clinical services complemented each other so that a more balanced evaluation of cases was attained. This provided a broad therapeutic approach, combining neurosurgical, neurological, physical, and psychological techniques. Thus, emphasis was placed on progressive early activation, on performance of light duties, and on maintaining motivation for duty in the theater; hopes for secondary gain were suppressed; and neurotic mechanisms were attacked. Such management was effective, although, of course, it was still necessary to evacuate a good number of patients with fixed symptomatology to the United States.
This combined approach was also necessary in spinal cord and peripheral nerve injuries. Where neurosurgical care was no longer necessary, the problem became one of neurological and psychological management. It was not at all uncommon for patients to present combinations of organic and psychological disorder, some to a degree taxing the diagnostic acumen of the neurologist. A number of these recovered sufficiently to be restored to duty in the theater; others had to be evacuated.
Rehabilitation of the brain injured
The usual arrangement in the neurological-neurosurgical centers was for the Neurological Section to assume the care of patients with closed head injury and of those having open injuries after they had received necessary neurosurgical treatment. This task necessitated the cooperation not only of the professional services but also of numerous ancillary divisions. Upon completion of all necessary clinical neurological evaluations, the general procedures followed were:
1. Careful psychological testing to evaluate the patient's deficit.
2. Determination of pretraumatic personality as a contrast to posttraumatic deviation.
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3. Special reconditioning and reeducational program coordinating occupational and physical therapy, educational moving pictures, classes, and exercise.
4. Psychotherapy sessions in which the patient received explanations, reassurance, and instructions, and was given a positive, hopeful attitude. Efforts were made to disabuse him of the idea of invalidism.
5. Red Cross and social service information, particularly concerning domestic and community factors.
6. Contacts with relatives to give them an understanding of the case and to enlist their cooperation.
7. Therapeutic trials at home after the patient was stabilized in order to obtain an indication of his reactions in such an environment. This was supplemented by a Red Cross report on the effects of his visit.
8. Evaluation of capabilities, interests, and aptitudes so as to give the patient understanding of his potentialities in seeking employment. Some hospitals kept abreast of the job possibilities and guided the patients into those for which they were best suited.
It was believed that these policies, with necessary modifications, proved their value and that a large proportion of patients were salvaged for useful lives.
Aphasic language disorders
Aphasic language disorders were seen with increasing frequency in the specialized general hospitals caring for neurological and neurosurgical patients. Most of these cases had resulted from severe head injuries sustained in combat. Many had, in addition to aphasia, other associated neurological defects of a motor or sensory nature and concomitant emotional and intellectual changes. Neurologists and neurosurgeons alike appreciated the fact that the language defects in most traumatic problems of the brain tend to improve spontaneously. For this reason, some of the professional consultants were initially hesitant to set up a special language program for the care of such patients, believing that it would entail unduly prolonged hospitalization for a relatively small group of patients. However, because it was realized that much could be done in speeding the healing progress, in directing improvement, and in influencing the patient's pathological reaction to his speech and other defects through skilled management, a program to this end was worked out by the Neurology Branch of the Neuropsychiatry Consultants Division.
The neurologist was made responsible for the early study and treatment of all aphasic disorders. His staff was properly augmented by the addition of a clinical psychologist who assisted in the evaluation of the brain-injured patient and collaborated with him in the speech training program. An enlisted or civilian speech therapist was assigned where the caseload made such additional help necessary.
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In general, the terminology and principles enunciated in TB MED 155, issued in April 1945, were followed, being elaborated upon by individual staffs as experience was gained.
Those cases with surgical implications received the collaborative attention of neurosurgeon and neurologist so that the patient might receive speech training early, with other treatment measures, and be accordingly advanced in his training. Upon conclusion of surgical procedures, the patient was transferred to neurology for further rehabilitation.
Voice recorders and other related apparatus were utilized in this program. Some special training materials were obtained, usually from sources outside the Army, such as the Red Cross and university clinics particularly interested in the subject.
Patients with aphasia due to brain trauma sometimes made amazing improvement, certainly more than had been experienced in the average civilian case. This may be attributed to their comparative youth, early definitive treatment, and availability of good hospital care; to the hopeful spirit of youth; to the specialized attention of therapists; and to the general encouragement, banter, reciprocal aid, and interdependence found in a group of young men in military hospitals. In any event, those concerned in this restitution program received ample reward in the satisfaction of seeing many of their patients regain function.
It was estimated that the average aphasic patient remained in the hospital for about 6 months. Although some made astonishing improvement and others made sufficient progress to function acceptably outside the hospital, a minority showed little progress. Consequently, arrangements were made with the Veterans' Administration to designate certain of their hospitals for the prolonged care and rehabilitation of severe or unimproved aphasic patients.
Peripheral nerve injuries
Although the subject of peripheral nerve injuries perhaps more properly belongs to the neurosurgeon, the preoperative and postoperative management of nerve injuries is of prime interest to the neurologist. Each neurological-neurosurgical center had its own arrangements for the management of these cases; in all, however, the liaison between neurology and neurosurgery was closely knit and effectively maintained. In some centers, patients with peripheral nerve injuries were admitted to the neurosurgical service and remained there throughout hospitalization, being examined at intervals by the neurologist as consultant. In others, they were admitted to the neurological service with the neurosurgeon as consultant. If operation was agreed upon, the patients were transferred to neurosurgery and remained there until discharge. Still other centers, more ideally, admitted all severe nerve injuries to the neurological service where complete examinations were performed. If operation was indicated, the patients were
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transferred to neurosurgery. After the need for surgical supervision was removed, these patients were returned to the neurological service which assumed the responsibility of followup examinations, retraining, rehabilitation, and discharge. This freed the surgeon for his prime purpose and gave the neurologist splendid opportunities to study the restitution of the damaged nerve and its areas of supply.
An example of this last-mentioned type of organization was that at Cushing General Hospital. Maj. (later Lt. Col.) Frederic H. Lewey, MC, who was chief of the Neurology Section at that hospital, described the procedures routinely employed on every patient with peripheral nerve injury, as follows:
1. The muscular power is examined by means of the so-called 'fish-hook' method. An ordinary spring scale is applied to measure the force in pounds required to overcome the voluntary resistance of a certain muscle. The average values for the various muscles and their standard deviations have been determined in a large random sample of normal soldiers. Experience has shown that this method of examination is not more time consuming than the old one of estimating arbitrarily the loss of power in percentage of the normal, and that the method of mere estimation gives, even in the hands of experienced neurologists, utterly incorrect information when compared with the power actually determined.
2. The muscle atrophy accompanying denervation is recorded and its recovery checked by hand and foot prints which give at the same time a graphic impression of the trophic condition of the skin.
3. The earliest possible detection of the presence or return of innervation is of singular importance in judging the prognosis of a nerve injury of unknown character. It may mean foregoing an operation with unnecessary waste of the surgeon's time, or it may mean, on the other hand, saving months of time by urging immediate exploration of a nerve.
a. No one method of studying the electrical irritability of the nerve-muscle apparatus has so far been satisfactory in these endeavors. It is attempted to determine whether any and which method gives the best results by repeated comparison of the electromyogram, the strength-duration curve, and the cathode-closing tetanus of the same patient with his clinical course.
b. Many months of hospitalization are saved by determining the permeability or impermeability of a nerve scar or suture 8 to 12 weeks after exploration or suture instead of after 8 to 12 months. Operation under local anesthesia and stimulation of sensory fibers distal to scar or suture has proved to be by far the most sensitive method. However, it is a qualitative method and does not give a reliable indication of the type and number of nerve fibers passing the injury and of the prognosis for recovery. Recording, during operation, the amplitude, and latency of action currents, elicited across the injury, permits a better quantitative insight into the type and number of viable nerve fibers in the peripheral stump.
c. The determination of the injury current of an interrupted nerve is tried to decide how much of the nerve should be resected to reach a good cross section of nerve fibers.
4. Sweat tests are recorded in peripheral nerve injuries, especially in connection with the determination of the skin temperature by means of thermocouples before, during, and after injection of sympathetic ganglia for causalgic type pain prior to sympathectomy.
5. Many patients arrive from overseas in casts, applied for fracture or instead of a splint, with a frozen joint. They have to be mobilized before neurosurgery can be
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contemplated. The facilities of the physiotherapeutic section do not allow treatment of more than 20 minutes daily per patient. A mechanical apparatus for the automatic movement of wrist, elbow, and knee joints has been improvised which can be run and regulated by the patients themselves and permits treatment of our patients three times a day for one-half hour each. Experience has shown that the necessary mobilization is performed 25 to 30 percent faster than by the old methods of manual movement, freeing, in addition, a physiotherapist.
6. Each patient is presented at the end of his examination-as a rule one week after admission-to a combined conference every Saturday morning in which the staffs of the neurological and neurosurgical sections, the chiefs of medicine and surgery, representatives of the orthopedic and physiotherapy section and sometimes the plastic surgeons participate. A decision is made whether a patient needs operation and if so, what kind, in which sequence, and whether in combination with plating fractures or plastic repairs. This conference reduces the consultation service to a minimum.
7. Patients are transferred after an operation to the neurosurgical wards where they remain until the sutures are removed and the extremity again extended. Thereafter, they return to the neurological section.
8.The recovery from and the regeneration of a nerve injury or suture takes many months, often more than a year. No patient must be discharged from the hospital and the Army until he has attained maximum hospital benefit. It is distressing for patients and medical officers alike to see the patients sit around for weeks and months, frequently morose and useless, but occupying a bed that could be used to much better avail for a seriously ill person. A prolonged work furlough has been introduced in this section with excellent results. The patient who exercises his injured extremity grudgingly 3 or 4 hours daily while in the hospital does it gladly 10 hours a day when paid ten dollars in a factory. He is proud to help effectively the war effort, and his own pocketbook at the same time. Industry is grateful for the increase in manpower. The patient is returned to this Hospital not later than 3 months for a checkup of his improvement and decision as to whether and when he is ready for CDD. The opportunity of gradual adjustment to civilian life after years of Pacific or European warfare has been considered a great help by most of the patients.
Several hundred patients have been converted at the present time in this way from in-patients to out-patients, freeing permanently the corresponding number of beds for fresh patients.
Of the first 500 patients with peripheral nerve injuries discharged from the Army at Cushing General Hospital, 58 percent recovered without any surgical procedure, 16 percent had nerve sutures, and 26 percent had surgical explorations, in half of which local pathology was corrected.
Blast concussion
World War II afforded an unexcelled opportunity to study the effect of explosive blast upon the central nervous system.6 It must be admitted, however, that, while better understanding of the condition occurred and existing concepts expanded, no final decision concerning its organic and psychogenic nature was reached.
6(1) Medical Department, United States Army. Internal Medicine in World War II. Activities of Medical Consultants. Volume I. Washington: U.S. Government Printing Office, 1961, pp. 377-380. (2) Medical Department, United States Army. Surgery in World War II. Neurosurgery. Volume I. pp. 215-260.
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Mediterranean theater.-The following excerpts have been abstracted from the report of a study conducted in the Mediterranean theater:7
The original purpose of the study was two-fold: (1) To determine whether such a delicate instrument as the electroencephalograph could be transported over difficult terrain under combat conditions and utilized effectively in forward areas. It was demonstrated that such could be done, if not with ease, yet well within the realm of utility. (2) To examine patients with cerebral blast concussion as soon as possible after injury and to evacuate as many as possible to a similar (nonmobile) unit in the 12th General Hospital at Leghorn where subsequent developments could be studied by similar means. It was thus hoped to gather useful information pertaining to the mechanism, diagnosis, treatment, cause, and prognosis in such cases.
Although the plan was not carried out exactly as planned because of the tactical situation and the type of war being waged at the time (April 1945) in the Po Valley, it proceeded mainly as a field operation.
The study consisted of a comparative analysis of 82 cases of various types and degrees of cerebral concussion as observed soon after injury. In 16 of the cases, repeated examinations were made from 2 to 105 days after injury. The cases were divided into two types: Those subjected to blast injury (B), and those subjected to direct blow by a solid object such as a shell fragment, moving vehicle, and the like (S).
Each of these groups was analyzed with respect to-
1. Evidence and degree of concussion (unconsciousness, amnesia, confusion).
2. Subsequent symptoms (headache, tinnitus, deafness, vertigo, giddiness).
3. Time elapsed between injury and examination.
4. The presence and relative significance of pathology as determined by:
(a) Craniofacial injury.
(b) Neurologic examination.
(c) Electroencephalographic examination.
(d) Psychometric examinations.
5. Localizing value of these various examinations.
6. Detailed analysis of the encephalographic changes.
The results of the study were as follows:
1. Electroencephalography can be performed adequately in the field with a mobile unit.
2. Few of the blast cases showed any evidence of encephalopathy longer than 2 days after injury other than abnormalities of cortical electrical activity. These changes persisted up to 12 days and in one case as long as 105 days after injury. Patients subjected to direct cranial injury
7Von Storch, T. J. C., and Kounin, J.: A Study of Cerebral Concussion. In Annual Report, 33d General Hospital, 1945.
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by a solid object showed more evidence of injury than the blast cases. This encephalopathy persisted longer and could be demonstrated by neurologic as well as electroencephalographic examination. Properly speaking, these cases exhibited cerebral contusion rather than concussion.
3. Unconsciousness was used as a criterion of concussion. Pretraumatic amnesia occurred in 86 percent of the cases concussed by an object but in only 9 percent of those due to blast. Pretraumatic amnesia was present also in 10 percent of the cases with considerable psychogenic complications. Posttraumatic amnesia and confusion were of little value in determining the presence of concussion.
4. The presence of headache, tinnitus, deafness, giddiness, or vertigo bore no significant relationship to the presence of cerebral concussion.
5. Craniofacial injury was present in varying degree in all groups and was of no value in determining the presence of cerebral concussion.
6. Neurologic examinations were most frequently positive in the cases with relatively severe injury due to blow by an object. They were not of much value in blast cases.
7. Psychometric examinations were of the same significance as the neurologic examinations.
8. Electroencephalography revealed encephalopathy most frequently and of greatest degree in those more severely injured by a solid object. On the other hand, cortical electric dysrhythmias were present in approximately one-half of those patients who were not rendered unconscious. Hence, the electroencephalogram either revealed-
(a) A subclinical encephalopathy, or
(b)Other cerebral dysrhythmias unrelated to concussion.
9. Detailed analysis of the electroencephalogram revealed that-
(a)Patients with cerebral concussion due to blow by an object tended to show normal or low voltage, normal or random frequency of mild to moderate degree with bursts of abnormal (high voltage slow) activity mild to severe in degree, mild to considerable evidence to focal damage, and little or no response to hyperventilation.
(b) Patients with cerebral concussion, due to blast, tended to show normal voltage and frequency with mild random activity, slight evidence of focal pathology and no reaction to hyperventilation.
(c) Those cases in either group who were not rendered unconscious had entirely normal records, as a rule, except in those who were in the proximity of a blast, fast activity and occasional bursts were evident. In both groups, there was a tendency to a slight response to hyperventilation.
(d) The cases with significant psychogenic complications had a slight tendency to low voltage records with mild random activity, slight bursts but considerable reaction to hyperventilation. These records were
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often of the psychomotor type and probably represented preexistent cerebral dysrhythmias.
10. Reliable evidence of focal encephalopathy was most frequently found by neurologic examination in the patients more severely injured by direct blow with a solid object.
11. The investigation was inconclusive but revealed sufficient information to warrant further studies.
European theater.-A detailed clinical study of blast injury was carried out in the European theater by Maj. Howard D. Fabing, MC,8 at the 130th General Hospital. The following summary is from his report:
Study of 80 consecutive cases of blast injury in combat soldiers was carried out. It was found that the disorder occurs among all ranks, in new troops as well as in veterans of combat. All type of explosive agents can cause the disorder. Some soldiers become blast victims following single nearby explosion, others succumb as the result of the cumulative effect of a barrage. The unconsciousness produced by blast is characterized by a retrograde amnesia for the sound of the explosion and anterograde amnesia of variable length, but lasting an hour in the usual case. The unconsciousness is seldom characterized by coma, but rather by dissociated aimless behavior. Upon return to consciousness the patient complains of protracted headache which is non?specific in position or quality and which may be constant or intermittent. In addition, he complains of tinnitus which is usually non-persistent, and of diffuse anxiety symptoms. About one half of the patients complain of generalized somatic soreness for a day or two after blast injury. They show no evidence of focal central nervous system damage on neurological examination, and few have bleeding from any of the orifices. Study of their spinal fluids show normal pressure, and normal cellular and protein content. Bleeding into the fluid is extremely rare (2.5 percent).
A successful method of therapy was discovered during an inquiry into the nature of the unconsciousness of these patients. It was found that memory for the unconscious period could be recalled under chemical hypnosis; that it was therefore an amnesia of the type seen in hysteria. Furthermore, it was noted that there was a dramatic relief of symptoms in cases in which there was good conscious recall for the amnesia's material.
Clinical experimentation with the technique of chemical hypnosis led to a modification which proved successful in bringing about recovery of post-blast amnesia. The method employs sodium pentothal intravenously to produce chemical hypnosis and exploration of the amnesic material, followed by rapid waking with intravenous coramine. The technique is described in detail. It proved of therapeutic value in more than 90 percent of cases.
The problem of individual susceptibility to blast injury is raised. The relationship between blast injury and head injury is pointed out, and it is demonstrated that the pentothal-coramine treatment technique can be employed successfully in some cases of the chronic sequelae of head injury as well as in blast injury.
It is concluded that so-called blast injury is in more instances a disturbance in higher nervous physiology, i.e., that it is a psychoneurosis. A neurophysiologic theory of the pathogenesis of blast injury [along Pavlovian lines] is advanced, and an attempt is made to understand the neural mechanism of chemical hypnosis in these cases. It is noted that this formulation is consistent with current psychodynamic theory, the difference being one of terms. It is pointed out that study of the mechanisms of the
8Fabing, H. D.: Cerebral Blast Syndrome in Combat Soldiers. Tr. Am. Neurol. A. 71: 29-33, June 1946.
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production of blast injury may lead to a better understanding of the neural basis of other more complex neuroses.
The preceding two reports detail the opinions formulated on relatively early cases of the blast syndrome. The opportunity to evaluate later cases occurred at the 96th General Hospital and in the Zone of Interior where patients were admitted several weeks after the injury and after having passed through several consecutive hospitals. These evacuated patients continued to complain of intractable and generalized headache, giddiness, irritability, impaired concentration, nonretentive memory, blurring of vision, and trembling. Examination revealed little other than hyperhidrosis, hyperactive reflexes, and fine hand tremor. A psychiatric investigation almost invariably disclosed the existence of material of strong emotional tone antedating the explosion. Any existing anxiety was aggravated during the chain of evacuation by the all too frequent diagnosis of 'cerebral concussion due to blast.' This contributed to the fixing and focalizing of symptomatology thus posing difficult problems in therapy. The syndrome was so typical of anxiety state with some conversion features that psychotherapy was obviously the treatment of choice. This often produced encouraging results.
From evidence available, the conclusion seemed inescapable that while an actual brain injury due to blast may occur, this is rare, and that in the vast majority of such cases, there is an antecedent emotional unrest, a sudden overwhelming of psychic defenses, and then anxiety and conversion symptoms.
Epilepsy
Admissions for epilepsy in World War II constituted somewhat over 10 percent of all admissions for neurological conditions (table 60), and as indicated before, the disability discharges for epilepsy constituted some 29 percent of all disability discharges for neurological disorders. Idiopathic grand mal was the most frequent expression of the disorder. Many soldiers had deliberately concealed their affliction at the time of induction hoping that the regularity and training of military life would be beneficial; others, because they were thwarted from obtaining jobs in civilian life or had repeatedly lost them. Many had the inception of seizures during military service, and it is possible that the rigors, responsibilities, excitement, fatigue, and frustrations of such an existence were precipitating factors. It was characteristic of most of these persons with epilepsy, however, to be strongly motivated to remain in service. The soldier with epilepsy minimized his affliction, was irked at hospitalization, and, as a rule, either objected to separation or resigned himself to this procedure. This attitude was in distinct contrast to that of the neurotic who, because of 'fainting spells,' was admitted to the hospital to be observed for epilepsy.
About 13 percent of patients with open head wounds developed epi?
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lepsy; of these, penetrating injuries produced the greatest number. A relatively small number of epilepsies occurred as a symptom of brain tumor, brain abscess, or inflammatory cerebral disease.
The ordinarily accepted methods in the diagnosis and treatment of epilepsy were followed. Explanation and superficial psychotherapy were employed in addition to drugs. The Red Cross made available, to appropriate patients, literature of the American Epilepsy League as an educational guide.9 Surgical procedures were used where indicated. The Posttraumatic Epilepsy Center at Cushing General Hospital has already been mentioned (p. 531).
Although it is realized that the indiscriminate acceptance of epileptic persons into military service would be imprudent, it would appear that, for those of normal intelligence, with few seizures, and with adequate premonitory symptoms, a place could be found. They could perform clerical or manual duties of a nature not dangerous to themselves or others and, thus, not only contribute to the national effort but also gain, in addition, the satisfaction of accomplishment too often denied them.10
Peripheral Neuritis
Of special interest was the almost worldwide occurrence, during 1944 and 1945, of a large number of cases of multiple radiculoneuritis. These were reported from the China-Burma-India, Pacific, Mediterranean, and European theaters at about the same time. Almost half were related to faucial or cutaneous diphtheria. In the faucial form, the onset of neuritic symptoms occurred about 3 to 4 weeks after sore throat began. In the cutaneous form, the onset varied from the 23d to the 158th day after appearance of the skin lesions, averaging 70 days. Neuritis symptoms consisted of paralysis of accommodation, paresthesias, and nerve palsies, often progressing to severe paralysis and atrophy of muscles. Recovery was slow. Of special interest was the frequent albuminocytologic dissociation in the spinal fluid, the protein increasing to as high as 300 to 500 mg. percent with little rise in cellular elements. This dissociation often led to the diagnosis of so-called Guillain-Barr? syndrome, but when the symptoms and signs were correlated, it became apparent that the condition was diphtheritic, even though it was not always possible to isolate virulent Corynebacterium diphtheriae from the infected skin or faucial lesions.
In other cases presenting evidence of infectious radiculoneuritis, with or without albuminocytologic dissociation, the etiology was more obscure,
9The discharge of epileptic soldiers was also given special attention through the military and Red Cross social service groups arranging for a careful 'followup' program, often arranging for local physicians' care before they left the hospital, especially when dependent on medication to control seizures.-W. H. E.
10During the Korean War, persons with idiopathic epileptic diseases controlled by the usual medication were acceptable for military service, Under current (1965) Army policy, all epileptic disorders are unacceptable for service in peacetime but controlled seizure disorders are acceptable during general mobilization.-A. J. G.
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and factors such as malnutrition, fevers, sulfonamides, and various toxic and infective agents were invoked.
Another puzzling type of neuritis seen particularly in the Pacific and Burma areas involved the shoulder girdle, usually on one side. The course was principally initiated by sharp pain for a day or so followed by paralysis and atrophy of the deltoid, spinati, latissimus dorsi, and serratus magnus, and by mild sensory diminution. Recovery was slow and, usually, incomplete. Trauma did not seem to play a role; poliomyelitis was excluded by the presence of sensory changes. Almost all the cases occurred in persons having malaria or dysentery. Atabrine (quinacrine hydrochloride), which was extensively used, was suspected by some as an etiological factor, but its role was never proved. In one of the hospitals in the United States (Station Hospital, Camp Livingston, La.), two soldiers were found to have anesthetic leprosy.
Multiple neuritis of varying severity was frequently seen in repatriated prisoners of war. (See pages 551-552 and 553-554.)
Herniated Nucleus Pulposus
Although MR 1-9 specifically stated that individuals having evidences of herniated nucleus pulposus or a history of operation for this condition were nonacceptable for military service, there were a number of such persons inducted. These inductees, together with personnel who developed the condition incidental to the rigors of service, constituted 6.6 percent of the admissions for neurological disorders (derived from table 60). That this was an important problem with ramifications into professional, administrative, legal, and manpower spheres was early recognized, and the need for all medical officers to be cognizant of these implications prompted the issuance of Circular Letter No. 43, Office of The Surgeon General, on 13 February 1943.
The purpose of this circular letter was to direct the attention of medical officers to the diagnostic and therapeutic problems of herniated nucleus pulposus. It covered the characteristic clinical manifestations of the condition and laid down rules governing myelography. The directive also stressed the line-of-duty status of patients so afflicted and advised that any surgical intervention was the combined problem and responsibility of orthopedic surgeons and neurosurgeons. Emphasis was placed on the inadvisability of performing elective operations for herniated nucleus pulposus antedating induction.11
Nevertheless, the problem was ever-present. As close cohesion developed in the centers, most of such cases were admitted on the neurological service where diagnostic studies were carried out. Myelography, using Pantopaque (iophendylate), was usually performed at this time, either by
11Circular Letter No. 190, Office of The Surgeon General, U.S. Army, 17 Nov. 1943.
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the neurologist or the neurosurgeon, depending on local arrangements. It was generally believed that this procedure should be routinely done, not only to prove the clinical diagnosis but also to provide the surgeon with accurate localization. After roentgenograms were taken, the Pantopaque was aspirated, a not too difficult procedure in experienced hands.
Cases selected for operation were transferred to the neurosurgical service. Those to be treated conservatively were usually placed under orthopedic supervision when the problem was primarily musculoskeletal.
During 1943 and early 1944 when there were urgent demands for the utilization of all available manpower, approximately 43 percent of herniated disk patients were retained on limited-service assignments. Persistent or recurrent symptoms were frequent and led to rehospitalization of many of these patients. It became apparent that, under the stresses of military service, retention of soldiers and officers with herniated nucleus pulposus, whether treated conservatively or surgically, was fraught with uncertainty. After issuance of WD Circular No. 212, on 29 May 1944, prohibiting the return to duty of soldiers without special qualifications who could not do a reasonable day's work, there was a notable increase in the rate of discharge for this condition. This is reflected in table 63, relating to patients admitted for herniated nucleus pulposus in 1943 and their military status as of February 1945. These data indicate that 27 percent were still on duty as of February 1945 (73 percent were separated). (Note the wide differences when these data are differentiated by method of treatment, table 63.)
With the dimunition of personnel requirements on cessation of warfare in Europe and the accumulation of further experience, a final plan of management was embodied in WD Circular No. 209, issued on 13 July 1945. This circular recognized the recurrent symptoms of those returned to some form of duty. Conservative treatment was recommended in all cases not incurred in line of duty, with subsequent separation from the service, except those cases with intractable pain or evidence of neural paralysis. Corrective surgery in such cases could be done with the consent of the patient. In those patients who incurred the condition in line of duty, either conservative or surgical treatment could be performed, depending upon the wishes of the patient. Disposition was to be accomplished under existing directives. The operative treatment of these cases was made the sole responsibility of the neurosurgeon.
Thus, the evolution of the management of herniated nucleus pulposus in the military setting was difficult, trying, and discouraging.
NEUROLOGICAL DISORDERS IN ALLIED REPATRIATES AND JAPANESE PRISONERS OF WAR
The scope of this section is entirely clinical and represents some observations, made by the writer, of the physical and neurological status
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Personnel and military status | Total | Method of treatment | ||
Excision or laminectomy | Other operations | No operation | ||
Enlisted men: | ||||
| Admitted (1943) | 450 | 101 | 32 | 317 |
| Status as of February 1945: | ||||
| In service | 90 | 47 | 3 | 40 |
| Separated: | ||||
| Number | 360 | 54 | 29 | 277 |
| Percent | 80 | 53 | 91 | 87 |
Officers, male: | ||||
| Admitted (1943) | 62 | 33 | 6 | 23 |
| Status as of February 1945: | ||||
| In service | 44 | 26 | 2 | 16 |
| Separated: | ||||
| Number | 18 | 7 | 4 | 7 |
| Percent | 29 | 21 | 67 | 30 |
Females: | ||||
| Admitted (1943) | 8 | 4 | --- | 4 |
| Status as of February 1945: | ||||
| In service | 5 | 3 | --- | 2 |
| Separated: | ||||
| Number | 3 | 1 | --- | 2 |
| Percent | 38 | 25 | --- | 50 |
Total personnel: | ||||
| Admitted (1943) | 520 | 138 | 38 | 344 |
| Status as of February 1945: | ||||
| In service | 139 | 76 | 5 | 58 |
| Separated: | ||||
| Number | 381 | 62 | 33 | 286 |
| Percent | 73 | 45 | 87 | 83 |
of some Allied repatriates removed from Japanese prison camps in Japan and China to U.S. Army hospitals in Saipan and the Philippine Islands, and also of Japanese prisoners of war in the Prison Hospital at New Bilibid (Philippine Commonwealth Prison) and the nearby prison stockade after the Japanese surrender.
Allied Repatriates
U.S. military personnel
The first repatriates examined were a group of 75 American troops removed from Japan and hospitalized in Saipan. These troops had been
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imprisoned since earliest hostilities in the Pacific; first in the Philippines and, later, in Japan.
Information derived from histories taken from these men was quite similar, with the various presenting clinical disorders having occurred at about the same time in all patients examined.
Diet.-The diet during imprisonment had always been low in calories; dietitian's estimate was from 800 to 2,000 calories, usually about 1,500. Food intake was never adequate from the standpoint of a balanced diet since it was regularly low in proteins, fats, and vitamins, and always very high in starches. The main staple was rice, with yams, leafy vegetables, and oil (coconut). Very little meat or fish was ever contained in the diet, and fruit was rarely obtainable. The diet was the same for everyone and, therefore, especially inadequate for those who had to work and for men of above-average stature. The recovered prisoners stated that generally the larger men had suffered more and, when sick, recovered less frequently than did the men of small stature.
General symptoms.-Chronologically, the earliest disorders described by these troops were progressive severe weight loss, and in about 4 to 6 months, many noted swelling of their feet and ankles. This varied in degree and, at times, disappeared. There was also general lassitude and easy fatigability. In the first year of imprisonment, many noted very sore mouths and bleeding and swollen gums (scurvy); others had painful fissures at the angles of their mouths (riboflavin deficiency). Many, too, described burning sensations of the feet and told how they could barely walk because of pain and burning in soles of their feet. In some, the burning pain of the feet appeared to be an isolated phenomenon; in others, it seemed to be an accompaniment of the prodrome of dry beriberi, since there developed shooting pains and persistent burning in soles of the feet. These shooting pains often ascended to the knees and might also later affect the hands and forearms. There were also visual symptoms; first, a dimness, notably in the evening, and, later, varying degrees of blindness. Night blindness and corneal ulceration were also described as isolated symptoms.
That pellagra was also common was evident from descriptions of sore mouths; swollen, painful, reddened hands and feet or other exposed body surfaces; and, occasionally, mental dullness and impaired memory.
Far more common, however, was the swelling of the feet and ankles during the day, and of the face each morning-a dependent type of edema, which might become quite severe and, additionally, produce a large swelling in the scrotum and abdomen, which was completely incapacitating. With this edema was described a severe frequent nocturia of 12 to 15 times during the night.
The disorders, first described, were always made worse, or at times precipitated, by malaria, dysentery, or intestinal worms, all of which were prevalent in the Pacific Ocean Areas.
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These then were the clinical histories of the repatriates, most of whom had, or at the time of examination manifested, symptoms of these disorders and were responding well, for the most part, to a purely supportive regimen of diet and vitamins.
Of particular interest was the fact that many of the repatriated troops, having been edema free and ambulatory, with only minor distress in their feet, before embarking from Japan, developed severe edema, and a few extremities became almost paralytic. This occurred while on warships, en route to Saipan, when the men were permitted to satisfy a voracious appetite during their week at sea; some of these cases subsequently became severe therapeutic problems. Also in the hospital, it was early apparent that these very starved and physically wasted men could not tolerate a full diet; least well did they tolerate large blood transfusions even though some men were very anemic and had low levels of blood protein. Hence, it became the practice to feed the more severely ill patients, calorically, according to weight plus about 15 percent; to give multivitamin capsules; and to reserve small transfusions of blood for only the severest cases of malnutrition. As a rule, the clinical course was good, and in about 10 days, the patients could tolerate a regular diet and gained strength rapidly, All the repatriated troops seen at the hospital in Saipan already had had an improved diet for 3 to 4 weeks before arrival at the hospital, because food had been dropped to them by air after 16 August 1945, and they had been at sea for a week.
Neurological disorders.-Of this group, there were six severe organic neurological cases and two psychiatric problems. The most severe organic case was a soldier, 31 years of age, white, and of average height, who had been in good health before imprisonment. He had lost weight severely in the early months, intermittently had had edema of his ankles, had had sore mouth on one occasion, and then, after about 9 months of captivity, began to have dimness of vision especially at dusk. Shortly thereafter, he noted failing vision in the regular daylight. He also began to have weakness in his feet which shortly developed into burning and shooting pains in his feet and legs. Several months later, he began to have tremor of his head, marked unsteadiness in arms and legs, and lastly, his legs became quite numb and very weak-hands to a lesser extent; also he noted his memory becoming rather poor for daily happenings.
Upon examination of this patient, pronounced emaciation of the body as well as severe atrophy of the extremity muscles was observed. There was a marked head tremor and tremor of arms and hands, the right greater than the left. Nonequilibratory tests were performed in a very ataxic manner, and pronounced intention tremor was present in the finger-to-nose test. There was great weakness in forearm and hand muscles, and a bilateral drop foot was present. All deep tendon reflexes were absent. Plantar irritation produced neither flexion nor extension, and abdominal reflexes
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were not obtained. There was marked sensory loss in the feet (pain, touch, position, and vibration) which feathered out to the knee and, to a lesser extent, was present in the hands. There was pallor of the optic nerve heads, the left more than the right, and bilateral central scotomata of moderately severe degree (he could not read); pupils were sluggish but equal, and the extraocular movements were normal. Mentally, the patient was euphoric, memory for recent events was rather poor, and he complained of an inability to think things through. Otherwise, he was in good contact and cooperative.
Thus, this was a patient with signs very suggestive of a superior polioencephalitis of Wernicke, in addition to a beriberi type of multiple neuritis.
The other organic cases were patients with multiple neuritis of moderate to severe degree, affecting upper and lower extremities, and with central or paracentral scotomata of varying degree. In these men and in others not showing actual visual loss, there was the additional complaint of tiring, burning and watering of the eyes when reading or trying to focus visually for any length of time. This condition quite probably represented an accommodative fatigue due to weakened extraocular muscles in keeping with the general asthenic state. Except for the symptoms of central nervous system involvement noted in the previously described patient, the development of neuritis, with disability, in the other neurological patients was almost identical in time of occurrence.
From the standpoint of treatment, the repatriated prisoners received a high-vitamin, well-balanced diet and showed pronounced improvement relative to malnutrition and general strength. Vision showed some initial increase in acuity, but whether this improvement was due to an alleviation of the vitamin A deficiency is questionable. Further, observation was too short to confirm this improvement; also, it is doubtful that recovery ever occurs from such large scotomata.
Psychiatric symptoms.-The two psychiatric cases were quite dissimilar. One patient was an obvious withdrawn hallucinating schizophrenic who, over a period of 3 weeks, had shown little or no change in behavior although malnutrition was much alleviated. The symptoms of the second came closest to possibly being related to malnutrition and vitamin deficiency. This patient was very undernourished, weak, and apathetic; he answered questions slowly, but correctly; and he showed faint sparks of interest from time to time, and would ask questions. His memory was poor for recent events; he seemed confused and bewildered; and he stated that he could not think well and had lost his mind. With improvement from malnutrition, there was concomitant gradual improvement of this patient's mental state.
Just how much pure psychological disorder was present is difficult to evaluate; however, a certain amount of apathy, 'dulling of their senses,'
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and bewilderment was present by complaint, in a considerable number of these very malnourished repatriated troops, which fortunately improved after a time under adequate dietary care.
British Commonwealth troops
The second group examined consisted of British Commonwealth repatriates made up of Australian, Canadian, and English troops. Many were survivors from the garrison at Singapore, who were taken to Thailand where, under working conditions of building a railroad through the jungle, they suffered severely from malaria, dysentery, and cholera, with the usual high mortality rate. Subsequently, while being transported to Japan, three-fourths of their number were lost from torpedoing at sea. Other repartriates were of the original very embattled garrison at Hong Kong. In this latter group or camp, although there had been no cholera, there had been a severe epidemic of diphtheria with a high mortality. Altogether, a total of 550 repatriates were examined.
The history of very inadequate diet, weight loss, disease, and hardships in these repatriates was not unlike that of the American prisoners. It was largely a matter of the locale of imprisonment.
Neurological cases.-Of this hospitalized group of 550 men, 10 percent were neurological cases, and approximately, 1 percent were psychiatric cases. In the neurological group, 17 were severe problems, 9 of which clearly involved the spinal cord. Two of the patients with spinal cord diseases, labeled beriberi, had degenerative disorders, predating capture, which were characterized by diplopia, ataxia, and pyramidal tract signs (probably multiple sclerosis.) These patients had been in the prison hospital most of the time and, although malnourished, showed no signs of neuritis. The other seven patients with spinal cord conditions exhibited a moderate degree of combined system disease not unlike that seen in pernicious anemia (no anemia was found) with presence of pyramidal tract signs; in addition, there were bilateral central and paracentral scotomata with associated pallor of optic nerve heads and evidences of multiple neuritis in the lower extremities. The picture was a mixed one; the early history was invariably that of a multiple neuritis of beriberi type with spinal cord involvement appearing later in the course of the disease. One patient was almost completely blind, with only a small amount of peripheral vision remaining.
The other eight severe neurological disorders were all advanced cases of multiple neuritis with accompanying central scotomata of varying severity and mild to moderate pallor of the optic nerve heads. These patients gave the history, with little variation, of dimming vision, about 8 months after capture, which was first noted in the evenings. For this symptom, many received vitamin A with prompt improvement. Later,
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however, they noted their vision was also impaired in the daylight hours, and about this time, foot pain developed, which progressed to severe degrees with shooting pains in the soles and up the legs. These symptoms varied in severity for months. Gradually, however, vision became permanently impaired; also, as extremity pain subsided, numbness and weakness became more apparent. Two of the patients had anesthesia and analgesia in the legs up to the knees and over the hands and forearms, with lateral foot drop and absent tendon and periosteal reflexes. All could walk with guarded steps, aided by a cane, but several had considerable foot pain.
All the severe neurological patients stated they had much trouble in thinking. They described a sort of 'mental blurring' in which they were unable to think quickly, clearly, or completely, or recall recent events with any degree of clarity. This mental state became progressively worse over a period of many months, before release from captivity.
Defects in hearing were not prominent among these repatriates although a few complained of tinnitus. Two of the patients with spinal cord disorders had bilateral nerve deafness of a degree sufficient to make it difficult to obtain a history.
The remaining patients with neurological disorders exhibited varying grades of multiple neuritis. Some had hyperesthesia, hyperalgesia, and pressure pain in the muscles of the calves and feet; others had spots of hypesthesia and hypalgesia; and still others complained of 'like bugs crawling' sensations in the extremities which were regaining function. All these patients, at one time or another, had some swelling of the feet, although this was not present at the time of examination.
Generally, a high-caloric, high-vitamin diet promptly alleviated the malnutrition and weakness. Patients with milder disorders showed almost miraculous improvement in the few weeks they were hospitalized (they had also received an improved diet for 3 weeks before arriving at the hospital). Patients with more severe neurological disease showed good general response to food and vitamins, but the basic neurological disorder was little altered during this period of observation (3 weeks), with the exception of the mentally obtunded state from which there was a steady and gratifying improvement.
Psychiatric cases.-All the psychiatric patients in this group showed depression with malnutrition. Two were severely retarded and quite mute, would sit on the side of their beds staring at the floor, and had attempted suicide before repatriation. The other four milder patients were very quiet, expressed ideas of guilt, shame, and worthlessness, but cooperated with ward routine. All these patients showed some improvement in their several weeks in the hospital, although the two more severe patients were removed to the hospital ship because of better psychiatric facilities. All the psychiatic patients gave the appearance of situational depression, and their rather prompt improvement suggested a good ultimate prognosis.
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Of the many repatriates in this group, other than the neurological and psychiatric patients, all suffered from malnutrition; in addition, some had malaria, dysentery, or intestinal parasites. Here, again, it was of interest to observe the appearance of edema on heavy initial feeding, its disappearance on a more gradual dietary regimen, and its reappearance in some repatriates who got up and foraged for more food. Many of these patients showed a moderate secondary anemia and a low blood protein; the edema, in these instances, was apparently due to a hypoproteinemia and not to beriberi, as previously regarded. The general outcome of these medical cases was good-malnutrition was alleviated by balanced feeding and the associated diseases were overcome without much difficulty by adequate treatment.
Discussion
In both the American and British Commonwealth repatriates, there was history of a diet deficient in calories and seriously deficient in protein and all water-soluble vitamins; that is, B complex, vitamin C, and, to some extent, the fat-soluble vitamin A. This severe dietary deficiency early became manifest in malnutrition and dependent edema, followed, in only a few months, by the evidences of vitamin deficiency such as sore hypertrophied gums, due to lack of vitamin C; fissured angles of the mouth, due to lack of riboflavin; acute symmetrical dermatitis and sore mouth of pellagra, due to lack of nicotinic acid; and later, manifold symptoms of beriberi neuritis, due to lack of thiamine hydrochloride. Early, too, was the frequency of 'burning feet,' very probably related to vitamin B deficiency. The prompt response of early visual symptoms to vitamin A administration also warrants its inclusion in the probable overall vitamin deficiencies.
Both the malnutrition and the vitamin deficiency were frequently aggravated by other diseases, by poor living conditions, and by the frequently added burden of physical work. All of these hardships made for a picture of starvation and disease rarely observed and experienced in modern times.
Japanese Prisoners
Following the recapture of Manila and the Japanese surrender, a great number of starved, wounded, and otherwise ill Japanese troops became the responsibility of the U.S. Army Medical Department. These sick and wounded were initially hospitalized at New Bilibid which facilities were soon greatly overtaxed with 4,400 bed patients. Later, they were moved to newly constructed buildings in a nearby prison camp, by which time the hospitalized census rose to over 6,000 patients, the great majority of whom were medical cases. There were, additionally, large numbers of ambulatory ill Japanese prisoners who also showed advanced
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grades of malnutrition, many with dependent edema, and who were managed on a regular prisoner status by the military police.
The Japanese soldier, conscripted for the most part from the peasant and fisherman classes, measured an average height of 5 feet 3 inches with a long torso, and short, relatively thick, arms and legs. His discipline was largely one of literal, unthinking, blind obedience. Generally, good cooperation was easily obtained from the Japanese in the care of their sick, who, in turn, seemed very appreciative of whatever was done for them.
There was little stirring under this vast tentage at New Bilibid; cots by the thousands were occupied by these small, wasted men, many with ulcerous, edematous extremities and protuberant bellies. The apathy, stench of the sick, and frequency of death, which was a very public affair, lent a depressing character to an already appalling medical problem. Later, it was possible to improve both management and morale of patients, in particular, and of personnel, in general, by removal to the new hospital.
Interrogation of Japanese Army physicians from both forward and rear echelons yielded the following summary data:
The Japanese soldier's normal diet consisted of three canteen cups of rice, plus meat or fish each day. Yams and other vegetables were regularly available. Some cheese was frequently obtainable. Much of their food was cold-storage type and very adequate. Medicines, too, were always available in ample quantity.
The health of the Japanese soldier was good until late in December 1944 and early January 1945, after which time it declined markedly. The blockade of the Philippines was in effect for a full year before V-J Day, but although their own food supply failed, they were able to 'live off the land' until the American invasion drove them into the mountains. Here, they subsisted on leaves, grass, and roots. No meat, fish, rice, or fats of any kind were obtainable. The sick and wounded could not be adequately cared for and many died. Many others became sick and either died of inanition or were too weak to recover from intercurrent illnesses. Medicines too were dissipated, leaving the Japanese without means of combating the then rampant malaria and dysentery.
General symptoms.-The Japanese medical officers pointed out that whereas beriberi was common in Japan, it was rarely accompanied by inanition. Thus, in Japan, three types of beriberi were recognized-dry, wet, and mixed. The dry type usually occurred first; then the mixed appeared. Most cases were of the mixed type when seen by the physicians. However, among Japanese troops in the Philippines, after retreat to the mountains, body wasting was quite severe, as a rule, and it became difficult to differentiate between severe malnutrition and beriberi. Later, both were always associated.
The earliest symptoms of beriberi in this group of Japanese patients were, generally, aches and pains in the body and extremities, fatigue, and, often, some hyperesthesia over the anterolateral surface of the legs
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(peroneal nerve distribution) and in the antecubital fossa area, extending up and down in the distribution of the medial and lateral antebrachial cutaneous nerves. This first phase would change into hypesthesia and hypalgesia, often with accompanying tinnitus and mild deafness (vision was never affected). In about 3 to 4 weeks, systemic effects would develop with swelling of the ankles, cardiac enlargement, and often abdominal ascites and fluid in the chest. Many of these soldiers died suddenly of cardiac failure. Some became delirious, and a few became psychotic. Frequently, malaria or dysentery would complicate the conditions of beriberi and malnutrition. Thus, in the Japanese troops, there was a high incidence of morbidity and mortality before capitulation.
Case reports
Direct examination of a great many of these patients (fig. 50) by the author confirmed, in largest part, the clinical observations of the Japanese physicians. The following case records serve to elucidate the most frequently noted neurological findings:
Case 1.-N.S. (fig. 50, right), Japanese, age 35 years. Soldier was in apparent good health and well fed until June 1945 when rations were reduced to half and no meat whatever was available. In mid-June, he began to experience weakness in the
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knee joints. Early, in July, his unit retreated to the mountains of northern Luzon. After 2 weeks in the mountains on a very restricted meat-free diet, he noted, for the first time, swelling of his feet and ankles, which progressed upward until it involved the entire lower extremities and scrotum. During the 4 weeks after capture, by the end of August 1945, almost all the edema had cleared but he had developed great weakness of both extremities, with no evidence of malaria or dysentery.
Physically, the patient was very emaciated and pale, with a slight facial edema and pitting edema of both feet. Other findings were: Blood pressure 125/65; pulse rate, 70; heart enlarged slightly to the right; P2 accentuated, all tones distant; liver 1 fingerbreath below costal margin; spleen not palpable; no ascites evident.
Neurologically, the muscles of both lower extremities were atrophic and tender. The patient had difficulty in standing, having to climb up his legs with his hands. Gait was ataxic, and the patient had to watch the ground carefully to maintain balance. The Romberg test was positive, knee jerks were absent and Achilles reflexes much diminished. Hypalgesia was found over the lateral surface of feet, and the second and third toes were bilaterally analgesic. Vibration sense was absent in all toes, perceptible over the foot and normal in the ankles. Upper extremities and cranial nerves were normal. Mentally the patient appeared intact.
Diagnosis.-Malnutrition with beriberi, neuritis, and possible early myelopathy.
Case 2.-M.K., Japanese, age 33 years. Patient was in good health until retreat to mountains in March 1945, when rations were very restricted and no meat was available. In July, he noted much fatigue on slightest exertion and some increased sensi?tivity on volar surfaces of the arms and the lateral sides of the legs, which shortly changed to numbness in both legs and feet. About 2 weeks later, he began to have swelling of the feet, which progressed upward to involve the scrotum, penis, and face. Walking became very unsteady, and in the 4 weeks before capture, his thinking had become very slow and his hearing, bilaterally diminished with tinnitus. There was no malaria. After capture, the edema cleared, and the patient felt stronger.
Physically, he was emaciated and pale, with no edema. Blood pressure was 100/40; other findings were negative.
Neurologically, the gait was ataxic and guarded, and the Romberg test was mildly positive. There was weakness of dorsal flexors of the feet and of extensors of the leg, with right triceps and ulnar reflexes diminished and all other tendon and periosteal reflexes absent. Abdominal reflexes were present but cremasteric reflexes were absent. Moderate hypalgesia was found on the medial surface of the thighs, in the ilioinguinal nerve distribution (this was strangely quite common), in both common peroneal nerve distributions, and also, to a less extent, over the volar surfaces of both forearms. Vibratory sensation was absent in the toes, diminished on the dorsum of the feet, and very diminished in the fingers of both hands but becoming normal at the wrists. There was moderate bilateral deafness; otherwise, the cranial nerves were normal.
Diagnosis.-Malnutrition with beriberi neuritis and possible early myelopathy.
Case 3.-T.N., Japanese, field grade officer, age 37 years. This patient had had six attacks of malaria in the past 2 years, the most recent being in July 1945. In June 1945, his troops began their retreat to the mountains where the entire food supply was greatly curtailed, until capture late in August 1945. Early in July, the patient noted edema of both feet, which rose slowly to the thighs; then, he began to have a sense of pressure in the chest, with palpitation and dyspnea at night. Shortly after this, he also noted clumsiness in the use of his hands, unsteadiness in walking, ringing in the ears, and 'tardiness of thinking.'
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On physical examination, the patient was found to be well built, with moderate weight loss. The heart was enlarged, both to the right and left. Other findings were: P2 accentuated; pulse rate 72, regular; blood pressure 125/75; spleen palpable 3 finger-breaths below costal margin; and moderate edema of the feet and of the legs to the knees.
Neurologically, he showed an ataxic gait, a moderately positive Romberg, moderate adiadokokinesis, symmetrically diminished deep-tendon reflexes, and diminished sensation to pain in the ilioinguinal, lateral femoral cutaneous, and peroneal nerves with accompanying tenderness in both calf muscles.
Diagnosis.-Beriberi neuritis with probable early myeloencephalopathy; beriberi heart disease; and chronic malaria.
Case 4.-K.T. (fig. 50, left), Japanese, age 50 years, civilian carpenter attached to troops. The patient was well until July 1945, when his unit retreated to the mountains and received half rations and no meat or fish. One month later, only potatoes and a few leafy vegetables constituted the diet. Early in September, he noted swelling of the face and feet, which soon progressed to involve the legs and scrotum. He noticed unsteadiness in walking and weakness in the arms. Shortly before surrender in the hills, late in September 1945, he had a severe diarrhea with accompanying severe weight loss.
Physically, the patient was emaciated, pale, and weak. Edema was severe in the legs and scrotum, with abdominal ascities present. Heart was enlarged both to the right and left, sounds very distant; pulse rate, 75, regular; and blood pressure 110/65; liver enlarged slightly; and spleen not palpable.
Neurologically, his station and gait were normal. The deep tendon reflexes were active and equal. Muscles of the calves and feet were tender. There was a marked hyperesthesia and hyperalgesia over both feet and legs to the knees, especially over the distribution of the peroneal nerves, and also a marked hypalgesia in the ilioinguinal nerve distribution. No changes were noted in the upper extremities or cranial nerves.
Diagnosis.-Malnutrition with beriberi neuritis and beriberi heart disease.
Case 5.-S.T., Japanese, age 26 years; prior health was good. This patient had a severe attack of malaria early in July 1945, and then with his unit retreated into the mountains late in July. The diet consisted of potatoes and vegetables in sufficient quantities, small amounts of rice, but no meats, fish, or oils. In mid-September, he first noted some numbness of the left foot and lateral side of the left leg and, about the same time, the sudden appearance of swelling of the feet, which progressed rapidly to involve both legs and the scrotum.
Physically, the soldier was well built and in a fair state of nutrition. Heart was enlarged to both sides; P2 accentuated; spleen palpable 3 fingerbreaths below costal margin; and moderate pitting edema of both feet and tibias.
Neurologically, he was entirely normal except for hypalgesia over the dorsum of the feet and over the anterolateral surface of the legs, more on the left side than on the right.
Diagnosis.-Beriberi heart disease; early beriberi neuritis and chronic malaria.12
From the standpoint of treatment, the Japanese patients received a moderately well balanced diet of about 1,200 to 1,500 calories with multi?
12Although the cases presented here exhibit similarities, there are finer differences which should be noted. These variations in the manifestations of nutritional deficiencies demonstrate the need for thorough neurological examinations.-W. H. E.
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vitamin capsules and, occasionally, the addition of 10 mg. of thiamin chloride each day. Patients with malaria and any other disease received appropriate therapy. Response to treatment was uniformly good, except for some of the patients with cardiac disease, many of whom died very suddenly.
As soon as these patients were ambulatory, edema free, and gaining weight, they were transferred to the regular prison stockade and maintained on a regular prisoner regimen.
Dependents
There was, additionally, a group of dependents of the Japanese soldiers-100 wives, 35 infants, and a few older children (fig. 51). Malnutrition of moderate to very severe grade was present in all. The nursing infants were cachetic and had obvious vitamin deficiencies, consisting of infantile beriberi, scurvy, and especially cheilosis. Mortality in these infants was great; the majority died in a few weeks' time. The older children behaved
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nutritionally like the adults, and many exhibited a gradual improvement, as did the majority of the women, on an improved dietary regimen.
Discussion
Among the Japanese examined, acute starvation was noted, which could have been regarded as borderline, from the standpoint of vitamin adequacy, occurring not only in the Philippines but also in their homeland. The picture was regularly one of severe malnutrition with evidence of hypoproteinemia and varying grades of B complex and vitamin C deficiency. This particular group was again additionally ravaged by the usual diseases so prevalent in the Philippines; that is, malaria and dysentery. Specific diagnoses were often difficult to establish because of the many mixed conditions and, to no little extent, because of the great paucity of laboratory facilities available at that time in the prison hospital.
One limited study showed clearly a high incidence of moderate to severe degrees of secondary anemia and low plasma protein, often well below the critical level for edema.
Neurologically, there was noted ataxia, tinnitus, mild deafness, and a regular selective impairment of certain peripheral nerves (peroneal, antebrachial, cutaneous, ilioinguinal, and radial) which occurred with great frequency. However, aside from complaints of slight blurring in a few cases, no visual symptoms were encountered and no scotomata evidenced in complaint or examination, nor were there any extraocular palsies.
Transfusions were given in many instances, but here again, the larger transfusions resulted in the sudden death of some patients, and thus smaller transfusions were utilized. Vitamins in the form of multivitamin capsules were regularly administered. The diet was never excessive, so that overfeeding was not a problem.
SUMMARY
Lessons have been learned during World War II with regard to the basic organization and utilization of medical specialists. In the light of this experience, the following remarks would seem pertinent:
In the event of another national emergency, it would appear imperative that a highly competent neurologist be immediately assigned to the Office of The Surgeon General. His duties would encompass prompt establishment of policies relating to the recognition and management of all neurological disorders in the Army and to the coordination of such policies with those of other professional and administrative branches.
Procurement and assignment of neurological specialists should be based upon an established need and their utilization as neurologists assured. Since a separate military occupational specialty number has been
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adopted for these specialists, it would obviate much of the difficulty previously experienced in identifying such personnel.
Experience has taught that centers specializing in the different medical and surgical subspecialties are feasible, economical of personnel and material, and of particular benefit to the patient. Neurological-neurosurgical centers, modeled after those used in the Zone of Interior, during World War II, should be designated as soon as practicable and placed in geographically strategic locations in the United States. Well staffed and equipped, these centers would also institute courses of training in neurology for medical officers to be assigned to general and station hospitals, elsewhere, and would also serve as a place to indoctrinate militarily other incoming specialists in neurology.
Key professional personnel staffing these centers should be, as nearly as possible, permanently assigned, so that genuine continuity of professional management and scientific observation over an extended period of time can be made possible.
Theaters of operations, in the light of experience in this war, should have neurological-neurosurgical centers comparable to those established in the United States, located in base medical installations, to support the ongoing military operations. Neurologists in these centers would be available for consultation to any satellite medical installations. Further, it is believed that each major theater would profit by the assignment of a neurological consultant who could coordinate all phases of neurology in both rear and forward echelons within the theater.
The problem of management of trauma to the head, spinal cord, and peripheral nerves has exemplified the necessity for close liaison among neurosurgery, neurology, and psychiatry. All three must be intimately related, and all should develop better basic knowledge in the related specialty.
In regard to neurological disorders which were found among both the Allied repatriates and the Japanese prisoners of war, the following findings are submitted:
1. All Allied repatriates examined showed advanced chronic malnutrition and vitamin deficiency resulting from diet seriously deficient in proteins, fats, and all water-soluble vitamins, including to some extent the fat-soluble vitamin A.
2. The edema present appeared more often related to hypoproteinemia than vitamin deficiency per se.
3. Whereas vitamin deficiency was very important in the production of neurological disorders, there can be little question that deficient nutritional aspects, especially as regards proteins and fats, were also important.
4. The health of many repatriates was also gravely impaired by such intercurrent diseases as malaria, dysentery, and intestinal parasites; some also by cholera and diphtheria.
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5. The Japanese prisoners demonstrated en masse the effect of acute severe starvation which occurred while they were hiding in the mountains, where they had few food supplies and were unable to forage effectively. Their diet, at this time, thus was deficient in protein, fats, and vitamins.
6. Both the neurological and systemic aspects of beriberi were common among the Japanese, along with severe malnutrition. Additional effects of the very prevalent malaria, dysentery, and intestinal parasites were frequently noted.
7. Psychoses were singularly few in both Allied repatriates and Japanese prisoners of war.
8. Treatment of all cases, both Allied and Japanese, resolved itself about a supportive program of a high-protein and otherwise well-balanced diet, multivitamins, and, in some, whole blood transfusions. Treatment of intercurrent disease was accorded as indicated.
9. The systemic aspects of starvation responded excellently to treatment, as a rule-the neuritic element improved completely, if mild, and more slowly if severe. The myelopathy noted in Allied cases was of long standing and showed little change while under observation. The myelopathy evidenced in the Japanese was at the very early stage; it improved along with the improvement of the general neuritic pathology. Although the gross aspects of vision often improved, there was little or no change noted from the larger scotomata. Since scotomata represent lesions in the central nervous system, little improvement may be anticipated.
