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MEDICAL DEPARTMENT

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IN WORLD WAR II

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Contributors

ELDRIDOE H. CAMPBELL, M. D. (deceased)

Formerly Colonel, MC, AUS; late Professor of Surgery, Albany Hospital, Albany, N. Y.

RoBERT L. CAVENAUGH, Colonel, MC, USA

Chief, Laboratory Service, 2d General Hospital.

FRITZ J. CRAMER, MN. D.

Associate Professor of Clinical Neurological Surgery, College of Physicians and Surgeons,

Columbia University, New York, N. Y.; Associate Attending Neurological Surgeon,

The Neurological Institute, New York, N. Y. Formerly Lieutenant Colonel, MC,

AUS.

HARTWIG KUHLENBECK, M. D.

Professor of Anatomy, Woman's Medical College of Pennsylvania, Philadelphia, Ila.

Formerly Major, MC, AUS.

DONALD D. MATSON, -%I. D.

Associate Clinical Professor of Surgery, Harvard Medical School, Boston, Mass.

Formerly Major, MC, AUS.

AAGE E. NIELSEN, 'I. D.

Associate Clinical Professor of Neurosurgery, Wayne State University, Detroit, Mich.

Formerly Major, MC, AUS.

WILLIAM G. PEACHER, M. D.

Clinical Instructor of Surgery (Neurosurgery), State University of New York, Syracuse,

N. Y. Formerly Major, MC, AUS.

DAVID L. REEVES, M. D.

Santa Barbara, Calif. Formerly Colonel, MC, AUS.

GEORGE E. ROULHAC, M. D.

Neurosurgeon, St. Luke's Hospital, St. Louis City Hospital, and Missouri Baptist

Hospital, St. Louis, Mo. Consultant, Neurosurgery, Ellis Fischel State Cancer

Hospital, St. Louis, Mo. Formerly Captain, MC, AUS.

STUART N. RowE, M. D.

Associate Professor of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pa. Formerly Lieutenant Colonel, MC, AUS.

HENRY G. SCHWARTZ, 'M. D.

Professor of Neurological Surgery, Washington University School of Medicine, St.

Louis, Mo. Formerly Lieutenant Colonel, MC, AUS.

RI. GLEN SPURLING, N%. D.

Professor of Neurosurgery, University of Louisville School of Medicine, Louisville, Ky.

Formerly Colonel, MC, AUS.

A. EARL WALKER, M. D.

Professor of Neurological Surgery, The Johns Hopkins University, School of Medicine,

Baltimore, Md. Formerly Major, MC, AUS.

BARNES WOODHALL, M. D.

Professor of Neurosurgery, Duke Medical School and Hospital, Durham, N. C. Formerly Lieutenant Colonel, MC, AUS.

Vii
X NEUROSURGERY

careful planning for D-lay, to be sure that competent planning was being

competently implement ed.

A large and important part of the administrative background of neurosurgery in World War 11 concerns personnel. The prewar status of the specialty, even in civilian life, is evident from the fact that it was not until 1941

that the American Board of Neurological Surgery first began to function. The

neurosurgeons certified by this Board provided the nucleus of Army neurosurgeons, but it was the special training courses in neurosurgery, set up for

young, well-trained general surgeons in civilian medical schools, which provided the majority of neurosurgeons who cared for the neurosurgical casualties

of World War II. Intolerable shortages would have occurred in this special

field without the outstanding work and judicious placement of these young

medical officers.

In World War I, the previous prohibitively high case fatality rate in head

injuries was dramatically reduced by the efforts of Colonel Cushing, who

served, in effect, as a consultant in neurosurgery in the Surgeon General's Office.

He accomplished these results by placement of neurologic surgeons and teams

inl hospital units near the front, by professional instruction, and by dissemination of detailed instructions for the care of head injuries. The principles of

debridement of craniocerebral wounds which (Colonel ('ushing taught in World

War I were the basis of the management. of these wounds in World War II.

The effects of debridement were enhanced and its risks were reduced by improved technical methods, the use of chemotherapy and antibiotic therapy;

modern methods of resuscitation, the bold use of redebridement and delayed

debridement when it was necessary, the closure of all dural defects, and the

use of such adjunct measures as early ambulation. Debridement, however,

remained tile keystone.

Of tile numerous advances in the management of head injuries in World

War II, there should be mentioned cranioplasty with modern agents, especially

tantalum; the attention devoted to speech defects in aphasic patients; and the

management of posttraumatic epilepsy.

Not. the least. important and significant chapter in this volume is the one

devoted to mortal head injuries. The reluctance of neurosurgeons to admit

that any head injury was inevitably lethal is demonstrated by many of the

cases described. The corollary of their reluctance was that any wounded

soldier who had any chance at all to survive was given the chance, however slim

it might. be. It was this unconquerable spirit which underlay the brilliant,

record of neurosurgery in head injuries in World War II.

Tile editors and authors of this volume have added to their wartime

service in the Medical Corps by the time and effort, they have devoted to the

preparation of this permanent record of their work.

S. B. HAys,

.llajor General,

The Suireon General.
Foreword

This volume and a second volume on the same subject now in preparation

tell the story of neurosurgery in World War II. Tihe story, as in all other

volumes of the history of the Medical Department in this war, includes a frank

statement of errors and failures as well as a record of brilliant success achieved

in this specialty.

Tile first neurosurgical volume deals with administrative considerations

of neurosurgery and with head injuries. The second volume will cover injuries

of the spine, including peripheral nerve injuries and rupture of the intervertebral disk.

As this first volume relates, neurosurgery as a Medical Department

specialty was really an outgrowth of World War II. In World War I, in spite

of the superb work of a few neurosurgeons, most particularly the late Col.

Harvey Cushing, M(". neurosurgery was not a sharply defined specialty as,

indeed, it was not in civilian life. After the war, even the slight degree of

specialization which had been achieved in the Medical Corps (luring the war

languished completely. Most neurosurgical injuries were handled on orthopedic or general surgery sections of hospitals. Those injuries and conditions

which could not thus be treated were referred to civilian neurosurgeons or were

cared for in Army hospitals by special arrangements with local neurosurgical

consultants. These arrangements, as the text points out,. did not constitute a

system capable of handling the enormous neurosurgical load which World War

I produced. There were no prewar plans for patient loads of such magnitude.

The first neurosurgeons, in fact, who entered the service were-very wiselyadvised to bring their own instruments and other neurosurgical equipment

with them.

In war, as has been repeatedly pointed out, everything must give way to

military efficiency. Medical planning is part of the military plan. Without

an efficient administrative setup, the most experienced clinician could not

apply his best skills to the management of casualties. Not the least important

part of this first neurosurgical volume, therefore, is the account of the administrative development of neurosurgery, for it was the administrative background

which brought to pass the outstanding clinical care of neurosurgical casualties,

the remarkable lowering of the mortality rate as compared with the rate in

World War 1, and the equally remarkable functional restoration of so many

of these wounded men.

Part of the administrative story revolves around the development of

neurosurgical centers and their repeated expansion as the casualty load grew

heavier. Part of the story concerns the provision of equipment for these

centers, the assignment of trained personnel to them, and the evacuation of

neurosurgical casualties to them, a policy an(I practice expedited by the rapid

development of air evacuation. Part of the administrative story involves the

Ix
Preface

Although the history of neurosurgery in World War II had been conceived

many months earlier, tile first definite plans for its; preparation were not 1tiadle

until March 194.. The comprehensive prospectus which was finally draw'i

tip, in the spring of 1946, diffcred inl many respects from the original outline

and reflected the extensive experience with comlbat-intcurred injuries of the

intervening nmonths. Work was pursued actively during the first 6 mionthss

of 1947, and tile completed manuscripts were delivered to tile Historical l)ivision, Office of the Surgeon General, in June 1947, with the expectation that

they would be pub)lished promptly.

This anticipation was not fulfilled, chiefly because of inability on the part

of editorial personnel then in the Office of the Surgeon General to agree with

us that the story of clinical neurosurgery in World War II is history in the true

sense of tile word.

When the present determined effort to revive this project was undertaken

in 1956, almost 10 y"ears, after thie original material had been prepared, we %% ere

frankly reluctant to resume our activities. It was only when we were assured

by the newly appointed director of the Historical Unit, United States Army

.Medical Service, Office of the Surgeon General, speaking for Maj. Gen.

George E. Armstrong, then The Surgeon General, that tile manuscripts would

be published essentially as they were originally written that we agreed to

undertake the task. The material has been re-edited, but the substance is

entirely unaltered. In other words, each chapter still represents the original

material prepared by the author, at the conclusion of his military service.

while all technical matters were fresh in his menmory.

We -al do(10 no better in this preface than to quote from the preface which

was written for the mnuscripts prepared for publication in 1947, as follows:

In the preparation of the history of neurosurgery in World War II, we have endeavored

to record faithfully our mistakes as well as our achievements. We have also pointed out the

major difficulties under which we labored in that war and the possible solutions for them in

future wars. Our objective has been to assemble all pertinent data into two reasonably

small, easily readable volumes, which will provide adequate source material for the military

neurosurgeons who come after us. We have limited the clinicul sections to the three major

categories of nearosurgical casualties; that is, head injuries, spinal cord injuries, and peripheral nerve injuries.

The authors fort he various chapters were selected on t he basis oft heir interest in the special

subjects under discussion and their previous contributions to them. From approximately

200 Army neurosurgeons, an entirely different g, oup might just as wvell have been selected.

Certainly there are missing from the list of contributors the names of many neurosurgeons

who might have spoken with complete authority. The opinions exprussed by the authors

are their own. Editorial revisions were malde, b)ut the essential sub)ject matter was not

altered in any way by the editors. Unless otherwise indicated, all material in the sections

on administration and on the development of clinical policies is derived from the l)ersonal

XI
XII N EURtOSURG ERIY

experienc's, the official diaries, and the interim and final reports of the authors, supplemented,

as necessary, by correspondence and interviews with neurosurgeons who were assigned to

the various theaters and areas.

Our gratitude is due to the contributors to these volumes for their cooperation in produeing their manuscripts so promptly and so efficiently. Had it not been for their willingness to sacrifice the time which might well have been spent rehabilitating their own lprivate

practices after their wartime service, the neurosurgical history of W\orld War II might not

have been published for many years, if ever.

In the revived project., there will be two volumes, as originally planned.

This volume, the first, (teals with (1) administrative details, withiout which

clinical knowledge could not be applied practieall'y; (2) the development of

professional policies; and (3) head trauma. The second volume will be devoted exclusively to injuries of the spinal cord and the peripheral nerves.

We are grateful to many persons who have assisted us in the preparation

of these volumes, but our first word of appreciation must be to the man who

planned the surgical series of the history of the Medical Department of the

United States Army in World War II. Had it not been for the late Dr. Fred W.

Rankin, formerly Brigadier General, Medical Corps, and Chief Consultant in

,Surgery, Office of the Surgeon General, there would have been no neurosurgical

history. It was under his stimulus that we began to produce it.

Also, there would have been no revival of the neurosurgical history except for the stimulus of Col. John Boyd Coates, Jr., MC, Director, Historical

Unit, United States Army Medical Service, and Editor in Chief of the Army

Medical Department history. He had to overcome many difficulties, including our initial intransigence, when we decliied to have anything to (1o with

the resurrected project, and he deserves our special thanks and appreciation

for his determination and his cordial and intelligent cooperation in our work.

Through the years, we have come to know with high regard and personal

esteem four Surgeons General of the Army, Maj. Gen. Norman T. Kirk, Maj.

Gen. Raymond W. Bliss, Maj. Gen. George E. Armstrong, and Maj. Gen. S. B.

Hays, presently The Surgeon General. They have all been hIelpful to us at.

various stages in the production of these volumes.

Finally, and perhaps most important of all, we are indebted to Miss

Elizabeth M. McFetridge, who did the major editorial work on every chapter

in these volumes. Without her efficient help we could not possibly have

accomplished our task.

R. GLEN SPURLING, M. D.

BARNES WOODHALL, M. D.
NEUROSURGERY

Volume I
MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department

of the U. S. Armsy in World War I1 are prel)ared by The Historical Unit,

U. S. Army Medical Service, and published under the direction of The Surgeon

General. U. S. Army. These volumes are divided into two series: (1) The

administrative or operational series; and (2) the professional, or clinical and

technical, series. This is one of the volumes published in the latter series.

VOLUMES PUBLISHED

ADMINISTRATIVE SERIES

flospitalization and Evacuation, Zone of Interior

CLINICAL SERIES

Preventive Medicine in World War II:

V'ol. II. Environmental Hygiene

Vol. III. Personal Health feas-ure. aml Immunization

Vol. IV. Communicable Diseases Transmitted Chiefly Through Rexpiratory and Alimentary Tracts

Surgery in World War II:

General Surgery, vol. II

Hand Surgery

Oph thaiimolo pj and Otolaryngology

Orthopedic Surgery in the European Theater of Operations

Orthopedic Surgery in the M1fediterranean Theater of Operations

The Phy.siologic Effects of Wounds

Va.cular Surgery

Miscellaneous:

('old Injury, Ground Type

United States Army Dental Service in World War II

V1
"MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR H

NEUROSURGERY

Volume I

Prepared and published umder the direction of

Major General S. B. HAYS

The Surgeon General, United States Army

Editor in Chief

Colonel JOHN BOYD COATES, Jr., MC

Editors for Neurosurgery

R. GLEN SPURLING, M. D. BARNES WOODHALL, M. D.

Associate Editor

ELIZABETH M. MCFETRIDGE, M. A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D. C., 1958
SURGERY IN WORLD WAR II

Adi-sory Editorial Board

MICHAEL E. DEBAKEY, M. I)., Chairman

FRANK B. BERRY, M. D. JOHN B. FLICK, M. D.

BRIAN BLADES, M. D. FRANK GLENN, M. D.

J. BARRETr BROWN, M. D. M. ELLIOT RANDOLPH, 1M. D.

STERLING BUNNELL, M. D. (dec.) ISIDOR S. RAvDIN, M. D.

NORTON CANFIELD, M. D. ALFRED R. SHANDS, Jr., M. D.

B. NOLAND CARTER, IN. D. HOWARD E. SNYDER, M. D.

EDWARD D. CHURCHILL, M. D. R. GLEN SPURLING, M. D.

MATHER CLEVELAND, M. D. BARNES WOODHALL, M. D.

DANIEL C. ELKIN, M. D. ROBERT M. ZOLLINGER, M. D.

Colonel JOHN BOYD COATES, Jr., MC (ex officio)

Colonel DOUGLAS B. KENDRICK, MC (ex officio)

Colonel JOSEPH R. SHAEFFER, MC (ex officio)

The Historical Unit. United States Army Medical Service

Colonel JOHN BOYD COATES, Jr., MC, Director

Colonel OTHMAR F. GORIUP, MSC, Executive Officer

Lietitenant Colonel R. J. BERNUCCI, MC, Special Assistant to Director

Lieutenant Colonel R. L. PARKER, MSC, Special Assistant to Director

JOSEPHINE P. KYLE, Special Assistant to Director

Lieutenant Colonel C. A. PENDLYSHOK, MSC. Chief, Special Projects Pranch

DONALD 0. WAGNER, Ph. D., Chief, Historians Branch

WILLA B. DIAL, Chief, Editorial Branch

WILBOUR C. LoWN, Chief, Promotion Branch

Lucy W. LAZAROU, Chief, Research and Archives Branch

HAZEL G. HINE, Chief, Administrative Branch

For sale by the Superintendent of Documents, U. S. Government Printing Office, Washington 25, D. C.

Price $5.00 (Buckram)
Contents

Page

FOREWORD -- .IX

PREFACE------ - -------------------. XI

Part I

ADMINISTRATIVE CONSIDERATIONS IN NEUROSURGERY

Chapter

I The Zone of Interior- ---- ------ :3

Historical Note -------------------------------------------------- 3

Early Neurosurgical Planning in World War II ---------------------- 5

Expansion of Neurosurgical Centers --------------------------------- 11

Training Program ------------------------------------------------ 24

Records and Visual Recording ---------.-------------------------- 31

Statistical Data ------------------------------------------------- 31

Visits to Hospitals ----------------------------------------------- 34

II The Mediterranean (Formerly North African) Theater of Operations ------- 36

Evacuation and Hospitalization ------------------------------------ 39

Neurosurgery in Forward Hospitals -------------------------------- 40

Neurosurgical Centers -------------------------------------------- 41

Utilization of Neurosurgical Personnel ------------------------------ 42

III The European Theater of Operations ----------- ------------ 45

Functions of the Senior Consultant in Neurosurgery ------------------- 45

Assignments of Neurosurgical Personnel ----------------------------- 48

Critique of Assignment of Neurosurgical Personnel -------------------- 58

Care of Neurosurgical Casualties ----------------------------------- 60

Critique of Care of Neurosurgical Casualties ------------------------- 66

Redeployment of Neurosurgical Personnel --------------------------- 67

Training, Educational Endeavors, Dissemination of Information ------- 69

Supply and Equipment ------------------------------------------ 74

Records and Photographs ----------------------------------------- 80

Research ------------------------------------------------------- 82

Statistical Data_ ---------------------- 82

Part If

THE MANAGEMENT OF HEAD INJURIES

IV Historical Note ----------------------------------------------------- 89

V Head Injuries in the Zone of Interior ----------------------------------- 91

Administrative Considerations ------------------------------------- 91

Reconstructive Management ----------- -------------------------- 92

xnI
XIV CONTENTS

Chapter Page

VI The Mediterranean Theater of Operations ------------------------------ 99

Scalp Wounds --------------------------------------------------- 99

Fractures of the Skull -------------------------------------------- 100

Penetrating Wounds of the Brain ---------------------------------- 101

Redebridement and Delayed Debridement -------------------------- 105

Adjunct Therapy ------------------------------------------------ 106

Complications of Head Injuries ------------------------------------ 107

Disposition ------------------------------------------------------ 108

VII The European Theater of Operations ----------------------------------- 109

Head Injuries Before D-Day -------------------------------------- 109

General Policies of Management ----------------------------------- 110

Wounds of the Scalp --------------------------------------------- 111

Closed Head Injuries --------------------------------------------- 111

Penetrating Wounds of the Brain ---------------------------------- 112

Injuries of the Carotid Artery ------------------------------------- 119

Antimicrobial Therapy ------------------------------------------- 119

Statistical Data ------------------------------------------------ 120

VIII The Management of Acute Craniocerebral Injuries Due to Missiles --------- 123

General Considerations of Penetrating Head Injuries ----------------- 123

Objectives of Treatment ----------------------------------------- 124

Essentials of Treatment ------------------------------------------ 125

First Aid Treatment --------------------------------------------- 127

Preoperative Measures ------------------------------------------- 128

Priority for Surgery --------------------------------------------- 134

Preparation for Operation ---------------------------------------- 136

Anesthesia ----------------------------------------------------- 137

Classification of Cranial Injuries ----------------------------------- 140

Debridement --------------------------------------------------- 140

Local Chemotherapy and Antibiotic Therapy ------------------------ 147

Repair of the Dura ---------------------------------------------- 148

Repair of the Scalp ---------------------------------------------- 150

Dressings ----------------------------------------------------- 156

Special Types of Penetrating Craniocerebral Wounds ----------------- 157

Postoperative Management --------------------------------------- 175

Evacuation ---------------------------------------------------- 180

Case Fatality Rates --------------------------------------------- 180

IX Penetrating Wounds of the Cerebral Ventricles --------------------------- 183

Historical Note ------------------------------------------------- 183

Clinical Material ----------------------------------------------- 183

Pathologic Process ---------------------------------------------- 189

Diagnosis of Ventricular Penetration ------------------------------- 189

Management --------------------------------------------------- 190

Factors of Mortality -------------------------------------------- 192

Summary and Conclusions ---------------------------------------- 199

X Infections Following Acute Gunshot Wounds of the Brain ----------------- 201

Prevention of Infection ------------------------------------------ 201

Management of Infected Wounds ---------------------------------- 203

Meningitis ---------------------------------------------------- 204

Brain Abscess -------------------------------------------------- 208
CONTENTS XV

Chapter Page

XI Blast Concussion and Cerebral Injuries I)ue to Explosion Waves ----------- 215

Definition and Terminology --------------------------------------- 215

The Incidence of Blast Concussion----------------------------- 222

The Recognition of Blast Concussion ------------------------------ 225

Pathologic Changes of Blast Concussion ---------------------------- 227

Clinical Features of Blast Concussion ------------------------------- 236

The Electroencephalogram in Blast Concussion ---------------------- 244

Cerebral Concussion and Blast Concussion -------------------------- 250

The Treatment of Blast Concussion -------------------------------- 259

XII Cranioplasty -------------------------------------------------------- 261

Historical Note ------------------------------------------------ 261

Preparation of Tantalum Plate ------------------------------------ 262

Operative Fixation of Tantalum Plate ------------------------------ 266

Cranioplasty With Acrylic Resins ---------------------------------- 268

Indications for Cranioplasty -------------------------------------- 269

Statistical Data------------------------------------------------ 271

Case Reports -------------------------------------------------- 271

Summary and Conclusions --------------------------------------- 278

XIII Posttraumatic Epilepsy ----------------------------------------------- 279

Administrative Considerations ------------------------------------- 279

Clinical Investigation --------------------------------------------- 279

Analyses of Clinical Findings -------------------------------------- 281

The Epileptic Attack --------------------------------------------- 286

Medical Management -------------------------------------------- 289

Surgical Management -------------------------------------------- 292

Anesthesia ------------------------------------------------------ 302

Technique of Operation ------------------------------------------- 302

Pathologic Examination of Excised Tissue -------------------------- 313

Postoperative Care --------------------------------------------- 315

Cranioplasty --------------------------------------------------- 316

Postoperative Examinations -------------------------------------- 316

Occupational Therapy and Rehabilitation --------------------------- 316

XIV Speech Disorders Resulting From Gunshot Wounds of the Head and Neck-- 319

Historical Note -------------------------------------------------- 319

Concepts of Speech Difficulties Early in World War II ---------------- 320

Establishment of the Army Program for the Correction of Speech

Defects ----------------------------------------------------- 320

Management of Speech Disorders in Overseas Theaters --------------- 321

Administrative Considerations of Speech Clinics in Zone of Interior .... 321

Diagnostic and Therapeutic Regimen ------------------------------- 323

Classification and Management of Speech Disorders ------------------ 326

Disposition ---------------------------------------------------- 332

Statistical Data ------------------------------------------------ 333

XV Clinicopathologic Aspects of Fatal Missile-Caused Craniocerebral Injuries

(An Analyses of 24 Cases) -------------------------------------- 335

Materials and Methods ------------------------------------------- 335

Cranial Lesions ------------------------------------------------ 336

Pathologic Considerations ---------------------------------------- 338

Surgical Considerations ..----------------------------------------- 373
XVI CONTENTS

Chapter Page

XV Clinicopathologic Aspects of Fatal Missile-Caused Craniocerebral InjuriesContinued

Group I (Nonsurgical) ..- 375

G r o u p 1 1 (S u r g ic a l ) . . . .. . . .. . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . .- 3 8 4

Sum m ary and C onclusions -..----- ..----.... .... ........... ... 39

APPENDIXES

A Course of Instruction in Neurosurgery --------------------------------- 401

B Extracts From Manual of Therapy, European Theater of Operations ------- 403

C Special History and Examination Forms -------------------------------- 411

D Battle Wounds and Battle Injuries of the Head and Brain ---------------- 425

NDEX--------------------------------------------------- 429

Illustrations

Nu mber

1 Location of neurosurgical centers, Zone of Interior, April 1945 ---------------- 19

2 Neurosurgical treatment facilities, United Kingdom Base, ETOUSA- 52

3 Sterile supply table for neurosurgical operations_ 76

4 Roentgenogram of penetrating wound of frontal bone --------------------- 132

5 Roentgenograms of penetrating wound of frontal area --------------------- 133

6 Roentgenograms showing intracerebral bone fragments --------- 133

7 Roentgenograms showing intracerebral bone fragments ------------------- 134

8 Techniques of debridement in penetrating head injuries ------------------.--- 141

9 Technique of debridement of cerebral wound --..--------------------------- 144

10 Technique of debridement of cerebral wound --------------------------- 144

11 Technique of debridement of cerebral wound ----- ----------------------- 145

12 Techniques of repair of dural defect---------------------------------- 150

13 Techniques of repair of scalp injuries -.-.--------------.------------------ 151

14 Techniques of repair of scalp injuris --.---------------------------------- 152

15 Techniques of repair of scalp injury --.--------------------------------- 152

16 Technique of repair of scalp injury ---------------------------------------- 153

17 Techniques of repair of scalp injuries --------------------------------- 153

18 Technique of repair of scalp injury ---------- ---------------------------- 154

19 Technique of repair of scalp injury --.---.---------------.------------- 154

20 Technique of repair of scalp injuries ... -- .. ------ ---------- - 155

21 Technique of closure of scalp ------------------------------------------- 155

22 Compound depressed fractures due to nonpenetrating missile wounds ---------- 158

23 Injury of longitudinal sinus --------------------------------------------- 160

24 Technique of debridement of comminuted skull fracture --------------- 160

25 Technique of management of wound of longitudinal sinus -............ 161

2 6 G u tter w o u n d o f v ertex ---- ---- ----- ..- --- ---- -- --. . .... . ... .. . .. . . . .. .. . 16 4

27 Coronal section showing penetrating wound of head --------------------- 165

28 Coronal section in fatal transventricular wound 166

29 Technique of debridement of intraventricular wound- -.--- --------------- 167

30 Coronal section in fatal through-and-through cerebral wound. --- ------ 169

31 Coronal section in perforating cerebral wound -.------...... ............... 171

32 Severe shell-fragment wound of head ----------.-------- ---------------- 176

33 Roentgenograms of penetrating wound of parietal region -------------------- 185

34 Roentgenograms of penetrating wound of frontotemporal region ----------- 186

35 Roentgenograms of penetrating wound of frontoparietal region -------------- 188
CONTENTS XVII

.Vu mber Page

36 Roentgenograms of penetrating wound of frontal bone ---------------------- 193

37 Roentgenograms of penetrating wound of parieto-occipital region ------------ 194

38 Roentgenograms of penetrating wound of midparietal region ---------------- 196

39 Roentgenograms of penetrating wounds of frontal and parietal regions -------- 198

40 Roentgenogram of penetrating wound of frontal region --------------------- 205

41 Roentgenograms of penetrating wound of parietal region -------------------- 205

42 Roentgenograms of penetrating wound of frontotemporal region before and

after cranioplasty -------------------------------------------------- 209

43 Roentgenogram of penetrating wound of frontal region --------------------- 210

44 Shock wave following underwater explosion -------------------------------- 220

45 High-pressure shock wave ----------------------------------------------- 221

46 Formation of crater in underground explosion ----------------------------- 221

47 Distribution of electroencephalographic findings in blast injuries -------------- 245

48 Distribution of electroencephalographic findings in blast injuries -------------- 246

49 Technique of construction of tantalum plate in cranioplasty ----------------- 265

50 Postoperative view after cranioplasty ------------------------------------ 273

51 Deformity of supraorbital region ----------------------------------------- 276

52 Defect of frontoparietal region -.----------------------------------------- 277

53 Chart showing causative factors in posttraumatic epilepsy ------------------ 283

54 Electroencephalogram in penetrating wound of temporal region -------------- 287

55 Electroencephalogram during Metrazol activation ------------------------- 298

56 Pneumoencephalograms in posttraumatic epilepsy -------------------------- 300

57 Pneumoencephalograms in posttraumatic epilepsy -------------------------- 301

58 Exposed cortex showing arachnoidal proliferation -------------------------- 304

59 Exposed cortex showing arachnoidal proliferation -------------------------- 305

60 Cerebral cortex showing traction on sylvian vessels ------------------------- 306

61 Electrode holder on calvarium ------------------------------------------- 307

62 Spontaneous electrocorticograms of epileptogenous foci --------------------- 307

63 Electrocorticograms in psychomotor and grand mal epilepsy -----------------. 308

64 Surgical field showing frontal cerebral scar -------------------------------- 310

65 Surgical field before and after removal of cerebral scar and epileptogenous

focus ------------------------------------------------------------- 311

66 Surgical field showing removal of cerebral scar and epileptogenous focus- - ---- 312

67 Technique of subpial resection ------------------------------------------- 313

68 Postcranioplasty roentgenograms ---------------------------------------- 314

69 Photomicrograph of cortex in posttraumatic epilepsy ----------------------- 315

70 Photomicrograph of arteriole in caudate nucleus --------------------------- 341

71 Photomicrograph of arteriole in internal capsule --------------------------- 342

72 Photomicrograph showing perivascular edema in medullary center of hemisphere ------------------------------------------------------------ 343

73 Photomicrograph showing pathologic changes in cortex --------------------- 343

74 Photomicrograph showing cortical changes and possible neuronophagia -------- 344

75 Photomicrograph showing distorted cytoarchitectural pattern in cortex ------- 344

76 Photomicrograph showing nerve cell changes in cortex ---------------------- 345

77 Photomicrograph showing pathologic changes in caudate nucleus ------------- 346

78 Photomicrograph showing cortical necrosis in parietooccipital region ---------- 347

79 Photomicrograph showing ghost nerve cells in cortex adjacent to parietal lobe

wound ---------------------------------------------------------- 348

80 Photomicrograph showing nerve cell changes in inferior olivary nucleus ------- 349

81 Photomicrograph showing pathologic changes in cerebellar cortex ------------- 349

82 Photomicrograph showing disappearance of Purkinje's cells in cerebellar cortex- 350

8.3 Photomicrograph showing pathologic changes in white substance of parietal lobe- 350

455735-58-1
XVII[ CONTENTS

Number Page

84 Photomicrograph showing pathologic changes in white substance of parietal lobe. 351

85 Photomicrographs showing pathologic changes in axis cylinders, near damaged

area of internal capsule -------------------------------------------- :52

86 Photomicrographs showing pathologic changes in white suhstance of parietal

lobe ------------------------------------- --------.-------- - 353

87 Photomicrograph showing pathologic changes in axis cylinders near damaged

area of internal capsule ---------------------.-----------.-------------- 354

88 Photomicrograph showing pathologic changes in medullary center of damaged

parietal lobe ------------------------.------------------------------ :. 54

89 Photomicrographs showing pathologic changes in choroid plexus of fourth

ventricle -------------------------------------------------------- 355

90 Photomicrograph showing pathologic changes in ependyina of fourth ventricle- 356

91 Photomicrograph showing pathologic changes in ependyma of lateral ventricle- 356

92 Photomicrograph showing pathologic changes in white substance of parietal lobe- 357

93 Photomicrograph showing pathologic changes in white substance of frontal lobe- 358

94 Photomicrograph showing pathologic changes in cortex------.. 358

95 Photomierograph showing nerve cell changes in frontal cortex _ 359

96 Photomicrographs showing pathologic changes in cortex ------- 360

97 Photomicrograph showing changes in cortex of parietal lobe_ 361

98 Photomicrograph showing marginal gliosis in frontal cortex- -- :162

99 Photomicrographs showing mitosis in cortex of parietal lobe ------ 363

100 Photomicrographs showing mitosis in molecular layer of cerebellar cortex 364

101 Phoi3micrograph showing mitosis in glious element of frontal cortex ----- 365

102 Photomicrograph of artery in region of diagonal band of Broca- ----------- :165

103 Photomicrograph showing venule of nucleus amygdalae ---------------..- - 366

104 Photomicrograph showing pathologic changes in corpus striatum ---------. :366

105 Photomicrograph showing pathologic changes in cortex adjacent to parietal lobe

wound ------------------------------------------------------------ 367

106 Approximate pttttern of skull fracture ------------------------------------ :168

107 Photomicrograph showing granular corpuscles in sulcus terminalis of damaged

thalamus --------------------------------------------------------- 368 1 

108 Photomicrograph showing granular cells in white matter of occipital lobe ------. 369

109 Photomicrographs showing proliferative changes in cortex of frontal lobe ------ 370

110 Photomicrograph showing pathologic changes in cortex adjoining medullary

center of occipital lobe --------------------------------------------- 371

111 Photomicrograph showing capillary proliferation in occipital cortex- -.---- -. - 371

112 Photomicrographs showing pathologic changes in capillary of cortex- ---------- 372

113 Photomicrograph showing ependymitis in lateral ventricle ------------------- 373

114 Approximate pattern of cranial wound of entry and exit -------------------- 376

115 Coronal section showing missile track ------------------------------------- 377

116 Photomicrograph showing petechial hemorrhages in cortex ------------------- 378

117 Photomicrograph showing nerve cell changes in caudate nucleus -------------- 379

118 Approximate location of wound of entry ---------------------------------- 381

119 Dorsal view of brain showing wound of parieto-occipital region -------------- 382

120 Oblique section of brain showing destructive wound ------------------------ 382

121 Coronal section showing destructive wound ------------------------------- 382

122 Photomicrograph showing pathologic changes in wall of sylvian aqueduct - ---- 383

123 Diagram of missile track through brain ----------------------------------- 386

124 Coronal section showing destructive wound ------------------------------- 386

125 Coronal section showing missile track in occipital lobe ---------------------- 387

126 Approximate outline of skull defect ------------------------------------- 389
CONTENTS XIX

Nuniber Page

127 Coronal section showing destructive effects of wound of parietal and temporal

lobes ------------------------------------------------------------ 390

128 Photomicrograph showing pathologic changes in white matter of parietal lobe... :391

129 Photomicrograph showing pathologic changes in white substance of parietal

lobe ....---------------------------------------- 391

1:30 Approximate location of defect in temporal squania- 393

Tables

I Workload at Neurosurgical Center, Walter Reed General Hospital, 1943-44 .... 14

2 Patient load in 26 neurosurgical centers in Zone of Interior, 1942-45 ---------- :32

3 Causes of 332 deaths in neurosurgical centers in Zone of Interior ------------ 33

4 Analysis of 269 procedures performed by a neurosurgical team in European

theater ----------------------------------------------------------- 85

5 Penetrating cerebral wounds operated on in United Kingdom hospitals ----.--- 115

6 Comparative data on incidence and mortality rates in penetrating cerebral

wounds and compound skull fractures managed in First U. S. Army units_- 121

7 Data on penetrating cerebral wounds managed in Seventh U. S. Army hospitals.. 122

8 Symptoms and pathologic findings in brain in atmospheric blast injuries ------- 231

9 Encephalographic data in late cases of blast concussion ---------------------- 245

10 Data concerning double alpha in blast concussion and other conditions -------- 247

11 Electroencephalographic trends in concussion and blast injuries and psychogenic

complications ----------------------------------------------------- 249

12 Location of head injury in 240 cases of posttraumatic epilepsy---------------- 282

13 Duration of impairment of consciousness after injury in 237 cases of pcsttraumatic epilepsy ----------------------------------------------------- 28:3

14 Pneumoencephalographic observations in 109 penetrating wounds of the head - 300

15 Early results of cortical excision in 39 cases of posttraumatic epilepsy ---------- 317

16 Later results of cortical excision in 36 cases of posttraumatic epilepsy ---------- :117

17 Organizational data in program for speech disorders at Zone of Interior general

hospitals ---------------------------------------------------------- 333

18 Distribution of speech disorders at Brooke and McGuire General Hospitals------ :333

19 General topography of destructive lesions in 24 penetrating wounds of the brain. 337
Part I

ADMINISTRATIVE CONSIDERATIONS

IN NEUROSURGERY
CHAPTER I

The Zone of Interior

Barnes Wm oodhall, .11. D.

HISTORICAL NOTE

As background for an account of the development of administrative and

clinical policies in neurosurgery in World War II, it may be useful to outline

briefly the comparable policies in effect in World War I,' as well as in the

interim between the two wars. It should be noted at the outset that in World

War I neurosurgery was not a sharply defined specialty as it was in World War

1I and that neurosurgical cases were for the most part handled tinder other

categories.

Although a Division of Neurology and Psychiatry was created in the

Surgeon General's Office in July 1917, medical officers with special training in

these fields were seldom utilized in accordance with their training. The service

at Letterman General Hospital, San Francisco, Calif., was almost the only

exception. When the Surgeon General's Office was reorganized in November

1918, the Division of Neurology and Psychiatry ceased to exist as such and was

absorbed into the Division of Internal Medicine. When the armistice was

signed on 11 November of that year, a total of 693 officers with some training

in neurology or psychiatry or, occasionally, in both fields were in service, 430

in the United States and 263 overseas.

Very few opportunities for training in either neurology or psychiatry had

existed before the war. During the war, 6-week courses in these specialties

were given at various medical institutions throughout the country. They were

attended by between 200 and 300 medical officers, about, 20 percent of whom

were regarded, at the conclusion of the courses, as qualified specialists.

When a Division of Head Surgery was established in the Surgeon General's

Office in July 1917, the plan was that all neurosurgical patients returned to

the United States would be cared for in brain sections of special hospitals operating under this division. It was realized that at the close of what was termed

the "surgical wound period," patients with injuries involving the nervous system would cease to be surgical and would become neurologic problems, but it

would have been impossible, as the Medical Department of the United States

I Bailey. P.: Division of Neurology and Psychiatry. In The Medical Department of the United States Army In the

Wodld War. Washington: Government Printing Office. 1923. vol. 1, pp. 3W4-394.

3
4 N EUIIOSURGERY

Army was then organized, to effect the change from the standpoint of hospital

organization.

When neurosurgical patients returned from overseas in greater numbers

than had been anticipated, it. was found that, provisions for their care in the

special hospitals established at Cape May and ('olonia, N. J., were not adequate

in either beds or qualified personnel. Furthermore. the civilian demand that

casualties be hospitalized as near their homes as possible had to he taken into

account. In response to these needs and demands, more than a dozen general

hospitals in various parts of the country were designated to receive neurosurgical casualties, who were assigned to them, as far as possible, on the basis of

the nearness of the installations to their homes.

As patients began to be returned from overseas, the Division of Head S.rgery in the Surgeon General's Office found it impossible to augment its personnel

to meet the expanding demand. Because there was then no special neurologic

service in the hospital organization of the .Medical Department,, neurosurgical

patients were sent to divisions of general surgery, to which such neurologists and

neurosurgeons as were available were assigned. In the winter of 1918-19, officers with special experience in organic neurology were ordered to general hospitals designated to receive neurosurgical patients, with the recommendation

to commanding officers that they be assigned to the surgical services. Although

the organizational structure permitted no other arrangement, it was recognized

that this plan was not desirable or logical from the clinical standpoint. Tile

surgical necessities of patients who reached the United States, eventually to

the number of approximately 5,000, were few. Spinal cord injuries were seldom

operable. Secondary surgery was necessary in only occasional head injuries,

and not more than 15 percent of peripheral nerve palsies required surgical

interference.

The neurosurgical centers of World War 1, of which the center at ('ape

May were representative, were closed promptly after the war, the patient load

being transferred to the Veterans' Administration.

In the interim between the wars, injuries of the peripheral nerves and of

the spine were cared for on the orthopedic services of general hospitals. Head

injuries wtre assigned too the orthopedic or the general surgery sections. Tumors,

tics, brain abscesses, and other neurosurgical conditions were referred to civilian

neurosurgeons or were cared for in Army hospitals by local neurosurgical consultants who worked under the contract, system.

Without doubt., the system described was efficient, for the management. of

the relatively few neurosurgical injuries which occurred in peacetime in the

United States Army and for the similarly few diseases which required specialized

neurosurgical care. It. was not., however, a system which could envisage in any

future war neurosurgical hospital sections of even 150 beds, to say nothing of

specialized neurosurgical centers in which the patient census would sometimes

reach 2.000 (p.13). There were, moreover, no prewar plans for neurosurgical

loads of such magnitudes.
ZONE OF INTERIOR 5

The first neurosurgical service of World War II was set up at Walter

Reed General Hospital, Washington, D. C., in May 1942, under Maj. (later

Col.) R. Glen Spurling, MC.2 The peacetime neurosurgical load had not been

regarded as sufficiently heavy to warrant the assignment of a full-time neurosurgeon to it. Such neurosurgery as was necessary in the hospital had been

(lone on a contract basis by various neurosurgeons in the immediate vicinity,

including the late Dr. Walter E. Dandy of the Johns Hopkins Hospital,

Baltimore, Md.

When Major Spurling assumed his duties at the hospital, together with

his duties as consultant in neurosurgery to The Surgeon General, the previous

status of this specialty was clearly evident. There were no neurosurgical

wards; the neurosurgical patients were scattered about all over the hospital.

No assistants were assigned to the specialty. None of the nursing staff had

had any training or experience in neurosurgery. Electroencephalography was

not provided. There was almost no specialized neurosurgical equipment or

instruments; Major Spurling, in fact, had been encouraged to bring his own

instruments, andl he, in turn, made the same suggestion to the neurosurgeons

who came into the Army during the next several months. His first official

position was assistant chief of the surgical service; later, he served as acting

head of the service. As a result, he spent much of his time in administrative

and general surgical duties, as did the few other neurosurgeons then in service.

EARLY NEUROSURGICAL PLANNING IN WORLD WAR II

Establishment of Special Centers

Shortly after a neurosurgical service had been set up, as just related, at

Walter Reed General Hospital, The Surgeon General authorized the development of similar services in other general hospitals. The details of organization

were entrusted to Col. (later Brig. Gen.) Fred W. Rankin, MC, Chief Consultant

in Surgery, Office of the Surgeon General, and they occupied much of Major

Spurling's time for the next year.

Almost from the first, the planning contemplated the establishment of

special neurosurgical centers, in charge of highly trained neurosurgeons, with

a staff of younger men to be built up in each center as the work increased.

The number of special centers fluctuated as planning proceeded and conditions

altered, but the basic policies were never changed; namely, that all neurosurgical casualties received from overseas theaters would be managed in these

centers, that all elective neurosurgery would be performed in them, and that

clinical conditions would be handled uniformly in all.

The first plan, that five neurosurgical centers be located strategically, to

serve designated areas of the country,, had to be discarded because it was im2 When he entered the Me(dical Corps, Major Spurling was Clinical Professor of Surgery (Neurosurgery) at the Unl.

vetsity of Louisville School of Medicine and Secretary of the American Board of Neurological Surgery. His Intimate

acquaintance with the diplomates of the board and with the candidates for certification was to piove of great service in the

recruitment and assignment of medical officers trained in neurosurgery.-J. B. C., Jr.

455735v-58-2
iiN NFURt(P U1(E It Y

pratct ica&l to haQve' a satigle ('?i~ter SOI'V'lort. erv tha lle corps are' uia In August

1942, whent corps ar~eas were eliminlated alild service' ('onilialds -Aet (11p. a Ileurosurgical cenlter wits ('st &LlislU'd ill each (iof the iiune commandis, t he asslignment

of patienits to he based, ats far as bed capacities permitted, on thle rela! ion of thle

(-(-lters to the patietits' homes.

It wits not possible to predict at this t inue whether hospitals overseas or

those ill the Zonle of Initerior would hbetr the brunit of (lefiliitive iteurosurgery -

it was already clear, however, eveit ait t his early 'date, t hat t lhe specialized ('eliters,

wouldl be kept workinig at full capacity to hanidle casualties resultinig from

hostilities overseas ats well ats from the trauinig program inl the I Uitited1 States.

ShortlY after the 9 originial nieurostirgical ('('it ers had beeii (lesigiiated ill fact.

themcocentratmios of troops inl t rainiilig inl the South ad ti Southiwest requiredl the

establishmllent of 31 additioiaul iieulrosui'lgio'al cetit ers ill stat jolt hospitals ill

(commandsi(1 ill these areas.

B *y the middle of August 1942. the followinig centetrs were i'eaolY for operation, unlder the olirect ionl of thle nleurosurlgeonls list ed:

Walter Reed Genevral Hospital, Washinigtoni. D. C.. Maj. R. Glen Spurhin~g.

Lawsoni Genieral Hospital. Atlanita, Ga., Maj. William P. Van Wagenlen.

I a( iarde Genieral Hospit al, New Orleanis. L a., Capt. EvAeret t G. Granlthaml.

O'Reilly Genieral Hospital, Sprinhgfield, Mo., Maj. Frincis Murphiey.

Billings Genieral Hospital, Fort Beiijamiti Har'rison, Ind., 'Maj. Spencer

Bradele.

Perey' ,J4)iis (Geneual Hospital, Bat tle Creek, Mhichi., Capt. Frank 11.

Lettetiiuan Genleral Hospital, Stil Franicisco, Calif., M~aj. Edgar F. Finicher.

Tiltoni General Hospital, F~ort D~ix, N. .J., 'Maj. Rupert B. Raney.

Hoff Genieral Hospital. Sanita Barbara, Calif., Maj. D~avid L. Reeves.

Lovell Greneral Hospital. Fort 1)evenis, Mass., Capt. Walter G. Haynes.

Fort Sum Hfoustoii Stationj Hospital, Tex., Capt. Robert C. L. Robertsoni.

Fort Bragg Stationt Hospital, N. C., 'Maj. Augustus McCravev%.

Conference on Neurosurgery

Althiough some1( neui'osuirgio'al o'eiiters had been e'stablishied earlier, thle

begininiiig of neurosurgery as at specialty inl World War 11 may lbe said to (late

fromt the conferencee held at Walter Reed Gelieral Hospital, :31 August-5

September 1942. It, wats iniitiatedl by MXajor Spurlhig, ill chiarge of the neuirosurgical center at, this installation, it, at memorand~umI to The Surgeon General,

1 5 August 1942. The substance of this memnoranidumi was its follows:

Alt hough contract. service by civilian physicians had ill the past. provided

specialized care as niecessar~y for militarY personnel, the great expantsion inl the

size of the Army now justified the placinig of specialists at. hiospital!4 strategically

located inl the various service c'ommands. ltIn hue with this niecessity, the

Office of the Surgeon General was endeavoring to staff neurosuirgical centers, inl

Army general hospitals by securing, from civil pra't~ice, netirosurgeons of wide
ZONE OF INTEICI0U

experience and proved surgical abl~tiiY. who had been certified by the American

Board of Neurological Surgery. The experience at, Walter Reed General

Hospital iIndicated how rapidly, neurostirgical services were likely to expand

elsewhere. Before tile establishment of a sp~ecial neurosurgical service in N\fa%

1942, only occasional neurosurgical operation~s had b~een performied. Since(

that (late, there had beeni anl average of three maitjor operaitionis In this field each

week, including operations for brain tumiors, brain ab~scesses, b~rain scars with

andl without skull (defects, subdural hteniatomas, open woundIs of the skull and

b~rain, cerebrospinal fluid fistulas, tumiors of the( Spinal cord, progressive exoplhthalmos, anl(l ruptured intervertebral disk. The latter -onditionl had become at major military problem andl wouldl, of itself, amply justify the estab)-

lishment, of a special neuirosurgical service, especially since the introduction of

Pantopaque (iophendyla te) for diagnIosis. 3

At the time this memorandlum was written, thet patient loadl in the neierosurgical centers was madle tip of officers and enlisted men in training camps and(

b~attle casualties requiring reconstructive surgery. InI some locations, dependents were inclIuded in the neurosurgical load. It was expectedl that thle patient

load in these centers would increase steadily and that overseas casualties with

neurosuirgical injuries wvould eventually b~e surpassed in number only by ort hopedhic casualties.

The conference proposedl in this memorandlum began on :31 August 1942.

tit Walter Reed General Hospital, an(l lasted for 6 days. Its purpose was

stated to be the establishment of uniform nieurosurgical policies, particularly1

concerning ruptu red intervertebral dhisks. Those present included:

From the Offic of the Surgeon General.-Col. Arden Freer, MC, and Colonel

Rankin, NIC; ' Lt. Col. William L. Porter, MC, and Lt. Col. (later Col.)

Leonardl T. Peterson, NIC; and Capt.. (later Lt. Col.) Albert, G. Clark, MIC.

firom the neuro.~urgical cenlers.-Maj. (later Lt. Co01.) Spencer Braden, NIC;

Maj. (later Col.) Joseph M. Cameron, MC: Maj. Edgar F. Fincher,` MC; Maj.

(later Lt. Col.) John W. Kane, MC'; Maj. later It. Col.) Augustus McCravev,

\1C; Maj. (later Lt. (Co1.) Francis Mfurphey, MC; Maj. Rupert B. Faricy, MIC;

Maj. (later Lt. Col.) David L. Ree\l ~s, MC; Maj. (later IA. Col.) Mtax Schnitker,

MIC; Maj. (later Col.) R. Glen Spurling, MC; Maj. (later Lt.. (C01.) William P.

Van Wagenen, MIC, Capt. (later Lt. Col.) Everett, G. Grantham, MC; Capt.

(later Lt. Col.) Frank H. Mayfield, MC; Capt. (later Maj.) William Patton,

MC; andl Capt. (later It. C0l.) Robert C. L. Robertson, MC.

From the Nary.-Comdr. (later Rear Adm.) Winchiell Craig (MIC) USNR;

Lt. C'omdr. (later Capt.) James C. White (MC) USNR; and It. (later Lt.

Comdr.) Robert H. Pudenz (MIC) USNR.

Also in attend~ance were Lt. Col. (later Col.) Loyal Davis, MIC. who had

3 Intervertebral disk as a military problem is discussed in detail in Medical Department, United States Army. Suirgery in World War 11. iNeurosurgery, vol. II. [In preparation.J

4 It is fitting, at this point, to mention the services to neurosurgery rendered in World War 11 by the late Brig. Glen.

Fred WV. Rankin, MC, Chief Consultant in Surgery, Office of the Surgeon General. General Rankin's particular train.

ing and experience were in large-bowel surgery, but he so thoroughly understood the general principles of surgical practice

and their universsi applicability to ill spe'cialties that the success of the neurosurgical program in World War 11 can be

largely attribited to his endieavors.
8 NEUROSURGER Y

been designated as Senior Consultant in Neurological Surgery, Office of the

Chief Surgeon, ETOUSA (European Theater of Operations, United States

Army), and Dr W. Jason Mixter, of Boston, Mass.

Colonel Rankin pointed out, in opening the conference, that its purpose

was "to discuss the controversial subjects pertaining to wartime neurosurgery

and to make certain recommendations for the guidance of those concerned."

Both the discussion and the recommendations were necessary, lie observed,

because up to this time methods of neurosurgical therapy had been left entirely

to the discretion of individual neurosurgeons, subject only to the approval of the

chiefs of the surgical services, and uniformity of practice had been completely

lacking.

Clinical subjects discussed at the conference included intractable pain (for

which the term "causalgia" had not yet come into general use), craniocerebral

injuries, low back pain and sciatic pain, posttraumatic head injury syndromes

(still not understood or appreciated in their wartime significance), and injuries

of the spinal column and spinal cord. The clinical programs of later conferences, the agenda of which often furnished sharp contrasts to the agenda of

earlier conferences, reveal how, as the war progressed, the nature of clinical

problems changed, as (lid concepts of their management.

At this first conference, for instance, there was, understandably, an extensive discussion of the ruptured intervertebral disk. This was a relatively new

condition, dating back, in its clinical concepts, only to 1934, and Pantopaque

inyelography was a new diagnostic technique. Rupture of the lumbar disk

was, as already mentioned, to prove a serious wartime problem from the standpoint of loss of manpower days, but it was a problem which was to be solved

not by the surgical solution proposed at this conference but, in most cases, by

separation of the patient from service. The intere.st expressed at the conference in paraplegia proved well founded; there is no brighter chapter in the

history of neurosurgery in World War II than the competent and compassionate

long-term management of injuries of the spinal cord. Tantalum was just

being introduce(d in the treatment of skull defects and peripheral nerve injuries,

and its use was to attract a great deal of attention later in the wai. Its employment was somewhat controversial as far as nerve injuries were concerned,

but there was no debate over the value of tantalum in cranioplasty.

An important action of the conference was the adoption for general use

of the neurologic form then in use at. Walter Reed General Hospital. The

chart in use at the same hospital for cases of ruptured intervertebral disk was

also a(iopte(d for general use. The hope expressed that a uniform system of

recording would b)e instituted in all neurosurgical centers and would make

possible an adequate comparison of results was unfortunately never realized.

Early Dissemination of Neurosurgical Information

Newsletter.--Before the conference at Walter Reed General Hospital,

neurosurgeons at the various neurosurgical centers had no means, other than
ZONE OF INTERIOR 9

personal letters or other personal contacts, of exchanging information with

each other. One of the most useful actions of the conference therefore proved

to be the adoption of a plan to distribute a monthly newsletter to all neurosurgeons in service. These letters were to be prepared by the chiefs of neurosurgical sections in the specialized centers and were to be both informal and

unofficial. In fact, the mention made of this action in the minutes of the

meeting was subsequently deleted.

In spite of their unofficial character, these newsletters were to prove of

great importance and value because, until official dimctives began to be issued,

they formed the basis of neurosurgical practice in the Army. The enthusiasm

with wlKi:h they were received, as well as the requests for them from officers

to whom they were not distributed, furpishes implicit, evidence of the inexperience of neurosurgeons drawn from civil n life in the management. of combatincurred injuries and of their eagerness to compensate for it.'

Inter-Hospital Letter No. 2, dated 4 January 1943, makes clear the type

of information included in these communications:

* * * * * * *

Major R. Glen Spurling, Walter Reed General Hospital, Washington, D. C. November 25,

1942.-* * * we are opening our new neurosurgical ward tomorrow morning. We have

forty-nine beds and it is a beautiful set-up * * *. We are expecting a large group of patients

soon. I will give you more information about how they are distributed, particularly the

amount of neurosurgery in each hundred casualties, at a later date. This report will be my

next contribution to the Monthly Letter, for I think it will indicate to all of you just what

you may expect when you get a bunch of casualties.

* * * * * * *

Major Francis MIurphey, O'Reilly General Hospital, Sprinqgfield, Mo., December 10,

1942.--There is very little to report from here in regard to the service. I have a ward of

my own and am naturally responsible for the ward administration, the property as well as

writing the histories and preparing the patients for disposition, whether they are returned

to duty or C. D. D.

So far I have done about fourteen discs and have already sent two of them back to full

duty. I have been held up, of course, because I could not get any Pantopaque. I did

filially get six more ampules from Van Wagenen. I have had very little else in the way of

surgery except a couple of peripheral nerves and that brain tumor which I had to come back

to operate on, which, incidentally, was a glioblastoma * * * and a brain abscess.

I have only one suggestion for the letter and that is in the technique of injecting the

Pantopaque. Shortly after I arrived, I had too much difficulty doing the puncture with

the patient on his abdomen, so at the present time I do the puncture with the patient on his

side in the old-fashioned way and. with the needle still in him, turn him over on his abdomen.

I then check to see whether the needle is still in the canal and inject the Pantopaque then.

It is just as easy to remove the Pantopaque after the puncture has been done in this manner

and saves an incredible amount of time. So far I haven't broken any needles off.

Lt. Robert H. Pidenz, Naval Medical Center, Bethesda, A1d.. December 17, 1942.-* * *

I have just returned from ten days' leave in Montreal, where I picked up a few pearls which

may be of interest to the group:

1. Drs. Penfield, Cone, and Elvidge have performed tantalum cranioplasty in eight

instances. All of the cases have healed per primam. The longest postoperative period in

3 The round robin letter prepared and distributed by the American Academy of Neurological Surgery proved of equal

value and was received with equal enthusiasm. Its contents were provided by both civilian physicians and medical

officers of the Armed Forces.
10 N E;UIROSUItG(EIt Y

aly 0,iW CA1a is bo uhOllt teia monolthlS. IlI Ie Wpatient a tantalumt plate was inserted to fill Ihe

skull defect resulting from remioval of a neoplasni invading the skull. The neoplasin proved

to be malignant and the plate was subsequently removed for radiotlivrapeutic reasons,

''antalIIni will allow passage of only l-l4- of the X-ravs.

2. D)r. Arthur ('hilde informed mue that they are using Panltopa(ue almost exclisively

for mvelographv. When dificuilties in procurement present themselves, they have substituted Lipiodoi. Their series of cases now exceeeds 80. They have not experienced any

untoward reaction to the use of this material. No case has been explored unless there is a

definite, defect in the column on X-ray.

3. There are s')nme very interesting results in the studies of the pist-traumnatic syndrome.

motion sickness, blackout, cerebral edema and t he local use of the sulfonamides on the brain.

Unfortunately, this work is ini the confidential category of the National Research Council

and I had better get permission to report their findings. Will try to d(o so by the time the

next circular is ready for publication.

* * * * * * *

Captain Frank 1i. Malhfi Id, Percry Jones General Hlospital, Iattle ('reek. Michigan,

,Januar!y 18, 1!43.---* * * we received 40 patients on January 15th and had formal flag

raising and all.

Today I am doing the iPantopaque myelography. It is the first procedure on the operative schedule. Wednesday I will operate on this Mai. (len Spurling will be iii town

that day and I am holding the cast, to put on for himt * * *

Data from overseas. -Meantime, Colonel Davis, who had been in the

European theater as senior constiltant in neurological surgery since early in

September 1942, submitted certain observations for transmission to neurologic

surgeons in the general hosl)itals in tlie United States. His remarks were

endorsed by Brig. (ell. (later 'Maj. (Gen.) Paul R. Hawley, Chief Surgeon,

ETOUSA, as follows:

The exchange of information with experts ini the United States is believed to be highly

desirable and is approved in this office. It is hoped, however, that this will be an exehanui and not, as has been the case up to this time, information traveling in one direction

only.

In spite of General llawley's emphasis on the importance of a free exchange of information and although reports from overseas were prepared

frequently and were maintained on a high level of authority, netirosurgeons

in the Zone of Interior never found a. satisfactory method of iml)lemnenting his

suggest ion.

Since Colonel D)avis' notes represent one of the first reports on neurosurgery from overseas, his observations are reproduced in full:

After a short initial tour to acquire information concerning neurological surgery in this

theatre, thlie following observations seem to me to be pertinent. although not entirely new

in all instances:

1. The length of the period of posttraumatic amnesia following craniocerebral injury

is an important factor in determining the prognosis.

2. Patients with craniocerebral injuries should be got out of bed as quickly as; possible

after they are oriented and are in a stable physical condition. Various types of occupational therapy should be instituted immediately. I have seen enough evidence to change

my op)inion that such injuries should be kept flat in bed for any given time.

3. It has been possible to return to military duty over 60r' of patients with craniocerebral injuries of all types.
ZONE OF INTERIOR 11

4. It is important that all neurological surgeons in the medical corps of the United

States Army should keep complete and detailed records of their patients so that all of the

material may be pooled after the duration for a significant contribution to military neurological surgery.

5. It is important that careful records of diagnosis, examination, and operative notes

accompany neurosurgical patients who are invalided to the United States for further treatment in U. S. General Hospitals so that their therapy may be continued without interruption.

6. Enough clinical evidence should be gathered quickly by neurological surgeons in the

United States so that Pantopaque for myelograms can be placed at the disposal of neurological surgeons in this theatre.

7. Craniocerebral injuries which have been immediately debrided superficially, had the

head shaven, cleansed carefully, sulfanilamide powder introduced, and a sterile dressing

applied, have been operated upon definitively as long as 36 hours later with primary healing

of the wound.

8. In one quarter it is believed that delayed secondary peripheral nerve sutures are

followed by more perfect nerve healing than primary sutures. I did not see sufficient evidence to justify me in accepting this viewpoint which would mean changing my opinion

that a primary end-to-end suture immediately after the receipt of the injury, without or

with the use of sulfanilamide in the wound, is the operation of choice.

9. Electrotherapy at frequent intervals coupled with massage and passive movement

of the effector mechanisms will beneficially affect muscle atrophy following peripheral nerve

injury. The benefit comes through increasing the blood supply to the muscles paralyzed.

10. A series of unilateral and contralateral subdural hematomas have been found following various types of craniocerebral injuries, with symptoms, resembling in their onset.

those of middle meningeal hemorrhage. 6

EXPANSION OF NEUROSURGICAL CENTERS

Early in 1943, it became evident, that neurosurgical casualties received in

the Zone of Interior might be next in importance to orthopedic casualties in

respect to numbers, length of treatment, and proportion of permanent disability. Few neurosurgical patients were evacuated from the Pacific as the

aftermath of Pearl Harbor, but, in the first 135 casualties received from North

Africa, there were 24 neurosurgical patients (18 percent of the total), who

presented 16 peripheral nerve injuries, 4 penetrating wounds of the brain, 4

closed head injuries, and 1 gunshot wound of the spine with paraplegia. The

evident need of these patients for specialized neurosurgical treatment, as well

as other types of specialized treatment, fully justified the effort already expended in the development of what might be termed "one-man" centers and

also emphasized the need for still further expansion of this plan.

War Department Memorandum No. W40-9-43, dated 6 March 1943,

definitely established the role of neurosurgery as well as of other specialties

in the United States Army Medical Department. It specified that all patients

6 In a comment on Colonel Davis' notes, Colonel Rankin pointed out that practically all the points mentioned in

them had been covered quite well at the neurosurgical conference held at Walter Reed General Hospital. He doubted

t hat it would be possible to return to military duty 60 percent of casualties with combat-incurred head injui les. Colonel

Davis' figures referred to closed head injuries, and later events proved Colonel Rankin's doubts entirely justified.

I One patient had two injuries.

I Some months earlier, neurosurgical conditions had been defined as surgical lesions of the brain, spinal cord, peripheral nerves, and sympathetic nervous system.
12 NEUROSURGERY

received from overseas who required specialized treatment should be classified

by the general hospitals receiving them according to types of treatment required

and should be promptly reported to The Surgeon General for transfer to an

appropriate designated specialized hospital. Neurosurgical centers were designated in this memorandum as follows:

Ashford General Hospital, White Sulphur Springs, W. Va.

Brooke General Hospital, Fort Sam Houston, Tex.

Bushnell General Hospital, Brigham City, Utah

Fitzsimons General Hospital, Denver, Colo.

Hoff General Hospital, Santa Barbara, Calif.

Kennedy General Hospital, Memphis, Tenn.

Lawson General Hospital, Atlanta, Ga.

Lovell General Hospital, Fort Devens, Mass.

McCaw General Hospital, Walla Walla, Wash.

McCloskey General Hospital, Temple, Tex.

Nichols General Hospital, Louisville, Ky.

O'Reilly General Hospital, Springfield, Mo.

Percy Jones General Hospital, Battle Creek, Mich.

Schick General Hospital, Clinton, Iowa

Tilton General Hospital, Fort Dix, N. J.

Walter Reed General Hospital, Washington, D. C.

These centers were strategically located in relation to the distribution of

the actual and anticipated neurosurgical load as of March 1943. Centers at

the station hospitals in the South and Southwest, as well as at the general

hospitals originally designated as centers but not included in this list, were

gradually closed, the casualty loads in these particular locations having so

altered as not to justify their continuance. By midsummer 1943, changes in

the casualty load and its geographic distribution again necessitated changes in

the location of the neurosurgical centers. The centers at Lovell General

Hospital, Tilton General Hospital, and Hoff General Hospital were transferred to Cushing General Hospital, Framingham, Mass., England General

Hospital, Atlantic City, N. J., and Birmingham General Hospital. Van Nuys,

Calif., respectively, and additional centers were established at DeWitt General

Hospital, Auburn, Calif., and Wakeman General Hospital, Camp Atterbury,

Ind. Special neurosurgical sections, with accredited neurosurgeons in charge,

were also established at Halloran General Hospital, Staten Island, N. Y., and

Letterman General Hospital.

The adequate care of neurosurgical casualties involved not only the establishment of neurosurgical centers and shifts in their locations as regional

casualty loads increased or decreased but also the expansion of the centers to

several times their original size. The progressive rise in neurosurgical casualties

after November 1943, when hostilities in overseas theaters became more active,

made it necessary to raise the original 150-bed ceilings in the centers to between

350- and 500-bed ceilings in general hospitals which had average bed capacities
ZONE OF INTERIOR 13

of 1,500 to 2,000 patients. By September 1944, when formal plans were made

for neurosurgical ceilings of these levels, continued expansion in most of the

centers had already forced a bed census approaching them. At this time, the

neurosurgical center at Fitzsimons General Hospital was transferred to Newton

D. Baker General Hospital, Martinsburg, W. Va., the center in Schick General

Hospital was transferred to Mayo General Hospital, Galesburg, Ill., and the

center at Birmingham General Hospital was transferred to Hammond General

Hospital, Modesto. Calif. An additional center was established at Northington General Hospital, Tuscaloosa, Ala.

After this reorganization, the 19 neurosurgical centers, which were staffed

by 88 medical officers designated as neurosurgeons, had a bed capacity of 9,250

distributed as follows:

A¥umber

General hospital of beds

Ashford, Hammond, Brooke, Bushnell, Cushing, England, Newton D. Baker, Halloran, Kennedy, Lawson,

McCaw. Nio,ols. O'Reilly, Percy Jones, Mayo, Wakeman, and Northington --------------------------- 500 each

Walter Reed------------------------------------ 400

DeWitt- -------------------------------------- 350

Before the war cnded, the neurosurgical load at O'Reilly General Hospital

and Halloran General Hospital had sometimes reached 2,000 patients. Even

more indicative of the growing importance of neurosurgery was the rapid

development of this specialty at Walter Reed General Hospital in 1942, 1943,

and 1944 (table 1). In his annual report dated 10 January 1943, Major Spurling recorded that, between the establishment of the service in May 1942 and

the end of the year, he had performed 105 major neurosurgical procedures,

with only 2 postoperative deaths, both in patients with hopeless malignancies.

These figures (lid not include encephalograms, arteriograms, and myelograms.

In August, a department of encephalography had been established, in charge

of an experienced organic neurologist. In November, a neurosurgical ward had

been set up, with provision for 49 patients and with its own ward officer. The

majority of conditions treated in 1942 were still of the kind encountered in

civilian practice, but casualties had been received and treated from Pearl

Harbor, Australia, and Burma, and casualties from North Africa were beginning

to be received.

During 1943, the rising casualty load was reflected in both the number and

the kind of neurosurgical admissions. In August 1943, neurosurgical facilities

were increased to 56 active beds and 60 convalescent beds; these wards had

originally belonged to general surgery, in which the census had decreased as

the neurosurgical census increased. In October 1943, a second neurosurgical

operating table was provided, and the average weekly neurosurgical operations

rose from 6 to between 15 and 20.

Over this same period, the recruitment of two nurses with neurosurgical

training and experience had provided for instruction of hospital nurses in this

specialty. Unfortunately, the constant shifting of nurses from section to
14 NEUROSURGERY

TABLE 1.- Workload of the Aeurosargical Center, Walter Reed General Hospital, 1943-44

Admslsions I Admissions

Category Category

1943 1944 1943 1944

Direct ad.missions I 5 1, 138 Operations-Continued

Admissions from-- Sterile abscesz.. (I) -

Medical service 71 M4 Fixation of scapula . (4)

Other swgical servi•,s 191 319 Fusion of cervical spine .................... (I)

Deaths ............. . 11 20 llemilaminectomy and spinal fusion . . (t)

Consultations 881 1. 114 Incision and drainage of absces.- - _ . (3)

D)ressings ...........- 3,352 7,695 Interlaminar exploration -. .....- -- (31)

Pneumoencephalograms- 71 M Laminectomy .................... (M) (11)

Mlyelograms ........... 280 379 Laminectomy, with removal of foreign

Operations ----------- 487 &%5$ body ----------- -------------------- (1)

Alcohol nerve block_. ----- (9) laporatomy ............. .... --- (I)

Aneurysmorrhaphy ------ (I) Ligation of carotid artery ---- (2)

Angiogram. (3) (2) Myeomectomy ----------------- -- ()

Appendectomy . ... (6) Naffziger decompression ----------.---- (1)

Biopisy orimd•thle --- (1) Needle exploration of abscess of brtin (2) - --- 

Cranioplasty ý--ý----- --- (60) Nerve graft ------------------------- (28) (26)

Cranioplaty, with use of tantalum INeurectomy ------------------------ (2) (4)

plate -------- --- (-------------- () Neurolysis ---------.--------------- (55) (131)

Craniotomy_----------------------- (34) (54) Neurolysis, with endoaneurysmorD)ebridement ------------------.------- (14) rhaphy ------------------ . (I) ......

I)ebridement, with suture of .scalp Neurorrhaphy ----------- - (40) (148)

laceration ----------------------- --- (10) Osteoplasty ---------.---------- ().

D)ecompression of nerve root -------------- _ - (2) Periarterial sympathectomy . (I)

Elevation of depressed fracture of skull (6) Removal of--

Excision of- Foreign body --------------------- (6)

Amputation neuroma - (0) ----- Ruptured Intervertebral disk. (155) (150)

Carotid sinus ...... - () Tumor of muscle --- --- (1)

Cicatrix ---- --" (3) (46) Resection of nerve graft. (4)

Neurolibroma - . - --- (2) Resuture of wound ------ (I) -....

Neuroma --- -5) Revision of wound ------- (16)

Scalp wound ---- .. (1) Scalenotomy -------- (10). (9)

Scar --------- (4) Secondary closure of wound (3)

Sinus (--------------- (4) Section ofSubcutaneous tumor (5) Facial artery .......------ (2)

Exploration of- Nerve~. ------

Axilla --------- (I) Sequestrectomy ---- (-)

Brachial plexus (1) Spinofaclal anastomnosis -----... (3)

First stage grift I (3) Sympathectomy -........- ------ (2)

Nerve - (9) (24) Transplantation of nerve ------- (4)

Wound ---------------- - (9) Trephine, exploratory_.. (20) (12)

Evacuation of- Ventriculogram --- (20) (28)

Epldural abscess of cord. .(1) ------ Ventrlculostomy -........ (I)

NOTE.-Flgures In parentheses are subtotals.

section made detailed training very difficult. Some enlisted men rendered

excellent service in nursing capacities, but the great majority were insufficiently

trained for the exacting demands of neurosurgery and never equaled nurses in

their ability. During most of the war, it was possible to keep sterile nurses

with special training in neurosurgery in their positions in the operating rooms.

Before the war ended, however, not a single scrub nurse remained at the instrument tables at this hospital.

In June 1942, the first set of neurosurgical instruments was received at

Walter Reed General Hospital. The committee which had selected them had
ZONE OF INTERIOR 15

chosen wisely and well, but, with few exceptions, these tools were poolr reproductions of excellent instruments. The (irills, the lighted retractors, and the

rongeurs were all of good quality, but the silver-clip outfit was classified by

Major Spurling as perfectly hopeless. By demonstrating to the supply officers

the deficiencies of this equipment as compared to his personal equipment and

by pointing out to them how readily a life coul( be lost from hemorrhage

because of these deficiencies, Major Spurling was able to convince them that

the original contracts must be cancelled and new specifications for neurosurgical

equipment, written. It was well into 1943, however, before the problem of

neurosurgical equipment and supply was on its way to solution. In February

1943, Major Spurling noted in his official diary that the new silver-clip equipment was not yet ready and that it. had taken more than 3 months to secure a

supply of Pantopaque.

Organization of 500-Bed Neurosurgical Centers

Personnel.--The authorized basic personnel for a neurosurgical center

with a patient load of 500 consisted of a chief of section, 2 assistants, and I

ward officer for each 100 patients. The staff was fluid, and assistants and

ward officers were increasedi as the patient load increased. At many centers,

the authorized staff was never approached. At Percy Jones General Hospital,

for instance, when the neurosurgical census was 1,780, the staff consisted of

2 neurosurgeons, 3 general surgeons with neurosurgical training, and 6 ward

officers, none with any neurosurgical training at all. In November 1945, when

the neurosurgical census was 1,450 patients, the staff consisted of a total of

S officers. Shortages of ward officers were particularly cominion and were

seriously felt.

The chief of section in all neurosurgical centers was a neurosurgeon

certified by the American Board of Neurological Surgery anti capable of intervening, with a reasonable hope of success, in any neurosurgical problem,

whether of military origin or related to neurosurgical injuries and conditions

observed in civilian practice. He carried the administrative responsibility of

the section but also gave his personal attention to such difficult neurosurgical

conditions as tumors and abscesses and to obscure neurosurgical problems.

Because of the preoccupation of the chief of section with these matters,

the assistant neurosurgeons formed the backbone of the neurosurgical effort

in the specialized centers. They might not be able to cope with all problems,

but in most of the centers these officers were well trained, expert. surgeons, who

were able to evaluate properly and treat adequately the vast numbers of

peripheral nerve injuries anti skull defects which comprised the workload.

They also operated on the ruptured intervertebral disks which formed a large

part of the workload until surgical management of this condition was prohibited.

One point not always taken into consideration by hospital commanders

antl others in the analysis of neurosurgical workloads was that all neurosurgical

procedures are long and that. some of them are very long. At the center at
16 NEUROSURGERY

O'Reilly General Hospital, for instance, three neurosurgeons, by spending half

of their time in the operating room, managed to average about 90 surgical

cases a month. This was a good record, but it did not meet the necessities

of the situation. In some instances, operation was delayed so long that it was

not, as effective as it might have been if it. had been performed earlier.

All neurosurgeons carried heavy workloads and worked very long hours.

At one general hospital, when the chief of surgery ordered all personnel to

work daily until 2100 hours, it was found that the neurosurgical personnel

were already working until that time and even later.

The tasks of the ward officer in the neurosurgical center resembled those

of an interne in any hospital. It, was not feasible, from any point of view, to

make him a permanent member of the neurosurgical staff, chiefly because of

the fluctuating needs of the services in all hospitals. With the increasing

tendency, as the war progressed, to limit the number of special centers in a

single hospital, it was possible, under the specific table of organization for the

hospital to recruit ward officers as they were needed from various sources, such

as other services with lessened responsibilities, limited-duty personnel, and

floating personnel undergoing indoctrination.

There was not, of course, general agreement with this point of view about.

rotation of officers. Some chiefsof sections stated that, if a similar situation

ever arose again, fixed ward officer personnel should be authorized, because

their rapid turnover militated against the ideal management of neurosurgical

casualties. The theory is sound, but the realities make it doubtful that fixed

ward officer personnel would ever be justified in a neurosurgical center.

To the more or less permanent staff of the neurosurgical centers were

added, at various times, officers on temporary duty, student officers, and

oflicers taking refresher courses. The mainspring and nucleus of a successful

neurosurgical center, however, proved to be a permanently assigned and experienced chief of service and his assistants. Their experience, while different

from that of neurosurgeons with overseas service, was not gained any more

easily, and the point of view Nas realistic that such a staff should be disturbed

as infrequently as was compatible with professional and military necessities.

By September 1944, when there was an increasing demand for neurosurgeons

in overseas theaters, there was also an increasing workload of rehabilitative

neurosurgery in the specialized centers in the Zone of Interior. The Surgeon

General therefore gave orders that the personnel of the Zove of Interior centers

be frozen, in order to provide a more or less permanent nucleus of neurosurgical personnel for the successful continuation of rehabilitation surgery.

Relationship of specialized centers to general hospital organization.-

In most hospitals in the Zone of Interior, the neurosurgical center was a component of the surgical service. The chief of section was responsible to the

chief of the surgical service and through him to the commanding officer. On

the medical service, the neurologic section was similarly organized. The adl iuy. Lt. Col. I)urward (. Hall. Director, Military Personnel Division. Personnel Service, Surgeon General's

Office, 4 Nov. 1944, sectlion 4: Conference, scarcity of specialsts' personnel in the Zone of Interior.
ZONE OF INTERIOR 17

ministrative separation of the neurologic and neurosurgical sections, both of

which were vitally concerned with affections of the central and peripheral

nervous systems. was not conducive to the utmost efficiency either in the

treatment of patients or in the clinical and experimental study of problems

of common interest as, for instance, open head injuries (p. 91). It was realized

early in the war that a more rational plan of organization woulh effect a closer

relationship between neurosurgeon and neurologist by which their individual

identities would be preserved but at the same time their efforts would be fused

and the study anti treatment of diseases and injuries of common interest would

be carried out in the same ward space. The pressure of casualties hastened the

evolution of this ideal plan, though it was never completely achieved.

From the standpoint of neurosurgical administration, it would have been

highly desirable to divorce neurology anti psychiatry and to organize a single

section of medical andl surgical neurology. Major Spurling pointed this out

shortly after the neurosurgical service was organized at Walter Reed General

Hospital. At this time, there were 10 neuropsychiatrists, but only 1 organic

neurologist, on the neuropsychiatric service. As a result, psychiatrists answered most consultations, and the chances were that a disease that was really

organic might sometimes be classified as functional.

Facilities and administration.-The facilities of a neurosurgical center of

500 beds consisted of (1) a diagnostic or preoperative ward; (2) an operative

or acute treatment ward, subdivided into a recovery ward, a postoperative

ward, and a paraplegic ward; and (3) a convalescent ward (or wards).

The preoperative or diagnostic ward could be operated most efficiently

when it was divided into units of 50 patients each, with each unit under a.

ward officer. Patients in this ward were ambulatory, could go to mess, anti

were capable of carrying out fatigue duties on the ward under the supervision

of an enlisted wardmaster. They presented, in addition to diagnostic problems,

the usual types of peripheral nerve injuries, skull defects without disabling

neurologic sequelac, and injuries and symptoms referable to the back. After

a preliminary survey by the ward officer, the patients in this ward were dispatched to other hospital units for special stuldies or for consultative review, or

even to other hospital installations. At weekly rounds by the chief of section

and the staff, decisions were arrived at. concerning operation; conservative,

nonsurgical therapy; transfer to other therapeutic sections; or some type of

military disposition.

The operative or acute treatment ward was also administered in units of

50 patients, each unit being under the immediate care of an assistant neurosurgeon assisted by a ward officer. Patients were admitted to this ward from

convoy or from other wards for specialized treatment. When the numbers

justified it, special lesions were treated in special subdivisions.

The recovery section of the operative ward was administered as a separate

unit, to permit concentration of nursing care for patients who had just been

operated on. Patients with acute head injuries or with other acute neurosurgical conditions were also treated in this space.
18 NEUROSURGERY

The main postoperative section of the operative ward contained patients

in various stages of recovery from operation, as well as patients undergoing

the first stages of rehai)ilitative treatment for neurosurgical injuries. Patients

with septic or chronically infected injuries were isolated in a (detached portion

of the main postoperative ward or were treuted in a separate septic unit.

Wound dressings were accomplished from a cart in the main ward, or in adjoining dressing rooms. Casts designed to change the position of the joints

in peripheral nerve injuries were changed in the ward under professional supervision; all beds were fitted with overhead frames to facilitate the procedure.

The paraplegic section was part of the main postoperative ward. Patients

with paraplegia of traumatic or neoplastic origin were best segregated for

medical and nursing care, because of the demanding nature of their care, the

nutritional problems involved, an(l the recurring episodes of bladder and skin

infection. Under this plan, the traine(d personnel who cared for such patients

reached their highest peak of efficiency.

Convalescent wards with as many as 200 patients could be supervised

under a single war(d officer. His tasks, which largely involved channeling

treatment and preparing patients for disposition kept him fully occupied.

The chief of section made biweekly rounds; the progress of rehabilitation

in neurosurgical states, particularly in peripheral nerve injuries, is usually so

slow that more frequent observations were not necessary and would not have

been useful. As many as 25 patients could be studied at each of these rounds.

Since about 20 percent of all patients with bone and joint injuries had

concomitant peripheral nerve injuries, die patient load justified combined

neurosurgical-orthopedic wards. This arrangement was found to be most. efficient for the management of such casualties, who consiste(d of both ambulatory

and bedridden patients.

Organization of Larger Neurosurgical Centers

In January 1945, in anticipation of the increased casualty load expected

by August 1945, the total ceiling for neurosurgical beds in the Zone of Interior

was raised from 9,250 to approximately 21,900. Since facilities for further

expansion were not available at Brooke General Hospital, the neurosurgical

center there was transferred to McGuire General Hospital, Richmond, Va.

The center at Walter Reed General Hospital, except for a small neurosurgical

section, was transferred, for the same reason, to Halloran General Hospital.

The neurosurgical section handled only a few battle casualties, and its activities therefore bore little resemblance to the activities of the other centers.

The ceiling of 21,887 neurosurgical beds allotted in January 1945 represented a practically threefold expansion of the original capacity of the centers.

The bed allotment proved none too liberal, and the ceiling was sometimes exceeded in the months before the war ended. Had combat continued, further

expansion would undoubtedly have been necessary. It was thought that it
ZONE OF INTERIOR 19

couIld he accomfplishe~d within tile& cenkters alread 'v establishedl (fig. 1) and that

the authorization of additionial centers would not, le Indicated.

The expansioni of the bed capacity of thle neurosurgical centers, was not

accompaniedl by a corresponding increase in professionial personnel. At thle

peak of operations, thle 19 centers were staffedl b, 92 medical officers classified

ats neuirosuirgeons, 26 of whom were certified by thle American Board of Neurological SuirgerIy. This wats a ratio of 1 nieurosuirgeon to ev-ery 237 patients.

Thle nieurosurgical program wats also continuously handicapped by a lack

of experieiicedl neurologic personnel. Ideally, thle diagnostic aspects of all

*4 -7 -

o / Percy

IF -B.ushnell /ini---- ~ - Janes ,

Zf I./~ - fo W

OeMt~\.~0 Wakem~an

eHammond n------- 0

.1,. _ - _ ~ - 0 'Reilly j NihI,

NI A n--~-

*-5 Northo glon

FIG, URi L- Locat ion of neu'trosutrgical centers in general hospitals in the Zone of Interior in

April 1945.

neurosurgical injuries should have been thle task of the neurologist, not. tie

nteurosurgeoni, but it. was niever possible to secure changes in existinig tab~les of

organiizationl which would have providled sufficient neurologic personnel to

achieve, this objective. TIhis policy, for obvious reasons, wouldl have been particularly desirable in the larger iieurosurgical centers.

These were. major dhifficulties, and they prevented thle achievement, of anl

ideal organizat~ion. Nonetheless, extensive changes in organization were necessandyv made when centers with an original capacity of 150 to 500 beds, were

expanded t~o centers hin which the neuirosuirgical patient loadl at times exceeded

2,000. 1In genieral, th le expanded load requ ired a physical segregat ion of pq tienit s

with specific lesions and ani adIministrative separationi of thle componients of

diagnosis, treatment, anmd convalescence or dIisposi tion.
20 NEUROSURGERY

In most centers handling a thousand or more neurosurgical casualties,

patients were admitted to a common admission ward, from which they were

segregated according to whether they needed nonsurgical treatment, neurosurgical treatment, or purely diagnostic surveys. In the latter group were

patients with such conditions as closed head injuries, convulsive states, suspected cerebral neoplasms, and sciatica. Patients with cra.ial injuries, peripheral nerve injuries of the upper and lower extremities, paraplegia, and combined orthopedic-neurologic injuries were further segregated into special wards.

This method of assignment promoted efficiency of treatment, led to a better

understanding of technical problems, and was conducive to a rapid rate of disposition.

An interesting development of the expanded neurosurgical program was

the establishment of so-called nerve laboratories in which unified preoperative

an(I regenerative studies of nerve injuries were carried out.. In these laboratories, histories were recorded, photographs were taken, neurologic and electrodiagnostic studies were carried out., and pertinent data were assembled on special forms. The unified methods employed, in addition to facilitating all the

studies, permitted a more rapid turnover of patients.

The principles of physical segregation of patients accordi..g to their special injuries and the administrative separation of the components of diagnosis,

therapy, and disposition were designed (1) to give to the neurologist, when he

was available, his proper responsibility for diagnosis; (2) to allow neurosurgeons

to spend their time profitably in the operating rooms; and (3) to make ward

and administrative officers responsible for the routines of administration and

disposition. The use of fu'lough barracks, where patients returning from

furlough were processed in terms of progress, was another useful plan, which

prevented the accumulation of ambulatory patients in hospital beds.

Only by a carefully detailed organization such as this could heavy patient.

loads be efficiently controlled and cared for. Efficient organization was, however, attended with at. least one obvious disadvantage, a loss of the doctorpatient relationship. When one group of medical officers worked up patients,

another group treated them, and a third group cared for them after operation,

there was always the danger that efficiency might degenerate into a productionline type of management as undesirable in military as in civilian practice.

There was also a certain professional loss in the necessity for emphasizing

administrative details. As the workload built up, the original plan of staff

conferences intended to include not only the neurosurgical staff but the staffs

of other sections became increasingly difficult. and eventually was abandoned

in most. of the centers.

M[ethiods of handling the workload varied from center to center. The

following (summarized) report from the center at ('ushing General Hospital

describes a plan of organization which worked admirably when it. was tested

under heavy pressure.
ZONE OF INTERIOR 21

'rganizatioii of the Neurosurgical Center

at Cushinig General Hospital

rihe nteurologic awd neurosuirgical sectionis at ('uslhing Genieral Hospital

alwaYs represented a single working unit whet her they were coiblined into a

sinlgle service, as thYwere originally, or were separated a(1mininst rat ivelv into

miedical and( surgical services, as they were later. nie (.ose- cooptratioll

proved as useful front the adiminist rat ive as fromn t ht professional point of

view. lin timies of stress, wliei there was a heavy in flux of patients, thle Servico'

Could be4 expanded. lit quieter periodls, it 01-o1(1 be contracted. Bed space

could be utilizedi with great efficiency. Personnel andt eqluipment couldl be1

shifted fromt one section to aniother without dlelay, accordIing to currenlt er-

(juireients. 'The( (livision of work betweeni tile sectionls miade it possible ito

keep abreast of inicoming patients, and, even when large conivoy' s arrived, there

wvas no b~acklog. The neuirosurgeon, who was freed simultanieously fromt the

time-consuming initial examinat ioni of patients anid front the inevitab~le paper-

%, ork contiecteti with their later observationi andl finial dfispositionl, was enlabledi

to dlevote his ftill timie to thle surgery which was his p~rim~ary task.

Routine of admission and diagnosis.- Patients who presented i eurosurgical emnergeticies;, pa '.eiits withi rupt uredi in tervert ebral (1isks. andl pa raplegics were adlmitted(l tirectly to thle wardis onl whichm they were to be treatedl.

All other patients wer(e adimit ted to the( neurologic section, which was set tip ats

atn admitting detpartment for bothi neurologic amid nicurosurgwcal patients.

H-ere, wit hiin a week of his admission to t he hospital, every patienlt was

thoroughly worked uip under a routine which was elab~orately (letailedl, yet which

operate(l a11lmost Oil the( principles of anl assembly linc. One routine was used

for head inijuries and aniother for peripheral nierve injuries. Material from hothI

typ~es of injuries was collected in a register for later statistical evaluation.

The ob~jective of thle systemt of examiniat ion usedl at the ('ushing" Genleral

Hospital Neurosurgical (Center was twofold: (1) To shortenl tile timie of hiospitalization and thius to free 1)e(ls as promptly as possible for new casualties;

and (2) to recordl neurologic (deviations froin the( normal in mnumerical values

wvhich could be reproduicedl anti reexamniiedl com-paratively' ; that is, lin suich

phisyical termis as kilograms, millimeters, secondts, aniil volts. Except for thle

list' of such terms, r-eal evaluation of progress would have b~een impossib~le; it

was not practical to tiescribe inl adhequate wvordls, or to bear in mindl over long

periods of timte, the( status of the niiiltittidle of patients, who Ipasse(l thlroughl the(

centers,. These dlata, howvever, were essential. The presence or albsence of

improvement in muscle power, sensitivity to pain amid touch, electrical irritabilit 'v of nerves an(i muscles, andt tile presenceT or absence' of sweating, all in-

(dicate tile- course of a peripheral nerve injury, tile need for surgical intervention, thle success of neurolysis or nelmrorrllaplly or nerve graft, andl tile sp)ont aneous recovery of cont usedl or bruised nerv-es.

Head injuries.- Head injuries were ilan(Ile(l onl separate wvands. Tile

p~atients were examinied accortling to a special routine, were studlied withl and
2-9 NEUROSURGERY

without medication, and were treated according to the indications. They

were followed up after discharge on certificate of disability to determine whether

convulsions developed subsequently. The clinical, roentgenologic, and neurosurgical findings during debridement or the insertion of a tantalum plate, as

well as the results of spinal fluid, electroencephalographic, and psychologic surveys, were correlated with long-term developments in the condition of the

patient. The attempt to keep in touch with patients after their discharge, to

obtain information concerning their progress, and to advise them concerning

medication and other treatment, was carried out with great efficiency by

American Red Cross personnel.

Specially trained members of the professional and nursing staff were

assigned full time to all aphasic patients, and hemiplegics were thoroughly

trained in the use of the intact arm,

Peripheral nerve injuries.-Special methods of testing were employed ,I

instances of peripheral nerve injury as follows:

1. Muscular power was determined by means of the so-called fishhook

method, in which an ordinary spring scale was applied to the finger to measure

the force in pounds required to overcome voluntary resistance of an affected

muscle. The average values for the various muscles and the standard deviations had previously been determined in a large random sample of normal

soldiers. Experience soon showed that this method of examination was no

more time consuming than the former method of estimating, on an arbitrary

basis, the loss of power in terms of percentages of normal. It also showed that

the former method, even in the hands of experienced neurologists, frequently

provided entirely incorrect information as compared with the data secured by

the new method.

2. Muscular atrophy accompanying denervation was recorded, and recoverv was checked, by handprints and footprints. A graphic record was

provided at the same time of the trophic status of the skin.

3. The presence of, or return of, innervation was checked at the earliest

possible time. This information is obviously of the greatest importance in the

prognosis of a nerve injury of unknown character. The results of the examination frequently prevented an unnecessary operation, with resultant saving of

the time of operating personnel, who were always in short or even critical

supply. On the other hand, the results sometimes indicated immediate exploration of the damaged nerve and thus saved the patients weeks and months

of disability.

4. No single method of studying the electrical irritability of the nervemuscle apparatus proved satisfactory, but repeated comparative studies were

carried out in which the patient's clinical course was correlated with the

electromyogram, strength-duration curve, and cathode-closing tetanus.

5. The permeability or impermeability of a nerve scar or nerve suture

was tested 8 to 12 weeks after operation, rather than 8 to 12 months afterward,

as was the previous custom. Many months of hospitalization were often

saved as a result. Operation under local anesthesia, with stimulation of sensory
ZONE OF INTERIOR 23

fibers distal to the sear or suture, proved by far the most sensitive method

employed. This is, however, a qualitative method, which provides no reliable

indication of the type or number of nerve fibers passing through the injury.

It also supplies no information concerning prognosis. The amplitude and

latency of action currents elicited across the injury and recorded during operation were found to supply a better quantitative insight into the type and

number of viable nerve fibers in the peripheral stump.

6. Sweat tests were recorded, especially in connection with the determination of the skin temperature by means of thermocouples, before, during, and

after injection of sympathetic ganglia before sympathectomy for pain of the

causalgic type.

Treatment.-After the patient had been completely worked up, usually

within a week after his admission to the hospital, he was presented at a combined

conference, held each Saturday morning and participated in by the staffs of

the neurologic and neurosurgical sections; the chiefs of the divisions of medicine

and surgery; representatives of the orthopedic and physiotherapy sections;

and, if necessary, representatives of the plastic surgery section. At this

conference, the case was discussed in full detail, and it was decided (1) whether

the patient required surgery, (2) what procedure was indicated if he did require

it, (3) in what sequence stage surgery should be performed, and (4) whether, if

other injuries were associated, the required neurosurgery should be done alone

or in combination with orthopedic or plastic surgery. A conference conducted

along these lines gave the patient the benefit of the carefully considered opinion

of a group of specialists, while, from the administrative side, it reduced the

details and delay of consultation to a minimum.

Many patients arrived from overseas with frozen joints, as the result of

immobilization in casts applied for fractures or used as a substitute for splints

in nerve injuries.'0 These joints had to be mobilized before neurosurgery could

be undertaken. The limited facilities of the physiotherapeutic section at

Cushing General Hospital made it impossible to treat any single patient for

more than 20 minutes daily. A mechanical apparatus devised within the

hospital ended this difficulty by providing for the automatic movement of

wrist, elbow, and knee joints. The apparatus, which could be operated by

the patient himself, released physiotherapists for other duties and also made

it possible for each patient to be treated 3 times daily for 30 minutes at a time.

An 8-month experience with it proved that mobilization of frozen joints could

he achieved by this method in 25 to 30 percent, less time than by former methods.

10 While some patients with peripheral nerve injuries arrived at this and other centers in poor condition, most of them

had been well treated. On a well-organized service such as the one at Cushing General Hospital, errors made repeatedly

in the same overseas hospital or by the same surgeon were promptly recognized and reported. Thus, ip January 1945, the

chief of the neurosurgical center at this hospital wrote to the Senior Consultant in Neurological Surgery, Office of the Chief

Surgeon, ETOUSA, that uniformly poor results were being observed in cases treated by a Captain - of the - General

Hospital. Descriptions of operative findings, the repoi t continued, were too meager to be useful. Infection was common.

Joints were more than usually frozen. Conditions in which this officer had to work, the report concluded, might explain

the results, but the impression was that he was undertaking too much for his surroundings or his ability. With this sort

of specific reporting, the overseas consultant could take action at once to correct the errors which were being made.
24 NEUROSURGERY

Patients with peripheral nerve injuries were transferred from the neurulogic

to the neurosurgical ward for operation and remained on the latter ward until

sutures were removed and extremities were extended. They were then transferred back to the neurologic section. This plan resulted in all effective use

of bed space.

The work-furlough system.-The introduction of the work-furlough

system also resulted in the release of a large number of needed beds for incoming

casualties and had happy results for the patients themselves. Spontaneous

recovery from a nerve injury, or nerve suture and regeneration of an injured

nerve, always takes months and may require a year or more; combat-incurred

injuries did not (liffer from civilian injuries in this respect. War Department

policy required the retention of patients in hospital until they had attained

maximum hospital benefits, but rigid observance of this regulation resulted in

the distressing spectacle of "barracks happy" patients sitting around wards

for week and( months, always useless, unhappy because they had nothing to

do, and, in addition, occupying bed space which could have been used to better

advantage for more urgent needs.

The 90-day work furlough solved this problem. Patients who exercised

injured extremities grudgingly 3 or 4 hours daily in a hospital gladly exercised

them 8 and 10 hours daily in a factory, while at the same time, they aided the

war effort, improved their own financial status, and had the added advantage of

living with their own families, which additionally improved their morale. At

the end of 3 months or of some other specified period, they returned to the

hospital for determination of their progress and for a decision whether they

should be returned to duty or discharged on a certificate of disability. At one

time, as many as 200 patients with peripheral nerve injuries at Cushing General

Hospital had been converted from inpatients to outpatients by the workfurlough system, and the same number of urgently needed beds had been released for incoming casualties.

Clinical research.-The cooperation of the neurologic and neurosurgical

sections at Cushing General Hospital permitted the joint investigation of a

number of problems. Among them were the use of nerve grafts and their

long-term results, studies on the electrophysiologic phenomena already mentioned, and studies of the tensile strength of nerves in connection with their

extension after end-to-end suture over gaps up to 13.5 cm. in extent.

TRAINING PROGRAM

In 1941, just, before the United States entered World War II, tile American

Board of Neurological Surgery first began to function. The approximately

200 certified neurosurgeons, even if all of them had been suited by age, health,

and academic and other responsibilities to enter the service, would have been

totally inadequate to handle the neurosurgical load. The certification listings

of the newly organized board, however, served as a reservoir of younger sur-
ZONE OF INTERIOR 25

geons, of certified ability, who could be utilized for service overseas and in the

Zone of Interior. The units sent overseas early in the war, many of them

affiliated hospitals, were chiefly supplied from this source, as were the

neurosurgical centers which were established and rapidly expanded in the

Zone of Interior. Evacuation hospitals and neurosurgical teams in auxiliary

surgical groups also assimilated an additional number of well-trained neurosurgeons who were physically qualified for service and who had just completed,

or were in process of completing, formal training in this speciality.

The situation was extremely serious. The need for neurosurgical personnel

was promptly evident, partly in the light of the World War I experience and

partly in the light of the high proportion of neurosurgical casualties among

the wounded returned from North Africa in the early months of fighting there.

To meet the requirements of tables of organization of general and other hospitals would have stripped every civilian hospital and clinic in the country

and still left the Army short of needed neurosurgical personnel. Provision for

the hospitals which were first organized and for the expanding neurosurgical

centers had, as just indicated, taken nearly all the certified neurosurgeons

available for service. It had also taken the majority of neurosurgical residents.

Additional neurosurgical medical officers were urgently needed, but a period

of6 months was to elapse before another group of medical officers with specialized

training in neurosurgery would become available from the training program in

this specialty set up by the Office of the Surgeon General.

First Courses of Training

Planning for the training program just referred to was begun in January

1942, by the Office of the Surgeon General, in anticipation of the need for

trained neurosurgeons. The Division of Medical Sciences of the National

Research Council, at the request of The Surgeon General, recommended that

arrangements be made for training medical officers in neurosurgery at the

Neuropsychiatric Institute, University of Illinois, Urbana, Ill., and the Neurological Institute, College of Physicians and Surgeons, Columbia University,

New York, N. Y. Facilities were available for these courses in May 1942,

but, due to a shortage of available candidates, training was not begun until

September.

The student officers selected were young general surgeons who, during

their hospital experiences, had had some contact with functioning neurosurgical

services. The first part of the course included dissection of the central

and peripheral nervous systems, cadaveric demonstrations, and lectures on

neurophysiology. At the end of a month of intensive instruction, the 24 to

30 officers in each class were divided among the neurosurgical centers for a

period of preceptorship that usually lasted 3 months but was sometimes extended for 5 to 6 months. Many of the approximately 125 officers thus trained

developed into excellent traumatic neurosurgeons and held responsible posts

during the war.
26 NEUROSUIRGERtY

Later Courses

There was, however, rather general dissatisfaction among the students

with the kind of training given in these first courses. In the Inter-Hospital

Letter dated 22 March 1943, Major Spurling pointed out that their dissatisfaction with the results of tile courses of training was shared by the men who

were giving them. He then outlined the following plan of training which was

to be substituted for them in the future:

* * * the selection of candidates is probably the most important step in the whole procedure. It is contemplated that only men will be selected for training who have had three

years of general surgery, preferably in a place where they have seen a large volume of traumr:1 ork. Furthermore, no candidate will be accepted for training unless he indicates a

.) undertake the course. Each candidate will be interviewed by a representative of

geon General's Office. Since all new medical officers entering the Army are sent to

Cariisle Barracks, Pennsylvania, for six weeks of basic training, it is contemplated that the

selections will be made from this group. However, if any of the Army neurosurgeons are

acquainted with any young general surgeons who would like to undertake the course, please

write to me immediately.

The first part of the training program will [phase I] consist of four weeks instruction

at Columbia University in the anatomy and physiology of the nervous system with particular

emphasis placed upon surgical application. Most of the four weeks period will be spent in

the dissecting room, where all operations on the head, spine, and peripheral nerves commonly

encountered in warfare will be done on the cadaver. A few lectures on the pathology of

trauma to the nervous tissue will be given, but otherwise there will be no instruction in this

course except anatomy, basic physiology, and cadaver surgery.

At the end of four weeks the class * * * will be distributed to the Army general hospitals having neurosurgical services * * * for a two months' preeeptorship [phase II].

* * * it is fully realized that in some of our general hospitals the volume of work is small,

and two students might not find enough to do to keep them busy. I would appreciate

suggestions from each of the groups regarding the optimal and maximal number of students

he can handle.

The method of instruction, once they arrive under your care, will be largely an individual matter. It is anticipated that these men will be placed in evacuation or field hospitals overseas to do the emergency head, spine and peripheral nerve cases. In other words,

their problems will be largely those of stopping hemorrhage, preventing infection, and

debridement of brain and extremity wounds. Obviously they should be taught to do a

simple neurological examination and learn the importance of certain clinical signs with

respect to head trauma. They should learn to use the suction, the electrical surgical apparatus, silver clips, muscle implants, etc. After all, these technical details can be taught

just as well on one type of operative procedure as another, and the fact that most of us do

not have much acute head trauma should not interfere seriously with the teaching of these

fundamental details. The students should be assigned to the ward work, writing histories,

doing neurological examinations, dressings, assisting at operations; they should be instructed

by the roentgenologist in the interpretation of head films; and should study what gross

pathology there is available. They should have definite assigned reading to be completed

by the end of the course. The two months period * * * might just as well have been

three months except that the personnel division anticipates the need for these men for overseas duty at the latter part of the summer.

The course of training described in this letter and designed to replace the

earlier courses was put into effect at the Neurological Institute, College of

Physicians and Surgeons, Columbia University, (appendix A, p. 401), under the
ZONE OF INTERIOR 27

direction of Dr. Tracy J. Putnam, 24 April 1943. All of the first group of

officers chosen for specialized training had had fairly satisfactory previous

training in general surgery. Aln occasional proctologist and gynecologist was

included in the first group, but these specialties were not represented in the

groups of neurosurgeons subsequently trained.

Forty-eight officers were graduated from the two courses conducted at

the Neurological Institute at Columbia University. In January 1944, tile

course of instruction was transferred to the University of Pennsylvania School

of Medicine, Philadelphia, Pa., under the direction of Dr. Francis C. Grant.

By the time of the transfer, the source of officer personnel for training had

shifted fhom physicians with general surgical training, who predominated in

the courses given at Columbia University, to postgraduate neurosurgical

students who had completed available civilian training and wished to continue

specialization under Army auspices. Tile young general surgeon, however,

still remained the backbone of the group of 74 officers trained at the (niversity

of Pennsylvania.

Theoretical Training

The formal program of instruction originally planned was followed closely

in the first course held at the University of Pennsylvania, 17 January to 12

February 1944. Progressive changes in the teaching schedule were partly

stimulated by a student critique submitted on 12 October 1944 but for the

most part were based on a clearer comprehension of the results desired in the

course. They were described as follows by Dr. Grant on 6 December 1944:

In the first schedule * * * we stuck pretty closely to the Government terms of sixtyfour (64) hours for neuroanatomy; sixteen (16) hours for neurophysiology; twenty-four (24)

hours for cadaver surgery, fourteen (14) hours for neuropathology; ten (10) hours for neurologic examinations; sixteen (16) hour- for clinical neurosurgery; sixteen (16) hours for

neurologic and neurosurgical clinics, etc.

At the time of the second course, I rerouted things a little bit and put most of the

twenty-eight (28) open hours into neurosurgery and neurology.

In the third and fourth courses we cut out entirely neurophysiology and neuropathology. We abandoned neurophysiology quite frankly because we did not have anyone

here who taught it very well. The men for the most part had not had any of it since their

Sophomore years in school and neither they nor I could see the practical application of

the subject matter. They were definitely allergic to it and I felt that the time could be

put to better use in other ways. As far as neuropathology is concerned, again, I could not

see that this was necessary.

In the last course, therefore, we kept neuroanatorny at about the required number of

hours; put in about ten (10) more hours on neurosurgical and neurologic clinics and devoted

the bulk of the remaining time to straight neurology. I also introduced roughly six (6)

hours on x-ray film diagnosis and the use of sulfa drugs and penicillin; the care of the bladder

in spinal cases, and a couple of hours on neurological ophthalmology.

As far as the textbooks are concerned, I think the books described in the original Government Outline of the courses are excellent, if you can get them.

At the present time, we have twelve copies of Glen Spurling's "Practical Neurologic

Diagnosis" hidden away for the next course, but the other textbooks suggested are pretty

hard to come by at the present time. Rowbotham and Monrad-Krohn are published in
28 NEUROSURGERY

England and are unavailable. I think the Neurosurgical volume in the Military Surgeomi'

Manual is pretty useless.

It would be a great help to tie if you could send me copies of the various suggestions and

orders, etc., that are put out from time to time by the Surgeon General's Office on the

treatment of neurosurgical wounds * * * . If they are not too confidential, they would

keep me informed of the latest ideas. After all, if I ain going to try to teach these men.

I don't want to give theni information which is currently out of date in Army neurosurgical

circles.

Practical training.-ln the second or practical phase of neurosurgical

training, officers who had completed the first part of the course were assigned

by ones and twos to the neurosurgical centers for 60 days each. The ability

of the respective centers to follow the specified program of instruction was

naturally dependent upon the patient load but was chiefly influenced by the

surgical tasks which were uppermost at any given time. Yearly statistics

show that when the first two groups of neurosurgeons-in-training reached the

centers, most installations were at a low ebb of activity and were preparing for

the deluge to come. At the time, they were really serving as hospitals for

reconstructive surgery, and instances of acute head trauma were scattered and

were quite inadequate for training purposes. Fortunately, the centers expanded rapidly soon after students began to be assigned to them, and those

who did not have the opportunity to learn the lessons of acute traumatic neurosurgery in the Zone of Interior rapidly learned them under preceptors overseas.

In actual practice, the second or practical phase of neurosurgical instruction was much less formalized than the outline would indicate (appendix A,

p. 401). The students, at least in centers in which the patient load was heavy,

became integral, hard-working parts of the neurosurgical staff and by progressive steps participated in all phases of the work. They were placed in

charge of preoperative wards, where they could assimilate the many-faceted

picture of peripheral nerve injury, study neurologic defects in head injuries,

and explore the real mysteries of painful backs. They became acquainted

with the often pressing tasks of intersection consultations." They observed

the sudden onset of such complicating diseases as malaria and hepatitis. They

also learned the administrative details concerned with the issuance of passes

and furloughs and the other minutiae of a military hospital.

In the second phase of training, students assisted at operations, and,

under guidance, themselves performed neurolyses, neurorrhaphies and concomitant stimulation studies, and maneuvers designed to restore nerve defects. They learned to repair skull defects with tantalum or acrylic resins.

They also observed the exposure of the brain for the resection of tumors.

Acute battle-incurred head injuries were, of course, not seen in Zone of Interior

hospitals, but acute head injuries were seen in practically all station hospitals, as the result of training accidents, traffic accidents, brawls, and similar

causes. They were not seen nearly as frequently in the general hospitals of

11 These consultations were hmong the important duties of all neurosurgical centers, as a few illustrations will show.

At Hammond General Hospital, there were 1,203 consultations in the year ending on 1 September 1945. At McCaw General Hospital, there were 1,595 between April 1943 and September 1945, Including 222 on the outpatient service. At

O'Reilly General Hospital, there were 4,317 during the total period of operation of the neurosurgical center.
ZONE OF INTERIOR 29

the Zone of Interior except in patients for whom the general hospital was

acting as a station hospital.

In the third phase of training, tile students learned, in tile postoperative

wards, tile care of patients with battle-incurred injuries and the uses of penicillin and the sulfonamides. They also studied the results of nerve regeneration.

In addition to the clinical work outlined, student officers studied neurosurgical roentgenograms as part of their intensive training, joined the hospital

staff at conferences and autopsies, and also continued cadaveric dissection, to

complement the study of peripheral nerve visualization at the operating table.

This training was ideal for future work in a neurosurgical center in the

Zone of Interior, though it was obviously merely supplementary to tile experience with fresh wounds which could be gained only by service in an active

theater of operations. In retrospect, however, it can fairly be said that the

training program in neurosurgery accomplished the ends for which it was

designed. When the students had concluded the course, they could be assigned as assistant neurosurgeons either in overseas units or in neurosurgical

centers in the Zone of Interior. No method of formal training can fit a neurosurgeon to care for gunshot wounds of the brain and spinal cord received in

battle; he can gain that experience only under field conditions. A background

of neurosurgical anatomy and of the principles of diagnosis and therapy is,

!iowever, essential, and( it was adequately presented in the first phase of the

neurosurgical training program, while, in the second phase, training ill reconstructive neurosurgery was thorough and adequate. Many of these young

neurosurgeons were working in a field entirely alien to their earlier experience,

but, through application and devotion to duty, they developed remarkable

skill in a new and difficult field, and they were largely responsible for whatever

measure of success was achieved by the neurosurgical centers.

Evaluation of training program.-The courses at the University of Pennsylvania were suspended early in 1945, after the supply of qualified general

surgeons was exhausted and the neurosurgical needs of the Medical Department had been fulfilled. If they should be reestablished, in some future war,

the curriculum (appendix A) should be further scrutinized, with the idea of

eliminating unnecessary and pragmatic courses unrelated to the demands of

this special field of military surgery.

In the opinion of many observers, the neurosurgical training program

was one of the major medical accomplishments of the war. In the prewar

years, there was a decided tendency in all of the surgical specialties, including

neurosurgery, to underestimate the value of a sound background in general

surgery as a preliminary to specialized training. Neurosurgeons, more than

other specialists, were inclined to emphasize the theoretical rather than the

practical aspects of their specialty. As a result of the wartime experience,

it can now be said, without qualification, that a sound background in general

surgery is highly desirable in the training of the civilian neurosurgeon and is an

essential requirement in time of war.

The success of the training program in neurosurgery, the first such course

455735.-5&-----3
30 NEUROSURGERY

to be set up, also taught another important lesson, that the same sort of quick,

intensive training is applicable to all specialties. This is a possibility which

is of great importance from the military point of view in the prospects it opens

of quickly overcoming shortages of specialists in one field or another.

Other Methods of Training

The well integrated and practical training available in the neurosurgical

centers in the Zone of Interior was made available to other medical officers in

addition to those formally enrolled in courses of instruction:

1. Partly qualified neurosurgeons were in numerous instances admitted

directly to the neurosurgical centers for practical training in the military

aspects of their specialty, upon recommendation by civilian neurosurgeons of

accepted standing. This simplified procedure proved a great saving of time

and effort. Indeed, if time had been available for administrative and operative

duties and if facilities for neuroanatomic dissection could have been provided,

the entire task of neurosurgical training might well have been made a function

of the neurosurgical centers under the direction of the chiefs of service.

2. Medical Corps officers with an initial background of neurosurgical

experience greater than that of the usual student officer were assigned to the

neurosurgical centers on temporary duty, to gain practical experience.

3. Neurosurgeons returned from active theater duty also often found it

profitable to orient themselves in terms of rehabilitative neurosurgery through

the facilities of the centers.

4. Refresher courses were provided at the centers for small groups of

officers, seldom more than eight at a time, who were assigned to the first and

second echelons of medical service. The courses lasted 4 days each and were

presented under the direct tutelage of the chief of section. During the period

of instruction, combat-incurred injuries were rapidly reviewed from the point

of view of (1) conditions under which the soldier becomes a casualty, (2) causes

of wounds, (3) first aid, (4) emergency medical treatment, (5) treatment in

other echelons of medical support, and (6) timelag from battlefield to evacuation

hospital. All available types of battle casualties were studied in ward rounds,

and rehabilitation was made a more personal matter to these officers by their

service as assistants at the operating table. The general relationship between

the fresh neurosurgical injuries and their eventual repair was discussed in a

final conference with the chief of section at the conclusion of the 4-day period

of instruction. Suitable recent reports on neurosurgical subjects were mandatory reading during the course.

All the experience in the training program supported the belief that,

in any future war, the procurement of trained neurosurgeons must depend

primarily upon a pool of existing talent supplemented by well-grounded general

surgeons who are taught intensively the well-defined types of neurosurgical

injuries which form a common pattern in warfare. For realistic achievement.,

surgeons in the second group can best begin their training in a rehabilitation
ZONE OF INTERIOR 31

hospital in tile Zone of Interior, after which they can continue it under experienced guidance either in tile field or in the United States.

RECORDS AND VISUAL RECORDING

Standard United States Army medical history forms used in World

War II had evolved from experience. They were generally adequate but were

not satisfactory for recording neurosurgical injuries or illnesses; such records

must be very detailed if they are to be useful. Most neurosurgical centers

overcame this deficiency by the sort of special notations used in many civilian

hospitals. This was ail excellent method in trained hands but was very time

consuming. Much more satisfactory from every standpoint were tile special

forms finally employed, such as the forms for peripheral nerve examination,

head injury, ruptured lumbar disk, and the dermometer chart.

In cases treated by experienced neurosurgeons, the recording was almost

invariably detailed and adequate. In many instances, however, the records

were not satisfactory. A record, for instance, which (lid not indicate the precise

condition of a nerve at debridement or the precise details of previous surgery

might result in an unnecessary operation because of its inadequacy. When

the Peripheral Nerve Registry was set up, the forms prepared for it were sent

overseas; when they were properly emploi ed, they furnished all the information

necessary for later treatment in the Zone of Interior.

Neurosurgery is a specialty in which graphic recording is always useful

and frequently essential. Because all neurosurgical centers did not have

adequate provision for such recording, a great many useful and important

clinical data were lost. In some centers, equipment was provided but trained

personnel to operate it was not, and, again, valuable material was lost. Some

of these deficiencies were eventually remedied but too late to salvage many

data that it would have been most desirable to preserve.

STATISTICAL DATA

Surveys of representative neurosurgical centers in 1944 and 1945 indicated

that about 75 percent of the patient load was made up of casualties from overseas. Peripheral nerve injuries, back injuries, including ruptured disks, and

head injuries constituted, in that order, the important technical problems.

More than half of all patients admitted underwent some sort of surgery. Disposition, however, was fairly rapid; in 1 center, wvith a bed allotment, of 400,

1,541 patients were admitted in the course of a 12-month period.

The lack of an official recurring report from the neurosurgical centers

made it difficult to estimate the patient load in terms of types of injury, character and duration of treatment, and disposition of cases. Some information on

patient load, however, can be secured from figures collected in September 1945.

Each center was requested to submit its own figures on admissions, consultations, operations, and deaths, so that some idea might be gained concerning
32 NEUROSURGERY

these various items. The figures (tables 2 and 3) are not presented as definitive. The same patients, because of transfers from one installation to another,

undoubtedly sometimes appear in the reports of more than one center, and

there may also be duplications in the number of consultations for this or other

reasons. The number of deaths, however, is entirely accurate. It should be

observed that while all fatalities in a neurosurgical center are necessarily

classed as neurosurgical in origin, as is the usual clinical practice, a number of

the deaths in these installations (tables 2 and 3) were actually due to concurrent disease or to other causes entirely unconnected with the original

neurosurgical injury or disease.

TABLE 2.-Patient load in 26 neurosurgical centers at general hospitals in Zone of Interior,

May 1942-September 1945

Hospital Admissions Consultations Operations Deaths

A shford ....... .. .......... .... ....... 3, 206 1,202 2,410 7

Baker ...------ ----------------- 1,502 576 874 2

Birmingham ' ----------------------- 346 101 128 1

Brooke I ..--------------------------..--- 364 490 183 8

Bushnell ------------------------------- 2, 779 2,304 1,755 12

Cushing -------------------------------- 1,883 2,683 1, 289 8

DeWitt -------------------------------- 1,382 493 630 6

England 2 .............................. 5,025 1,715 1,838 13

Fitzsimons I ----------------------------- 305 455 163 12

Halloran - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 728 798 203 5

Halloran ............................... 2, 277 737 908 6

Hammond ------------------------------ 2,505 1,103 1,087 17

Hoff ---------------------------------- 781 943 292 6

Kennedy ------------------------------- 3,880 2,770 1,689 23

Lawson -------------------------------- 4,232 985 1,705 31

Lovell I -------------------------------- 1,081 1,688 742 10

Mayo --------------------------------- 1,935 1,425 1,335 13

MeCaw -------------------------------- 2,217 1,595 1,389 8

McCloskey ----------------------------- 4,500 2,049 1,143 23

McGuire ------------------------------- 2,332 610 1,287 5

Nichols -------------------------------- 3,470 1,912 1,315 29

Northington ----------------------------- 880 938 691 5

Percy Jones ---------------------------- 3,057 2,957 1,948 12

O'Reilly -------------------------------- 4,818 4,317 2,110 24

Schick --------------------------------- 712 1,022 432 4

Wakeman ------------------------------ 2,305 837 761 11

Walter Reed -------------------------- 2,360 2,247 1,526 31

Total ---------------------------- 60, 952 38, 952 29,833 332

SThese centers were transferred or discontinued during the course of the war. Other centers in the list came into

existence at various times In 1942 and operated until after V-J Day.

2 Thomas M. England after 14 November 1944.

' The center at HaUoran General Hospital was operated as a supplementary installation from I July 1943 to 30 June

1944. It was reestablished in January 1945 and thereafter fulfilled all the functions of the usual neurosurgical center.

The material for the two periods of operation was not precisely the same and therefore is presented separately.
ZONE OF INTERIOR 33

TAXLz 3.-Distribution by cause of 33.e deaths in 60,956 neurosurgical admissions in 26

aeurosurgical centers in Zone of Interior, May 1942-September 1945

Cause of death Number Cause of death Number

Cerebral causes: Spinal cord-Continued

Traumas. Paraplegia-Coutinued

Acute injuries ----..------............- 49 Infectlous hepatitis -------------------- 3

Gunshot wound, acute ---------------- 2 Bronchopneumonla ------------------- 2

Gunshot wound, old, poetoperatlvei Bronchopulmonary flstu' .....--------- I

hemorrhage -------------------------- I Pulmonary abscess, multiple-.-... . I

Gunshot wound, old, residual infction. k Respiratory failure, acute ---------

Subdural hematoms, bilateral ------- I Rheumatic endocarditis, acute cardiac

Neoplasms: dilatation------------------.--------

Glioma, type not specified ------ 30 Cardiac embolus -----------------------

Glioblastoma multiforme ----------- - -25 Aneurysm of aorta, dissecting --------- I

Meningloma--------------- ----------- 6 Septicemia, Sin phyocccu. sureas----- I 1

Pinealoma... 5 Retroperitoneal abscess, decubitus

Metastatic tumors ------------------- - 5 ulcers -------------------------------- 2

Medullobiastoma, cerebellar ........... 4 Amylotdosis, decubitus ulcers --------- I

Neurinoma, acoustic ------------------ 4 Cause not reported -------------------- 9

Ependymoma ----------------- - 4 Infections:

Cranlopharyngioma -------------------- 4 Meningitis, tuhereulous --------------- 3

Astrocytoma .......................... 3 Meningitis, pneumococcl -------------- 1

Adenocarcinoma, pituitary ------------- 2 Meningitis, pneumococcle, after myeloAdenoma, pituitary ------------------- I gram -------------------------------- I

Teratoma --------------------- I Meningitis, coccldloldal ----------------- I

Sarcomn, dura, recurrent- I 1 Meningitis, with chronic arachnoiditis,

Infections- postoperative ------------------------ I

Abscess, cerebral 2........... 6 Meningitis, type undetermined -------- 5

Fungus, cerebral, cerebritis ------------- I Neoplasms:

Arachnolditis ------------------------- I Lymphoma ---------------------------- I

Meningoencephalitis -------------------- 3 Syringomyelia ------------------------- I

Encephalitis --------------------------- I Hodgkin's disease ---------------------- I

Interventricular block, cerebral ab- Type not specified --------------------- 5

scess, postoperative ------------- I Traum• s:

Tuberculoma -------------------------- 1 Fracture, cervical cord ----------------- 7

Vascular causes: Gunshot wound, cervical cord ......... 2

Subarachnoid hemorrhage -------------- 2 Ruptured lumbar disk:

Cerebellar hemorrhage, cause unknown. I Aneurysm common Mliac artery, postThrombosis, cerebral ------------------- 1 operative ----------------------------- 1

Aneurysm, cerebral -------------------- 3 Spinal analge-ia .......---------------- I

Miscellaneous causes: Hemorrhage Mliac artery, postoperative- I

Tic douloureux, postoperative hemorrhage . ..-----------------------------. Total ------------------------------ 8

Atresia aqueduct of Sylvius ------------ 2

Hydrocephalus, cause undetermined.. - 1 Miscellaneous causes:

Status epilepticus ---------------------- 2 Hepatitis, acute .--..............-------- 2

Pancreatitis, acute hemorrhagic ..- ----. I

Total -------------------------------- 202 Carcinoma. cervical region ------ --------- I

Stab wound, chest -------------.. ....---- I

Spinal cord: Overdosage drug ....-----------.--------- 1

Paraplegia: Melanosarcoma, chest wall --------------- I

Urinary sepsis ------------------------ 14

Urinary sepsis, with cerebellar abscess. I Total ------------------------------- 7

Uremia, cerebral edema ----------------

Meningitis, abscess about foreign body. 1 Cause not stated I ------------------------------ 45

Removal of foreign body, postoperative. I

Cachexisa . .--------------------------- 4 Grand total ----------------------------- 332

'Including 2 deaths while on furlough.
34 NEAI'R8URGERY

VISITS TO HOSPITALS

One of the duties of the consultant in neurosurgery in the Office of tile

Surgeon General was to visit tile neurosurgical center. to evaluate personnel,

observe the organization and management, disseminate information, demonstrate techniques, correct errors, and, in general, survey the center and report

on its performance and results to the Chief Consultant in Surgery, Office of the

Surgeon General.

The following (summarized) reports of two of these visits, the first in early

December 1944 and the second in the middle of April 1945, are presented as

typical.

December 1944

When the - general hospital was visited, there were 1,820 patients. of

whom 587 were on the neurosurgical section. Of the 38 medical officers, 6

were on the neurosurgical service. The center was in full action, heavy

operating-room schedules being kept, with teams working both morning and

afternoon. In November, 132 neurosurgical operations had been done. There

was a backlog of 22 cases, estimated as a week's work. The operating rooms

were well equipped, except that there was no stimulator, and were well

supervised.

The following report was made:

Staff.-Major - is an adept, hard-working neurosurgeon, with Board

qualifications. He is particularly interested in head injuries and their sequelae

and is a student of electroencephalography. He is an able administrator and

has a closely knit, efficient organization. He may lack some initiative and

drive, posibly because he came from a very inactive professional service

elsewhere. Another explanation may be that the chief of surgery is an

extremely dynamic individual, with interests in another field, and Major

may possibly be submerged by the association.

Lieutenant is a scholarly, technically adept military surgeol, of

considerable promise. He is held in high regard by the chief of the neu.-osurgical service.

Lieutenant - is a very industrious and conscientious surgeon, though

he lacks experience and training in nerve surgery.

The student officer will never be a military neurosurgeon and should be

reclassified as a ward officer.

General organization.-Patients are admitted directly to the neurosurgical

section, and there is no close association with the recently established neurological section as far as military injuries are concerned. The usual preoperative

studies are carefully made, but no special studies are undertaken, and few

patients have undergone electrical diagnostic studies. These, when requested,

are done very well, but they are unduly prolonged, and the timelag may be 2 or

3 weeks. It is obvious that a simplified method of electrical diagnosis is needed,

probably to be carried out under the supervision of the neurological section.
ZONE OF INTERIOR 35

There is some confusion at present about the type of cases to be sent to

the convalescent hospital for tile center, particularly in regard to the facilities

available there for physioti! erapy and followup care. Patients are therefore

held at tile center until definite signs of regeneration are available.

A combined orthopedic-neurosurgical ward, where combined injuries are

studied by members of both staffs, is serving a valuable purpose.

Specific professional problems.-These problems are as follows:

1. Nerve injuries.-Nerve explorations are done under general anesthesia,

and no stimulator is available. The staff seems somewhat doubtful about the

rather obvious advantages of local anesthesia, even without a stimulator.

The observed incisions were far too limited in scope. The staff seemed

unfamiliar with standard methods of far-reaching nerve mobilization and,

indeed, doubted the wisdom of this procedure. As a result, far too many bulb

sutures had been performed with scant indication for this distinctly secondgrade type of nerve repair. The impulse for secondary operation was lacking.

There was also a lack of appreciation of the value of early definitive

treatment of nerve injuries. The significance of detrimental changes in the

distal stump was not well appreciated. Many patients were undergoing

posture changes in various types of splints, to further joint movement, or were

undergoing nerve stretching, to facilitate, theoretically, subsequent operative

procedures. This is a theory that stems directly from lack of knowledge of

other mobilization methods.

There was no neuropathologic check of distal or proximal stumps, although

some valuable work in this field had only recently been carried out in this

center.

Finally, both postoperative splinting and other hand splinting seemed

poorly understood. With short incisions and lack of nerve mobilization, the

hand was frequently-and quite unnecessarily-dressed in acute flexion.

Periods of postoperative immobilization were far too short, averaging about 3

weeks for sciatic nerve, and immobilization was limited to a knee case. The

radial nerve splint was misused, the hands being immobilized, to all intent, in

the Percy Jones splint, which was not correctly applied, so that no patient

could flex fingers or hands. Patients in casts were also not using mobilizing

splints.

These various points were discussed with the staff. It was recommended

that two of the officers be sent to another center, on temporary duty, for further

training in peripheral nerve surgery. It was also recommended that the hospital

pathologist be urged to review all peripheral nerve material.

2. Head injuries.-These were very well handled by Major -, and a

valuable and intensive study of the late results of combat-incurred wounds is

under way. An electroencephalograph is available.

3. Paraplegia.-There are 13 such patients, with 8 personnel in attendance.

The patients are on the urological ward, and intermittent urethral bladder

irrigations are carried out with solution M. There are no overhead frames or

reconditioning equipment, but they have been ordered. One patient was
36 NEUROSUIRGERY

relieved of pain by (,ordotomy. There are very few decubitus ulcers, because

of careful nursing, and all arrangements are very satisfactory.

4. Ruptured disks.-The new regulations concerning treatment were

explained. Too much effort had been made previously to return to duty

obviously unfit men who had no special qualifications for service.

Summary.-This is one of the best neurosurgical centers, though the

personnel need further training in more refined peripheral nerve surgery. It is

unfortunate that foil a number of reasons the former interest in combined vessel

nerve injuries has diminished. The explanation seems to be that the emphasis

is now entirely on the vascular lesion, which represents a threat to life, and not

on the neural dysfunction, which is a threat to rehabilitation. The opportunity

for a very fruitful study of these combined disabling injuries is being neglected.

The solution might be the direct assignment of a neurosurgeon to the vascular

service. The orthopedic-neurosurgical ward is of value in expediting the

treatment of the peripheral nerve injury.

April 1945

The neurosurgical bed allotment in the - general hospital, formerly

1,440, had just been reduced to 1,000. At the time of the visit, there were 320

neurosurgical patients in the hospital and 300 on furlough. The surgical backlog of 50 patients consisted in large part of recent acquisitions. Eight officers

were assigned to the neurosurgical service.

The following report was made:

Staff.-Major - is a well-trained, mature, hard-headed surgeon, a fine

organizer, and a good leader.

Major - is probably a good neurosurgeon but is a disappointing section

chief with a poor viewpoint toward military service.

Captain -, who is on limited service, is an enthusiastic, very energetic,

fine military surgeon, though still in the developmental stage.

Captain is an older man, a recent student, but adept in routine

affairs. He is on limited service.

Lieutenant - is another promising military neurosurgeon, who should

be promoted. He is a former student and is on limited service.

There are three ward officers.

Only three of the officers assigned to neurosurgery are first-rate military

neurosurgeons. Major-- will shortly report from overseas, and Major

who is being held at - General Hospital for no good reason, should be returned to this hospital.

Organization.-Lack of neurologists has previously prevented a common

admitting ward, and the reduced size of the neurosurgery section at present

makes this plan unnecessary. Exchange of patients with the one neurologist

is prompt, and no cases are held on the section unnecessarily. At this time,

the section is divided into head, peripheral nerve, paraplegic, combined ortho-
ZONE OF INTERIOR 37

pedic-neurosurgical, and officers' wards, and these divisions fit well into the

permanent and semipermanent structures of the hospital.

Head injuries.-All head injuries, skull defects, tumors, and the like are

segregated under Captain -, who, with Major -, is directly interested in

several important problems in this field. The most impressive work, now under

way for 2 years, has been a study of speech defects, in the recognition and

treatment of which Captain is a recognized authority. Ninety-nine

patients have been followed to date, and treatment has been initiated in all

severe aphasics. These studies will be reported in detail in the Bulletin of the

U. S. Army M1ledical Department and in a speech journal. This work is very

worthwhile.

A second fruitful study is concerned with a description of occipital lobe

injuries with visual field defects and their prognosis. This work will also be

reported.

A third study concerns the use of tantalum foil between the dura and

cerebral scar after removal of dural-cortical scar adhesions. It is related to the

method of cranioplasty used in this section. Plates are not swaged but are

formed by hammering. Operations are under general anesthesia. The dura is

opened and the meningeal-cortical sear is divided; its extent and depth are

determined by brain puncture. Tantalum foil (0.00025) is then placed as noted,

and cranioplasty is carried out by the tantalum wedge inlay method.

This study is completely uncontrolled as an effort to control either posttraumatic symptoms or convulsions, particularly the latter, since no electroencephalographic studies are available. In past reports, two adverse reactions

to tantalum foil have been noted. The advantage of using local anesthesia

in cranioplasty was discussed with the staff.

Thirty-seven other head cases were reviewed. The technical results were

good. There were no complicated cases. Six early cranioplasties were

reviewed. Various simple techniques were used, and all results were good,

without complications. No patients were observed with infection or retained

skull fragments.

Peripheral nerve injuries.-Peripheral nerve cases were also segregated.

Operations on several patients were observed. The technique was delicate.

but there was a lack of use of major transposition procedures. The advantages

of local anesthesia were not well appreciated. Tantalum wire was used, but

foil was used infrequently. Postoperative positioning was adequately maintained for sufficient periods of time. Splinting was poor, and the mobilizing

radial nerve splint was introduced. Few complications were seen. The

Peripheral Nerve Registry was explained in detail. It is believed that the

use of the registry forms will stimulate corrections of any gross defects in the

care of these patients.

Combined orthopedic-neurosurgical section.-This (new) section embraces

three large, well-designed wards, on which 70 patients were examined, most

of them recently admitted. As in other centers, combined injuries of the

radial nerve and humerus and of the sciatic nerve and femur were most common.

455735T--58.-.-
38 NEUROSURGERY

One patient was a striking illustration of the advantages of early surgical

attack on sciatic lesions. None of the patients with injuries of the upper

extremity had been received in any kind of mobilizing splints; at that, their

hands looked considerably better than some observed after splinting. Only

two frozen hands were observed in which cast fixation could be implicated,

and, in both cases, vascular ligation had been necessary. Major - and

Lieutenant -, who are detailed to this section, have an intelligent point

of view about the extremity as a whole. Mobilizing radial splints were

instituted in all appropriate cases, and the necessity for early sciatic nerve

exploration was stressed.

Paraplegia.-The paraplegia ward, situated on the second floor of a

permanent building, is large, airy, sunny, and rather impressive. Only the

very ill were segregated. The few officers were placed in large 4-bed wards.

All beds have Balkan frames, and reconditioning is established. The mattresses

are somewhat soft, but bedboards have been ordered.

The control of urinary sepsis is in the hands of Captain -, an enthusiastic, impeccably trained urologist. Details of his self-controlled bladder

irrigation sets and reports of his various studies have been published.

Forty-five patients were examined, 19 with complete and 26 with incomplete injuries. Sixteen of the patients with complete injuries had decubiti,

though the nursing care was thorough and good. Surgical treatment of the

ulcers had been a little tardy but was now under way. Only a few nutrition

studies have been made. The incomplete paraplegics were mostly ambulatory,

but wheelchairs were few, and this deficiency has retarded more active ambulation for the complete paraplegics. Metal wheelchairs should be available.

Morale is high, and the whole ward, though new, already represents a

high degree of aggressive professional care.

Ruptured disks.-There were few patients and no evidence of overemphasis

upon this problem.

General comments.-Physiotherapy is at present quite inadequate for

the patient load. This is to be remedied by a new building.

Six fairly large operating rooms are available, but equipment has been

slow in arriving.

Neuropathology is nonexistent.

The electroencephalograph is at the hospital but still in crates because

permission to build the necessary auxilliarv equipment, and installation has

not yet been received.

There appears to be scant central control of the neurological load.

Electrodiagnostic methods are almost nonexistent because of the heavy

physiotherapy load and the lack of apparatus.

Photography, for some reason, is under Public Relations, which seems a

poor arrangement for securing clinical illustrations.

Summary.--In all, 145 patients were examined. This is a good neurosurgical center, and there is nothing beyond a few technical and supply details

to worry about in it.
CHAPTER II

The Mediterranean (Formerly North African)

Theater of Operations

Eldridge H. Campbell, Jr., M. D.1

EVACUATION AND HOSPITALIZATION

Neurosurgical policies in the Mediterranean (formerly North African)

Theater of Operations, United States Army, were so largely dictated by local

conditions of fighting and terrain that some mention of these considerations

is essential for backgound. In the Tunisian campaign, evacuation of casualties,

like supply, was extremely difficult because of the wide dispersion of fighting,

the frightfully bad roads, the inadequate means of transportation, and the

distances from the battlefield to the nearest hospitals. During the fighting

in southern Tunisia, it was sometimes necessary to move patients 60 to 110

miles by ambulance to the nearest evacuation hospital, from which another trip

of 400 miles by train (later by air) was necessary to reach the nearest general

hospital at Oran. As a result of these unfavorable conditions, some of the

more severely wounded patients died, chiefly of shock, before an evacuation

hospital could be reached.

The fluid status of the fighting frequently made it impractical or entirely

impossible to bring evacuation hospitals farther forward. The plan was therefore evolved of placing field hospital platoons within litter-carrying distance of

the divisional clearing stations. These hospitals, the mission of which was

limited to the care of patients with any type of injury which would make them

nontransportable, were small, flexible, and highly mobile. After a little practice, it was possible for their personnel to move and set them up within a few

hours. Professional work in them was chiefly done by specialized teams from

the 2d and 3d Auxiliary Surgical Groups. Living conditions in field hospitals

were often difficult, and the workload was likely to be heavy, but the outstanding service rendered in them resulted in the saving of many lives and limbs.

SA consultant In newmsurgery was never formally appointea in the Mediterranean theater. When the need arose,

Dr. Campbell, then a lieutenant colonel In the Medical Corps, represented the consultant in surgery to the Theater

Surgeon. Gaps in this chapter are due to this fact; they could not be overcome because of Dr. Campbell's death while the

history was In preparation.

89
4() NEUROSURGERY

NEUROSURGERY IN FORWARD HOSPITALS

Except in unusual circumstances, however, neurosurgery did not prove

practical in field hospitals, for several reasons, as follows:

1. There was seldom enough work in a single platoon to keep members

of a neurosurgical team occupied with their specialty.

2. The attachment of neurosurgeons to field hospitrls therefore involved

a waste of specialized personnel, which was always in short supply and which

could be put to better use in larger installations, in which there was more neurosurgery to be done.

3. The policy of placing neurosurgeons in field hospitals and assigning

them to other surgery when there was no neurosurgery to be done di(l not solve

the problem of neurosurgery in forward hospitals. It involved the waste of

neurosurgical personnel already mentioned, and it did not promote efficient

surgery, since neurosurgeons had no training in the type of surgery (abdominal,

thoracic, and vascular) which chiefly occupied the personnel of field hospitals.

The problem was therefore solved in two ways. The young general

surgeons with broad training who were placed in the field hospitals careied

out such immediate treatment as was necessary in neurosurgical patients, who

were then evacuated to the rear as promptly as possible. If serious neurosurgical injuries occurred in nontransportable patients, a neurosurgeon came

forward from the nearest evacuation hospital and performed the necessary

surgery.

The management of any type of neurosurgical injury at the level of the

field hospital presupposed, of course, the provision of special equipment, such

as suction apparatus, electrocautery, and silver clips, but this contingency was

readily cared for by slight changes in the table of equipment for field hospital

units.

Evacuation Hospitals

Evacuation hospitals proved the most practical installations for definitive

neurosurgery in forward areas. Under favorable circumstances, they were

located between 10 and 50 miles behind the frontline, on the direct line of

evacuation or as near to it as possible. They could practically always be

reached within a maximum of 4 hours, and sometimes within a minimum of

30 minutes, after casualties had left the clearing station. They possessed

numerous advantages over the field hospital. They were usually behind the

zone of enemy shelling, though at the Anzio beachhead this was not true,

nor was it always true elsewhere. Reasonably adequate operating facilities

were usually available. A special ward, with trained personnel, could be set

aside for neurosurgical patients. Allied specialties, such as ophthalmology

and maxillofacial surgery, were usually represented, which simplified the

consultations frequently necessary in neurosurgical injuries. Finally, patients

could be held at an evacuation hospital after surgery until they were ready

for the much longer trip to the general hospital in the base section.
MEDITERRANEAN THEATER 41

Neurosurgical Teams

The advantages listed for evacuation hospitals often proved purely theoretical in the North African theater, as has already been indicated, and sometimes

in the later Italian fighting also. The trip from the frontlines to the hospital

was frequently long and rough. Furthermore, from the standpoint of the

neurosurgeon even more than of other surgical specialists, there was likely to

be too much or too little to do. Because of long distances between medical

installations in which definitive care could be given, it was the natural tendency of evacuation officers to send the majority of patients with head injuries

to the nearest hospitals, with the result that, within a few (lays, the neurosurgical teams working in them would be overwhelmed with work while teams

in hospitals farther to the rear would be almost idle.

The uneven distribution of casualties was compensated for by supplementing neurosurgical teams in forward hospitals with teams from hospitals farther

to the rear. Although this plan had the effect of concentrating neurosurgical

casualties at the most forward establishments, it was found practical to handle

such concentrations without difficulty. Later in Italy, in the Fifth U. S. Army

area, where the plan was fully effective, it became evident that two neurosurgical teams working 12-hour shifts could accomplish better work, and proportionately far more, than a single team working for 24 hours.

The flexible use of neurosurgical teams in North Africa was found impractical only in the few instances in which lines of evacuation did not converge for

long distances. The wisdom of the judicious placement of specialized medical

personnel was clearly established. Had the principle of pools of surgical

teams, rather than inflexible tables of organization, been in effect for all hospitals, including station and general hospitals, in the communications zone, and

had all army and theater consultants had complete authority to move personnel

quickly, a more efficient use could have been made of the limited supply of

neurosurgeons.

NEUROSURGICAL CENTERS

It was originally the plan of the surgical consultant to the Surgeon, Mediterranean theater, to organize at the general hospital level two or more centers

in which patients with neurosurgical injuries and neurosurgeons with specialized

talent could be brought together. Each neurosurgical service was to be in

charge of an experienced neurosurgeon, under whose direction less experienced

neurosurgeons from other base hospitals would work. As part of the program,

neurosurgeons in forward hospitals would be exchanged from time to time with

those at the special centers.

The advantages of this plan were obvious. Neurosurgeons working at the

base would thus meet at first hand the problems of the management of head

injuries, for instance, while they were still acute, while surgeons working in

forward hospitals would become familiar with early reparative neurosurgery

and with the diagnosis and treatment of complications of neurosurgical injuries.
42 NEUROSURGERY

The medical center at Bizerte was selected as admirably suited for the

institution of this plan. since its five general hospitals and several station

hospitals were situated within an hour's ambulance haul of each other. The

33d General Hospital was selected as the neurosurgical center for several reasons. It was centrally located in respect to the other hospitals at Bizerte. It

wis readily accessible otherwise, being near the Sidi Ahmed airport and the

Karouba (locks. All patients coming into the base underwent triage at this hospital. It already had two neurosurgeons on its staff, and it had operating-room

and ward nurses already experienced in neurosurgery. Still later, a medical

artist was assigned to the hospital.

In spite of these advantages, however, the program devised worked only

reasonably well when the 33(1 General Hospital was in operation as a neurosurgical center. The influx of neurosurgeons, it is true, engendered new enthusiasm on the part of all concerned. Better work was accomplished. Information on neurosurgical policies and practices was more easily spread. On

the other hand, the system of exchange of personnel between army and base

areas was not put into operation with any real degree of efficiency for more than

a y"ear. Even more important for the success of the plan, some hospital commanders recalled their organically assigned nuerosurgeons who had been attached to the other installations after they had served in them only a short

time. The resulting loss of talent, already in critically short supply, was

serious because of the heavy concentration of neurosurgical casualties at the

33d General Hospital. The result was that specialized talent was wasted in the

hospitals not serving as specialized centers because they did not receive neurosurgical casualties, who were still being sent to the neurosurgical center. The

neurosurgeons recalled to them frequently had so little to do in their own field

that they were put to work in general and orthopedic surgery.

UTILIZATION OF NEUROSURGICAL PERSONNEL

In spite of the limited success of the plan of specialized centers in North

Africa, the opinion persisted that only by this or some similar method could

critically short specialized personnel be used to the best advantage. Existing

shortages, furthermore, were aggravated by an uneconomical use of neurosurgeons for administrative and other nonspecialized duties. On one occasion,

for instance, at the time of extremely heavy fighting at Anzio and Cassino,

several forward hospitals each had 150 or more wounded men awaiting operation, and all hospitals in the base were also extremely busy. The 33d General

Hospital was then staging in Naples, and its commanding officer was requested,

through the Surgeon, Peninsular Base Section, to furnish 11 general surgeons

and neurosurgeons to work in forward medical installations. These officers

were assembled on a volunteer basis, but, instead of being taken to the forward

hospitals for which they had volunteered, they were taken to Naples, where

they were assigned such nonmedical duties as checking prostitutes.
MEDITERRANEAN THEATER 43

Transfer of personnel was also frequently very slow. At the beginning of

the North Apennines campaign, the Consultant in Surgery, Office of the

Surgeon, Fifth U. S. Army, Maj. (later Col.) Howard E. Snyder, MC, urgently

requested, through channels, that several surgical and neurosurgical teams be

loaned from the base. Since the 33d General Hospital was then inactive, several

general surgical and neurosurgical teams were provided, all on a volunteer

basis. Although there was complete agreement on the part of all concerned

that these teams were needed and should be supplied, it was 10 days before the

necessary orders for their movement were received.

These were exceptional instances, it is true, but they were not isolated,

and they help to explain why, until late in the war. neurosurgical personnel in

the Mediterranean theater was always in short supply and was not used as

efficiently as it might have been.
CHAPTER II1

The European Theater of Operations

R. Glen Spurling, M. D.

The Professional Services Division created in the Office of the Chief

Surgeon, Headquarters, ETOUSA (European Theater of Operations, United

States Army), in the summer of 1942 was composed of senior consultants in

all major specialties. After their appointment, these consultants originated all

policies pertaining to specialized care and seided such problems concerned

with it as were referred to them. From an administrative standpoint, the

activities of the senior consultants were limited to hospitals in the rear echelons

of the theater; that is, in the communications zone and in the advanced section

zone. Actually, however, their services were fully utilized by the surgeons of

the armies, an(d at no time during the active campaign, from a neurosurgical

standpoint, were difficulties encountered in coordinating the professional

services of hospitals in the forward and rear echelons.

This account of the activities of the neurosurgical consultants in the

European theater therefore properly begins with the statement that, at all

times, the senior consultant in neurosurgery had a completely free hand in all

professional matters, as a result of the full cooperation given him by the chief

of the Professional Services Division and the Theater Chief Surgeon. Numerous

difficulties were encountered, but they were never on this level. Not a single

recommendation of professional policy was disapproved by either of these

superior officers, and their advice, which was always available for the asking,

was invaluable in expediting and correlating the suggestions made regarding

professional practice.

The first senior consultant in neurological surgery, in the European

theater, Lt. Col. (later Col.) Loyal Davis, MC, was appointed in August 1942

and served in the United Kingdom from 6 September 1942 until 13 September

1943, when he was relieved because of illness. Maj. (later Lt. Col.) John

Scarf, MC, acted as consultant in the specialty until 15 March 1944, when

Col. R. Glen Spurling, MC, succeeded him. Colonel Spurling served until

12 July 1945, when the neurosurgical consultant system in the European theater

was terminated.

FUNCTIONS OF THE SENIOR CONSULTANT

IN NEUROSURGERY

In the structural organization of the Medical Corps in the European

theater, the senior consultant in neurosurgery was directly responsible to the

45
46 NEUROSURGERY

chief of the Professional Services Division and, through him, to the Theater

Chief Surgeon. The over-all function of this consultant was to formulate

professional policies relatin•g to his specialty, to plan the structural organization

of neurosurgical care in terms of day-to-day as well as long-term requirements,

and to recommend alterations in plans and policies to meet special situations

as they arose.

Evaluation and Assignment of Personnel

The most important, function of the senior consultant in neurosurgery

concerned the supervision of neurosurgical personnel in the theater. Initial

assignments had frequently, and of necessity, been made without special reference to professional ability and training, either on the basis of sheer expediency

or to satisfy table of organization requirements. With the objective of placing

each neurosurgeon in a position in which his abilities and capacities could best

be utilized, the evaluation of all personnel in the European theater was a

continuous process both before and after D-day. Both senior consultants in

neurosurgery already knew personally many of the neurosurgeons assigned to

the theater. It was their business to study the training, experience, ability,

and temperament of those they did not know, and to evaluate the performance

of all neurosurgeons.

Changes in assignment were frequently recommended as a result of this

analysis. Some recommendations had to do with more efficient utilization of

personnel, who were always in critically short supply and wastage of whom

was particularly to be deplored. Other recommendations concerned the transfer of less experienced neurosurgeons to positions in which their work could be

supervised by more experienced officers. A few assignments were deliberately

changed in order to utilize officers who, under certain conditions, might easily

have become emotionally upset and who, because of the changed assignment,

proved to be useful and productive surgeons.

The intimate knowledge concerning each neurosurgeon, necessary for his

appropriate assignment, was acquired by the senior consultants in neurosurgery

by regular visits to hospital installations at all levels, as well as special visits

when special needs or difficulties arose. These opportunities were utilized in

various ways. Meetings were held with neurosurgeons in evacuation and

general hospitals, in an endeavor to unify policies and practices, clarify new

directives, and generally insure not only that the intentions of the neurosurgical

section of the Professional Services Division, Office of the Chief Surgeon,

Headquarters, ETOUSA, were carried out but also that their principles were

understood, so that they could be applied intelligently. The senior consultant

acted as a professional consultant on difficult, obscure, or important. cases and

frequently was in the operating theater for purposes of demonstration and

instruction.

Before D-dav, and in the early days of the European campaign, when all

general hospitals were located in the United Kingdom, it was possible for the
EUROPEAN THEATER 47

consultants to exercise personai supervision oer all professional personnel in

them. As general hospitals were transferred to tile Continent in increasing

numbers, and as the battlefield extended over a greater area, more of Colonel

Spurling's time was spent on the Continent and less could be spent in the

United Kingdom Base. The difficulties which might have arisen from his

prolonged absences were avoided by the appointment of a regional consultant

in neurosurgery for each hospital center in the base.

The chief responsibility of the regional consultants concerned tie prompt

and accurate triage of neurosurgical patients, but their services were also available to the surgical coordinator of each hospital center for the implementation

of neurosurgical policies and for advice concerning the assignment and reassignment of neurosurgical personnel. They were responsible to the senior

consultant for any departures from official policy.

At the request of the consulting surgeons of the armies, neurosurgical

consultants had been named for each army before it went into action on the

Continent. These consultants were assigned to evacuation hospitals on

temporary duty while functioning in a consultant capacity under the supervision of the surgical consultant for each army. It was their duty to advise

the surgical consultants concerning neurosurgical policies in the army; to visit

the evacuation hospitals where, as a result of the critical shortage of neurosurgeons, less experienced men were necessarily in charge of services; and, by

instruction and demonstration in the hospital wards and operating theaters,

to attempt to improve the quality of neurosurgical care of battle casualties.

Whenever facilities prevented the prompt evacuation of casualties to general

hospitals, patients with complicated neurosurgical injuries were transferred to

hospitals to which experienced neurosurgeons were assigned.

Informal conferences regarding the care and evacuation of neurosurgical

cases in the field were held almost weekly with Col. Joseph Augustus Crisler,

MC, Consultant in Surgery, Office of the Surgeon, Headquarters, First U. S.

Army, both before and after D-day, and relations with the surgical consultants

of the other armies in the theater were equally close and cordial. The facilities

of the Office of the Senior Consultant in Neurosurgery, Office of the Chief

Surgeon, Headquarters, ETOUSA, were always available to army neurosurgical consultants, but, on the whole, the press of circumstances made it

necessary for them to make their own decisions. The competent performance

of their duties by these consultants played an important part in elevating the

standards of neurosurgical practice in evacuation hospitals.

Equipment

Perfecting the distribution of physical equipment and supplies was another

important phase of the work of the senior consultant in neurosurgery in the

European theater (p. 74). As he moved from one hospital to another, lie was

able to observe deficits, to note what was in short supply and what was in

excess, and to recommend the correction of shortages and excesses alike. He
48 NEUROSURGERY

was also able to report on the usefulness and value of new equipment and to

see to it that it was properly used in the installations in which it had been

placed.

Liaison

Liaison with appropriate medical officers in the Allied forces was another

duty assigned to the senior consultant in neurosurgery. The liaison was productive of good will as well as the exchange of medical information, which

often was of great importance. It enhanced the medical prestige of all Allied

medical services and was a matter of necessity in forces destined to operate as

a unit under a single supreme commander.

During his period of service, Colonel Davis accompanied the chief surgical

consultant in the theater on the joint Anglo-American Medical Mission which

visited the Soviet Union early in the summer of 1943.

ASSIGNMENTS OF NEUROSURGICAL PERSONNEL

The consultant system in neurosurgery was set up in the European theater

in September 1942. The first activities of the neurosurgical section were conducted under considerable difficulty because of the personnel situation. Although neurosurgery is a highly specialized field, neurosurgeons had been

removed from the tables of organization for general hospitals early in 1942.

When Colonel Davis reached the theater, in September 1942, he found that the

only two neurosurgeons then in the United Kingdom were functioning in their

respective organizations under the guise of "septic" surgeons. A third neurosurgeon, who arrived a little later, functioned in the same capacity. When

the 3d Auxiliary Surgical Group arrived in England, the two neurosurgeons

assigned to it were sent on with it to North Africa.

In the fall of 1942, when neurosurgical work was limited to civilian-type

injuries, the two general hospitals in the theater, to which qualified neurosurgeons were assigned, were entirely capable of handling all the craniocerebral,

spinal cord, and peripheral nerve injuries that were encountered. All such

casualties had to be transferred to one or the other of these organizations

because the three other general hospitals then in England did not have on their

staffs officers with the proper professional qualifications to care for them.

This situation obviously would not meet the requirements when battle casualties would be received in large numbers.

In spite of Colonel Davis' endeavors to secure additional personnel, experienced neurosurgeons continued to reach the European theater very slowly, and,

as of 1 April 1944, there were only seven fully qualified specialists in the United

Kingdom. Twenty-one other medical officers had had, according to their

records, some neurosurgical experience. All of them had been interviewed

and their qualification cards had been completed by Major Scarff, who had

acted as neurosurgical consultant during the interim between Colonel Davis'

return to the Zone of Interior and Colonel Spurling's arrival in England in

March 1944, but their actual abilities were unknown. During April 1944,
EUROPEAN THEATER 49

general hospitals arrived in tile theater almost daily; however, few had neurosurgeons assigned, for the revised tables of organization for 1,000-bed general

hospitals, which provided for a neurosurgeon (C-3131),' had not vet become

effective. As a result, by 1 May 1944, the number of qualified neurosurgeons

in the United Kingdom with full training and sufficient experience to head

services in large general hospitals had increased to only 11. Concurrently, the

number of medical officers with some neurosurgical training, whose qualifications were, however, either unknown or unproved, had reached only 30.

Visits to Hospitals

Summarized accounts of visits to hospitals in the United Kingdom Base

before D-day will indicate how these inspections were utilized for the evaluation

anti proposed reassignment of neurosurgical personnel.

15 December 1943.-The chief of the surgical service at the -th

General Hospital is a forceful, forthright officer, who takes the direct approach

to all problems and pursues them aggressively until results are achieved. He

has the strong loyalty of his officers, and the morale of the unit is high. He is

a general surgeon of considerable experience and competence.

There is no neurosurgeon in this unit and nobody in it who professes to

know very much about the care of neurosurgical injuries. This hospital,

fortunately, is less than an hour away from the -th General Hospital,

where there is a good neurosurgeon. It was therefore agreed that whenever

patients with serious neurosurgical injuries were received, a consultation would

be held with this neurosurgeon and with the regional consultant in neurosurgery

for the area andl that the patient would immediately be transferred to this

hospital if these neurosurgeons so advised.

16 December 1943.-The - th Station Hospital is a very well run

organization, one indication being the excellent mess. There is, however, no

neurosurgeon here, or anybody who knows much about neurosurgery. This

hospital is about an hour and a half from the -th General Hospital, and the

same arrangements for the transfer of neurosurgical patients were made as

had been made at the -th General Hospital.

19 January 1944.--The neurosurgeon at the -st General Hospital is

an attractive young man with a nice personality but with only meager neurosurgical training. During the course of a 3-year rotating residency in surgery

at -Y, he spent 6 months as assistant to a neurosurgeon, Dr. . He knows

how to deal with acute trauma of the cranial vault and the surface of the brain

and could probably (teal satisfactorily with penetrating wounds of the brain,

but he knows little or no neurology and is not competent to do elective cranial

surgery. He would be a good man for some hospitals, but he is not competent

to meet the demands likely to be placed upon the neurosurgeon in this hospital.

Plans should be made to reinforce this hospital with a stronger and more

SThe classification symbol for neurosurgeons was MOS (Military Occupational Specialty) 3131, with the letters

"A. "B," "C," and "D" indicating the degree of professional proficiency.
50 N EURO•URGERY

experienced neurosurgeon, though tht( presentt ilculill)ben1t should also be given

a chance to prove his worth.

26-27 March 1944.-The neurosurgical sectioi in the ..... General

Hospital is functioning in a station hospital setup. The neurcsurge,'n has

had 4 years of general surgical training and 2 years of neurosurgery with

at --. tie is b)rigl t, alert, and well rounded in the subject. Although

he has hadl very little experience in ehhctroneurosurgery, he hils seen and( helped

with a great deal of excellent work. A lunh)osacral disk then on the ward was

correctly diagnosed and localized on clinical findings, and lIe was preparing to

transfer the patient to olte of the general hospitals because he did not feel that

he had had enough experience with this type of case to handle it himself.

His patients with head trauma, some of them with difficult, complicated injuries,

had all been treated with fine judgment. The state of the wounds indicated

that this nian is a careful, technical surgeon. A.n expertly trained operatingroom nurse is available to assist him.

Neurosurgical eqtnpinent was incomplete, hut orders had (been )lut through

channels for the necessary instruments. A p)ortabhle elect'rosurgical unit was

particularly needed. Captain--- had invented several very ingenious devices,

one of them a bullb syringe with a two-way valve which could h)e used to provide

continuous irrigationI of a wound. It would be useful to any neurosurgeon.

30 March 1944.-The --- th Station Hospital is performiing a vital function

in caring for Army Air Force l)ersonnel, and the neurosurgeon on the staff is

thoroughly qualified to handle all types of neurosurgery. Hie is doing a good

jot) hut should have an assistant at the earliest possil)le moment.

12 April 1944.--The neurosurgeon at the - th General Hospital in the

-- th Medical Center is thoroughly qualified. He has had adequate training

and a number of years of experience in private practice. All his cases were

exceedingly well done. Several patients with disks had had complete symptomatic relief, lie understan(ls neurosurgical problems thoroughly, and he is

the logical man to head the neurosurgical setup ip this hospital group.

At the -- th General Hospital, the surgeon in charge of neurosurgery

has had a very limited experience and apparently would not b)e a good team

man. He would be better in an auxiliary surgical group in an evacuation

hospital, where lie wouhl be working under supervision.

At the ---- th General Hospital ii) the center, there is no recognized

neurosurgeon, although two surgeons on the staff have had considerable

experience. They could handle emergency neurosurgery i)ut coulh not take on

the exclusive responsib)ility of a neurosurgica! service.

At the - d General Hospital, the neurosurgeon is intensely interested

in the subject but has had only skete(hy training. He is Careful and studious

and couhl go far if given the proper opportunities. He woui't be well qualified

to (1o peripheral neurosurgery but has had little experience in brain surgery.

Certainly he has had insufficient experience to be in a setup in which he would

be required to handle acute head trauma without support. He would (1o better

as an assistant.
EUROPEAN THEATER 51

As a result. of the inspection of the hospitals in this medical ce... r. it was

recommended to Col. James C. Kimbrough, MIC, Chief, Professional Services

Division, Office of the Chief Surgeon, Headquarters, ETOUSA, that the

proposed neurosurgical center be established in the hospital nearest the airport

at which casualties from the Continent would be received. Since this location

was not known at the time, it was recommended that neurosurgical casualties

bc concentrated at the -th General Hospital in the center, where Major

- was already well established, with trained assistants and nurses. This

setup, however, should be regarded as only temporary and should not be permitted to overshadow the final decision, which should depend upon the location

of the airport. Various recommendations for reassignment of personnel were

made in the light of the comments on the neurosurgeons observed and evaluated

during the visit to this center.

Neurosurgical Centers

As of 1 'May 1944, when the total number of neurosurgeons of all degrees

of training and experience in the United Kingdom numbered only 41, as just

stated, there were 59 general hospitals in the theater. Heavy neurosurgical

casualties were anticipate(d, and it was obvious that the available personnel,

who were of all degrees of training and experience, could not possibly be spread

out over all these hospitals. Evacuation hospitals staging for the invasion of

the Continent also had to be provided with neurosurgeons. Tile conclusion

was inescapable that competent care could be given to neurosurgical casualties

only in specialized neurosurgical centers, so located as to facilitate triage and

evacuation to them.

In a memorandum to Brig. Gen. (later Maj. Gen.) Paul R. Hawley, Chief

Surgeon, ETOUSA, dated 6 May 1944, dealing with plans for the care of neurosurgical casualties, Colonel Spurling recommended the establishment of 10

specialized centers for neurosurgeiy at. strategic points throughout the United

Kingdom. The proposal was approve(d, with minor changes, on 17 May 1944.

On 10 June 1944, Circular Letter No. 81 was issued listing nine hospitals for

specialized neurosurgica! treatment (fig. 2).

Approval of the proposal to establish these specialized centers permitted

an economical use of the neurosurgical personnel available in the theater.

The chief of service in each center was a fully qualified meurosurgeon of considerable experience. The assistants on tile service had considerably less experience, though some of them were graduates of the short courses in neurosurgery given in the Zone of Interior (p. 24).

An effort was also made to assign all nursing personnel with neurosurgical

experience to the neurosurgical centers, to work in the operating rooms and on

the wards, and a similar effort was made to assign to them enlisted personnel

with neurosurgical experience. Finally, personnel with experience in physical

therapy and physical education were assigned to the neurosurgical centers.

Since few other types of wounds require for their proper treatment the

combined efforts of as many different specialists as do neurosurgical casualties,
52 NEUROSURGEl1 Y

~ SCOTLAND

NORTH

SEA

I RE AND

MILES

Key:

1. 67~th Generai Ilospital, Miisgrove Park, T1auinton, 6. fSth General Hospital, R~edgr.ave Park, hear BotesSoinersetshire. dale, East Suffolk.

2. 10(4th General Hlospital (later 117th General Ilosphital), 7. 1st General hlospital (later 7th General Hospital).

Frenehay l'ark-, Bristol, Gloueestcrshire. North Mimms Park, North .Mrirms, Ilertfordshjrc.

3. 91st Ge'neral Hospital, Churchill, hlead.ington, Ox- 8. 95th General Hospital, Hermitage, near Newbury,

forulshire. Berkshire.

4. 411th sutt ion lIoslpital, I)iddingtosi, nea•r Saint Neots, 9. l.'5th General H~ospital, Odstoek, near Salisbury,

lI witingdonshire. Wiltshire.

5, 231st Station H~ospital, .Morley hall, near Wymond. NorGolk. E N, 

F:,;itil.: 2.--luospitals with facilities for Slpccialized itcurosturgical treatenitt iin theC United

,i0gdot Base, ] 09TS.
EUROPEAN THEATER 5:3

special pains were taken, through the cooperation of tile consultants group, to

assign to each of the neurosurgical centers competent specialists in radiology,

medical neurology, orthopedic surgery, plastic surgery, urology, otolaryngology,

antl ophthalmology.

Many difficulties were naturally encountered in effecting the large transfer

of personnel required by this program, and a number of compromises had to be

made, but, by 1 June 1944, the task was completed, and the neurosurgical services in the designated centers were ready to receive casualties.

In the fall and winter of 1944, acute special treatment hospitals were established on the Continent, at Liege, Bar-le Due, and Nancy, and in the Paris

area. This plan had to be adopted, because, with the coming of winter, bad

weather often made air evacuation to the United T;' - -e uncertain or

impossible. These hospitals, however, were not iw i neurosurgical

patients for definitive care unless air evacuation was impossible or unless the

patients were not transportable, for other reasons, after they could be trailsferred from evacuation hospitals.

With the expansion of general hospital facilities on the Continent, which

began after the liberation of Paris in August 1944, it was expected that there

would be a demand that more and more definitive neurosurgery be done in these

installations. The policy was occasionally discussed, but it was consistently

discouraged by Colonel Spurling. Practically all neurosurgical casualties had

to be evacuated eventually to the Zone of Interior, and it was his opinion that

as long as neurosurgical beds were available in the United Kingdom and evacuation facilities were available from it, the better plan was to continue to provide

definitive neurosurgical care in the hospitals in this base rather than on the

Continent. With tile exceptions just noted, this general policy continued in

effect to the end of the war in Europe.

Evacuation Hospitals

A problem of pressing importance in the planning for D-day was the staffing

of the evacuation hospitals of the First U. S. Army, which was to spearhead the

invasion of the Continent. Colonel Davis, in January 1943, had stated an

excellent set of principles for the employment of neurosurgical personnel in

wartime, and they were generally adhered1 to. They were as follows:

1. Qualified, experienced neurosurgeons, of recognized ability, are not

necessary in the combat zone. They will be of greatest usefulness in general

hospitals in the communications zone, in which definitive, complete neurosurgical care should be given.

2. Medical officers trained in general surgery and instructed in the most

effective methods for the immediate surgical treatment of neurosurgical wounds

should be assigned to the combat zone.

3. Casualties with neurosurgical injuries, after initial wound surgery,

should be evacuated as rapidly as possible to general hospitals in the communications zone for definitive treatment by experienced neurosurgeons.
54 NEUItOSUItG Elt Y

4. Mobile neurosurgical teams, with appropriate equipment, should not

be sent forward into the combat zone. It. would be wiser to attach to these

mobile teams young general surgeons, who, preferably, have had some neurosurgical experience during their residencies and whose basic surgical training and

experience have been of such a quality that they would do neither too much

nor too little in the initial wound surgery of neurosurgical casualties.

By a rather complicated shifting of personnel, it was eventually possible

to assign to each evacuation hospital a so-called working neurosurgeon. A

surgeon of this class had usually had 3 or 4 years of general surgical training

and, in addition, had completed the short course in neurosurgery given in the

Zone of Interior (p. 24). He had not usually had a great, deal of independent

surgical experience, but, since his general surgical background was good, it

was believed that he would function well at the evacuation hospital level, and

certainly better at that level than at the level of th( general hospital, in which

it was planned that definitive neurosurgery would be done.

The situation in the Third U. S. Army, which had been engaged in intensive

training in northern England for several months before D-day, differed from

the situation in the First U. S. Army in that each of the evacuation hospitals

attached to it had arrived with its own neurosurgeon. At a meeting arranged

with these neurosurgeons and with the chiefs of the surgical services of these

hospitals, it became clear that, a number of changes in personnel could profitably

be made.

If a designated neurosurgeon seemed to possess insufficient qualifications

for his assignment in the evacuation hospital, lie was relieved of duty in it and

transferred to a general hospital as a neurosurgical ward officer. His replacement, was furnished from the general hospital list. The shifting of personnel,

while based on correct principles, unfortunately had to t)e done on a rather

haphazard basis in many instances because the capabilities of many of the

officers for doing independent neurosurgery were completely unknown. It was

believed, however, that the experiences in handling neurosurgical casualties

which would be reported by the First U. S. Army could be used as a guide for

the wiser allocation of neurosurgical personnel in the Third U. S. Army whien

it eventually went into action.

Transit Hospitals

Medical planning for the inva._:on of France called for casualties wounded

in the period after D-day to receive their first definitive neurosurgery in

England, at the level of transit hospitals on or near the coast. These were

fixed hospital installations which served in the United Kingdom Base (and later,

occasionally, on the Continent). They operated as evacuation hospitals and

held casualties only long enough for the performance of sufficient definitive

surgery to make them safely transportable to general hospitals located farther

inland. These hospitals were placed with reference to their accessibility by

rail and aml)ulane.
EUROPEAN THEATER 55

Individual neurosurgeons were not assigned to transit hospitals, which

were staffed, instead, by neurosurgical teams. These teams, six of which were

alerted for D-day, were composed of personnel supplied by general hospitals

farther north in England. Each team consisted of a surgeon, all assistant

surgeon, an anesthetist, a scrub nurse, and two trained aidmen, and each team

had its own allocation of specialized neurosurgical equipment. The training

of these teams had included practice in knocking down their equipment,

transporting it, and setting it up quickly in another location, ready for instant

use. Special training in operating-room technique was also provided.

The allocation of the neurosurgical teams to transit hospitals was left to

the decision of the senior consultant in neurosurgery and the surgical consultant

to the Southern Base Section surgeon, under whose jurisdiction most of the

early casualties from the Continent naturally fell.

In March 1944, Colonel Spurling recommended to Col. (later Brig. Gen.)

Elliott C. Cutler, MIC, Consultant in Surgery, Office of the Chief Surgeon,

Headquarters, ETOUSA, that it would be advisable to supplement the teams

to be assigned to the transit hospitals by three additional standby neurosurgical

teams, which would be called upon if neurosurgical casualties exceeded the

estimates and the provisions for their care proved inadequate. In such an

eventuality, these teams could be mobilized quickly and assigned as they were

needed. It was recommended that personnel for them be obtained from

fixed hospitals then assigned to locations in what would probably be a negative

zone immediately after D-day. Finally, it was recommended that each team,

like the teams from the auxiliary surgical groups, consist of a neurosurgeon of

considerable experience, an assistant surgeon, an anesthetist, an operating-room

nurse, and two enlisted surgical technicians.

This recommendation was accepted and the teams described were provided,

but they did not have to be called upon, since the pre-D-day provisions for the

care of neurosurgical casualties proved adequate.

Auxiliary Surgical Groups

Auxiliary surgical groups proved to be among the most effective medical

units functioning in the European theater. Their efficiency was chiefly due

to two factors. The first was that they were carefully staffed and contained

some of the best surgical talent in the theater. The second was that, from

the standpoint of administration, these teams could be utilized more simply

than could the personnel of other medical organizations. The use of the teams,

which was dictated by the tactical situation, was controlled, for the most part,

by the surgical consultant to the army surgeon. Their movement from one

location to another, as the need for their services arose, could therefore be

achieved without a complicated series of administrative orders.

The auxiliary surgical groups, as originally constituted, provided for four

neurosurgical teams each. The 3d Auxiliary Surgical Group, however, which

had been assigned to the First V. S. Army, had only two neurosurgical teams
56 NEUROSURGERY

on its table of organization. After consultation with Colonel Crisler, surgical

consultant in the First U. S. Army, it was decided to create two additional

neurosurgical teams in this group. This was accomplished by transferring

so-called working neurosurgeons from the general hospital pool. The 1st

Auxiliary Surgical Group had been assigned to work temporarily with the

general hospitals in the United Kingdom. Its ranks had been depleted of

one neurosurgical team, and it was decided that no replacement would be

attempted immediately.

Changes in Assignment of Personnel

As circumstances of evacuation changed from time to time after D-day,

neurosurgical personnel were shifted to meet the changing circumstances. In

northeastern England, for example, where casualties were derived for the most

part from the Army Air Forces, the neurosurgical load gradually decreased as

fighter protection for bombers became more effective. As a consequence, early

in the summer of 1944, it was possible to close a neurosurgical center in East

Anglia aod to shift its personnel to a hospital in southern England, where

the need for trained neurosurgeons was then acute. At about the same time,

a general hospital near London was found inconvenient for evacuation, and

its neurosurgical personnel were transferred to a hospital in a location where

neurosurgical casualties were being received in large numbers.

Neurosurgical services in hospitals designed for specialized treatment.

increased steadily in size, and by December 1944 the patient load at these

centers varied from 150 to 650 each. Neurosurgical staffs in the larger centers

had from time to time been augmented by neurosurgeons iewly arrived in

the theater; all officers with neurosurgical qualifications had been utilized for

this purpose. Current needs, however, continued to be so pressing that in

most of the neurosurgical centers it was necessary to withdraw surgeons from

general surgical services and rapidly train them in neurosurgical principles

and techniques. In one of the largest, centers, at the 160th General Hospital,

Stowell Park, Gloucestershire, Eigland, 16 neurosurgical officers were once

assigned at the sarnm time; morning and afternoon operative schedules 'were

in effect, and as many as 150 major neurosurgical procedures were carried

out in a single month. 'Iie average patient-officer load in most centers was

consistently greater on the neurosurgical than on any other service.

In order to care for the heavy load of neurosurgical casualties, it wati

found expedient to increase the personnel of existing installatiolis rather than

to establish additional special treatment hospitals. The supply of fully qualified neurosurgeons was still extremely limited, and a service headed by a

well-qualified neurosurgeon, assisted by less well qualified medical officers,

functioned more efficiently than did new services headed by indifferently

qualified nedrosurgeons. The arrangement described permitted experienced

neurosurgeons to apply their skills in complicated cases and also to function

as teachers and demonstrators for younger, less well trained officers.
EUROPEAN THEATER 57

Shifting personnel to meet the requirements of changing circumstances

proved a never-ending difficulty. Commanding officers, however much they

might desire to improve professional services in their installations, were obliged

to adhere rigidly to tables of organization. This difficulty in the assignment

of neurosurgical personnel was circumvented by assigning neurosurgical officers

to hospitals in the vicinity in which table of organization vacancies existed

and carrying them on a temporary ,duty status in the hospitals in which the

need for their services existed. Although the arrangement was not desirable,

if only because it frequently deprived officers who had rendered outstanding

services of their chances for advancement in rank, as matters stood it seemed

the only way in which the more important need of rendering specialized

professional care where it was most needed could be met.

Free movement of highly trained professional personnel between hospital

installations in a theater of operations is obviously necessary for proper professional care of casualties. It should be a relatively simple procedure. The

senior consultant in neurosurgery, ho;vever, frequently recorded in his official

diary that he had found it the most complicated task hie had to perform in

the European theater and one which neither the passage of time nor his increasing experience in administrative matters in any way simplified.

Rotation of personnel.--After the initial phases of the European campaign

had been concluded, a plan was worked out in the Chief Surgeon's Office for

the rotation of personnel for 60-day periods between forward hospital units

and units in the rear echelons. As far as neurosurgeons were concerned, it

was promptly evident that personnel working in general hospitals had very

little conception of the problems facing surgeons in evacuation hospitals and

that surgeons in forward units knew little of surgical procedures undertaken

in general hospitals. Also, surgeons in forward units were anxious to follow

tip patients they had treated and to enjoy what they believed to be the quiet

activity of installations in the year.

A rotation system was finally put into effect in December 1944, and

approximately half of the neurosurgical personnel in the European theater

had the benefit of the program before the end of hostilities. The free exchange

of ideas, the fuller appreciation of each other's problems, and the heightening

of morale which comes with changes of assignment made rotation of personne.

a valuable innovation.'

An important byproduct of the rotation program was that army neurosurgeons became fully aware, some of them (,,, I ,e first time, of the importance of

thorough debridement at the initia.' operb:ion for craniocerebral injury.

Observations in a general hospital made i,'q l .e 1 devastating effects which could

result from incomplete debridement. Nunrosurgeons from general hospitals,

for their part, learned in forward installations how difficult it is to do superior

SRotation was an excellent plan, In theory, for all personnel. It was entirely practical for neurosurgical personnel,

whose numbers were limited. Their exchange could always, therefore, be handled on a personal and individual basis,

and very few medical units were involved. Rotation, however, was entirely impractical for most other medical personnil, especially battalion and regimental surgeons, the very nature of whose missions would have made it particularly

desirable.-J. B. C.. Jr.
58 NEUROSURGERY

neurosurgery under field conditions. Even experienced officers were often

chagrined, on their return to the general hospital level, to find that debridements

had been incomplete anti inadequate anti that, as a result, wounds were

int, ýcd, sometimes in cases which they had handled themselves in forward

hospitals.

Some neurosurgeons ended their periods of service with a remarkably wide

experience. One of them, for instance, was chief of the neurosurgical service

in a named general hospital in the Zone of Interior for 18 months before he went

overseas. During 30 months overseas, he served in the field with an auxiliary

surgical group in North Africa, Sicily, France, Belgium, Holland, and Germany.

During a portion of this time, lie acted as consultant in neurosurgery to an

army surgeon. He then worked in a neurosurgical center in England, where

the later results of primary procedures in forward areas could be evaluated.

Finally, lie was in charge of a neurosurgical center in the Zone of Interior. His

experience included hundreds of ordinary skull fractures and simple lacerations

of the scalp, more than a hundred penetrating wounds of the brain, 62 brain

abscesses, 31 cases of cerebral fungi, over a hundred laminectomies for injuries

of the spine, and more than 300 peripheral nerve lesions. His total experience

comprised more than 1,100 neurosurgical procedures, the great majority done

in evacuation or field hospitals near the frontlines. It ranged from emergency

procedures in clearing stations to peripheral nerve surgery in a general

hospital.

It was Colonel Spurling's opinion, as a result of this brief experience with

rotation of personnel of forward and rear echelons, that such a policy should be

arranged for, in advance, in all future medicomilitary plans, on the ground that

it contributes to better professional care and improves morale among medical

personnel at all levels in the chain of evacuation.

CRITIQUE OF ASSIGNMENT OF NEUROSURGICAL

PERSONNEL

At the end of the campaign in Europe, in a memorandum to General

Hawley dated 25 May 1945, Colonel Spurling, on the basis of the neurosurgical

experience during the active fighting, made further comments regarding the use

of auxiliary surgical groups in the management of neurosurgical casualties.3

The original plan, he pointed out, had been to provide each evacuation hospital

with a working neurosurgical team. In order to do this, it had been necessary

to cut corners on qualifications, and, as a result, some of the work done by less

experienced men in the early days of the European invasion was not up to

standard.'

3 Semiannual Report, Senior Consultant in Neurosurgery, Office of the Chief Surgeon, Headquarters, ETOUSA, 1

Jan. 1945 to 30 June 1945.

4 In previous analyses of the neurosurgical experience, Colonel Spurling had warned against the pitfalls which had to be

avoided in the assignment and reassignment of personnel. In particular, he stated, great care had to be exercised, in

disturbing good units to build up the staff of poor units, that all units, by the time the job was completed, would not be

uniformly second rate.
EUROPEAN THEATER 59

An analysis of the neurosurgical experience seemed to indicate that the

plan adopted had been responsible for considerable wastage of trained personnel.

These neurosurgical teams had not worked actively more than a third of the

time that they were attached to evacuation hospitals. As the tactical situation

constantly shifted, these hospitals were often moving, were shut down, or were

awaiting movement. At these times, although their neurosurgeons were idle,

they could be reassigned or detached from them only with difficulty, because

of the natural reluctance of commanding officers to part with their professional

personnel for fear that they would never get them back.

On the basis of this experience, Colonel Spurling suggested that neurosurgeons in an active theater of operations should not be authorized in the table

of organization of an evacuation hospital but should be organized into teams

assigned to auxiliary surgical groups, to be dispatched to functioning evacuation

hospitals as needed, at the discretion of the consultant in surgery to the army

surgeon. One neurosurgical team could thus care for the casualties in two

evacuation hospitals, and the services of the neurosurgeons who composed it

would be utilized almost continuously. He further suggested that each team

should be composed of a chief neurosurgeon; an assistant neurosurgeon capable

of handling an operating table under the supervision of the chief neurosurgeon;

a qualified anesthetist; an assistant anesthetist, preferably an aidman; two

aidmen trained as scrub nurses; and four aidmen trained as operating-room

assistants.

Colonel Spurling called attention to the fact that nurses did not appear

in these proposed teams, because it had been the rather general experience of

neurosurgical officers that trained aidmen met conditions better in army areas.

He also pointed out that aidmen had been substituted for assistant anesthetists.

The reason was that more than half of all neurosurgical procedures are done

under procaine infiltration anesthesia and that trained aidmen, under the supervision of an anesthetist, could take blood pressures, administer fluids, and be

responsible for the general care of the patient on the operating table.

The opinions just expressed by Colonel Spurling concerning the utilization

of neurosurgical personnel in the European theater in World War II were quite

generally held. The average number of surgical cases handled during the active

fighting, from D-day to V-E Day, by each neurosurgeon was 150. Each of

these officers, had he been moved freely from installation to installation as be

was needed, could easily have done a hundred or more cases each month. War

is wasteful, but this wastage was not necessary.

There are at least two reasons why it would probably be better not to

authorize a neurosurgeon (or any other critical specialist) on the tables of

organization of any field or evacuation hospital. The first reason is that these

units are necessarily deactivated for longer or shorter periods for staging and

other purposes; during these periods, specialists do not function, and their

services are therefore totally lost. The second reason is that when once a

medical officer is authorized on a table of organization of any unit by specialty
fit) NEUlSUIt(ER Y

MOS, it is a major operation to attach hin to another organization for any

reason. 5

It would therefore seem more eflicient to make neurosurgeons, along with

other critical specialists, members of teams which would be freely mobile and

entirely self-contained, so that they could he moved ini a few hours' notice

from one location to another as the need for their services arose. Movement

couhl be by small plane or command car. Standard operating supplies are

available at all installations, anl the teams would need to carry nothing beyolld

their own specialized equipment. A mobile hospital truck, such as was used

by British and Canadian neurosurgeons in World War II, is somewhat more

elaborate than is necessary and retards mobility in bad weather. Moreover,

United States Army forward hospitals are better equipped than either British

or Canadian hospitals, and specialized equipment for these teams could be

correspondingly reduced.

During World War II, neurosurgical teams from auxiliary surgical groups

which were attached to evacuation hospitals were, in effect, supplemental

personnel. They served in addition to the neurosurgical personnel provided

in the table of organization, and neither they nor the organic neurosurgical

personnel were fully utilized. By the plan just proposed, there would be no

organic neurosurgical personnel in evacuation hospitals; instead, neurosurgical

teams would be attached temporarily to these hospitals as the need for their

services arose. The administrative difficulties of such a plan should not be

insuperable. Had it been in effect in the European theater in World War II,

the same number of casualties could have been handled, and handled far more

effectively, with half the neurosurgical personnel used.

CARE OF NEUROSURGICAL CASUALTIES

Care of Civilian-Type Injuries

When the European theater was first established, neurosurgical injuries

encountered in United States Army hospitals, with the exception of a few

combat injuries sustained by Army Air Force personnel, were the result of

accidents comparable to those encountered in civilian practice. Originally,

most United States Army soldiers with this type of hijury were treated in the

British EMS (Emergency Medical Service) hospitals, where they remained for

various periods of time before discharge, without supervision by United States

Army medical officers.

Eventually, on Colonel Davis' request, a census of these patients was

furnished General Hawley's Professional Services Division, with the name,

SWhile this plan undoubtedly has the advantages stated, there are certain disadvantages connected with It which

must be borne in mind. Against the gain in efficient use of personnel in short supply in this specialized field must be set

the loss in morale and in esprit de corps invariably sustained by personnel who are not permanently assigned to some unit.

This loss, although intangible, is almost always ultimately reflected in performance. Furthermore, the matter of promotion must be considered; this always presents difficulties for personnel who are never in one place for any length of time.

Finally, if this plan were adopted for neurosurgical personnel, it might, with equal reason, be applied to other specialist

personnel, which would inevitably produce a reductio ad absurdum.-J. B. C.. Jr.
EUROPEAN THEATER 61

organization, date of admission, and diagnosis of each mail. At a meeting

with the chief consultant in neurosurgery of tile EMS, Mr. Geoffrey Jefferson,

and his regional associates, a plan was evolved whereby the senior consultant

in neurosurgery would be informed of tile admission to all EMS hospitals of

all United States Army soldiers with neurologic injuries. The United States

Army consultant would then see the patient personally, or would arrange to

have him examined by a United States Army neurosurgeon, or would delegate

the man's care to the regional EMS neurosurgeon until one or the other of

these plans could be put into effect. When this policy was fully implemented,

it proved most effective. The use of the facilities of EMS hospitals was

reduced to a minimum, and, if they had to be employed, the nature of the

injury and the course of the patient were known to the senior neurosurgical

consultant or his delegated representative.

The clinical principles by which neurosurgical injuries were managed at

this time in hospitals in the United Kingdom Base are described under appropriate headings in this volume and in volume II ' of the neurosurgical history.

Circular Letter No. 75, which covered the management of craniocerebral,

spinal cord, and peripheral nerve injuries, as well as the management of ruptured disks, was issued from the Office of the Chief Surgeon on 4 December

1942.

At the same time that these principles of clinical management were set,

forth, the policy was established that patients with neurosurgical injuries should

be treated only in general hospitals in which qualified neurosurgeons were on

the staff. Until a general hospital was established in East Anglia, it was

necessary to use two station hospitals in this area, the 49th and the 231st, for

the definitive surgical treatment of these patients. Otherwise, tile policy just

stated was strictly adhered to.

Care of Combat-Incurred Injuries

In planning for the care of neurosurgical casualties before D-day, it

promptly became evident that a forthright definition of what constitutes such

a neurosurgical casualty must be formulated and must be authorized by the

Chief Surgeon. The definition which was finally approved, and which remained

in effect throughout the European campaign, was that all surgical lesions of the

central, peripheral, and sympathetic nervous systems were to be considered

neurosurgical problems. This definition was in contrast to that currently in

force in the British Army, by which neurosurgical injuries were limited to

surgical lesions of the central nervous system.

Operation of Specialized Centers

After the plan for the establishment of specialized centers for the treatment

of neurosurgical casualties in the United Kingdom had been approved (p. 51)

6 Medical Department, United States Army. Surgery in World War If. Neurosurgery. Volume II. [In preparation.]

455735V-58-5
(12 NE UROSURGERtY

on 17 'May 1944, the following proposedI eircular letter was drafted by Colonel

Spurling:

.Subject: Care of Neurosurgical Casualties in the U. K.

1. The following hospitals are designated as special treatment centers for neurosurgical

patients: 91st General Hospital, 67th CGeneral Hlospital, 158th General Hospital, 98th

General Hospital, 100th General Hospital, 160th Getneral Hospital, 55th General Hospital,

83d General Hospital, 65th General Hospital, 49th Station Hlospital, 231st Station Hospital, and 18t General Hospital.

2. All neurosurgical casualties in the U. K. will be evacuated to the nearest designated

center for treatment and disposition as soon as the condition of the patient jperinits sate

tranisportation.

3. The senior neurosurgeon in each center will act as regional consultant.

This letter, it. will b(' inoted, made it mandatory to transfer to these specialized centiiters. till neurosurgical and other casualties requiring sp~ecializedl care

as soon its their cond~ition permnittedl transportation. For somle reason, nlever'

fully clarified, the publication of the circular letter dlealinigwith the neu(ýtrosuirgical

centers was dlelayed in administrative channels until 4 (laYs after 1)-dIay.N

Theni thle following letter 7 Was issued:

1. Certain diseases and injuries require treatment in which a high degree of specialization is needed. To provide this specialized treatment,, certain hospitals in the U. K. have

been provided with the necessary equipment and staffed with qualified p~ersonnel.

2. There are three (3) hospital centers in operation in the U. K.; the 12th H[ospital

Center, Malvern Wells, Worcs., the 15th Hospital Center, Cirencester, Glos., the 6810

Hospital Center, Whitchurch, Flintshire. In eachi of the. above listed hospital centers, there

are one or inore hospitals provided with equipment and personniel for highly specialized

treatment in:

a. Neurosurgery

b. Thoracic surgery

c. Plastic and niaxillofacial surgery

d. Surgical treatment of extensive b~urns

e. Urological surgery

3. In addition to hospital centers, there are located throughout the UL. K. a mnumber of

hospitals with personnel and equipment necessary for specialized treat nient

Location I-Iaint No.

Churchill, Ileadington, Oxon ------- 4144

.Musgrove Park, Taunton, Somerset- 4108

()dstock, Nr. Salisbury, Wilts- 4124

Hermitage, Nr. Newbury, Berks ------ 4140

Frenchay Park, Bristol, Glos -------- 4166

Itedgrave Park, Nr. Botesdale, East Suffolk 4209

Diddington. Nr. St. Neots, Hunts ----- 4204

Morley Hall, Nr. Wyniondham, Norfolk --- 4210

North Minims Park, North Minims, Herts. - 4211

4. The Commanding Officer of any hospital lacking facilities and Sufficiently qualified

personnel for the specialized treatment of any patient, Will transfer the patient to the most

available hospital center or hospital designated in paragraphs 2 and 3 above. The Comn7 Circular Uetter No. si, Offie of the Chief Surgeon, Headquarters, ETOVS A, 10 June 1944, subject: Hospitals With

Facilities for Specialized Treatment.
EUROPEAN THEATER 63

manding Officers of the centers will designate the hospital within the center to which the

patient will be admitted.

Because of the wording "lacking facilities and sufficiently qualified personnel," this letter was interpreted by some commanding officers of general

hospitals as permissive and not mandatory. As a consequence, a period of

considerable confusion ensued, in the course of which operations on neurosurgical casualties were sometimes done in general hospitals by personnel

with little or no neurosurgical experience. Eventually, although the circular

letter was never rescinded, the situation was clarified, and thereafter casualties

who required specialized neurosurgical care were transferred, without unnecessary delay, to the special treatment hospitals which had been set up for the

care of such casualties.

Evacuation

After the initial rush of casualties following D-day and dissemination of

information concerning the location and objectives of the specialized neurosurgical centers, triage of neurosurgical patients proceeded efficiently. In

particular, delay in evacuation from the far shore steadily lessened, chiefly as

the result of improvement in the management of port facilities.

In the initial planning for D-day, hards had been established for the

unloading of craft at Weymouth, Plymouth, and Southampton, on the southern

shore of England. All three points were conveniently located in reference to

the invasion beaches on the Normandy coast. The hard at Plymouth was

seldom used for neurosurgical casualties, and the hard at Southampton never

functioned to full capacity.

About D-plus-15-day, small numbers of casualties began to be evacuated

by air, and by the end of June approximately half of the wounded were thus

reaching England. As air evacuation steadily increased in efficiency, more

and more freshly wounded neurosurgical patients began to arrive in England,

and hospital needs changed correspondingly. Two new transit neurosurgical

centers were therefore established in close proximity to airfields, the corresponding decrease in the number of sea-evacuated casualties making it possible

to shift the personnel from one of the original transit hospitals in southern

England to meet the new conditions.

Once the system of air evacuation was fully established, most of the

seriously injuried neurosurgical casualties were flown to the United Kingdom

Base hospitals during the summer of 1944. Only the more lightly wounded

were brought over by sea. Weather conditions were fortunately good, and

air transport was seldom hindered, so that it was not unusual to receive neurosurgical casualties in transit hospitals in England 12 to 14 hours after they had

been wounded on the Continent. In one recorded instance, a soldier with a

gunshot wound of the brain was being prepared for surgery in a

general hospital in England only 4 hours after he had been injured in France.

In another instance, the timelag was only 5 hours. During the winter, air
64 NEUROSURGERY

evacuation was erratic because it uas at the menrcy of the weather, and most

casualties were transported by sea.

A system of air evacuation of neurosurgical casualties to tile Zone of

Interior was set up in the summer of 1944, and for a time it was thought that

this was the ideal method of transportation for them. With tile coming of

bad weather in the fall and winter, air transportation became less and less

satisfactory, and, at the same time, reports from neurosurgical centers in the

Zone of Interior indicated that casualties with injriles of the spinal cord, who

furnished the most serious problems of evacuation, were arriving in better

condition by ship) than by air. Air evacuation was resumed in the spring and

was more satisfactory because of the lessons which had been learned about

how to care for spinal cord injuries in transit.

Inspection of Neurosurgical Facilities in the United Kingdom Base

On D-plus-4-day, by which time casualties were being received in a

steady flow from the Normandy beaches, Colonel Spurling made complete

rounds in all transit hospitals, evacuation hospitals, and field hospitals in

southern England, to determine the effectiveness of the plans which had been

set up for the triage and professional care of neurosurgical casualties. His

report of 29 June 1944 to Colonel Kimbrough made the following points: 8

1. Not all commanding officers of hospital installations had had advance

information concerning the location of specialized centers for neurosurgical

treatment. As a result, some neurosurgical casualties had not been well

handled, especially in hospitals to which neurosurgical teams were not assigned.

2. Treatment had been delayed too long in some instances. Some casualties, seen immediately on their arrival, had been wounded 5 (lays previously

in France and had been without definitive neurosurgical care during this time.

On the whole, however, first aid neurosurgical care had been excellent.

3. Delay in treatment of neurosurgical casualties in transit hospitals could

readily be corrected. Reasons for the delay included overeagerness on the

part of administrative officers to evacuate seriously injured patients farther

to the north; use of neurosurgical casualties who should have been considered

nontransportable to fill up hospital trains because evacuation directives had

been interpreted to mean that trains must. be completely filled before they

moved; failure to use ambulances to move neurosurgical casualties to special

treatment hospitals; and a basic delay, which was steadily being reduced, inherent in evacuation of casualties from the far shore.

In this report, Colonel Spurling expressed himself as being, in general,

greatly impressed with the excellent care rendered by neurosurgical personnel

and with their ingenuity in improvising equipment and methods to meet military conditions. In this connection, he wrote to Col. (later Brig. Gen.) Fred

5 Informal Routing Slip, Lt. Col. R. 0. Spurling, to Col. 3. C. Kimbrough, Chief, Professional Services Division,

Office of the Chief Surgeon, Headquarters, ETOUSA, 29 June 1944, subject: Tour of Special Treatment Hospitals and

Transient Hospitals for Neurosurgery in the SBS.
EUROPEAN THEATER 65

W. Rankii', MC, Chief Consultant in Surgery, Office of the Surgeon General,

as follows: "I was greatly impressed with the manner in which the young

neurosurgeons took hold of a difficult situation and delivered a thoroughly

competent job. -Many of them worked without rest for 3, 4, and 5 days. I

failed to see one instance of negligence, and I saw very few cases in which

mature judgment had not been exercised."

Inspection of Neurosurgical Facilities on the Normandy Beachhead

On the invitation of Col. (later Brig. Gen.) John A. Rogers, MC, Surgeon,

First U. S. Army, Colonel Spurling visited the Normandy beachhead on 12

July 1944 to study the management of neurosurgical casualties in army evacuation hospitals and other installations and to make such recommendations as

seemed indicated for the future functioning of these units. After a 4-day

inspection trip in all forward units, including collecting stations, division

clearing stations, field hospitals, and evacuation hospitals, and after consultation with tile cons~iiltants assigned to the First U. S. Army, the following

recommendations went. made to the surgeon of that army:

1. The tendency in evacuation hospitals to do too much definitive surgery

should be restrained, and all transportable casualties should be evacuated to

the United Kingdom for this type of care.

2. All patients with head injuries should be evacuated without surgical

treatment except patients with insignificant injuries, such as scalp wounds,

who may be expected to return to duty within 10 days, and patients with

brain wounds which do not permit of transportation. Injuries in the latter

category were defined as compound brain wounds with presenting cerebral

tissue (fungus), brain wounds as.;ociated with progressive deterioration in the

patient's condition, and brain wounds associated with other injuries which in

themselves contraindicated prompt evacuation. Unconscious patients were

always to be held and treated until the exact status of the intracranial injury

was determined, after which they would be evacuated or held according to the

indications.

3. Patients with injuries of the spine accompanied by paralysis should be

promptly evacuated by air when this was possible. They should be left on

stretchers and an attempt made to improve their condition according to instructions in the Manual of Therapy. If air evacuation was not possible, and

if there was reasonable doubt about complete severance of the spinal cord,

exploratory operation should be carried out, under local analgesia, without

opening the dura unless definite indications existed for this procedure. It was

emphasized that the decision concerning the need for operation should be made

by the nearest available neurosurgeon.

4. Two neurosurgicai teams should be outfitted in a mobile surgical unit

and made available for roving assignments in the Omaha and Utah sectors of

the Normandy beachhead. The duties of these teams were defined as supervision of work in evacuation hospitals in their respective zones, and operation
66 NEUIROSUItGEIIY

of their mobile units in whatever evacuation hospitals the Consultant in Surgery, First U. S. Army, should designate as most in need of their services. It

was also suggested that the personnel of the teams should go forward to field

hospitals and, if necessary, to division clearing stations to care for nontransport able neurosurgical casualties.

5. The basic suggestions made in this report were inicorporated in a letter

issued from the Office of the Surgeon, Headquarters, First U. S. Army, 20

July 1944. Later, these same policies were adopted by the Third, Ninth,

Seventh, and Fifteenth U. S. Armies as they successively became operational.

Uniform management of neurosurgical casualties was therefore in effect, for

all practical purposes, throughout the period of active hostilities in Europe.

They were followed consistently except when the local tactical situation, adverse flying weather, or diffhculties of evacuation for other reasons made it

necessary to modify them.

CRITIQUE OF CARE OF NEUROSURGICAL CASUALTIES

On the basis of his observations of the care of neurosurgical casualties

during the active fighting in Europe, the senior consultant in neurosurgery on

25 May 1945, submitted to Colonel Kimbrough a memorandum entitled "Some

essential facts we have learned in this theater about the care of neurosurgical

casualties." In it., the following points were made:

1. A competent neurosurgical team can handle the neurosurgical work of

at least 5,000 active hospital beds.

2. The present tables of organization for general hospitals, which provide

a neurosurgeon (C-3131) for each 1,000-bed hospital, are wast eful of specialized

personnel. The neurosurgical workload in an installation of this size is not

heavy enough to keep him occupied.

3. By utilizing the 1,000-bed hospital as part of a hospital center or hosl)ital group an(l by designating one of the hospitals in the center as a specialized treatment center for neurosurgery, as was done in tile United Kingdori Base, wastage of neurosurgical personnel is overcome. In some such cellters in the United Kingdom, a chief of service supervised 4 or 5 operating

teams, and a high degree of efficiency was attained. Loads of 600 patientts

were carried month after month, and between 100 and 150 major neurosurgical

operations were performed each month. Difficulties about the trainsfer of persoiiiel which arose from table of organization requirements were readily overcome ill hospital centers. Finally, early triage of casualties, which is essential

if the best, results in neurosurgery are to be secured, was extremely efficient in

hospital centers.

4. If hospital centers are not considered practical, hospitals of 1,500- to

3,000-bed capacity might solve tile neurosurgical problem. Hospitals of

2,000-bed capacity were brought to France in support of the Sevcnth U. S.

0 .Medicil News Letter No. 14, Office of the Surgeon, Ienadquarters, First U'. 5. Army, 20 July 1944, subject: M:minge men~lt of Ne.uro-SuRlrgioa•l (C:jAs.
EU ROPEAN THEATER 67

Army and fully justified the assignment of first-rate neurosurgical talent to

them.

5. If general hospitals in the Pacific were to be organized oil a 1,000-bed

basis, the only practical solution of tile neurosurgical problem in them wouhl

be to group them into hospital centers and to designate one hospital in each

center as a specialized treatment center for neurosurgery, with the assignment

of neurosurgical personnel adjusted according to the workload. The chief of

section should be a well-qualified man (A, B, or C-3131), but his assistants

could be young general surgeons who had had some neurosurgical experience

(C or D-3131).

Colonel Spurling concluded the memorandum by pointing out that if, in

a future war, the establishment of hospital centers should not prove practical,

neurosurgical personnel would best, be conserved by the organization of the

neurosurgeons available at the general hospital level into neurosurgical teams,

to be attached either to an auxiliary surgical group or a headquarters pool,

whence they could be dispatched to whatever points might be most in need of

neurosurgical services. This plan would eliminate table of organization difficulties which had complicated tile shifting of neurosurgical personnel in World

War II in the European theater. A similar plan had, in fact, worked very

satisfactorily iii army evacuation hospitals during that period.

REDEPLOYMENT OF NEUROSURGICAL PERSONNEL

After V-E Day, neurosurgical casualties in evacuation hospitals on the

Continent were quickly cleared to general hospitals in the Communications

Zone, and most of them (about 90 percent) were eventually transferred to the

United Kingdom for further treatment and disposition. As a result, most

neurosurgeons in forward hospitals soon found themselves with nothing productive to (o. A reasonable period of inactivity was naturally welcome, but,

after it had extended for several weeks, activity became desirable. Whenever

possible, therefore, these officers were sent, on temporary duty, for periods of

30 to 60 days, to neurosurgical centers in the United Kingdom, and, while they

were there, every effort was made to permit them to visit British neurosurgical

installations also.

This program could not be completed because of the urgency of redeployment of units to the Pacific, which made it necessary to recall the officers to

their units. Staging, unfortunately, again resulted in long periods of inactivity, without contact with professional work, which had a very bad effect

upon morale, in addition to the obvious waste of highly skilled personnel.

Table of organization requirements for hospitals to be redeployed directly

from the European theater to the Pacific called for 59 neurosurgeons, with the

fulfillment of the requirement mandatory as long as a qualified neurosurgeon

was available, regardless of the length of his overseas service or any other

consi(leration. As soon as the requirements for the Pacific, became known and

a survey of the situation could be made, the following memorandum, repro-
68 NEUROSURGERY

duced almost in full because of the gravity of the shortage of personnel it

indicates, was addressed to General Hawley on 11 June 1945, under the title

"Review of neurosurgery in the ETO with respect to redeployment":

1. An analysis has been made of all neurosurgical personnel in this theater, based upon

all available information in the Personnel Division [of the Theater Chief Surgeon's Office].

Critical scores are not yet available, but the records of most of these men I know personally.

2. Available personnel: There are 92 men listed and classified as 3131 and they are

rated as follows:

a. B-3131-12 (fully qualified neurosurgeons).

b. C-3131-31. For the most part this group consists of young general surgeons

who Ihave been trained in traumatic surgery through short courses in the States.

c. D-3131-49. Of this group 25 are known to be capable of acting as chiefs of

services in evacuation hospitals or auxiliary surgical groups. The others have been acting

as assistants or ward officers on established neurosurgical services. Eight are nine-month

internes who have worked as ward officers on n(urosurgical services for a period of months.

The reason many of these men were given the classification of 3131 was to keep them in

neurosurgery as assistants or ward officers. No lower classification to accomplish this

purpose was available. Therefore, there is a wide spread in the capabilities within the group.

3. I have listed, with some misgiving, the personnel as follows:

a. Qualified for chiefs of neurosurgical services in evacuation hospitals-32.

b. Qualified for chiefs of neurosurgical services in general hospitals-40.

c. Qualified for chiefs of neurosurgical teams, auxiliary surgical groups-8.

d. Qualified as assistants (ward officers) in general hospitals, evacuation hospitals,

or auxiliary surgical groups--12.

4. Requirements: According to the present T/0, approximately 170 neurosurgeons

are required. Fulfillment of this quota is obviously impossible. By eliminating most of

the neurosurgeons from the indirectly deployed general hospitals, the urgent need is as follows:

a. For direct redeployment:

(1) 34 neurosurgeons for general hospitals.

(2) 17 neurosurgeons for evacuation hospitals.

(3) 8 neurosurgeons for auxiliary surgical teams.

b. For the Army of Occupation: 2 neurosurgeons for general hospitals.

c. For the U. K. Base: 2 neurosurgeons for general hospitals.

d. Total number of neurosurgeons urgently required-63. All of these men should

be capable of heading a service.

5. Balancing of requirements with available personnel:

a. There are 38 places required for general hospitals, and there are 40 qualified.

or questionably qualified, men available to fill these posts.

b. There are 17 evacuation hospitals that must be staffed immediately, and there

are 32 men thought to be qualified for these assignments. This allows a surplus which may

be carried over to the indirectly redeployed evacuation hospitals.

c. There are 8 auxiliary surgical teams requiring neurosurgeons. There are 8

men believed to be qualified as neurosurgeons who are available for these posts.

6. Discussion of the neurosurgical situation.-Neurosurgeons are properly classified as

critical personnel in all theaters of operation, as well as in the ZI. Months or years are

going to be required to discharge these responsibilities, and, therefore, no neurosurgeon

who is physically qualified will be released from service for many months, or even years.

As a consequence, the neurosurgeons cannot anticipate a reasonably early separation from

the service. Approximately 35 of the neurosurgeons in this theater have had long periods

of overseas service, many of them having been through two or more campaigns, and many

of them with high point scores. If the present requirements are met, it will mean that

practically every one of them must go to the Pacific Theater direct. This is a particularly

grave hardship to the men who have had long periods of overseas service and will result,
EUROPEAN THEATER 69

in many instances, in a breaking of spirit which uill greatly hamper their future usefulness,

to the service. These men have carried as large a patient load, or larger, during these campaigns as any other group of surgeons or physicians. Many of them are tired, and justifiably

so.

7. Solution:

a. There are 19 neurosurgical centers in the ZI, with staffs ranging from 5 to 16

officers. Very few of these officers have had any overseas service-in many instances through

no fault of their own--and many of thein would welcome an opportunity for overseas duty.

Some of the men in this theater could take over the ZI work without a hitch and do it better,

for that matter, because of their experiences in active campaigns.

b. There should be an immediate transfer of personnel between the ZI and the

ETO. This, I believe, could only be done by an arrangement with The Surgeon General's

Office by which officers of like grade and ability could be exchanged as casual officers. Such

a move would, I believe, be to the best interest of the service, and it would provide better

neurosurgical care for the wounded soldier, both at home and abroad.

The personnel injustices which it was thought would be necessary at the

beginning of redeployment were somewhat. relieved by a request from the Office

of the Surgeon General for the immediate return to the Zone of Interior of about

25 fully qualified neurosurgeons. It was expected that these officers, most

of whom had had long overseas service, would be assigned to neurosurgical

centers in the Zone of Interior, thus releasing personnel without overseas

service for assignment to Pacific. After this request had been fulfilled, enough

personnel were still available in the European theater with sufficient training

and with relatively short periods of overseas service to meet the requirements of

units being deployed directly to the Pacific and also to meet the neurosurgical

needs of the army of occupation.

All redeployment difficulties were terminated by the ending of hostilities

in the Pacific in August 1945.

TRAINING, EDUCATIONAL ENDEAVORS,

DISSEMINATION OF INFORMATION

Training Before D-Day

Methods of training.-TThe special treatment hospitals established in the

United Kingdom Base in March 1944 provided facilities for the training of

officers, nurses, and enlisted personnel of newly arrived units. As soon as

each neurosurgical center was estal)lished, a training program was set up in

it. Each chief of service prepared his own standing orders of procedure and

saw to their distribution among the professional specialized and general staff,

nurses, and enlisted men. Such local regulations were extremely important in

the smooth conduct of the affairs of a ward; they concerned both neurosurgical

professional policies and the paperwork connected with records, disposition

boards, and similar matters.

As neurosurgeons came into the European theater, whether as casuals or

assigned to general or evacuation hospitals or auxiliary surgical groups, they

were placed on temporary duty with hospitals with long experience in the

4557355--58-6
70 NEURtOSUlRGEltY

theater or, more often, with one of the neurosurgical centers for evaluation and

further training. Oflicers assigned to evacuation hospitals and auxiliary surgical teams often had long waiting periods before their units were called into

action, and many of them couhl be utilized in the centers for periods of 3 or 4

months. The plan not only provided valuable additional training for officers

thus assigi)ed but also helped materially in carrying the load of neurosurgical

casualties in the earl*y (lays of the European campaign.

Another great advantage of this plan was the opportunity it afforded the

senior consultant in neurosurgery for a proper evaluation of newly arrived personnel and for their reassignment if necessary. Most of the office'rs arriving

in the theater in 1944 and 1945 were general surgeons whose only neurosurgical

training was the short courses given in the Zone of Interior. They had been

assigned to their units on the basis of their qualification cards, without firsthand

knowledge of their experience, temperament, or other qualities, and many of

them proved to b)e misassigned. It was possible, by reassignnment, to remedy

most of these errors before D)-day.

Chiefs of neurosurgical sections were encouraged to ho01 weekly conferences dealing with all important cases an(l with other matters of clinical and

administrative interest. These conferences, to which staffs of other services

were invited, prove(l of great value in the general training program.

Since the end results of coram)at wounds largely depend upon the type and(

quality of the initial woun(d surgery by which they are managed, special attention was paid to the instruction of medical officers in divisions staging in the

theater just before they went into combat. This instruction increased in practical value as experience in coml)at, increased. It supplemented the training

in fixed hospitals just describ)e(d and was an essential part of the training of

young medical office,-s with no combat experience an(d limited neurosurgical

training.

One of the difficulties of the training program was the frequent practice of

rotating nurses through various hospital services.'0 The principle may be

soundl, but the practice had to be discontinued in neurosurgical centers. There

are far too many technical details in the specialty of neurosurgery to make

ward1 or operating-room nurses of great value before training, which could( not,

of course, b)e undertaken when casualty loads were heavy.

Medical field service training school.-A medical field service training

school was established at Shrivenhani, Berkshire, England, by the Chief Surgeon, ETOUSA, in 1943. It was particularly designed for general (luty medical

officers assigned to comnl)at units. Officers of all grades were, however, given

the opportunity to atten(d it as circumstances permitted. Instruc'tors were

drawn, for the most part, from the Professional Services Division, Office of the

Chief Surgeon, Headquarters, ETOUSA, and each class was instructed in the

fundamentals of first aid ca-e of various types of casualties. Neurosurgical

instruction consisted of lectures, lasting from all hour to an hour and a half each,

10 A It hough rotation of nurscs was the practice in .&,me hospitals In the Europxean theater, it was not theater jxiliey.-

J. B. ('., Jr.
EUROPEAN THEATER 71

Supplheented by demonstrations on the eIlergt-ncy care of injuries of the head,

spine, and peripheral nerves.

Utilization of British neurosurgical clinics and organizations.-Dtu ring the

long period from the arrival of the first neurosurgical personnel iii the United

Kingdom in 1942 to D-dav, British and Canadian neurosurgical clinics provided the only facilities available for active training of United States Army

neurosurgical personnel. The cooperation of these Allied neurosurgeons with

their American colleagues during this interim was superb. The facilities placed

at the disposal of American neurosurgeons included tile clinics of Brigadier

Hugh Cairns, RAMC, and Air Vice Marshall C. P. Simon, RAMC, at St.

tlugh's Hospital for Head Injuries, Oxford; the clinics of Mr. John O'Connell

at Hill End Hospital, London, of Mr. Norman Dott, Edinburgh, and of Mr.

Geoffrey Jefferson, Maawhester; the Canadian Neurological Hospital No. 1, at

Basingstoke, under Lt. Col. Harry Botterell, RCAMC, and his colleagues; an(d

Mr. Herbert Sedden's unique hospital for peripheral nerve injuries at Oxford.

So thoroughly were these fine clinics utilized that scarcely a single American

neurosurgeon failed to visit or study in one or more of them during his tour

of duty in the European theater. The opportunities thus afforded not only

provided valuable educational opportunities but also were of great assistance

in keeping up the morale of the neurosurgeons during the long period of waiting.

The consultants in neurology, neurosurgery, and allied specialties, in both

the British Army and the British Emergency Medical Service, together with

a large number of other nieurosurgeons in military and civilian services, extemdled every courtesy to the senior consultants in neurosurgery. After September 1942, the United States Army consultants were guests at every meeting

of neurologic sections of the British Army consultants in this specialty. They

were also guests of the subcommittees on craniocerebral injuries, spinal injuries,

and peripheral nerve injuries of the 'Medical Research Council. In turn, many

British and Canadian neurosurgeons visited United States Army hospital

installations in the United Kingdom Base and on the Continent and were

also guests at neurosurgical conferences in both areas.

The meetings of the British Society of Neurological Surgeons, which were

lhehd regularly throughout the war, were always open to United States Army

neurosurgeons. The stimulus afforded by these metings played an important

part in the educational program of tile American group, and the close comiradeship which resulted from the association had important implications for

the war period and for the future.

Similarly, the contacts with British neurologists and neurosurgeons through

the Section of Neurology of the Royal Society of Medicine contribi.ted greatly

to tile success of the American neurosurgical program. The meetings were

always open to United States neurosurgeons, who were present whenever conditions permitted their attendance and some of whom became Fellows of the

Royal Society of 'Medicine.

Similar liaison on the Continent was developed as rapidly as circumstances

permitted. Neurosurgery on French casualties was done, for the most part,
72 NEUROSURGERY

in United States hospitals. Immediately after tile liberation of France, contacts were established with French neurosurgeons in civilian hospitals, and

neurosurgeons in tile French Army visited neurosurgical services in United

States Army hospitals in the Paris area and elsewhere. Visits by the senior

consultant in neurosurgery to the clinic of Prof. Clovis Vincent, at the H6pital

de la Piti6 in Paris, were particularly productive and helpful. With General

Hawley's authorization, Professor Vincent's first assistant at this hospital and

two other neurosurgeons who were with French outfits on D-day entered Paris

with the Chief Surgeon's Office after that city fell.

Critique of methods of training.-The results of tile various expedients

adopted in the European theater to train professional personnel without

previous neurosurgical experience and to supplement the training of those

with limited experience were, on the whole, exceptionally good. Should a

similar situation ever arise again, most of these techniques might well be

employed again.

The greatest defect of the training program was that it did not make tile

fullest possible use of the experience accumulated by the consultants in nleurosurgery. If these consultants had been permitted to return to the Zone of

Interior at intervals, to relay their experiences to division medical officers

about to be sent overseas, the tasks of these latter officers would have been

greatly simplified. This plan might not have been feasible after the invasion

of the Continent, but it could profitably have been employed before D-day,

when the theater was inactive.

This plan, too, might well have been the first step in a program of close

liaison between professional services in tile European theater and the Office of

the Surgeon General. Undoubtedly, it would have prevented further misdirection of effort in the operational training directed to neurosurgery. Consultants in ne "rosurgery to the Royal Army Medical Corps were firm ill their

opinion that the plan described was the best possible way of providing instruction in military neurosurgery for division medical officers, and it is unfortunate

that it was never implemented in the United States Army Medical Service.

Conferences

Preliminary plans for the European theater had envisaged regular conferences to be attended by all available neurosurgical officers. Because of the

stress of work, however, the first formal conference was not held until 20

December 1944. An informal meeting of all neurosurgeons in the United

Kingdom Base had previously been held in conjunction with the fall meeting

of tile British Neurosurgir'al Society at Basingstoke.

After the December 1944 meeting, conferences for the base neurosurgical

personnel were held at bimonthly intervals. Mimeographed abstracts of the

(liscussions were sent to every neurosurgeon in both base and army areas, and

by this means, as well as by the informal discussions possible at the conferences,

unification of therapeutic practices in general hospitals was largely achieved.
EUROPEAN THEATER 73

The meetings provided the opportunity for reports on new clinical methods,

sometimes with arrangements for subsequent clinical trials on a large scale.

They also made it possible for army neurosurgeons to secure details concerning

the condition in which their patients were arriving in the rear echelon.

Two conferences each were held with the neurosurgeons of the First

and Third U. S. Armies and one conference each with the neurosurgeons of

the Seventh and Ninth U. S. Armies. Although these conferences were held

during the active campaign, it was possible for almost every army neurosurgeon, as well as the chiefs of services in evacuation hospitals, to attend them.

The exchange of information between forward and rear echelons was important, and the meetings, like the base conferences, provided opportunities

for unifying treatment throughout the theater and also played an important

part in keeping professional practices at a high level.

It is unfortunate that these conferences were not begun earlier. They

were of great value. One of the final recommendations of the senior consultant in neurosurgery was that, in future planning, regular monthly meetings of the neurosurgeons assigned to each army and to general hospitals in

the communications zone should be provided for from the start.

Publications

Neurosurgical experiences in the European theater were reported at the

conferences just described, in the Bulletin of the U. S. Army M4edical Department and in the current medical literature. About 25 formal papers were

published from the theater. Thee substance of these reports, with additional

data, is incorporated in appropriate sections of the clinical sections of this

volume and volume II of the neurosurgical series.

Manual of Therapy

A manual of therapy setting forth principles of treatment to be followed

in the European theater was issued 5 May 1944. This manual was in preparation when Colonel Spurling arrived in the theater in March 1944, and one

of his first duties was the revision of the sections dealing with neurosurgical

casualties (appendix B).

The introduction to this manual, by General Hawley, well sums up the

objectives followed in the preparation of the neurosurgical sections:

*** ****

This manual sets forth principles of treatment which have been tested in active

operations by both our own forces and those of our Allies. In it are incorporated many of

the professional policies of the medical service of ETO. These policies will be followed

habitually. Any one of them may, and should, be disregarded in an individual case where

there is sound reason for departing from policy. Personal preference for other methods of

treatment as a routine is not a "sound reason." Departures from policies will be made

because of special circumstances associated with individual cases.

i See footnote ti, p. 61.
74 NEUROSURGERY

Tile objectives sought in the preparation of the neurosurgical sections

of this manual were to lay down principles to be followed b', medical officers

who, without specialized neurosurgical training, would be required to handle

neurosurgical casualties on their own responsibility. Thie booklet was not

intended for experienced neurosurgeons; unification of definitive treatment

was provided for by other means, including frequent contact between them and

the senior consultant in neurosurgery.

At the close of the European campaign, the Professional Services Division

undertook the revision of the Manual of Therapy in the light of the experiences

gained during the period of hostilities. In neurosurgery, the only really important changes had to do with the transportation and care of paraplegics.

SUPPLY AND EQUIPMENT

In the early days of hostilities in Europe, one of the major difficulties

of the senior consultant in neurosurgery had to do with supplies and equipment. The few United States Army hospitals in the United Kingdom in 1942

suffered fromn all almost complete lack of the specialized instruments and

equipment essential in the performance of neurosurgical operations. This

was because such supplies as were arriving were being used to outfit hospitals

for the North African invasion. Attempts to make up the neurosurgical

deficit from local instrument houses were not successful.

As of March 1944, when Colonel Spurling assumed his duties as senior

consultant in neurosurgery in the theater, the neurosurgical supply situation

was still chaotic. The supplementary list of neurosurgical instruments, which

was presumably standard for each general hospital, was not complete in any

installation in the theater. The supplementary neurosurgical kits, originally

intended for use in evacuation hospitals and by auxiliary surgical teams, were

also, without exception, found incomplete. Individual neurosurgical items

were scattered through various medical supply depots all over the United

Kingdom.

Major Scarff, who had been acting as consultant in neurosurgery before

Colonel Spurling's arrival in the theater, had made a beginning in the correction of the supply situation by having collected at a single depot (G30 in

London) enough individual neurosurgical items from other depots to complete

50 neurosurgical kits for auxiliary surgical teams. Whenever an individual

standard item was lacking, a similar item was purchased from British sources.

It had been recognized that the assembly of 50 neurosurgical kits was

little more than a stopgap procedure, and in March 1944 general measures

wvere taken to correct the whole supply situation. The first step, a complete

inventory of all neurosurgical equipment available anywhere in the European

theater, revealed that almost enough standard items were available in scattered

locations to complete 100 neurosurgical kits. The Supply Division of General

Hawley's office agreed to assemble all these items in a single depot (G30) and

further agreed that, in the future, all supplies for neurosurgical purposes should
EIVROPEAN TIHEATER 75

be concentrated in the same depot. Tlihis agreemen t meant that future requisitions for neurosurgical supplies could be automat ically forwarded to G30

to be filled.

As soon as the supplies scattered over the Untited Kingdom had been

concentrated in it single depot, it was possible to comphlete 100 ncurosurgical

kits, ail -)f which had previously lacked one or more standard items. Incomplete kits which had been issued to general and evacuation hospitals and to the

neurosurgical teams of auxiliary surgical groups were recalled and exchanged

for complete kits. After all these installations had been provided for, there

wias still a sufficient reserve of completed kits to meet immediate ftit ture demands.

Items in excess supply were held for replacement purposes. Although the

standard neurosurgical kits (fig. :3) were not ideally suited, in a number of

respects, to the needs of military neurosurgery, their distribution as described

provided the various inedical organizations with enough equipment and

instruments to permit the performance of almost atny neurosurgical operation

likely to be necessary.

Evaluation of Equipment and Supplies

Col. (later Maj. Gen.) S. B. Hays, MC, after his assignment as Chief,

Supply Division, Office of the Chief Surgeon, Headquarters, ETOUSA, did an

excellent job of procurement and distribution of neurosurgical supplies and

equipment. After the initial difficulties just, described had been overcome, the

supply situation was gradually clarified, and equipment and instruments

began to be received in sufficient amounts to be adequate for all purposes.

It was sometimes found that deficiencies in special hospitals were the

result of poor organization in the hospital rather than of any fundamental

deficiency in the central supply system. In one general hospital, for instance,

surveyed in the spring of 1944, there was no table upon which the cerebral

headrest would fit, and no Pantopaque (iophendylate) for myelography. The

neurosurgical instrument list was also very incomplete. No effort, as far as

could be determined, had been made to overcome any of these deficiencies.

In general, both equipment and instruments were of excellent quality and

in ample supply. The following general criticisms, however, were almost

universal among neurosurgeons and therefore cannot be attributed to individual

practices and desires:

1. Fine-pointed mosquito forceps, which are of great importance in traumatic neurosurgery, as civilian experience had long since proved, were missing

from the kits. Had this type of hemostat been supplied, in amounts up to 6

dozen for each kit, neurosurgical work would have been greatly facilitated,

particularly in general hospitals in which large amounts of peripheral nerve

surgery were done, and the quality of surgical technique would have been

greatly improved.

2. Scalp clips for controlling bleeding from scalp wounds and scalp incisions, which had also been proved to be of great importance in civilian
76 UIKi~t I()SUR Ei'R

-Icj C ~-
EUROPEAN THEATER 77

neurosurgery, were missing from the neurosurgical kits. A clip of this type

(preferably the Raney clip) should have been supplied in each kit in amounts

up to 6 dozen, with appropriate clip-carrying racks and with forceps for their

application. The control of hemorrhage from the scalp without the aid of

these clips is a difficult and time-consuming process.

3. Too much emphasis had been placed upon instruments for turning

bone flaps. Experience in civilian practice had shown that the use of bone

flaps in traumatic neurosurgery is most infrequent, and it could reasonably

have been presumed that, as actually happened, it would be similarly infrequent

in military neurosurgery. As a consequence of the inclusion of these instruments, the neurosurgical kit was unnecessarily cumbersome, and the critically

short material used to manufacture the instruments could profitably I:ave

been diverted to more useful purposes.

4. Before D-day, tantalum plate for thie repair of skull defects and tantalum

wire and tantalum foil for use in peripheral nerve surgery were almost impossible to secure in the European theater. British neurosurgeons had tantalum plate available for their needs long before United States Army neurosurgeons could secure it. Experiences accumulated in the Zone of Interior had

proved that tantalum in various forms was essential neurosurgical equipment,

but initial attempts to procure supplies of it in the European theater were

unsuccessful and accompanied by many frustrations. Although ample supplies

were available in the theater after November 1944, tantalum was still being

carried as a nonstandard item at the end of the war in Europe, a policy which

was not justified in view of its established value in neurosurgery.

5. Fibrin foam and thrombin also never became standard items. Both

had proved of the greatest value in the control of hemorrhage alid were to

prove of particular importance in frontline neurosurgery, in which it was

necessary to deal with the complex and difficult problem of hemorrhage from

large venous sinuses. There is, in fact, almost no neurosurgical procedure in

which these agents are not of value. The first supplies were secured as the

result, of a personal appeal to Dr. E. J. Cohn and Dr. Franc D. Ingraham, of

Harvard UniversityV Medical School. They alvays had to be secured on special

requisitions, though they were both available in limited quantities by this

means after November 1944.

Difficulties of supply of particular items were partly due to difficulties of

production. Both fibrin foam and thrombin had to b, secured from animal

or human sources. Gelatin foam, which can be used with either human or

bovine thrombin, is now an acceptable and readily procurable substitute for

fibrin foam, and oxidized cellulose cotton has excellent, hemostatic properties

when saturated with bovine thrombin. Neither substitute, however, was

available during hostilities to relieve the situation in Europe in World War II.

6. Electrosurgical units of the portable Bovie type were standard equipment in all general, evacuation, and station hospitals but were not part of the

equipment of auxiliary surgical teams. This was unfortunate. When auxiliary

surgical teams functioned in general or evacuation hospitals, two or more
7S4 N EUR'OSU IMERY

neurosurgical tables were often in use in the operating room at the same time,

and the etficienc" of the teams was greatly reduced because of their dependence

on the single electrosurgical unit with which the hospital was equipped. From

the standpoint of portability, the unit, which is no bulkier than the accessory

neurosurgical kit, could readily have been included in the equipment of

auxiliary surgical teams.

The Bovie electrosurgical unit proved the best of its kind in any Allied

army. It did not break down even under field (conditions, and it shouli be made

standard equipment in any installation in which neurosurgery is done. ('olonel

Spurling pointed out soon after his arrival in the theater in March 1944, at a

conference in the Chief Surgeon's Office, that the fact that a neurosurgeon

was not assigned to an installation did not mean that it should not be provided

with this unit. The reason was that head injuries might have to be handled

on an emergency basis by the staff of tile hospital, or by an adjacent neurosurgeon who would come to the hospital to operate on the patient, and electrosurgical equipment is the most essential item in surgery for penetrating wounds

of the head.

7. The small portable electric cortical stimulator, delivering faradic and

sinusoidal Crarent and provided with a variety of electrodes, was made available

to neurosurgical centers in the Zone of Interior in 1942 but was never made

available in the European theater. The substitute (inductorium) purchased

from British sources was of inferior quality and much less satisfactory. A

cortical stimulator is essential equipment in any hospital in which peripheral

nerve surgery and elective brain surgery are performed, and it should be

standard future equipment in all neurosurgical centers.

8. The portable suction pump, which was standard, proved satisfactory

in all respects except that it was provided in insufficient quantities in the

tables of equipment. With the number of neurosurgical casualties treated,

each general hospital could readily have used at least six.

9. In neurosurgical centers, there was need for a suction pump of greater

capacity than the portable suction pump provided in tables of equipment.

Twenty-five stationary pumps, from each of which as many as six leads could

be taken, were purchased from British sources and greatly facilitated the

hindling of the large volume of neurosurgical work.

10. The foot suction pump developed by Lt. Col. Ralph M. Tovell, MC,

Senior Consultant in Anesthesia, Office of the Chief Surgeon, Headquarters,

ETOUSA, proved a most valuable piece of accessory equipment, particularly

when the electric current failed, as it not infrequently did, or when equipment

was out of order for one reason or another.

11. The standard portable operating table supplied to evacuation and

field hospitals proved unsuitable for neurosurgery. A particular objection was

that it could not be adapted to the prone position in which operations on the

back of the head must be done. The standard operating table supplied to

general hospitals proved too heavy and cumbersome for neurosurgery. The
EUROPEAN THEIATER 79

table used by the Royal Army Medical Corps was excellent for neurosurgical

purposes, and early in the war it was possible to purchase it in sufficient,

quantity from British sources to equip the 400-bed evacuation hospitals then

in the theater. Enough tables could not be purchased, however, to equip

forward hospitals in the later days of the fighting in Europe.

12. Air mattresses of simple design, without ridges, constructed to fit

hospital cots or beds, were not available in the European theater. They are

essential in the management of paraplegic patients, whose care is always

a serious neurosurgical problem. The nursing and transportation of paraplegic

battle casualties involved difficulties far greater than those encountered in

similar patients in civilian practice, and air mattresses of the type described

would have simplified these difficulties and immeasurably reduced the incidence

of pressure sores.

In the absence of an ideal article, the standard operating-table pad was

substituted. Its inner-spring construction made it useful for this purpose,

and, because the pad exactly fitted the litter, its narrow width facilitated

transportation. The excess supply of operating pads in the European theater

made it possible for most hospitals handling paraplegic casualties to secure

a pad for each patient during the long evacuation from frontline hospitals to

general hospitals in the United Kingdom Base. It was unfortunate, however,

that, air mattresses were not made available in sufficient quantity for all hospitals handling neurosurgical casualties to use them for all paraplegic patients

and to have at least a dozen in reserve.

13. Although the use of casts, splints, and braces was kept to a minimum

in neurosurgical injuries in the European theater, because the modern therapeutic trend is toward early motion and minimum fixation, they sometimes had

to be used. Splints were particularly necessary in peripheral nerve injuries.

It would therefore have been advantageous if a small braceshop had been

attached to each neurosurgical center. A properly fitted spring-type brace,

which is necessary for the correction of footdrop, was never available in the

European theater.

Physical Therapy Equipment

Physical therapy is an integral part of peripheral nerve repair, and the

program in the European theater suffered because tables of equipment proved

totally inadequate for the diagnostic and therapeutic load in the neurosurgical

centers. At least three times the allotted amount of floor space could profitably

have been used. The standard machine which delivers faradic, galvanic, and

sinusoidal current proved quite satisfactory for both diagnostic and therapeutic

work, but the need was frequently urgent for half a dozen to be used at the same

time instead of the one or two which each general hospital possessed. Deficiencies in physical therapy equipment were particularly unfortunate in centers

in which both neurosurgical and orthopedic patients were concentrated.
80 NEUROSURGERY

RECORDS AND PHOTOGRAPHS

Records

The maintenance of uniform, adequate clinical records in the European

theater was always seriously handicapped by lack of clerical help. The result

was that medical officers had to spend a~i excessive amount of time writing

records in longhand and that operative notes, examinat ion reports, and followup

records were generally inadequate. In the general hospitals, particularly those

in the United Kingdom, the elaborate forms required for disposition boards

inevitably slowed up evacuation and produced an unnecessary backlog of patients

on the neurosurgical services. Some of these difficulties were corrected during

the latter part of the European campaign by elimination of the clinical abstracts

originally required.

The importance of complete operative reports, particularly from forward

hospital units, was fully realized but never fully implemented, and the inadequacy of the notes sometimes led to unnecessary neurosurgical explorations in

the Zone of Interior (p. 31). Once the policy of rotation of neurosurgical personnel between frontline hospitals and general hospitals in the rear was put into

effect, however, frontline records showed an almost overnight improvement.

When neurosurgeons from evacuation hospitals saw for themselves in general

hospitals exactly how important it was to record operative findings accurately,

as well as the difficulties and complications which might arise when the records

were not exact, they bent their efforts toward correcting the situation, with

strikingly good results.

The movement of requests for followup data from one echelon to another

was always slow and inadequate. This was unfortunate. Better organized

relations between evacuation and general hospitals overseas, and between

overseas hospitals and hospitals in the Zone of Interior, would undoubtedly

have improved the quality of the work done in each echelon. Neurosurgeons

in forward hospitals who wanted to know the outcome in cases they had handled

frequently attached followup cards to the patients' emergency medical tags.

The cards were often lost en route to the neurosurgical centers. Even more

often, overworked neurosurgeons at the centers failed to fill them out and return

them.

When planning was in progress for the invasion of the Continent, it was

realized that, because of the expected pressure of work, records were likely to

suffer. It was appreciated that when the patient load became heavy, records

would necessarily receive less attention. Routine Army reports did not contain

the details of neurosurgical data necessary for satisfactory analysis of neurosurgical material, and while it was agreed that Army medical officers should not

be burdened with additional, superfluous paperwork, it was also thought that

as many of these details should be preserved as the burden of work would

permit.

In an endeavor to suit the method to the circumstances, a simplified
EUROPEAN THEATER 81

questionnaire was devised, which each neurosurgical chief of section was to

prepare monthly and to return to the senior consultant in neurosurgery. The

essential data requested concerned penetrating wounds of the brain, spinal cord

injuries, and peripheral nerve injuries. Data were kept as a day-to-day record

and could readily be assembled at the end of the month. The reports were

tabulated bimonthly by the senior consultant in neurosurgery and were distributed in mimeographed form to all neurosurgeons in the theater.

At the close of the European campaign, a final statistical analysis of neurosurgical data from all United Kingdom Base neurosurgical centers was thus

available (p. 82). The summary of the work done in these installations from

D-day to V-E Day may not have been entirely accurate, but it would not have

been possible at all if the plan outlined had not been carried through.

There were numerous reasons why statistical analysis of neurosurgical

casualties similar to the one just described was not accomplished in hospitals

in army areas. The chief reason was that monthly reports limited to neurosurgical data were not deemed practical by the army surgeons and their

surgical consultants, and their point of view is quite understandable, in view

of the very heavy load carried by neurosurgeons during the European campaign.

On the other hand, such details, were they available, would be of immeasurable

value in planning for future neurosurgical casualties, and it is unfortunate that

they were not secured, as they could have been without undue hardship, had

closer liaison been possible between the senior consultant in neurosurgery and

individual neurosurgeons. Most of the neurosurgeons in the army areas

kept personal records, and, had they been provided with a uniform worksheet,

uniform data would have been available at the close of the campaign with

little more effort on their part-perhaps even less effort-than was expended

in keeping their individual forms. Because such a worksheet was not provided,

a final, accurate compilation of neurosurgical data proved impossible. The

records which had been kept individually were so diversified and were collected

from such varying points of view that those which were examined proved

almost useless for this purpose.

Pictorial Records

From the standpoint of the neurosurgeon, far too little emphasis was

placed upon photography as a means of recording important professional work.

Large numbers of pictures were collected in the neuiosurgical centers, but they

were collected by the initiative of individual medical officers. The Army did

not furnish cameras, photographic supplies, or personnel. The only team

of photographers and artists from the Army Pictorial Service which functioned

in the European theater was attached to the 1st Medical Laboratory, and its

services, because of a series of errors, the responsibility for which must be

shared by all concerned, were never fully utilized.

No matter how efficiently this team might have functioned under happier

circumstances, it could not possibly have supplied adequate coverage for all
82 NEUROSURGERY

the nearosurgical centers in the United Kingdom Base Section. Furthermore,

its unwieldy organization was not conducive to efficient work in more than

two general hospitals at one time.

From the neurosurgical standpoint, a better solution of the photographic

problem in the future would be to provide equipment and supplies, and perhaps

a technician, for each general hospital of 1,000 beds or more in which specialized

neurosurgical work is done, and to attach a photographic consultant to the

staff of the Chief Surgeon to supervise the work of the individual photographic

laboratories. For lack of this or some similar system, an enormous amount

of important neurosurgical material was completely lost during the European

campaign in World War II.

RESEARCH

No formal research programs in neurosurgery were undertaken in the

European theater, chiefly because the burden of clinical work wa, -,) heavy

(luring the period of active combat that neurosurgeons had little anything but the treatment of casualties. Many worthwhile c. ',udies

were, however, undertaken and reported. Attention is called ,iem n at

appropriate points in this volume and in volume II 12 of the neurosurgical

history.

STATISTICAL DATA

In the preliminary planning for the invasion of the Continent, it had been

estimated by Colonel Spurling that about 10 percent of the seriously wounded

casualties reaching evacuation hospitals would be neurosurgical. The estimate

was based on the United States experience in North Africa, the British experience at Dieppe, and his own experience on the neurosurgical service at

Walter Reed (p. 5). Head injuries were expected to account for 2 to 3

percent; spinal injuries including fractured vertebrae, penetrating wounds of

the spine, and acute disk lesions, would account for 0.5 to 1 percent; and peripheral nerve injuries, including extremity wounds in which one or more major

nerve trunks would be involved, would account for 7 to 8 percent.

These predictions proved quite accurate. In a surveya month after D-day,

Colonel Spurling found that about 10 percent of all casualties reaching general

hospitals were neurosurgical. Head injuries represented about 4 percent,

injuries of the spinal cord about 1.5 percent, and peripheral nerve injuries

5 to 6 percent.

Statistical data on peripheral nerve injuries and penetrating wounds of

the brain collected from neurosurgical centers in the United Kingdom, as well

as the limited data collected in the army areas, appear in this volume and

volume II of the neurosurgical series under appropriate headings. In order

to illustrate the amount of material and the types of cases handled by

neurosurgical teams in various echelons, three individual (greatly condensed)

n1 See footnote 6, p. 61.
EUROPEAN THEATER 83

reports to the senior consultant ini neurosurgery are appended, each covering

the period from the inception of the service through V-E Day or later.

Report No. L.-Neurosurgical Team No. 2, 3d Auxiliary Surgical Group, worked in

First U. S. Army installations between 13 July 1944 and 13 May 1945, in 9 evacuation

hospitals (95th, 34th, 45th, 67th, 96th, 97th, 102d, 103d, and 128th) and in 4 field hospitals (13th, 45th, 47th, and 51st). During this period, 283 major neurosurgical procedures

were performed (260 craniotomies, 23 laminectomies), and approximately 200 additional

operative procedures of a minor nature, such as suture of lacerations of the scalp and debridement of wounds, were also carried out. No statistical record was kept of the other

cases treated, which included large numbers of closed and compound head injuries, closed

and compound spinal injuries, and peripheral nerve injuries. These injuries were seen ill

consultation in various hospitals in the First U. S. Army area but did not require surgery.

The ease fatality rate in the 283 major neurosurgical operations was 9.5 percent (27

cases). Of the 27 deaths, 26 occurred in penetrating wounds of the brain; the remaining

fatality followed lalninectomy.

There were 24 deaths in the 161 penetrating wounds of the brain treated in evacuation

hospitals and 2 in the 31 similar wounds treated in field hospitals. There were no deaths ill

the 58 compound depressed skull fractures treated in evacuation hospitals or in the 10

treated in field hospitals.

The single death which followed laminectomy occurred in I of the 6 cases treated in

field hospitals.

The surgical case fatality rate in the 147 United States soldiers with penetrating wounds

of the brain was 8.8 percent, compared with a rate of 30.0 percent in 45 German prisoners of

war with the same injuries.

Cownpound head injuries.-The following observations were made in 192 penetrating

wounds of the brain treated by surgery:

Metallic foreign bodies were retained in 59 wounds and bone fragments ill 102 wounds&;

the latter were of the gutter type. There were 31 through-and-through injuries.

In 46 intracranial injuries, one frontal sinus, or both, were involved 26 times, the maxillary sinus 12 times, and one or both ethmoids 17 times. The mastoid process was injured

9 times. One eye was destroyed in 20 cases and both eyes in 5.

In 25 injuries coinplicated by involvement of the dural sinuses, the longitudinal sinus

was involved 16 times, the transverse sinus I I times, and the straight sinus once.

In 60 cerebral injuries, associated injuries (exclusive of facial wounds) included 7 penetrating wounds of the chest, 7 penetrating wounds of the abdomen, 2 thoracoabdominal

wounds, and 24 wounds of the extremities without fractures.

The following additional data were collected from the 192 penetrating wounds of the

brain treated surgically: There were 11 extensive subdural and 3 extensive ext radural hematomas. There were 39 transventricular wounds, 1.1 of which were fatal. The dura was left

open ill 6 cases and closed in 67. Ill the other 119 eases, free pericranial grafts were used in

102, temporal fascia grafts ill 14, fascia lata grafts in 2, a"nd a free galeal graft in 1.

Analysis of the 26 fatalities following craniotomy revealed the following data: Twentyone patients were in deep coma on admission and did not recover from it any time before

death. Eight patients exhibited Cheyne-Stokes breathing when operation was undertaken.

Five had normal, regular respirations at this time, but 6 had audible evidence of puhuollary

edema and 7 had irregular, stertorous breathing. Seven had bilateral fixed pupils at operation. It was the experience of Neurosurgical Team No. 2 that no patient who had bilateral

fixed pupils when he was first seen ever recovered, no matter what other signs he might

or might not present.

Ini 15 cases, the brain lesions involved both hemispheres, and in 11 they were unilateral.

Fourteen lesions were transventricular.

Three patients presented extensive thrombosis of the longitudinal sinus. Two patients

were found at necropsy to have postoperative hematomas of the surgical wounds, following
84 NEUROSURGERY

frontal and occipital lobectomy, respectively. It is possible that these clots contributed to

the fatal outcome.

One patient died on the operating table. He was moribund when first seen and presented

uncontrolled bleeding from multiple lacerations of the dural sinuses and cortical vessels. Of

the remaining patients, 10 died within 24 hours after operation, 8 between 24 and 72 hours

afterward, and 7 between 4 and 8 days afterward.

The causes of death were as follows: One patient (as already noted) died of hemorrhage

on the operating table. Seventeen patients died with the syndrome of progressive respiratory

irregularity and failure, hyperthermia, and terminal pulmonary edema. Two patients, both

with extensive thoracoabdominal wounds, died of massive pulmonary congestion 6 days after

operation. Two patients, both German prisoners of war, one 50 and one 60 years old, died

on the second and the fourth postoperative day, respectively, of circulatory failure, pulmnonary edema, and anuria. One patient died on the fifth postoperative day of overwhelming

meningitis, 12 hours after the first clinical evidence of the disease, and in spite of daily intrathecal and intramuscular injections of penicillin. The local wound was clean at necropsy.

The etiology and type of the meningeal infection were not determined. One patient died on

the eighth postoperative day, 36 hours after a transfusion followed by circulatory and

respiratory collapse, hyperpyrexia, and anuria. One German prisoner of war, 60 years old,

died 8 hours after operation. Only 75 cc. of whole blood had been given on the operating

table when the transfusion had to be stopped because of a severe chill and circulatory collapse.

One German prisoner of war died on the third postoperative day, immediately after the

intravenous administration of anti-gas-gangrene serum for gas gangrene of both legs.

Compound injuries of the spine.-The indications for the 23 laminectoinies performed

by Neurosurgical Team No. 2 were as follows: Partial, (clinically) favorable lesions in 5

cases; gross spinal fluid fistulas in 5 cases; associated injuries which made transportation

impossible in 17 cases; and nontransportability due to the patient's poor general condition

and unsatisfactory respirations in 1 case.

The neurologic picture in the first 48 hours after operation showed no improvement in

9 of these 23 )atienits, slight iml)rovement in 8, and marked improvement in 4. In 2 instances,

there was no record of the neurologic status.

The single death in the series occurred in a patient with a through-and-through wound

of the abdomen involving the transverse colon, the liver, and the cauda equina. Laminectomy was performed 3 days after laparotomy; the dura could not be closed. Death occurred

on the 10th postoperative day from meningitis of Bacillus coli origin.-Capt. DONALD D.

MATSON, MC.

Report No. II.-Neurosurgical Team No. 4, 1st Auxiliary Surgical Group, functioned

in five United States Army hospitals between September 1943 and V-E Day. During

this time, this team worked in 2 general hospitals, 2 evacuation hospitals, and 1 station

hospital. It performed a total of 269 neurosurgical procedures with 9 deaths, 3.35 percent.

Periods of inactivity were caused by staging for the channel crossing (6 weeks), lack of

supplies of tantalum (14 days), and movements with an evacuation hospital (several days).

The policy of the team was to make no selection of cases but to operate in the order of

seriousness on all patients who, it was believed, would not succumb to the trauma and stress

of surgery. In some instances, delays of as long as 48 hours after admission to the hospital

were deliberately practiced, to permit the use of supportive and resuscitative measures.

The shortest elapsed time between injury and wound closure was 6 hours and the longest 7

days. The majority of the patients were observed for periods of 10 to 14 days after operation except when evacuation at the end of 5 to 7 days was necessary because of the tactical

situation. The small number of observed infections (7) was attributed to the good results

achieved by the concentration of all neurosurgical procedures in a separate operating room,

removed from other cases.

A breakdown of the 269 operations performed by this team is presented in table 4.
EUROPEAN THEATER 85

TABLx 4.-Analysis of 269 neurosurgical procedures performed in general, evacuation, and

station hospitals by Neuroeurgical Team No. 4, Ist Auxiliary ,Surgical Group

Injury or operation Cases Deaths Case fatility

ratio

Head wounds: Nuuer Number Percent

Penetrating wounds ------------------------ ----- 67 4 5.9

Perforating wounds- - 5

Depressed fractures with intact dura_ - 22 ......... . . .-

Scalp lacerations:

Severe lacerations ----------------------------- 26 1 3.8

Minor lacerations ------------------------------- 30 ---

Skull defects 2• -.............- - - - - - - - - - - - - - ---- - - - - - 9 - - - - - - - - - - - - - - - - -

Brain abscess ..------------------------------------- 1 --

Laminectomies ------------------------------------ 25 2 8.0

Subdural explorations ------------------------------ 13 2 15.4

Herniated nucleus pulposus -------------------------- I.----------.------.---

Peripheral nerve injuries:

Neurorrhaphy --------------------------------- 41 ----------.--------

Neurolysis ------------------------------------- 29

SSecondary closure.

2 Tantalum plating.

Head injuries.-One of the 4 deaths in the 67 penetrating wounds of the head occurred

after a relatively mild left frontal wound, which had penetrated the brain for only 2.5 cm.

The patient also had a fracture of the left radius and three compound fractures of the pelvis.

Although he was received in profound shock, he responded well to therapy except that

voiding could not be induced. He was operated on for the head injury 24 hours after

admission to the hospital, under local anesthesia. Death occurred on the fifth postoperative

day. During this interim, he passed no urine. The nonprotein nitrogen of the blood was

greatly increased, but ureteral catheterization failed to disclose any pathologic changes.

Post mortem examint tion revealed a clean head wound, in which healing was progressing

satisfactorily. The kidneys were rather pale, but no blood or crystals were found in the

tubules.

The second patient in this group had two penetrating wounds of the brain, in the right

frontal and right parietal regions, respectively. In each area, multiple foreign bodies had

traversed both lateral ventricles and lay beneath the skull on the left side. The patient

was deeply unconscious, and his condition was so poor that the wounds were attacked

separately. He died 48 hours after the second operation. Post mortem examination

revealed great destruction of both frontal and parietal lobes and almost complete necrosis

of the corpus callosum.

The third patient had an extensive left parieto-occipital wound. He was operated on

20 hours after wounding and died 4 days later. His depth of unconsciousness was always

profound. At autopsy, a fracture was found across the base of the middle fossa. The

left petrous pyramid was fractured anteriorly and posteriorly, so that, except for its dural,

vascular, and neural attachments, it lay free.

The fourth patient had an enormous left frontoparietotemporal wound, with destruction

of most of the left frontal lobe and part of the temporal lobe. At operation, the brain was

extremely dirty and foul smelling, and organisms were easily smeared from necrotic tissue.

After debridement, the wound was left open, and the brain was treated as a fungus cerebri.

The patient died on the 12th postoperative day, but details are not known, since he was

never transportable and had to be left in a holding unit when the hospital was moved.
86 NEUROSURGERY

The single fatality in the 56 scalp lacerations occurred on the operating table. The

patient had been wild and belligerent since admission. The roentgenograms, which for

this reason 'n-ere not entirely satisfactory, showed a possible small defect beneath the laceration. The patient did not take the anesthetic (ether, by the endotracheal route) satisfactorily, but the wound %as quickly explored and closed. No fracture was found. As he was

recovering from anesthesia, he had a generalized convulsion and died almost at once. Post

mortem examination showed lacerations of the tips of the frontal and temporal lobes on both

sides.

Both patients who died after closed head injuries were received after prolonged periods

of unconsciousness. Neither responded to exploratory burr holes, oxygen, nasal feedings,

and other routine measures.

Spinal injuries.-The two patients who died after laminectomy both had injuries of

the cervical spine. One of them was received a week after wounding. He had had no

previous surgery. Meningitis was present, with profuse leakage of cerebrospimal fluid. The

wound was debrided and the dura closed after a great deal ot dirt had been removed from

the spinal canal. His course was progressively downhill after operation, and he died in

36 hours. The second patient withstood lanminectoiny and had a satisfactory convalescence

until the fifth day, when a massive atelectasis developed. Response to bronchoscopy was

good. On the eighth day, when the patient was ready to leave the hospital, lie (lied suddenly

and without warning. Autopsy revealed a massive right-sided pulmonary infarction.-

Capt. R. M. PEARDON DONAGHY, MC.

Report No. III.-The report of the neurosurgical section of the 15th Hospital Center

in the European theater covers the period from 1 June 1944 to 1 July 1945 for all cases except

the combined nerve-orthopedic injurite, which were observed between 1 March and 1 July

1945.

Penetrating 'rounds of the head.-There were 777 such injuries, of which 25 terminated

fatally. Surgical procedures, which were performed on an average of 5.2 days after injury,

included 29 primary debridements; 198 secondary operations (debridements, cranioplasties,

operations for osteomyclitis, wound closures); 41 craniotomies for repair of dural fistulas,

removal of foreign bodies, and excision of brain abscesses; and 67 miscellaneous procedures,

including burr holes, drainage of abscesses, and lplastic procedures on the scalp.

In 270 instances, dural rlpair was carried o.t at the primary operation. After complete

debridement, 122 patients still had retained bone fragments.

Infections included 65 superficial scalp infections, 63 subgaleal infections, 72 brain

abscesses, and 43 instances of meningitis.

Spinal cord injigries. -There were 334 injuries of the spinal cord, 47 at the cervical,

164 at the thoracic, and 123 at the lumbar level. One hundred and sixty-five patients

presented complete physiologic loss and 169 incomplete physiologic loss. There were 12

fatalities.

Of 141 patients operated on, 23 showed prompt improvement after surgery. There

were 19 wound infections and 9 instances of meningitis.

Peripheral nerie injuries.-Exclusive of 154 combined nerve and orthopedic injuries,

1,251 peripheral nerve injuries were observed at the 15th Hospital Center, of which 256

were treated by neurolysis and 165 by nerve suture, on an average of 61.5 days after injury.

There were no fatalities. Primary wound healing occurred in 414 cases. Tantalum wire

was used in 164 cases and foil cuffs in 397. Silk was used in only one case.

In 123 wounds of the extremities with peripheral nerve paralyses, secondary wound

suture was performed on an average of 24 days after injury. There were no fatalities.

Primary wound healing occurred in 92 cases, and 4 wounds broke down completely; superficial infections occurred in the remaining 27 cases. Preparation for surgery included chemotherapy in 92 cases and local treatment of the wound in 96.

Miiicellaneous cases.-There were 467 cases not covered by any of the categories described. In 251 cases in this group. encephalography, repair of ruptured intervertebral

disks, and various minor operations were carried out.-Lt. Col. STUART N. RowE, MC.
Part 11

THE MANAGEMENT OF

HEAD INJURIES
CHAPTER IV

Historical Note

Barnes Woodhall, M. D.

By the end of World War I, as a result of the experiences of surgeons in

the United States Army and in Allied armies, a considerable body of knowledge

had been accumulated in tile field of military neurosurgery. Tile comment is

frequently made that the written record in this area of experience, and in other

areas as well, was buried in the official medical history of the war, which did not

attain wide circulation. The criticism is not fair. The official medical history

was available to all surgeons who wished to study it, as were a number of texts

on neurosurgery and numerous contributions on military neurosurgery in

tile periodical literature.

Between the two World Wars, some neurosurgeons in teaching institutions

demonstrated their interest in military neurosurgery by means of clinics and

occasional clinical notes and thus transmitted their knowledge, experience,

and definitive conclusions to the medical students whom they taught. Years

of peace, however, are not conducive to the maintenance of interest in gunshot

wounds of the brain, the peripheral neuraxis, and similar subjects, and it is an

indisputable fact that the new generation of military neurosurgeons entered

the neurosurgical centers which were established in the Zone of Interior in

1942 poorly prepared for the management of battle-incurred neurosurgical

injuries. Much of the old had to be relearned, and new developments occurred

with almost startling rapidity.

During World War I, as the record shows, there were no striking advances

in many of the previously accepted methods of neurosurgicaI treatment. This

was not true of injuries of the head. Between June 1918, when the late Col.

Harvey Cushing, MC, was appointed neurosurgical consultant in the Surgeon

General's Office, and the signing of the armistice that ended the war in November of the same year, the modern neurosurgical management of battleincurred injuries of the brain came into existence.

Early in World War I, the results of these injuries were poor. The neurosurgical section of the official history of the Medical Department contains the

statement: "The results of the early operations for penetrating wounds of the

skull, so far as figures rendered them available, had been lamentable, the

estimated operative mortality from reports in literature varying from 50 to 65

percent * * *." I Later in the war, although the Deuxnouds Hospital, which

was supporting the First U. S. Army, did not receive casualties until ani average

SThe Medical Department of the United States Army In the World War. Washington: Government Printing Office,

1927, vol. XI, pt. I. p. 749.

89
90 NEUROSURGERY

of 36 hours after injury, the surgical case fatality rate in 106 craniotomies was

only 33 percent and the total case fatality rate in 175 craniocerebral injuries

was only 20 percent.2

This improvement in results was brought about through (1) the placement of neurologic surgeons and neurologic teams in hospital units near the

front, (2) professional instruction, and (3) the dissemination of detailed

directions for the care of craniocerebral wounds. More important, however,

than any of these considerations were the personal professional activities of

Colonel Cushing himself. The principles of debridement of craniocerebral

wounds which he established in World War I proved equally valid in World

War 1I. They were enhanced, but they were not altered, by the addition of

modern chemotherapy and antibiotic therapy. The experience of World War I

was of inestimable value in the management of battle-incurred injuries of the

brain in World War II.

With the exception of cranioplasty, the late treatment of head wounds

in World War I offered a limited field for neurosurgical procedures or neurosurgical interest. It was generally agreed that autogenous bone, most often

secured from adjacent intact skull but sometimes from the tibia, ribs, or ilium,

was the cranioplastic material of first choice. In an occasional selected case,

a celluloid plate was inserted.

Because of the higher incidence of infection in World War I as compared

with World War I, considerable interest was necessarily shown in brain

abscess and cerebral fungus. The important part played by infection is illustrated by the extensive experimental studies made at the Army Neurosurgical

Laboratory in Baltimore, which were chiefly concerned with these aspects of

head injuries.3 The reconstructive surgery of cerebral scars, the medical

prophylaxis of posttraumatic epileptic seizures, and the rehabilitation of

hemiplegic and aphasic patients were all problems for the future.

In the late management of head wounds, neurosurgery in World War II

advanced considerably beyond the achievements of this specialty in World

War I. In the early management of these wounds, neurosurgeons in World

War II merely had to build upon the firm foundation laid in World War I by

the activities and practices of Colonel Cushing.

3 Ibid., p. 774-775.

SIbid., p. 848.
CHAPT ER V

Head Injuries in the Zone of Interior

Barnes Woodhall, It. D.

When the United States entered World War II, Zone of JIt erior hospitals,

which were to bear the brunt of the sequelae of head injuries, had the benefit

of three recent advances to assist them ill the achievement of this mission.

The first was electroencephalography, which had become of establishcd value

as an adjunct imeasure in the localization and interpretation of convulsive

disorders. The second was the new drugs available for the medical therapy of

convulsive states. [he third was tantalum and the acrylic resins which, although they were new and comparatively untested, seenied to offer vgreat

possibilities as cranioplast ic materials.

During the first. months of United States Army participation ill World

War II, the neurosurgical emphli'asis, rather naturally, was upon penetrating

heaul wounds as compared with closed head injuries. It soon became evident,

however, that in a mechanized army, closed inijurics and the factor of blast.

(p. 215) could not be casually dismissed as potential causes of cerebral trauma.

At this time, when neurologists and psychiatrists were fully occupied with large

numbers of psychiatric casualties, all patients with cerebral trauma were, of

necessity, treated on neurosurgical sections. Sequelae of ]lead injuries in the

fields of both neurology and neurosurgery were widely various, ranging from

speech defects, headache, and vertigo through mental disturbances and convulsive disorders to retained foreign bodies including bone chips, skull defects,

and cerebral abscesses.

ADMINISTRATIVE k'ONSIDERATIONS

Correlation of the functions of the neurologist and the neurosurgeon ill the

management of these patients, who were their joint responsibility, was accomplished at various centers in various ways. In some, it was achieved by

constructive personal arrangements between the respective chiefs of sections.

In others, the cooperation was less intimate. In still others, a comparable

division of labor and interest was never accomplished. These results might,

have been anticipated; by hospital regulations, electroencephalography, speech

control, and the estimation of the neurologic defect were under the general

management of the medical service, while the same patient's difficulties as they

were related to the causative skull defect were the responsibility of the surgical

service. Administrative regulations, therefore, for all practical purposes, made

it necessary to consider the patient with a damaged nervous system as the

91
92 NEUROSURGERY

result of a head injury not as a single person with a multitude of complaints

and with objective signs of injiry but rather as two persons. Till the end

of the war, the medical officers responsible for the solution of these problems

always found it difficult and fri,,quently found it impossible to transcend the

regulations which kept this fallacious point, of view operative.

RECONSTRUCTIVE MANAGEMENT

The majority of patients with head injuries received from overseas had

been excellently treated. In comparison to the late evacuation, undue prolongation of immobilization, frozen joints, and other errors which characterized

the early experience with peripheral nerve injuries, patients with head injuries

were, almost without exception, received in good condition.

Only about a third of all patients with penetrating injuries were, however,

entirely free of disabling defects or symptoms, while in others who were presently asymptomatic there was electroencephalographic evidence of epileptogenic foci. No unequivocal statements, therefore, could be made that their

future would be secure from sequelae of their wounds. This consideration, plus

the fact that a large proportion of men with head injuries who were returned

to duty had to be separated from service within periods of months, led to the

development of the policy that all casualties with penetrating injuries should

be treated adequately and then promptly separated from service. When this

policy was fully implemented, patients with cranial injuries were being disposed

of so rapidly that many of them were out of service within a month of their

return from overseas.

As a result of excellent treatment overseas and the policy of separation

from service after adequate treatment in the Zone of Interior, the mission of

hospitals in the United States was clear. It chiefly concerned penetrating

wounds. Patients with such wounds always had to be surveyed, and many of

them had to be treated, from one or more of the following points of view: (1)

Residual infection; (2) retained metallic or other foreign bodies, particularly

bone fragments, and their influence upon infection and other manifestations

of injury; (3) neurologic defects, with emphasis upon pneumoencephalography;

(4) skull defects and their repair; and (5) convulsive states, with particular

attention to electroencephalography and the resection of cerebral scars.

A well-rounded clinical description of the syndrome of the acutely injured

b)rain was soon available through the contributions of neurosurgeons experienced

in, and adept at, the surgery of these injuries. Diagnostic refinements were

introduced. A technical bulletin on the technique of electroencephalography

and the interpretation of electroencephalographic findings was issued.' The

indications for, and the technique of, cranioplasty were also described in detail.

Evaluation of all features of the cerebral injury, which was a laborious

task, received only limited attention while the war was in progress. This was

partly because attention was devoted to other, more immediately urgent, matI War Department Technical Bulletin (TB MED) 74. 27 July 1944.
IIEAD INJURIES, ZONE OF INTERIOR 93

ters but chiefly because this phase of reconstruction is essentially a long-term

problem.

Infection

The first responsibility of the neurosurgeon in Zone of Interior hospitals

was to complete the task, begun overseas, of eliminating infection. This was

usually a minor problem. In the relatively few cases of late residual infection

observed in neurosurgical centers in the United States, the influence of inadequate debridement and inadequate postoperative care was clearly manifest.

In most of these instances, retained bone fragments, which were always an

evidence of incomplete debridement, were the cause of persistent infection,

and the practice of radical resection was soon developed for the management

of such patients In an occasional case, the location of the fragments was such

that only drainage was employed, for fear that resection might destroy whatever residual vision the patient had.

In occasional instances, a solitary abscess had developed about a retained

metallic fragment, just as it might have developed in any other area of the

body. In the absence of clear indications for surgery, conservatism was the

rule in this type of case, though occasionally a well-encapsulated abscess was

removed in toto. Penicillin proved of great value in the conservative management of brain abscesses, particularly in the early stage, in which cerebritis is a

prominent feature.

Cranial Defects

A second responsibility of the neurosurgeon in the Zone of Interior was the

restoration of the integrity of the skull after wounding. Most patients with

penetrating wounds of the brain were left with unsightly scars and other

defects, for which some sort of reconstructive surgery was necessary. Although

this was often a major task, because the defects were numerous and were frequently technically difficult to repair, a technique was rapidly evolved which

proved safe and effective for general use.

Cranioplasty was performed overseas in a limited number of cases, but the

results are inconclusive because of the lack of official reports. When the dura

and brain were not lacerated, it was a safe procedure when performed early,

and it undoubtedly expedited returns to duty, at least theoretically, when

manpower was in short supply. Schorstein, 2 who commanded a British

mobile neurosurgical unit, reported that 28 of 33 patients who underwent

primary skull closure with acrylic plates had been back to duty, mostly in a

lower category, for 3 months or more at the time of writing. It was later

learned that two patients in this group had sustained delayed infections.

The United States Army experience seems to have been less satisfactory.

Neurosurgeons in Zone of Interior hospitals observed a number of postoperative infections and did not regard the cosmetic effect as good in all cases.

SSchorstein, J.: Primary Skull Closure With Acrylic Plates. Brit. 3. Surg., Supplement No. 1, Wounds of the

Head, pp. 256-267, 1947.

455735-58---
94 NEUROSURGERY

In their opinion, this procedure was better done in a general hospital some

months after primary healing.

Neurosurgeons in the Zone of Interior also found the use of tantalum foil

over the injured brain not only useless but dangerous. The foil was invariably

found in a crumpled mass, adherent to the tissues. Almost every patient thus

treated had either an associated cerebritis or a distinct increase in the local

scar, and at least two patients were known to have developed status epilepticus

shortly after the foil was employed.

Indications.-The indications for repair of cranial defects remained those

which had been standard in prewar neurosurgery; that is, localized pain,

headache, vertigo, vertigo upon change of posture, deforming defects, and fear

of further injury. The mere presence of a skull defect 3 cm. or more in diameter

was usually regarded as a sufficient indication for cranioplasty, especially in

view of the military directives which precluded the return to duty of a patient

with a skull defect of larger area or with a defect which would prevent the

ready use of military headgear.

Tantalum.-In World War I, as already mentioned (p. 90), cranioplasty

seems to have been carried out almost entirely with autogenous bone, usually

derived from adjacent calvarium or from the tibia and less often from other

bony structures such as the ilium, the scapula, or the rib. In complicated and

larger defects, the use of celluloid plates was advised.

By the onset of World War II, a number of alloplastic substances had

become available for clinical trial, such as Vitallium, zirconium, tantalum, and

certain synthetic resins such as methyl methacrylate. The most promising

of these, tantalum, was introduced into the neurosurgical centers in the fall of

1942. Certain statements concerning possible adverse reactions after its use

appeared from time to time, but objective evidence to substantiate them was

never forthcoming in the whole cranioplastic experience with this agent. The

thin, translucent connective tissue capsule which appears about a tantalum

plate after it is in place is apparently nonprogressive in nature.

Even before the war, experimental and clinical studies had demonstrated

that tantalum possesses at least two properties which are essential in any

material used in the repair of the skull. The first is that it is so relatively inert

in tissues that, for all practical purposes, it can be considered absolutely inert.

Experimental studies indicate that it does not react to heat, cold, or electrical

fields.

The second desirable feature of tantalum is its malleability. When it was

originally introduced, it was applied by crude molding, cutting, and contouring.

These original crude methods had obvious disadvantages. One was loss of

time at the operating table. Another was the fact that although plates shaped

in this manner were adequate for the convexity of the skull surface, they

could not be used for multicontoured defects, such as those likely to occur in

the supraorbital region. Refined techniques of molding the malleable plate

before cranioplasty were rapidly developed. The preparation of plates of

complicated shapes gradually evolved by the use of a die and counter die or
HEAD INJURIES, ZONE OF INTERIOR 95

by the use of a hard rubber piston, by means of which the plate could be

contoured and swaged over the original impression.

Materials required for the formation of tantalum plates, as well as the

technicians needed to make them, were available in all dental laboratories, and

the skill and experience of Army Dental Corps officers had much to do with

the successful treatment of patients in neurosurgical centers, particularly

those with large skull defects.

Techniques.-All techniques devised for the insertion and fixation of

tantalum plates proved to have features of distinct value. In no field of reconstructive surgery, indeed, was the ingenuity of United States Army neurosurgeons so clearly demonstrated as in the many technical methods devised

for this purpose. A sound knowledge of the blood supply of the scalp and

of the principles of shifting flaps of scalp, both derived from experience in

acute head injuries, proved essential in the exposure of skull defects preparatory

to cranioplasty with tantalum.

In the actual insertion of the plate, it was soon found that because of the

predominance of linear scars, approach to the defect was usually possible by

simple excision of the original scar, with dissection and retraction of a flap

of scalp. Cranioplastic incisions about horizontal scars were promptly abandoned, it being observed that they were almost always followed by necrosis

of the incisional line, or, occasionally, by actual gangrene of the original scar.

Fixation was obtained with wire sutures, with screws, or with tantalum points

applied by various techniques.

The experience at Kennedy General Hospital, Memphis, Tenn., may be

cited as typical. Up to September 1945, 316 tantalum plates had been inserted

in the skull as part of cranioplastic procedures required by combat-incurred

defects. Various types of fixation were tested and discarded before fixation

with glazier's pegs was adopted. Still later, slots were cut near the edge of the

plate for the insertion of the pegs, or, when slots were not practical, notches

were cut into the edge. The best cosmetic results were achieved when the plate

was placed directly on the outer plate of the skull, without any countersinking.

At Hammond General Hospital, Modesto, Calif., 152 skull defects were

repaired in the year ending on 21 August 1945. In only a few instances was

it necessary to open the dura for exploratory purposes before adjusting and

fixing the plate in position. At first, the plates were held in position by the

use of tantalum wires strung through perforations in the outer table of the

skull and the tantalum plate; the perforations were made by means of an

electric motor and dental drill. This method was discarded when the use

of tantalum wedges was found to afford a firmer fit and also to save time at

operation. Perforations in the plates, however, continued to be used, partly

to permit a free drainage of fluids after operation and partly because the

growth of connective tissue through the openings helped to hold the plates

firmly in position.

At this hospital, the policy at first was to inlay plates only in the frontal

region, the time taken to inlay them elsewhere being thought to be an unneces-
96 N EUIt OsUit(EItY

sary requirement. Later, tile inlay method was used in most operations

because the fit was better with this technique and there was less likelihood

of the development of ridges under the scalp.

Postoperative removal of tantalum.--Although there was definite evidence

that perforations in the tantalum plate somewhat weakened its strength, there

was also considerable evidence that, they possessed certain advantages. One

of the most important, as just noted, was that they provided for drainage of

the fluid which invariably collected beneath the plate. They also permitted

complete expansion of the cranial content and the dura to the under surface

of the plate. The latter fact became increasingly apparent during the later

phases of the neurosurgical experience, when a small number of tantalum

plates had to be removed as part of the attack upon epileptic foci. With a

tantalum plate in situ, it, is not possible to secure complete pneumoencephalographic studies of the cerebral scar because the plate acts as a barrier to

roentgen rays. Considerable evidence accumulated, however, that the electroencephalographic recording of such a focus is not obstructed by an intervening

tantalum plate, although the exact location of the focus is perhaps made more

diffuse by the presence of the intervening element.

Complications.-Some tantalum plates had to be removed for postoperative infections, which could usually be traced to the original acute infection. Scattered instances of pneumatocele were observed, all in cases in which

plates had been placed over skull defects affecting the air-containing sinuses.

With these exceptions, no complications of any consequence followed the use

of tantalum in the correction of skull defects, and not many plates had to be

removed.

Results.-On the whole, the results of cranioplasty were good both cosmetically and clinically. Headaches and dizziness, particularly on changes of

position, were generally less marked. Neurologists who followed these patients

reported improvement in both neurologic and aphasic disturbances, but the

period of observation during the war was not long enough to warrant generalizations, and whether there was an actual improvement in cerebral function or

merely the psychic improvement associated with correction of the skull defect

could not then be determined.

Acrylic resins.-It is undeniable that the emphasis upon, and the good

results of, cranioplasty with tantalum influenced adversely the development of

other materials for the same purpose, such as the acrylic resins. The situation

was recognized early in the war, and studies with these resins were instituted

at the neurosurgical centers at Fitzsimons General Hospital, Denver, Colo.,

and Newton D. Baker General Hospital, Martinsburg, W. Va., where approximately 70 cranioplastic procedures were performed with them. The immediate

technical results were good in all cases, and no undue tissue reactions occurred.

In retrospect, however, cranioplasty with tantalum met all the objectives of the

repair of large numbers of skull defects, and, subject to the few qualifications

mentioned, it seems likely that this material will maintain its status as a

cranioplastic agent.
HEAD INJURIES, ZONE OF INTERIOR 97

Convulsive States

The treatment of the somatic functional sequelae of head injuries, such as

aphasic and convulsive states, differs from the treatment of infection and the

restoration of skull defects in that the passage of time is the deciding factor.

The very nature of the lesions makes the two tasks incompatible. They demand a different armamentarium and different, though equally highly specialized, professional care.

Pneumoencephalography was performed in only a relatively small percentage of penetrating head injuries, chiefly in patients with convulsions or

with striking neurologic defects. Electroencephalography was carried out,

whenever possible, in all head injuries and was of considerable value in the

identification of preclinical convulsive states, the localization of convulsive foci

and the differential study of cerebral injury following blast.

The experience with encephalography was particularly extensive at Kennedy General Hospital. Late in 1943, a civilian physician experienced in this

field was employed, and a special laboratory was set up. At the peak, 6 technicians and 2 secretaries were necessary to handle the load. Of the 2,617 studies made, 411 were for skull defects or depressed fractures in which surgery,

usually plating, was required, and 425 were made on patients who had suffered

blast concussions, with no evident trauma of the skull or body.

Early in the history of the neurosurgical centers, it became apparent that

some policy must be established regarding the surgical treatment of cerebral

scars. Previous experience had shown that, when the brain is penetrated by a

missile, an incidence of subsequent convulsions in the neighborhood of 40 or 45

percent might be expected. About half of the attacks could be expected to

develop during the first year after injury and the remainder within the next 4

years. The problem was particularly serious in neurosurgical centers during the

war. The neurosurgeons assigned to them were working under a great deal of

pressure because of the heavy patient load, and not all of them were talented in

this special field. Even if they had been, there was little time to dedicate to a

specialized group of casualties.

The fundamental issues were twofold: (1) Whether prophylactic excision

of cerebral scars should be done, and (2) whether, if the policy of excision was

established, it should be carried out in all neurosurgical centers or whether this

highly specialized group of patients should be concentrated in one or two

centers.

Expressions of opinion on the subject were invited from well-recognized

authorities in the field of posttraumatic convulsive states, including Dr. Wilder

Penfield of the Neurological Institute in Montreal. As a result of the survey,

a policy of conservatism was decided upon. Prophylactic excision of cerebral

scars was not advised, and patients who developed convulsive states were

treated under a long-term regimen of medical care, including the administration

of the new anticonvulsive drugs. The results were not impressive in the few

cases in which prophylactic excision of scars was carried out, and in some
98 NEUROSURGERY

instances the neurologic status of the patients was worse after operation than

before.

In November 1945, a posttraurnatic epilepsy center was established at

Cushing General Hospital, Framingham, Mass., under the direction of Maj. A.

Earl Walker, MC, for the specific purpose of pursuing studies on this problem

under ideal conditions. Approximately 300 patients formed the nucleus of the

study. At the present time, only tentative opinions can still be expressed concerning the incidence, diagnosis, and therapy of convulsions following gunshot

wounds of the brain. Many more years must pass before definitive statements

can be made upon these points. The data presently available concern such

matters as infection, the influence of retained bone chips, and results of electroencephalographic studies (p. 279).
CHAPTER VI

The Mediterranean Theater of Operations

E/dridge H. Campbd/, Jr., M. D.

A review of 14,000 battle wounds treated in Fifth U. S. Army hospitals

in the Mediterranean Theater of Operations, United States Army, in 1944

disclosed that, exclusive of maxillofacial wounds, 6.17 percent involved the

head. One-third of the head injuries were classified as intracranial. The

remainder involved only the scalp. The case fatality rate for all the head

injuries observed in 1944 was 8.1 percent, but during this year 24.4 percent

of all deaths which occurred in these installations were attributed to cerebral

injuries. Of the patients with penetrating head injuries who survived to reach

general hospitals, another 3.7 percent died, chiefly as the result of complications of wound healing.

Scalp injuries, although they were associated with a low case fatality rate,

presented numerous difficulties of management. Penetrating head injuries

presented problems of the gravest import. Closed injuries of the head, except

for the policy of early ambulation (p. 106), were treated according to standard

policies.

SCALP WOUNDS

Scalp injuries, as just noted, comprised two-thirds of all head injuries

observed in the Mediterranean theater and from the standpoint of numbers

therefore represented a very important group. They were also of importance

from the practical military standpoint that the majority of soldiers with such

wounds, if they were correctly managed, could be promptly returned to duty.

Complications were limited to cases in which the defect was large or in which

underlying damage was overlooked because of inadequate exploration, usually

in the belief that the wound was purely superficial.

Scalp wounds overlying penetrating wounds of the brain presented special

problems which required prompt solution. Primary epithelization of such

wounds is requisite to sound wound healing.

The type of incision employed in wounds of the scalp, whether or not they

overlay deeper wounds, and their closure without tension were factors of great

importance in the management of these cases. The limited elasticity of the

tissues of the scalp often made it impossible to effect simple direct closure

without undue tension. Closure under tension could lead to local dehiscence

or even mild wound necrosis, and both could lead, in turn, to infections of real

seriousness.

99
1 0(1 NEFUIlt0Ot"ItG EJLY

The technique of closure of scall) wounds- was directly related to thie type

of incision used. Whenever practical, the simple vertical or curvilinear type

of incision proved most satisfactory. Quite often, however, neither one of these

incisions couhl be employed because extensive areas of tissue had been destroyed by the original incision or because extensive debridement had been

required.

One or another of the following techniques was employed to overcome

t hese diffieult ies:

1. Small defects were included in the center of a horseshoe flap or in one

leg of a tripod incision, according to the technique devised by British surgeons

in Worhl War I. In an incision of this kind, the increased tension was distributed over a wider area than in simple vertical or curvilinear incisions.

2. The galea was undermined, to permit larger flaps to be mobilized and

tissue to be stretched without undue increase in local tension.

3. Lateral relaxation incisions were frequently employed, though they

proved useful only if they were generously long, so that tension was distributed

over a wide area.

4. When loss of skin was particularly extensive, the rotation of one or

more pedicle flaps was useful. In this technique, pericranium was left ill situ

to nourish the graft.

When relaxing incisions or pedicle grafts were employed, it was found

essential to cover the defect at once with a split-thickness graft. The additional procedure did not greatly prolong (fie operating time and went far to

insure primary healing. On a few occasions, failure to take this precaution

is known to have resulted in local infections and discharging wounds which

seriously compromised the primary incision.

The use of a free graft over the original scalp defect. was found to be unwise,

partly because of the likelihood of an incomplete take and partly because of

the risk of faulty healing if reexploration of the wound should be required.

FRACTURES OF THE SKULL

"The treatment of fractures of the skull produced I)y blunt force followed

the policies usual in civilian injuries of the same sort. Fractures caused by

missiles, however, presented a much greater variety of types than are ordinarily

seen in civilian practice. The most common of these was the rounded perforation with blown-in fragments, in which the particles became, in effect, missiles

themselves and usually traveled in directions other than those taken by the

metallic fragments. Metallic fragments were likely to be broken into lits

by the impact. Dirt, hair, bits of metal, and other foreign material were often

driven into the bone edges and could be removed only by the rongeur.

If the missile struck the opposite wall of the calvarium with insufficient

force to perforate it, there occasionally resulted a pavement fracture which was

expressed instead of being depressed. Tangential or less forceful impacts on

the calvarium resulted in the familiar type of depressed fracture in which the
MEDITERRANEAN TII EATER 1)1

dislocation of the inner table far exceeds that of the outer. The possibility

of intracranial ricochet always had to be borne in mind and added materially

to the g.-avity and complexity of the wound.

Fracture lines extending from the skull injury were either continuous or

discontinuous. Continuous fracture lines might be as short as 1 to 3 cm.,

but in more serious injuries they were longer and embraced comminuted

fragro overriding of which might be observed near the wound of entry

or tnd of exit. The discontinuous type of fracture occurred at some

(li irom tile perforation in the calvarium and was not connected with it

01o Ay of its radiating tracts. Tile mechanism of discontinuous fractures

wt, er clearly elucidated, but they were a clear illustration of the important

fact that injury to neither the skull nor the brain was necessarily confined to

the track of the missile.

PENETRATING WOUNDS OF THE BRAIN

Selection of Cases for Surgery

Generally speaking, delay in operating on patients with head injuries was

not responsible for many fatalities. The time element was naturally important,

liut it became apparent early in the Tunisian campaign that it was not a serious

consideration, if any consideration at all, in most deaths from cerebral wounds.

The great majority of soldiers with penetrating head wounds which entailed

irreparable damage to vital parts of the brain died on thi field where they had

been wounded. Had it been possible to treat all of these casualties at the level

of the division clearing station, perhaps a few lives might have been saved.

From the tactical standpoint, this was not a feasible plan, and its practical

value was also open to question. Neurosurgeons assigned to field hospitals

almost invariably found that the great majority of nontransportable patients

with wounds of the brain who came under their observation had injuries which

were primarily lethal, as proved by necropsy. It was also found that the

majority of patients with such injuries who were transportable were not

seriously affected by the ambulance ride to the evacuation hospital, even if

the distance was long. If, as frequently happened, a patient with a serious

head injury was rendered nontransportable by other wounds, the solution of

the problem was to send a neurosurgeon forward from the nearest evacuation

hospital to care for him.

In most of the primarily lethal head injuries, if death did not take place

on the battlefield, it occurred soon after the casualty reached the hospital.

Between 15 and 25 percent of patients with penetrating wounds of the brain

who lived to reach evacuation hospitals were found to have suffered extensive

injuries to the basal ganglia or the midbrain structures. At necropsy, it often

appeared remarkable not that they had died but that they had survived for

hours or even days and had not died instantly.

Operation was carried out in some of these potentially fatal cases, partly

because there was a conscientious desire to give every wounded man any

455735r-58-8
102 NEUROSURGERY

chance of survival he might have, and partly because it was not always possible

to identify hopeless wounds with absolute certainty (p. 335). Many profitless

operations were performed because of this policy, and the surgical case fatality

rates were correspondingly increased. In periods of great stress, it would

have been of practical advantage to be able to identify mortally wounded men,

so that surgical efforts could be more profitably directed toward men with all

absolute, or a better, chance of recovery. It was found that decerebrate

rigidity, fixed pupils, and profound disturbances of circulation and respiration

were of the gravest import and usually indicated mortal damage to basal

ganglia or midbrain structures, but it was also found that no single one of them

was a certain harbinger of death and that operation could not justifiably be

withheld on the basis of any one of them in itself.

In the absence of major injuries elsewhere in the body, shock was seldom

marked in patients with penetrating head wounds which did not involve

injury to the basal ganglia or the brain stem. Severe blood loss from the

scalp or from a lacerated dural sinus was much less common than might have

been expected. In grave injuries to the brain stem, the usual picture of

clinical shock was often altered by discrepancies in vital signs. A high blood

pressure, for instance, might accompany a rapid, thready pulse, or an elevation in temperature w:-it accompany a clammy skin. It was a fixed rule

that a patient in shock was not treated surgically until he had been resuscitated by the usual measures, on the principle that, if he could not be brought

out of shock, he would not be likely to tolerate a major surgical procedure.

Hematoma Formation

One type of head injury proved the exception to the rule that postponement of surgery was not harmful in these cases. The patient with a hematoma did best. under minimal transportation and prompt operation. If no

neurosurgeon was within easy reach, the necessary surgery was done by a

competent general surgeon who had had some special training in neurosurgery.

Clots were of variable size and extent. They were almost universally

found in injuries of the cerebrum and cerebellum but were not common in

the subdural and extradural spaces. The incidence varied widely, judging

from the reports of the neurosurgeons in the theater, but hematomas were

present in enough cases to make a search for them mandatory whenever

debridement of the missile track failed to relieve intracranial tension. Distal

intracerebral or intraventricular hematomas were notoriously responsible for

persisting intracranial pressure and, if they were not evacuated, for a fatal

outcome.

Wounds of the Ventricle

Wounds of the ventricle were associated with such a high immediate

mortality that relatively few casualties in this category survived to reach

hospitals. Associated injuries of the basal ganglia and brain stem were pres-
MEDITERRANEAN THEATER 103

ent in a high proportion of cases, and the clinical picture often included deep

coma, rapid, stertorous respiration, rapid pulse, high pulse pressure, and

decerebrate rigidity or flaccidity. Diagnosis was not always simple. There

was seldom a sufficient amount of cerebrospinal fluid drainage from the wound

to indicate the location of the injury, while the course of the missile, once it

had entered the body, could not always be traced, even when bone fragments

were revealed by roentgenologic examination. If the patient with a suspected

wound of the ventricle reached the hospital in condition for surgery, or could

be resuscitated, the results were oftentimes unexpectedly good.

Cerebrospinal Fluid Fistula

Laceration of the dura adjacent to a fracture of the frontal or ethmoid

sinus or the mastoid process was likely to result in a persistent leak of spinal

fluid. In some instances, the fistula healed spontaneously, but if it occupied

the site of a missile track, it was usually larger, and spontaneous healing was

much less likely. The interposition of bits of sinus membrane, bone, or

arachnoid tissue also tended to prevent or delay healing. Infection of the

cranial cavity was always a possibility under the circumstances.

Diagnosis was often difficult. Fractures of the frontal sinuses were

demonstrable in stereoscopic roentgenograms, but ethmoidal injuries usually

were not. Not infrequently, it was impossible to be sure which side of the

cribriform plate was perforated.' The presence of air in the subdural or subarachnoid spaces was considered almost diagnostic of fistula, as was the presence of air within the cerebrum or ventricular system. The escape of spinal

fluid was not always obvious. Even mentally clear patients did not notice

it in a surprising number of cases, and careful observation as well as direct

questioning was necessary to detect it.

How soon the dura was closed in ventricular injuries depended upon the

patient's condition. If meningitis had developed before the fistula was

diagnosed, or if for any reason operation had to be postponed, vigorous antimicrobial therapy was relied on to tide the patient over the intervening period.

In meningitis, the patient's serious general condition, as well. as the presence

of edema of the brain, made operation hazardous. Penicillin was used in

large doses intramuscularly and intrathecally, and an adequate blood level

of sulfathiazole or sulfadiazine was maintained. As soon as the intracranial

I Roentgenologic examination In head injuries in forward hospitals was not en2tirely satisfactory. Single anterior,

posterior, and lateral exposures were made in all cases, but, without good stereoscopic views, it was often impossible to

localize indriven bone fragments accurately or even to demonstrate their presence with certainty. Excellent work was

sometimes done under field conditions, but, on the whole, the views made In head injuries were not so helpful as they

should have been. Roentgenology in general hospitals in the base was excellent, as might have been expected.

(The difficulty described with roentgenograms taken under field conditions In the Mediterranean theater was not

encountered in the European theater, probably because in the latter theater Col. Kenneth D. A. Allen, MC, Consultant

in Radiology, personally supervised every army and communications zone medical installation to be certain that useful

films were being produced. Many experienced neurosurgeons stated that some of the finest roentgenograms of the head

which they had ever used were made In evacuation hospitals in which the only equipment was a portable X-ray unit

and a stationary grid.-R. G. S.)
1 04 NEUIR)SURG ERY

pressure was reduced and the patient's general condition was improved, dural

repair was undertaken.

'When there was no certainty which side of the cribriforin plate was perforated, approach was through a coronal scalp incision, which permitted the

cutting of small osteoplastic flaps on either side. Large dural lacerations,

particularly those over the cribriform plate, usually required a patch of living

fascia for firm closure. When the injury was adjacent to a frontal sinus, it

was sometimes possible to operate extradurally. If it was over the ethmoid

sinus, repair was much more satisfactorily achieved from within, because the

dura in the ethmoid region strips poorly and traumatic enlargement of the

opening was therefore a probability. The fascial patch had to be sufficiently

large to overlap the margin of the defect by 5 to 10 mam. in all directions.

German's method of utilizing dural flaps from the crista galli proved suitable

for the repair of small rents in the adjacent (tura.

Closure of the Dura

Closure of the dura when the existence of a cerebrospinal fluid fistula did

not provide an absolute indication was originally a much disputed point in

the management of penetrating wounds of the head. The majority of these

injuries seemed to heal without difficulty, whether the dura was left open or

was closed. The argument that it should be left open to permit spontaneous

drainage if infection occurred did not prove valid; drainage was never satisfactory under the circumstances, and secondary debridement was usually

necessary. In a number of instances, on the other hand, it was thought that

deeper wounds had been effectively shielded from superficial infection when

the dura had been closed by suture or graft, while in numerous wounds of the

spinal dura, closure appeared to prevent inward extension of epidural infection.

In deeply infected wounds of the brain, another possible advantage of dural

closure was the prevention of fungi, or at least a delay in their formation.

When penetrating wounds of the brain involved the paranasal sinuses,

every effort was naturally made to close the overlying dura at the initial

operation, in order to prevent fistula formation and to minimize the risk of

infection. It also became the general policy, as the war continued, to close

the dura under other circumstances. When simple suture was not possible,

a graft of living tissue (pericranium, temporal fascia, or fascia lata) was used

and seemed to impose little additional burden on the wound.

Drainage

From the beginning of activity in the Mediterranean theater, it was the

policy to close all head wounds without drainage after debridement, on the

principle that a drain was of limited value in the evacuation of blood or serum

while its presence was likely to predispose to the development of infection and

of spinal fluid fistulas. The few surgeons who originally favored drainage

soon ceased to employ it as its bad effects became evident.
MEDITERRANEAN TtHEATER 105

REDEBRIDEMENT AND DELAYED DEBRIDEMENT

Superficial infections occurred in approximately 19 percent of the head

injuries treated in tile 'Mediterranean theater in 1943 and in approximately 16

percent in 1945. In this category are included infections which extended no

deeper than the dura, wound dehiscence, mild degrees of necrosis, and any

other result less than healing per primam. For the most part, these infections

were strictly localized, and they occurred, as a rule, because closure had been

accomplished under too great tension or because the silk used was too heavy.

In many instances, removal of the sutures, sometimes supplemented by the

application of warm compresses, was all that was necessary to control the

infection, though subsequent healing was sometimes delayed. If the wound

was large and, particularly, if debridement had not been done adequately,

dirty, purulent granulation tissue was likely to develop, and weeks might be

required for complete healing. If the dura had been left open in these eases.,

the consequences were sometimes serious.

Infections of a graver type were the greatest single hazard to recovery in

head injuries. 'Most often, they followed incomplete debridement or inadequate

hemostasis or both. The presence of clots and of pulped brain tissue offered

an excellent medium for the growth of the bacteria which were always carried

into the injury with the missile. If the infectious process was not too extensive

and if bacterial contaminants were not too numerous or too virulent, spontaneous healing sometimes occurred. As a rule, however, active therapy of

deep infections was necessary, because in the majority of cases they developed

about retaiped bone fragments; this was true of 90 percent of the brain abscesses

observed in the Mediterranean theater.

The introduction of redebridement of infected wounds of the brain and of

late debridement of infected, neglected wounds represented the most important

single advance in the management of head injuries in the Mediterrnean

theater. The policy was first employed toward Lhe end of the Tunisian campaign, at the 21st General Hospital, by Lt. Col. Henry G. Schwartz, MC, and

Capt. George Roulhac, MC, in a series of 130 cases. Redebridement of wounds

elsewhere in the body, including those associated with compound fractures,

had by this time come into use fur cases in which early surgery had been

omitted or had been inadeqmate, and the same principles were simply applied

to head wounds. No arbitrary time limit was established within which debridement might be regarded as safe. In some cases observed at the 21st

General Hospital, it was carried out as long as 51 days after wounding. The

wound was then tightly closed, and no drainage was employed. The results

were practically always good. While it sometimes seemed desirable to postpone operative intervention until definite abscess formation with encapsulation

had occurred, this practice was soon discontinued. Encapsulation was frequently slow, and it was realized that in the interim a good deal of damage

could be done by infection, including further destruction of brain tissue and

the development of cerebral fungus and fatal meningitis.
106 NEUROSURGERY

When debridement was done late, or when redebridement was practiced,

it was usually found that the track of damaged, devitalized tissue was sharply

differentiated from healthy tissue. As a result, operaition was sometimes

simpler than in the first few hours after wounding. Soft, necrotic material

could readily be removed by suction, and the limits of the healthy brain could

be recognized without difficulty.

When the infected track was well encapsulated, the analogy between this

type of infection and the civilian type of abscess was so striking that in the

first months of the war, civilian methods (open drainage and marsupialization)

were favored. As time passed and the effectiveness of debridement, whether

performed as a primary or a secondary procedure, became more and more

evident, tight closure of the wound was carried out, and drainage was omitted

in both encapsulated and nonencapsulated cavities. For drainage to be omitted

with safety, it was necessary that the wall of the cavity be gone over millimeter

by millimeter with the sucker until all gray, shaggy exudate had been removed

and healthy-looking pink granulation tissue became evident.

ADJUNCT THERAPY

Antimicrobial Therapy

At the beginning of the Tunisian campaign, it was the policy to dust

sulfanilamide crystals into all wounds before applying the hrst dressing. 2

At the same time, a sulfonamide drug was given by mouth and was continued

until after debridement. This policy was used in head wounds, with the

warning that sulfonamides must not be permitted to come into contact with

neural tissues. As time passed, less and less reliance was placed on local

chemotherapy and more and more on thorough wound debridpment. As was

learned by experience everywhere, unless debridement had been well done,

chemotherapy did not prevent infection, while if the operation were properly

performed, healing per primam was the rule even when chemical agents were

not used.

After penicillin became available, in the spring of 1944, it was administered

routinely to all casualties by the intramuscular route, in dosages of 25,000

units every 3 hours. Sample studies suggested that this measure was helpful

in preventing infection, but the apparent improvement which occurred at this

time must be evaluated in the light of other factors, chiefly more complete

debridement and a more generous use of whole blood, both of which were now

the general policy.

Early Ambulation

Before the United States entered World War II, British neurosurgeons,

following the example of German neurosurgeons, had begun to treat all head

' In some of the first casualties received at Walter Reed General Hospital, Washington, D. C., from North Africa,

sulfathiazole had been used in wounds, because of shortages of sulfanilamide crystals. It caked In the wounds and had

to be picked out with forceps.
MEDITERRANEAN THEATER 107

injuries, closed as well as open, by early ambulation as soon as the patient

was capable of the necessary movement. In the early days of the war, when

overcrowded hospitals necessitated a rapid turnover of patients in Great

Britain, the method was tested on a large scale, and it was found that early

ambulation following cerebral concussion not only is safe but actually results

in a lowered inci(lence of the posttraumatic syndrome.

Early in 194ý. neurosurgeons in Army general hospitals in the Zone of

Interior had begun to practice early ambulation in closed head injuries, but

there was little opportunity overseas to test the L- ethod on a large scale until

the North African campaign, in the fall of 1942. The first report on its use in

this theater was made by Capt. (later Maj.) Edwin W. Shearburn, MC, and

Lt. (later Capt.) Edwin H. Mulford, MC, from the 8th Evacuation Hospital in

Casablanca. In 72 cases of acute head injury with cerebral concussion observed between 18 November 1942 and 6 March 1943, there was only I instance

of posttraumatic syndrome following its use, against 4 instances in 18 cases

which were observed over the same period and in all of which, for various

reasons, early ambulation could not be used. No bad effects of any kind were

observed in cases in which it was employed. After this time, the method

became routine in the Mediterranean theater and was also adopted in the other

theaters of operations.

COMPLICATIONS OF HEAD INJURIES

Cerebral Fungus

Cerebral fungi (herniation) fell into two groups, as follows:

1. The so-called benign type was manifested by local cerebritis associated

with superficial wound infections. It was likely to occur in cases in which the

dura had been left open. The fungus grew slowly, was seldom large, shaggy, or

friable, and was not associated with high intracranial pressure, progressive

neurologic changes, or deep infections. Treatment was limited to wet dressings,

since, in most cases, the natural tendency was toward healing and retraction of

the hernia. If bone fragments were present, they were removed. In the few

cases in which benign fungi were excised, examination of the tissue showed a

fibrotic process which suggested that the hernia would have subsided spontaneously in time.

2. So-called malignant fungi developed as a result of deep abscess formation, liematoma formation, or, less often, massive necrosis of brain tissue.

They were associated with increased intracranial pressure, and, once they had

extruded through the open dura, they grew rapidly, became shaggy, and bled

easily. A hernia of this type occasionally was the sequel of intense cerebritis

or of a virulent local wound infection, usually in an inadequately debrided

wound.

In this type of fungus, progressive destruction of neural tissue was the

rule, and early surgical interference was therefore essential, following pre-
108 NEUROSURGERY

operative localization of retained bone and metallic fragments by stereoscopic

roentgenograms. Removal of the necrotic portion of the fungus often tended

to reduce pressure locally and sometimes uncovered a sinus leading down to

an abscess, which could be treated by appropriate means. Fatalities, which

could usually be attributed to the presence of an unsuspected abscess or to its

delayed evacuation, were fairly frequent.

Epilepsy

Convulsions sometimes occurred between the time of wounding and

debridement, but when progress was satisfactory they seldom occurred within

the first month after operation. Their earlier development, within the first

week or two after operation, usually indicated the presence of an abscess, a

hematoma, or a pocket of necrotic tissue in the cerebrum. The convulsions

were most often Jacksonian in type and were likely to be associated with some

degree of motor weakness.

DISPOSITION

The majority of patients with penetrating wounds of the brain. in the

Mediterranean theater were evacuated to the Zone of Interior because of skull

defects, residual neurologic changes, or associated injuries. Patients with scalp

wounds could usually be returned to duty after a relatively brief convalescence.

In closed head injuries, disposition depended upon the extent of the injury and

the outcome of treatment; in many instances, return to full duty was possible.

Had appropriate materials been available, many skull defects which necessitated

reclassification and disposition to the Zone of Interior could probably have been

repaired overseas.
CHAPTER VII

The European Theater of Operations

R. Glen Spurling, M. D.

HEAD INJURIES BEFORE D-DAY

Except for head injuries sustained by Army Air Force personnel, all

craniocerebral injuries observed in the United Kingdom before D-day were of

the type encountered in civilian life. Patients with closed injuries were

treated by conservative measures in the hospitals to which they were first

admitted. In their management, a liberal policy was instituted, in contrast

to the generally accepted policy in civilian practice, and large numbers were

promptly returned to activity and later to full duty.

Patients with compound craniocerebral injuries admitted to station hospitals were transferred as soon as possible to the nearest general hospital for

definitive treatment. The wound was protected with sterile dressings, the

scalp was shaved over a large area surrounding the wound, sulfanilamide powder

was sprinkled into it, and a sterile compression dressing and bandage were applied. Morphine was not given. No surgical interference was undertaken at

any but a general hospital without consultation with the senior consultant in

neurosurgery or his authorized representative. Treatment of open head injuries followed the principles laid down in Medical Bulletin No. 12, Office of the

Chief Surgeon, Headquarters, ETOUSA, dated 1 November 1943. These

principles were, in general, those followed in civilian practice before the war.

In Essential Technical Medical Data dated 22 August 1943, Col. Loyal

Davis, MC, then the senior consultant in neurosurgery in the theater, reported

the results of 147 head injuries treated according to these principles in the year

ending on 30 April 1943. These patients were chiefly treated in three general

and one evacuation hospital, and Colonel Davis commented that when patients

were treated primarily in hospitals other than those in which officers with

neurosurgical personnel were in charge, the occurrence of the posttraumatic

syndrome was very high. He also commented on the precipitate decrease in

the number of admissions for head injuries after the use of jeeps by enlisted

personnel had been restricted to those on authorized missions.

There were no deaths in these 147 cases, and 88 of the 99 patients with

closed injuries were returned to duty. In contrast, only 18 of 48 patients

with open head injuries could be returned to full duty in the theater, and only

2 others to limited duty. Thirty-two of the forty-eight patients in the latter

group developed the posttraumatic syndrome.

109
110 NEUROSURGERY

GENERAL POLICIES OF MANAGEMENT

In the Manual of Therapy, prepared in tile European theater before D-day

(p. 73), emphasis was laid on certain important considerations in the early

management of combat-incurred head wounds. Among these considerations

were thle following: (1) That the sole objective of emergency treatment was to

improve the condition of tile patient sufficiently to permit transportation to an

installation where competent neurosurgical care was available; (2) that high

priority evacuation was always indicated in head injuries; (3) that the unconscious patient was to be transported on his side, with the foot of the litter

elevated, to permit postural drainage; (4) that every scalp wound should be

regarded as having serious implications until it was proved not to have; (5)

that shock seldom resulted from uncomplicated head injuries and that its

presence therefore demanded a search for other possible injuries; (6) that if

shock were present, its treatment by the usual routine took precedence over

the treatment of all other conditions; (7) that local measures should be reduced

to a minimum; and (8) that morphine was not to be given unless other injuries

demanded it, and then with great caution.

Special emphasis was placed upon the prompt recording of data essential

for the efficient future treatment of the patient, including the time of injury,

the state of consciousness when lie was first seen, the pulse rate (counted for a

full 30 seconds), the respiratory rate and rhythm, the blood pressure, and the

presence or absence of paralysis in the extremities.

These policies were based on the recorded experiences in World War I

(p. 3), the combat experiences of the British in the first years of World War

I[, and the United States experience at Pearl Harbor and elsewhere in the

Pacific. They were promptly confirmed by the experience in the first weeks

after D-day, which made clear the following important points:

1. Every wound of the scalp must be regarded as a possible penetrating

wound until the presence of foreign bodies within the cerebrum is ruled out by

roentgenograms.

2. Infection tended to occur in the wound of entrance rather than around

the foreign body, which was usually sterile and which could be left in situ at

debridement, for subsequent removal under ideal conditions. Bone fragments,

not missiles, proved the chief cause of infection.

3. Patients with head injuries withstood transportation well for the first

several hours after wounding but poorly for the first few days after operation.

The best policy was therefore to move them back to hospitals in which definitive

treatment could be carried out without undertaking any surgical measures

other than debridement.

4. Subdural hematomas should be suspected in troops of armored units

and in paratroopers.

5. Debridement could be safely undertaken even 5 or 6 days after injury.

In the first days of the fighting on the Continent, many patients with compound

head wounds were received in hospital installations in the United Kingdom
EUROPEAN THEATER l11

after delays of such length, having had no treatment other than first aid. All

of them had had sulfonamide therapy, and most of them had had penicillin in

adequate amounts. The wounds were in remarkably good condition, and

debridement and delayed primary wound closure were usually successful, even

at this late date.

6. The ceiling for air transportation of patients with head injuries was

3,500 to 4,000 feet. If they experienced breathing difficulties during the flight,

the policy was to turn them on the side, face down, and elevate the foot of the

litter; these measures were particularly important if there was fluid in the lungs.

On the basis of the experience immediately after D-day, the following

broad principles of management were emphasized:

1. If penetrating wounds of the brain were seen soon after wounding,

surgical debridement of the cont used brain tissue, meninges, skull, and scalp,

in that order, was the treatment of choice. Dural defects should be repaired

with fascia from any available source. The wound should be frosted throughout with sulfanilamide powder it policy that was later discontinued). Sulfathiazole should never be used locally (p. 106), nor should penicillin until more

data on its possible irritating properties became available. Closure should

be tight, without drains. Sulfonamide and penicillin therapy should be continued systematically after operation.

2. If penetrating wounds of the brain were observed late, the same plan

of treatment should be adopted in the absence of infection. If infection were

evident, the usual plan of care for infected wounds should apply.

Particularly in forward echelons, the treatment of head injuries occupied

the major portion of the neurosurgeons' time and effort. The majority of the

wounds were caused by penetration of missiles into the scalp, skull, and brain,

but there was also a considerable number of closed head injuries.

WOUNDS OF THE SCALP

One of the important lessons learned by neurosurgeons in the European

theater was the value of sliding flaps to cover large defects in scalp wounds.

The use of this method permitted a more complete and more adequate debridement of the wound margins and at the same time provided a means of closing

the wound without tension. Lt. Col. (later Col.) Eugene M. Bricker, MC,

Senior Consultant in Plastic Surgery, Office of the Chief Surgeon, Headquarters,

ETOUSA, prepared an article on closure of scalp defects by means of sliding

flaps. This article, published in the Medical Bulletin, Office of the Chief

Surgeon, helped materially to disseminate the advantages of the sliding-flap

method of closure among neurosurgeons throughout the theater.

CLOSED HEAD INJURIES

Closed head injuries were for the most part treated by conventional

methods. The most seriously injured casualties were evacuated as promptly

as possible to fixed hospitals. Casualties who had suffered only cerebral
112 NEUROSURGERY

concussions, or even contusions, were kept within the Army area, since early

experience had proved that if they once reached the level of the general hospital,

an early return to duty was unlikely.

An important new concept in the treatment of this group of patients was

early ambulation. The value of this method had been demonstrated earlier

in the war in the German Army and the British Army, as well as in British

civilian hospitals and United States Army hospitals in the Zone of Interior.

It had become routine in the Mediterranean theater (p. 106) and was part of

the original planning for head injuries in the European theater. Every effort

was made to keep the patient out of the horizontal position. When consciousness was regained, he was kept in the semisitting position the entire time he

was in bed, and he was encouraged to get out of bed as promptly as possible.

Depressed fractures of the skull without dural penetration, which were

relatively common, furnished few therapeutic problems. If there was little

evidence of underlying cerebral damage, debridement was followed, as soon

as wound healing permitted, by cranioplasty with tantalum. A small number

of patients successfully withstood tantalum repair of the cranial defect at the

time of the original debridement. The one-stage operation was naturally

advantageous, but it was attempted only when the wound was small and comparatively clean and when the casualty load did not require a rapid turnover

of patients. Many patients treated by tantalum repair were returned to

limited duty, and some to full combat duty, within the European theater.

PENETRATING WOUNDS OF THE BRAIN

Penetrating wounds of the brain, which comprised approximately a fifth

of the neurosurgical casualties in the general hospitals in the European theater,

made up the major portion of the neurosurgical load in the evacuation hospitals.

In the first days of the European campaign, as already mentioned, initial

debridement was often carried out in the neurosurgical centers in the United

Kingdom. As the campaign progressed and more and more hospitals were

transferred to the Continent, most initial neurosurgery was done in them,

although secondary procedures were necessary in installations in the United

Kingdom in about a quarter of all cases.

The soundness of the policies of complete debridement, repair of dural

defects, and careful primary closure of scalp lacerations was established beyond

dispute in this theater. When most, of the initial operations were still being

done in the United Kingdom Base, it was found that complete closure of the

head wound was possible, with safety to the patient and usually with primary

healing, after timelags from 6 up to 10 days. The chief indications for secondary surgery were the removal of bone chips or large missiles left in situ at the

first operation; drainage or complete excision of brain abscesses; repair of

cerebrospinal fluid fistulas; and excision of cerebral fungi, with subsequent

closure of overlying cranial defects.

Most patients with penetrating wounds of the brain were returned to
EUROPEAN THEATER 113

the Zone of Interior as soon as possible after operation. Many had residual

neurologic defects. Some developed convulsive seizures within a few weeks

after injury. Some required cranioplasty for large cranial defects.

Closure of the Dura

In penetrating wounds of the brain produced by jagged metallic foreign

bodies, the dura was usually badly fragmented, and simple suture was not

possible. British neurosurgeons, with a large experience in earlier campaigns,

had come to disregard dural perforations and to content themselves with

thorough debridement, omitting plastic repair of the dural defect unless the

injury was in the immediate vicinity of the accessory nasal sinuses. This

policy was not in accord with practices in the United States, and United States

Army neurosurgeons were instructed to close all dural defects when the original

debridement was done unless valid contraindications existed. Accurate statistics are not available to confirm the value of this method, which was employed

throughout the fighting in Europe, but it was thought significant that British

neurosurgeons began to change their own policy and, by the close of the campaign in Europe, were repairing the dura with greater and greater frequency.

Methods employed to close the dural defect included the use of fascia lata,

pericranium preserved in alcohol, human dura, and human fibrin film. The

routine use of fascia lata for dural repair proved impractical, and most neurosurgeons learned to use pericranium unless the defect was too large. Fibrin

film for dural repair had been developed in the Zone of Interior by Dr. Franc

D. Ingraham of the Harvard Medical School, under a contract with the

National Research Council, and it had been used with considerable enthusiasm

in neurosurgical centers in the Zone of Interior.

Maj. Arthur D. Ecker, MC, made two important contributions to the

problem of dural repair. The first was the demonstration that it is possible

to dissect the pericranium and galea intact and thus to provide a thicker tissue

for repair of the dura. Dissection of the two layers without separation is

facilitated in this technique by the use of physiologic salt solution to distend

the fatty layers of the scalp above the galea.

Major Ecker's second contribution was the demonstration that it

is possible to reflect pericranial grafts into the region of the dural defect

without detaching them at one margin, their viability thus being assured

because part of their blood supply is preserved. This technique proved

particularly valuable in tears around the anterior cranial fossa associated

with cerebrospinal fluid leaks. Histologic studies made in some of the cases

in which pericranial grafts were left attached at one margin established their

viability and thus confirmed the feasibility of the method in infected wounds,

in which free transplants of fibrous tissue of other types were likely to slough.

At the December 1944 meeting of the neurosurgeons of the United

Kingdom,' the consensus was that grafts of fascia lata were most likely to slough

"Minutes, Meeting with Neurosurgeons, United Kingdom '•w. 20 Dee. 1944.
114 NEUROSURGERY

and that the best results were likely to be obtained by the Ecker technique.

Dissemination of this information through the efforts of the senior consultant

in neurosurgery led to their general use and to the confirmation of their worth

by a thorough clinical trial. In the interrogation of a German neurosurgeon

in a prisoner-of-war camp some months after tile December meeting, Colonel

Spurling found that the German had used the Ecker technique for the past

2 years and that, prior to that time, he also had had poor luck with fascia

lata transplants.

Management of Retained Foreign Bodies

Early in the war, British neurosurgeons had called attention to the danger

of leaving bone fragments in situ in operations for penetrating wounds of the

brain. They had shown conclusively that late brain abscess was of far greater

frequency in incompletely debrided wounds than in wounds from which all

foreign bodies, including bone fragments, had been completely removed.

The only contribution of United States neurosurgeons to this problem was the

demonstration (first in the Mediterranean theater, p. 105) of the safety of

early reexploration in such cases, with excision of the gliotic tract containing

foreign material, and simultaneous repair of the dura and of the skull defect

with tantalum.

At the December 1944 meeting of the neurosurgeons of the United Kingdom

Base, it was pointed out that the figure of 17 percent for retained bone fragments after primary operation, which appeared in the statistics collected to

date by Colonel Spurling, was probably misleading, for two reasons. The

first was that most of the wounds observed in neurosurgical centers, from which

the data had been collected, concerned complicated wounds; patients whose

wounds had healed primarily had already been evacuated from general hospitals

to the Zone of Interior. The second reason was that the collected data covered

only the patients treated in the United Kingdom. It was decided that these

considerations should be taken into account thereafter and that an attempt

would also be made to determine the situation in this regard in evacuation

hospitals. Data collected in this manner showed a decided rise in the percentage of retained fragments, to 44 percent in the November 1944-January 1945

period, and to 35 percent from 1 February until V,-E Day (table 5).

Before the end of the war, it was accepted practice in the European theater,

when a shower of retained bone fragments was demonstrated in a wound, to

reexplore it as soon as the patient's condition permitted, whether or not there

was evidence of infection. After operation, the patient was returned to the

Zone of Interior, with his wound cleanly debrided and with an essentially intact

skull.

In the early days of the European campaign, not much attention was paid

to metallic foreign bodies retained in the brain (p. 110). These missiles were

often found at great distances from the contused track, as the result of scattering

of bony fragments from the skull. The possible danger of the retention of
EUROPEAN THEATER 115

TABLE 5.-Percentage data on 2,276 penetrating cerebral wounds operated on in

United Kingdom hospitals

Retained Infections

bone __ __ __ _ _ _ _ _

Case Aver- Primary fragPeriod Cases fatality age dural ments Super- Subrate timelag repair after ficial galeal Brain Meninprimary scalp infec- abscess gitis Total

opera- infec- tions

tion tions

D-day to 1 Aug. Number Days Percent Percent Percent Percent Percent Percent Percent

1944 ------------ 494 4.3 4 63.0 17.0 12.0 5.5 7.5 95 33.5

1 Aug. 1944 to I

Nov. 1944 ------ 942 4.3 4 60.0 1&5 11.2 5.0 5.6 5.0 26.8

1 Nov. 1944 to I

Feb. 1945---------393 4.0 11 71.0 44.0 9.0 4.6 12.2 3.6 29.4

1 Feb. 1945 to

V-E Day ------- 447 5.1 8 55.0 35.0 10.1 6.9 13.0 17.0 47.0

Total------- 2,276 4.4 6.7 61.5 1 25.8 10.8 5.4 8.6 7.9 32.7

these fragments was realized, but it was originally thought that the danger of

removal, which often introduced the risk of traversing essentially normal brain

tissue, was greater than that of leaving them in situ. Later, the reverse was

found to be true.

Neurosurgeons in the forward areas were the first to recognize that subdural or subcortical hematoma formation was likely to occur in traversing

wounds of the brain in association with the presence of foreign bodies. They

had observed that, when the patient's condition had failed to improve after

the first operation, a hematoma was often found on later exploration for

foreign bodies. The observation became so general that all neurosurgeons in

forward areas soon learned to investigate the site of metallic foreign bodies by

burrhole exploration. As experience increased, it became the routine, in the

management of patients with traversing wounds of the brain, to explore the

region of the metallic foreign bodies for a possible hematoma even before

debridement of the wound of entrance. If a hematoma was demonstrated,

its immediate evacuation usually so greatly improved the patient's condition

that the more formidable procedure of debridement could be proceeded with

in a more leisurely manner. This concept, which was entirely new, was

presented by Capt. (later Maj.) Donald D. Matson, MC, in an article entitled

"Hematomas Associated With Penetrating Wounds of the Brain." 2

Complications

Brain absces9.--The first realization of the possible risk of infection

associated with retained metallic foreign bodies came in an autopsy at the

160th General Hospital, on a patient who had arrived with an infected wound

*Matson, D. D., and Wolkin, J.: Hematomas Associated With Penetrating Wmjnds of the Brain. 3. Neurosurg,

3:46-53, January 1946.
116 NEUROSURGERY

and a large brain abscess in the hemisphere, at the site of entrance of the missile.

Although the abscess was excised successfully, his condition continued to

deteriorate, and at autopsy a large abscess surrounding a metallic foreign body

was found in the contralateral hemisphere. The wound of entrance had been

on the left side in the frontal region, and the foreign body was in the same

location on tile right side; there had therefore been few clinical signs to indicate

the proper management of the case. As a result of this observation, all neurosurgeons in the theater were instructed to explore the region of the foreign

body in every traversing, penetrating wound of the brain if a cerebral abscess

or hematoma could reasonably be suspected.

In the early phases of tile campaign, neurosurgeons were permitted to

treat brain abscess by whatever methods they had been accustomed to use in

civilian practice. Conventional drainage was usually employed. Several

surgeons later reported favorably upon the results of radical excision of the

abscess wall, and the whole subject was discussed in detail at the first meeting

of neurosurgeons in the United Kingdom, as part of the discussion of penetrating

wounds of tile brain.' It was difficult, it was pointed out, to distinguish

between necrotic and infected brain, since in so many instances culture of the

pus was sterile and since negative cultures were often obtained in the presence

of active infection when the patient was being given sulfonamide drugs and

penicillin. On the other hand, many surgeons present emphasized that the wall

of an abscess, regardless of the report oil cultures, always contained living

organisms in great numbers and that a urgical procedure which did not deal

with the wall was not a complete procedure.

In view of these observations a change of policy was decided upon. An

anatomic definition of brain abscess was adopted; a brain abscess was to be

indicated by microscopic or macroscopic pus present in tile cavity. In cases

in which there was profuse superficial infection of tile scalp and the process was

a cerebritis rather than a localized abscess, conservative methods were to be

followed until localization had occurred, after which radical excision of the

abscess wall was to be attempted. The wound was to be treated locally with

sulfanilamide and penicillin, and both agents were to be given in large doses

for several days after operation by the systemic route. The dura was to be

closed tightly, with the aid of grafts if necessary, and the scalp wound was to

be closed without drainage. If tile inflammatory process was close to the

ventricle or basal cisternae, penicillin by the spinal route was to be given for

prophylactic purposes for several days after operation.

This method, which was originally suggested by the French neurosurgeons,

Vincent and David, had previously been employed all over the world but only

sporadically. It is believed that its use in the European theater was its first

application on a large scale to the treatment of traumatic brain abscess.

Tube drainage methods were employed in cases in which the abscess

re-formed after excision, as well as in cases in which the causative organisms

3 See footnote 1, p. 113
EUROPEAN THEATER 117

were found to be penicillin resistant. As this practice implies, bacteriologic

studies were mandatory before radical surgery was undertaken.

During the 6-month period in which this method was used before the

close of the European fighting, results of treatment of brain abscesses steadily

improved. In addition to a decreased morbidity and the elimination of

multiple operative procedures, it was thought that the incidence of convulsive

seizures following brain abscess was materially reduced.

Meningitis.-The incidence of meningitis at the level of the general

hospital, exclusive of cases of brain abscess complicated by active meningitis

or meningeal irritation, was approximately 8 percent in the European theater.

Most patients recovered under a combined regimen of penicillin by the intraspinous route and sulfadiazine by the systemic route.

Gram-negative bacillary meningitis, however, for a time threatened to

become a serious problem. The first cases were observed in the summer of

1944, and the incidence steadily increased until, by the spring of 1945, the

situation was grave. The causative organisms were, for the most part, Bacillus

pyocyaneus, Kiebsiellafriedldnderi and other members of the coliform group.

Only a few of the patients went on to recovery in spite of massive (loses of

sulfadiazine and penicillin. This might have been anticipated, since all the

causative organisms are penicillin resistant.

The solution of the problem was the demonstration by Major Ecker that

a combination of urea (1 oz.) and sulfadiazine (2 gin.) in dextrose solution by

vein every 4 hours produced almost immediate improvement. His first series

of successfully treated cases was reported in the summer of 1944, and the

method was brought to the attention of United Kingdom neurosurgeons at the

conference in December. At the second conference in February 1945, the

pooled experience showed 10 recoveries in 16 cases.' At the third conference,s

in April 1945, it was again reported that most cases caused by the coliform

bacilli, particularly B. pyocyaneus, had responded dramatically to the combined

regimen of urea and sulfadiazine and that certain cocci resistant to penicillin

and the sulfonamide drugs alone had also responded well, though most patients

with meningitis caused by K. friedldnderi, Type A, had died in spite of therapy.

The high incidence of meningitis of this origin was undoubtedly responsible

for the considerable increase in the neurosurgical case fatality rate observed

in the United Kingdom hospitals between 1 February 1945 and V-E Day

(table 5).

Cerebrospinal fluid fistulas and aeroceles.-Penetrating wounds of the

frontal region of the skull were frequently associated with rhinorrhea and

aerocele. In the past, these complications had had serious implications. With

the advent of antimicrobial therapy, the incidence of complicating meningitis

had been greatly reduced, though, in improperly handled cases, it was likely

to occur after medication had been discontinued.

A decision concerning the repair of dural tears in this type of injury has

4 Minutes, Meeting, United Kingdom Base Neurosurgeons, 15 Feb. 1945.

A Minutes, Meeting, United Kingdom Base Neurosurgeons, IR Apr. 1945.
118 NEUROSURGERY

always been difficult. Many times, the leakage of cerebrospinal fluid ceases

spontaneously. There is always concern, however, that the fistula may reopen

or that, infection may extend along the fistulous tract to the meninges.

The policy of early repair was followed in the neurosurgical centers throughout the European campaign. As soon as the patient's condition permitted

elective surgery, the fistula was exposed through a unilateral or bilateral frontal

bone flap, and plastic repair of the dura was accomplished by a pedicle flap of

pericraniuin or a transplant of fascia lata. The operation was frequently

long and tedious, because of the extensive damage to the dura associated with

the injury, but closure of the leak was almost uniformly successful, and complications were practically nonexistent. Statistical data are not available, but

the risks of the procedure can be assumed to have been remarkably low from

the fact that in the final statistical analysis of 2,276 penetrating wounds of the

brain treated in the United Kingdom Base it was found that only 4 percent of

the deaths were caused by meningitis, including deaths from chemically resistant types of disease.

Fungus cerebri.-Fungus cerebri was relatively frequent in German prisoners of war with head injuries but was seldom seen in United States Army

wounded because of the adequacy of their treatment in forward hospitals.

This complication was observed, however, in a number of patients whose wounds

became infected or who developed deep-seated brain abscesses.

When World War I1 began, little had been added to the treatment of this

distressing condition since Cushing's contribution in World War I. Tie underlying principle of therapy had continued to be protection of the fungus from

trauma and from the irritation of the endless dressings which were required. In

many instances also, in spite of every precaution, the ventricle wandered into

the structures of the fungus, and a ventricular fistula resulted. All in all, this

complication was one of the most annoying and most difficult faced by neurosurgeons in the European theater.

At the second meeting of the neurosurgeons of the theater in the United

Kingdom Base, Maj. Francis Carmichael, MC, presented an original plan of

treatment for cerebral fungus. Accurate bacteriologic studies were first made.

Then, if nonresistant chemical organisms were present, they were treated with

applications of acetic acid and with other local measures until they had disappeared from the wound. When this had been accomplished, the fungus was

trimmed with the electrosurgical unit until the presenting brain tissue could be

tucked into the opening in the skull. This portion of the procedure could be

facilitated by preoperative dehydration and spinal puncture. Finally, a

tantalum plate fashioned to fit exactly over the skull defect was swaged into

place, and the scalp was closed over the plate, either directly or by a swinging

flap. No attempt was made to repair the dura; the presenting fungus was

simply left to fit snugly against the smooth inner surface of the tantalum plate.

Before operation, it was always necessary to exclude the possibility of an intracerebral abscess behind the fungus. This was accomplished by needle exploration or, particularly if a distant abscess was suspected, by ventriculography.
EUROPEAN THEATER 119

After operation, antimic'obial therapy was continued in maximum doses

by the systemic and intraspinal routes until all signs of infection had completely

subsided. The chief immediate postoperative problem, increased intracranial

pressure, could usually be controlled by the use of a dehydrating agent, preferably sucrose or concentrated human serum albumin, and by daily lumbar

punctures.

Major Carmichael's report at the February 1945 meeting consisted of three

cases, to which Maj. (later Lt. Col.) Wesley A. Gu~tafsen, MC, added three

other cases. In all of these cases recovery was without incident. Major

Ca:-michael's report was later published.' In the ensuing months, equally good

results were obtained in 25 cases treated by this technique in the neurosurgical

centers in the United Kingdom.

INJURIES OF THE CAROTID ARTERY

Early in the European campaign, an occasional patient was observed without evidence of head injury but with a gunshot wound of the neck associated

with concomitant contralateral `z-miplegia. The only logical explanation of

such a phenomenon was an injury to the carotid artery, with resulting ischemia

of the ipsilateral hemisphere. In some cases in which there was no evidence

of disruption of the carotid artery, arterial spasm was postulated as the explanation of the ischemia.

In a report on spasm of the internal carotid artery associated with gunshot

wounds of the neck,7 Major Ecker was able to demonstrate by pneumoencephalography that in the cases which had been under his personal observation

atrophic changes had occurred in the ipsilateral hemisphere. In the following

months, more and more such cases were encountered, and the observations

described were confirmed. Treatment by early Novocain (procaine hydrochloride) block of the stellate ganglion was planned, but hostilities ended before

the method could be tested fully. These observations opened up an entirely

new field in traumatic neurosurgery, and further laboratory investigation of the

mechanism of injury was considered to be indicated.

ANTIMICROBIAL THERAPY

Antimicrobial therapy was regarded in the European theater as of very

great importance in the treatment of penetrating wounds of the brain, but only

as an adjunct to early, adequate surgery. In most cases in which it failed to

prevent infection, debridement was found to have been inadequate. Routines

of therapy varied with individual surgeons, but penicillin and sulfadiazine were

regularly administered by the parenteral route before and after operation and

were continued until complete wound healing had ccurred. Sulfanilamide and

penicillin were usually used by the local route also.

6 Carmichael, F. A., Jr.: The Reduction of Hernia Cerebri by Tantalum Cranloplasty. A Preliminary Report. J.

Neurosurg. 2: 379-383, September 1945.

E ,cker. A.: Spasm of the Internal Carotid Artery. J. Neurosurg. 2: 479-484. November 1945.
120 NEUROSURM IERY

Penicillin was used freely by the intraspinal and intravenous routes, according to the indications. It was always used as early as possible when the injury

was complicated by meningitis or brain abscess. It was also used prophylactically before closure of cerebral spinal fluid fistulas.

STATISTICAL DATA

In Essential Technical NMedical Data, ETOUSA, dated 17 August 1944,

it was stated that wounds of the brain, spinal cord, and peripheral nerves

comprised 10 percent of all surgical cases treated in the United Kingdom.

Statistical data collected in Normandy by Colonel Spurling indicated that head

injuries usually comprised at least 3 percent of all injuries treated in evacuation

hospitals and that the proportion sometimes rose to 5 percent. The mortality

rate in these hospitals for head injuries varied from 5 to 8 percent.

Relatively few penetrating wounds of the brain received primary definitive

care in the United Kingdom Base, the majority of patients with these injuries

being cared for in evacuation hospitals. A large proportion of the patients

studied in the final statistical survey of neurosurgical data in the United Kingdom (table 5) are those who required secondary procedures because of complications, chiefly retained bone fragments, cerebrospinal fluid fistulas, and wound

infections. The patients in this analysis were cared for in 9 specialized neurosurgical centers by approximately 20 neurosurgeons. In general, the regimen of

management was the same in all centers; that is, the same indications for

reoperation were observed, the same surgical technique was employed, and the

critical analysis was made according to the same criteria.

Difficulties in collecting statistical data from the various field armies have

been outlined elsewhere (p. 80). During the European campaign, however, an

effort was made to make sample studies of penetrating wounds of the brain in

the First and Seventh U. S. Armies. The material, while not precisely comparable, nonetheless illustrated the general situation in respect to these wounds

in both Armies. The data were submitted to the Chief Surgeon, ETOUSA,

25 March 1945, and, after they had been approved by him, were distributed in

mimeographed form to the neurosurgeons of the theater.

Data from the First U. S. Army (table 6) which were collected from the 13

evacuation hospitals which supported it include all penetrating wounds of the

brain and all compound fractures of the skull without dural penetration in

which surgery was done from D-day to 1 November 1944. Unfortunately, when

these data were requested it was not specified that information was also desired

on patients who had reached the hospital alive but who had (lied without

surgery after admission. The data are therefore open to the criticism that

they are somewhat selective and represent only favorable cases, as exemplified

by the case fatality rates of 14.8 percent for penetrating wounds of the brain

and 1.3 percent for compound fractures of the skull. The criticism, however,

would not be precisely fair. It is true that any surgeon can keep his case

fatality rate low if lie operates only on favorable cases, while a surgeon whose
EI'ROPEAN THEATER 121

"TABLE 6.-Distribuiion of cases ,,d postoperatire deaths in 1,102 penetrating cerebral wounds

and 390 compound skull fractures managed in 13 hospitals of the First 1'. S. Army

Penetrating cerebral Compound skull injuries fractures llospital

Cases Deaths Cases Deaths

NVu irbr N' umber Nutmber NVu mber - 135 34 31 1

B. 77 27 13 0

C_ 97 12 21 1

D .84 14 15 0

E . 95 5 54 0

F 69 12 32 1

G .43 5 12 0

I 38 8 14 2

S... - 57 3 14 0

K- 94 5 59 0

- 249 33: 98 0

M --------- 64 5 27 0

Total - 1,102 163 390 5

criteria of operability are broader-like a surgeon with poor judgment who

selects cases unwisely-will show a higher rate. The cases in this series

undoubtedly include many in which the casualty, when lie was first seen,

appeared to be a bad risk but in which he was transformed into a surgical

possibility after proper resuscitative treatment for 12 to 14 hours.

It should also be emphasized, however, that the case fatality rates for

penetrating wounds of the brain and compound skull fractures without dural

penetration (14.8 and 1.3 percent, respectively) by no means represent the

whole picture of such casualties in the First U. S. Army. In the early days

of the campaign, a policy was decided upon by which, in times of stress, only

the most serious head injuries wouhl be operated on in evacuation hospitals,

while patients whose general condition was satisfactory would be evacuated

by air to the United Kingdom for primary definitive treatment. The figures

must be read with this qualification in mind.

It will be noted (table 6) that two hospitals, designated as A and L, handled larger numbers of cases than any of the other units. This was the result

of deliberate planning. The work in them was done by experienced neurosurgeons who had been given the responsibility of supervision of the neurosurgical work in evacuation hospitals in the early days of the campaign and

who, at the same time, acted as neurosurgical consultants for the Surgeon,

First U. S. Army.

The chief defect in First U. S. Army statistics, the failure to include in

the group of penetrating head wounds the patients who had been admitted

to hospitals but who had died before surgery, was borne in mind when data
122 NEUROSURGERY

from the Seventh U. S. Army were requested, and the figures collected from

that source (table 7) are accurate in this respect. One hundred and ninety

(16.2 percent) of all casualties with head injuries were so seriously injured

that they died soon after hospitalization or could never be brought to a status

in which surgery was considered practical.

These factors are reflected in certain of the data. Records of the individual hospitals show wide variations in the surgical case fatality rate. When

it was lowest, the overall case fatality rate was likely to be high. The figures

might, on superficial examination, be interpreted to mean that neurosurgeons

of certain installations were timid. The truth is more likely to be that they

showed the best possible judgment in the selection of cases for operation.

The two most experienced neurosurgeons in the Seventh U. S. Army, who.

worked in units L and M, operated independently of each other but had.

remarkably consistent records. Their series of cases, furthermore, represent

the largest and probably the most representative series of head injuries managed in Seventh U. S. Army hospitals.

TABLE 7.-Essential data in 1,176 penetrating cerebral wounds managed in 14 hospitals of the

Seventh U. S. Army

Hospital Total deaths Surgical deaths Total ___ _- ___ Surgical _ _ _--____

cases cases Number Percent Number Percent

A ----------------------------- 84 20 23.8 51 4 7.8

B ----------------------------- 96 33 34.4 84 21 25.0

C ----------------------------- 34 9 26.5 29 4 13.8

D ----------------------------- 76 34 44.7 52 12 23. 1

E ----------------------------- 63 14 22.2 52 3 5.8

F ----------------------------- 87 16 18.4 76 5 6. 6

G ----------------------------- 72 13 18.0 66 7 10.6

H ----------------------------- 39 11 2& 2 31 3 9.7

I ------------------------------ 95 27 2& 4 80 12 15.0

J ------------------------------ 67 30 44.8 52 17 32.7

K ----------------------------- 19 4 21.1 15 0 0

L ----------------------------- 174 41 23.6 133 16 12.0

M ----------------------------- 165 41 24.8 143 19 13.3

N ----------------------------- 105 34 32.4 85 14 16.5

Total ------------------- 1,176 327 27.9 949 137 13.7
CHAPTER VIII

The Management of Acute Craniocerebral

Injuries Due to Missiles

Donald D. Matson, M. D.

GENERAL CONSIDERATIONS OF PENETRATING

HEAD INJURIES

Early in World War I, surgical mortality in acute penetrating missile

wounds of the brain averaged 50 to 60 percent. During the war, this rate was

greatly reduced, principally by the use of operative techniques introduced by

Harvey Cushing. At one casualty clearing station, during a 3-month period

in 1917, Cushing's own surgical team operated on 133 patients with dural

penetration. The case fatality rate for the first 44 cases was 54.5 percent.

For the next 44 cases, it was 40.9 percent, and for the third set of cases (45),

the rate was reduced to 28.8 percent.' In World War II, during a 5-month

period in the European Theater of Operations, United States Army, the surgical

case fatality rate in two field armies averaged about 14.5 percent.2

This improvement cannot be attributed to any single innovation in

therapy. The basic principles of operative treatment were not significantly

altered, though the equipment to carry them out was vastly improved. The

following factors are believed to be the most important in the lowered mortality:

(1) The placement of trained neurosurgical personnel in forward hospitals, in

which there was adequate specialized equipment; (2) the rapid evacuation of

casualties to these hospitals, which permitted early definitive debridement

and repair; (3) the availability of blood in large amounts in the forward areas

for replacement therapy; and (4) the universal employment of sulfonamide and

penicillin therapy in all compound injuries.

In World War II, the line of battle was seldom fixed for any length of time,

and it was therefore as necessary for expert medical care in forward areas to be

mobile and adaptable to changing tactical situations as it was for combat and

supply units to meet these requirements. In this war, the proportion of injuries

due to high-explosive shell fragments, aerial-bomb fragments, and land-mine

1 (1) Cushing, H.: Notes on Penetrating Wounds of the Brain. Brit. M.J. 1:221-226,23 Feb. 1918. (2) Cushing, H.:

A Study of a Series of Wounds Involving the Brain and its Enveloping Structures. Brit. J. Surg. 5:358-684, April 1918.

(3) Hanson, A. M.: Management of Gunshot Wounds of the Head and Spine in Forward Hospitals, A. F. F. In The

Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927, vol.

XI, pt. I, pp. 776-794. (4) Horrax, G.: Observations on a Series of Gunshot Wounds of the Head. Brit. 3. Surg. 7:10-54

July 1919.

2 Essential Technical Medical Data, European Theater of Operations, for March 1945. Inclosure 8, subject: Statistical

Analysis of Penetrating Wounds of the Brain From Army Evacuation Hospitals.

123
124 NEUROSURIGERY

fragments to those due to small-arms fire was greatly increased over that of

World War I. In the series of injuries upon which this chapter is based, as

well as in 3 series, caltbyIS the ratio was about I gunshot wound to 9 wounds

caused by fragments of various types of high-explosive missiles.

The helmet was modified early in the war to give added protection to the

frontal, occipital, and temporal areas. This precaution undoubtedly reduced

the morbiditv and case fatality rates from wounds of the head, particularly

by the dh, ),n of small shell fragments and the transformation of many

potential rating brain wounds into simple gutter and tangential wounds

of the skw, -A scalp alone. When, however, large shell fragments or machinegun or rifle bullets hit the helmet at a direct 900 angle to its curved surface,

they often penetrated it and carried fragments of it into the brain.

The task of primary, definitive operative treatment of head injuries,

particularly the time-consuming, tedious debridement of penetrating wounds

of the brain, was a tremendous one, and the global distribution of the fighting

necessitated the services of a large number of surgeons. Although, for this

reason, there were many minor variations in operative techniques and methods

of supportive therapy, this chapter attempts to record, in a general way, the

problems faced, the results achieved, and the lessons learned.

OBJECTIVES OF TREATMENT

The treatment of acute penetrating wounds of the brain caused by all

types of high-explosive missiles was directed primarily toward four ends as

follows:

1. The immediate saving of life.-Actually, this was an uncommon accomplishment of early operation. Very occasionally, persistent bleeding from torn

dural sinuses or cortical vessels could be controlled only by operative intervention. Cerebral compression which occasionally occurred from intracranial

hematomas, extradurally, subdurally, or in the depths of a wound track could

be relieved by surgery, with dramatic improvement in the patient's general

condition.

2. The prerention of in~ection.-This was perhaps the most important,

duty of the neurosurgeon in the treatment of acute head injuries. The most

common cause of infection was inadequate primary debridement, debridement here meaning 100-percent surgical excision of all tissues which had been

contaminated, macerated, or severely contused by the destructive agent, or

which showed enough evidence of ischemia to presage subsequent necrosis.

This type of debri(lement implied direct inspection of each layer of the wound,

including skin, galea, pericranium, cranium, dura, leptomeninges, cerebral

cortex, subcortical tissues, and, if necessary, the interior of the ventricular

system itself. It also meant removal of foreign substances carried into the

3 Maltby. . . L.: Penetrating Craniocerebral Injuries. Evaluation of Late Results in a Group of 200 Consecutive

i'en•trating Cranial Wounds. J. Neurosurg. 3: 239-249, May 1946;
ACUTE CRANIOCEREBRAL INJURIES 125

brain. In addition to the surgical procedure, the early and adequate use of

chemotherapy was a major responsibility of the operating surgeon.

3. The presertatioti of nerrous function.-The key to this primary aim of

early treatment is found in the work of Penfield and his associates, 4 who stated:

There is a startling difference between the result of direct brain laceration where injured

cerebral tissue is left in place, and the result of clean excision which leaves no destroyed

cerebral tissue behind. In the former case a rich plexus of new-formed vessels appears and

a core of mixed connective tissue and astrocytes is formed. This is surrounded by a zone of

intense fibrillary gliosis in which the most robust glial fibers point toward the contracting

cicatrix. * * * The excision of cerebral tissue, however, results in little or no new vessel

formation and only a very small amount of gliosis which is apt to be found in a thin and inconstant layer in the grey matter * * * while there may be none in the white matter.

Thus the excision results in a fluid-filled space almost free from gliosis, while laceration

results in intense glial and connective tissue proliferation.

Clean removal of devitalized cerebral tissue, relief of cerebral compression, and

repair of dural defects all served, therefore, to minimize formation of meningocerebral scars and to permit the maximum recovery of neurophysiologic

defects.

4. The restoration of anatomic structure.-Accurate closure of the dura and

scalp at the time of primary debridement of the wound always provided the

best opportunity for satisfactory anatomic reconstruction.

ESSENTIALS OF TREATMENT

The Neurosurgical Team

The majority of acute penetrating craniocerebral injuries were cared for in

evacuation hospitals, under the supervision of a neurosurgeon assigned to the

hospital or under the direction of a mobile neurosurgical team (usually from an

auxiliary surgical group or mobilized from an inactive general hospital) temporarily attached to it. For satisfactory care of any significant number of injuries, a team trained for this particular type of work proved imperative.

The actual debridement of the wound of the brain was the problem of the

operating surgeon, but complete management of the patient and of the operating

equipment required the coordination of all members of the team.

When there were many craniocerebral injuries, there were usually large

numbers of other wounds as well; as a result, only one operating table per team

was usually available. This shortage necessitated foresight in the preparation

of the patient and of the operating equipment, which was carried out as completely as possible by personnel not needed in the operation. With proper

organization, a single neurosurgical team could often treat from 5 to 8 craniocerebral wounds, depending upon the severity of the injuries, on a 12-hour shift.

When large numbers of casualties were concentrated at one hospital during

heavy fighting, it was advantageous to have two neurosurgical teams available,

4 Penfield, Wilder (ed.). Cytology and Cellular Pathology of the Nervous System. New York: P. B. Hoeber, Inc.,

1932, vol. II, p. 458.

455735-58--.9
126 NEUROSURGERY

so that each could work a 12-hour shift and thus maintain uninterrupted

surgical treatment.

For continued effective operation, it was found that tile following personnel

should be assigned to a neurosurgical team, whether the team was all integral

part of a medical installation, such as all evacuation hospital, or a mobile team

temporarily attached to tile hospital:

1. A trained neurosurgeon or a well-qualified general surgeon who had

received special instruction in the technique of handling nerve tissue, to serve

as the responsible operator and chief of the team.

2. Another surgeon or a capable, well-trained enlisted surgical technician.

3. A medical officer or trained nurse-anesthetist, who was needed even

when local anesthesia was used because it was necessary that a responsible

person be present to observe the patient and give supportive treatment.

4. A surgical nurse or an enlisted surgical technician trained in the handling

of neurosurgical equipment, to serve as scrub nurse.

5. A trained enlisted man, not on the operating team, who would be

available at all times to move the patient, arrange lights, shave the next patient,

do catheterizations, clean instruments, and procure supplies.

Equipment

Certain specialized equipment was regarded as essential for definitive

primary operation on craniocerebral injuries. As emphasized by Cushing,5

this is all-or-nothing surgery, and operation should not be attempted unless

complete debridement and repair can be carried out. While adequate surgery

was undoubtedly performed occasionally with insufficient equipment, the following items, in addition to standard surgical supplies, were considered to be

necessary for satisfactory work:

1. A portable electric suction unit or other means of providing reliable

strong suction.

2. A portable Bovie electrosurgical unit.

3. A headlight, narrow lighted retractors, a small malleable light, or other

lighting suitable for illumination of deep, narrow wounds.

4. Pressed cotton, dental roll, or long-fiber bulk cotton, which could be

made into moist pledgets for sponging and for protection of normal brain tissue.

5. Special instruments, such as a hand drill with cranial perforator and

burr, sharp periosteal elevator, narrow malleable retractors, ventricular cannulas, silver clips, and small curved round needles for dural sutures.

6. No. 8 to No. 10 French soft rubber catheters, each with a hole in the

side near the tip for irrigation of the wound.

7. No. 00 or 000 silk, for accurate approximation of the dura and scalp,

or cotton or nylon of similar size.

5 (1) See footnote 1 (1) and (2), p. 123. (2) Cushing, If.: Organization and Activities of the Neurological Service,

American Expeditionary Forces. In The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. I, pp. 749--758.
ACUTE CRANIOCEREBRAL INJURIES 127

8. Bone wax.

9. Fibrin or gelatin foam, which are efficient absorbable hemostatic agents

and were of great value when they were available.

Records

It was the duty of every surgeon doing primary debridement and repair

of craniocerebral wounds to make a record of his operative findings and manipulations. Since treatment could seldom be continued for any length of time

after operation by the surgeon who did the original operation, it was imperative

that an accurate record of the operation and of all other therapy accompany

the patient when he was transferred from one medical installation to another

in the necessary chain of evacuation. The data needed by those responsible

for secondary care and eventual reconstructive surgery were best provided by

a brief but comprehensive operative note written or dictated by the operating

surgeon himself immediately following operation. Experience showed that

tY . rative note shoul include statements concerning (1) the size andl locati• of ie cerebral wound and an estimate of the amount of cerebral tissue lost,

(2) (iet removal of intracerebral bone fragments, (3) the removal of metallic

foreign bodies, (4) the type and amount of local chemotherapy used, (5) the

absorbable hemostatic agents used, (6) the size of the dural defect and the type

of closure, (7) the type of scalp closure, (8) drainage, and (9) complications

which had occurred, such as unusual bleeding or involvement of the dural

sinuses, ventricular system, paranasal air sinuses, or mastoid.

All these data could be included in a short paragraph. A mimeographed

diagram of the head and brain on which the operative findings could be sketched

quickly was used by some surgeons, and it was found very useful not only by

them but also by others who treated the patient subsequently.

In addition to the operative note, it was important that records made to

accompany the patient on transfer include the following data: Positive neurologic findings and the patient's general condition before operation, complications of the postoperative period, changes in the neurologic picture, total

amounts of chemotherapy and other medications, additional operative procedures, and transfusions.

Recording this pertinent information was an integral part of the care of

the patient; it was found to be especially important in highly mobile warfare,

when there were frequent and unforeseen transfers from one hospital to another.

FIRST AID TREATMENT

Initial treatment was usually given by battalion aidmen either on the field

or at a nearby battalion aid station. No reliable figures are available for the

time interval between wounding and first aid treatment. It naturally varied

considerably with the character of the fighting but was usually prompt and was

often provided almost immediately after wounding.
128 NEUROSURGERY

Early in the war, first aid treatment consisted of dusting powdered sulfanilamide into the wound 6 followed by the application of a firm, dry, sterile

dressing. Occasionally, hair around the wound was clipped or shaved in first

aid stations, but this was not the rule. Conscious patients often were given

a (lose of a sulfonamide by mouth. Later in the war, penicillin therapy was

begun in the battalion aid station or clearing station, and most casualties. when

they arrived at field or evacuation hospitals, had already had 20,000 to 40.000

units intramuscularly.

It was the general policy not to give morphine sulfate to patients with

head injuries on the field and in aid stations, though the rule was occasionally

violated when the patient was in extreme delirium, was agitated, or had painful

injuries elsewhere.

The maintenance of an adequate airway in unconscious patients throughout

first aid treatment and transportation was of vital importance.

PREOPERATIVE MEASURES

The Management of Shock

Traumatic shock was treated by the intravenous administration of plasma

on the field or in aid stations when it was thought necessary to support the patient for evacuation to a hospital. Upon his arrival at an evacuation or other

fixed hospital, the treatment of shock was given preference over all other

therapy except the maintenance of an adequate airway. Intensive therapy for

patients with only craniocerebral injuries was seldom necessary. Usually,

they responded quickly to the removal of wet clothing, warmth, sedation, rest,

and one or two transfusions of plasma or whole blood. Oxygen was administered by intranasal catheter or Boothby-Lovelace-Bulbulian mask., and small

doses of caffeine were often used to advantage.

A more serious problem was encountered in patients with craniocerebral

injuries who also had thoracic or abdominal wounds, or extensive compound

wounds of the extremities with excessive pain and loss of blood. In these patients, shock was likely to be profound, and rapid infusion of large amounts

of whole blood was often a lifesaving measure. Blood was not withheld when

it was needed, though it was thought at times to be dangerous in that it would

increase cerebral edema.

Concentrated plasma (2 units of plasma made up with 1 unit of distilled

water) was frequently used for comatose patients in shock. Physiologic or

other salt solutions were not administered intravenously. Fifty percent dextrose in amounts of 50 to 100 cc. occasionally was given, with good results, to

patients with depressed or irregular respiration who were receiving shock

therapy and awaiting operation.

It should be emphasized that excessive manipulations for neurologic examination, roentgenographic examination, shaving the head, and all other proceI WD TB MED 147, March 1945
ACUTE CRANIOCEREBRAL INJURIES 129

dures which did not contribute to the patient's immediate welfare were delayed

until shock was alleviated.

Neurologic Examination

An attempt was made to carry out a brief neurologic examination oil every

patient with an injury of the head as soon after his admission to the hospital

as his general condlition warranted. The policy was never to omit this examination before operation. In periods of heavy fighting, anti under the stress of

long hours of operating with insufficient rest, this often seemed difficult to the

neurosurgeon, but an examination, thorough enough to plan proper surgical

treatment, could usually be carried out in less than 5 minutes, with no more

equipment than a flashlight, a reflex hammer, and a pin. The practice of seeing

a patient with a craniocerebral injury for the first time after he was on the

operating table, with his head shaved and a compound wound presenting for

debridement, was strongly condemned. The surgeon who permit ted such shortcuts did not (to justice to his patient or himself.

Observations of the following points were found to be the most significant

in estimating intracranial damage and in planning the time and type of operative treatment:

State of consciousness.-If the patient could understand and answer

questions readily, no further tests were needed. If he failed to respond, the

simplest measure of his level of consciousness was his response to painful

stimuli, which was tested by pinprick, by pulling hair on the trunk or extremities, or by firm pressure over the supraorbital notch. Serial observations at

intervals by the same person were especially valuable. When the depth of

coma increased in spite of supportive treatment, it almost invariably meant that

intracranial hypertension was increasing from diffuse or intraventricular bleeding or that direct injury to the brain stem or basal ganglia had been severe.

In estimating tile level of consciousness, care was taken to note the amount

of sedation previously given, as well as the status of the peripheral circulation.

Since morphine or barbiturates were occasionally given subcutaneously to

patients with head injuries in the forward areas, the Field Medical Record was

checked for evidence of this medication as part of the examination.

It was shown repeatedly that when shock was present, morphine or

sedatives given by subcutaneous injection were not absorbed and consequently

were not immediately effective. It was necessary, therefore, to exercise

particular caution in giving additional medication before the efficiency of the

circulation had been restored by appropriate shock therapy. In addition, the

state of consciousness was sometimes masked by shock itself in the absence of

any sedation. A patient in this condition who appeared unresponsive, restless, and apparently comatose was often found alert and cooperative as soon as

his circulation had improved.

Respirations.-The rate and character of the respirations constituted one

of the most reliable guides to the extent of injury to the central nervous system.
130 NEUROSURGERY

Slow, deep, stertorous breathing and irregular respirations of the CheyncStokes variety indicated a grave prognosis. In the absence of sedation,

respirations below 10 to 12 per minute almost invariably meant massive

intercranial hemorrhage.

Rapid, shallow breathing and labored respirations were seldom due to

lesions of the central nervous system alone. When they were present, there

was usually trauma to the chest or encroachment upon the airway itself.

Eye signs.-The presence of fixed, dilated pupils was invariably an

ominous sign. A patient who presented this sign when first observed after a

penetrating wound of the brain almost never recovered. It did not matter

what the other vital signs were; if both pupils were dilated and fixed, the patient

almost always succumbed, usually within 48 hours, and whether or not operation was performed.

A unilateral dilated, fixed pupil usually accompanied extensive cerebral

damage on the same side, but the patient sometimes recovered. Direct injury

to the orbit or to the eye itself often accounted for a fixed pupil or a blind eye.

In conscious patients, gross testing of the visual fields by confrontation

proved of great value. Partial or complete homonymous hemianopsia, which

was often seen in compound depressed fractures of the occipital region, indicated a high priority for surgical treatment because of the frequency of recovery

of lost vision following early operation.

Paralysis.-Although examination of the extremities was occasionally

hampered by splinted fractures of the long bones, in almost every instance,

satisfactory appraisal of motor function could be obtained. A complete

flaccid paralysis of the arm and leg associated with a central type of facial

palsy almost always indicated a large loss of substance from the contralateral

cerebral hemisphere. Significant early recovery seldom took place in these

cases. On the other hand, an early spastic type of hemiparesis associated

with a cortical wound usually indicated a much less extensive loss of tissue, or

none at all. In these cases, there was a greater likelihood that the dysfunction

was due to local contusion or to pressure from hemorrhage, edema, or foreign

bodies. This type of hemiparesis often showed early improvement after

debridement.

Isolated monoplegias were almost never seen. Spastic paraplegia was

seen with wounds of the sagittal sinus and with parasagittal wounds. Spasticity of all four extemities invariably indicated a poor prognosis. It was usually

seen only in patients already moribund.

Aphasia was usually associated with a complete flaccid hemiplegia of the

right side. All types and degrees of aphasia were seen with various lesions in

the left frontotemporal region. When aphasia was partial in the acute stage

of injury, or when complete motor aphasia existed with partial hemiplegia or in

the absence of any paralysis, it was usually found to improve rapidly after

operation.

Reflexes.-In unconscious patients, whose motor function was difficult to

appraise, examination of the reflexes was especially valuable. Total areflexia
ACUTE CRANIOCEREBRAL INJURIES 131

indicated extremely profound coma and was an ominous sign. With extensive

subanachroid hemorrhage, significant findings included stiffness of the neck,

generally hyperactive deep-tendon reflexes, and positive Babinski responses

bilaterally. Lateralization of pathologic changes not readily apparent from

examination of the wound itself was often made possible by comparison of the

superficial- and deep-tendon reflexes of the two sides.

Cranial nerve palsy.-Patients with penetrating injuries which directly

involved the base of the brain (lid not often survive long enough to reach a

neurosurgeon. Occasionally, fractures radiated from a point of injury to

involve the base of the skull. In these instances, cranial nerve palsies were

sometimes seen, particularly palsies of the third, sixth, seventh, and eighth

nerves. In penetrating wounds or radiating fractures through the mastoid,

a peripheral type of seventh-nerve palsy was common and was often accompanied by at least a partial lesion of the eighth nerve.

No attempt was made to examine all the cranial nerves in every case, but

when cranial ncrve palsies were apparent, the examiner's attention was directed

toward possible complicating injuries of the base of the skull.

Summary.-It was the practice that every patient with a penetrating

craniocerebral wound should have an early preoperative examination and

evaluation, not only of his general status and the nature of his external wound

but also of significant neurologic manifestations. Positive observations were

noted on the record for comparison with findings at subsequent preoperative

and postoperative examinations. Experience proved that these observations

should include (1) the state of consciousness, (2) the character of the respirations, (3) the size and activity of the pupils, (4) the nature and severity of

paralysis, (5) abnormalities of the reflexes, (6) the presence of cranial nerve

palsies, and (7) the character and frequency of convulsions.

Roentgenologic Examination

Second in importance to clinical examination of the patient during preoperative preparation was roentgenologic examination of the skull. In addition

to the examination of patients with obvious penetrating wounds, roentgenograms were made on all patients with scalp wounds, no matter how small, and

on all patients who were unconscious or who had positive neurologic signs,

even if no wound of the head was visible. Trifling scalp wounds were often

found to conceal extensive cerebral injury.

Posteroanterior and lateral roentgenograms of the skull were made routinely. Stereoscopic films were not available in the forward areas, though

they would have been of great value. Unavoidable factors often prevented

pictures of high technical quality. It was usually possible, however, to make

satisfactory posteroanterior and lateral films, which were usually sufficient to

permit fairly accurate localization of intracranial metallic foreign bodies and

to postulate the structures through which the foreign bodies must have passed

from the wound of entry.
1,32 N 1- UOSLAW E It Y

[lie visualizattloll of mtineii-i-l honle frilgineii s. pro vtlded l ilt .el veil aort.

accuratte guide to tile locationl of tile( cerelbrzl woundt t rack. O ft en the actuanl

patt liwnv of the iiaiS.'ihe couild he out lined ill thle tilnilv aY it rail of honle fralgmlents

of vari-ous sizes. II igh1-%velocitIv missiles, ill st rikinig thle rounided skull and dura

at, various aingles, were oft en deflected iii extrneyhaie pliit terlis. Roenitgenogralits" were ali l anvaluIatil e a i(I to clinical examul ilta t loll ill these instaniceS

ill Clarifying ( lie- p)athiologic statte before operation. For Inst ance (fig. 4), a

metallic foreign hotly mlight paiss inl onle direct ion from thle point of entry, or.

ricochet across thle skuidl. whitile honle fragmien ts were v ll I~ an ain )ter.

Fti(; l:iF 4.- Eat era roeiitgeiiogruni of IpcIel rat tg wV( t 0( of frontal bone. All

aiccurate preoperal Wve esliulmit ion of thle direct ion mdui dcp1)h of a lie wound traick

ill tile hIwaiui is gainled by) st uidvinug t he posil ion of t he int racerelmra h~one frnugineiat s.

The actua natlumber of nt racerelbral hone fnignments could frequentl Iv1)

counted (fig. 5). As these fragmlenits Were remnoved alt operlit oll, thleyN Were

saved, colliitedl, lin1( ('ollpilred with titlie roelitgeiog(rzil Inls inl tilie opera tli' room11.

Obvious (liscrepancies ill thle anlonil11t of tilie indrivenl hone visallized ill the

roentgenogra~ms antd that recovered ait operat ioul were thlas mulnledia tel v

apparent.

Sometimes thle indtrivenl bonle Wats seen inl clusters of smaill comminuted

fragments. TIle indivitlual fraigmeiits couild not b~e countedi ill such a1 Case. h ut

a comiparisoni of thle totail moss of nt racerelbrol bone removed at operation withI

that seen ill tilie roe Iit vemio-ri' ls was of va1lue (fig. ()

The path taiken by a penlet rating foreign b~ody wvas occlisioiilly indicated

by t he presence of init racerebrail alir. A Small11 collect~ioni of alit- ill tilie temporal
'IAIOC A~iti I It I.B PA I. INVI I ItI Vs

I N\I r n ) ( I I ( - 11 .Il f r: Iu III(.. I u I ~~I % icI I111. lu - 14- ,u I ( i I Iit u I I I lc hIct p:iric~l A c 1iN

Bi. Lnivral i("- pou~iu~ sit iuIul of blluuit nuild -h ll frauu:w I-.1011S

Iolw, forinjst zllice, 1111li1 fiudi4' the I 114 ith of ai f iiii l.u whilch act 11,11lv had

eli t(4e4 t hII(4IIl-hI I Illt Ililout It andh I11 hell passed I iOIZhi- I bvi ant~ ruln) an 14 It(' flo)or

lhe Bv,)ii; i11iiddhi'c of ofoodr)SS1vio-a cosdrb~,at-110

Nvals (hi-elvdII( toward~ I1121hkiI1lZ -sat si-"lIc b luiti', but1 114) .1 It'ullj) was-lld. 112( to

takvi 1-oilttiI4'II' jM41 )ItIh iolpni i- SItllihok. Theiiid 112(1(ress-ill" Wasl (I'xauiiuiui't

45-.i7::5' .5s Ilo
to b~e surie It)hadi'apliqi~~ue niatei1-ilS' were piresent. If thle hail. cooit aiiie( I nid,

grNIVtd . or ot her forevi-Il bodlies, t hey.\ wverv reviioved b efore thle filmls wr iid

Figii re 7shows thei~ confuising ty-pe of pictutre ol a iiied w I et dirt. anid small

St olle-, were p~resenit IIiI lie Scal p woti id. W~hienever possible, filiiis weeIIu.n l

wVithI thle side of thle Voliihid of etitranice neareshet the fihili.

F14;1 m. 7. -Ilvaiii t rvilltgvIiogra Ill., givings. f.11,4 impIJ)I(.,iolI of hhil1ll)('r (of lii lfacevreral

tEoije fra:gmliiMw becau(Ise of 10111d 11111 gravel ill pntii i40i hair and( ill scaI)Wlp won..A. tl Rovill -

geilogi1:rh1 before leva(I Nv shaved'(. B~. 1Roeiuig iognim~ n-pewdh nfler livad wa (omplte;IttY

Shiavedl. Arrow point-; to S.imple depressed fraci iiie of ver-tex.

Rovtilt -eio-rai is taUkeli of irrait iona~l del] 111011s, 111)ic10op-ratIive pa Iitivit S

XVere lisltil ' v of iio va1 tie. Ill suich pat ieiit s. thle periodI of eflectV( wePreopera tive

ilici icalI oi cotiih b e used opportutnely to hiake roeti t genlogra* ills, wi-t Iial~

tilm for levehopnicii I an in iterpret at loll of' th lie I isI whlie preopera tive prepa oi is were I eiiig. coni llet u I(. If I-oeql I getogrI-i ills were poor beca use of fa tilt v

lccli iqute ot othe ir avoidalIe caus~es. addlit ionalI roett t get ioira ills were inn 1de

whieliever 1)ossilde.

IPostoperat~ivi e roei it -reiiogra nIl- ill thle forwa rd h ospit als were Ind( ica ted

oilvl\ wh en sigh fihiea ut amiioiunts of ind~lrivenl bonie couild n ot heI ~ ocated (1111-1i h

lie origilia. di ehidemiet t or. wieti t here were coiivtilsive seizurles of tw li JackSoiiiaii) I *ype (itiiihg, thle firt-, few pos5toperative (Iii vs. There xv.ve [Ito iiidi('it IMiIS

for vent rica lail ail. stutdies ill t reat mii et of, thlese acute Itnjutiries.

PRIORITY FOR SURGERY

Ide(l('IJV it wals dvsIniblte to Operate ohiel r pat icitl withI at 'omipIoundi

eia1ii joCUrt I ral Iiiij1a iv as sooli as, possiblle. Ill p~ract ice, it was fouii(d that ita period

of liabhil iza tion of I or 2 hiotirs. and( even till) t(o 10 to 12 hours, was ustial , v

I etief icia I, wI it her or niot t11 lipatienti \\It wsIll actutil Shock . Bevon d thle tinue

taken to ini1prove t lie P ieiit 's greiieraI coiloit ioll, t here was iio Vilt tIle ill fiurt her

olelaY. and1( t here was sotiet ilies (lcfitiit hazard.

I'll fort 11121t iatv. there was secioloni aii evhil (list ribuitioii of work iii Owli

forward areas. A sudiel~le flood of casua11ltes o'ccurredl withi every ma~jor etiguige-
ACUTE CRANIOCEREBRAL INJURIES 135

ment, and the backlog of surgery mounted quickly. This meant that some

system of priority for the available surgical facilities had to be established.

To set up an effective system required the most efficient use of the neurosurgeon's skill and experience, in cooperation with the activities of those in

charge of shock therapy and other preoperative measures.

In general, any wound which penetrated the dura was considered more

serious than a nonpenetrating compound depressed cranial fracture. In rush

periods, patients with the latter type of injury were usually evacuated to a

medical facility farther to the rear. Before evacuation, an attempt was made

to shave the area about the wound, dust sulfanilamide into it (a practice

discontinued later in the war), apply a firm dressing, and administer systemic

chemotherapy.

Patients found to require the highest priority for surgical intervention

included1. Those with active bleeding which could not be controlled by application

of a firm dressing or by placing a hemostat or ligature on an artery in the scalp.

Bleeding from lacerated cortic ii vessels or dural sinuses usually stopped

spontaneously after the formation of a clot under a firm dressing, though

occasionally it persisted until operative intervention was carried out.

2. Those with transventricular wounds. These patients deteriorated

rapidly, sinking deeper into coma with increasing respiratory failure. This

was particularly true if large amounts of spinal fluid were being lost through

the wound or if the ventricular system contained old blood and macerated

brain. Hyperthermia was very often seen. Haynes 7 observed that patients

in this group were usually moribund within 8 to 12 hours after injury. The

earliest possible operative intervention, therefore, was thought to offer them

their best chance for recovery.

3. Those with large herniations of cerebral tissue. Such herniations were

often due to intracranial hypertension secondary to a large hematoma in the

depths of the wound of the brain. Patients with this type of injury could be

saved only by early operation.

4. Those showing progressive failure of consciousness or increasing neurologic signs.

When two patients had wounds of approximately the same seriousness,

the one who had been wounded first was operated on first. Contrary to all

previous observations, in World War II the duration of the wound at the time

of operation, at least up to 48 to 72 hours, was found to make little difference

in the incidence of infection or the case fatality rate. Criteria other than

the length of time after wounding were therefore used to determine priority

for operation during this period, provided that the patient was receiving

adequate supportive therapy and chemotherapy.

Lowest priority for surgical intervention was given to patients with

wounds at both extremes of severity. If the patient's general condition was

7 1laynes, W. 0.: Transventrlcular Wounds of the Brain. J. Neurosurg. 2: 463-468, November 1945.
136 NEUROSURGERY

good and his neurologic examination negative, simple compound depressed

fractures without dural penetration were never considered urgent. At the

other extreme, patients who were obviously in extremis, with bilateral dilated,

fixed pupils, Cheyne-Stokes respiration, or generalized rigidity were not

operated on if other patients with craniocerebral injuries needed tile neurosurgeon's attention.

PREPARATION FOR OPERATION

During the entire preoperative period, systemic chemotherapy was continued at regular intervals. Original dressings, which had usually been applied in an aid station or on the field, were apt to be adherent to herniated

cerebral tissue. Unless they were removed with the greatest gentleness, clots

were pulled away and bleeding was started.

Local preparation.-As soon as possible after the patient's admission to

a unit in which definitive treatment could be carried out, his entire head was

clipped with ordinary mechanical or electric clippers or was sheared with

scissors. Clipping or shearing was often difficult when there were clotted

blood, dirt, and macerated cerebral tissue in the hair. In such instances,

cutting the major part of the hair off first with scissors was of help. When

the hair was matted with dried blood, it was helpful to wash the head first

with a mixture of soap and hydrogen peroxide.

After the entire head had been clipped, it was shaved cleanly for a distance of at least 3 inches from all wounds, or, preferably, completely shaved.

It was usually necessary to finish this preparation after the patient was on the

operating table under a good light. Preparation of the head was often a tedious

and time-consuming process, and, insofar as possible, it was carried out with

the patient on a litter or separate operating table, in order not to delay the

operating team. Shaving about the wound edges was often very painful and

could be completed satisfactorily only after premedication or even surgical

anesthesia had been administered. For shaving around craniocerebral wounds,

the most, satisfactory implement proved to be the ordinary safety razor blade

held with a straight or curved half-length clamp.

After the scalp was shaved, it was thoroughly washed with warm water

and soap. If there was o0( dried blood about tile wound edges, the addition

of hydrogen peroxide to the soapy water was advantageous. This mechanical

scrubbing with soap and water applied with gauze sponges was considered the

most important step in the preparation of the field and was never neglected.

The scrubbing was followed by additional cleansing of the scalp with gauze

sponges soaked in 70 percent alcohol alternated with sponges soaked in bichloride of mercury. Painting the scalp with 2.5 percent iodine solution or

tincture of Merthiolate (thimerosal), followed by alcohol, also constituted

a satisfactory preparation. When local anesthesia was used for field block,

the skin was washed again with alcohol or repainted with antiseptic solution

after the injection.
ACUTE CRANIOCEREBRAL INJURIES 137

Positioning on operating table.-Great care was taken in getting the

patient into satisfactory position on the operating table, especially if local

analgesia was to be used. All clothing was removed, and he was covered with

sheets or blankets according to his condition and the environmental temperature. Gentle immobilization was accomplished by the use of a broad piece

of canvas across the thighs. The arms were loosely restrained at the sides or

on padded armrests. The operating table was usually broken or tilted, so that

the head was slightly elevated.

'The most satisfactory support for the head proved to be a soft sandbag

or a firm rubber-covered pillow about 6 to 10 inches square and 2 to 3 inches

in thickness. All lesions in the frontal areas and vertex could be managed

easily with the patient lying on his back. If the lesion was in the temporal or

parietal region, he was rotated toward the opposite side, and a pillow or sandbag of sufficient size to give adequate support was placed under the shoulder

on the side of the lesion. If he was conscious and restless, he was allowed to

lift and turn his head slightly from time to time during the operation.

For wounds in the occipital and postparietal areas, the classical cerebellar

or face-down position was used. For this purpose, a well-padded horseshoeshaped headrest was employed, which carried the weight of the head on the

forehead and malar regions and allowed the anesthetist free access to the

patient's nose and mouth. In this position, especial care was taken to elevate

the chest from the operating table by sufficient support under the shoulders

to permit free respiratory exchange. A tightly rolled blanket or a narrow,

firm pillow or sandbag placed diagonally under each shoulder served admirably for this purpose. When no operating table was available, an elasticbandage sling fastened to the handles of the standard litter was used to support

the forehead.

Draping.-The simplest possible system of draping with sterile towels

and sheets was used to exclude completely from the operative field everything

except the prepared area of scalp. It was satisfactory to follow the standard

civilian practice of using a Mayo stand immediately above and caudad to the

operative field, to serve the double function of elevating the drapes from the

face and supporting a tray for the most frequently used instruments. A

generous area of the scalp was usually exposed in draping for cranial operations, because of the frequent necessity for extending wounds and doing plastic

procedures to achieve satisfactory closure.

ANESTHESIA

Three types of anesthesia were commonly used in the primary debridement and repair of acute penetrating brain injuries in World War I: (1)

Local infiltration of procaine hydrochloride, combined with various types of

preoperative medication; (2) intravenous injection of Pentothal Sodium

(thiopental sodium); and (3) intratracheally administered nitrous oxide-
i38 ~N EURO)SURGERtY

oxygen-ether. Avert in. (tribromoethanol) was available to a few suirgeons

anld was used by theml to goodi advantage.

The selection of anesthesia varied with thle general condition of ti'.. paitienit,

hie locat ion and typ~e of his injury, the p)resen~ce of complicating wouinds, elsewhere in the body, tihe anesthetic facilities availab~le, and the individlual p~reference of t he surgeon.

While certain prolblemns (lelnande(1 a specific typ)e of anesthesia, suchi as

int ratracheal ether for crainiofacial wounds, thle great, majority of penetrating

injuries of the lbrain couldl be handled satisfactorily unmder local anesthesia

alone, unde(r local anesthesia plus intravenous thiopental sodliumi, or undler

thiopen tail Sodlimzii alone. Patients who were deeply comiatose or moribund

or whose resp~irations were depressedl or irregular were operatedl 011 undler local

infiltrat ion alone. W~hen there were comiplicating wounds of the extremities,

it, wats commnon p~ract ice to care for the craniocerebral injury first, under local

infiltration, andl then pult. the~ patient to sleep with thiopental 50(hiuni~ for thle

oither p~rocedutres. When penetrating inj uries of thle chest, or albdonien wvere

p)resent, with craniocerelbral inj uries, they naturally took p~reced(ence for siir,'ival

intervention. Often the injury of the brain could be debrided subsequentfly

under the Samle anesthesia. If the injury of the brain. wats extensive or if the

p~at ient 's condlit ion mnilit at ed against, fiirtiher p)rolongat ion of general anesthesia,

thle wound of thle head wats usually operated onl 24 to 361 hours later, uinder local

infilt rat ion of p~rocaine hydrochloride.

Local anesthesia.--One percent, procaine hydrochloride, to which 3 to 5

dIrolps of 1:1,000 solution of epinlephrine per oiunce (30 cc.) wvere adldedl, was

used'( routinely for local infilt~ration andl field block. While it wats seldom

necessairy to use miore than 100 cc. of procaine hydrochiloride, as mulch as 150

cc. of I lpercent lprocauine hydrochloride was often usedl ini extensive woundls

wit bout ill effects.

P~rocaine hydrochloride w~as best. inj ectedl in normal t issues, away from,

rather t10an through, contauniinatedl woundl~ edlges. Bleedinag, p~articulairly

from the scalp), was always less when local infilt~ration was used. A cooperative

patient, under local anesthesia, could soimet imes aidl in the (lelrideleent of his

own wound by straining and coughing gently uinder the surgeon's dlire(ction

andl thus forcing devitalized tissue anl deb~ris from the (depthls of the woundl.

Whien. local anesthesia waus used, preop~eraitive sedlation wvits always important. Pentobarbital sodium (0.4)9 t~o 0.39 gin, by miouth) or Sodium Anl-t~al

(aniobarbital sodiumi) (0.39 to 0.58 g~n., given su bcutitaneously 1 hour before

op~eration), together with 11I to 16 nig, of muorphine sulfate intravenously ait thle

timie t-he head was being prepared, wats ordhinalrily found to constitute satisfactory prep~aration for local anest~hesia. Paraldeleydle, in (loses of 12 to 20 cc.

by rectum or 4 to 7 cc. intramuscularly, p~rovedl anl excellent, sub~stit~ute for tile

b~arb~itutrat es, especially in overactive, rest less patients,. Complicat ions from

lhe use of intravenous morphine in patients with open wounds of the head ivere

almost never observedl providled that the morphine wvas not usedl ill the presence

of respiratory irregularity or depression. The effect, of 16 mug. of intravenous
ACUTE CRANIOCEREBRAL INJURIES 139

morphine was invariably prompt and usually lasted from 1% to 2 hours. If

the drug was given just before local procaine hydrochloride infiltration was

begun, its effect lasted throughout the average craniocerebral debridement.

It was never used in patients with severe closed injuries of the head.

Pentothal Sodium (thiopental sodium) anesthesia.-One of the outstanding advances in the primary operative treatment of all casualties in World

War II was the availability of thiopental sodium for intravenous anesthesia;

this was true for craniocerebral wounds as well as for other types. Some

surgeons used it for as high as 85 percent of their craniocerebral operations.

It proved to be an ideal form of anesthesia for restless, overactive, and uncooperative patients, who would not tolerate local anesthesia alone. Complete

muscular relaxation was not needed for this type of operation. It was necessary only to keep patients quiet and free from apprehension and pain. When

the drug was given slowly and carefully in combination with local infiltration

of procaine hydrochloride, it was usually possible to keep patients asleep for

2- to 3-hour procedures with from 1.5 to 2.0 gm. of thiopental sodium. Thiopental sodium was not given in solutions stronger than 2.5 percent to patients

with craniocerebral injuries. Induction was slow, and the danger of apnea and

laryngospasm was over before surgical manipulations were begun.

For long procedures, an intravenous needle was inserted and kept open

by a slow drip of suitable fluid, so that additional thiopental sodium could be

given as needed. A skillful anesthetist soon learned to give it just before it

was needed. Some surgeons preferred a steady but adjustable drip of from

0.5- to 1-percent thiopental sodium solution. Oxygen, when needed, was most

satisfactorily administered through a nasal catheter. Atropine sulfate, from

0.43 to 0.65 mg. subcutaneously, was used routinely before thiopental sodium

anesthesia.

Thiopental sodium proved especially valuable for wounds around the ear

and mastoid and about the orbit, where local infiltration was difficult. It was

also admirably suited for patients with associated injuries which could be

repaired at the same time or immediately following the repair of the cranial

injury. It was contraindicated in patients with craniocerebral wounds involving the nasopharynx, paranasal sinuses, or the floor of the mouth, in

patients with respiratory depression or irregularity, and in deeply comatose

patients.

Intratracheal ether anesthesia.-The primary indication for this type

of anesthesia was the presence of wounds involving the frontal, ethmoid,

sphenoid, or maxillary air sinuses, or the nasopharynx. In these areas, it

was essential that a clear airway, as well as adequate relaxation, be maintained

throughout long operative procedures. It was particularly important that

anoxia be avoided during induction and maintenance of inhalation anesthesia

because of its rapid reflection in increased intracranial pressure. Thorough

aspiration of the trachea when the tube was first inserted and again before it

was removed was very useful; if there was persistent respiratory obstruction,

bronchoscopy was occasionally necessary.
140 NEURtOSURG ERY

CLASSIFICATION OF CRANIAL INJURIES

In Worid War I, Cushing ' described nine different categories of head

wounds due to missiles. More recently, classification of these wounds has been

into three general groups: (1) Lacerations of the scalp alone, (2) compound

linear and depressed fractures of the skull without dural penetration, and (3)

compound fractures with penetration of the dura and brain. The last-named

group of wounds may be usefully subdivided into the gutter type of wound in

which depressed bone fragments have been driven into the substance of the brain

but no foreign body is present, penetrating wounds in which a missile is retained in the brain, and through-and-through wounds in which a metallic

foreign body has passed completely through a portion of the intracranial

chamber.

Certain additional complicating injuries could occur in any one of these

three categories of penetrating brain wounds, such as involvement of the ventricular system, fractures and wound tracks passing through the paranalaal

air sinuses or orbit, laceration of the dural venous sinuses, and large intracranial

hematomas.

The operative management of wounds of the scalp, skull, dura, and brain

will be described in turn. After the general principles for handling each of

the tissues involved has been considered, attention will be devoted to the

various special types of injuries.

DEBRIDEMENT

Wounds of the Scalp

It was repeatedly shown in World War II that when scalp wounds were

debrided early, with adequate preparation and supportive chemotherapy, wide

block excision of skin around penetrating wounds was unnecessary. Indeed, as

experience increased, it became more and more evident that a minimal excision

of skin from the wound margins was the procedure of choice. Surgeons who

removed a centimeter or more of skin around penetrating wounds very often

found closure impossible without extensive plastic procedures. On the other

hand, the surgeon could not allow his plans for closure to influence the thoroughness of the debridement. If there was reasonable doubt about the blood supply

of any area of scalp, that area was removed.

All devitalized tabs of skin were removed routinely, together with any

dirt, hair, bits of bone, particles of headgear, or other foreign bodies in the

wound. Each layer of the scalp was inspected separately. Often the deeper

layers were more damaged than the superficial. As narrow a margin as could

be excised feasibly with a scalpel or sharp scissors was then trimmed from

the wound margins (fig. 8). It was repeatedly observed that extensive loss

I See footnote 1 M3), p. 123.
ACUTE CRANIOCEREBRAT. INJURIES 141

Len. ofPericranium

skin excision

FIGUR RS.-8Steps in debridemient of scalp, pericraniuml, skull, and dura.
142 ., -)OSURGERY

of blood could occur from the scalp if hemorrhage was not controlled by

pressure and retraction of the galea as debridement proceeded.

In contrast to minimal excision of the scalp, w~ide removal of devitalized

muscle in the temporal and occipital regions was carried out.

When debridement of the scalp had been completed, the instruments

used for this purpose were discarded. Self-retaining retractors were introduced,

or hemostats were applied to the galea to separate the wound margins. If the

underlying cranial wound was not adequately exposed, the scalp wound was

immediately extended. If it was readily apparent that there had been a lo.s

of skin sufficient to prevent closure, it was often wise to anticipate subsequent

plastic procedures at this time.

Wounds of the Skull

Not until debridement of the scalp had been completed and the wound

margins walled off was attention directed to the bone (fig. 8). All contaminated

bone was removed, whether it lay loose in the external wound or deep within

the cerebral substance or remained in continuity with the rest of the cranium.

In addition, of course, it was essential to remove sufficient bone to give adequate exposure to an underlying wound of the meninges and cerebrum.

All comminuted fragments were removed, even if they (lid not appear

contaminated, because of the risk of infection plus the unsatisfactory cosmetic

result which almost invariably followed attempts to replace them. With

modern methods, it usually proved just as easy to perform a large cranioplasty

as a small one, and wide removal of bone was therefore regarded as the method

of choice.

During World I, block resection of an area of bone surrounding the cranial

wound was carried out by (trilling four or more burrholes and connecting

them with a saw or rongeur of the Montenovesi type. In World War II,

this technique was no longer thought necessary or desirable. A more direct

approach was found to be quicker, easier, and just as effective.

The method of debridement of the bone varied with the type of wound.

If large, loose fragments were present or had been completely driven through

the dura, it was usually possible to start removal of bone, with rongeurs, at

one margin of the defect. Removal was carried back at this point until a

margin of about 1 cm. of normal dura was exposed (fig. 8). Starting at this

point, and keeping the instrument always over normal dura, it was possible

to rongeur the bone quickly and safely entirely around the defect (fig. 8).

This technique was always much easier than nibbling at the edge of the defect

all the way around because frequently the dura was damaged and retracted

underneath the bony margin. There was also less danger of contaminating

new areas, as well as less bleeding associated with debridement, when operation

was carried out from normal bone and dura toward the defect.

If the wound in the bone was small, if fragments were wedged tightly in

the defect, if there was a comminuted depressed fracture with no exposure of
ACUTE CRANIOCEREBRAL INJURIES 143

the dura, or if the depressed fracture was over a dural sinus, debridement was

carried out as follows:

A burrhole was made adjacent to the wound of the bone through an area

of undamaged bone, to expose normal dura. Starting at this point, the surgeon

rongeured toward the defect and around its margin, again keeping the instrument over normal dura. In this way, the danger of starting bleeding from an

unexposed site in the dura or brain wound was greatly decreased.

In removal of bone, care was taken to preserve the pericranium over undamaged areas as far as possible, since it was often needed for subsequent repair

of a dural defect. When flaps of scalp were swung, it was especially important

to leave the pericranium intact as a bed on which to place a free-skin graft.

Control of bleeding from the bone was no particular problem as there was

usually no increase in vascularity. Bone wax was used for diploic hemorrhage.

Thin strips of fibrin foam were occasionally of value in controlling persistent

ooze from underneath a bony margin. Sutures placed from the dura to the

galea were sometimes used to hold the dura tightly to the bony margin for the

same purpose.

Wounds of the Dura

Extensive excision of dura around a traumatic defect was neither necessary

nor desirable. The entire dural defect was exposed, after which, under direct

vision, the edges were carefully examined. Only obviously necrotic tags and

badly shredded areas were removed. If there was visible gross contamination

of dural margins which could not be readily wiped or washed away, the involved area was excised as frugally as possible. Often, no dura at all was

removed. The importance of tight dural closure was considered to be so

great that considerable attention was devoted to the preservation of the dural

edge as the debridement proceeded. The dural opening was never enlarged

unless it was necessary to control cortical bleeding or remove a large superficial

foreign body.

Wounds of the Brain

Special techniques.-Adequate debridement of penetrating injuries of

the brain followed the general principles of wound debridement elsewhere in

the body. It was necessary, however, to make use of some of the specialized

methods and equipment of the neurosurgeon in order to carry it out with

thoroughness and facility. These specialized methods had to do principally

with the control of bleeding in the central nervous system and with the protection of normal cerebral tissue. The necessary special equipment has already

been described.

No attempt was made to debride a wound track in the btain until adequate

exposure had been obtained. Debridement of the scalp, bone, and dura was

completed before attention was directed to the wound of the brain proper.

This procedure not only gave the best possible exposure but also minimized

the danger of introducing new contamination into the depths of the wound.
144 NEUROSURGERY

Wherever possible, each step in the debridement of the brain wound was

carried out under direct vision. Upon completion of dural debridement, it

was frequently advantageous to place one or more traction sutures on each

margin of the dural defect to facilitate the exposure (fig. 8). Debridenient

Saline

S• SVent-ica ~ Ventricular No.8 catheter

cannula

A

Fi;t-RE 9.-Debridement of cerebral wound. A. Gentle probing in entrance wound

with catheter or ventricular cannula to help confirm direction and depth of track before

starting debridenient. B. Removal of macerated cerebral tissue and clotted blood by irrigation and suction.

Suctioni Malleable

light

Electrocautery -

Bleeding -'

vessel //:

Metallic -4A fragments

FIm-Rs 10.-Debridenient of cerebral wound. A. Hemorrhage in depths of wound

controlled by application of electrocautery to metallic suction tip held against bleeding

vessel. B. In deep), narrow wound tracks, too small to permit use of ordinary retractors,

a small malleable light is inserted to permit suction under vision.
ACUTE CRANIOCEREBRAL INJURIES 145

was then continued as a combination of various maneuvers (figs. 9, 10, and 11),

depending upon the characteristics of the particular brain wound.

Before starting debridement of the brain wound proper, the roentgenograms

were carefully reviewed to note the position of any indriven bone fragments

and metallic foreign bodies in relation to the position of the wound of entrance.

Gentle probing in the entrance wound, with a catheter or ventricular cannula

(fig. 9A), then helped to confirm the direction and depth of the track before

debridement was started.

Most of the removal of macerated cerebral tissue and clotted blood was

accomplished by judicious use of suction (fig. 9B). Fragments of bone, hair,

Malleable

Slighted

retractor

FIGURE. ll.--Debridement of cerebral wound. Bone chips and metallic foreign bodies are removed with forceps, under direct vision, with the aid of a malleable lighted retractor.

clothing, and headgear, and the missiles themselves, were removed gently

with forceps as they were exposed. Since suction should never be employed

except when the point of the sucker is under direct vision, this technique

was not used in the depths of a narrow track unless a lighted retractor or

small malleable light could also be introduced or the depths of the track could

be illuminated adequately by overhead light.

Gentle irrigation of the brain wound with warm physiologic saline solution

was often of considerable aid in the removal of macerated tissue (fig. 9B).

Irrigation and suction were used simultaneously. The surgeon had to be careful

never to force saline solution into the depthis of a narrow wound, because this

might disseminate contaminated material into uninvolved tissues. Ascroft '

0 Ascr-oft, P. B.: Treatmnat of Head Wounds Due to Missiles: Analysis of 500 Cases. Lancet 2: 211-218, 21 Aug. 1943.
146 NEUROSURGERY

emphasized tile dangers of irrigation in deep wounds, and "Munro 10 expressed

tile same opinion in discussing the care of compound craniocerebral wounds

ill civilian practice. Careful irrigation of the walls and floor of the wound track

under direct vision proved, however, a safe and useful procedure.

As debridement proceeded, all endeavor was made to keep bleeding under

control at all times, both to insure the best visibility and to prevent unnecessary

loss of blood. ,Many cortical vessels which had thrombosed were necessarily

reopen&ed during debrideinen t. They were coagulated with the electrosurgical

unit (fig. 10). Silver clips were applied to larger vessels. Generalized oozing

could usually be controlled with warm, moist cotton packs, with fibrin foam,

or withl muscle stamps. The troublesome deep bhediing which was occasionially

encountered around the falx or in the distant surfaces of a hemisphere was

controlled l)y whatever techiique was most appropriate.

Fragments of bone driven into cerebral tissue were extracted with extreme

caution and always under direct vision if this was at all possible (fig. 11).

Bone fragments were extracted along the same path by which they had entered,

to avoid damage to normal brain.

Management of foreign bodies and bone fragments.-The primary aiti

in debridement of a wouiid of the brain was always the removal of all b)one

fragments and other organic foreign material, as well as aspiration of macerated

cerebral tissue .(d o0( blood. When deep infection was discovered at the

general hospital level, it was almost invariably found to be associated with

retained bone fragments. Campbell "1 discussed this problem in a report based

upon 100 cases of colnpounld comminuted skull fractures produced by missiles,

in 94 of which there were indriven bone fragments. There were 20 (deep infections in 49 cases ini which only part or iione of the fragments were removed,

while ill 45 cases in which thorough debridemnent. was done, there were only 2

deep infections. Rowe anid Turner 12 reported from a neurosurgical center ill

the communications zone that brain abscess developed within 6 weeks in 25

percent of their patients with retained boine fragments.

It was the general policy to remove metallic foreign bodies at debridement

whenever this was possible without damage to normal tissue. If, however,

removal meant an approach through uninjured tissueor necessitated all exposure

considerably greater than that necessary for debridement of the wound, the

metallic foreign body was left in place. It. was remove(] later if it was very

large or near the surface or if it was giving rise to any signs or symptoms.

The chief reason the metallic foreign body was exposed, if this was at all

feasible, was to permit the exposure and removal of small bone fragments anld

other contaminated material that might have been carried all the way ill

ahead of it. When the metal had penetrated considerably deeper than the

10 Munro, Doridd: Cranlo-C(erebral Injuries, Their l)nagnosls and Treatment. New York, Toronto. and TA)ndon:

Oxford University Press. 1938.

"1 Campbell, Eldridge lt..Jr.: Compound, Comminuted Skull Fractures Produced by is.-iles; Repxort Based Upon 0uo

Cames. Ann. Surg. 122: 375-397, September 1945.

12 Rowe, S. N., and Turner, 0. A.: Observations on Infection in Penetnating Woundsofthe Head. J. Neurosurg. 2:391-

401, September 1945.
ACUTE CRANIOCEREBRAL INJURIES 147

bone fragments, the track usually had sealed behind it. The infrequency of

infection around unremnoved metallic foreign bodies siggests that any contaminated material carried in on the foreign body must have been sterilized by the

heat ot the missile.

In very narrow, deep tracks, it was not always possible to visualize the

depths of the wound well enough, even with a narrow malleable retractor, to

remove bone fragments under direct vision. Ulnder these circumstances, fragments cou( l often be located by gentle probing in the track with a rubber

catheter or with a blunt ventricular cannula. WVhieii the fragments were located,

an attempt was marie to visualize them and pick them out with forceps. Wheni

the point of entrance of a wound track in the brain was wide enough, gentle

palpation of the walls and depths of the track with the gloved index finger was

of great aid in locating small fragments of bone. The finger was never forced

into a wound and was never used fnr dissection but was useful in cautious palpation of the base of wide, shallow Wounds.

No attempt was made to do block excisions of wound tracks by electrosurgical dissection, as had bleen suggested in the early (lays of the war."3 This

practice proved unnecessary and impractical. Instead, debridement was carried

out by keeping within the wound track and removing loose, necrotic, an(d

macerated tissue in all directions until normal cerebral tissue was reached.

When bleeding was well controlled and visibility good, the margins of the wound

track were usually easy to determine.

LOCAL CHEMOTHERAPY AND ANTIBIOTIC THERAPY

There is no question about the important part played by chemotherapy

and antibiotic therapy in the reduction of the morbidity and mortality rates

in craniocerebral injuries in World War II. Controlled obsevations of tile

importance of chemotherapy are difficult because no large group of patients

was treated without it. Several reports, however, are available which compare

the incidence of infection in patients treated with sulfonamides alone in early

campaigns and in patients treated with sulfonamides and penicillin in later

campaigns. In Martin and Campbell's " series, the respective rates of infection were 23 and 13 percent. In Haynes' 11 series, they were 21.1 and 6.8

percent. In Slemon's 16 experience in the British Army, they were 31.2 and 9.2

')ercent. In evaluating the incidence of infection, it should be remembered

that the period when penicillin and the sulfonamides were used jointly was also

a period during which surgical experience in the management of war wounds

had materially increased.

Though some form of local chemotherapy was almost universally employed,

individual surgeons applied it by many different methods. A common method

13 Ilorrax, G.: A Proposal for the More Radical Treatment of Gunshot Wounds of the Brain. Canad. M. A. J. 43:320-

324, October 1940.

14 Martin, J., and Campbell. E. H., Jr.: Early Complications Following Penetrating Wounds of the Skull. J. Neurosurg. 3: 58-73, January 1946.

is Haynes, W. G.: Penetrating Brain Wounds; Analysis of 342 Cases. J. Neurosurg. 2: 365-378, September 1945.

'a Slemon, H. V.: Forward Neurosurgery in Italy. J. Neurosurg. 2: 332-339, July 1945.
148 NEUROSURGERY

was to dust all layers of the craniocerebral wound witt a powder made by

adding 1 gin. of sulfanihunide to each 5,000 units of penicillin. Walker and

his coworkers "7 found that penicillin introduced subcortically was a convulsive

agent but that this was true only when the quantities used were much larger

than required for therapeutic purposes. As much as 20,000 units of penicillin

was used repeatedly by many surgeons in various types of acute cerebral war

wounds without clinical convulsive manifestations.

In deep, narrow tracks, which could not be dusted satisfactorily with a

powder, 10,000 units of liquid penicillin diluted with saline solution was usually instilled before closure of the (lure. In the United States Army, sulfathiazole was not used in wounds of the brain, though the British reported its loval

use without the convulsive complications noted earlier in the laboratory and

in civilian practice.'s In injuries near the motor cortex, a maximum of 10,000

to 15,000 units was not exceeded.

Munslow 19 reported no difference in the incidence of infection when penicillin was used locally in the Mediterranean theather in the later campaigns of

the war. In a well-debrided wound, there seemed to be little indication for

local application of a sulfonamide, provided that penicillin had been used and

that adequate systemic chemotherapy was maintained. No amount of local

or systemic chemotherapy was regarded as a substitute for careful, complete,

surgical debridement.

REPAIR OJ THE DURA

In the past, there had been no general agreement about closure of the

dura at the time of primary debridement. Early in World War II, British

neurosurgeons thought it should never be closed but should be left open for

drainage of contamihated material.20 With added experience, however, dural

closure became the procedure of choice, especially among United States Army

neurosurgeons.

The (lura is the most effective natural barrier to the entrance of infection

to the brain from outside. Cairns 21 stated that if. the majority of brain wounds,

infection developed in the superficial laye,.s and spread to the deep layers.

The dura is also the most effective barrier against cerebral herniation and escape

of spinal fluid. In addition, a smooth, well-healed dura is the best propihy

laxis against the formation of an adherent cerebral scar at the point of injury.

A tight dural closure was therefore thought to be of paramount importance

in the management of every acute craniocerebral wound, and considerable

17 (1) Walker. A. E., and Johnson, H. C.: Convulsive Factor in Commercial Penicillin. Arch. Surg. 50: 6&-73,

February 1945. (2) Walker, A. E., Johnson, 1I. C., and Kollros, J. J.: Penicillin Convulsions; Convulsive Effects of

Penicillin Applied to Cerebral Cortex of Monkey and 'Man. Surg., Gynec. & Obst. 81: 692-701, I)ecenmber 1945.

' (1) See footnote 9, p. 145. (2) Ascroft, P. B.: Neurosurgical Experiencte in Egypt and Libya. Arch. Neurol. &

Psychiat. 21: 295-296, March 1944. (3) Eden, K. C.: -NMobile Neurosurgery in Warfare; Experiences in the Eighth Army's

Campaign in Cyrenaica, Tripolitania, and Tunisia. Li,.:eet 2: 6S9-492, 4 Dec. 1943.

19 Munslow, R. A.: Penetrating Head Wounds. Expi-iences From Italian Campaign. Ann. Surg. 123: 180-189,

February 1946.

20 See footnote 18 (2) and (3).

21 Cairns, II.: Penicillin in Head and Spinal Wounds. brit. J. Surg. 32: 199-207, July 1944.
ACUTE CRANIOCEREBRAL INJURIES 149

time was often devoted to this part of the procedure. Whenever possible, the

margins of the dural laceration were brought together directly with fine silk

sutures. When this could not be accoml)lished, as it could not be in well ovet

half of the dural penetrations which form the background of these observations,

some form of graft was employed to fill in the defect. Partial closure of large

dural defects by direct suture was frequently possible, leaving a residual gap

that could be closed by a relatively small graft. Often the dura was found

split for some distance beyond a defect, without actual loss of substance.

These splits needed only cleansing and direct suture.

After debridement, it was infrequent to have a dural defect larger than

4 to 5 em. in diameter which required grafting. The reason was that the

greater the loss of dura, the larger, as a rule, was the loss of the underlying

cortical tissue. Consequently, by the time debridement of the brain wound

had been completed, there was likely to be enough relaxation of the dura to

bridge the defect, at least partially. This was especially true in long, ragged

dural lacerations associzite(l with gutter or tangential wounds. On the other

hand, when a missile had penetrated the brain more nearly at right angles to

the surface, there was apt to be a punched-out defect of the dura, with a deep

and narrow wound of the brain. There was no relaxation of dura in this type

of wound after (lebridement, and a graft was therefore necessary.

The dura was repaired with free grafts of temporal or occipital fascia,

with fascia lata taken from the lateral aspect of the thigh, with free. grafts of

pericranium, or with a pedicle flap of pericranium rotated from adjacent bone

(fig. 12). In general, pericranium used in the form of a free graft was found to

be the most satisfactory material available. By undermining and elevating

the galea from the pericranium, a large patch could almost always be obtained,

without further enlargenment of the scalp wound, from bone adjacent to the

defect. Measurable contraction was usually found to have occurred after

separation of the pericranial patch from the bone. A generous patch of

pericranium was therefore excised, usually one-third to one-half as large again

as the dural defect to be repaired. The pericranial graft was held in place

with multiple fine silk sutures or, occasionally, with silver clips.

In some instances, it was possible to use a pedicled pericranial graft, as

recommended by Ecker. 2 The advantage of this method presumably was in

the maintenance of a more adequate blood supply to the graft. By this method

(fig. 12 A and B), a pedicle of pericraniinn was outlined, so that a wide base

was left attached to bone and the graft could be rotated and sutured to the

margins of the dural defect.

Pericranium was usually more readily available than fascia and also was

nearer the thickness of dura. Fascia lata was used by some surgeons only in

large dural defects on the undersurface of the frontal lobes, in which communication into the nose and tihe paranasal sinuses was present. Here it was

22 Ecker, A. D.: Tight Dural Closure With Pedicled Graft in Wounds of the Brain. I. Neurosurg. 2: 384-390, September 1945.
150 NEUROSURGERY

3 O,~'1)onor

'-. ,/" ... • 

FiGURE 12.-Techniques of repair of dural defect. A. The scalp on one side of the

debrided wound has been undermined by separating the galea from the pericranium, and

a pedicle flap of pericranium has been outlined. B. The flap has been rotated and sutured

tightly to the margins of the dural defect. C. A free graft of pericraniuni has been taken

from adjacent bone and sutured over the dural defect. Free grafts of temporal fascia

or fascia lata are used in the same manner.

considered desirable to achieve as watertight a closure of the dura as possible

and also to give some support to the brain in the absence of the underlying

bony structures. Shearburn and -Mudford 23 used preserved dural grafts in

56 cases butt subsequently abandoned this method.

Fibrin film was not available in the forward areas during the major campaigns, and its use in acute penetrating wounds due to missiles therefore (lid

not receive anl extensive trial. It should be valuable, however, as a dural

substitute in these injuries, especially underneath a pericranial or fascial

graft, for the prevention of adherent cicatrices. Ingraham, Bailey, and Cobb 24

recommended its use in uninfected wounds when the duia could not be closed

completely.

REPAIR OF THE SCALP

Scalp wounds were extended, relaxing incisions made, and skin flaps

rotated or advance(d in such a manner as to effect tight closure of wounds

without tension. The most universally applicable and satisfactory type of

incision was a generous S-shaped one (fig. 13). A curvilinear incision was

made in one direction from one end of the long axis of the wound, and a similar

curvilinear incision was made in the opposite direction from the other end.

Underminitig of the scalp was always carried out in the areolar layer since

the galea, with skin firmly attached, is freely movable over the pericranium

in this layer. Extensive mobilization of the scalp for two-layer closure in a

23 Shearburn, E. W., and Mulford. E. H.: Penetrating Wounds of the Brain. Management in Evacuation Hospital.

Am. J. Surg. 72: 441-447, September 1946.

24 Ingraham, F. D., Bailey, 0. T., anti Cobb, C. A., Jr.: The Use of Fibrin Film as a Dural Substitute and in Prevention of Meningocerebral Adhesions; Further Studies and Clinical Results. J. A. M. A. 128: 10,S-1091, 11 Aug. 1945.
ACUTE CRANIOCEREBRAL INJURIES 151

FIGURE 13.-Techniques of repair of scalp. Al. Tripod incision

outlined around triangular-shaped wound; all arms of the incision are

curved in the same direction. A2. S-shaped incision outlined around

transverse wound in temporal area. BI. Closure of tripod incision

leaves weak point at junction of the three arms directly over the bony

defect. B2. After closure, the S-shaped incision assumes a gentle

curve without tension.

gently curved line then became possible under minimum tension and with

minimum distortion of the blood supply. Often a simple, elliptical incision

with linear extensions was sufficient.

Surgeons in World War II generally agreed that the tripod and "Isle of

Man" incisions recommended after World War I 25 should be avoided whenever

possible. If they were used, the arms of the incision were always curved

rather than straight and were all curved in the same direction (fig. 13). If it

was necessary to make an extension away from the long axis of a wound, it

was found wise to make it as nearly as possible at a right angle to the line of

closure of the wound (fig. 14). Sharp points of skin were avoided, especially

when the base of these points was away from the source of blood supply.

Relaxing incisions (fig. 15) were seldom necessary for closure of scalp

wounds and were avoided whenever possible. It waz almost always preferable

to elevate a flap of scalp and slide or rotate it across a defect rather than to

attempt to relax one or both mtargins of the defect and approximate them

directly over the underlying wound. When relaxing incisions were used, it

was important that they should not be placed across the normal blood supply,

since almost certain ischemia of the strip between the wound margin and the

relaxing incision would follow. A relaxing incision was never sutured; it

ceased to be a relaxing incision if it was closed.

The method of choice for closure of large scalp defects proved to be the

use of the sliding or rotation flap (figs. 16, 17, 18, 19, and 20). It was important that the base of the flap always be directed toward the blood supply

and that it be curved gently to avoid leaving sharp points at the angles. The

2• See footnote 1 (1) and (3), p. 123.
152 NEUROSURGERY

A 8

FG1GRE 14.-Techniques of repair of scalp. A. Through-andthrough wound with entrance in left orbital rim and exit at vertex.

Coronal incision is outlined with posterior extension around exit

wound. B. The entrance wound is closed separately and the coronal

flap reapproximated. Note that the posterior extension is closed at

right angles to the coronal incision.

PERICRANIUM

A B

FIGURE 15.-Techniques of repair of scalp. A. Large frontal wound

at hairline outlined by coronal incision. A relaxing incision is outlined

parallel to the line of closure. B. The scalp is advanced to effect

closure of the wound defect. Note that the relaxing incision is considerably longer than the scalp wound itself and is not resutured.
ACUTE CRANIOCEREBRAL INJURIES 153

A I

FIGURE 16.-Technique of repair of scalp. A. Large transverse

wound in parietal region outlined by sliding flap with its base toward

blood supply. B. Smooth curved wound closure without tension after

advancement of scalp flap.

flap was made large enough to swing across the defect and permit a two-layer

closure without tension; it was usually about three times the size of the defect

to be covered When it was necessary to swing a flap the base of which was

at an angle to the blood supply, as in transverse wounds with large loss of

tissue just above the ear, the base was made particularly wide (fig. 19).

Occasionally, sufficient mobilization of scalp was possible to permit

primary closure of the donor site of a flap. If not, a split-thickness graft was

laid directly on the exposed pericranium or fascia (fig. 19). It was useful to

.. ~~~i".- ........ 1.1. ..

t___ 

A

FIGURE 17.-Technique of repair of scalp. A. Wounds of entrance

and exit in perforat'ig wound connected and extended to outline large

frontoparietal-temporal scalp flap. B. Flap advanced upward and

forward to cover huge bony defect. Wide undermining of the scalp

has thus been made possible. and primary closure is possible without

tension.
154 NEUROSURGERY

(44.

FIGURE 18.-Technique of repair of scalp. A. Generous temporoparietal scalp flap outlined for closure of frontal defect. B. Flap

rotated forward, leaving scalp defect to be grafted well posterior to

underlying craniocerebral wound.

have another surgeon cut the graft from an accessible donor site, such as the

thigh, while the debridement was in progress. The graft could then be sutured

into position while the repair was being completed without unduly prolonging

the operative procedure. If immediate grafting was impossible or if it was

undesirable because of the patient's general condition, it could be done at a

later date. Grafts were never placed directly over debrided wounds at the time

of primary operation if it was possible to swing full-thickness grafts of uninjured scalp over the defect and then graft the donor site. In very extensive

I),

A

FIGURE 19.-Technique of repair of scalp. A. Low transverse

wound in mastoid area with avulsion of upper part of ear. A pedicle

flap with a wide occipital base is outlined. B. Flap rotated and

sutured to margins of scalp defect including posterior surface of external ear. The donor site has been covered with a primary splitthickness graft.
ACUTE CRANIOCEREBRAL INJURIES 155

A B C

FIGURE 20.-Technique of repair of scalp. A. Through-and-through frontal wound

with extensive comminution of bone. A coronal incision is outlined to include the exit

wound. The entrance would is debrided separately. B. Wide exposure of entire craniocerebral wound obtained after reflection of coronal flap. C. Closure of entrance wound and

reapproximation of coronal flap behind hairline.

avulsed wounds of the scalp, there was sometimes insufficient skin available to

cover the defects; in such instances, split-thickness grafts could be laid directly

on the pericranium, the dura, or even the exposed cortex itself if necessary.

Probably the most important single measure in the prevention of cerebral

fungus formation with all its distressing sequelae was a tight two-layer closure

of the scalp without tension. A great deal of attention was therefore devoted

to this apparently simple procedure. A group of suitable incisions and the

resulting closures achieved, all based on actual cases, are illustrated in figures

13, 14, 15, 16, 17, 18, 19, and 20.

Interrupted sutures of fine silk were used throughout for separate closure

of the galea and skin (fig. 21). Continuous sutures were never to be used in

Gatea - - --

Fic.-RE 21.-Closure of scalp. The galea is closed with inverted, interrupted sutures of fine silk. The skin is always approximated in a separate layer, also with interrupted silk sutures.
156 NEUROSURGERY

these contaminated wounds. Black silk, No. 00 or 000, was used routinely by

most surgeons. If the galea and skin could not be brought together without

tension by using silk of this size, tile (losure was regarded as too tight and a

plastic procedure of some kind was indicated. Pulling superficial layers of the

scalp together with mattress sutures of heavy silk or catgut sinply to get a

defect covered almost invariably resulted in necrosis of skin margins and failure

of primary healing.

DRESSINGS

Dressing of craniocerebral injuries in the acute stages was often a major

problem. Many types of dressings were used, depending on the circumstances.

If careful hemostasis was carried out during the debridement, postoperative

extradural or subgaleal hematomas were not frequent, and drains were seldom

necessary. In the majority of instances, there was therefore no need to disturb

the dressing for 3 or 4 (lays.

For the average patient, who was not to be transported early, a simple

pressure dressing of gauze was held in place by a melon-type dressing over the

entire head made of ordinary rolled gauze bandage 2 to 4 inches in width. This

was anchored by several long strips of adhesive tape, placed in crisscross fashion

over the vertex and held by circular strips.

When elastic bandages of 3- and 4-inch widths were available, they were

admirably suited for the melon-type dressing of the entire head to hold in place

either a scanty or a voluminous dressing. Additional security could be gained

by a chin strap of gauze or soft felt attached at both temporal regions.

Light plaster-of-paris headcaps were used frequently in the forward areas.

Some surgeons used them routinely. Others thought them neither necessary

nor desirable except for the following three categories of patients: (1) Those

with extensive skull defects, especially when there were associated radiating

fractures and marked comminution (the so-called eggshell or bursting type of

fracture); (2) those who were extremely restless, uncooperative, and belligerent

and who repeatedly pulled loose other types of dressings; for example, patients

with injuries of the frontal or temporal lobe, who, particularly in the first few

postoperative (lays, often would leave no other kind of dressing in place unless

they were kept under the heaviest sedation; and (3) those who could have only

limited observation and nursing care because tactical circumstances necessitated early evacuation after operation.

Plaster caps were never applied when drains were used or when it was

thought that early inspection of the wound for the detection of a hematoma or

other complication might be desirable. When used, they were well padded to

insure protection of the scalp from pressure necrosis if there should be increased

edema postoperatively. An outline of the underlying wound and bony defect

was drawn on the outside of the cap and the date of application was added to

guide other surgeons in subsequent removal of the cap.
ACUTE ClRANIOCEREBRAL INJURIEIS 157

SPECIAL TYPES OF PENETRATING CRANIOCEREBRAL

WOUNDS

The operative treatnent of a variety of specialized types of craniocerebral

injury due to highi-explosive missiles will be considered in the sections to follow.

Tile general principles of wound managenient which have been outlined applied

in every case, in addition to the particular features which will be mentioned.

Compound Linear and Depressed Fractures of the Skull

Compound linear and depressed fractures of the skull without dural penetration were seen frequently, though they were only about. one-third as frequent

as penetrating wounds of the brain. During periods of great activity, patients

with these simpler lesions were usually not operated on in forward areas but

were evacuated to hospitals farther from the frontlines. When time permitted,

they were operated on as soon after injury as possible.

No attempt was made to excise fissured fractures without depression or

comminution. They were treated surgically in the same manner as simple

laterations of the scalp, anld systemic chemotherapy was used. A burrhole

was made, however, and the dura was opened in all linear fractures, and even

in scalp wounds without fracture, if there were localizing neurologic signs.

When depressed fractures of the skull were associated with contaminated

wounds, no effort was made to elevate fragments and leave them in position,

as was frequently (lone in closed injuries of the head. After debridement of

the scalp and excision of contaminated pericranium, a burrhole was drilled in

normal bone at one side of the depressed area. The hole was always made

with caution because depression of the inner table usually extended well beyond

that of the outer. Starting at the burrhole, bone was rongeured toward the

depressed area and around it until all interlocked and contaminated fragments

had been removed.

Ascroft stated that fracture of the outer table never occurred alone and

that the inner table was always more extensively involved than the outer.

The inner table, in fact, was occasionally found depressed, with underlying

dural contusion and subdural hematoma. without any visible fracture in the

outer table (fig. 22A). There was also sometimes only slight depression of the

outer table, with actual comminution of the inner table and dural penetration

(fig. 22B). In every case. bone was removed from both tables until a smoothedged defect was achieved all the way round.

The dura underlying depressed fractures was frequently torn without

penetration of the brain. Simple dural suture was carried out in such cases.

If the dura was intact but appeared markedly contused or discolored, it was

opened; this procedure would often release a small local subdural hematoma

and sometimes macerated cerebral tissue as well. After removal of all clots

and devitalized brain tissue by gentle irrigation and suction, the dura was

sutured tightly. When depressed fractures were accompanied by neurologic

455735-58-11
A Subdural hematoma

Fiq;liiE 22.- -( (ill1)ild (liJt-'sse( fractulres dmli to) a i~ mllpie issile wouiids.

A. Out~ter tahiv oif skull int act while inner1 :lIble is fracetulredl mid( dlepressedl. 11w lulIderl 'vig

dimtra iv . he intact hil also dlepressedl. Bleneath t his area, localhized stil)dlr:1l ('lots arv

commloni, and( thle braini Ina *v be ((lit usedI or even mavuerated. It. Linear crack withi slight.

depression ini 1)111r t ahie, while inner t able is cominiilted andl~ a loose fragmient 1nu, pelietrate(I the dura' and1( evri lral 51l)tZibstan.

Signs refe'ratble to 0 1v lietidet] yil coirtex. suchlits aphasial i'iI rests, 11(1d

hcniiauiopsia , thle dii1-1 i'awas allway s opened. t o he cert aml tha litll s111ditral21 (lots

anid dev italiiize( I I a in t issue hadnI been remtovedI. If th~e neuorologic exainai ~ltionl %-its negatt i e anid tihe (In11-1 was trot dIiscolIored , it was niot ofpeile(I.
ACUTE CRANIOCEREBRAL INJURIES 159

Some of the most satisfactory immediate results of head surgery were seen

in the prompt disappearance of neurologic deficits following early operation

on depressed fractures without dural penetration. Striking improvement of

aphasia within 24 hours was often noted in fractures of the left frontotemporal

area. Similar rapid improvement in homonymous visual field defects was

observed after operation on depressed fractures over the occipital cortex, as in

the following case:

A staff sergeant was admitted to an evacuation hospital in Belgium on 4 October 1944

with a lacerated wound, 2 cm. in length, of the right occipital region, which he had sustained

2 (lays before. He was in excellent general condition, and neurologic examination was

negative except for a left homonymous hemianopsia. Roentgenograms revealed an occipital depressed fracture on the right side.

After excision of the scalp wound and removal of all depressed bone fragments, the dura

was found intact but depressed and contused. The dura was opened because of the

hemianopsia. There was a small amount of dark liquid subdural blood; the cortex was

contused but not macerated. The dura and scalp were closed tightly.

There was marked improvement of vision within 24 hours, and by the fourth postoperative day, when the patient was evacuated, the visual fields were almost normal. The

wound healed primarily.

Wounds Involving the Dural Sinuses

Craniocerebral wounds which involved laceration of the dural venous

sinuses constituted one of the more difficult technical problems for the surgeon

responsible for the treatment of patients with acute injuries. Operative

treatment of patients with these wounds should have been undertaken only

when special neurosurgical equipment was available and when whole blood for

transfusion was already in the operating room or nearby.

In *Matson's experience, the longitudinal sinus was most frequently involved (16 times) and the transverse and sigmoid sinus next (11 times). Tile

straight sinus was involved in only one instance. The problems in management of these lesions were essentially the same, no matter which sinus was

involved.

Sinus injuries could be predicted before operation from the location of the

visible wound and examination of the roentgenograms (fig. 23). In such cases,

preparations were made to cope with possible vigorous hemorrhage. The

head was elevated during debridement to reduce the pressure in the large venous

channels unless a falling blood pressure contraindicated this position. It was

extremely important that these patients should remain quiet during operation

and should not strain or groan. It was even more important that a good airway

be maintained at all times. Therefore, if the patients were at all restless or

uncooperative, general anesthesia, with intravenous thiopental sodium, or

intratracheal ether was always used.

The scalp wound was debrided in the usual fashion. Exposure usually

revealed depressed fragments of bone turned on edge and driven through the

dura in the region of the venous sinus, or a mass of clotted blood, macerated

brain, and comminuted bone fragments overlying the sinus (fig. 24). Since
I oil) N VI-V I!t OSV It It l ! N , 

•AA

Fii i: 2:1. Inj1ry*v of longitildinil sinrirs. A\. Positionj ofii Nof nd lwivhie.i si•htid alert.

.illr-gl()ll to iII\'4'tigale' I ble~ilh' invoIven' ient of lonigittl(inI simius. B. 1l,:tral riiinit iniograin •hiowviing mnrked(I (hdepreissin of n•oth tabdle of knili throtigh ar.a nif loingitnilii:iI Airnms.

F'iln firt henr w larns', .stlrgeonn I hat. m•jn. is almost certainlY inivolved.

Impacted

bone fragments

I"I(miiiR 21. I•,bridemrnennt of voinilpj) id vinriniiilitelid deprresse•' fra'ttire

wilh iiilpaiction of honl fragnilils. .A. Thle .•.e:lp anid perio.•ltenili have hbeeni

d(IllrideId. .I biin'rhole is drilled i hiroilh norinal lhonie aldjacent to ti•e depressed

airv. IIB. Satg aiti i l thi.• irrhol,. and keepinig ailway over norinal duira,

borne is ronig.erid • nt iil all coimiiiiilllted anii depl)ressed fragnmenits of both ounter

arid inner t~lhle. have beeni remioved.
ACt'TE "HANIOCEREBI{AL INJURIES 161

the cardinal principle in the management of sinus Injuries is not to dlisturb the

point of laceration of the (lural sinus until the area is well exposedl, the removal

of a generous amiount of bone from the surroun(ling area was usually require(l.

Figure 25 illustrates the steps In the managemenit of a typical fpeletratilig

woundI with dlepresse(l fracture through the longitudinial sinus. One or more

burrholes were mnade in normal bone adijacent to the lesion but well away from

thle sinus (fig. 25A). Starting at these holes, Ibone was Ivfloved with a rongeur,

PericraniMuscl Cotnplde

FX~u RE 25. -Managemnent, of penetrating craniocerebral injuries involving longitudinal in~Ius

Insert ,hows position of entrance wound.
162 NEUROSURGERY

working toward the point of depresidon into the sinus but not disturbing it if it

could be avoided. If bleeding from thie sinus started, it was controlled with

pressure on cotton pledgets and suction until exposure of the surrounding bone

had been comphlt,d (fig. 25B). Before removal of bone fragments or foreign

bodies in the sinus itself was attemptedl, it. was often found useful to place one

or more stav sutures through the dura oil each side of the sinus (fig. 25C).

Depressed bone fragments in the sinus were finally gently teased free and

removed. It was necessary tiat, strong suction be available at this time.

'When this method of approach was used, it was often possible to visualize

the actual tear in the sinus and close it with silk sutures or with silver clips

(fig. 25D). If the bleeding was too profuse or the margins of the lacerated

sinus couhl not be brought together, bleeding was best controlled by the application of a muscle stamp -or' fibrin-foam pledgets soaked in thrombin. To

prevent rapid loss of large amounts of blood, the fibrin foam or muscle was

prepared alhead of time, not after the bleeding from the sinus had begun. If

the laceration in the sinus was large, sutures previously placed were tied over

the muscle stamp to hold it snugly in position. Once bleeding had been controlled by fibrin foam or muscle, care was taken not to disturb these substances.

Bone fragments depressed into the sinus underneath an intact bony

margin were not removed, since bleeding, which could be exceedingly difficult

to control, was almost certain to result. When small tears in the dural sinuses

were .overed by clotted blood which wvas not contaminated and which did not

contain comminuted bone fragments, the clots were usually left alone.

If a dural sinus had been completely divided, there was usually clot

formation in the severed ends. Such a wound couhl sometimes be debrided

without, dislodging the clots. Usually, however, it was necessary to use some

method of occluding the sinus. When there was active bleeding from a completely divided sinus, it usually seemed wiser to close the sinus with a silk

ligature, or with silver clips if possible, than to use fibrin foam. In one case

in which bleeding from a completely severed longitudinal sinus was controlh- d

readily witb fibrin foam soaked in thrombin, the patient did well for 2 days,

then suddenly lapsed into profound coma and died within a few hours. At

post mortem examination, although no local hemorrhage was evident, the

longitudinal sinus was found completely filled with a thrombus from the point

of application of the fibrin foam in the frental region back to the torcular

Herophili. When simple tears in the (lural sinuses were present, therefore,

even though they were large, the use of fibrin foam was recommended. Whien

the flow of blood had been interr'upted by complete division of the sinus,

bleeding was better controlled by ligation.

When bleeding from a sinus occurred underneath an intact bony margin and

further debridement was unnecessary. hemorrhage was best controlled by fibrin

foam or muscle tucked between the dura and the overlying bone. The dura

was then held up snugly against the bone by silk sutures, placed as close as

possible to the bony margin, from the dura to the galea.
ACUTE CRANIOCEI'EBI1AL INJURIES 163

An example of a dural sinus injury follows:

A soldier was admitted to an evacuation hospital in Belgium on :31 January 1945. lie

was semiconscious and in mil(d shock: the neurologic examination was negative excep)t for an

homonymous hemianopsia on the, right.. A jagged wound of the scalp in the left occipital

region was filled with blood ('lot. Roentgenograms revealed a comminuted fracture of both

the occipital bone and the left parietal bones, with bone fragments driven 5 or 6 cmr. into the

left occipital lobe.

After treatment of shock, with good results, debridement was carried out under I

percent )rocaine hydrochloride field block anesthesia. As comminuted, depressed bone

fragments were removed to expose the dural defect, furious bleeding was encountered from

a tear 1.5 cm. long in the longitudinal sinus about 2 cm. proximal to the torcular Herophili.

It was controlled with fibrin foam and three figure-of-eight silk sutures. One and one-half

to two ounces of pulped brain tissue were then aspirated from the wound track, which

crossed the occipital horn of the lateral ventricle. Bone fragments were removed from the

lateral ventricular lumen and from beneath the falx. The straight sinus, which was also

lacerated, was closed with two silver clips. Ten thousand units of liquid penicillin were

instilled in the ventricle, and the dura and scalp were closed tightly. One thousand cubic

centimeters of whole blood were given during and immediately after operation.

The postoperative course was uneventful and the wound healed primarily. At the

time of evacuation, the patient was ambulatory and afebrile, but there was no improvement

in the hemianopsia.

Intracranial Hematomas

Hematomas of varying size were usually found with penetrating wounds

of the brain. As a rule, they were small and of no significance as far as the

patient's general condition was concerned. Often, large hematomas formed

in the superficial layers of a wound underneath the first aid dressing. In

fact, what appeared to be huge cerebral herniations frequently turned out to

be chiefly hematomas (fig. 26).

Of great importance were the sizable intracortical hematomas .ound at

points along the tracks made by small missiles or by indriven bone fragments.

Hematomas of this kind were often found at the deepest point of the wound

track, where an explosive type of lesion frequently occurred. In cases of this

sort, treatment was usually very satisfactory, since there was likely to be

rapid improvement in both the neurologic deficit and the patient's general

condition after evacuation of the clot.

An illustrative case is cited:

A private was admitted to an evacuation hospital in Belgium on 15 January 1945,

semistuporous and aphasic but not in shock. There was a wound of entrance, I cm. in

diameter, in the left eyebrow, without herniation of brain tissue. Roentgenogramns showed

a depressed fracture of both plates of the left frontal sinus and a metallic foreign body, I cm.

in diameter, deep in the left parietal area.

Through an eyebrow incision, all depressed fragments of bone and the entire mucosa

of the left frontal sinus were removed, revealing a hole, 1 cmi. in diameter, in the dura. As

the entrance of the brain track was exposed, 40 to 50 cc. of dark clotted blood were extruded

under pressure, leaving at large cavity within the frontal lobe. Debridement of the track

was completed to a depth of 8 cm., and 10,060 units of liquid penicillin were instilled into

the bottom of the wound. The foreign body was not removed. The dura and skin were

closed tightly.
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ACUTE CRANIOCEREBRAL INJURIES 165

bone f ragment

fragment

Subdural

hemnatoma

FIGURE 27.-Coronal section illustrating penetrating wound in

which high-explosive shell fragment is seen close to surface at point

distant from wound of entry.

tion of the foreign body. It was sometimes possible to retrieve the foreign

body itself; the attempt was made if it was of any size or was readily located.

More important, however, was evacuation of any hematoma and macerated

brain tissue in its neighborhood or in its path through the brain. If the

clinical picture was that of cerebral compression out of proportion to the

extent of the visible wound, preliminary exploration over a distant foreign

body proved advantageous before attacking the wound of entrance.

An example of this type of injury follows:

A corporal was admitted to an evacuation hospital in Belgium on 3 January 1945.

He was stuporous, with a blood pressure of 180 systolic and 50 diastolic, and a pulse of 48.

A wound 10.0 by 2.0 cmr. in size in the left frontotemporal region was associated with herniation of brain tissue. Right hemiparesis was present. Roentgenograms showed numerous

intracerebral bone fragments in the left temporal area and 2 pea-sized metallic foreign

bodies close to the midline of the left occipital region about 2 cm. beneath the bone.

Under local anesthesia, a burrhole was first made over the expected site of the metallic

fragments, after which the dura was quickly opened. A minimal amount of subdural blood

was present, but the brain was bulging. When a ventricular needle was inserted, about

60 cc. of dark subcortical clot was evacuated and the foreign bodies were removed. The

patient's general condition improved considerably, and routine debridement, with temporal

fascia repair of the dural defect at the entrance wound, could be accomplished.

The patient was evacuated on the eighth postoperative day with a right hemiparesis

and right visual field defect. He was fully conscious and eating well, and his wounds were

well healed.

Transventricular Wounds

In World War I, Cushing 27 reported from a forward aid station that when

missiles crossed the ventricular system, the wounds were 100 percent fatal;

27 See footnote 1 (2), p. 123.
wheni bone fragments alone enitered at ventricle, tile case fatalit 'v rate was almost 50 percent. lit the samne warl, IlorraX 21 reported froin a base hospital it

case fiitilit ,v ratte Hi t ransveiitrictilar wounids of 557.1 percent. lin World War

II, vent ricuilar woundIs again were amiong the most ser'iouis, but ill rep~orts lw,

laVnjeS 29an other~l S~tu(lieS, tilte fatalit.N. rate ill surgical cases was; reduced to

about :30 to 40 p~ercent. Wi~th strongr suctijon and1( facilities for- electrostirger 'v

available, its well ats bloo0d for rep~laIcemient therap , , ea r)l,, thloroughi (ebride.

lilent of ill traveti t ricular wvounds becamlie much mlorle feasible. This p~rocedlure

not onlyV reduiced thne (Iflamagilig central effects of 01(1 1)100( (fig. 28), maceratedl

b)railn tissule, andi( Other dlebris ill tilie Vent ricles buit also redluced tile liablilityv of

subsequent iinfect ion because of early removal of the sources of contamlinlatfion.

Thie inciden~ece of veintricuilitis and meningitis, the chief causes of (deathi ill

Patijents winth venltrictular wouinds xvluo surviv-ed the Imnmedliate inijury, wvas also

great ly red uced b~y tile uise of local Ititi Systemic chemlotherapy .

Examninat ion of thle roenitgenogramns and of tile posit ion of tile wound of

entrance almost always ind~icated whe(t her it mmlssii., 0on bone fragments had

entered1 t he vet~itrides. If spinal fluid wats seen to leak fromn tihe wound of

Fz~i *o., 28. - oronal seto ~lIhrough t braiin in fata d Iransven trividiar 11 m11(1. Note complete

cast of clotlIed blood( thlrotighotit vet'itriculhar systemui.

See Im ol 13(10 I'). P. 123.

1~Svp footnotes 7,1. 135: amt 15, v. 147
ACUTE CRANIOCEREBRAL INJURIES 167

entrance when the patient strained, no further evidence was necessary. When

it had been established that a transventricular wound was present, or when

such a wound was suspected, the highest priority for operation was given unless

the patient was moribund.

In the operative management of ventricular wounds, adequtte exposure

and light were especially important (fig. 29). The preliminary debridement of

Malleable - light - Suction

Penicillin in

10 cc. syringe

A/U

FIGURE 29.-Debridemeint of intraventricular wound. A. Gentle suction of macerated cerebral tissue, bone chips, and old blood within the ventricular lumen is carried out

under direct vision with the aid of a small, malleable light. B. From 10,000 to 20,000 units

of diluted liquid penicillin are instilled directly into the ventricle and the depths of the

wound before closure of the dural defect.
168 NEUROSURGERY

tile scalp, cranium, dura, and cerebral wounds was carried out as already outlined. Whenever possible, tie wound in the brain was debrided all the way

(town to the ventricle ulnd(er direct vision. With the aid of a lighted retractor

or a small, malleable light (fig. 29A), it was often possible to visualize the ventricular wound itself and to remove bone fragments and blood clots from the

lunen (fig. 29 B). Gentle irrigation with warm physiologic salt solution facilitated removal of macerated cerebral tissue andt debris. When the walls of the

wound track collapsed or the track was not wide enough for the operator to

see d(irectlv into th" ventricular lumen, gentle irrigation and suction of old

blood and debris were carried out through a ventricular cannula introduced

blindly into the ventricle. As much of the debridement as possible down to,

and inside of, the ventricle was always performed, however, under direct

vision. In wounds which crossed thite midline, (lebridemenlt of the opposite

lateral ventricle could occasionally be carried out through the foramen of

Monro and tile third ventricle. When this was not possible, a burrhole was

placed on the opposite side, and the lateral ventricle on this side was irrigated

through a ventrieular cannula.

When debridement had been completed, from 10,000 to 20,000 units of

liquid penicillin were instilled into the ventricular system. The penicillin was

well diluted with physiologic salt solution, to insure good circulation throughout the ventricles and to lessen the likelihood of local irritation. Studies by

Walker and his coworkers 3) showed that not more than 20,000 units should be

introduced directly into the ventricles at ariv one tim(e. In all transventricular

wounds, it was Matson's policy to give 10,000 units of penicillin intrathecally

by the lumbar route daily for at least 5 (lays after operation; penicillin was

given systemically in full dosage for at least another 10 dlays.

Tile dural repair in transventricular wounds received particular attention,

for in them a watertight closure was especially desirable to lessen the possibility

of formation of a cerebrospinal fluid fistula or tile development of ventriculitis

from outside contamination. If dural grafts were used, they were made large

enough to allow suture without tension. Catheters or drains were never left

beneath the dura.

Foreign bodies loose in the lateral ventricle were removed successfully on

several occasions. It was thought that the attempt should be made if the

foreign body was of any size. A very small metallic foreign body in the third

or the lateral ventricle, not easily visualized at the time of (tebri(lenient, was

left alone. Attempts to remove small intraventricular foreign bodies through

new transcortical exposures were not warranted at primary operation.

When a missile crossed one of the lateral ventricles or the third ventricle

or drive bone fragments into the ventricular lumen, the possibility of intraventricular hemorrhage was always present. If hemorrhage was massive, filling

the entire ventricular system, the patient usually did not survive long enough

to reach a hospital in which definitive surgery could be carried out'. When

patients with such conditions did reach the hospital, they were usually mort30 See footnote 17, p. 148.
ACUTE CRANIOCE'REBRAL I NJURIIES16

build, with dilated, fixed I)ul-is, irregulahr, moist resp~iratit ons, andI generalized

rigidity. When this clinival picture was present, sturg'ical initervenition was

linvariablyl of no avail.

The following procedure was- at templlted on 3 or' 4 such pati enats withI smiall

wounds of entr %: Delbridenient of tile wound downa to the lateral Vent ricle, with

removal of as mutch clotted blood as possible from the lumnen, followed 1) , thle

placement of a burrhole oii tile opposite sidle, tile insertion of at ventricular

canmiula into this lateral venitricle, and~ the irrigation of clotted blood from the

lumien of the ventricle onl this side. There was no clinical implrovemenit in any

case, however, and at post. morten examination it was seen that ver-y little of

the total amiount of clottedl blood in thle ventricuilar system had act uallY beenl

removedl (fig. 30).

Fi-:-RE' 30.-Coronal section through brain in fatal through-and-through w~ounid showing

cast of blIood clot filling entire ventricular system.

One of these cases is described:

Ani officer admitted to an evacuation hospital in G'ermany on 10 March 1945 was comnatose b)ut not in shock. Respirations, which were 20 per minute, were quiet and regular. The

pulse was 76 and the blood( pressure 120 systolic and 70 diastolic. Both pupils were dilated
170 NEUROSURGERY

and fixed to light. The patient did not respond to painful stimuli. There was a wound of

entrance, 1.5 cm. in diameter, in the left frontotemporal region. Roentgenograms revealed

a metallic fragment, 1.0 cm. in diameter, deep in the right cerebral hemisphere.

At operation, the wound of entrance was excised, and 1 to 2 oz. of pulped brain tissue

and blood clot under pressure were removed from a narrow wound track which entered the

left lateral ventricle. Dark liquid blood, as well as clotted blood, was removed from the

ventricle by irrigation. A burrhole was then made on the opposite side, and a ventricular

needle was introduced into the right lateral ventricle. Again dark blood, both liquid and

clotted, was removed in small amounts by irrigation. Tight closure of both wounds was

carried out.

The patient went progressively downhill and died about 18 hours after operation. Post

mortem examination revealed a solid cast of blood clot throughout the ventricular system,

including the aqueduct and fourth ventricle. The operative efforts had not significantly

altered the total amount of intraventricular blood clot present.

If hemorrhage into the ventricular system was extensive but solid clotting

throughout the ventricles had not taken place, it was occasionally possible to

evacuate large amounts successfully and for the patient to recover. Such a

case is cited:

A sergeant was admitted to an evacuation hospital in Germany on 1 March 1945, in

very poor condition. He was in moderate shock and in deep coma, with slow respirations.

Reflexes were all markedly depressed and the extremities flaccid. The right pupil was dilated

and fixed; the left was dilated but reacted to light. There was a wound, 2.0 by 3.0 cm., in

the right frontal region with herniation of brain tissue. Roentgenograms revealed a fracture

in the right frontal region with indriven fragments of bone, a small metallic foreign body in

the midline, and a larger foreign body about 1 cm. from the surface low in the left postparietal

region.

Under local anesthesia, the right frontal wound was debrided. About 50 cc. of macerated

brain tissue and numerous indriven bone fragments were removed from a track which entered

the frontal horn of the lateral ventricle. It was possible to lift considerable clot from the

lateral ventricle and also from the third ventricle through the foramen of Monro. The dural

defect was repaired with a pericranial graft, and the scalp was closed. A burrhole was then

placed over the site of the foreign body on the left side. No subdural hematoma was present.

The cortex was contused, and a ventricular needle dropped easily into a track from which

an estimated 15 to 20 cc. of dark fluid and clotted blood were evacuated. The track was

debrided down to the ventricle on this side, which was irrigated gently, in order to remove

the old blood.

After operation, the patient's condition was immediately improved, and it continued to

improve slowly until he was evacuated on the tenth postoperative day. He was still semistuporous, but he was taking fluids by mouth.

When the lateral ventricles were involved by small missiles without hemorrhage, there was often very little reaction. There seemed no reason why recovery should not follow adequate debridement and repair of such injuries.

When there was gross damage to the ventricular wall, even without massive

bleeding, the prognosis was poor. Haynes,3

" in reporting 100 transventricular

wounds, thought that maceration of more than one-third of the wall of a lateral

ventricle was incompatible with life.

31 See footnote 7, p. 135.
ACUTE CRANIOCEREBRAL INJURIES 171

Through-and-Through Wounds of the Brain

It has long been appreciated by neurosurgeons that, when a missile passes

completely through a portion of the intracranial cihanll)er, there is more destruction of soft tissues and more extensive comminution of the skall at the

wound of exit thani at the wound of entrance (fig. 31). Because a large number

rM C 4ja1 -

F1I;HRE 31. -- Coronal section illustrating perforatiag wound d(Ie to highexplosive shell fraggments. Small indriv',n bone fragments are characteristically found at the wound of entrance. At the point of exit, a larger,explosive type of lesion, with a bursting fracture, hematoma formation,..nd

cerebral herniation, is commonly seen.

of cortical vessels are apt to be lacerated at the site of exit, hematomas which

may be extradural. subdural, or intracortical are often associated with the exit

wound. This statement does not refer to the ordinary maceration of brain

with small hemorrhages which occur all along the course of every brain wound,

but rather to the large hematomas usually located at or near the exit of the

wound track from the brain.

These findings led to the suggestion that in through-and-through brain

lesions, if the two wounds were to be approached separately, the wound of exit

should always be explored first. 32 Rapid evacuation of a hematoma, in a situation otherwise too precarious to permit much surgical intervention, sometimes

resulted in sufficient improvement in the patient's general condition to permit

thorough debridement and primary repair of both exit and entrance wounds.

If necessary, attention to the wound of entry could be delayed for 24 hours or

more after preliminary debridement of the exit wound, and supportive treatment

3 See footnote 26, p. 164.
172 NEUROSURGE(RY

couhl be given until the pat i&1i's general condition warranted definitive repair.

Chemotherapy and antibiotic therapy made such delay possible without significant added d(anger of infection. Wiether or not a hiematoma was found,

debridemet'A of the more extensive exit wound first was thought to be thie procedure of choice.

When roentgenograms revealed comminution of the bone between the

points of entrance and exit in through-and-through wounds near the surface

limited to one side of the head or across the frontal or occipital areas, exposure

was best achieved by connecting the two wounds with a linear incision or by

raising a scalp flap so as to include both wounds (fig. 17).

A case illustrative of improvement following preliminary debridement of

the exit wound in a through-and-through injury is cited:

A Germnan prisoner of war was admitted to an evacuation hospital in Gernmay on 28

March 1945, in very poor condition. He was in moderate shock and profound coma and gave

no response to painful stimuli. Left facial paralysis and left heiniplegia were present. The

respirations were Cheyne-Stokes in type, and oral secretions drained from the mouth. The

right pupil was larger than the left. There was a wound of entrance, 1.0 cmt. in diameter,

low in the right occipital region with herniation of brain tissue, and a wound of exit, 2 cm. by

2 cmr. in size, in the right frontal region at the hairline, also with herniation of brain tissue.

Roentgenograms revealed defects in the skull corresponding to these scalp wounds. No

metallic foreign body was evident.

Under local anesthesia, the wound of exit was first excised. After removal of comminuted

fragments of the frontal bone, 15 to 20 cc. of extradural clot was found. When the brain

wound was uncovered, at least 50 cc. of clotted dark blood emerged under pressure from the

brain track. After debridement of the track, the dural defect was repaired with a pericranial

graft. It was noted that the patient's breathing at once became more regular and his pulse

of better quality. The wound of entrance in the occipital region was then debrided and

repaired in the routine manner.

Postoperatively, there was steady improvement. The patient was afebrile after the

third day. He began to move his right side and respond to pain on the first postoperative

day, and by the fourth day he took fluids by mouth and responded accurately to questions.

The left hemiplegia remained complete. The wounds healed primarily.

Craniofacial Wounds

Penetrating wounds of the craniocerebral tissues which also injured

adjacent structures of the fece deserve particular attention. In this category

are included wounds involving the paranasal air sinuses, orbit, middle ear,

and mastoid. From the technical standpoint, they probably constituted the

most difficult injuries handled by the neurosurgeon in forward areas. They

were less serious injuries in one respect, however, in that usually only silent

areas of the brain were involved.

In World War I, craniofacial wounds were considered among the most

serious, and the case fatality rate from infection was extremely high. At that

time, most of these wounds were left open; cerebral herniation and fungus

formation resulted, and meningitis almost invariably followed. With chemiotherapy, however, and the availability of blood for replacement therapy at
ACUTE CRANIOCI:ItI'•BIRAL INJURIES 173

the time of primary debridenent, a much more extensive and definitive primary

operation became possible in \Word War 11.

Debridement.--The objective of treatment of this type of injury was the

complete removal of all contaminated, necrotic, and macerated tissue, followed

by primary repair, which would isolate the brain and subarachnoid spaces

from contaminated areas as completely as possible. In addition, the surgeon

had to preserve structures needed for plastic reconstruction of the face, so that

the best possible cosmetic result would be obtained.

Complete debridement of an extensive compound wound involving one

or both orbits, the frontal and ethmoid sinuses, and the nasal and facial bones

in addition to the frontal lobes of tile brain, the floor of the frontal and middle

fossac, and perhaps the calvarium, was a time-consuming and! formidable

procedure. It was Matson's firm belief that such wounds should not be operated

on in stages or be left open. Instead, inunediate, complete debridement and

repair should be carried out by the neurosurgeon with the assistance or advice

of the otolaryngologist and ophthalmologist. If the surgeon was not prepared

to (10 this, or if circumstances were such that sufficient time could not be

devoted to tile case, then it was better to evacuate the patient farther to the

rear, to a center where complete primary treatment could be undertaken.

The disadvantages of an additional delay of even 48 hours or more did not

outweigh the advantages of proper primary management of these wounds.

Webster, Schneider, and Lofstrom 33 expressed the same opinion in reporting 40

cases of orbitocranial wounds seen in a general hospital, in 5 of which redebridement was necessary.

The debridement and repair of the average craniocerebral wound took

between 1 and 2 hours. A craniofacial wound, on the other hand, often required

as long as 3 to 4 hours. The surgeon had to be prepared to spend this amount

of time, if necessary, and proper supportive measures had to be available.

Inhalation anesthesia through an intratracheal tube was essential. Local

anesthesia and intravenous Pentothal Sodium anesthesia were contraindicated

because blood and mucus in the pharynx or running down into the respiratory

tract might encroach upon the airway during operation and precipitate

laryngospasm or complete respiratory obstruction. Only after induction of

inhalation anesthesia, insertion of an intratracheal tube, aspiration of all blood

and mucus from the nasopharynx and trachea, and packing off of the pharynx

had been completed was debridement of a craniofacial wound started.

These injuries were usually handled through the wound of entrance. To

obtain the best exposure, it was found that debridement of the intracranial

and facial components of the wound should be carried out simultaneously.

There wvas usually marked comminution of the orbital, nasal, zygomatic,

sphenoid, and frontal bones. The contents of the orbit were frequently completely macerated, and the globe was often collapsed or even unrecognizable.

When the paranasal air sinuses were involved, the mucosa was usually lacerated

33 Webster, J. E., Schneider, R. C., and l(ofstrorn, J. E.: Observations Upon the Management of Orbito-Cranial

Wounds. J. Neurosurg. 3: 329-3.36, July 1946.

45573;51-58----12
174 NEUROSURGERY

and at least partially separated from the bone, and the lumen was filled with

maceratedl cerebral tissue, blood clot, and comminuted bone fragments. In

Matson's series, the frontal sinuses were most commonly involved (26 times),

tie ethnmoids next (17 times), and then the maxillary antrums (12 times).

Whenever there was a communication between the intracranial chamber and

a paranasal sinus, the entire mucosal lining of the sinus was removed, in addition

to the debris found within the luImen.

Removal of comminuted fragments of the supraorbital plate and greater

wing of the sphenoid was particularly helpful in making it possible to visualize

dural lacerations on the undersurface of the frontal lobe. The dura ,,is

frequently torn loose from the floor of the frontal fossa except for its attachments at the sphenoid wing and the crista galli. Freeing these dural attachIments often resulted in sufficient mobilization of the dura for closure of defects

without grafting.

Closure of dura.-In craniofacial wounds, watertight repair of dural

defects was particularly important. Since these wounds communicated directly

with tile nasal sinuses or the nose itself, continuity with a contaminated area

continued, in spite of complete debridement of the sinuses and removal of the

mucosa. At least partial closure of the dural defect was almost always feasible,

and a graft could then be used to complete the closure. A free graft of temporal

fascia or pericranium was most commonly used. Particular care was taken

to suture the graft in position as tightly as possible, by means of silk sutures

placed close together.

If the dural defect extended posteriorly on the undersurface of the frontal

lobe toward the optic chiasm and cavernous sinus, it was not always possible

to reach the margins of the dural defect. In these instances, care was taken

to remove any bone fragments protruding through the dura. A generous graft

of temporal fascia, fascia lata, or pericranium was then prepared and sutured

in place as far posteriorly as possible, after which the free graft was pushed

backward to lie over the margins of the dural defect. A piece of temporal

muscle could sometimes be wedged beneath the graft, to hold it up in position.

Fibrin foam was used for the same purpose.

Plastic surgery.-In debridement of wounds of the face, orbital region,

and about the ear, all the skin possible was preserved f( r subsequent plastic

procedures. Plastic operations were carried out at the time of debridement

and repair of the brain wound if they were necessary to accomplish primary

skin closure. Simple undermining of the scalp and skin of the face often

permitted sufficient mobilization for closure. If not, the wound was extented,

or scalp flaps were swung to effect primary closure. When the skin could not

be closed primarily, Webster, Schneider, and Lofstrom recommended the use

of a temporary fascial graft to the dural defect and a petrolatiim-impregnated

gauze pack, followed by a split-thickness skin graft in about i0 days. This

should seldom be necessary if debridement of skin and the primary plastic

closure has been carried out wisely.
ACUTE CRANIOCEREBRIAI, INJURIES 175

Drainage.---In many of these wounds, a large (lead space remained when

debridement had been completed, particularly when the conte`nts of the orlbit

and paranasal air sinuses had been removed. If this cavity was not too

large, it was simply drained by a rubber-tissue d(rain through the lateral aspect

of the wound closure. If the cavity was extensive arid involved the maxillary

antrum and nose, a petrolatum-impregnate(d gauze pack was placed loosely iII

the cavity and brought out through the nose. It was gradually removed

during the first 4 to 5 dlays after operation.

Antimicrobial therapy.---In all wounds involving the paranasal sinuses,

sulfanilamide and penicillin powder, or penicillin solution, was left in all parts

of the wound as closure was carried out. In addition, 10,000 to 20,000 units

of penicillin were usually injected into the wound every day for tile first 4 or 5

postoperative days. The patients were also given both sulfadiazine and penicillin systemically for at least 10 days after operation. When a cerebrospinal

fluid fistula was present, chemotherapy was continued until tine leakage of

fluid stopped.

An example of primary treatment of a severe craniofacial wound is

presented:

A soldier was admitted to an evacuation hospital in Gerinany on 23 'March 1945. He

was conscious but in mild shock and was confused and disoriented. There was a huge

lacer 'ted wound of the right frontotemporal-orbital region with herniation of brain tissue

and maceration of the orbital contents (fig. 32A).

After the patient had been treated for shock and roentgenograms had been taken,

nitrous oxide-oxygen-ether anesthesia was induced and maintained through an intratracheal

tube.

The skin edges were debrided, herniated cerebral tissue and blood clot were aspirated,

and multiple comminuted fragments of the frontal, temporal, zygomatic, orbital, ethtnoid,

nasal, and maxillary bones were removed. Both frontal and both ethmoid sinuses were

completely exenterated. The entire right bony orbit and its devitalized contents were

removed. The superior plate of the antrum was fractured but was left in place. One and

one-half ounces of pulped brain tissue were then removed from the right frontal lobe and

about one-half ounce from the left frontal pole. The dura was mobilized from the floor of

the frontal fossa and sutured across the midline, and a residual dural defect underneath the

right frontal pole, 2.5 by 5.0 cm., was closed tightly with a free graft of pericranium. Penicillin and sulfanilamide powder were frosted throughout the wound, and a rubber-tissue

drain was brought out the lateral angle. It was possible to mobilize the skin of the cheek

and the forehead sufficiently to carry out a two-layer closure without tension. Five hundred

cubic centimeters of whole blood and 500 cc. of Alsever's solution were given during the

3:,,-hour operative procedure.

Convalescence was remarkably smooth, with no leakage of spinal fluid. The drain was

removed in 24 hours. Sutures were removed on the fourth postoperative day, at which time

the photograph shown in figure 32B was taken. When the patient was evacuated on the

seventh postoperative day, he was afebrile, and the neurologic examination was negative.

POSTOPERATIVE MANAGEMENT

The general principles of good postoperative care for all major surgical

problems were applicable to penetrating injuries of the brain, with additional

attention to certain special requirements. It was desirable to assign attendants
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ACUtE,, (hA N IOCEIIEIIIAL I N.J URIES 177

of thle bed wats railseti to promiot e drainage of excessive lbroiicliial secretions,

hil t tilet daniger of inicrteased venlous congest joll ill ihe cerebral circiulatioln had

to be consideretd carefulliY before t his was done. A much more satisfactorv

p)1*11 was to leavte O let p~at itent flat anid a-iiraiite( tilie JplarYlix lid111( iothI 1 

fre'quent ly with Ii iechaitical or electric suet ion.

Sedation. No stat~ed formula for tile use of ainalgesic-s aiitl( setlatives was

unlivt'rsally satisfactory, and thle suirgeonl oft en hadi to uise aill his owl) j udgnIt'nt 111di~lingenut.lik:x Iit"r g'iieral. patients wit 11 simple uncomplicated W otl lilds

of thle vaulit had lit tle paiii. ( rainiofacial wounds. however, were oftetn very

paiiful.l 11ntd patients, withI injuries tof tit' head oftt'n hatd severt' painiful Woillmiis

t'lst'wliere ill thle body.

Acet'tlsalit'*vxlic acid, abut'e tlr inl combiniat ion withl smlall tioses of codel('iit

or with phenacetinl anti caffeine' sodium benzoate. was- given freely antd was

uisually suifficient to control tilie ortlnarY heatdachie and postoperative dliscomufor't. Morphine sulfate ili (loses of 0.008 giin., 0.01 gmn., or oeeasionallv

of 0.()161 gill, wats givenl to pat ients with Ii 1('ntrat lug wvounds of tilit head foil

relief of pain provitded that they were iunder good supervision antd that there

wvas lit) pretexist ing rt'spiratory de tprtessiton tor irrt'gulari ty. Barhittiara tes given

iln small tltoses 2 or 3 timt'is tduring, thle day, and inl dosses tip to 0.2 gmn. ati

bedtimet, providetdt sufficitent rtelaxation for sltel).

For the control of thle restless, tieliriolus, uncooperative patient (ats so)

mlauiy, with frontal anid temp~oral lbie iijtiurits proveti to be), paraldlehytde was

lite most useful anti elfective du. It wats often conltinuedI regularly for a

number of daYs withouit harm. It was atdminiisteredl ly rectum, p~referab~ly

ill (lost's of 15 to 25) tt'. antd coulti be( repteatedI every 3 to 4 hours. It was

also t)(casiollally* givenl by inlouti ill (lt oses of 10 to 15 cc., though it was less

well tolerated by t his routt'. Intramuscular injection was used for quicker

act ion, andt( whent tilit oral andt rectal routes wtere imp~ract ical ; 4 to 7 cc. were

lislitilly giv'li tdeep ill thle gutit'al muscles. Wh'len immtediate' action was nie--

('ssary ill 11iaataaagt'abltt, tieliriotis p~atienits, I to :3 Cc. might lbe givt'li

intravenouisly. C1 hloral hydralt' also proved a useful sedative.

Fluid intake.-()rtiliarily. thtere was no0 particuilar problem ili the postopterathive adminiist rat ion of fluaits to patients with penetrating craniocerebral

injuries. Fluids, were niot, restricted. As inl other surgical situations, the enit erionl wats ma in tenanice of adequate hydration as tdeterminetd by thle volume

of tilet urinary out put and tilet moisture of thet skin anid flhlucouis surfaces.

Inl coaiscaiolas patienits, fltlds Wtere giveut free'ly by mouth0 un1les's vomiiting

wits frequtent. Then fluids given orailly inl smnall amnotnts ait frequent initervals

were supplemen'ft'i edi ly l)arentIeral fltii ids. Sinct' all these patients were recteiving sialfolamitlle as we'll as, penicillini therapy, anl at ttempt was matde to maiintaiui a 24-hour fluid intake of 2,50) It) :3,000 cet. Whit'n fluitd was giv('uu by the

parentt'ral roulte, aoto more t han 1,000 t't. of tilet total was givt'a as phlysiologic'

stilt soliation. Blootd plasmia and whole blood( were counted as saline solution.

Tralisfiusionls of whiolt' blood were giveni (luring t(lit' postopterativt' petriodl

for replacemenit o~f rt't cells as net''detd. ]ii thle forward areas, if tile patient's
I T" NEURI()SURGERY

general condition was good, blood was not usually given unless the red cell

count was less than :3,000,000 per cubic millimeter. Plasma transfusions were

used frequently to sustain falling serum protein levels.

If, at the end of 48 to 72 hours after operation, the patient was still

unable to take any fluids by mouth, a Levin tube was passed for administration of nourishing fluids. Though this was not always feasible in forward

areas, it was carried out whenever possible.

Chemotherapy and antibiotic therapy.-The principles of chemotherapy

and antibiotic therapy, once debridement had been completed, were in general the same as for contaminated wounds elsewhere in the body. Chemotherapy was usually well under way by the time operation had been completed,

because, as a rule, preoperative treatment with sulfonamide, with or without

penicillin, had been started at the first station at which the casualty had been

seen and had been continued during the preoperative and operative periods.

All patients with penetrating craniocerebral injuries continued to receive

sulfadiazine and penicillin after operation. In general, a daily dosage of 6 to 8

gm. of sulfadiazine, given in divided doses at 4-hour intervals by mouth, or

2 or 3 times daily intravenously, provided an adequate blood level for prophylaxis, that is, 8 to 15 mg. per 100 cubic centimeters. In the presence of

actual infection, the dosage was increased to raise the blood level to 15 to 20

mg. per 100 cc. A fluid intake of 3,000 cc. per 24 hours was maintained after

the desired blood level was obtained, and the urine was checked frequently

for sulfadiazine crystals.

Penicillin was usually administered intramuscularly every 3 hours in doses

of 20,000 to 30,000 units. When wound debridement had been delayed beyond

48 to 72 hours in the presence of actual infection, as well as in transventricular

wounds and in injuries involving the paranasal air sinuses, this dose was

increased to 40,000 units. The administration of penicillin intramuscularly

was continued for 3 to 5 days postoperatively in simple compound depressed

fractures without dural penetration, for 5 to 7 days in simple penetrating

wounds of the brain; and for at least 10 days in wounds treated after delay,

transventricular wounds, and -craniofacial injuries. Penicillin was given for an

even longer time in the presence of any inflammatory reaction about the wound

or of persistent rhinorrhea or otorrhea.

Because of the failure of penicillin to penetrate the subarachnoid space in

significant amounts, efforts were made to treat the subarachnoid space directly

when it had been contaminated grossly. Therefore, in addition to introducing

10,000 to 20,000 units of penicillin directly into the lateral ventricles at operation in transventricular injuries, it became Matson's practice to instill 10,000

units by the lumbar subarachnoid route daily for 4 to 5 days after operation.

This prophylactic intrathecal penicillin was also given occasionally to patients

with craniofacial injuries when dural defects had been difficult to close.

When the cell count in the spinal fluid was increased or clinical meningeal

signs were present, the intrathecal dose of penicillin was increased to 10,000

units, 2 or even 3 times daily. If there was actual gross infection, as much as
ACUTE CRANIOCEREBRAL INJURIES 179

30,000 to 40,000 units of penicillin were given intrathecally. Ordinarily,

however, doses of over 10,000 units at one ti ',re not used. It was necessary

that penicillin used in this fashion be fresh], d, clear light yellow, and well

diluted with spinal fluid or physiologic s. oiation (1,000 units per cubic

centimeter) and that it be introduced slowly. Repeatedly, spinal fluid with

counts of 500 to 5,000 white blood cells per cubic millimeter, associated with

clinical meningeal signs, was observed to clear dramatically after 1 or 2 doses of

penicillin introduced intrathecally by lumbar puncture.

Lumbar puncture.-Postoperative lumbar punctures were not done

routinely in patients with penetrating craniocerebral injuries but were performed

only for the following reasons: (1) Diagnosis and treatment of associated

massive subarachnoid hemorrhage; (2) prophylaxis and treatment of meningeal

infection, as just described; (3) drainage of sufficient fluid to reduce an elevated

pressure to approximately half its initial value, a procedure very useful occasionally for persistent, severe headache unrelieved by ordinary medication

or when there were signs of increasing intracranial hypertension; and (4)

diagnosis of persistent fever, coma, or unexplained complications of recovery.

Dressings.-There was usually no need to change the dressing or examine

the wound before the third or fourth postoperative day if the patient was doing

well. At this time, skin sutures were removed if a tight galeal closure had L

accomplished. The wound was carefully palpated to detect any

subgaleal collection of fluid; if fluid was present, it was aspirated.

If drainage had been instituted, the dressing was changed earlier _an

usual (in 24 to 36 hours), and the drain was removed. Drainage was almost

never necessary if all precautions were taken to achieve complete hemostasis

as repair was carried out.

Bladder drainage.-In unconscious patients, bladder drainage was usually

instituted immediately after operation. This prevented distention, made it

possible to measure the urinary output, and also aided materially in the care

of the skin and in general management by keeping the bed dry. Chemotherapy

was continued as long as constant urinary drainage was continued.

Irrational, uncooperative patients, who were often difficult problems

because of incontinence, frequently refused to leave an inlying urethral catheter

in place unless their hands were restrained. Frequent changes of linen and

blankets were necessary in these cases to prevent the skin from breaking down.

Management of convulsions.-Convulsions were not common during the

acute phase of penetrating cerebral injuries but were occasionally seen. The

occurrence of repeated convulsions of the Jacksonian variety during the first

few days after operation suggested that debridement had been incomplete or

that a postoperative hematoma was present in the track of the brain wound

or in the subdural or epidural space.

Generalized convulsions also occurred occasionally during the postoperative as well as the preoperative period. During such generalized seizures, care

had to be taken to keep the patient's airway clear and to prevent further

injury from violent involuntary movements.
I SO NEtUROURtGERIY

Seizures were usually well controlledl by the use of barbiturates or paraldehyd~e. Slow administration of a 2.5-percenit solution of thiopental sodiumil

intravenously until relaxation occurired was founid to be the most slitisfactory

method of stopping severe convulsions. A regular p~rophiylact ic regimien of

stedaition~ wits iniit iatedl iii every' pat ient who had aniy postoperative seizures.

EVACUATION

A standard schledulle for evacua tion of patimen ts withI craniocerelbral injurines,

from forward hospitals was frequently imipossible because of the( rapidly moving

line' of battle and the lack of transp~ortation facilities because of weather. InI

general, patients withI penet ratinug wounds of the brain t raveledl better before

Opernationl than they dido III the first :1 to .5 postoperative (lays. An at tempt

was made, thmerefore, to maove themi to relatively fixed installations before

operation and then keep thein there during the early postoperative periodI.

Patients with comp~oundl dlepressed fractures without dural p~enetrationl and

those with simlller Penetrating cerebral Wounds.1 We're usually evacuatedi within

2 to .5 (lays; those with more extensive injuries were kept in forward hospitals

for 7 to 10 (lays if possible.

Unless, it wats ab~solutely necessary, p~atienlts were not evacuated until they

wvere taking fluids by mouth iii adlequate quantity. Comatose, highly. febrile,

or failing patients were not evacuiated unless the tactical situation diemandled

it. All patients with transventricular wvounds, cerebrospinal fluid leaks, and

usually contaminated wounds were not evacuated for at least 7 days, to ins-ure

unint errupt ed chemotherapy throughout this period. Wh~enever circumstances,

madle early post operative evacuatIion necessary%, eve ry effort was mnade to ap~ply

anl especially secure headdrestsing anti to arrange for administration of fillids,

and chemiot h(rapy (luring t ransp~ort at ion.

P~atien ts wvit h craniocerelbral injuiiries t olera ted air evacuation very wveil ati

the altitudes ordinarily traveled from the forward areas to hospitals in the

communications 7one. No hesitation wvas felt ill evacuating thein byv this

means if they were ait aill readyv for transportation.

CASE FATALITY RATES

The case fatality rate of acute wvounuds of the brain is (difficult to determine with any accuracy in military' surgery because of the varying o'ircunistances unduter which these wounds were t reatedl. The rate varied accordling

to the echtelon in which surgical intervention was carriedl out, the type of warfare, the terrain, the spe'ed of evacuation, the availability of trained medical

personnel, and the length of lines of communications. W~hen neulrosurgical

teams functioned close to the scene of combat and received casualties very

early (2 to 6 hours after injury), they often operated onl patients with woundis

of the head who wouldl not have survived to reach a hospital farther to the

rear (6 to 24 hours after injury). The s-urgical fatality rate in tile group oiler-
ACUTE CRANIOCEREBRAL INJURIES 181

ated on early was naturally higher than in those who survived to reach a

hospital farther to the rear.

When there was a rush of casualties into one hospital during heavy fighting, patients often succumbed without surgery who might otherwise have been

operated on. Also, in spite of the fact that the surgeon's aim should always

be the reduction of the overall fatality rate, individual surgeons differed over

what constituted operable injuries and in their enthusiasm for tackling extensive

lesions.

By far the greatest number of patients with wounds of the head were

operated on in evacuation hospitals in all theaters, and it is surprising how

uniform the operative fatality rate was in the statistics available.

During a 5-month period in 1944, 12 hospitals in the First U. S. Army

admitted 1,236 patients with penetrating wounds of the brain who were operateed on; the postoperative fatality rate was 14.1 percent. 34 In a 5-month

period, 14 hospitals in the Seventh U. S. Army admitted 949 patients with

penetrating wounds of the brain who were operated on, with a postoperative

fatality rate of 14.4 percent.35 In unpublished observations and in reports of

individual surgeons (Haynes,5 6 Gaynor and Gurwitz, 37 Munslow,35 Weaver and

Frishman,39 Shearburn and Mulford,40 TinsleyY Ascroft, 42 and Slemon 43) from

evacuation hospitals, the postoperative case fatality rate ranged from 10.8 to

14.7 percent. These figures are not based on similar periods of followup observation, but, in general, they include all deaths up to the time of evacuation

from the hospitals in which the operations were done, which is an average

period of observation of 5 to 10 days.

The majority of postoperative deaths occurred within the first 24 to 48

hours. Most of the patients who (lied within these periods exhibited the

syndrome of progressive respiratory depression and irregularity, hyperthermia,

deepening coma, and terminal pulmonary edema. At post mortem examination, they were found to have either massive intraventricular hemorrhage (figs.

28 and 30), injury of the brain stem or basal ganglia, or multiple small hemorrhages and areas of contusion throughout the brain. The clinical course was

almost certainly very little influenced by the operative procedures carried out.

Death from meningitis in the early postoperative period was almost unheard of in patients whose wounds were properly debrided before clinical

evidence of infection. Some of the postoperative deaths occurred in patients

who might have recovered from their craniocerebral injuries but for the added

3

4

Annual Report, Surgeon, First U. S. Army, 1944.

3 See footnote 2, p. 123.

30 See footnote 15, p. 147.

" Gaynor, W. C., and Ourwitz, I.- Experiences With 156 Penetrating Wounds of the Head. Ann. Surg. 122:12-22,

July 1945.

A See footnote 19, p. 148.

" Weaver, T. A., Jr., and Frishman, A. J.: A Report on the Treatment of Cranlocerebral Wounds in an Evacuation

Hospital. J. Neurosurg. 3:148-156, March 1946. 4 See footnote 23, p. 150.

it Tinsley, M.: Penetrating Wounds of the Head. Surgery 19: 535-542, April 1946.

42 See footnote 9, p. 145.

43 See footnote 16, p. 147.

455735T-58-----13
182 NEUROSURGERY

insult of severe wounds elsewhere in the body, particularly penetrating wounds

of the chest and abdomen.

The overall case fatality rate in wounds of the head deserves just as strict

an analysis as the postoperative case fatality rate. Martin and Campbell reported that a survey of 14,000 battle casualties treated in the Fifth U. S.

Army in Italy in 1944 disclosed that 6.17 percent of the wounds involved the

head and that one-third of these were intracranial; 24.4 percent of all deaths

in field and evacuation hospitals were attributed to head injuries. These observers also reported 1,000 autopsy examinations made on soldiers who succumbed before reaching aid stations (studied by Tribby 44); 133 had head

wounds only, antd 401 had head wounds of sufficient severity to have caused

death in association with other wounds.

The overall case fatality rate in patients with penetrating injuries of the

brain who reached eracuation hospitals alive averaged about 25 percent. The

Seventh U. S. Army (14 hospitals) during an al)proximately 5-nmonth period

in 1944 had 1,176 patients with penetrating injuries of the brain; the overall

case fatality rate was 27.8 percent.45 Surgeons in three evacuation hospitals

reported overall case fatality rates of 26.3, 20.7, and 29.0 (Gaynor and Gurwitz, Weaver and Frishman, and Shearburn and Mulford).

"44 Tribby. William W.: Examination of One Thousand American Casualties Killed in Action in Italy. 1945. 6 vols.

IOfmicial record.1

'3 See footnote 2, p. 123.
CHAPTER IX

Penetrating Wounds of the Cerebral Ventricles

Henry G. Schwartz, M. D., and George E. Roulhac, M. D.

HISTORICAL NOTE

In 1918, in a report of 30 battle-incurred wounds of the ventricle confirmed by operation, autopsy, or both, Cushing I pointed out that one of the

most serious complications of penetrating wounds of the brain is the opening

or the traversing of the ventricle by a missile or by bone fragments. Operation

under these circumstances in World War I consisted of debridement with

blind irrigation of the track of the missile. The dura was not widely opened.

The average interval between injury and operation in this series was 25 hours,

the range being from 5 to 72 hours.

Eight of the 30 casualties recovered. Death was attributed to infection

in 12 cases, to trauma and hemorrhage in 9, and to intercurrent causes in 1.

Further analysis of the individual case reports, in which there is some overlapping of mortality factors, reveals that in 5 cases, the primary cause of death

was hemorrhage, which was variously subdural, intracortical, or intraventricular. When the 12 casus in which death was due to infection are excluded,

the remaining 5 fatalities could be more directly ascribed to the effects of

extensive damage or pneumonia.

Huynes,' in 1945, reported a series of 100 ventricular injuries sustained

in World War II in the Mediterranean and European Theaters of Operations,

United States Army. Operation was performed in 77 cases, with a case

fatality rate of 33.7 percent and a 10.3-percent incidence of infection. Penetrating wounds were classified on the basis of the size of the missile and the

damage incurred. Wounds with narrow tracks, produced by small missiles,

were treated by blind suction and irrigation through either the brain needle

or a long glass aspirator until the ventricle was reached.

CLINICAL MATERIAL

This chapter is based on an analysis of 50 consecutive battle-incurred

wounds of the head with ventricular penetration, a:l observed in the Mediterranean theater in World War II and all verified by inspection of the ventricular opening at either operation or autopsy. One patient died before operI Cushing, H.: A Study of a Series of Wounds Involving the Brain and Its Enveloping Structures. Brit. 1. Burg.

5: 558-684. April 1918.

2 Haynes, W. G.: Transventrlcular Wounds of the Brain. 1. Neur•surg. 2: 4ft468, November 1945.

183
184 NEUROSURGERtY

ation, 24 hours after he was wounded. All of the others were operated on.

There was no selection of cases, and 110 patient Was denied operation l)ecause

he was moribund or for a11y other reason.

In 36 of the 49 surgical cases, primnary surgery was perfornied in forward

hospitals. In 31 of the 36 cases, debrideluent was inadequate, and secondary

operation was necessary at the 21st G(eneral Hospital, because of infection )r

retained foreign bodies. There were 10 deaths in this group. The remaining

13 patients had their primary operations at this hospital. There were 4 deaths

in this group.

Primary Operation in a Base Hospital

The 13 patients who underwent primary debridement at the 21st General

Hospital were seen at intervals varying from 3 to 96 hours after injury. The

average interval was 39 hours, but more than half ý)f the patients were seen

within 24 hours. All four deaths in this group, as demonstrated by autopsy,

couhl be attributed to damage to vital centers.

Infection developed in only two cases. In one, the scalp was closedi under

too great tension, and an abscess developed in the wound track. In the other,

an ab)scess formed around a metallic foreign body and leaked into the ventricle.

Both patients recovered promlptly after adequate surgery. Details of these

cases follow:

Case I. -A 29-year-old soldier, struck in the right parietal region by a mortar-shell

fragment on 14 November 1944, was comatose when he was admitted to the 21st General

Hospital 17 hours later. The left side was spastic and pathologic toe signs were present

bilaterally. Brain and blood clot protruded through a wound in the right parietal region

3 em. in diameter. Roentgenograms showed a fracture in the right parietal bone, with

multiple indriven bone chips, and a large metallic foreign body in the midline at the level of

the lateral sinus (fig. 33).

Operation was performed 18 hours after injury. The right parietal wound was debrided.

A forked track filled with necrotic brain, blood clot, and bone fragments was followed under

direct vision through the posterior portion of the right lateral ventricle and the occipital

lobe to the tentorium. Necrotic cerebellar tissue extruded through a hole in the tentorium,

and there was considerable bleeding from the posterior fossa. Suboccipital craniotomy

was done, and the macerated anterior lobe of the right cerebellumn was sucked away.

A track led from the hole in the tentorium to the rostral part of the vermis. The

metallic foreign body seen in the roentgenogram was found directly in the midline, just

caudal to the aqueduct, and was removed.

Both wounds were closed tightly, though because of loss of skin in the parietal region,

it was necessary to fashion and rotate a skin flap to effect closure. By further undermining

anteriorly, it was possible to close the donor site as well. This proved an error, since it

resulted in too much tension on the suture line.

Chemotherapy was begun immediately after operation. The patient's condition

improved, and he began to respond. The cerebellar incision healed per primam. The

parietal wound, however, became macerated at the central portion several days after operation, because of too great tension at the suture line, and aspiration beneath the skin flap

showed slightly purulent fluid. Examination of this fluid revealed numerous pus cells and

SThe 21st General Hospital acted as a base hospital as well as a forward hospital at various stages of the eampeign in

the Mediterranean, particularly in Italy.
Fial~lrv4 33:. Pvliii rnililaL. wouiiiic tf righti lImiieal rv,'ionul. A\. \ii14rophslerihul I(4iigt ~iioUlr:klll of skull be4fore operail lull. ýhvlg4Wii hol~lm l:Igniiilt, 11(tld tiH:ll~ie foreigni hod lv ill pariet1:1

lobe). B4. Laiirt- ni wil4l iOll l-bf4?l4 opera':tionl. C. Towne's p~roject ion of skull :ifter

Op-rati oll, S1i'iwilii, (14:111nuwvai of boiie frng~lioeiits .111d1iti~li foreVizu I4o(I. I). LateralI

roctit -i-~nogua lln alft r openl'it lonl.

(~ixtt S diltvs (\4lo op ) Il(4ls. l144 Im -4eiiIondtio begin1 tol' deteriorw iu Hlfc is neck b11vvlw

(lifT zmd I-ielivre. wn a'Ifranklilli(:O1w jug cv1iten-brosillail4xlid lirlgi Il pariioited I'(iiulldi ll

julinli ~f1 \%vr xvoiiiiourl xxlo pen-4icilini wasoo :lirecfthed lilr1:1 ililt- fpel~ij xi l 14 *il iil

itof 10,000 lClil-1 evor , 41)tOlO( hours. Volio xv4)lt( hours I'(4111 whll-)i infeto hwas. afer tilly

5.('441441:lVg (l-col,1t1:. v cii lolo)14) vl~ \\.:I-; iixiiul 'I wa:1Clllof-O veli('r4ssic ui 'I.fr:C. Ihe lillgte

i Fr~lijli Imhor 1110. wns l tioo~piti. cie: The dlvo. rva I oltI4heftir :I~ IllIO finp was1no sivll~iil
186 NEUROSURGERY

Case 2.-A 21-year-old officer was struck by mine fragments on 15 May 1944. Evacuation was delayed, and he received no definitive treatment. When he was admitted to the

21st General Hospital on 19 May 1944, he was drowsy, and his neck was extremiely rigid.

There was marked papilledema oil the left side. The right eyelids were swollen and shat.

On the right frontotemporal region was an extensive area of contusion and laceration. The

left arm was weak. A wound of the left foot had not yet been debrided.

Roentgenograms (fig. 34) showed a fracture of the right orbital ridge and a defect at the

sphenosquamosal suture line. Several small metallic fragments were seen in the right

temporal region. A larger fragment lay just anterior to the right mastoid, and another

piece of metal was seen in the occipitoparietal region near the midline.

At operation, which was performed shortly after admission, a defect in the right orbit,

which did not extend intracranially, was debrided down through a tear in the orbital capsule.

After the temporal muscle had been retracted, a defect was visualized in the anterior part of

the squamous bone, just above the zygoma. It was enlarged, and retractors were inserted

FIGURE 34.-Penetrating wound of right frontotemporal region. A. Anteroposterior

roentgenogram of skull before operation, showing metallic fragments in situ, including one

large fragment just anterior to right mastoid area (a) and fragment in parieto-occipital region

near midline (b). B. Lateral roentgenogram before operation. C. Posteroanterior roentgenogram after operation, showing clean removal of metallic objects in right mastoid and parietooccipital regions. Metallic objects now present are silver clips used for hemostasis. D.

Lateral roentgenogram after operation.
WOUNDS OF CEREBRAL VENTRICLES 187

into the mouth of a track which extended posteriorly and medially and from which necrotic

brain and blood clot were sucked out. This track was followed into the temporal horn of

the ventricle. When the opposite ventricular wall was visualized, it was found to be bruised

by the course of one of the metallic fragments. No attempt was made to go beyond the far

wall of the vent-icle or to remove the fragment in the occipitoparietal region. The wound

was closed tightly after hemostasis had been secured. Sulfadiazine was begun at once.

The patient improved after operation, and the head wound healed well. A mild otitis

media which developed on the right cleared up after removal of the large metallic fragment

from the posterosuperior portion of the auditory canal. On the fifth postoperative day,

the patient began to complain of severe headache, and ex'mnination showed that the temporal

defect was tense.

On 24 May, the wound of entry was reopened. The track leading to the ventricle was

grossly clean, and smears and cultures were later reported negative. This wound was

therefore closed, and an opening was made with a perforator in the right parieto-occipital

region, at a point thought to be near the retained foreign body. Very foul pus was aspirated

from an abscess located at a depth of 3 cin. Gram-positive rods were seen on smear. Two

days later, following repetition of the roentgenograms to secure better localization, the

fragment was removed. It lay in a pocket containing a small amount of pus and was

surrounded by neciotic brain tissue. The perforator opening was closed.

After again doing well for 5 days, the patient became drowsy and again showed signs

of increased intracranial pressure. On 31 May, following ventriculography, the right

occipitoparietal burrhole wias reopened. A large quantity of pus at once gushed out.

Retractors were inserted through the previously created dural defect. The walls of the

track, which communicated with the lateral ventricle, were covered with thick exudate.

The track was sucked out, and 10,000 units of penicillin were instilled into it. The wound

was closed with silk sutures. A narrow corrugated rubber drain was placed in the wound

and left in situ for 48 hours. This was contrary to the usual practice in contaminated

head wounds, but at this stage of the war, some hesitancy was still felt about tight closure

if clostridial infection wias sumspected. Bacteriologic examination revealed Clostridium

sporogenes. The drain was removed in 48 hours, and healing was complete 10 days after

operation.

The patient's course following the third operation was entirely satisfactory, though

convalescence was delayed by a wound of the left foot, which was closed secondarily on 18

June. Ambulation was then permitted. Examination at this time showed a temporal

field defect in the left eye; the central field was intact. Vision in the right eye, because

of retinal detachment and vitreous hemorrhage, was limited to light perception. Hearing

on the right was 6/20 and on the left 20/20. There was slight weakness of the left arm, but

fine hand movements were present on this side.

The patient was evacuated on 14 July 1944. He was followed up by letter for 20 months.

During this time, there was no recurrence of infection, vision improved so greatly that he

could play as good a game of golf as before his injury, and, when last heard from, he was

leading an active life on his farm, just as he had before he entered service.

Two patients returned to combat duty, their reassignment being dictated

by the gravity of the tactical situation at the time. Their histories follow:

Case 3.--A 25-year-old French-Arabian soldier, wounded on 13 May 1944, was admitted

to the 21st General Hospital in a stupor 18 hours after injury. Examination disclosed

a penetrating wound of the right temporal region, and roentgenologic examination revealed

a bone defect 3 cm. in diameter; a shower of bone fragments; two small metallic fragments

deep in the right parietal lobe; and a metallic fragment in the left parietal lobe just beyond

the midline.

At operation, after retraction of the right temporal muscle, a dural defect 1.5 cm. in

length was seen, through which a mass of necrotic brain tissue and blood clot gushed.

Retractors were inserted into the missile track, which traversed the body of the right
188 NEUROSURGERY

ventricle, and bone chips and all daamaged brain tissue were removed. The group of bone fragments

was removed from the ventricle. The track was followed for a depth of 7 cm. The two

small metallic fragments in the right parietal lobe were removed. It was not thought

that any indication existed to go through to the opposite side of the brain, to remove the

metallic foreign body in the left parietal lobe. As debridement progressed, the previously

pulseless brain began to pulsate freely.

After op,,ration, there was temporary weakness of the left arm and the face, which

cleared completely within 2 weeks. The patient developed a low-grade pneumonia but

otherwise had a smooth convalescence. He was out of bed on the ninth day. Because

of the current tactical situation and his own great desire to return to his regiment, he was

permitted to return to combat duty w;ith his outfit on 1 June 1944, 18 days after wounding.

Case 4.-An Arab soldier was admitted to the 21st General Hospital on 30 January

1944, 48 hours after he had sustained a tangential wound in the left frontoparietal region.

He presented weakness of the right arm and face and was aphasie. Operation consisted

of debridement with removal of 15 indriven bone fragments (fig. 35). The missile track

extended into the anterior horn of the left ventricle. The falx was visualized at the end

of the track. Tight closure was effected, after mobilization of the scalp by means of a modified Isle of Man incision.

FIGURE 35.-Penetrating wound of left frontoparietal region. A. Posteroanterior

roentgenogram of skull before operation, showing numerous indriven bone fragments.

B. Lateral roentgenogram before operation. C. Anteroposterior roentgenogram of skull

after operation, showing clean removal of bone fragments. D. Lateral roentgenogram after

operation
WOUNDS OF CEREBRAL VENTRICLES 189

The wound healed per primam. Sensory aphasia disappeared within 48 hours and

weakness of the right arm after 2 weeks. Motor speech returned at the same time. The

patient rezurned to full duty on 25 February, 27 days after wounding.

Primary Operation in Forward Hospitals

Of 36 patients with ventricular injuries who reached the 21st General

Hospital after primary debridement in forward hospitals, 31, as already

mentioned, required secondary surgery. In this group were 12 patients with

abscess, 3 with meningitis, and 14 with meningitis and ventriculitis. Two

other patients had retained bone chips but presented no clinical evidence of

infection. The original operations had been performed from 3 to 29 hours

after injury, the average being 15 hours. Ten of the thirty-six patients died,

infection being responsible for nine deaths and brain damage for the tenth.

PATHOLOGIC PROCESS

The pathologic process in wounds involving the ventricles needs little

comment, since it is essentially the same as was seen in other wounds produced

in World War II by high-explosive shell fragments or bullets. The first effect

of the injury was a shattering of the skull, the extent depending upon the size

of the missile involved and the angle at which it struck. The extent of the

dural tear, which was always jagged, deperided upon the size and velocity of

the missile, the comminution of the skull, and the number of indriven bone

chips and foreign bodies. The missile track was usually filled with pulped

brain, blood clots, and bone and metallic fragments. The size of the opening

into the ventricle depended upon the size of the missile and the angle at which

it had traversed the ependyma. The ventricle might be filled with bright red

blood or blood clot and with bone chips, hair, and other material, or the opening might be only a tiny slit which had sealed off under pressure of surrounding

edematous brain.

If debridement was incomplete and an abscess developed in the missile

track, pus might leak into the ventricle to produce ventriculitis. If the

ventricle itself was not cleaned out, infection might develop primarily within

the ventricular systemn.

Failure to effect hemostasis in a bleeding choroid plexus might produce

clots in the entire system, or on a single side, with a block of the foramen of

Monro. Similarly, infection within the ventricles which produced a shaggy

exudate over the ependyma and choroid plexus might extend throughout the

system and might lead to foramina block.

DIAGNOSIS OF VENTRICULAR PENETRATION

It did not prove possible to diagnose ventricular penetration on the basis

of symptomatology. Signs present in any given case depended upon the area

455735--58--14
190 NEUROSURGERY

of cerebral involvement rather than on penetration of the ventricular wall.

The patients were usually seriously and acutely ill, as was to be expected from

the amount of cerebral tissue which must be damaged before a missile or bone

fragments could reach thie depthi at which the ventricles lie. On the other hand,

a few patients in whom the track of brain damage was narrow and hemorrhage

was slight might present a deceptively good general appearance.

Ventricular penetration was suspected whenever roentgenologic examination revealed a track outlined by bone chips leading toward the normal position

of the ventricle, though it was not always found to exist under these circumstances. The diagnosis could be made with reasonable certainty whenever

films showed, as they occasionally did, a radiopaque foreign body which

shifted with movements of the head.

Routine anteroposterior and lateral stereoscopic roentgenograms of the

skull were found to be of particular value when ventricular penetration was

suspected. Their diagnostic aid was twofold: (1) They gave a dimension of

depth to foreign bodies, and (2) they also assisted in the detection of shifts of

position. Furthermore, accurate visualization of the pattern of a group

of bone fragments often confirmed the suspicion of ventricular penetration.

MANAGEMENT

Treatment of ventricular wounds did not differ from the treatment of

other penetrating wounds of the brain, though the procedure was more serious

because of the depth at which the ventricles lie.4 As experience accumulated

during the war, radical surgery with closure became the routine practice in

almost all cases, even when gross evidence of infection existed.

Operation

Patients suspected of having ventricular injuries were given first priority

for surgery, because the longer the interval between wounding and operation,

the greater was the risk of infection or clots in the ventricles. Preliminary

treatment for shock or dehydration was begun promptly, and operation was

performed as soon thereafter as possible.

The crux of treatment of penetrating ventricular wounds was adequate,

thorough, aggressive debridement of the entire missile track, including the

ventricle, under direct vision. It was soon found unsafe to assume that

adequate removal of all pulped brain, clot, hair, bone, and metal could be done

without visualization of these foreign materials. Debridement was inadequate

without visualization, and there was always danger of producing extensive

damage outside of the missile track and of causing further hemorrhage. Following the track was seldom difficult. As narrow malleable retractors were

placed deeper and deeper and pulped brain and clot were removed, tension

4 Schwartz, H. G.. and Roulhac, 0. E.: Craniocerebral War Wounds, Observations on Delayed Treatment. Ann.

Surg. 121:129-151, February 1945.
WOUNDS OF CEREBRAL VENTRICLES 191

fell rapidly, and the track could readily be spread, without danger of additional

damage to the brain.

Radical, complete (lel)ridement with primary closure was equally essential

in late secondary cases with abscess and ventriculitis. Since the cure of ventriculitis could not be expected until the source of contamination was removed,

the abscess was evacuated under direct vision, and the shaggy exudate was

thoroughly sucked off the walls of the track. The ventricle was then inspected,

and blood clot and fragments of bone were removed, as were metallic foreign

bodies if they could be readily reached, without inflicting additional trauma.

Metallic foreign bodies usually proved iinocuous, but they occasionally required

removal by drastic means.

Closure of the dura was accomplished in most cases, whether operation was

primary or late secondary, by grafts of pericranium, temporal fascia, or fascia

lata. The danger of loss of a graft through infection was negligible in a thoroughly debrided ventricular wound, just as it was in uncomplicated penetrating

brain wounds. On the other hand, the presence of a watertight dural closure

minimized the danger of a ventricular fistula if a scalp wound which had been

closed under too much tension gave way. If the dura was not closed, there was a

tendency for ventricular fluid to collect under the widely mobilized scalp, thus

inhibiting galeal-pericranial apposition and keeping the suture line constantly

under tension. If great care was not taken, the wound was likely to spread

from tension, and a fistula might develop, with disastrous consequences from

infection.

Fresh pericranium or fascia proved the material of choice for watertight

closure. In two cases in this series in which the ventricles were widely opened,

fibrin film was used as a dural substitute. The technique was not satisfactory;

fluid continued to accumulate beneath the galea until the film was removed

and was replaced with fascia.

Chemotherapy and Antibiotic Therapy

There is no doubt that complete debridement was the factor in World

War II which chiefly decreased the moibidity and mortality of penetrating

wounds of the brain. The role played by chemotherapy and antibiotic therapy,

while it was undoubtedly extremely important, is difficult to evaluate precisely

because these agents were so often given indiscriminately.

Sulfadiazine and penicillin were used parenterally, alone or together in

various combinations, in wounds of the ventricles, and it is believed that they

were effective. In addition, in penetrating ventricular wounds, it was the usual

practice to instill 10,000 to 20,000 units of penicillin into the ventricle before

closure. This treatment proved adequate in cases in which signs of ventriculitis

were not present. If definite ventricular infection was found at operation,

penicillin, in amounts of 20,000 to 50,000 units was administered daily by the

intrathecal route until all signs of infection had disappeared. If there were

some contraindication to intrathecal administration, such as internal hydro-
192 N EUItROSURGERY

cephalus, tile penicillin wais illjeCted directly into ti'e ventricles through the

bone defect or through perforator openings ma(le especially for this purpose.

No deleterious consequences were observed to follow tile intraventrieular

inject ion of penicillin.

FACTORS OF MORTALITY

Analysis of the material in this series and of comparab)le material reported

by other neurosurgeons revealed three factors of paramount importance in

wounds of the ventricles: (1) the introduction of iinfection with resultant

ventriculitis; (2) henmorrlage into the ventricular system; and (3) a&sociated

damage to vital centers.

Infection With Resultant Ventriculitis

The introduction of infection has, properly, always been a greatly feared

complication of ventricular penetration, and its serious potentialities were evid(ent in these cases. Treatment was directe(d toward removal of potential

sources of infection, or toward the eradication of infection if it had already

occurred. The following case reports are illustrative:

Case 5. -A 26-year-old soldier, wounded in the left frontal region by a shell fragment on

5 March 1944, was submitted to craniotomy 24 hours later at an evacuation hospital. A

missile track 7 cm. long was cleaned out, sulfanilamide was introduced, and the wound was

closed with a drain. Chemotherapy was instituted immediately atter operation. When the

drain was removed on the following day, leakage of cerebrospinal fluid occurred.

When the patient was admitted to the 21st General Hospital on I I March 1944, he had

a defect in the lower part of the wound through which sanguinopurulent material was draining. Compression of thee upper port ion of the wound caused gas to escape through the defect.

Cultures of the pus were reported positive for staphylococci and streptococci. Roentgenologic examination (fig. 36A and B) revealed a large frontal dfect involving the supraorbital

ridge and the left frontal sinus, with extensive linear-fracture lines. In the left frontal region,

in a position corresponding to the anterior horn of the ventricle, was a large nest of retained

bone fragments. Lumbar puncture revealed the pressure elevated to 310 mm. 1120. The

fluid was cloudy and contained 250 cells per cubic millimeter.

At secondary craniotomy on 14 March 1944, a large amount of pus and necrotic brain

tissue was removed. Retractors were inserted through a track 8 cm. long and 1.5 cm. wide,

which led directly to the anterior portion of the lateral ventricle. Four bone chips were removed from the depth ot this track. The wound was closed without drainage.

The patient improved steadily for 5 days. Then, when the lower end of the wound

was spread, 10 cc. of pus escaped. Purulent drainage steadily increased, and the patient

became aphasic. Repeated smears and cultures showed grain-positive rods. Roentgenograms revealed that the nest of bone chips previously seen in the left frontal region had been

removed (fig. 36C and D). Another exploration revealed an abscess just beyond the limits

of the previous exploration.

Thereafter the patient's course was steadily downhill. Signs of meningitis progressed.

Bilateral postparietal burrholes were made on 4 April, and 10,000 units of penicillin were

injected daily into each ventricle, a total of 155,000 units being administered. Sulfadiazine

and penicillin were also given parenterally. Death occurred on 12 May 1944. Autopsy

revealed extensive encephalomalacia of the left hemisphere, basal ganglia, and thalamus;

marked left frontal cerebritis; and lateral ventriculitis.
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194N V VlROSV It(; F;ItY

Case 6. A 20- %car-uutt Vrtinel .oldicir ri-vvixteil k miuulirie Iieuieiilu wuii o:

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tiluuu th- 11:11ii "e as revvived iat thlt 21st ( u'uural Illuupitaul tiut 2.1 Notiuulutr. hi- nteck

as st i~t, he %%as disouieuitu'u. aun( lhe pri-sentteul etouiijt v atikattrosik. 'Ihei I rat Is\ erst % omit Iu

over the oceiptit %%,k hruukeuu u1(llt andI inifet-Ov. aunit thl, e naujui~m iueit-iuuu %%as a1m liu ufuehed.

There, %\ve bilateral huernias of tlt,~ occilpital hd)b.. ltutduuguuu- h. 317A aund III Ievuahle uuuuuuuniu iulntirevu louue fr2LguIoikus. Suulfadtia,.in ttivrapuv %%.is but.Luuut.

Fiu ut 37.-Peuiet rat jug wotund of jparictto-uuecijut z region ill muidl~init. A. Post ero'-

:unt erior roen t giuograin of skull after primary operatliou. Arrow indlicat es re-idlutal bone.

fragmniits. B1. L at eral roent genograun after p~rimiary operaticiou. C . 1'osteroantlerior velkt neuulogramu after dluijiitivie siirgery, showinug *eauim remtOValI of fraiginviut s. Note~ air iii ventricWuar syst em, restultinug fromt opeiiimg of occipital horn of left lateral ve-ntricle. I). L at eral

roetit getograni after detinuit ive operat ion.

A severe u'elluulit is of theli scalpi wats somuuewhat uimproved 1by thet utse of wet drvsýýiugs. ( 1111

2S Novembher, thet wotund edges were excisedu and sp~readl apart. The buone defect wa-Is en1-

larged, midt t he longit udinial siuits was expuosed: it hiadt been couuluet ely * lest royedl just alit erior

to the torcular 1 eropluili for a dtistanice of 2 emIl. Two large bone. fragmneuts were remonved

from the st uiip of thet sintas. and bleeuding wats olit rolled. Two tracks iii the left occipital

funguis were cleaned out to at dept it of 3 cmt. veah. Tilt wound wats left oipeni bicctuse the-
WOUNDS OF CEREBRAL VENTRICLES 195

procedure, on account of the overwhelming scalp infection, had been planned merely to

remove bone chips and establish adequate external drainage.

The patient steadily improved on sulfadiazine therapy until 9 December, wheti the

temperature became elevated and cervical rigidity returned. Penicillin was given intrathecally. The scalp became much cleaner under local treatment, and another operation

could be performed on 16 December. A track was found, just lateral to tile left occipital

fungus, which led directly into the occipital horn of the lateral ventricle. After the track

had been debrided, the body and temporal horn were well visualized. The ventricular

fluid was cloudy, and the wall was smooth and glistening. The choroid plexus was coagulated, clipped, and excised. It was thought wiser not to close the dura with a graft at this

time. A single pedicled flap of scalp was mobilized to cover a defect 12 by 4 cr., and tile

scalp was closed after 10,000 units of penicillin had been instilled into the ventricle.

In spite of daily intrathecal injections of 20,000 units of penicillin, signs of meningitis

persisted. Spinal fluid cultures were consistently positive for Slaphylococcus albus (Micrococcus pyogenes var. albus). On 28 December, the patient became much worse. Lumbar

puncture did not affect the tension of the occipital defect, but puncture of the right ventricle

through an anterior burrhole readily decompressed it, which indicated that a block existed

at or below the aqueduct.

Penicillin was injected into the ventricle daily, and by 6 January, the block had disappcared, and the patient was greatly improved. Large amounts of fluid, however, continued

to collect below the scalp defect, and the wound was reopened on 16 January. The porencephalic cavity in the left occipital lobe measured 60 cc., and there was an opening into the

occipital horn 8 mm. in diameter (fig. 37C and D). The track was clean except for a small

amount of exudate at the ventricular opening. The dura was closed tightly with a fascia

lata transplant, and the scalp was closed in layers with silk sutures.

The patient showed progressive improvement following this last operative procedure,

though his course was still interrupted by repeated flarcups of staphylococcic meningitis.

Penicillin therapy was continued, and the fluid was permanently clear after 10 February.

By this time, the patient was able to get about, the wound was solidly healed, and there

was light perception in both eyes. When he was evacuated to a French hospital on 7 March,

neurologic examination was negative except for visual loss.

Hemorrhage Into the Ventricular System

Aggressive efforts were always made to arrest or prevent hemorrhage and

to remove as much blood and blood clot from the ventricles as possible. Ventricular hemorrhage was a less frequent complication than infection in these

cases, probably because patients with serious hemorrhage died soon after

injury and did not reach rear hospitals. The infrequency of hemorrhage in this

series of cases of course in no way lessens the importance of this complication,

nor did it in any way modify the practice of removing a blood clot in the ventricle

under direct vision.

A typical history of hemorrhage follows:

Case 7.-A 27-year-old soldier, who had received a penetrating wound in the right

midparietal region on 22 December 1944, suffered immediate paralysis of the left arm and

leg but was able to talk on admission to an evacuation hospital, where operation was performed 26 hours after injury. Pulped brain and 200 cc. of blood clot were removed, together

with bone spicules, and the wound was closed after the instillation of 50,000 units of penicillin.

On the sixth postoperative day, meningitis developed, and intrathecal treatment with

penicillin was instituted.
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WOUNDS OF CEREBRAL VENTRICLES 197

after instillation of 20,000 units of penicillin. The scalp was closed by means of a rotation

flap, and the donor area was covered with a full-thickness skin graft.

The wound healed per primam, papilledema rapidly cleared, and the patient's improvement was steady. Roentgenograms, however, revealed a retained bone fragment

which shifted its potition between the temporal horn and the body of the ventricle (fig. 38D).

Since cultures made at the first operation had been positive, it was thought best that this

fragment ae removed. This was done on 20 January, through a temporal approach; operation had to be delayed because the patient had contracted laryngeal diphtheria.

All wounds healed promptly, though about a month after the first operation in the

base hospital, the parietal wound became puffy at one point, and exploration revealed a

small cotton pledget beneath the galca. It was removed without difficulty. Aphasia began

to cle:• in a week after the last operation. The patient was then able to report that as

a c& ,d been left handed. When he was evacuated on 21 March 1945, the eye grounds

wi i, though there was left homonymous hemianopsia, and his speech was improved,

thi, as by no means normal. The left arm was still paralyzed, but considerable power

haw Wed in the left thigh.

Associated Damage to Vital Centers

Most series of ventricular injuries, like this one, make it clear that a

fairly large proportion of fatalities can be expected in this type of wound from

associated damage to vital centers. This is a factor which is not particularly

amenable to improvements in therapy. The fact that there were only six

deaths from this cause in this series (including the death which occurred before

operation) is explained by the seriousness of such damage; most patients did

not live long enough to permit operation. On the other hand, some patients,

as the following case history shows, may survive long enough to undergo extensive surgery only to die days or even weeks later. This particular patient

withstood the effects of intraventricular hemorrhage but succumbed to a

lesion of the brain stem.

Case 8.--A 23-year-old soldier sustained penetrating wounds of the left frontal and

parietal regions on 31 May 1944 (fig. 39A and B). He lost consciousness immediately and

remained comatose. Debridement was undertaken at an evacuation hospital 24 hours

after injury, but the patient's condition was so poor on the operating table that a complete

operation had to be abandoned. The scalp was closed.

When he was received at the 21st General Hospital on 4 June 1944, he was still in coma.

Examination revealed a sutured scalp wound, 6 cm. long, in the left parietal region. Both

wounds were tense and did not pulsate. Roentgenograms showed bone defects underlying

both wounds. Two small bone chips were seen in the parietal lobe, and a metallic fragment was seen in the midline near the base (fig. 39C). After removal of the skin sutures,

the scalp wounds began to gape, and the parietal wound broke down and discharged foul

pus.

On 7 June, the parietal wound was opened widely, and the purulent cerebral hernia

was amputated. A necrotic track was followed for 3 cm. During this procedure, the brain

remained quite tense. It began to pulsate, however, when a ventricular needle was introduced and a large quantity of blood clot and old blood was aspirated. Because of the

patient's poor condition, it was thought best to attempt to tide him over with ventricular

punctures rather than to explore the ventricle under direct vision. Cultures on both aerobic

and anaerobic media showed staphylococci.

The patient's condition remained poor. When he again showed evidence of pressure,

ventricular puncture was done on 10 June, and 40 cc. of old brown blood mixed with clot
ntwillr i r ;Jti ilulu I i ul wfiiii orr it qwi n itti 1 '%tif.tl imi 1i 11tt 1 iiipllih( Jill- i111d fltmlv, li niro tltl-fIits

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WOUNDS OF CEREBRAL VENTRICLES 199

SUMMARY AND CONCLUSIONS

This chapter has as its background 50 consecutive penetrating wounds of

the ventricle, in all of which ventricular penetration was verified by direct

inspection at operation or at post mortem examination.

Fifteen of the fifty patients (died, including one who (tied before operation

could be carried out. It 36 cases in which primary operationi was carried out

in forward hospitals. there were 10 deaths, 9 due to infection and 1 to brain

damage. In 31 of these cases, secondary operation at, the base hospital was

necessary. There were 4 deaths, all due to brain damage, in 13 cases in which

primary operation was done at the base hospital.

In case of ventricular injury in which survival is sufficiently long for operation to be done, infection is responsible for fatalities at least as often as is

brain damage. Associated injuries are responsible for a small proportion of

deaths, the number not being greater because death usually occurs promptly.

Prompt, thorough debridement of the entire missile track, including the

ventricle, is the most effective means of lowering the morbidity and mortality

rates in penetrating ventricular injuries. It must be carried out under direct

vision. The same treatment is indicated in infected cases, with removal of

debris, retained bone fragments, and pus. Wounds should be closed primarily,

without drainage.

Chemotherapy and antibiotic therapy, no matter how they are administered, are effective only when they are combined with complete surgery.
CHAPTER X

Infections Following Acute Gunshot Wounds

of the Brain

Stuart N. Roue, M. D.

The immediate fatalities which follow penetrating wounds of the brain, as

well as the fatalities which occur shortly after wounding, are a result of destruction of vital areas of the brain. Infection is the principal cause of death in

casualties who survive the initial effects of cerebral wounds only to die later.

Much of the treatment carried out from the time of wounding until final recovery must therefore be directed toward the prevention of infection or, if it

has already occurred, toward its control.

In World War I, a discouragingly high toll was taken by infection following

acute gunshot wounds of the head.' Between World Wars I and II, great

strides were made in the prevention and treatment of bacterial diseases, and it

is therefore not surprising that in World War II fatalities from infections

following penetrating wounds of the head should have been reduced to a figure

slightly less than 4 percent. Reports from different surgeons in different theaters of operations revealed case fatality rates well in accord with this overall

figure.

The incidence of infection varied with the level of the hospital. According to Haynes, infection occurred in 12.6 percent of the injuries of the brain

observed in evacuation hospitals. Webster, Schneider, and Lofstrom 3 and

Maltby,4 reporting from general hospitals, found the incidence to be 16 percent

and 23.5 percent, respectively.

PREVENTION OF INFECTION

The most important single measure in the prevention of infection was

careful, complete debridement, which implied the removal of all necrotic brain

tissue, all blood clots, and all fragments of bone, as well as the achievement of

a very dry field before closure.

1 (1) Cushing, H.: A Study of a Series of Wounds Involving the Brain and Its Enveloping Structures. Brit. 3. Surg.

5: 5&5--M84, April 1918. (2) Kerr, H. H.: A Statistical Analysis of Gunshot Wounds of the Head. In The Medical Department of the United States Army in the World War. Washington: Government Printing Office. 1927, vol. XI, pt. I, pp.

841-847.

3 Haynes, W. G.: Penetrating Brain Wounds. Analysis of 342 Cases. 3. Neurosurg. 2: 365-378, September 1945.

8 Webster, J. E., Schneider, R. C., and Lofstrom, 3. E.: Observations on Early Type of Brain Abscess Following

Penetrating Wounds of the Brain. 3. Neurourg. 3: 7-14, January 1946.

4 Maltby, 0. L.: Penetrating Craniocerebral Injuries: Evaluation of the Late Results in a Group of 200 Consecutive

Penetrating Cranial War Wounds. 3. Neurosurg. 3:239-249, May 1946.

201
202 N EUtROSURGERY

Closure of the scalp wound was an essential part of (lebridehnent, but it,

was equally essential that the closure be effected without tension. The pressure of patients awaiting surgery and the comparative ease with which the

wound edges could be pulled together with heavy silk sutures sometimes

encouraged the surgeon to use this method of closure, to save time. When

the patients reached neurosurgical centers in thle communications zone, tile

damaging effects of this technique were frequently apparent. The sutures

had cut through the skill. The wound edges had separated. Healing was

unsatisfactory. The end result was almost invariably secondary infection.

The course of events just described was entirely unnecessary. Cturved

scalp incisions, wide undermining, rotation of flaps, and sometimes relaxing

incisions all were feasible and all permitted closure with two layers of interrupted silk sutures, without excessive tension.

Early surgery.-The policy of early surgery in evacuation hospitals was

practiced whenevec it was possible. Some surgeons believed that, in order to

prevent infection, it was essential to operate promptly after wounding, but., as

the war progressed, it was found that patients with head injuries who were

sent to general hospitals for initial surgery usually did well. When the operation had been done in a forward hospital, the patient was evacuated to a general

hospital as soon as his general condition permitted, without regard to whether

or not the sutures were still in situ. The risk of contamination was increased by

repeated wound dressings, but, if tile initial debridement had been adequate,

this increase was minimal and could be disregarded.

Antimicrobial therapy.-Antimicrobial therapy was employed prophylactically in all penetrating wounds of the brain. Sulfonamides were employed systemically until penicillin was introduced, after which it was used

routinely.

Early in the war, it was standard practice to use sulfanilamide locally immediately after wounding. In numerous instances, wounds seen 4 to 6 days

after they had been incurred, with the first dressing still in place, showed no

evidence of infection, and only occasionally did serious infections occur when

these wounds were debrided, even though, as just mentioned, initial wound

surgery had been deferred for these and longer periods.

How much local chemotherapy had to do with these good results is open

to question. Subsequent observations suggested that the effects of this

technique were offset by the presence of exudate or devitalized tissue and also

indicated that the added trauma which accompanied the local application of

sulfanilamide powder more than counterbalanced any benefit which might be

derived from it. In the European theater, in 1944 and early 1945, local chemotherapy 'Aas thought to be of value in the prevention of infection, but the

circumstances did not permit carefully controlled studies, and, before the end

of the war, this method was discontinued as both a prophylactic and a therapeutic measure.
GUNSUOT WOUNI)S O1F BRAIN 203

MANAGEMENT OF INFECTED WOUNDS

Surgical management.-rhe general management of an infected cranial

wound followed the same principles at all levels of medical care. The details

of management depended upon a number of considerations, including the

adequacy (or inadequacy) of the original debridement; the closure of the dura

(or failure to close it); the type of closure of the scalp wound; the causative

organisms and their susceptibility to penicillin; the degree of infection (superficial or invasive) ; the general condition of the patient; the severity of concomitant injuries; and the response to simple drainage and to antimicrobial therapy.

If the original debridement was known to have been complete and the

infection did not seem deep seated, the first necessity was to provide adequate

open drainage for the escape of the exudate, to prevent its intracranial spread.

This was usually accomplished by reopening the wound, or a- portion of the

wound, or, occasionally, by instituting drainage through a stab wound.

When the initial operation was known, or suspected, to have been inadequate, radical secondary debridement was required. The same policy was

followed when it was clear that infection was already established. The margins

of the scalp wound were excised, and the wound was opened sufficiently to

permit a comprehensive view of the entire involved area. Granulation tissue

was excised, and all foreign material, including silk sutures and bone wax, was

removed.

If the infection involved underlying brain tissue, clean excision of all

devitalized and infected tissue was undertaken along the entire track of the

wound.

These procedures were in keeping with the basic principles advocated for

all wound infections. In many instances, the response to simple drainage

supplemented by antimicrobial therapy was rapid and satisfactory, and more

radical surgical intervention was not required.

Adjunct therapy.-Every effort was made to promote wound healing by

correction of low hemoglobin levels, hypoproteinemia, vitamin deficiencies,

and inadequate fluid and nutritional intakes. In addition, the powerful

weapons of modern antimicrobial therapy were employed promptly and

vigorously.

The general plan was to use sulfadiazine in doses of 4 to 6 gm. every 24

hours and penicillin intramuscularly in (loses of at least 20,000 units every

3 hours. Cultures and smears were made routinely, and an effort was also

made to determine the penicillin sensitivity of the causative organisms.

Penicillin was rather widely used locally, partly on the basis of experience

in United States Army hospitals and partly on the basis of the British experience. It was often the practice, to cover the period over which a high systemic

level was being built up, to apply a concentrated dose to the infected area

immediately after drainage had been instituted. Two techniques were

employed as follows:

1. A small Dakin tube was placed in the wound and carried out through
204 NEUROSURGERY

the dressing. Sometimes a sterile medicine dropper was inserted into it.

Penicillin was instilled into the tube in small amounts, every 2 hours, by a

nurse.

2. The wound was dressed daily, and penicillin was instilled directly into

it with a syringe and needle. This method resulted in less continuous application of the penicillin but also offered much less opportunity for secondary

contamination of the wound.

If the tube method was used, the tube had to be left in place long enough

to permit the delivery of effective doses of peiiicillin, but, at the same time, it

had to be removed before secondary infection became a possibility.

The decision for or against, using penicillin intrathecally had to be made in

each individual case. Unless the spread of micro-organisms to the meninges

seemed imniinent, this route was not employed, in view of occasional local

reactions in the subarachnoid space. 0! the other hand, if there was any

suspicion that meningeal infection might b( developing, a prophylactic dose of

about 20,000 units of penicillin was usually given promptly by the intraspinal

route, in the hope that it might halt the beginning involvement of the meninges

and prevent the development of full-blown meningitis.

MENINGITIS

Meningitis, fortunately, was not of very frequent occurrence. The

incidence varied both with the location of the hospital I and with the timelag

between -wounding and initial wound surgery.

Sources of infection.-There were, obviously, numerous possible sources

of infection of the meninges after penetrating cranial injuries. A very large

break might. have occurred in the natural barriers between the exterior of the

body and the cerebrospinal fluid. Wounds produced by large shell fragments

or by multiple smaller fragments (figs. 40 and 41) sometimes opened a very

wide portal for the invasion of the cerebrospinal fluid by micro-organisms oil

the scalp or the helmet or on the missile itself. Wounds of the gutter type

offered the same opportunity. If these large openings remained patent, for

any length of time or if debridement of the wound was not possible within a

relatively short time, even the most vigorous antimicrobial therapy was likely

to prove useless.

Even if the wounds were less extensive, it, was still possible that organisms

might be harbored by metallic fragments, particularly if they were of considerable size, and by bone fragments. Bacteria were also harbored in necrotic

cerebral tissue and blood clot. A gradual spread of infection from any of these

5 (1) Walker, A. Earl, and Johnson, Herbert C.: Penicillin in Neurology. Springfield: Charles C Thomas, 1946.

(2) Erickson, T. C., Marsten, M. U., and Suckle, 11. M.: Complications of Intrathecal Use of Penicillin. J. A. M. A.

132: 561-5615, 9 Nov. 1946.

6 (1) Weaver, T. A.,Jr.,and Frishman, A.J.: A Reporton the Treatment of Craniocerebral Wounds in an Evacuation

Hospital. J. Neurosurg. 3:1484-1%, March 1946. (2) Campbell. E. Ht., Jr., and Martin, J.: Cerebral Fungus Following

Penetrating Wounds. Surgery 19:748-7.55, May 1946.
f' '1 N t I, -\s II I., - I IS t I-I - II r 1- vI I, :I I 1

I -i I' I I I .\ I Ii 1 I I . II It -i I r : I IIr I I111 I~ l I14 II It - I II I . I If lI' 41 I I 1 i
206 NEUROSURGERY

foci, if it was not interrupted by surgery, eventually involved the spinal fluid

and meninges.

It was observed relatively early in the war that the point of entrance of a

missile, as well as its course within the head, was of considerable importance in

relation to the possible development of both meningitis and brain abscess.

Thus, a missile passing through one of the paranasal sinuses or the orbit was

much more likely to carry infection than a missile which entered the intact

scalp above the sinuses.

Another source of meningitis that developed later was the presence of a

persistent passageway or fistula between the exterior of the head and the subarachnoid space, with resulting rhinorrhea or otorrhea, or the presence of a

chronic cerebrospinal fluid fistula through the wound itself.

A delayed wound infection, spreading inward, might also give rise to meningitis. In an occasional case, in which there was no direct opening between

the exterior and the subarachnoid space, meningitis apparently developed on an

embolic basis.

Bacteriology.-The micro-organisms responsible for meningit is were usually

streptococci or staphylococci. Occasionally, gram-negative organisms, including the colon group or Klebsiellafriedlknderi, were the offenders. Meningitis of meningococcic origin was very uncommon.

Diagnosis.-The diagnosis of meningitis was not always easy. A certain

degree of meningismus followed all head injuries, and an increase in the number

of white blood cells in the spinal fluid, as a result of hemorrhage at various

points along the track of the bullet, was almost. invariably present for some days,

or even for weeks, after injury. Fever was also frequently present for some

time.

Meningitis occasionally began insidiously, with relatively little febrile

reaction, partly, perhaps, because the patient was receiving antimicrobial

therapy at the time. In general, the diagnosis depended upon evidences of

wound infection; the usual systemic signs of spreading infection, such as a rise

in temperature, a chill, or a toxic mental change; and signs of meningeal irritation. The final diagnosis rested upon spinal puncture, the finding of an increased cellular reaction in the fluid, and the finding of organisms on smear or

culture. The clue to the diagnosis, however, was the constant suspicion that

infection might be present in the meninges.

Management.-Once the diagnosis was established or strongly suspected,

prompt and vigorous systemic chemotherapy and antibiotic therapy with both

pencillin and a sulfonamide was instituted. Even though the causative organisms were not yet identified, it was standard practice, whenever the spinal fluid

appeared grossly cloudy, to instill penicillin into the subarachnoid space at the

time of the original diagnostic lumbar puncture. The amounts used varied

widely, depending upon the source of the infection, the condition of the patient,

and the surgeon's estimate of the gravity of the situation. On the average,

doses of 50,000 units every 12 to 24 hours were regarded as ample, though

doses up to 100,000 units were sometimes employed.
GUNSHOT WOUNDS OF BRAIN 207

One problem which immediately arose concerned the possible damaging

effects of the presence of penicillin in these amounts in the subarachnoid space.

Some brands of penicillin were found to be extremely irritating at the time of the

injection. Other brands were not, and, in general, few aftereffects were reported when treatment extended over only a few days. When, however, large

amounts of penicillin were used intraspinally over long periods (7 to 14 days),

there were sometimes clear-cut evidences of diffuse arachnoiditis, particularly

in tile spinal canal. In most cases, fortunately, treatment was not necessary

for long periods of time or in excessively large doses, and no late manifestations

could be attributable to the presence of penicillin within the spinal fluid.

Although penicillin was injected at diagnostic lumbar puncture whenever

the spinal fluid appeared suspicious, prompt identification of the organism and

determination of its sensitivity to penicillin were regarded as essential. If the

invader was gram positive, intensive systemic chemotherapy was instituted

immediately with sulfadiazine, which had been shown to penetrate the subarachnoid space more effectively than any other sulfonamide d(rug. The efficacy

of penicillin by the systemic route was debatable, but there was some evidence

to suggest that a low concentration might be built up in the spinal fluid when the

meninges were inflamed. It was not the custom, therefore, to withhold

penicillin, even though there was uncertainty concerning its reaching the spinal

fluid. Penicillin was always used intramuscularly, of course, if an infectious

process was present in the wound.

When the invading organisms were gram negative, the problem was more

complicated. Large doses of a sulfonamide drug, supplemented by large doses

of urea, seemed to offer the most effective therapy.7 Some patients recovered

under this regimen, but this type of infection was frequently fatal, and it

accounted for many late deaths from infection. Had streptomy-in been

available, tile story might have been different.

When a spinal-subarachnoid block was suspected, the prompt use of intraventricular chemotherapy was occasionally lifesaving. No evidence of serious

toxic cerebral effects from this method of treatment was accumulated during

the war.

Fistulas associated with rhinorrhea or otorrhea, which usually resulted

from penetrating wounds involving the cribriform plate, the paranasal sinuses,

or the petrous ridge, provided, as already mentioned, ready sources of infection

and gave rise to meningitis in a fairly large number of cases. Prophylactic

doses of the sulfa drugs were used routinely in the hope that spontaneous sealing

off of the cerebrospinal fluid fistula would occur. If it did not, a resort to

surgical management always had to be considered.

The timing of surgery was another serious problem. The patient's condition was not always ideal for extensive surgical intervention, and delay for

several weeks was usually justified unless there were obvious signs of impending

meningeal infection. On the other hand, relatively few cerebrospinal fluid

7 Ecker, A. D.: Tight Dural Closure With Pedicled Graft in Wounds of the Brain. J. Neurosurg. 2: 384-390, September 1945.
208 NEUROSURGERY

fistulas closed spontaneously after penetrating head wounds, and operation

was usually necessary.

The decision to operate and when to operate was made on the basis of the

findings in each case. In general, persistence of rhinorrhea or ot-orrhea for

more than 3 weeks was thought to be a sufficient indication for operation. A

large craniotomy was employed to permit adequate access to the involved area,

an intradural approach being used whenever it was practical. The use of fibrin

foam and of large fascia lata grafts held in place by as many sutures as possible

offered the best chance of success. Repeated operations were sometimes

necessary before closure of the fistula was obtained.

Adjunct therapy.-Of all supportive measures, the maintenance of an

adequate fluid and caloric intake and provision of adequate rest seemed of the

greatest importance. Transfusions were given as necessary to maintain the

hemoglobin level. Feedings through the Levin tube were helpful in the

stuporous patient. Restlessness was controlled by regularly administered

doses of barbiturates, paralhehyde, bromides, or chloral hydrate. Measures

to relieve discomfort by con t rol of the increased intracranial pressure included

elevation of the head of the bed, free catharsis, and, in occasional cases, spinal

or ventricular drainage.

Results.-The case fit! ality rate from meningitis averaged about 36 percent. Most of the fatalities were the result of gram-negative infections, which

were likely to be 100 percent fatal. Ecker, however, reported 3 survivals in

10 cases.

BRAIN ABSCESS

Sources of infection.-Brain abscesses developed from several sources

following gunshot wounds of the head. The usual foci were small collections

(clusters) of indriven bone fragments, which were commonly encountered when

initial debridement has been incomplete. These bone fragments, which were

present in about 20 percent of the head injuries observed in general hospitals,

came to be recognized as such a constant source of brain abscess that they were

regarded, per se, as an indication for prophylactic secondary debridement when

cranioplasty was done. This policy did not mean that all isolated deep fragments were routinely extirpated or that wide, traumatizing explorations were

undertaken in patients whose clinical progress was satisfactory. Nests of bone

fragments in or close to the missile track (fig. 42) were, however, carefully

removed in most cases to prevent the possibility of brain abscess.

Large metallic intracerebral fragments also provided a nidus for abscess

formation (fig. 43), particularly if the path of entrance led through the paranasal

sinuses, the orbit, or the mastoid cells. Infection might develop along the

track of the missile, around the fragments, or at both sites. In one case, for

instance, in which a left frontal wound involved the sinus, a left frontal abscess

was successfully extirpated. When the patient died suddenly a week later, a

right frontal abscess was found to have developed about a shell fragment in

the right frontal lobe.
(.1 N*SII44'j' %%MIIN .S 441' IMIAIN 20

r(34l i nu,3rl~lI$f3t Seia 12,11 i~ I of I n~e ilivirj l wlul)l pt-11ll(.1i~ lig wwf m :, 4kiiI f l fr oll

I(wI~i(l~l li lll(Ite ci1lilil iafi vVil U. :ol vnia:ihlli 1-1f Dr hii~~lll jdill( ~srkual :ifI fcrvmid %

iiti-bide-ju fi'11 ond veaut - ii iii-jil v ith :iIppienitiilj-j(ifg Inni.i I.:u i vru mr(3lli.Il(ill :ufi-el r i3llwllfI : liiiic fn itafec.t I ill zitit il ill5 rciirrel l ill011.' gr ).i - aleg al l ive 14ii1 I('Ct bus " i itu (i re-

,It dt thle an lt ito *(ier )041.I therap * vthele ava iilabe. Almontst all1 proved atal

iisia liv fronti theliep11)1ire ol a deep a bsvess liito (tile vetilt ric i r lSYSvis 011a soniw

AI)5Ctz5 fo~rmatill onie S)lutelll(s followed Nvolitti itifeet loll. but t ills was hlot

.I freq vileti (evelopl~leiit . eIi sbih i rae laar imlrtlee(r v.ai 

eiliist11 flaes. sill) lilti HY, wilile mnet list at We bra in ab scvss soimtie illis followed

5411Ilp Inifect ioni., thIis wats not 1 aflvriq ieo d lv~elopiiviei I ( Ivil.x ilsWt

it self unicomm non, 111d, Ill t ie few calses observed. Ito lindo erlv ihg, lilt ra evre brad

asceesse, were et icol [it eredI

Pathologic process. -A bscesses of (I ie bra iii vicwli udered Ill iii Ntai

511l'gerv d iib'erd ill Some reslpect 5 from t hose see'' ill pela't ilme. Ill genleral,
I lie ut, t-u~iiii seeiiletl1 'miiie% 11.t less- % 1liet 1.1114 .1 It bclII.'v of 1114.

w~s lilt rildIiihiic' .. \ino A her.I pliv4iblv iea-ýol firl Ih I-a 11.i Itv I % I vs-wr\ li-illenct. ofi

Ilte tmcrro-ornnmlstiii-i \\ I. t he woit M~id agv am(i Ih lit- civr'l 1)11\ 'ial Iiiite of

I lie, nltIjWill-. S' irI-.I te-1v.rI\*( ole 'or~aiIl- were foltiji mlone frcttimervt I 1I1:11 111

left frmitlal rttiirI itit' inj-tiIrack i v\i'uIvniI iiert tivalvthli4VI I lit' tuitutivjttri. Afte'r thte

oiriginal itetriulmetiu'u Ih btile litt etiiild tiv ývvfi 1t% jin- iin Ow liruitirurihun iiilli the wipiiiai regi.mtl.

IThis~ rIii'-0 \'ut.' ý: siiii-eqiierrltv rt'it tmtt I turuimuir. :I mlltt vraluitiltim v il 1thte It-ft teeipital

area, ýiirtv titi~ilt- ift thi-~ -ii NWert reitariti'il :k-. ttlvtinili' ýimirvv- '4 tale braini abI-v4-.'. Thei

patienht ri'tticrei cti~uitderaiht ' frmiti Itii' righ~ti hetiinptiv-6 wni :atptuma and %%:ut, Wa- :idat~iltmrv

whett lie %%:I t rat,u'ftrredtoi the Lineit (if Inrrterior.

Clinical picture and diagnosis.- 'thl(-efilicical pimt tire of brall in bscesses ill

miii I a ory stirgerv wais mn~i- les., d eli IIit a I tI d of farI I Ion. t'I is i In lots ofnset I Ia lit I Aas,

itme oftit bscessve seen In it (-%IIillt it I)t'act ice. am iiI di Ill'gnfosi wa ANISInI(IIlyoI co-son 

difliotl tII . Prey loils I r'a I 11111 ino i ItoIYi jptov idi'. I it realso. bl d ' e -. 12Il at toit for

hititi~i'Ii bl~llgiitg womidiis. or' s'orte Imicrelalsv ill t eilt' it actitipres'tlrt' bitt

also ilIISillv oliscitriti 2111v locall fivilr-olowe14 cliii tiges for Smile t titte. 'Iliv pre'-

dice41 if a pii ll-icit -t collect tori rttigIl t Ii 'mforv e lit i rslispecte cIIII Oiittl te onlset of

sI 11)or or' votiv illsa iis leraildeti t fll- sjtrcat.If of th l fiirtfeet a ii. "I'list was So I ikel \

to be Ow livoill-e of' evetvits when atiz foregign bodies Were presenlt. whet hat'r they
GUNSHOT WOUNDS OF BRAIN 211

were fragments of missiles or bone fragments, that the policy of removing them

for prophylactic reasons was instituted.

The most certain evidence of the development of a local abscess was increasing intracranial pressure. Protrusion of the scalp flap or of the wound,

with the diminution of local pulsation, was suggestive. Other reasons for suspicion were persistent headaches, a slow pulse, early choked disks, and elevated

spinal fluid pressure. The progression of neurologic signs, spreading wound

infection, persistent fever, and a rise in the white blood cell count were all indications for a search for possible abscess.

Less tangible changes in the clinical course also furnished grounds for

suspicion. These changes included mild mental disturbances, particularly

irritability, a tendency to drowsiness, and perhaps some slight personality

change.

An alteration in the character or location of the headache from which the

patient had already been suffering was significant. The slow pulse characteristically found in the brain abscesses seen in civilian practice was less helpful

diagnostically since bradycardia was usually present already in penetrating

wounds of the head and remained unaltered if a purulent collection developed.

Important findings on spinal puncture included increased pressure and

an increase in the number of white blood cells, particularly lymphocytes. In

the interpretation of these findings, however, allowance had to be made for the

pleocytosis usually present in head injuries.

If the presence of an abscess could not otherwise be established or excluded, the policy was to explore the suspected area either through the intact

skin, with a lumbar puncture needle, or through a nearby burrhole, with a

brain cannula. If these exploratory measures proved negative, they were

practically always innocuous; when they were positive, the experience was that

the suspected abscess was recognized and located more quicly than if diagnosis

had been delayed until the clinical picture of a full-blown intracerebral abscess

had been awaited.

Management-The management of brain abscesses following penetrating

cranial injuries varied widely during the war, just as it had varied in peacetime

practice. Almost all of the accepted neurosurgical methods were tried, including continuous drainage, repeated aspiration, and radical removal. Grant,8

Northfield,' and Meredith' 0 advocated simple aspiration. King" and Bucy

and Haverfield' 2 advocated some type of continuous tubal drainage. As the

war progressed, there was a gradual tendency to a more radical attack on the

lesion.'3

I Grant, F. C.: End-Results in One Hundred Consecutive Cases of Brain Abscess. Surg., Gynec. & Obet. 75:464-467.

October 1942.

9 Northfleld, D. W. C.: The Treatment of Brain Abscess. I. Neurol. & Psychiat. 5: 1-9, January-April 1942.

10 Meredith, 3. M.: Recognition and Management of Brain Abscess. Am. 3. Surg. 63: 10-15, January 1944.

11 King, J. E. 3.: Management of Abscess of Otorhinogenic Origin. Laryngoscope 50: 1146-1158, December 1940.

12 Bucy, P. C., and Haverfield, W. T.: Cranial and Intracranial Complications of Acute Frontal Sinusitis.

3. A. M. A. 115: 9"3-991, 21 Sept. 1940.

13 (1) Groff, R. A.. and Grant. F. C.: The Surgical Treatment of Brain Abscess by Exposure and Enucleation.

Ann. Surg. 111: 925-941, June 1940. (2) LeBeau, 3.: Radical Surgery and Penicillin in Brain Abscess. J. Neurosurg.

3: 359-374, September 1946.
212 NEUROSURGERY

With any of these methods, it was possible to visualize the lesion roentgenologically by the use of some contrast medium at the time of the original drainage. Air was occasionally used. When thorotrast was available, small quantities were injected. This medium had the great advantage of permitting some

visualization of the capsule, so that an estimate could be made of the tendency

of the abscess to refill merely by repeating the roentgenograms. Kahn's '

technique, the use of thorotrast with overlying decompression, which permitted

control of any herniation of the lesion toward the surface, was not employed in

any of the head injuries treated at the 160th and 184th General Hospitals in

England.

The simplest of all methods of abscess management, namely, repeated

aspiration followed by the injection of penicillin, was not successful in any of

the cases in which it was used at these hospitals. Although culture of the pus

was frequently negative, the organisms apparently lingered within the wall of

the abscess, and the lesion recurred even after it had been completely drained

and large doses of penicillin had been employed.

Continuous drainage of the abscess by the use of an indwelling tube was

occasionally effective, but recurrence of the purulent exudate was not infrequent

because of the persistence of organisms within the abscess wall.

The most effective method of dealing with an abscess of the brain after a

penetrating gunshot wound of the head proved to be its radical removal.

This technique was perfectly feasible. For one thing, the lesion was usually

close to the surface. For another, abscess formation in these circumstances

occurred in a previously traumatized area of the brain, and radical extirpation

therefore produced no additional crippling neurologic aftereffects. In cases in

which the abscess was completely removed and the wound tightly closed,

operation wos performed without difficulty; the wounds healed promptly, and

the lesion did not recur.

The technique devised by Webster and his associates of treating abscesses

in the frontal area by suction removal, followed by closure of the dura with a

temporary fascia lata graft, was intended to prevent leakage of the cerebrospinal

fluid an(i fungus formation. At a later operation, the temporary graft was

removed, and the defect was covered with a split-thickness graft. At the 160th

and 184th General Hospitals, this method was thought to have certain disadvantages, including possible early tension on the involved portion of the

brain, increased difficulty in carrying out a satisfactory cranioplasty, and,

finally, more widespread scar formation over the cortex. For these reasons,

this procedure was not employed in any of the cases treated at these hospitals.

Cerebral fungus was not encountered frequently. When this complication

did occur, the fungus was usually found to contain one or more brain abscesses,

which it was essential to drain before any other procedure was undertaken.' 5

After drainage, prompt closure of the skull by the use of a tantalum plate ap-

'4 Kahn, E. A.: The Treatment of Encapsulated Brain Abscess with Visualization by Colloidal Thorium Dioxide.

Univ. Hosp. Bull. 4: 17-19, March 1938.

"3See footnote 6 (2), p. 204.
GUNSHOT WOUNDS OF BRAIN 213

plied directly over the fungus was usually successful. If necessary, the fungus

could be reduced to the level of the skull margins by spinal drainage repeated

daily, as necessary, for a number of days. In most cases in which this method

was used, the scalp was closed completely over the tantalum plate when

cranioplasty was done.

This technique prevented further infection of the fungus, expedited the

healing of the wound by weeks, and minimized the neurologic damage which

would otherwise have resulted from the protrusion of the edematous and often

infected brain.

Adjunct therapy.-Antimicrobial therapy was used vigorously in the treatment of a brain abscess, whether or not it was treated surgically. Local

chemotherapy with both penicillin and a sulfonamide was employed in most

cases in addition to systemic therapy.

All of the usual supportive measures were also employed, with particular

emphasis upon the maintenance of a high hemoglobin level, by transfusion of

whole blood, and the prevention of hypoproteinemia by special attention to

the protein intake.

455735--58------15
CHAPTER XI

Blast Concussion and Cerebral Injuries

Due to Explosion Waves

Fritz Cramer, M. D.

DEFINITION AND TERMINOLOGY

Cerebral Concussion, Airborne and Solidbome

"Blast concussion" was the term commonly used in World War II to

describe the condition in which traumatic alterations of the substance and

function of the brain were caused by shock waves from nearby explosions

which passed to the central nervous system without the interpolation of a

solid blow to the head. Fabing,' who employed the term "cerebral blast

syndrome" for this condition, defined it as follows:

The blast injury syndrome is that morbid condition which results from the nearby

explosion of one or more agents, and causes the following tetrad of symptoms, (1) unconsciousness with retrograde amnesia for the sound of the explosion and of varying anterograde duration, but persisting an hour in the usual case, (2) protracted nonspecific headache, (3) tinnitus which is usually nonpersistent, and (4) diffuse anxiety symptoms.

Under the latter syndrome are included the vertiginous sensations and

the extreme intolerance to noises of which the majority of patients complain.

In thus defining this sometimes moot entity, Fabing used the generic definition for the syndrome of cerebral concussion and the postconcussional state.

Denny-Brown 2 deplored the use of the term "blast concussion" because

it implies a mechanism of production which differs from the mechanisms

usually comprehended as the causes; namely, acceleration-deceleration of the

skull and compression. This type of concussion, however, presents a challenge which must be met because it does have special limitations of incidence

to the traumas of war, because the mechanism of its production is in fact

unique, even though not unfathomable, and because it constitutes a syndrome

which is frequently manifest and is inexorable.

The term "blast concussion" (cerebral blast concussion) is used in tbis

chapter because it is in general use and has behind it well-established facts

concerning the mechanism by which it can be caused 3 and also concerning

SFabing, H. D.: Cerebral Blast Syndrome in Combat Soldiers. Tr. Am. Neurol. A. 71: 29-33, June 1946.

3 Denny-Brown, D.: Cerebral Concussion. Physiol. Rev. 25: 296-325, April 1945.

' (1) Scott, W. W.: Physiology of Concussion. Arch. Neurol. & Psychiat. 43: 270-283, February 1940. (2) Walker,

A. E., Kollross, 3. J., and Case, T. I.: The Physiological Basis of Concussion. J. Neurosurg. 1: 103-116, March 1944.

(3) Webster, 3. W., and GurdJlan, E. S.: Acute Physiological Effeets of Gunshot and Other Penetrating Wounds of

the Brain. J. Neurophysiol. 6: 255-262, July 1943.

215
216 NEUROSURGERY

the organic cerebral changes which have been d(emonstrated in experimental

cerebral concussion of all degrees of severity.4 It is granted that there is no

uniformity of definition of the term "concussion" as applied to the brain.

Most writers attempt to restrict its meaning to a very circumscribed condition characterized chiefly by a short period of posttraumatic unconsciousness

with which, it is presumed, no organic changes in the brain, or only reversible organic changes, are associated. The attempt at restriction is unsuccessful.

however, because of many factors, not the least of which is that these writers

themselves, in actual usage, employ the term to include not only concussion

but the postconcussional syndrome and p,,stconcussional encephalopathy.

Because of the tendency toward the indiscriminate use of terms, the following definitions are essential:

Cerebral blast injury implies traumatic cerebral changes identifiable by

neurologic sequelae and by tests such as encephalography.

Cerebral blast concussion (blast concussion) indicates the prime symptoms

generic to cerebral concussion, with emphasis on the pattern of symptoms seen

in this particular method of production, which implies indirect compression.

There may or may not be persistent neurologic findings. There may be molecular changes within the nerve cells and nuclear groups, as as possible injuries to the blood vessels. Gross lesions, including cerebral contusion and

laceration, may be responsible for persistent symptoms in the postconcussional

syndrome.

This use of the term "cerebral blast concussion" is general. Symonds 5

used the term "concussion" to indicate not only the effects of concussion on

the brain cells, or true cornmotio cerebri, but also, inevitably, some trauma to

the blood vessels. This trauma may be manifested by free blood in the spinal

fluid but need not be. Loss of consciousness is regarded as a prime symptom,

but merely as a single symptom, and not as an infallible index of the degree of

concussion.

Air-blast concussion in the sense in which the term is used by Schwab'

is not included in the definition of blast concussion. He described his personal

experiences with what is also technically known as muzzle blast, which is not

usually traumatic except under circumstances other than those related by him.

What lie described was in essence merely an intensely strong wind occurring in

the neighborhood of gunfire. It should not be confused with the term "shock

wave" and the accompanying air blast from a high-explosive missile.

In this chapter, the term "blast" is used in the strict sense to designate the

shock wave itself moving through air, fluid, or solids, including the living body.

On the other hand, the term "concussion" is used in the broad sense, to designate

4 (1) Groat, R. A., Magoun, H. W., Dey, F. L., and Windle, W. F.: Functional Alterations in Motor and Supranuclear Mechanisms in Experimental Concussion. Am. 3. Physiol. 141: 117-127, March 1944. (2) Windle, W. F., and

Groat, R. A.: Disappearance of Nerve Cells After Concussion. Anat. Rec. 93: 201-209, October 1945. (3) Windle, W. F.,

Groat, R. A., and Fox, C. A.: Experimental Structural Alterations in the Brain During and After Concussion. Surg.

Gynec. & Obst. 79: 561-572, December 1944.

s Symonds, C. P.: Concussion and Contusion of the Brain and Their Sequelae. In Injuries of the Skull, Brain and

Spinal Cord, edited by Samuel Brock. Baltimore: Williams & Wilkins Co. 1940.

6 Schwab. R. S.: Cerebral Airblast Concussion. J. A. M. A. 131: 101-103, 11 May 1946.
BLAST CONCUSSION AND! ('iE.IIEBRAI INJ UMlIES 217

a temporary posttraumatic state and its sequelae, whose chief, but not only,

physiologic characteristic is k!,s of conSciousness and whose morbid allatomy

is characterized by intracellular and interstitial cerebral changes, as well as by

imperceptible or minor gross injuries to the cerelbral vascular system.

Blast Concussion and Shellshock

Since the introdu( ion into warfare of missiles of high velocity an(l high..

explosive quality, men have noted and reported a morbid condition of the

central nervous system which in most respects is comparable to cerebral conlcussion and the postconcussion syndrome. For its causation, no other trauma

than the wave of the explosion or the compressive wave created by the missile

in flight could be ascribed. Various references in the medical literature concerning World War I indicate that nervous manifestations, specifically coilcussion, were long considered to have occurred at times from the violent forces

existing immediately about a flying missile, called the wind of the bullet l or the

wind of the cannonball.8

In more ancient times, before the use of high-explosive shells, the actual

passage close by of a nonexpioding cannonball was believed capable of causing

death. The "wind" of a round shot was believed to cause fatalities by the

compression of the air. It is not the purpose in this chapter to elaborate on

these earlier observations and interpretations except to note that the "wind of

the explosion" 9 and shell concussion or shellshock 10 were some of the terms

used in World War I to describe the same pathologic aad clinical phenomena

which have been described under the term "blast concussion" and allied terms

in World War II.

Controversial Aspects

Tile term "shellshock" soon became abused and fell into disrepute because

of its confusion in the minds of clinicians, as well as of the lay public, with the

psychogenic disturbances of warfare, chiefly the anxiety neuroses, hysteria,

and malingering. There was also equivocation, notably on the part of Mott,u

who described pathologic lesions in cases of this type. He questioned whether

other factors, including carbon monoxide poisoning, might have played a part

in producing the cerebral petechiae which were described, and lie discussed

some of the psychiatric aspects of the problem. It should be emphasized,

however, that Mott's thesis is, in essence, that true concussion and injury to the

brain were due to the effects of blast as we now speak of it. He considered that

the possible association wit h carbon monoxide poisoning, from t he accumulat ion

Nervous Manifestationq Due to the Wind of Explosives (editorial). Lan'-'t 2: 348-349, 14 Aug. 1915.

* The Pathology of Shell Concussion (editorial). Brit. M. J. 2: 264-265, 14 Aug. 1915.

9 Stevenson, W. F.: Note on the Cause of Death Due to Iligh-Explosive Shells in Unwounded Men Brit. M. J.

2: 4.50, 18 Sept. 1915.

10 Tulloch, A. B.: Shell Shock (letter to the editor). Lancet 2: 575, 4 Sept. 1915.

11 Mott, F. W.: The Effects of High Explosives Upon the Central Nvrvous System. Lancet 1: 331-338, 12 Feb. 1916.
218 NEUROSURGERY

of carbon monoxide in the dugouts in which the cases occurred, was a distinctly

secondary factor and not a primary cause of the syndrome.

For these reasons, in World War II there was a cautious approach to the

problem, which inevitably presented itself. Not only was there variance of

opinion whether the symptoms of cerebral disturbance were in fact, or in part,

due to organic cerebral damage, but Denny-Brown 12 has even stated his frank

disbelief that these symptoms are due at all to concussion by the primary

explosion waves.

The reasons underlying these variances in opinion may be simplified as

follows:

1. There has been a fundamental paucity of autopsy reports and of microscopic studies of the brains of persons dying from the primary effects of explosion waves.

2. There is a paucity of complete, minute, objective records of neurologic

examinations by trained neurologists.

3. By contrast, there has been a preponderantly psychiatric approach

to the problem, which has overbalanced the neurologic approach.

4. There were administrative fallacies in World War II, as in World War I.

In this connection, it seems worthwhile to quote Crichton-Miller's 13

rather adroit summary:

After the war [World War I] a commission was appointed to investigate the problem,

and reached a conclusion which may not unfairly be formulated thus: "We cannot deny

that there is such a condition as true shell-shock, but it has been so much abused that we

must never again admit its existence." * * * the naif conviction that a symptom can be

eliminated by refraining from allowing it a name had its inevitable result. The symptom

appeared, a designation had to be found for it, and so the clinicians-as opposed to the

ministerial authorities-described it as blast-concussion. It is to be hoped that this name

will not be exploited in the way in which shell-shock was exploited; but if it should be the

fault will lie not in the name, but in the situation.

In World War II, no forensic furor was raised over the term "blast concussion"

as there was over shellshock in the previous world war. On the contrary,

such great stress was placed on the purely psychiatric aspects of the problem,

and such caution was used in publicizing the organic aspects, that the net

error in diagnosis is probably much too low for blast concussion and much too

high for the neuroses and allied conditions. For example, it was reported at a

meeting of Allied psychiatrists at a base hospital overseas in June 1943 14

"that all cases of blast injury were diagnosed as exhaustion for administrative

reasons and to avoid the diagnosis of 'shellshock.' "

This administrative policy would vitiate the statistical value of many

records, as would the opposite policy of labeling combat neurosis as blast

effect to spare the individuals or the organization the stigma of a psychiatric

"Is Denny-Brown, D.: The Effect of High Explosives on the Post-Traumatic Syndrome. Tr. Am. Neurol. A. 69: 9&-

102,1943.

's Crichton-Miller, H.: Somatic Factors Conditioning Air-Raid Reactions. Lancet 2:31-34, 12 July 1941.

W Hanson, F. R.: Recent Experience of War Neurosis. Report of Societies: Meeting of Allied Psychiatrists at a Base

Hospital Overseas June 5, 1943. Brit. M. J. 2: 336-337, September 1943.
BLAST CONCUSSION AND CEREBRAL INJURIES 219

diagnosis. The probability that this practice occurred has also been reported."5

Aside from errors introduced by such policies, the fact that combat exhaustion

neurosis actually existed in many men who received concussion by blast, as

discussed by Swank and Marchand,16 has added another source of error and has

caused many cases of blast concussion to be hidden under the symptoms of

purely functional origin.

Because of the exigencies of warfare, few data are sufficiently complete

for scientific evaluation in the sense that such evaluation is required in controlled experiments. Conversely, it must be said that there are not sufficiently

numerous or intricate and extensive laboratory experiments in this field to

permit a true comparison with the clinical syndrome observed in human beings, or to disprove that the condition exists.

It is evident that those who have investigated this problem specifically

and have reported their findings have made great efforts to establish the facts,

ruling out those cases in which the diagnosis was suspect. Fortunately, there

are available eyewitness observations and estimates of the distances involved,

the relative position of the injured to the explosion, the relative protection

afforded by foxholes, and early medical observations, including autopsy reports, even though they are not abundant.

The Nature of Blast

By blast is meant the wave or shock or pressure transmitted through the

air, from the detonation of a high-explosive shell or bomb (one which is brisant

or capable of blowing things to bits). Its effects will be considerable in a

limited area which is just outside of its zone of brisance. Within this area,

everything is blown to bits. Beyond this zone, and before it loses its traumatic

effectiveness and becomes merely a sound wave, the shock wave, or explosion

pressure in air, as Corey 11 proposes that it be called, has the power to kill

outright or to injure by concussion. These phenomena are considered in

detail by Corey, Sutherland,'8 and Robinson,"9 as well as others.20 The shock

wave has the characteristic of passing through the surrounding medium without

moving the medium, whether the latter be air, water, a solid body, an animal,

or a human being (figs. 44, 45, and 46). The wave has a pressure phase, followed immediately by a vacuum phase, and an oscillatory period. The compression phase is of about 0.006 second's duration and of hundreds of pounds

per square inch of pressure. The suction phase is of about 0.03 second's duration and is equivalent to a pure vacuum. The velocity and duration of either

"I Rottersman, William, and Peltz, William: History of the Neuropsychiatric Work in the Western Pacific Base

Command, 14 April to 31 August 1945, p. 5. [Official record.]

16 Swank, R. L., and Marchand, W. E.: Combat Neuroses: Development of Combat Exhaustion. Arch. Neurol.

& Psychiat. 55: 236-247, March 1946.

'7 Corey, E. L.: Medical Aspects of Blast. U. S. Nay. M. Bull. 46: 623-&51, 5 May 1946.

"19 Sutherland, M. W.: The Physics of Blast. Lancet 2: 641-642, 23 Nov. 1940.

"It Robinson, Clark Shove: Explosions: Their Anatomy and l)estructiveness. New York City: McGraw-Hill

Book Co., 1944.

20 (1) Bernal, J. D.: The Physics of Air Raids. Nature 147:594-596, 1941. (2) Wakeley, C. P. G.: Effect of Underwater Explosions on the Human Body. Lancet 1: 715-719, 9 June 1945.
220 NEUROSURGERY

DOME

____ AIR

- - =WATER7E=j I- PLUME

•- -. GAS '

- -GAS AIR

-- and A WATER WATER

FIGURi 44.-Effects of underwater explosion. The shock wave travels through fluid

at nearly 5,000 feet per second. A. At the surface of the fluid and gas, a disruption of the

particles occurs. In the human body, shock is transmitted through the integument and then

through the solid and fluid portions, according to definite physical principles. Surfaces

within the gas-bearing organs, such as the alveoli of the intestine, sustain the greatest damage.

Hemorrhages also occur in other organs. The most serious damage occurs to the parts

most directly exposed to the shock wave. B. Plume re.rulting from underwater explosion.

This formation, which represents the mixture of gases and water thrown up turbulently after

the shock wave has passed, may hurl about any objects in its path, like the rush of wind

which follows an explosion in the air. Secondary damage may be caused by these objects.

It is the preceding shock wave which produces primary trauma in blast injuries. (Modified

from Wakeley.)

phase are such that the body of a man would be completely immersed for an

instant in a wave of almost uniformly altered pressure. It is, presumably, the

pressure phase of the wave which produces the injuries of medical importance,

and these injuries occur only relatively close to the source of the explosion.

The oscillatory period is important to walls and buildings, which may be concussed at great distances from the detonation.

The Shock Wave of Air Blast

Air blast, which is to be differentiated from its misnomer airblast or muzzle

blast, is the turbulent wall of moving air which is propelled for a limited distance by the momentum of the shock wave and the enormous expansion of gases

colliding with the immediately adjacent air. It may travel at 20,000 miles per

hour for a short. distance, carrying everything in its path, but its force is quickly

dissipated. This air blast may hurl bodies before it or lift them high into the

air, thus producing secondary injuries. The air blast close to the explosion,

being in essence a mass of compressed air, acts almost like a solid body blown

out from the explosion. Being of lighter weight than the solid bodies which

are loosened or hurled by the explosion, it travels ahead of the latter for a short

distance, practically simultaneously with the shock wave. For a limited

distance, the air blast and the shock wave run an identical course, but the

latter quickly outdistances the former. The term "blast," however, is the
BLAST CONCUSSION AND CEREBRAL INJURIES 221

PRESSURE

(LB.AQ. IN.)

30-

20- - 10 FT. FROM CHARGE

5 20 FT. . FROM CHARGE HAG ual FIURE 45.-Initial high peak and grad- fall of pressure of high-pressure wave.

Peak pressures of about 100 lbs. per square

0 inch, or 6 atmospheres, are required to

endanger human beings. These pressures

occur only close to explosions. The shock

3 30 FT. FROM CHARGE wave is always breaking, as the free front

portion loses energy, and is always dying

down, most quickly nearest to the explosion.

Ultimately, the shock wave degenerates

into an ordinary sound wave. (From

2 40 FT. FROM CHARGE Bernal.)

0

2 50 FT. FROM CHARGE

0 10 20 30 I I I I

MILLISECONDS

Crater plug being pushed

out and broken up.

I•es • mstrtin4 from

rfetd'Cracks startn rm~ fi'4~ as tension wave., surface. Gases escaping from

Formtionof cambe ''~ fully developed chamber

of compression. o

BEFORE EXPLOSION AFTER 0.002 secs. AFTER 0 -1 secs.

FIGURE 46.-Formation of crater in underground explosion. (From Bernal.)

one which should be applied to the shock wave, whether it be traveling in air,

water, or solid mediums.

Barrow and Rhoads 21 discussed the characteristics of the blast waves and

the reasons why persons or structures standing next to each other, and therefore

2l Barrow, D. W., and Rhoads, H. T.: Blast Concussion Injury. J. A. M. A 125: 9OO-{2, 29 July 1944.

455735T-58----16
222 NEUROSURGERY

presumably within the same effective range of an explosion, may nevertheless,

suffer fantastically different results. They have cited examples of the unpredictability or capriciousness of the wave, as follows:

1. B stands between A and C. A is thrown 42 feet and is killed. C is

thrown 15 feet into the air and is seriously injured. B receives only a tympanic

injury.

2. B stands behind A, resting his chin on A's shoulder. A is blown to bits.

B has only a fractured maxilla.

The authors observed that standing in the second row offers protection

except for the tympanum.

The physical characteristics of the blast wave are as follows:

1. Near , source, the outline is irregular, with many eddies in the

periphery. refore a man in the periphery, sheltered in such an eddy,

might esct .ious injury.

2. Like sound waves, the blast waves are reflected from surface to surface

and may be reinforced or neutralized by meeting similar waves in the same,

or the opposite, phase.

3. Pressures vary as the square or cube of the distance from the source;

this difference in critical pressures may be represented by a few feet.

The difference between the shock wave and the air blast can be easily

exemplified by comparing the two phenomena to two essentially equivalent

phenomena which occur in underwater explosions. Figure 44 illustrates how

the shock wave from an underwater explosion travels to the surface, there

raising a dome almost immediately, while the more striking plume caused by

the eruption of the gases from the detonation does not occur until moments

later. It is from the compression by the shock wave, as well as by secondary

reflectance from the surface of the water, that trauma ensues to individuals or

bodies of other types floating in the water.

THE INCIDENCE OF BLAST CONCUSSION

Studies During the Early Clinical Course

Two groups of investigators have made a special study of blast concussion

in the early stages.

Von Storch 22 and his collaborators set up a mobile unit in a forward evacuation hospital in Italy. The unit included a self-contained mobile electroencephalographic laboratory and was staffed by a neuropsychiatrist, a psychologist, two technicians, and a driver. These observers made a comparative

analysis of various types and degrees of cerebral concussion as observed soon

after injury. The course of the disorders was followed during the patients'

stay in an evacuation hospital, and, in some cases, in hospitals in the rear as

well.

"U Von Storch, T.: A Study of Cerebral Concussion. In Annual Report, 33d General Hospital, 1V45.
BLAST CONCUSSION AND CEREBRAL INJURIES 223

The patients were studied from a few hours to 16 days after injury, the

first preliminary observations being obtained as soon as they arrived in the

hospital, often while they were still in shock or while they were unconscious.

A history was obtained of the circumstances of the injury, its presumed severity,

and the immediate and subsequent results, symptoms, and sequelae. A general

physical, psychiatric, and neurologic examination was made. A thorough

psychometric study was done in as many cases as possible, and an electroencephalogram was obtained as soon as possible. It was demonstrated that

the electroencephalograph could be transported over difficult terrain under

combat conditions and could be used effectively in forward areas.

Of 75 cases of closed head injury, 33 were caused by blast, of which 16

(21.3 percent of the total number) were considered to be instances of true concussion; that is, the patients had been definitely unconscious at the onset.

Most of these injuries were considered to be cases of mild concussion. The

high percentage of these diagnoses made by definitive methods in a forward

echelon is of very special interest and importance. The farther such patients

move to the rear, the less apt is the diagnosis to be made or confirmed, unless

the symptoms and signs be severe and persistent and the accompanying record

unequivocal.

Relationship to artillery explosions.-Fabing23 undertook a special study

of blast concussion in the European theater, in a general hospital sufficiently

close to the front to have received patients as early as 45 hours after trauma.

Over 200 cases were studied, but only 80 could be reported because of the loss

of the first 130 records as a result of enemy action. Of the total number of

1,009 neuropsychiatric battle casualties observed between late January and

May 1945, 80 cases (7.9 percent) were diagnosed as due to blast. Fifty-six

of the diagnoses were made in forward echelons and twenty-four in the rear.

Fabing pointed out many interesting facts regarding the incidence of blast

concussion. It varies directly, he found, with the magnitude of the tactical

situation and is in all likelihood an index of the effectiveness of the enemy's

artillery. It occurs regardless of rank, and the incidence is spread evenly over

the categories of new replacement troops and combat troops of 3 to 4 months'

experience alike.

Those cases in which blast injury (blast concussion, wounded in action,

shell blast, etc.) was the first diagnosis made in the medical evacuation chain

constituted 70 percent of the total in which this diagnosis was corroborated

in subsequent studies, while in only 30 percent was this diagnosis made for the

first time in the special hospitals.

Schwab 24 gave a dissenting opinion regarding the incidence. While not

denying that air-blast concussion occurs, he stated that over 90 percent of

these diagnoses in Naval installations in the Pacific area were incorrect and

that extreme hysterical-anxiety states were produced in men who were exSSee footnote 1, p. 215.

% See footnote 6, p. 216.
224 NEUROSURGERY

hausted or otherwise sensitized to this form of trauma. He believed that only

3 cases out of well over 300 were correctly diagnosed as blast concussion.

Schwab's communication, however, is not sufficiently detailed to be of

value for analysis and comparison with the others cited. Furthermore, he has

introduced an element of confusion. He describes his own experiences on shipboard in the neighborhood of muzzle blast, in which the rush of wind tore open

his shirt, blew off his spectacles, and produced discomfort in the eyes and ears

without endangering him. The inference that this type of blast is similar or

equivalent to exposure to the atmospheric blast wave, that is, the high-explosive shock wave from an exploding missile, should be avoided.

Comparative Early and Later Studies

Aita and Kerman 2 made a critical study, including neurologic, psychiatric,

and electroencephalographic examinations, of patients treated later in the course

of their head-injury syndromes, in an Army neurologic-neurosurgical center.

They received their cases from 50 to 370 days (a median lapse of 144 days)

after trauma. Of 400 cases of closed head injury, 52 (13 percent) had been

diagnosed previously as blast concussion, blast encephalopathy, and similar

conditions. Of these 52 cases, 34 were considered due to blast trauma, and

18 probably due to other causes (8 to solidborne concussion, 8 to the nervous

strain of combat, and 2 to cerebral embolism). In all, therefore, 8.5 percent

of all closed head injuries seen in late stages were, in the critical judgment of

these observers, considered as due to blast concussion.

The standards of selection, testing, and evaluation of findings for the acute

injuries in Von Storch's group, and those for the late sequelae in Aita and

Kerman's group and in a group studied by Cramer, Paster, and Stephenson 2

are very similar and permit comi-sarison. The great difference between the two

(early and late) groups, other than the time interval, is that in Von Storch's

group, which lie estimates as 21.3 percent of all early closed head injuries,

there was no selection of cases other than in respect to etiology. The patients

doubtless represented many men who were later returned to some type of duty

and did not require evacuation to the Zone of Interior because of persistent

symptoms following their cerebral trauma. In the two studies made of late

clinical material, on the contrary, there had been a previous clinical and

administrative selection, since these patients had all required evacuation from

the battle zones because the severity or persistence of their symptoms, or both,

had rendered them ineffectual for active duty.

One may therefore summarize the data, from the studies made by Fabing,

Von Storch, and the Aita and Kerman group, respectively, as follows:

1. The incidence of blast concussion in all cases of neuropsychiatric battle

casualties in the battle zone was 7.9 percent.

"25Aita, J. A., and Kerman, W. Z.: The Closed Head Injury Syndrome Due to Blast. Bull. U. S. Army Med.Dept.

6: 411-427, October 1946.

N Cramer, F., Paster, S., and Stephenson, C.: Cerebral Injuries Due to Explosion Waves-"Cerebral Blast Concus

sion." A Pathologic. Clinical and Electroencephalographle Study. Arch. Neurol. & Psychiat. 61: 1-20, January 1949.
BLAST CONCUSSION AND CEREBRAL INJURIES 225

2. The incidence of blast concussion in acute head injuries in tile battle

zone was 21.3 percent.

3. Tile incidence of blast concussion in the subacute and chronic closed

head injury syndrome in the Zone of Interior was 8.5 percent.

THE RECOGNITION OF BLAST CONCUSSION

Fulton l and Pollock Is discussed tile blast-concussion syndrome of World

War II in relation to tile shellshock (concussion) syndrome of World War I

and included references to articles on, and names of, thie observers of this generic phenomenon in that period. With the exception of the tactical variants

of these two conflicts, and the increase in size and power of many of the missiles

employed, there may be said to be little essential change in the origins of the

problem, the clinical syndrome, or the treatment.

Mott, as already mentioned, raised the question of the possibility of

carbon monoxide poisoning as a cause of the petechial hemorrhages found in

the brains of soldiers who died front the primary effects of bomb explosions

without evidence of a blow to the head by any solid object. Lest that possibility be seriously cited again as the cause of the syndrome under discussion,

it . ( desirable to clarify the issue and state the following facts which refute t pi s.-.ibility:

High explosives do not depend upon the oxygen content of the air but

carry the oxygen required in chemical combination.

2. Although the carbon monoxide content may be increased in the atmosphere of an area under intensive bombardment, it is quickly dissipated in

the open.

3. Tile effect of the blast itself is instantaneous, whereas if carbon monoxide

poisoning were to be a factor, it would become operative only after a (comparatively) greatly delayed period.

4. In those instances in which death occurred as a result of the blast,

the span of life between the time of the explosion and death was only a fraction

of the time which would be required to produce death from carbon monoxide

poisoning.

The origin of shellshock in World War I was the battlefield. In World

War II, the sources of blast concussion and other cerebral blast injuries were

chiefly from the field, but there were also numerous observations of tile condition among civilians, as well as among soldiers not in actual combat, because

aerial bombing so greatly extended the zone of action.

Therein lies some possibility of a differentiation between the organic or

physiogenic and the neurotic or psychogenic aspects of this clinical syndrome.

There will be a discernible difference as the syndrome is encountered in the

soldier who becomes a casualty from the effect of explosion waves under tile

conditions of combat and the soldier or civilian who is injured by an explosion

By Fulton, J. F.: Blast and Concussion in the Present War. New England 3. Med. 226: 1-8. 1 Jan. 1942.

9 Pollock. L. J.: Blast Injuries of the Central Nervous System. Illinois M. J. 83: 16.5--1l8, March 1943.
226 NEUROSURGERY

while under conditions less fraught with horror and privation. The fighting

soldier will, or may, have been exposed to constantly recurring fire for days or

weeks; to hunger, starvation, thirst, and sleeplessness; to physical discomfort

of every sort; to tile intense emotional trauma produced by the loss of close

friends and others from his military detachments; and to tile sights and sounds

of a shambles. He will therefore experience the symptoms and exhibit the

objective picture germane to all soldiers who have suffered the excessive and

successive and cumulative psychosomatic traumata from the effects of battlefield stimuli. If, superimposed upon this definite pathologic emotional and

intellectual state, he has a cerebral concussion, there will be no obvious and

unequivocal signal which will differentiate the moiety of the syndrome due to

postconcussional encephalopathy from that of functional origin. Systematic

study is required to effect this differentiation.

Comparison of Battle Zone and Civilian Casualties

Swank and Marchand, observing combat exhaustion and combat neuroses

during the Normandy campaign, noted the relation of these conditions to blast

concussion. A soldier with combat exhaustion usually continued in battle

until an acute and severe incident, such as a near miss from artillery or mortar

fire, or a heavy artillery barrage, precipitated a breakdown. The soldier became

wild and confused and amnesic for that period. He exhibited tremors; fears,

particularly provoked by the noises associated with combat; stupor; and

confusion. In vwteran combat troops, amnesia was very seldom seen, if at all,

except in men who were confused and emotionally exhausted or in men suffering

from a blast concussion. It seemed certain that practically all infantry soldiers

suffered from a neurotic reaction eventually if they were subjected to the stress

of modern combat continuously and long enough. About A0 percent of those

who were evacuated because of a neurosis had been exposed to an acute incident;

that is, direct attack by small-arms fire, bombardment of various types and

degrees, or both. A much stronger explosion was required to precipitate the

abnormal cerebral state in the veteran soldier than in the untried soldier.

It was estimated that a much larger number of veteran troops broke down

under the psychic stresses than under the physical stress of a nearby explosion.

In soldiers suffering concussion, there was considered to be either a physiologic or an anatomic injury to the nervous system and its exteroceptive nerve

endings, as well as to other parts of the body. They were often reported to

have been unconscious or dazed immediately after the explosion, and they

remained so for a varying period, for which they were completely amnesic.

On recovering consciousness at a battalion aid station or farther back of the

line, their hearing was impaired, they had a constant buzzing in one or both

ears, and they complained of headache and dizziness. Many bled from the

ears, nose, mouth, or all of these orifices. Pains in the chest and other symptoms

due to blast might have been present, and frequently one or both tympanic

membranes had been ruptured. As the slow recovery from the effects of blast
BLAST CONCUSSION AND CEREBRAL INJURIES 227

occurred, over the course of 1 to 3 or 4 weeks, the symptoms of combat exhaustion usually became increasingly evident. In a few cases, the symptoms of

blast lasted for as long as 12 months; in these, anatomic damage to the nervous

system was probable. Some men with symptoms of severe concussion due to

blast exhibited no evidence of combat exhaustion.

PATHOLOGIC CHANGES OF BLAST CONCUSSION

General Effects

Abdominal and pulmonary lesions.-In 1940, Atkins "9 reported cases of

immersion blast injury, emphasizing the occurrence of perforation of the intestine, most commonly adjacent to the ileocecal valve, but stressing petechial

hemorrhages and lacerations of the brain and lungs as primary causes for death.

Abdominal lesions found at, operation and at post mortem were reported

by Cameron, Short, and Wakeley,4 0 but they failed to mention examinations

of the central nervous system, even though several of their patients had been

unconscious and some had sustained spinal paralysis.

Most of the reports on the pathologic processes in blast injuries deal

with the lesions in the abdominal and thoracic viscera, since, although all

organs and parts of the body may be affected, the hollow or air-containing

viscera sustain the greatest damage. Injuries to the ears,3 1 retinal detachment 32 and even isolated fractures of the first rib associated with blast forces n

have been reported. When sudden or early death has ensued, it has usually

been considered due either to massive disruptive, contusive, hemorrhagic lesions

of the viscera or to an indefinable effect upon the body as a whole, in which

no single lesion could be held accountable for the death. Hooker 3 observed

that there might be complete absence of pathologic evidence of the cause of

death in animals subjected to lethal air-blast forces and attributed the phenomenon to primary shock, characterized chiefly by a complete collapse of the

blood pressure. He found that the severity of the lesions in the lungs bore

little if any relationship to the severity of the gross damage to the brain. He

decried his inability to present the results of microscopic studies of the brains

of his animals, which were carried out by others and were apparently not

published.

Effects on central nervous system.-Evidences of involvement of the

central nervous system have actually been more frequently noted than they have

been emphasized, and there are, unfortunately, few complete studies which

F Atkins, H. J. B.: Lesions from Dover. Guy's Hosp. (az. 54:192-195, 29 June 1940.

0 Cameron, G. R., Short, R. H. D., and Wakeley, C. P. G.: Abdominal Injuries Due to Underwater Explosion.

Brit. J. Surg. 31: 51-66, July 1943.

31 Bettington, R. H. B.: Injuries to the Ear Due to Blast. M. J. Australia 2: 210-211, IS Aug. 1945.

"3 (1) Stallard, H. B.: Retinal Detachment: A Series of 78 Cases in the Middle East Force. Brit. M.J. 2:330-333, 9

Sept. 1944. (2) Evans, J. J.: Organic Lesions From Shell Concussion. Brit. M. J. 2:848, 11 Dec. 1915.

" Gutman, P. E.: Isolated Fractures of the First Rib Associated With Blast Forces. Am. J. Surg. 65: 408-412,

September 1944.

34 Hooker, D. R.: Physiological Effects of Air Concussion. Am. J. Physiol. 67: 219-274, January 1924.
228 NEUROSURGERY

include microscopy of the brains. The chief reason for this lack is that conditions of combat do not permit such studies. In most of the reports of post

mortem examinations, the examination of the nervous system is not mentioned,

and the inference is that it was not performed. In many other reports, this

was specifically stated.

Wilson and Tunbridge 3 reported the autopsy findings in 12 persons killed

outright by blast. A 500-pound aerial bomb had burst at one entrance to a

deep rock shelter, and, in the opinion of experts, the concrete roof at tile

opposite entrance had been blown off by the blast. All persons within the

shelter were stunned. Those who were later able to go home were dazed and

confused. Autopsies were performed on those bodies on which there was no

external evidence of trauma, but, because of a delay of 36 hours, the brains

were not examined. The principal macroscopic findings were extensive

bilateral pulmonary hemorrhage in all cases, hemoperitoneum in 6 cases, and

mediastinal hemorrhage in 3 cases. The pulmonary hemorrhage occurred

throughout the lungs; there was no constant location of the subpleural hemorrhage. Microscopically, there was seen widespread congestion of the

pulmonary capillaries, red blood cells in the alveoli and alveolar epithelium,

anti occasional emphysema with ruptured alveoli. Other factors which might

have caused death, such as burns, noxious gases, or suffocation, were ruled out

in these cases.

Wilson 36 observed that the blast injuries in the lungs occurred primarily

in the parenchyma immediately adjacent to the intercostal spaces, indicating

that the trauma occurred directly to the chest wall. Although the injuries to

the lungs were the most severe and the most demonstrable, he did not believe

that they were the immediate cause of death. His opinion was that the vital

centers had been damaged by the shock wave.

Cerebral Atmospheric Blast Injuries

Citation of cases.-Ascroft 17 reported the case of a gunner, aged 26 years,

who was injured accidentally at Benghazi by a small grenade of enemy origin.

There was no knowledge of his immediate posttraumatic state of consciousness.

When he was examined 2 hours later, he was conscious but apathetic and was

slow in answering questions, which had to be repeated. No detailed neurologic

examination was carried out, but he was observed to move his limbs. He was

operated on for injuries to the hands. He had also sustained many external

local lesions in the left chest above the seventh rib, as well as a penetration of

the left eye without injury to the skull. He did not recover consciousness

and had cyanosis and a bloody froth.

Autopsy revealed hemorrhages in the lung due to the blast (inasmuch as

no fragments entered the thorax) and fluid in the pleural cavity. The skull

33 Wilson, J. V., and Tunbridge, R. E.: Pathological Findings in a Series of Blast Injuries. Lancet 1:257-261, 27 Feb.

1943.3' Wilson, J. V.: The Pathology of Closed Injuries to the Chest. Brit. M. J. 1 470-474, 17 Apr. 1943. "7 Ascroft. P. B.: Blast Injury of the Lungs With Curious Lesion of the Cerebrum. Lancet 1: 234-235, 20 Feb. 1943.
BLAST CONCUSSION AND CEREBRAL INJURIES 229

and dura were normal. There were evidences of increased intracerebral pressure, in that the gyri were flattened and there was a small cerebellar cone and

tentorial grooving. There was also subpial bleeding over wide areas, and the

cortex was superficially lacerated in two areas, (1) on the undersurface of the

left frontal lobe, behind the olfactory bulb, and (2) in the left temporal region,

behind the sylvian point. The left precentral and postcentral gyri were swollen

and soft. The gyri and the posterior two-thirds of the right parietal lobe

were lilac pink. The junction of damaged cortex and underlying white matter

was very discrete. Histologic examination revealed vast numbers of recent

capillary hemorrhages in the cortex. No serious change was observed in the

nerve cells. There were no fat emboli. Ascroft considered that blast alone

was responsible for the lesions in this case.

Bell 38 reported the case of a man who was repairing the roof of a cinema

and who lay down on the tiles when a bomb fell 100 yards away. He caught

the full force of the blast on the left side of the body. On admission to the

hospital, he was confused and irrational. His confusion increased, and he

died 2 (lays later, with signs of consolidation of the left lung. Necropsy

showed gross contusion in the left side of the brain. Microscopy showed blood

cells among the brain tissue and in most of the alveoli of the lung, in which

many of the alveolar walls were torn.

Wood and Sweetzer 3' reported a case of blast injury with hemorrhagic

lesions in the brain. A 20-year-old Marine was transferred from the beachhead

with the diagnosis of atmospheric blast concussion. No further history was

available. He was semiconscious when received, did not regain consciousness,

and died on his fourth hospital day. There were no localizing neurologic signs.

Necropsy revealed contusions of the anterior and lateral thorax. The lungs

were heavy, and the lower lobes were red and contained frothy fluid. Small

hemorrhages were encountered in the parietal pleura and peritoneum, both

surfaces of the diaphragm, and the epicardium. There were lacerations of the

liver and spleen.

The scalp, the calvarium, the base of the skull, and the dura mater were

intact. The pia-arachnoid vessels were engorged with blood, and the cerebrospinal fluid was blood tinged. The brain contained punctate hemorrhages

which were principally in the white matter and were symmetrically located.

The body of each caudate nucleus and the midbrain near the substantia nigra

were involved. A few hemorrhages were also found in the white matter of the

cerebellum, in the brainstem, and in the upper part of the spinal cord.

Microscopy revealed the following: (1) The majority of the hemorrhages

surrounded a capillary or a venule; (2) the extravasated red blood cells were

well preserved; (3) some of the involved capillaries were thrombosed; (4) there

was no instance of fat globules; and (5) the white matter was rarefied in the

foci of bleeding, but no phagocytic glial cells were present. In some of the

3 Bell. R. C.: Analysis of 259 of the Recent Flying Bomb Casualties. Brit. M. 3. 2:689-692. 25 Nov. 1944.

is Wood, H., and Sweetzer, H. B., Jr.: Punctate Cerebral Hemorrhage Following Thoracic Trauma. U. S. Nay. M.

Bull. 46: 51-56, Januaty 1946.
230 NEUROSURGERY

hemorrhagic zones, a ring of astrocytes surround(ed the central capillary. No

hemorrhagic infiltration was seen around arterioles. Some arterioles and small

veins were surrounded by a rarefied zone filled with edema coagulum. II

several sections of the white matter, a single fat globule was demonstrated

within a capillary, but there was no bleeding around that vessel. The cerebral

capillaries were engorged with blood, but there were no fat globules present.

Wood and Sweetzer's explanation of the mechanism of the injury isconsidered elsewhere (p. 253).

Stewart, Russell, and Cone 10 observed a pheasant found 90 feet away

from the craters of two large bombs and reported that, although the bird

had no external evidences of direct trauma, it stood about with eyes closed,

exhibiting no fear and offering no resistance, and remained in any position

in which it was placed "like a catatonic." When the bird was killed and

examined, gross hemorrhages were found in the lungs and brain. The cerebral hemorrhages, which were in the forebrain, extended back as far as the

third ventricle, surrounding which there was a striking hemorrhage. Microscopic examination revealed the capillaries to be congested throughout. Hemorrhages of various sizes in both forebrains occurred chiefly in small veins and,

to a lesser extent, in the capillaries.

Ganado 41 described post mortem examinations on two girls who were

killed outright by blast injury. In these cases, there were no secondary

traumatic factors and no external evidences of trauma to the skull. There

was the usual congestion of the viscera and hemorrhages in the lungs. The

brains were found to be very large, edematous, and congested, with flattened

convolutions, but no hemorrhages were present. Ganado, who had examined

many corpses in which blast injuries had occurred in combination with other

injuries, considered these two girls to have been affected by "pure blast,"

although he proffered no exact cause of death. He considered, however, that

the brains were sufficiently abnormal to have accounted for cerebral symptoms

had they lived. He stated as follows: "The condition of the brain recalled

the clinical observation that many wounded exposed to blast had presented

* * * all the signs that are usually associated with cerebral concussicnunconsciousness or drowsiness, amnesia, irritability, headache, etc."

Cohen and Biskind 42 reported autopsy findings in 11 cases of atmospheric blast injuries, considered to be authentic, from the Army Medical

Museum. Nine of these casualties had sustained damage to the central

nervous system. Pronounced hyperemia of the leptomeninges and the brain

was a constant finding. Four cases showed diffuse leptomeningeal hemorrhage, severe in one case and moderate in the other three. Another case

showed extensive hemorrhage and a horizontal laceration in the vermis and

both cerebellar hemispheres, as well as many small punctate hemorrhages in

"40 Stewart. 0. W., Russell, C. K., and Cone, W. V.: Injury of the Central Nervous System by Blast. Lancet

1: 172-174, 8 Feb. 1941.

it Ganado, W.: Blast Injuries (correspondence). Brit. M. J. 2:118, 24 July 1943.

42 Cohen, H., and Blskind, G.: Pathologic Aspects of Atmospheric Blast Injuries in Man. Arch. Path. 42 12-34,

July 1946.
BLAST CONOESSION AND) CEREBRAL INJURIES 231

the cerebrum. Still anothier case shioweni multiple, dliscrete, red, punictiform

spots involving I to 2 em. of cortex in die right temporal lobe. 'lhree cases

showed1 a few hemorrhages, seen microscopically, ni thie perivascular spaces.

No special cy-tologic studies were (lone.

A sumumary of the symptoms referable to the central nervous system ill

these I11 cases and the pathologic findings inl the brain inl 9 cases of the I I are

givenl iii table 8.

TABLE 8.----Summnary of synsptoms referable to the central nerrous systemn and pathol ogic findings

in the brain in 9 of I11 cases of atmospheric blast injuries (adapted front Cohen and

Liiskind I

P'athologic findings

Cawe Symptoms and signs _______ ______________

No.

Leptomninnges Brain

I Pronounced restlessness----Hyperemnia ---------- Hyperemnia.-

2 Excitability, irrationality, No gross lesions ------ No gross lesions; ito special

mania. c. tologic studies done.

3 Patient dead on arrival at D~iff use, mioderate 1Hypereinia; no hemorrhages.

hospital. hemorrhages.

4 None mentioned in abstract~-;-------(10do-----------Focal punctate hemorrhages

grossly visible in right temporal lobe.

5-------------do ------------- Hyperemnia ---------- Hyperemia; occasional microscopic and perivascular hemorrhage.

6 Stupor, then extreme rest- Hyperemia; focal 1Hyperemnia; focal microscopic

lessness and irrationality, microscopic hem- hemorrhages.

orrhages.

7 Case omitted by authors-------------

8 None mentioned in abstract-' Hyperemia--------- Hyperemia.

9 UnconsciousnesE, disorienta- iDiffuse, severe hem- Punctate hemorrhages in ceretion, excitab lity, hyper- Iorrhage. brum. Large horizontal

active refiexet., bradypnea. tear and massive cerebellar

hemorrhage.

10 Case omitted by authors ------------

11 None mentioned in abstract_- Hvperemia ---------- Hyperemia; occasional microscopic and perivascular hemorrhage.

I Cohen, H., and Biskind, G.: Pathologic Aspects of Atmospheric Blast Injuries In Man. Arch. Path. 42: 12-M4.

July 39W.

Blast Trauma With Intracerebral Hematoma

In the opinion of Rogers,'3 structural changes have occurred in the brain

after blast injury more often than is realized. In support of this opinion, he

cited the following case:

A 1 9-year-old seaman was standling by a 4-inch gunl when it discharged.

43 Rogers, L.: Blast Injury of the Brain. M. J. Australia 2: 209-210, 18 Aug. 1C45.
232 NEUROSURGERY

He experienced a sudden stiffness al, I numbness of tile left hand and arm, from

which he recovered in 10 minutes. Three weeks later he had the first of a

series of attacks affecting the left extremities in a Jacksonian march, beginning

with the hand, and gradually giving way to a spastic hemiplegia. During

this period, the diagnosis of a possible hysteria was made. The patient,

however, contended: "All my trouble started when the big guns fired." After

a sufficiently detailed preoperative study, an exploratory craniotomy disclosed

subcortical hematoma with an extensive cavity.

This case should more properly be regarded as due to muzzle blast, or

air blast, than to blast concussion in its more typical form.

Grunnagle " reported a case of intracerebral hematoma resulting from

blast injury, without skull fracture. The patient, a sergeant, had previously

been observed in the same hospital in August 1944, for treatment of a fecal

fistula following appendectomy. He was observed to be an extrovert; lie was

cheerful and not in the least depressed by his experiences in combat missions

during his 30 months' service in the Southwest Pacific Area. During convalescence, lie participated actively in the performance of duties about the

ward. Because of a severe weight loss, he was evacuated from the hospital 2

weeks after admission, for further convalescence before return to duty.

He was readmitted to the same hospital 2 months later, on 27 October 1944,

with a history of having beep rendered unconscious by the blast from an enemy

knee-mortar shell on 20 October 1944, during the Leyte invasion. He had

suffered a minor laceration of the scalp in the left anterior frontal region from

a small shell fragment. When questioned, he stated that he thought he had

lost consciousness for a few minutes. Accompanying records stated that he

been drowsy, listless, and irrational at intervals during the first 3 days after

injury. He then had become more alert and complained frequently of frontal

headache.

Examination on admission found him listless and disinterested in his

surroundings. No information was volunteered, and the history had to be

elicited by direct questioning, to which only monosyllabic answers were given.

Headaches had been almost constant since the injury, but other complaints

could not be elicited; the patient was apparently not aware of the change in

his personality. When he was visited by the ward surgeon under whose care

lie had been during his previous hospitalization, his attitude was one of

indifference.

The temperature, pulse, and blood pressure were normal. There was a

healed scalp laceration about 2 cm. in length in the left temporal region.

Roentgenograms of the skull were negative for fracture. There was a small

metallic foreign body 2 mm. in size in the scalp, in the left temporal region.

Neurologic examination revealed slight resistance on testing for neck

rigidity. Kernig's sign was negative. There was no evidence of aphasia,

although the patient limited his conversation. The nasal borders of the optic

disks wero .noderately blurred, and there was some engorgement of the retinal

46 Grunnagle, J. F.: Traumatic Intracerebral Hematoma. J. Nerv. & Ment. Dic. 103: 298-300, March 1946.
BLAST CONCUSSION AND CEREBRAL INJURIES 233

veins, but there was no measurable elevation of the optic disks. Visual fields

appeared normal to gross testing. There was weakness of the right lower

face. Otherwise, examination of the cranial nerves was not remarkable.

Upon extension of the arms, slight wandering of the right arm occurred, and

dysdiadochocinesia was also noted on the right side. No difference in motor

power and no other abnormal neurologic findings could be detected.

Spinal puncture, performed on 31 October 1944, revealed a pressure of

260 mm. H2 0 and deeply xanthochromic fluid. The Pandy reaction for

globulin was 3 plus. No cells were seen. Repetition of the procedure on 5

November 1944 revealed an increase in the pressure to 330 mm. H20. The

fluid itself was of clear consistency and xanthochromic. The Pandy reaction

was 3 plus, and there was one cell per cubic millimeter.

The patient's general condition remained unchanged, but, during the

following 2 weeks, he became more drowsy. His personal habits deteriorated,

his bed being constantly dirty with cigarette ashes, butts, and particles of

food. He became incontinent of urine and used foul language in the presence

of the nurses. The facial weakness became more pronounced, and the optic

disks became elevated one diopter.

A diagnosis of subdural hematoma or left frontal intracerebral hematoma

was considered, and on 10 Nevember 1944 under local procaine infiltration, an

exploratory trephine opening was made in the left frontal region. The exposed

dura was of normal color. When it was opened, however, the cerebral cortex

was found brownish yellow and bulging through the dural opening. There

was no evidence of subdural fluid or blood clot, but at a depth of 3 cm. approximately 1 ounce of dark, liquid, old blood was found and evacuated.

The patient rapidly became alert and interested in his food. He requested

reading material. He volunteered that he had no headache. Forty-eight

hours after operation, he became continent of urine. He was permitted out of

bed on the third day after operation and was soon fraternizing with other

patients. His reactions 1 week later resembled those on his first admission,

before his blast trauma, and his personal appearance and habits again became

neat and clean. When lie was evacuated on 27 November 1944, the papilledema

had subsided to only slight haziness of the disk margins. The remainder of

the neurologic examination was negative except for a minimal lag of the right

lower face on spontaneous smiling.

Subdural Hematoma Associated With Blast Injuries

Among the patients discussed in a symposium on immersion blast injury

was one reported by Hamlin 4. with a subdural hematoma. This man, while

floating in the water, was rendered unconscious for a short period by an underwater explosion. He then vomited and was in shock. Severe injury to the

abdominal organs from the blast caused death 8 (lays later. Meanwhile, the

patient was wildly excited, delirious, and disoriented. The subdural hematoma

43 Hamlin, 11: Neurological Observations on Immersion Blast Injuries. U. S. Nay. M. Bull. 41: 26-32, January 1943.
234 NEUROSURGERY

found post mortem was over the left temporal region and measured 8 by 4 by

6 cm. Hamlin surmised that the subdural heniatoma had occurred as a result

of a direct blow to the head, but the detailed notes in the other portions of the

symposium regarding this patient would seem to rule out any basis for this

surmise. The case exemplifies the occurrence of both cerebral concussion and

subdural hematoma, both of which may have contributed to the abnormal

mental state.

Abbott, Due, and Nosik 46 observed a number of blast injuries, both of the

atmospheric and immersion types, in which post mortem examinations revealed nultiple hemorrhages throughout the body, varying from petechiae

to frank bleeding. They reported in detail 3 out of a total of 10 cases in which

subdural hematonias producing the typical syndrome were found and relieved

by surgical procedures. In five of these cases, the hiematomas were bilateral

and several patients had had subdural effusions.

Blast Concussion With Delayed Posttraumatic Cerebral Hemorrhage

In discussing cases of concussion in which there had been no solid blows

to the skull, Grinker and Spiegel "( described two instances of delayed posttraumatic hemorrhage which had come to their attention. These patients

had been exposed to nearby explosions, but the type of explosive and the

distance of the explosions from the patients were not documented in the report.

Both were concussed antd had had symptoms persisting for several weeks after

their l)attle experiences 0(nd consisting of anxiety, insomnia, and restlessness.

Because of the absence of any sign of external injury, the patients had been

treated for neurosis. At a later date, one of them had a sudden fall to the

ground, fractured his skull, and died of bleeding from a ruptured meningeal

blood vessel. Autopsy revealed, in addition, old hemorrhages within a severe

laceration of the frontal lobe. The second patient died after severe frontal

headache and coma had developed. Autopsy revealed extensive o0l injury

to the frontal lobes, into which fresh hemorrhages had taken place. Grinker

considered these cases as examples of blast concussion. Ile stated in a personal

communi, tion: "Perhaps some of our discharged patients with anxiety states

die in other hospitals with terminal hemorrhages into lacerated brains. It is

unfortunate that followup studies cannot be made; yet our opinion is that

such cases are infrequent."

A case in point is reported from the study by Cramer, Paster, aml Stephenson.4

" It was an instance of cerebral concussion due to the blast from a nearby

mortar-shell explosion, with prolonged unconsciousness and amnesia. The

i jurv was followed b)y l)osttraumatie headache, dizziness, irritability, and in46 (1) Abbott, W. I)., 1)ue, F. 0., and Nosik, W. A.: Subduril niematoma and Effusion as a Result of Blast Injuries:

First Preliminary Report. J. A. M. A. 121: C64-4k,. 27 Feb. 1943. (2) Abbott, W. D).. I)w,, F. 0., and Nosik, W. A.:

Subdural Ilernatoma and Effusion as a Result of Blast Injuries: Second Preliminary Report: D)iagnosis by Psychiatric

Examination. J. A. M. A. 121: 73%-741,6 NMar. 1943.

47 (rinker, Roy I., and Spiegel, John P.: War Neuroses of North Africa: The Tunisian Campaign (January-May

1943). New York: Josiah Macy. Jr. Foundation. 1943. "48 Se f(otnote 26. p. 224.
BLAST CONCUSSION AND CEREBRAL INJURIES 235

tolerance to noises; death, from (lelayed posttraumatic cerebral hemorrhage

from an area of encephalomalacia due to the blast injury occurred 3 months

later. Tile details were as follows:

Case report.-A 24-year-old white American private was admitted to Kennedy General

Hospital, Memphis, Tenn., on 9 February 1943, after transfer through a chain of evacuating

hospitals, with the transfer diagnosis of "Psychoneurosis; War Neurosis."

While in battle in Guadalcanal in November 1942. 3 months earlier, le was lying prone

in a shallow trench when an enemy mortar shell exploded nearby, rendering him unconscious.

He was taken to a hospital by litter and was told that he remained unconscious for 8 hours.

According to his own statement, he remained dazed and amnesic for the next 2 weeks. The

hospital records indicated that there was no sign of external injury to the head or elsewhere.

During this period, he took nourishment and attended to his physical needs but was restless

and complained frequently.

About 1 week after the trauma, he was removed to a base hospital, where he remained

6 weeks. He complained of headache, dizziness, tinnitus, and irritability to noises. He

was described as being depressed, with a diminished affect and a tremor of his hands.

Occasional unsteadiness of gait was noted, as well as past-pointing in the finger-to-nose

test. Medication afforded him no significant relief from his headache, and it remained

extremely severe for about 6 weeks. It was apparent from the hospital record that the

patient's symptoms were interpreted as of functional origin.

His complaints remained essentially unchanged in quality upon admission to the

neuropsychiatric service of the Kennedy General Hospital except that the headache was

no longer as severe as it had been for the first several weeks. He appeared well nourished.

He was somewhat restless and tense, but he mingled freely with the other patients and

participated in various hospital recreational activities. Psychiatric examination did not

reveal any personal determinants indicating a psychoneurosis. He continued to complain

of headaches, but his tension subsided considerably.

On 12 February 1943, 3 days after admission, while straining at stool, he had a sudden,

extremely severe pain in the temporal region (side not specified), which became gradually,

progressively, and relentlessly worse. He had extremely severe nuchal pain and vomited

several times. Neurologic examination revealed nuchal rigidity and Kernig's sign, apathy,

and restless somnolence. The deep reflexes were slightly preponderant on the left side,

with the biceps jerk spreading to the fingers, and a positive Hoffmann sign. Plantar flexion

was nornmal on the left, but on the right, there was fanning of the toes. There was a lower

facial droop on the left side.

Serologic studies of the blood, as well as the chemistry and cytology of the urine, were

normal. The cerebrospinal fluid was grossly and uniformly bloody.

The patient's mental attitude and emotional state were normal except for his restlessness and emotional response to his pain, and the display of some annoyance when the neurosurgeon attempted to elicit a detailed history of the trauma and the subsequent course

leading up to his recent acute complication. He was loathe to talk about his condition,

his explanation being that he felt that he had not been believed when he had been interrogated at various times in the past. Asked to state his chief complaint in his owvn words

he said:

"I don't 'complain,' sir. But only since you insist: I have had constant headache and

dizziness since I recovered consciousness, and treatment has given me no relief. I have

been told that I am psychoneurotic and that my complaints arise from my mind. I am

not competent to discuss a medical diagnosis, but to me my complaints have been very

real. The headache I have now is new and different from the one I had before. I don't

care what the diagnosis is, as long as I get some relief."

This patient grew progressively and sporadically worse, with crises of slow pulse, syncope, and excruciating headache, lie was seen in neurosurgical consultation because the
236 NEURtOSURGERY

persistence of severe headache since the onset of his illness made it desirable to rule out

chronic subdural hematoina, complicated by recent subarachnoid hemorrhage.

The possibility of chronic subdural hematoma seemred slight, but because of the urgency

of his present condition, bilateral trephine explorations were carried out in the early morning

of 19 February 1943. They revealed only some blood in the subarachnoid space, with

increased cerebral tension and edema of the cortex.

The clinical course continued progressively bad. The patient became apathetic and

febrile. Fixed, irregular, dilated pupils developed, the left being larger than the right

He expired on 20 February 1943, after Cheyne-Stokes breathing, a rapid, thre(, lv pulse,

and apnea had developed.

The clinical diagnosis was (1) ruptured congenital aneurysm in a case of cerebral blast

concussion or (2) cerebral blast concussion with delayed posttraumatic hemorrhage (spMtapoplexie) .*

The autopsy findings (Maj. Emmerich von Hlaam, MC) were as follows:

Gross pathology.--The skull and dura, aside from the bilateral posterior trephine openings, were normal. The leptorneninges were normal. The subarachnoid space, chiefly

around the pons and brain stem, contained hemorrhage. The brain weighed 1,280 gin.

The sulci were slightly flattened. There were no congenital aneurysms or varices. The

basilar vessels showed no evidence of injury or arteriosclerosis. The cervical spinal cord

removed with the brain showed no gross pathologic change.

Sectioning the brain after fixation revealed a massive hemorrhage involving and destroying the posterior part of the internal capsule, the caudate nucleus, and parts of the

thalamus on the left side. The hemorrhage had perforated into the lateral ventricle. The

tissue surrounding the hemorrhage was soft and grayish brown and contained numerous

small hemorrhages. The point of the bleeding vessels could not be determined. The brain

tissue of the right hemisphere was edematous.

Microscopic pathology.-Acute changes noted in the site of the lesion were massive

hemorrhage with extensive destruction of the brain tissue and numerous secondary hemorrhages. Other sections of the brain showed diffuse edema and an occasional thrombosed

vein which was markedly dilated.

Chronic changes in the tissue adjacent to the hemorrhage were characterized by severe

myelin degeneration with beginning gliosis and sonme hemosiderin pigment. The ependymal

lining was intact, but subependymal gliosis and edema were present. No pathologic changes

were found in the cerebellum.

The cause of death was attributed to a severe intracerebral hemorrhage with increased

intracranial pressure and extensive destruction of brain tissue. The age of the patient and

the normal appearance of the entire arterial system, including the basilar artery and its

branches, made arteriosclerotic, syphilitic, or mycotic arteritis rather improbable. No

miliary aneurysms were found.

The pathologic diagnoses were severe intraventricular hemorrhage and extensive,

subacute, traumatic encephalonalacia (due to blast concussion). The post mortem findings,

with the clinical history, pointed to the relationship of this brain hemorrhage to the blast

injury suffered in the Pacific war area.

CLINICAL FEATURES OF BLAST CONCUSSION

Atmospheric Blast Concussion

In a neuropsychiatric-neurologic-neurosurgical center of the Zone ot

Interior, Cramer, Paster, and Stephenson observed a large group of cases of the

closed head injury syndrome in which blast concussion had been the responsible

4' Bolllnger, 0.: Ueber tratumatische SpIt-apoplexie. Intenat. Beltr. z. Wlqsengch. Mcd. 2: 459-470, 1891.
BLAST CONCUSSION AND CEREBRAL INJURIES 237

factor. Most of the patients had been evacuated from overseas as neuropsychiatric problems. About half had been given the primary diagnosis of

psychoneurosis, further qualified by such diagnoses as war neurosis and conversion hysteria. In a few instances, the diagnosis of chronic subdural hematoma had been made early in the course of the illness, on the basis of persistent

headache, abnormalities of the reflexes, inequalities of the pupils, and, very

occasionally, a shift, demonstrated roentgenologically, of the pineal gland to

one side of the midline. These patients had had surgical explorations to rule

out hematoma.

It is of interest that this hospital did not receive any cases of blast injury

in which subdural hematoma was found. This is in contrast to the observations of Abbott and his associates and Hamlin. The apparent absence of

subdural hematomas does not rule out the possibility of the occurrence of small

subdural hematomas or effusions such as one often sees in autopsies in cases of

skull injury in which these particular lesions could not be diagnosed ante

mortem because they were not acting as expanding lesions.

In a few other cases, in which there were objective neurologic changes,

blast concussion was the primary diagnosis. In one case, acute cerebral hemorrhage due to blast injury was diagnosed immediately. For the most part,

however, it was apparent that a psychiatric, interpretative approach was used

during the early observation and diagnosis of most of these cases. It was more

readily apparent in the Zone of Interior, on an average of 5 months after the

injury, that not psychogenic factors but the residua of an organic trauma were

producing the persistent symptoms.

The selection of cases for this study was made from patients in whom direct

trauma, either by missile or blunt blow, or by gross acceleration and sudden

deceleration of the head, could be ruled out with as much certainty as can be

brought into a clinical problem of this type.

The causes of trauma were explosive missiles (mortar shells in about a

quarter of the cases), artillery shells of both Allied and enemy origin, and

aerial bombs. Most of the soldiers had had some sort of protection by trenches.

Several of them, exposed to blasts from heavy shells, estimated that they had

been within the lethal range of that type of shell, while some believed that they

were within 50 to 150 feet of exploding 155-mm. shells. About a third of the

patients were in the same hole or slit trench, or in the same immediate site,

as other soldiers who were either killed outright by the blast or were injured

by it, in contrast to injury by the fragments of the shell or debris from the

explosion.

Early symptoms.-Early symptoms were as follows:

1. Unconmciousness.-This was usually immediate. In a few cases it was

delayed for a matter of moments, or minutes, during which the individual had

the opportunity to attempt to do something practical, such as run to the

assistance of other wounded or seek better shelter. In these cases, the neurologic picture, both early and late, was significant of definite cerebral

hemorrhage.
238 NEUROSURGERY

About 20 percent of the patients were unconscious for less than 30 minutes,

60 percent were unconscious for from 9 to 18 hours, and the remaining 20

percent were unconscious for from 2 to 5 days. It is, of course, impossible to

try to estimate for what part of this period the soldier was in coma and for

what part in stupor and apathy. Because of the amnesia which followed, the

patients usually estimated the period of lost consciousness to be longer than

that indicated on available detailed records. The records more frequently

described the patients as being confused, dazed, and disoriented. A further

complication arises from the fact that hypnotics were administered in effective

doses early in the course of treatment.

2. Headache. - The first awareness after regaining consciousness was

usually of an extremely severe bursting type of headache, which continued

unabated, for a number of days or up to a few weeks, before it began to remit

to any notable degree. This headache (lid not respond to analgesics, and

time alone seemed to be the chief leaven.

3. Tinnitu.,.-This symptom occurred almost invariably but was not as

intolerable as most of the other symptoms.

4. Dizziness.--This was frequently described in terms of true vertigo and

had about the same frequency and course as the tinnitus.

5. Tremors.-These took various forms and occurred in about half of the

cases. Usually, they were generalized and consisted of violent involuntary

trembling of all four extremities and the body. In a few cases, the tremors

were monolateral or were confined to one extremity, usually the arm; in these

cases, the homolateral side of the face was also involved. Occasionally, the

tremor was confined to the head. Other involuntary movements observed were

seeming purposive movements. In one case a facial motor tic developed.

6. "Nervous" ,ymptoms.-"Nervousness" was the term m0,t patients used

to describe their other symptoms. The most frequent ( nplaint was the

inability to tolerate loud or sudden noises or sudden movements, which often

precipitated marked startle responses. Restlessness, anxiety, and fearfulness

were frequent. Fear was either spontaneous or in response to stimuli, such

as the explosion of a shell or the passage of aircraft overhead. Some patients

were wildly disoriented as well as fearful during the early phases and required

heavy sedation, which doubtless contributed to many of the reports of prolonged amnesia. Insomnia and battle dreams occurred frequently.

7. Symptoms oj neurogenic origin.-Anesthesia and paralysis were usually

very transient and were of various types, quadriplegic, hemiplegic, or monoplegic.

Late symptoms.-The late symptoms were as follows:

1. Headache.-In about 60 percent of the cases, the severe headache

usually did not persist without surcease for longer than 1 to 4 weeks. In about

20 percent, it persisted longer, sometimes with spontaneous relief and at other

times with relief following medication. No constant references either to

changes in the quality or location of the headache could be elicited, although
BLAST CONCUSSION AND CEREBRAL INJURIES 239

altering the position of the head sometimes played a part, in the production or

severity of the symptom.

2. "Nervous" symptoms.-"Nervousness" was complained of by most of

the patients. It was difficult, for them to elucidate this symptom further.

The inability to tolerate sudden or loud noises was the next most serious

complaint. About a quarter of the patients stated that they could not adjust

to the excitment of social gatherings and had been forced to forego this activity

because of their loss of equanimity. The same was true when they found

themselves in the presence of arguments and discussions. They became acutely

uncomfortable and were forced to withdraw, whether the. discussions were

friendly, serious, or contentious.

3. Dizziness.-This partook of true vertigo in less than 10 percent of the

cases. Most patients described only momentary periods of feeling dazed or

light headed.

Physical examination.-Unfortunately, complete neurologic examinations

of the early phases of these conditions were infrequent in the medical

records, and, as already noted, they were more often interpretative than

objective.

In the last phases, despite the anxiety and dejection which still colored

the patients' emotional behavior, their bearing was nevertheless unusually

cooperative and relatively dispassionate and objective. The attitude displayed

by the patient whose case is described in detail in the section on pathologic

changes (p. 234) serves as a prototype for the group.

Neurosurgical evaluation.-The group of patients who were selected by

the neuropsychiatric service for neurosurgical evaluation were examined as

critically as though they were suspected of harboring brain tumors. For the

most part, gross neurologic discrepancies did not persiK. Slightly more than

a third of the patients still displayed some tremor, usually fine and rhythmic,

occasionally of a coarser type, and most often involving the extremities on the side

on which there was a slight hyperreflexia. The head and frce were involved

only infrequently. About 25 percent displayed slight but definite and persistent

inequalities in the deep reflexes, one side having a relative hyperreflexia. Pupillary inequality, however, occurred more frequently than the inequality of the

reflexes; it was observed as often on the right side as on the left. It was noted

on repeated observation in slightly less than 50 percent of the cases that one

pupil was consistently larger than the other. When both conditions were

found in the same individual, they were more often contralateral than ipsilateral. This observation was one of the factors leading to the request for neurosurgical consultation, since this finding is well known in chronic subdural

hematoma.

In the earlier coiir~e of the collaboration, pneumoencephalography was

carried out in these particular patients. There was usually a visible and

measurable enlargement of one of the lateral ventricles, although no evidence

of subdural hematoma was found. The enlargement of the ventricle was
240 NEUROSURGERY

almost always contralateral to the hyperreflexia. It was interpret 1 -!% evidence

of a slight, cerebral atrophy resulting from the eneephalopathy .o,! wing the

trauma.

In a comparable study, Aita and Kerman w reported significant findings

in seven cases (20 percent, of their series). Their findings consisted of pathologic reflexes, brain-st em cerebellar-tract signs, brain-stem cranial nerve

(listurbances, masked facies, tremor, and, in one case, unilateral optic nerve

injury resulting in blindness. The group sustaining concussion by solidborne

head injury showed significant changes in nine cases (30 percent), pathologic

reflexes being the most outstanding finding. Aita and Kerman specifically

avoided the inclusion of cases in which gross primary injury to the brain or

skull had occurred and rigorously selected those cases in which the clinical

histories indicated concussion to have been caused by blast alone. They thus

chose to group the two categories of cerebral conc=,.ion and encephalopathy

together under the closed head injury syndrome.

Reports from the literature.--The case of a man sustaining cerebral blast

concussion was described by Tunbridge.' The accident was viewed by eye

witnesses, as follows:

A soldier, 32 years of age, was in an open square with two friends when an

enemy aircraft dived to attack a neighboring building. The other two men

fled for cover, while the patient decided to lie flat in a small gulley. The bomb

dropped within 5 yards of the gulley. He remembered nothing further of the

incident and was unconscious until he awoke in an ambulance. On admission

to the hospital, he was highly disoriented and irritable and had a complete

amnesia for the incident. He remained disoriented for about 48 hours. He

did not know that one of his friends had been killed by the explosion. The

amnesia was not broken down by Pentothal Sodium (thiopental sodium).

Physical examination of this patient showed hemorrhage into, and congestion of, the eardrums. His face was pitted with small particles of (lust.

Roentgenograms showed no fracture of the skull, but lumbar puncture revealed

uniformly bloodstained spinal fluid under 200 mm. H20 pressure; this procedure

gave relief from headache. This soldier eventually recovered and returned

to duty.

Barrow and Rhoads .2 also described as one of the clinical characteristics

of blast concussion in the patients whom they observed a pronounced decrease

in psychomotor activity. Their patients were listless and apathetic and seemingly overcome by fatigue and lassitude. They were content to stay in one

place, made no conversation, and had few requests. They did not complain

or cry out with pain. They did not request water or sedation. They were

men stunned and stupefied. Unconsciousness was of short duration. Tremor

such as that sometimes associated with intense emotion was common at the

U See footnote 25, p. 240.

31 Tunbridge, R. E.: Cause, Effect and Treatment of Air Blast Injuries. War Med. 7:3-6, January 1945.

#2 See footnote 21, p. 221.
BLAST CONCUSSION AND CEREBRAL INJURIES 241

time of hospital admission of conscious patients. Convulsions were observed

in some of those who were fatally injured, and others had muscular twitchings.

Memory was normal for the events leading up to the period of unconsciousness

and was not impaired after recovery of consciousness.

The vital condition of these patients was characterized by hypotension,

a slow pulse, slight fever, and shallow, sighing, slow respiration. When death

occurred, it was almost instantaneous. A survival of as long as an hour was

usually followed by recovery.

Similarly, Klemm, 1 selecting 36 patients out of 90 such admissions during

one month, studied them 10 to 20 days after they had sustained blast concussion.

The injuries resulted from a variety of missiles, which were estimated as having

exploded from 2 to 15 feet away. Klemm found that the clinical history

conformed to a uniform pattern, which was quite like that described. Of the

patients considered to have had pure blast injury, 25 percent had hemoptysis,

25 percent had epistaxis, and 50 percent had vomiting. He did not report the

details of neurologic examinations, which showed no remarkable changes. Two

patients exhibited generalized myoclonus, which in 3ne case persisted during

sleep. Persistent apathy and fatigue were noted. Klemm had no reservations

concerning the etiologic relationship of the blast factor or the diagnosis of a

true concussion, but he was unable to determine to what extent the harrowing

battle experiences had contributed to the persistence of the patients' apathy

and fatigue.

Stewart, Russell, and Cone 5" also reported a small series of patients

exposed to blast. Their patients showed no mark of external violence and

had no focal neurologic signs of injury to the brain. Some of them, however,

when examined some days later, had xanthochromic spinal fluid and evidence

of damage to the anterior horn cells of the spinal cord. Their mental state

was characteristically either apathetic and indifferent or depressed.

In common with others, Rogers - "* * * noted the apathy, lassitude and

dejection of certain of the human victims of air raids." He thought that

bloody or xanthochromic spinal fluid indicated small scattered cerebral hemorrhages in the central nervous system and believed that they occurred much

more often than had been recognized.

In a naval hospital in the Zone of Interior, Bailey " found that 25 percent

of the patients considered to have had blast concussion displayed organic

symptoms of various degrees, while 75 percent were regarded as having purely

neurotic symptoms. The latter symptoms were chiefly anxiety and occasional

evidence of hysterical fragments, but no obsessive-compulsive states were

observed. Electroencephalograms and details of the neurologic examinations

were not reported.

U Klemm, R. A.: Atmospheric Blast Concussion: Medical Aspects. U. S. Nay. M. Bull. 44:1228-1230, June 1945.

84 See footnote 40, p. 230.

33 See footnote 4V, p. 231.

56 Bailey, P.: Neuropsychiatric Casualties Resulting From Exposure to Atmospheric Blast. Arch. Neurol. & Psyebiat.

55, 551-553, May 1946.
242 NEUROSURGERY

A battery of psychologic tests and psychiatric, neurologic, and electroencephalographic examinations were employed by Lynn6 ' in the differentiation

of organic states as opposed to the neurotic reactions in closed head injuries.

In 2 of the 13 cases selected for this special study, the history and the evaluatiun

were definitely corroborative of blast concussion as the primary cause of the

persistent syndrome.

Immersion Blast Concussion

In a symposium on immersion blast injuries, Hamlin " presented the

neurologic observations in 12 persons out of 35 who were injured by underwater

explosion while swimming or floating after the loss of their ship. Five had

been definitely rendered unconscious, and another was probably unconscious.

Ten had red blood cells in the spinal fluid. Most had headaches. Other

findings, in varying degrees, were amnesia, disorientation, somnolence, and

personality changes. One patient, who exemplified the typical blast-concussion

phenomena, was of particular interest because he had sustained an earlier

air-blast concussion, as well as another immediately preceding his exposure to

immersion blast.

This patient had bursting retro-orbital headache, tinnitus, sensitivity to

noises, and nightmares of battle experience. He had spontaneous, involuntary

flexion movements of the upper and lower extremities involving postural muscle

groups; elevation and forward rotation of the shoulders; and occasional contractions of the muscles of the neck and trunk. The movements were paired and

became exaggerated under observation and conscious effort to control them.

They ceased with sleep. His speech was halting, emissive, and aphasic.

When distracted, he had difficulty returning to his train of thought. His

memory performance and calculation tests were poor. He had agnosia for

right and left. Yet his personality made a good impression, and the findings

were considered, by most observers, to be more organic than functional and

suggestive of extrapyramidal as well as diffuse insult to the cerebral cortex.

Cerebral Contusion From Blast

A nonfatal case of blast injury with neurologic signs but without direct

trauma to the head of "concussion" (unconsciousness) was described by Garai.5 '

A 29-year-old soldier heard a bomb in the air and threw himself into a gutter.

The bomb burst a short distance away, and, as he started to arise, a second

bomb fell behind and to the left of him; the resulting blast blew him a few feet,

across the pavement. He did not strike any object and was not unconscious;

he remembered seeing a man collapse some distance ahead. When the patient

arose to walk, he experienced pain in the small of his back, blood came from

a? Lynn, J. G., Levine, K. N., and Hewson, L. R.: Psychologic Tests for the Clinical Evaluation of Late "Diffuse

Organic," "Neurotic," and "Normal" Reactions After Closed Head Injury. A. Research Nerv. & Ment. Dis., Proc.

(1943) 24: 296-378, 1945.

5See footnote 45, p. 233.

"Garal, 0.: Blast Injury: Non-Fatal Case With Neurollgical Signs. Lancet 1: 788-789,17 June 1944.
BLAST CONCUSSION AND CEREBRAL INJURIES 243

his mouth, and he had bloodstained sputum and hematuria, all typical svmptoms of blast injury.

On examination 36 hours later at Sutton Emergency Hospital, he was

rational and composed. He had a slight icterus but no eccbymosis. Neurologic examination revealed( tile right pupil to l)e moderately dilated, without

light reaction, and sluggish to accommodation; this finding still remained

detectable a year later. The left plantar reflex was extensor in reponse. The

cerebrospinal fluid was under 100 nun. H20 pressure; it contained 20 rmg. of

protein, was clear, and contained no cells. The Wasserman, Kahn, and

Lange tests were all normal. The general physical examination revealed

bloodstained sputum, diminished excursion of the left side of the chest, patchy

impairment of the percussion sound, and displacement of the trachea toward the

left. There was impaired translucence of the left chest on roentgenologic

examination, without evidence of tuberculosis. The pulse rate was 70 and

the blood pressure 130/75. The abdomen was tender to palpation in the left

loin. The urine, for 1 week, contained some blood and albumin.

Garai considered thatThe right sided pupillary changes associated with signs of pyramidal involvement on the

left suggest a lesion, possibly haemorrhagic, in the peri-aqueductal grey matter of the upper

part of the midbrain. This may have been the result of contrecoup; or the effects of blast

on the thorax and abdomen may have caused a sudden increase in venous pressure in the

CNS with resulting haemorrhages.

The electroencephalographic records of this case in the acute and chronic

stages, which are of great interest, are reported in the section of this chapter

devoted to the electroencephalogram (p. 248).

In 26 out of 259 cases of injury from flying bombs, Bell 60 observed that

there were 4 instances of cerebral concussion and 3 of cerebral contusion.

Two of the three patients in the second group had blood in the cerebrospinal

fluid; one had sudden paralysis of the left arm, and one, described under the

section on pathologic changes (p. 240), had free blood cells in the brain tissue.

Bell also described two cases of paralysis of the pupillary mechanism, and,

although he attributed the paralyses to fear, it seems more proper to consider

them as of organic rather than psychogenic origin, since it is highly improbable

that even acute fear alone can produce a persistent paralysis of the pupillary

light reflex. The condition of one of these patients was described as acute;

his pupils were widely dilated and did not respond to light. The other patient

was an intelligent woman, aged 24 years, who had widely dilated pupils; the

right did not respond to light, and the left contracted only slightly. In a few

days, the left eye improved, and in about 6 months she made a full recovery.

It should be noted that there was a!so marked sweating in this case, and the

inference is that both the pupillary reflex and the sweating mechanisms should

properly be considered as evidences of lesions in a cerebral vegetative center

resulting from the intrinsic changes precipitated by the blast injury.

0 See footnote 38, p. 229.
244 N EUROSURGERY

THE ELECTROENCEPHALOGRAM IN BLAST CONCUSSION

Three groups of workers have inade encephalographic studies in relatively

large numbers of cases of closed head injury due to blast. Von Storch ý,

obtained electroencephalograms during the first hours and days after exposure

to blast injury in 33 patients. Aita and Kerman 62 studied 34 patients in later

stages. Stephenson 63 obtained routine electroencephalograms in 441 cases iii

which the diagnosis of blast concussion had been made, based on the clinical

criteria already enumerated. In Stephenson's group, unconsciousness had

occurred in 329 cases. Positive evidence of blast damage as demonstrated

by bleeding from the ears or nose, rupture of the eardrum, or conjunctival

hemorrhages was found in 77 cases. Five patients who had never had convulsions before the injury gave histories of convulsive seizures following exposure

to blast. The history of exposure to blast was doubtful in 2 patients included

in the series, and 3 were believed by the referring medical officer to be suffering

from psychoneuroses, with questionable exposure to blast injury.

Whereas many of the patients with milder blast concussion encountered

by Fabing and by Von Storch were returned to duty, the patients on whom

Stephenson's study was based represented those who had received more serious

concussion and had been returned to a hospital in the Zone of Interior. Tlese

studies, therefore, represent only the late, residual changes. The minimum

time which elapsed between the injury and the electroencephalogram ranged

from 3 weeks in 1 case to at least 80 w-eeks in 6 cases, the mean being 24.4 weeks.

The fact that changes in the electroencephalogram persisted so long after

trauma emphasizes the probability of real, irreversible traumatic changes in

the brains of these individuals.

The Results of Electroencephalography

The electroencephalograms obtained from the individuals studied by

Stephenson ranged from entirely normal to pathognomonically abnormal, as

judged by standard works on the subject*64

In figures 47 and 48, the distribution of normal, borderline, and abnormal

electroencephalograms in eight clinical groups of soldier patients is compared

with normal controls. The group suffering postconcussional symptoms after

blast injury had a larger percentage of normal readings than the group with

skull defects, epilepsies, focal injuries, and miscellaneous organic conditions,

but fewer normal readings than the group with migraine, other headaches, and

miscellaneous psychoses. The percentage distribution is represented in table 9,

in which it will be seen that a control series of 140 cases of normal individuals

"it See footnote 22, p. 222.

U See footnote 25, p. 224.

a See footnote 26, p. 224.

4 (1) Davis, P. A.: Technique and Evaluation of the Electroencephalogram. J. Neurophysiol. 4:92-114, January

1941. (2) Gibbs, F. A., Gibbs, E. L., and Lennox, W. G.: Electroencephalographic Classification of Epil-ptic Patients

and Control Subjects. Arch. Neurol. & Psychiat. 50: 111-128, August 1943. (3) War Department Technical Bulletin

(TB MED) 74, 27 July 1944.
BLAST CONCUSSION AN I) CEREBRAL I NJURI ES 245

(eivilians) cotitajinmd only 9.2 percent of ahiioirmd tracinigs, Nvhvivas at svrivs of

blast conicussion vCast's COnltaiii it't 15.9 pri tof atIbl~rial-1 recordIs.

CONDITIONS PERCENT

0 20 4 08 0

NORMAL CONTROLS

(140 CASES)

HE ADACHE

(201 CASES)

PSYCH OSES

(57 CASES)

MIGRAINE

(51 CASES)

BOMB BLAST

(441 CASES)

MISCELLANEOUS

(339 CASES)

FOCAL LESION

(761 CASES)

EPILEPSY

(768 CASES)

SKULL DEFECT

(442 CASES)

EM NORMAL Ii]BORDERLINE ABNORMAL

Fi(; uRE 47.-] )st rib)ItiotI of norinal, b~orderline, and abnornial electroencep~halogramls in

eight clinical groups of syinptonts and signs comipared with normal controls.

TAkBLE !).-Percentage distribution of normnal, borderline, and abnormal electroencepha lograms

in two series of late cases of blast concuission

Series Normal Borderline Abnormal

Percent 1Percent Percent

Controls ---------------------------------- -- 6 8. 6 22.2 9).2

Blast concussion I------------------------------------------------------ .56. 5 27. 6 15. 9

Blast. con1cussion 2-----------------------------------------------------57.0 36. 0 7.0

I Cramer, F., Paster, S., and Stephenson, C.: Cerebral Injuries Due to Explosion Waves-" Cerebral Blast Concussion." A P'athologic. Clinical and Electroencephalographic Study. Arch. Neurol. & Psychiat. 61: 1-20, January 194g.

2 Aita, J. A.. and Kerman, WV. Z.: The Closed Head Injury Syndrome Due to Blast. Bull. U. S. Army, At. D~ept..

6: 411-427, October 1946.

4557351-58 -- 1 7
246 NEUROSURtGERY

STATUS OF PATIENTS PERCENT

0 20 40 60 80 100

NOT UNCONSCIOUS,

NO SIGNS

NOT UNCONSCIOUS,

WITH SIGNS IEMEEMI

UNCONSCIOUS,

NO SIGNS

UNCONSCIOUS,

WITH SIGNS

MENORMAL BORDERLINE ABNORMAL

FwGURE 48.-I)istribution of normal, borderline, and

abnormal electroencephalogramns after bomb-blast concussion

with and without unconsciousness and with and without

physical signs of blast injury.

Stephenson's figures in table 9, when subjected to the chi square test (a

statistical test which measures the degrees of difference between the actual

frequencies) show definite, statistically significant deviation from the normal.

The incidence of borderline and abnormal records obtained from patients

exposed to blast injury falls well outside the limits of probable chance. In

the group of patients who had signs of neurologic disturbance, the recordings

show a greater incidence of abnormal electroencephalographic findings than in

those without abnormal neurologic signs.

Aita and Kerman included a greater number of cases under the borderline

heading. From the point of view of statistical probability, it would seem that

more of their cases might have fallen under the abnormal classification. This

point is raised because the incidences of normal findings in both series are

within 0.5 percent of each other, whereas the incidence of abnormal findings in

Aita and Kerman's study is identical for solidborne concussion, blast concussion,

and psychoneurosis (7.0 percent). Heppenstall and Hill 5 also found a 57-

percent frequency of abnormal encephalograms in the postconcussion syndrome.

In the group of acute cases studied by Von Storch, the electroencephalogram, in patients injured by blast, with questionable evidence of unconsciousness, tended more toward abnormality than it did in those patients who were

definitely rendered unconscious by the blast injury. Stephenson's group also

noted a greater aberration toward borderline and abnormal electroencephalograms in the patients who had not suffered a loss of consciousness than in those

who had; his examinations were made in the later stages. In the later stages,

however, the patients who had positive physical signs of blast trauma had

more definite abnormality in the electroencephalograms than did those without

physical signs. By way of comparison, Stephenson noted that the patients in

65 Heppenstall, M. E., and lIll, D: Electroencephalography in Chronic Post-Traumatic Syndromes. Lancet

1: 261-263, 27 Feb. 1943.
BLAST CONCUSSION AND CEREBRAL INJURIES 247

both series who had been injured by a solid blow to the head had more electroencephalographic abnormality than those injured by blast concussion.

This was true both in the study by Aita and Kerman and in that by Stephenson.

Both studies were comparable in respect to the time intervals between the

acute concussion and the electroencephalogram under consideration, as well

as in the proportions of cases which were normal and not normal.

The types of electroencephalographic abnormalities described by Stephenson included the following:

1. Increase in the percentage incidence of intermediate activity 0 of 13

to 18 cycles appears as follows:

Condition- Permtage

Blast concussion ---------------------------------- 27. 7

Closed head injury -------------------------------- 26.6

Open head injury --------------------------------- 23. 1

Normals ---------------------------------------- 20. 0

All others --------------------------------------- 23.3

2. Moderate increase in the incidence of disruption of the alpha activity

into double its frequency, giving rise to the occurrence of double alpha.

3. Suppression of alpha activity (table 10).

Although these figures do not appear statistically significant, they approach

very closely to the borderline and appear to indicate a trend. A larger group

of control cases with the same relative incidence would render the findings

definitely significant. The close agreement between the incidence of intermediate activity in blast-concussion and closed head injuries confirms the

impression gained in the laboratory that the blast-concussion group is, at least

TABLE 10.-Comparative frequency of double alpha and suppression of double alpha in blast

concussion and other conditions I

Frequency

Group classification Number Double Suppression

alpha of alpha

Bomb blast ----------------------------------------- 441 9. 1 6.6

Controls ------------------------------------------------ 140 6.4 2. 1

Epilepsy ------------------------------------------------ 768 4. 5 3. 9

Focal lesions -------------------------------------------- 761 6. 7 10. 7

Migraine ----------------------------------------------- 51 5.9 2.0

Headache, nonspecific ------------------------------------ 201 4. 5 2.0

Skull defects -------------------------------------------- 442 5.7 24.7

Psychotic states ----------------------------------------- 57 5.3 5.3

Miscellaneous ------------------------------------------- 339 4.7 2.6

SCramer, F., Paster, S., and Stephenson, C.: Cerebral Injuries Due to Explosion Wave&---" Cerebral Blast Concussion." A Pathologic, Clinical and Electroencephalographic Study. Arch. NeuroL & Psychlat. 61:1-20, January 1949.

6 Brazier, M. A. B., and Flnesinger, 3. E.: Characteristics of the Normal Electroencephalogram. 3. Cln. Investigation 23:303-311. May 1944.

07 Williams, D.. and Reynell, I.: Abnormal Suppression of CoTtical Frequencies. Brain 68:123-161. June 1945.
248 NEUROSURGERY

electroencephalographically, only a subdivision of the larger group of closed

head injuries, including concussion from any source.

There also occurred a moderate increase in the incidence of disruption of

the alpha activity into double its frequency, giving rise to the double alpha.

The increase in this characteristic is not sufficient to warrant the assumption

of any definite conclusions, but, again, it represents a trend.

Suppression of alpha activity occurredl significantly more often in the

electroencephalograms of patients with blast concussion than in normal controls. It was found more often in cases of closed head injury and most often

in cases with the very severe skull (defects. Williams and Reynell considered

this suppression of alpha activity to be "always abnormal * * * [and occurring]

around penetrating gunshot wounds of the brain, and also in the cortex underlying nonpenetrating gunshot wounds, and depressed fn"-, .... , -!d also in

other circumstances in which brain is violently percusset

When one analyzes the incidence of double alpha aiu ki s5uppression of

alpha activity, as shown in table 10, the evidence in Stephenson's series again

points toward definite brain damage.

Von Storch also observed that the electroencephalograph revealed evidence

of cortical dysrhythmias which were more severe and persisted longer in the

patients with concussion caused by a solid object. Blast concussion produced

changes which were less severe, less prolonged, and more variable in degree.

Although elect roencephalographic changes often persisted longer than neurologic

or psychometric changes, all three tended to run a parallel course with respect

to the duration of the changes. Since Von Storch considered unconsciousness

to be essential to the diagnosis of concussion, those cases in which it had not

been definite were not diagnosed as instances of concussion. Cortical dysrhythmias, however, appeared in a large number of the patients who were exposed

to blast but in whom there was no definite evidence of unconsciousness.

There were 17 patients in this group, 10 of whom manifested neurotic or

psychopathic tendencies, while 7 were otherwise normal individuals. About

a third of these patients manifested no abnormalities detectable by craniofacial,

neurologic, electroencephalographic, or psychologic examination, but over

two-thirds (70 percent) had positive evidence of injury as judged by these

four types of examination. Of 16 patients who had been rendered unconscious

by blast injury, only 9 percent showed no evidence of abnormality in the

examination, while 91 percent had positive findings.

In Garai's case (p. 243), a man who sustained a blast injury to the lungs

and other organs had clinical evidence of a cerebral lesion affecting the pupillary

innervation of the right eye and the pyramidal tract to the left side. Electroencephalography 48 hours after trauma showed a 9-cycle dominant rhythm,

40 microvolts, and equal inhibition in right and left hemispheres on opening

the eyes. The parietal areas had a 4- to 6-cycle frequency of 40 microvolts,

greater on the right side. This finding remained about the same 30 days after

trauma. At this time, "* * * 6-cycle waves in small bursts of significant

voltage [were] seen occasionally from all areas." Five days after trauma the
BLAST CONCUSSION AND CEREBIItAL INJURItES 249

same had been true for all areas, with less evidence of a significant focus.

One year later, the general character of the dominant rhythm was unchanged.

There was generalized irregularity, with tendencies to slow frequencies still

obvious. There was a 6-cycle rhythm of significant voltage from all areas,

greatest in the right parietal area.

Garai, bearing in mind that 10 percent of the normal population have

abnormal rhythms, considered the following factors in favor of an acquired

dysrhythmia in this case:

1. There was an asymmetry of the rhythm iii the two hemispheres.

2. There was a change in the rhythms in the course of time.

Von Storch noted that the various groups of cases tended to show electroencephalographic changes which, if not characteristic for individual cases,

were at least typical of the groups, as shown in table 11. In general, electroencephalographic, neurologic, and psychiatric abnormalities tended to follow

a parallel course with respect to duration and degree of change. Ih some

instances, cerebral dysrhythmias persisted longer than other evidence of

encephalopathy.

The higher incidence of borderline and abnormal cases which Stephenson

found in blast concussion was significantly greater than in his control group,

as was the suppression of alpha activity. The additional increase in intermediate activity and the double alpha were not statistically meaningful, but the

summation of these characteristics indicated a reasonable probability that

there was residual cerebral damage in these cases. The persistence of findings

for as long as 2 years after injury, the mean being 3 months, also lent emphasis

TABLE 11.-Comparative electroencephalographic trends in cases of concussion due to solid

blows and blast, and cases with significant psychogenic complications 1

Observations Solid blows Blast Significant psychogenic com- I plications

Voltage ------------ Normal or low 2----- -- Normal ------------- Low.

Frequency ---------- Normal 3 or mild to Normal with slight Mild random activmoderate random random activity. ity.

frequency.

Bursts of abnormal Mild to marked high Few if any ---------- Occasional, slow.

activity, voltage, slow activity.

Response to hyper- Little or none ------- None ------------- Considerable.

ventilation. Rhythms suggested

psychomotor epilepsy and probably represented

pretraumatic abnormalities.

I Von Storeh, T.: A Study of Cerebral Concussion. In Annual Report, 33d General Hospital, 1945.

2 25 to 50 microvolts.

1 10 seconds.
250 NEUROSURGERY

to the probability of relatively severe damage in those patients whose condition

became chronic and who were evacuated.

CEREBRAL CONCUSSION AND BLAST CONCUSSION

Theories of the Causes of Concussion

The elucidation of two principal mechanisms by which cerebral concussion

is currently believed to be produced may be simplified as follows:

1. In the acceleration-deceleration theory, the phenomena are the result

of a differential of momentum between the brain and skull, when the latter has

been caused to move at the rate of about 28 feet per second. Denny-Brown u

attempted to relate all concussion to this mechanism.

2. The compression theory, for which Scott 69 and Webster and Gurdjian 70

found experimental proof, depends on the belief that increase in the intracranial

pressure, whether by the transcranial or paracranial route, will produce typical

cerebral concussion. It is this etiologic category that most of those who have

been interested in explaining the phenomenon of blast concussion have found

the most suitable, since it is by the paracranial route that the blast forces

appear most likely to pass to the brain. It would appear that the experimental

work of recent years contains the cogent facts on which definitive formulations

regarding the basic cerebral alterations can be made.

Structural alterations in concussion.-Groat, Magoun, Dey, and Windle 71

proved that acceleration concussion and compression concussion were alike in

their clinical manifestations. Windle, Groat, and Fox 72 also proved that these

conditions are typified by the same histologic changes and, furthermore, that

these histologic changes occur immediately after the blow is delivered.

In controlled experiments, these observers delivered concussive and subconcussive blows to guinea pigs, the animals being prepared in such a manner

that it was certain that formalin reached the brain through its blood vessels

within 8 to 30 seconds, or sooner, after wounding. Histologic studies showed

that in the animals which were sacrificed immediately, there were significant

alterations in arrangement, size, and shape of the Nissl bodies of many neurons

of the basal ganglia, chiefly the small-celled ganglia of sensory function, such as

Deiters' nucleus and the sensory nuclei of the trigeminus. These were the

same nuclei in which Groat and his associates observed chromatolysis in other

animals in their series which were sacrificed a day or more after concussion.

Some of the Nissl bodies were fragmented and disarranged by the blow; in other

cells, their particles gave the appearance of agglutination. Similar changes in

the Nissl bodies were observed in two animals which were killed by strong blows.

"U See footnote 12, p. 218.

60 See footnote 3 (1), p. 215.

"70 See footnote 3 (3), p. 215.

71 See footnote 4 (1), p. 216.

72 See footnote 4 (3), p. 216.
BLAST CONCUSSION AND CEREBRAL INJURIES 251

Many of the changes observed in aninils sacrificed 14 to 24 hours after concussion resembled those seen when death occurred immediately after the blows.

Of particular note was the observation that the intracellular changes

found in animals which had received two subconcussive blows were equivalent

to those in animals in which one single, stronger blow had been sufficient to

produce the concussion. Windle and Groat 13 stated that from the cytological

point of view it is inconceivable that extreme degenerative changes involving

ballooning of the cell and complete loss of the Nissl substance can be reversible.

They further observed that the chromatolysis, as studied in successive

stages of its progression in a series of animals in the postconcussional period, led

to the eventual disappearance of as many as half the cells in certain nuclear

masses in tie brain stem. This change occurred in relative proportion to the

severity of the concussion.

Experimental Blast Concussion

Studies comparable to those just cited have not been carried out by

observers who have performed the experimental work in blast concussion, and

the number and scope of 'nvestigations have been very limited. Krohn,

Whitteridge, and Zuckerman 74 proved that (atmospheric) blast produces its

effects through the body surfaces and not by way of the trachea. Their

experiments bore out the general clinical observations that the greatest effect

is upon the aircontaining viscera. They did not attempt an analysis of the

finer structural changes in the brain-stem nuclei, by which the effects of blast

concussion upon the brain could be compared with those of direct cerebral

concussion. In rabbits whose bodies were protected while their heads were

exposed to blast pressures of 200 pounds per square inch, they found no thoracic

or abdominal lesions, but there were subpial hemorrhages over the olfactory

bulbs and bruising of the occipital lobes.

Corey 75 also observed that epidural and subdural hemorrhage occurs when

the head of an animal is immersed under water coincidentally with a detonation.

This phase of the experiments cannot be compared to any clinical counterpart

but suggests that if the body be h;npj.7 protected blast concussion is less apt

to occur.

When the animals in the experiments by Krohn and his associates had

the heads protected and the blast was trans:fiitted through the body walls,

typical damage to the lungs and other viscera was found. Some hemorrhage

into the ventricles of the brain was also noted in rabbits but not in other

species. The cause of death in those animals which succumbed to the blast

was either an undefinable, so-called primary shock when death was immediate

or complications of pulmonary damage wLen it was delayed.

Electrocorticograms were made in 2 cats and 2 monkeys. In the first

cat, there was a small depression of cortical activity from 14 to 17 seconds

73 See footnote 4 (2), p. 216.

74 Krohn, P. L., Whitteridge, D., and Zuckerman, S.: Physiological Effects of Blast. Lancet 1:252-258,28 Feb. 1942.

"7$ See footnote 17, p. 219.
252 NEUROSURGERY

after the explosion, followed by a temporary restoration of the previous activity.

The animal, however, died in 14 minutes. In the second cat, the record was

not readable for 5 seconds; 5 seconds later, electrical activity almost disappeared; after a further 12 seconds, it returned; and it, became apparently

normal after another 11 seconds.

In one monkey, the record was not readable for 20 seconds, and no abnormality was observed when it again become readable. In the other monkey,

before the explosion, there was a well-deeloped discharge of alpha waves of

9 to 11 cycles per second, as well as occasional large waves of 2 per second,

attributed to Nembutal (pentobarbital sodium). Twenty-three seconds after

the explosion, there was a small burst of alpha waves of 9 per second, then a

period of slow waves, larger and more frequent, which disappeared, the record

becoming normal again in 30 minutes. The animal died of asphyxial convulsions in I hour and 40 minutes. The authors compared these results with

those of Denny-Brown,7 6 in which, after direct blows to the head in experimental animals, all cortical activity was abolished immediately, returning after

3 minutes with slow regular waves reminiscent of concussion in the human.

The data from these two groups of experiments are not satisfactory for

comparison, however, particularly since two of the records in the cases of

Krohn and his group were simply reported as not readable during the first

several seconds and there is no knowledge of what they may have shown

during that period.

Corey reported experiments to test the gross effects of blast. Hle observed

that guinea pigs and rabbits outside a radius of 80 feet from exploding charges

of 1,750 pounds of TNT survived the explosion, but he gave no details of later

examination. Guinea pigs and rabbits placed behind a tree 32 feet from an

explosion and behind a parapet .50 feet away were killed. Likewise, goats 32

and 50 feet away, in trenches, whether protected by kapok or unprotected,

were killed. A guinea pig 50 feet away, placed in the long axis of the charge,

and a rabbit 75 feet away, behind a tree, survived. Others 50 to 75 feet away

died in 24 hours. Corey stated that injuries did not occur when the animals

were outside the flash area but were constant when they were within it.

Microscopic changes, the nature of which he did not specify, were found in

the central nervous system in 2 out of 7 animals studied, and transient depression of the central nervous system, which was not qualified further, also

occurred.

Mechanism of Blast Cfnuc 4on

The acceleration theory.-The concept th: ,',- :'ral concussion may occur

without direct action of the traumatic force upon the head is difficult for many

to accept.

Denny-Brown,7 7 who has written authoritatively on some phases of cerebral concussion, asserted: "Concussion, or indeed any similar physical damage

"Is Denny-Brown, D., and Russell, W. R.: Experimental Cerebral Concussion. Brain 64: 93-164, September 1941.

" See footnote 2, p. 215.
BLAST CONCUSSION AND ('EIREBRAL INJURIES 253

to nervous tissue resulting from the force of an explosion transmitted by air

or by water * * * remains an unproven condition."

There are, no di !(t, many who, for various reasons, share this opinion.

On practical gruinds, however, this statement. must be considered ready

for revision, in the light of the numerous published facts which have appeared

since Denny-Brown's observations (1945) and many of which are reported in

this chapter. Denny-Brown himself has not attempted to explain the phenomenon in a positive way but implies that secondary injuries have occurred

to thie, skull or that acceleration-deceleration has always occurred in some

manner.

Fulton 78 has suggested that Denny-Brown's acceleration-deceleration

theory may be applied to this problem as follows: There are two components

to be considered in blast. The first is a primary increase in pressure to 100

pounds or more per square inch, and the second is the rate of movement. He

continues as follows: "A wave of moving pressure that gives acceleration of

the body by virtue of its impact on the body wall-and hence imparts an

acceleration to the body as a whole, including the head-reproduces in a very

precise manner the type of acceleration or deacceleration known to be essential

for t he traumat ic-concussion syndrome."

The compression theory.--Others 1, have applied to the problem the

concept that tile compression wave travels to tile cerebrum through the body

mediums, chiefly by way of the blood stream. This general viewpoint was not

new to World War II, but it would appear that it has been a more or less

original conception of various observers.

The following statements furnish a synthesis of this concept:

1. It is characteristic of the shock wave that its rate of speed varies with

the compressibility of the mediums through which it passes. Its speed depends

upon many factors, including the distance from the explosion and the reflectance

of the wave by solid objects and surfaces in its path.

2. In air, tile speed of the shock wave corresponds to that of sound, which

is about 1,100 feet (335 meters) per second. While the wave is traveling through

water, the speed is about 4,800 feet (about 1,460 meters) per second. These

relationships also hold while tile shock wave is passing through a living body.

Thus, when the rapidly moving compression wave strikes the body, it is transmitted through tile various components of its anatomic structure at variable

rates of speed and with variable results. Upon striking the body walls, it is

transmitted faster through the blood stream than it is through compressible

tissues and the gas-containing viscera. It. is he-,, therefore, that the greatest

damage occurs, also because of another characteristic of the shock wave;

namely, that, at the junction or surface between fluid and gas, a shock wave

moving through the fluid produces a disruption of the surface. This is exemplified, outside tile body, in the case of an underwater explosion, by the so-called

doming of the surface of the water which occurs as the shock wave reaches the

M See footnote 27, p. 225.

" See footnotes 26, p. 224; 39, p. 229; 40, p. 230; and 45, p. 233.

4557355--58-is
254 NEUROSURGERY

surface, as distinguished from the later pluming, or geyserlike eruption, which

occurs when the gases from the explosion, following after the shock wave,

have reached the surface. This same characteristic of the wave holds true for

its effects within the body. Thus, the most typical injury due to blast is a

rupture of the walls of the pulmonary alveoli and of the gut, with attendant

hemorrhage.

3. The shock wave is also transmitted into the cranium and into the

spinal canal by the venous system and probably also by the arterial system.

Several possible factors are at once brought into play. There is a sudden,

violent increase in the intravascular tension of the cerebrum, with immediate

alteration of the physiology of the cerebral circulation and the possible rupture

of vessels. That there will be instantaneous vascular reflex alterations with

secondary stasis, edema, and diapedesis is inescapable. That there may be

hemorrhages of various sizes and degrees and locations, as there are in closed

head injuries in general, is also a foregone conclusion. At the same time,

however, there will be a concussion of the brain (and at times of the spinal

cord) independently of the vascular alterations themselves. The concussive

wave will be applied directly to the brain tissue as a shock wave not only by

way of the vascular system but also by way of the spinal fluid.

At this point, it is highly important to differentiate clearly in one's mind

between two qualities of the blood stream. First, as a circulating body of

fluid, the blood stream has the faculty, on the venous side of its circuit, of

reversing the direction of flow during phases of negative pressure. Second,

irrespective of its circulatory function, the blood stream represents merely a

large body of fluid, and in this respect, it is capable of transmitting a shock

wave in essentially the same manner as any body of fluid. It is this aspect

which is important in the explanation of blast concussion as a phenomenon of

cerebral compression.

A discussion of the physics of the blast wave by Sutherland 8o clarifies

this problem. The point must be emphasized that, as the shock wave itself

moves onward through any substance, there is not a movement or displacement of the matter itself with the exception of the displacement at surfaces of

unequal compressibility. There is merely an oscillation back and forth about

equilibrium positions of the particles of the matter through which the wave

is passing.

An understanding of the facts just stated throws light upon the problem

and should correct. certain misconceptions. For example, in the context of

Denny-Brown's 81 objections to the idea of blast concussion, it. is presumed

that a violent retrograde flow of blood into the cranium would have to occur

in order to produce cerebral trauma. On the contrary, according to the physical principles of blast, the shock wave alone would traverse the blood stream.

It would pass at a rate enormously faster than the blood could possibly flow.

Its effects in the brain and various other parts of the body must be considered

80 See footnote 18, p. 219.

61 See footnotes 2, p. 215, and 12, p. 218.
BLAST CONCUSSION AND CEREBRAL INJURIES 255

to occur within about a ten-thousandth of a second after the blast wave has

struck the body wall. This view of the mechanism of transmission of the

shock wave to the cerebrum corresponds to that brought out in the experiments

by Scott and by Webster and Gurdjian in their work with compression concussion, and in the dynamics proposed by Young.0

The Origin of Symptoms

There have been three principal approaches to the explanation of the

blast concussion syndrome, as follows:

The psychiatric approach.-The most manifest aspect of the problem in

its acute phase, after recovery from the initial unconsciousness, is the psychic

disturbance. Thus, a psychiatric approach has been the most frequent one,

except when there were frank complications of a surgical nature. In their

preliminary report on the war neuroses of North Africa, Grinker and Spiegel

laid stress on the admixture of true postconcussional symptoms with those

which were considered to be psychogenic. Many of their reports of cases in

which an explosion (frequently close enough to kill others in the same immediate site) precipitated a psychiatric disorder were so typical of blast concussion that they should normally fall into that category. The need for differentiating the cases of psychogenic origin from those of concussional origin

was recognized, so that patients with concussions could be treated in one way

and those with psychiatric conditions in another.

The difficulties encountered in making these differentiations on the basis

of the symptomatology alone is patent, for essentially identical somatic and

vegetative disturbances can be seen in individuals who have suffered organic

injury to the brain and in those in whom intense psychic stimuli have liberated

the symptoms. Therefore, it is obvious that anxiety states, regressions, and

conversions do occur. This would be expected in the light of the preoccupation which many soldiers in combat have with thoughts of their loved ones at

home; the safety of their own persons and those of their buddies and fellow

soldiers, for whose welfare they have a highly developed sense of responsibility;

and the regard for admitted fear which everyone has who is in or about to

engage in combat. On the other hand, it is equally obvious that a purely interpretative approach, as contrasted with a systematic study employing all the

modalities of neurologic analysis, will, in general, lay undue emphasis on the

psychogenicity of the symptoms. It largely depends upon the clinical background and personal point of view of the examiner whether he will describe

and treat the presenting symptoms as psychogenic, or as neurogenic (in the

sense of a physiologic functional disturbance), or as manifestations of a true

organic disturbance due to injuries of the central nervous system.

Functional neurogenic interpretation.-The point of view maintained by

Fabing is that the syndrome is of functional neurologic origin; that is, a true

neurosis. The symptoms are considered to arise from alterations in the physi-

" Young, M. W.: Mechanics of Blast Injuries. War Med. 8: 73-81, August 1945.
256 NEUROSURGERY

ology of tile brain in its various levels of functioning, as a result of the intense

stimulus of the blast force, but irrespective of any organic injuries.

In this point of view, it is proposed that the symptoms arise from cerebral

mechanisms as conceived by Pavlov and explained in his ternis. For example,

all of the patients in Fabing's series had aniesia for the sound of tile explosion,

although some may have remembered seeing its flash. Even tinder narcosynthesis, in which most other experiences during the postconcussional amnesia

were recalled, the actual 401111(1 of the eXJ)losionl reniaineld a hiatus in tiltillnconscious memory. According to tile Pavlovian theory employed, this woulh

be due to the fact. that the intense sound wave, to which the blast wave is

equivalent, acts as an ultramaximal stimulus. In passing through the auditory nerve, the wave does not prodluce normal excitation, in tile sense of hearing.

Instead, it produces in the temporal lobe an ultraparadoxical state of activity,

which inhibits the realization of the hearing of the sound. Consequently,

even under Pentothal S'odium (thiopental sodium) narcosynthesis, tile sound

of the explosion is never recalled. According to this theory, it is entirely outside tlhe memory because it has never been registered as anl experience. Fabing

has also explained the other symptoms of the syndrome by the use of these

same conceptions and Pavlovian terminology. Unfortunately, this imethod of

interpretation is somewhat too verbose and weighty to allow further epitomization here.

Fabing's further premise is that organic injuries, including hemorrhages,

do not produce tile symptoms of this syndrome, but are merely epiphenomena

to the physiologic (listl'uban(e.

Organic neurologic explanation.-The consideration of symptoms as

specific evidence of structural disorganization of various specialized areas of

the brain has been proposed by Cramer, Paster, and Stephenson. Their

interest in this phase was stimulated by experiences with cases which were

typical of the cerebral blast syndrome and in which evidence of encephalopathy

was displayed. These patients had persistent organic neurologic findings,

incontrovertible trends from the normal pattern in the electroencephalograms,

and, in one case, a delayed posttraumatic cerebral hemorrhage in the neighborhood of the thalamus from areas of softening produced by a previous blast

concussion and contusion.

Opposed to the attitude that either a purely physiopathologic or psychopathologic disturbance produces this syndrome is the estimate of Aita and

Kerman and of Cramer, Paster, and Stephenson, that there is truly organic

substratum in a substantial number of selected cases. This estimate was

based on tile persistence of symptoms and( physical signs in their cases, and

the trends away from the normal encephalograms, in contrast with the relatively

normal psychometric anti psychiatric studies. It appeared to Cramer and his

coworkers that evidence of disturbance of tile brain-stem centers was found in

the unconsciousness, tile tremors, the vegetative disturbances, and the hyperacusis which accompanied the startle reaction; the confusion and the emotional

lability; and the physical signs, particularly the inequality of the pupils.
BLAST CONCUSSION AND CEREBRAL INJURIES 257

The persistent dysrhythmias in the electroencephalogram may well be of the

same origin, in the light of the experiments of Kennard and Nims. 8 3 They

found, in Macaca mulatta, that damaging the cortex alone produced little or

no change in the pattern, whereas added damage to the basal ganglia produced

profound and permanent rearrangements. The electroencephalogram was

proved to be intimately related to corticogangliar function and not a summation

of cortical potentials alone. The most pronounced changes in their experiment

was "hypersynchrony" ("cusping" or "saw-toothing"). Stephenson found

9.1 percent of blast concussion cases had double alpha.

Unconsciousness, from this point of view, is attributed to disturbance in

the centers controlling sleeping and waking in the hypothalamus, midbrain,

and hindbrain. Davison and Demuth s have reported their findings in various

conditions in which lesions at the diencephalic and mesencephalic-metencephalic

levels were associated with disturbances of sleeping and consciousness. Jefferson I discussed this theory in relation to cerebral concussion. From this

point of view, the unconsciousness is seen as being proportional only to the

type and degree of involvement of these centers. Unconsciousness is not an

indication of the severity of the injury to the brain at large; it is the focal

symptom of altered function of specific areas in the brain, just as aphasia,

apraxia, and paralysis are similar symptoms.

That this alteration in function may also be produced by psychogenic

stimuli, just as many other conditions, including peptic ulcer, may be produced,

is recognized. Unconsciousness, or any other single symptom or sign, cannot

be taken alone as a substantiation of concussion, but each must be evaluated

with the whole. Unconsciousness was a first symptom in many soldiers suffering psychogenic ailments in battle. As reported by Von Storch, however, it

was the general opinion of all concerned in his study of concussion that the

soldiers examined in forward echelons tended to underestimate, rather than

emphasize, the aspect of unconsciousness. Direct observation was possible

in many patients admitted to the hospital unconscious after blast injuries, and

in others, eyewitnesses were available to prove the unconsciousness which was

used as a criterion of concussion. Yet concussion with unconsciousness due

to blast could not be differentiated by any single method of study from the

manifestations of injury due to blast without loss of consciousness. In electroencephalograms in the latter cases, there was more tendency toward abnormality

than in those of patients who had been rendered unconscious. This tendency

occurred to a lesser extent in patients hit by solid objects who did not become

unconscious. From these observations, therefore, one could infer either that

0 Kennard, M. A.. and Nims, L. F.: Effect on Electroencephalogram of Lesions of Cerebral Cortex and Basal

Ganglia in Macaca Mulatta. J. Neurophysiol. 5:335-348, September 1942.

84 (1) Davison, C., and Demuth, E. L.: Disturbances in Sleep Mechanism: A Clinicopathologic Study: III. Lesions

at the Diencephalic Level (Hypothalamus). Arch. Neurol. & Psychiat. 55:111-125, February 1946. (2) Davison, C.,

and Demuth, E. L.: Disturbances in Sleep Mechanism: A Clinicopathologic Study: IV. Lesions at the Mesencepbalometencephalic Level. Arch. Neurol. & Psychiat. 55:126-138, February 1946. (3) Davison, C., and Demuth, E. L.:

Disturbances in Sleep Mechanism: A Clinicopathologic Study: V. Anatomic and Neurophysiologic Considerations.

Arch. Neurol. & Psychiat. 55:364-381, April 1946.

88 (1) Jefferson, G." Neurological Interpretation of Acute Head Injury. Tr. Am. Neurol. A. 69:13-16, 1943. (2)

Jefferson, G.: Nature of Concussion. Brit. M. J. 1:1-5, January 1944.
258 NEUROSURGERY

the changes indicated actual cerebral concussion on a subclinical basis (or,

rather, concussion without unconsciousness) or that the changes in electrical

activity of the cerebrum were due to preexisting abnormalities.

Against the latter interpretation are Stephenson's observations, which

were made in the same type of patient but at a much later period. He also

found that the group subjected to blast who were not rendered unconscious

but who developed the postconcussional syndrome and in whom psychometric

and psychiatric studies favored an organic type of disturbance had more

electroencephalographic disturbances than those who had been unconscious.

Contrasting these findings, however, with his figures for normal controls and

for other types of disturbance, he considered them as definitely following the

trend for blast concussion.

Tinnitus and true vertigo, two relatively short-lived symptoms, are most

likely due to direct concussion of the auditory and vestibular mechanisms in

the inner ear. On the other hand, the hyperirritability to noises and sounds

and the sensations of floating, as well as a part of the persistent nonvertiginous

dizziness, are considered by Cramer and his associates to be due to basic lesions

in the auditory and vestibular nuclei and their representations in the thalamus.

This is the point of view which writers in the German language, as exemplified

by Stier,"6 have for many years been elucidating in respect to the postconcussional syndrome in general. It is also in conformity with the knowledge

regarding the lesions which occur in concussion, as cited earlier in this chapter

(p. 228).

Headache, which is the chief symptom immediately upon regaining

consciousness, is as difficult to explain on any single factor in this syndrome as

it is in concussion due to solid blows and in other conditions in which it occurs.

It may be as generic in origin as are the effects of the all-pervading shock

wave, which may be conceived of as affecting not only the brain and its vessels

but all parts of the integument of the brain as well. As is evident in the reports of autopsies, all of the meninges may be involved by hemorrhage, which

also may be subpial and intracerebral. Cerebral edema has been reported.

The trigeminal pathways, which mediate most of the headaches of dural origin,

are involved at times. The thalamus, which is the accepted penultimate center

for the elaboration of the sense of pain, may also be the site of lesions. Posttraumatic headache, as emphasized by Brenner, Friedman, Merritt, and

Denny-Brown 87 is of organic origin, irrespective of its greater incidence in

cases in which there are bad psychic, social, and economic states.

It is proposed, therefore, by those whose occupation and preoccupation

is in the field of neurologic surgery and organic neurology, that there is sufficient evidence for the somatic origin of this typically recurring train of

symptoms to permit explaining them on this basis without invoking purely

psychic mechanisms for their production. It is true that no single fact or

I Stier, E.: Uber Zwischenhirnschadigung durch Schadeltrauma. Arch. f. orthop. u. Unfall-Chir. 37: 446-448, 1937.

7 (1) Brenner, C., Friedman, A. P., Merritt, H. H., and Denny-Brown, D. E.: Post Traumatic Headache. J.

Neurosurg. 1: 379-391, November 1944. (2) See footnote 2, p. 215.
BLAST CONCUSSION AND CEREBRAL INJURIES 259

mode of diagnosis suffices alone to establish the diagnosis. Yet each method

of study reveals definite trends from the normal, and, when the results of

systematic study are combined, there is little room for doubt that blast concussion not only is an entity but also results in an organic disturbance of the

nervous system. It may well be, as Griinthal, Hiller, and Marburg " and

those whom tbey quote have suggested, that there are not only somatic predetermining factors in the causation of posttraumatic symptoms but that there

many also be factors in the personality which actually predispose to the incurrence of head injuries. Certainly, it is common experience that the individual who has already suffered one concussion is greatly predisposed to

develop inordinate symptoms after successive or subsequent head trauma.

This clinical fact has an organic basis, as pointed out in the experimental

work on concussion quoted earlier (p. 251).

Mental symptoms are not necessarily influenced by the pretraumatic

personality, as Adler 19 and Kozol 90 have observed, each in a study of 200 cases.

Pretraumatic psychoneurosis does not necessarily determine the presence or

absence of posttraumatic neurosis, and, conversely, a normal pretraumatic

personality is no guarantee of the absence of psychoneurosis after head trauma.

Various nontraumatic factors, such as physical disability, the family status, and

economic factors, may influence the posttraumaLic sequelae; yet it is the injury

itself which primarily determines the nature of the symptoms, be they somatic

or psychic.

This point of view militates against any formulation which endeavors to

explain the phenomena of cerebral blast injury or concussion upon the basis of a

purely psychogenic or functional "higher" physiologic basis. In order to apply

that formulation, one would perforce also have to explain the many other phenomena, including instantaneous death, on the same basis. Two or more men

in combat, let us say, are very close together, in one trench or emplacement or

vehicle. They are exposed to the blast of a close-by exploding shell, whose

fragments do not strike them. They do not move from their primary positions.

When some of them die outright and others become unconscious, it is indeed

difficult to concede that the one who lives to manifest the symptoms of a

postconcussional neurosis does so because of a predisposition to neurosis or a

subconscious desire for gain, any more than one can concede that the others had

a predisposition toward dying.

THE TREATMENT OF BLAST CONCUSSION

The end in view in differentiating the true concussions from the anxiety

states is that eventual treatment should be directed along appropriate lines.

98 Griinthal, E., Hiller, Fr., and Marburg, 0.: Traumatische, PrUasenile und Senile Erkrankungen ZirkulationsstUrungen. In Handbuch der Neurologie, edited by 0. Burnke and 0. Foerster. Berlin: Julius Springer, 1936, vol. XI,

pp. 1-100.

"n Adler, A.: Mental Symptoms Following Head Injury: A Statistical Analysis of 200 Cases. Arch. Neurol. &

Psychiat. 53- 34-43, January 1%1,.

00 Kozol, H. L.: Pietraumatic Personality and Psychiatric Sequelae of Head Injury. I. Categorical Pretraumatic

Personality Status Correlated With General Psychiatric Reactiov to Head Injury Based on Analysis of 200 Cases. Arch.

Neurol. & Psychiat. 53: 358-364, May 1945.
260 NEUROSURGERY

It has been recognized that tile patients whose symptoms are chiefly of organic

or postconcussional origin may require relatively long-term treatment, including

evacuation from the battle zones, when the symptoms are persistent. Rest

and broad psychotherapeutic treatmeit may lead to early rehabilitation of the

lesser concussions, but only time will heal the more severely injured brain.

On the other hand, the neurotic states requirt concerted psychotherapeutic

measures, and, when combat exhaustion is a large contributing factor, these

casualties may be rehabilitated within a relatively short time by appropriate

physical and mental relaxation and diversion.

It is a fortunate circumstance that the use of Pentothal Sodium narcosis

anti narcosynthesis not only produced marked therapeutic results in both the

neuroses of battle and the cerebral injuries but also served as a means of differential diagnosis to some degree. When there were frankly psychogenic moieties

in the blast concussion syndrome, patients were very greatly benefited by this

measure. The symptoms of frankly organic type, that is, headache, dizziness,

and hyperacusis, were often greatly modified by this treatment, but, in many

instances, they persisted, irrespective of all forms of therapy, and disappeared

only very gradually, with the passage of time. Evaluation of the neurologic,

psychometric, psychiatric, a, electroencephalographic and pneumoencephalographic findings during this period indicated that there were continuing subacute and chronic intranuclear legeneration and cerebral changes, probably

in the nature of glial cicatrization in the areas of encephialopathy.
CHAPTER XII

Cranioplasty

David L. Reeves, M. D.

HISTORICAL NOTE

Except for the repair of occasional defects caused by accidents, cranioplasty

in civilian neurosurgical practice before World War II had been chiefly directed

to the correction of deformities of the skull resulting from osteomyelitis, from

the removal of infected bone flaps, and from the excision of hyperostosing

tumors. There was rather general agreement that, whenever possible, autogenous bone was the material of choice for the grafts necessary in the operation.

The literature in the field of cranioplasty was exhaustively reviewed by

Grant and NorcrossI in 1939 and again, from the standpoint of the use of

metals, by Venable and Stuck 2 in 1943. Both reviews showed the good results

that could be obtained by the use of other types of materials.

The cranial defects which followed battle injuries stimulated an interest

in the subject in World War II, as in all previous wars. Although other materials were used, cranioplasty with tantalum or the acrylic resins best fulfilled

the needs of the military neurosurgeons who were called upon to handle the

large numbers of casualties with head injuries. The experimental work reported

by Burke I in 1940, Carney " in 1942, and Pudenz ' in 1942 and 1943 had shown

that tantalum was a most satisfactory alloplastic material for the repair of

cranial defects. Experiences with its use in the repair of defects caused by

battle-incurred wounds were reported by a number of military surgeons,

including Fulcher 6 in 1943; Reeves I and Robertson 8 in 1944; Woodhall and

1 Grant, F. C., and Norcross, N. C.: Repair of Cranial Defects by Cranioplasty. Ann. Surg. 110: 488-512, October

1939.

2 Venable, C. S., and Stuck, W. G.: A General Consideration of Metals for Buried Appliances in Surgcry. Surg.,

Gynec. & Obst. 76: 297-304, April 1943.

3 Burke, G. L.: The Corrosion of Metals in Tissues; and an Introduction to Tantalum. Canad. M. A. J. 43:125-128,

August 1940.

4 Carney, H. M.: An Experimental Study With Tantalum. Proc. Soc. Exper. Biol. & Med. 51: 147-148, October

1942.

& (1) Pudenz, R. H.: The Use of Tantalum Clips for Hemostasis in Neurosurgery. Surgery 12: 791-797, November

1942. (2) Pudenz, R. H.: The Repair of Cranial Defects With Tantalum. J. A. M. A. 121: 478-482, 13 Feb. 194.3.

5 Fulcher, 0. H.: Tantalum as a Metallic Implant To Repair Cranial Defects. J. A. M. A. 121: 931-933, 20 Mar. 1943.

7 Reeves, D. L.: The Repair of Traumatic Cranial Defects. Bull. Los Angeles Neurol. Soc. 9:112-119, March-June

1944.

3 Robertson, R. C. L.: Repair of Cranial Defects With Tantalum. J. Neurosurg. 1: 227-236, July 1944.

261
262 NEUIROSUIRGEIRY

Spurling,9 Mayfield and Levichd,' Schnitker and McCarthy,11 and Woolf and

Walker 12 in 1945; and Bradford and Livingston 13 and Turner " in 1946.

Wliether the plate used for cranioplasty was formed by preoperative

molding in a (lie and counterdie or by rough molding at the operating table

with a hammer and rounded form, the inherent malleability of tantalum

allowed adjustment by cutting or contour changing at the time of operation,

and thus eliminated the need for multiple operative procedures. In addition

to its malleability, tantalum has the further desirable qualities of noncorrosiveness, inertness in tissue, nonabsorbability, and absence of toxic ingredients.

As a result of the progress in the field of plastics, as well as the wartime

stimulation to the study of the problem of cranioplasty, it, was only natural

that the acrylic resins should also be employed for the repair of skull defects.

In 1943, Gurdjian, Webster, and Brown"' described their method of repairing

large skull defects with acrylic and reported that one patient was in excellent

condition with no evidence of deleterious reactions, at the end of 15 months.

In 1943, Kerr "8 reported seven such cases.

In 1946, E kins and Cameron 7 reviewed their experiences in 70 cases of

skull defect repaired with acrylic plates between June 1943 and January 1945.

They concluded that methyl methacrylate was a satisfactory material for the

repair of cranial defects, that it was sufficiently strong to assure permanency of

repair, that it produced a minimum of foreign-body reaction in the tissues,

and that it gave excellent cosmetic results. They perfected a technique by

which the plate could be inserted in a one-stage operative procedure.

Acrylic plates possess certain advantages "; that they are not subject to

physical effects incident to changes in temperature or to the effects of electric

phenomena, and that they do not interfere with the taking of pneumoencephalographic films. Their preparation, however, is more difficult than the preparation of tantalum plates, and it is questionable whether the acrylic resins will

ever prove as satisfactory for the repair of large defects as tantalum.

PREPARATION OF TANTALUM PLATE

During World War II, methods used for forming tantalum plates were

similar to those used for other alloplastic preformed materials. Adequate

9 Woodhall, B., and Spurling, R. G.: Tantalum Cranioplasty for War Wounds of the Skull. Ann. Surg. 121: 649-671,

May 1945.

10 Mayfleld, F. H., and Levich, L. A.: Repair of Cranial Defects With Tantalum. Am. J. Surg. 67: 319-332, February

'945.

It Schnitker, M. T., and McCarthy, W. D.: Osteomyelitis of the Skull-Its Treatment With Penicillin and Repair of the Defect With Tantalum. Surgery 18: 94-115, July 1945.

12 Woolf, J. I., and Walker, A. E.: Cranioplasty, Collective Review. Surg.. Gynec. & Obst. 81: 1-23, July 1945.

13 Bradford, F. K., and Livingston, K. E.: Failure in Early Secondary Repair of Skull Defects With Tantalum. J.

Neurosurg. 3: 318-328, July 1946.

1 Turner, 0. A.: Repair of Defects of the Skull. Arch. Surg. 53: 312-326, September 1946.

15 Gurdjian, E. S., Webster, J. E., and Brown, J. C.: Impression Technique for Reconstruction of Large Skull Defects.

Surgery 14: 876-881, December 194M.

16 Kerr, A. S.: The Use of Acrylic Resin Plates for Repair of Skull Defects. J. Neurol., Neurosurg. & Psychiat.

6 (N. S.): 158, July-October 1943.

17 Elkins, C. W., and Cameron, J. E.: Cranioplasty With Acrylic Plates. J. Neurosurg. 3:199-205, May 1946.
CRANIOPLASTY 263

descriptions have been published by Schnitker and 'McCarthy; Mayfield and

Levich; Woodhall and Spurling; Hemberger, Whitcomb, and Woodhall; 8 and

Woodhall." Impressions of the deformity were obtained either by the indirect (primary) method or by the direct (secondary) procedure. Tile onestage method was more commonly used than the two-stage procedure. In

either case, the technique for swaging the plate was the same.

Preparation of Mold

After the patient's scalp had been shaved, the defect was outlined, with

an allowance of an overlap of a centimeter, by means of an indelible pencil,

markings by which persisted on the cast. The material used for the impression

was a dental impression compound, such as Kerr's red compound for the indirect method and the green compound for the direct method, modeling clay,

or a hydrocolloid, such as Truloid.

After an application of mineral oil, the defect was filled in with the dental

impression compound, which had been softened in warm water and worked

manually until pliable. For the purpose of retaining the dental stone or plaster

of paris, the compound was applied considerably beyond the area of the defect.

It was hardened by the application of cold wet towels. When the hardened

compound was removed, the outline and depth of the skull defect were revealed

as an elevated mass in this primary impression. The sides of the dental compound were built up with wax strips or boxing wax to contain the dental stone

or plaster, which was poured in to form a model. A crossmark was scraped

into the depressed area of the dental stone or plaster of paris, to represent the

depth and extent of the bony defect. This area was filled in with tinfoil and

then with dental wax, which was contoured with a heated spatula to correspond

to the surrounding scalp outline. The crossmark scraped in the dental stone

kept the wax restoration from moving. The convexity of the wax fill was overemphasized, to compensate for the subsequent inlay of the plate.

A mold, including the wax restoration and an ample mass of the adjacent

skull contour, was made with some one of the molding sands and a die was

poured with zinc, or, in the case of larger defects, with Hydromite.20 After the

die had cooled, its surface was painted with a solution of alcohol and talc. A

soft clay, such as Moldine, was formed about the circumference of the zinc die

to act as a mold for the counterdie of poured lead. A similar procedure was

used when Hydromite was employed.

Because the hydrocolloid impression material gave a more accurate

reproduction of the detail of the surrounding skull or scalp contour, it was preferred by most neurosurgeons for multicontoured and large frontal defects. The

material was heated in a double boiler until it was of a smooth consistency and

is Hemberger, A. 3., Whitcomb, B. B., and Woodhall, B.: Technic of Tantalum Plating of Skull Defects. J.

Neurosurg. 2: 21-25, January 1945.

19 Woodhall, B.: Cranioplasty. In Surgical Treatment of the Nervous System, edited by Frederic W. Bancroft and

Cobb Pilcher. Philadelphia: 3. B. Lippincott Co., 1946, pp. 63-74. 20Hydromite (United States Gypsum Company) is a mixture of stone and plastic.
264 NEUROSURGERY

was then cooled to 1200 F. for impression over the scalp. To limit the flow of

the hydrocolloid and to facilitate removal of the impression, a cardboard base,

fitting like the brim of a hat without a crown, was placed over the calvarium.

A wire measurement of the circumference of the head was taken with heavy

copper wire to obtain the proper hat-brim size. The impression material was

painted over the defect and the surrounding contour with a soft brush to a

thickness of about 1 inch. Wire mesh might be added to strengthen it, and,

after it had been cooled with towels soaked in ice water, it could be reinforced

further with a layer of plaster of paris. After the mold had set, it was removed

with the cardboard, the outline of the defect was traced with a knife blade over

the marked outline, and the impression was poured in dental stone. The

remainder of the preparation did not differ from that already described for the

dental compound.

Preparation of Plate

The 0.015-inch tantalum plate was then cut to approximate contour, with

an increased diameter of approximately 1 cm. as an allowance for the varying

convexity of the plate and for the possible enlargement of the bony defect at

operation. The plate was swaged between the die and counterdie by means of

a handpress or hydraulic press. Pressure had to be applied gradually and evenly,

to allow stretching of the metal. After molding had begun, the plate was

removed and inspected for marginal wrinkles in the metal. The edges of the

excess metal could be trimmed off and any furrows or wrinkles obliterated

with a ball-peen hammer. Kinking or furrowing was more apt to occur in the

swaging of large and complicated plates. For purposes of drainage, a single

hole was punched in the proposed dependent portion of the plate or in its

central area, and the plate was reswaged. Some surgeons preferred plates preformed with numerous small perforations. Before the plate was used, it was

washed in carbontetrachloride, rinsed in water, treated for 10 to 15 minutes in

a bath of warm dilute (5 percent) nitric acid, rinsed thoroughly in water again,

and finally sterilized in the autoclave.

A method of using the female die and a heavy rubber pad in the pressing

cylinder gave excellent results and eliminated a time-consuming procedure. A

modification of this method was described by Baker 21 (fig. 49). Using a skinmarking pencil, he outlined the shape of the plate which would cover the defect,

allowing for an overlap of about 1 cm. He then filled in the skull defect directly

with ordinary modeling clay until the clay encroached on the line marked on the

skin and its surface was symmetrical with that of the opposite side of the skull.

The surface of the clay dried within a few minutes. It was then covered with

clear fingernail polish to prevent its being incorporated into the dental stone

used to make the mold. The dental stone was placed on the calvarium to form

an identical mold; when it had hardened, it could easily be removed. The impression made in the stone represented the shape and size of the tantalum plate

21 Baker, 0. S.: Cranioplasty With Tantalum Plate, A New Method of Forming the Plate Prior to Operation. Proc.

Staff Meet., Mayo Clin. 21:177-182. 1 May 1946,
CRANIOPLASTY 265

SkulI deectModeling clay

Skll de ec in defect

~ ,~. -Tantalu

stn

~b

Formedl

B Tantalum

b plate

FIGUE 49-Baertciqefrontctooftnamplt.AFilnofsuldet

with~~~~~ cla. . ethdsofforin moeln ~~~ mld ndplte
266 NEUROSURGERY

required. The plate could then be hammered out on the mold until it had been

shaped.

An alternative method used a power press. The mold was placed in a steel

cylinder and surrounded by more dental stone until it was held firmly in position; the plate could be swaged into the desired contour by the pressing

method, using a rubber pad. It was Baker's experience that smaller plates

within the hairline could be hammered out satisfactorily on the mold but that

larger plates were best swaged out in a power press.

If secondary repair of a skull defect was necessary after the debridement of

bone in acute injuries of the skull, the two-stage procedure necessitated the

preparation of a bone ledge around the defect and a direct impression of the

mortise joint and surrounding bone, with subsequent restoration of the defect

with a tantalum plate. A direct impression of the defect could be obtained at

the time of operation by use ol sterilized dental compound, usually Ken green

compound, which becomes softened more readily and at a lower temperature

than the red compound. The hydrocolloid impression material could be

similarly used after it had been autoclaved and cooled to 98.60 F.

Simpler methods of forming the tantalum plates weire also use(d with excellent results, particularly in defects of less complexity. These methods included the preforming of plates about a basic model of the skull, the hammering of plates with the use of preformed dental-cement molds or a basic

metallic model, and the similar preparation of the plate at the operating table

by hammering from a basic model. It was surprising what satisfactory results

could be obtained even with seemingly crude methods. The surgeon could

readily determine the result of his efforts by fitting the hammered plate against

the defect until it appeared correct.

OPERATIVE FIXATION OF TANTALUM PLATE

Cranioplasties with tantalum could be performed under local anesthesia

with the exception of those for frontal defects, which required general anesthesia. Scars on the scalp for the most part were of the linear variety, which

allowed approach to the skull defect through the original scar. Coronal incisions were desirable in frontal defects. The usual craniotomy incision, making use of sagittally directed scars and circumscribed vertical scars, was desirable in defects of the temporal bone because the mass of muscle in this region

and the increased vascularity after injury made direct exposure of the defect

difficult. Cranioplastic incisions about a horizontal sc - might result in

necrosis at the incision line. Plastic repair of a broad, thin scalp scar adherent

to underlying tissue was done before cranioplasty and might even require

grafting.

Two methods of applying the plate to the calvarium were used, the inlay

method and the onlay method. Many neurosurgeons found the onlay method

quite satisfactory for defects over the calvarium. The inlay method, in
CRANIOPLASTY 267

Reeves' opinion, required unnecessary prolongation of the operative procedure

without sufficient justification for its use.

Inlay Technique

After the skull defect was exposed, the pericranium was incised about

1 cm. about the border of the defect. This portion was resected, along with

anly excess connective tissue over the defect. Bone resection, removal of skull

fragments, resection of cerebral scar, dural repair, and other measures were

carried out as indicated. The border of the proposed ledge in the outer table

was outlined on the bone with an instrument, such as the ordinary dental

scaler, and the border was cut circumferentially with the lineator, an instrument designed for this procedure by Hemberger and his associates.

A bone ledge was cut out along this circumferential outline to a depth of

approximately 2 Dim. with a Stout No. 3 dental chisel. The preformed

tantalum plate was adapted to fit this ledge, the necessary adjustments being

made with heavy scissors or contour pliers, or by hammering on a basic model

of metal. Fixation of the plate was secured by tantalum wedges, which were

triangular trimmings of the tantalum sheet used to immobilize the plate in

the manner in which glazier points are used to immobilize a glass windowpane.

Seats for the tantalum points were made in the outer border of the bony ledge

with a triangular pointed instrument (perforator). The wedges were tapped

into position with a wedge director and were turned inward over the edge of

the plate. Ordinarily, four to six wedges were sufficient for a plate. If tantalum screws were used, it was found best to have perforations made along the

edge of the plate to accommodate them. Tantalum wires through the outer

Luable of the calvarium and the edge of the plate proved satisfactory, but the

tantalum wedges ( -screws were mechanically superior. Closure of the scalp

was carried out in the usual manner, and a firm dressing, with pressure distribtted evenly, was applied.

Onlay Technique

This method needs no additional description. Tantalum screws were very

helpful in the fixation of the tantalum plate in such a procedure.

Often a combination of the inlay and onlay methods was helpful: the

iihlay method was carried out at a location at which an overlying plate might

be noticeable, and the onlay method was carried out over the calvarium, where

the plate would not be seen. In large defects over the calvarium, the oaday

method with the use of tantalum screws allo,;ved a very rapid and satisfactory

fixation of the plate, while the inlay method might be very tedious and time

consuming, without any particular benefit and with possibly a detrimental

effect on the patient.
268 NEUROSURGERY

CRANIOPLASTY WITH ACRYLIC RESINS

The direct method was usually employed in tile preparation of acrylic

plates. Gurdjian, Webster, and Brown used the indirect or primary- method,

the preparation being carried out in much the same manner used for the tantalum plate. The desired amount of acrylic was cut with a handsaw and then

gently heated with a dry flame from a bunsen burner until it was soft and

pliable. It was adapted to the outer surface of the mold, and, in the process,

the edges of the glass were beveled to produce an accurate fitting. Holes were

drilled into the edges for the purpose of fixing the graft into position by means

of such suture material as tantalum. Only a small amount of readjusting was

necessary at the time of the operative repair of the defect. The acrylic was

exposed to dry heat on a bunsen burner outside the operating room or in the

operating room if local anesthesia was being used for the procedure.

For the direct method of preparing acrylic plates, Elkins and Cameron

placed in the wound a sterilized piece of dental base plate which had previously

been heated in a pan of hot water until it was pliable. After it had been molded

on the skull to the desired contour, it was removed from the wound and placed

in cold sterile water for a few seconds. The base plate had to be larger than the

defect, since it was used as an impression tray and since it determined the outer

contour of the completed acrylic plate. Two retention holes were punched in

the center of the tray by means of a heated blunt instrument. A layer of

impression material was spread on the inner surface of the impression tray, of

sufficient, thickness to permit an accurate measurement of the depth of the bone

edges. The material was pressed firmly into the inner surface of the tray, some

being allowed to extrude through the retention holes. An impression of the

bony defect was taken by reinserting the tray with its inner coating of wax into

the wound and pressing it down firmly. The tray was removed and the impression was inspected for defects. If the operator was satisfied with the impression, it was placed in a pan of cold water for hardening and was then sent to the

dental laboratory. The retractors were removed from the incision, and a sterile

dressing was applied to the wound without disturbing the drapes.

The material Elkins and Cameron found most advantageous was a previously prepared mixture of two-thirds beeswax and one-third petrolatum

product ; this was either boiled or autoclaved to insure sterility. Theimpression

material was firm when cool and had to be softened by molding in the hands.

In the dental laboratory, the tray and its impression were embedded in

ordinary dental stone in the lower half of a Pryor injector flask. After it had

hardened, the stone was coated with silex. The upper half of the flask was

filled with dental stone, and the halves were placed together. The lid of the

flask was placed in position, and the pressure plunger was adjusted to the

estimated top of the tray. After 5 minutes, the pressure plunger was removed

and the halves of the flask were separated. The wax impression material was

boiled out and the tray was removed, after which the impression matrix was

lined with light tinfoil and packed with acrylic resin in sufficient quantity for
CRANIOPLASTY 269

packing pressure and for all allowance of about 20-percent shrinkage. The top

of the injector flask and the pressure plunger were reinserted, and the plunger

screw was adjusted until the indicator was one-fourth inch above the housing.

The flask was placed in boiling water for about 35 minutes for curing; during

this process, the plunger screw required several readjutistmen ts.

After the heating, the flask was allowed to cool for 10 minutes. Then tile

parts of the flask were separated, and the acrylic plate was removed for polishing. Several small drillholes were placed around the edges of the plate for

wiring the plate into place in the defect, and two larger perforations were made

in its center for drainage. Sterilization was accomplished by leaving the plate

in Bard-Parker solution for 15 minutes. Elkins and Cameron estimated that

the entire procedure for completion of the plate required on an average 1 '

hours.

Small holes, corresponding as closely as possible to their counterparts in

the acrylic plate, were drilled in the edge of the bone defect. The plate was

fitted in position in the usual way and fastened in place by means of tantalum

on chromium steel wire threaded through the holes in the bone and plate.

Elkins and Cameron reported that the time for the entire procedure was

between 2% and 3 hours.

Either inlay plates the full thickness of the skull or onlay plates 2 to 3

mm. in thickness could be prepared by variations in tile impression technique.

For fixation of an onlay plate, metal screws were preferable.

INDICATIONS FOR CRANIOPLASTY

The indications for cranioplasty for war wounds of the skull were the same

as for wounds of the skull seen in civilian life. As Grant and Norcross summarized them in their classical paper, they included the following: (1) Severe

headache and other symptoms of the so-called syndrome of the trephined, such

as dizziness, vague discomfort at the site of the defect, a feeling of apprehension

and insecurity, mental depression, and intolerance to vibration; (2) the dc.nger

of trauma at the site of the defect; (3) pulsating or painful defects; (4) deforming

and unsightly defects; and (5) the assumed relief of an associated convulsive

state.

Woodhall and Spurling reported that the majority of their patients with

battle-incurred wounds of the head noticed localized tenderness upon palpation

in the area of the defect and complained of localized pain, which had a tendency

toward spontaneous resolution. (Cranioplasty benefited these subjective complaints. Vertigo and generalized headache, which were less common complaints,

seemed unaffected by cranioplasty; in all probability, they represented sequelae

of the cerebral injury. The revision of unsightly defects produced uniformly

gratifying results.

Woodhall and Spurling, in an investigation of the effect of cranioplasty

upon the electrical activity of the brain, studied 26 cases before and after

cranioplasty. They found no postoperative change in the character of the
270 NEUROSURGERY

cortical electrical activity in 12. In 10, there was evidence of improvement, and

in 4 the abnormal activity became even more manifest with the development of

epileptogenic foci. Bradford and Livingston did not think that the cranial

defect was the cause of convulsive seizures or that its repair would significantly

alter the incidence of convulsions. Reeves' experience was in accord with

theirs.

One of the complications influencing reparative surgery is the presence of

infection. Bradford and Livingston pointed out that secondary intervention

for tantalum plating in the presence of infection, or immediately following

wound healing, could not be justified on the basis of scattered successes. It was

their belief that secondary operation to cover a cranial defect should be delayed

for a minimum period of 3 months after primary healing and for a period of 8

months after healing if frank infection had been present. They likewise concluded that, when a patient had a cerebral hernia, treatment should be directed

toward the underlying pathologic processes and not toward mechanical block

of the escaping cerebral mass. They also pointed out that complete coverage

with good scalp is essential for successful cranioplasty with tantalum, and that,

if the cranioplasty with tantalum is not successful, the plate must be removed

promptly.

The Posttraumatic Convulsive State

Ascroft,2 2 in studying the occurrence of epilepsy after gunshot wounds of

the head, examined the records of 317 patients at the British Ministry of

Pensions whose wounds had been incurred in World War I. Cases of blunt

injuries and of wounds of the cerebellum were excluded. The followup period

varied from 7 to 20 years. The series represented a fair sample of head injuries severe enough to warrant award of a pension but not to cause death within

4 years.

Epilepsy had developed in 34 percent of these 317 cases. The incidence

of convulsions was twice as great in cases in which the dura had been penetrated (45 percent) as in cases of scalp and skull wounds in which the dura

was intact (23 percent). Epilepsy naturally was found to be more common

after wounds affecting the sensorimotor cortex than after those of the polar

regions of the cerebral hemisphere.

In a series of 76 penetrating injuries of the brain observed over a period

of 1 year or less, Woodhiall and Spurling 23 found that convulsions had developed in 15 patients within 4 months of the injury, while, in another 15 (a

total of 40 percent), there was electrical cortical activity highly suggestive of

an epileptogenic focus. Later, Woodhall reported that in wounds of duralcortical penetration, the statistics revealed an incidence of posttraumatic

epilepsy of from 35 to 50 percent and that the principal time for its onset was

within the first year, between the 4th and 12th months, after injury. In other

cases, the onset might occur within the following 5 years, or even later. Wood22 As roft, P. B.: Traumatic Epilepsy After Gunshot Wounds of the Head. Brit. M. J. 1:739-744, 17 May 1941.

23 See footnote 9, p. 262.
CRANIOPLASTY 271

hall also stated that in spite of adequate early debridement and more improved methods of combating infection, the incidence of posttraumatic epilepsy in a series of war wounds in World War I1 appeared quite similar to the

incidence in previous reports and that, during the early period of observation,

it had remained at a level of 40 percent.

STATISTICAL DATA

A personal study, in 1946, of admissions reported from 16 Army neurosurgical centers in the United States revealed 4,322 patients with skull defects

from craniocerebral wounds. When one considers the cases operated on in

naval centers and in overseas installations, it seems not unreasonable to

assume that at least 5,500 cranioplasties were performed during World War II.

Obviously, if this large series of cases were properly studied over a sufficient

period of time, a valuable contribution to this subject could be made.

In 1945, Woodhall and Spurling 24 analyzed 79 cases of tantalum cranioplasty. The majority of the skull defects were caused by shell fragments, a

fact which suggests failure to survive the impact of the higher velocity missiles of rifle and machinegun. Numerous other cases are on record in the

literature.

The distribution of the 194 cranioplasties upon which the experience

recorded in this chapter is based is significant. No operations were performed

in 1941 or 1942, and only three were performed in 1943. In 1944, 36 skull

defects were repaired, and in 1945, the number rose to 155, or 80 percent of

the whole series.

Information is available concerning the cause of the defect in only 121

of the 194 cases; in 71 cases the defects were caused by shell fragments. There

were no neurologic defects in 24 of the 125 cases in which sufficient data were

available to determine this point. All of the 24 cases of convulsive disorders

followed dural-cortical penetration, and most of them had become evident

within the first year following the injury. Undoubtedly, many other cases

of epilepsy occurred within this group but were not adequately recorded. If

these patients could have been followed carefully for a period of 5 years, there

seems little doubt that the incidence of convulsive disorders would have been

found to be 35 to 50 percent. Unfortunately, adequate records of electroencephalographic findings are not available.

In 4 of the 194 cases, removal of the plate was necessary because of infection. In two of these, the cranioplasty had been completed in spite of the

presence of a low-grade infection. In the early cases, it was not appreciated

that, pressure necrosis of atrophic scalp overlying the plate was likely to occur

when plating was carried out under scalp wounds that had healed leaving

thin wide scars; two plates were removed for this reason. Revision of the

plate had to be performed in two orbital defects because the plate overlapped

the orbital ridge and prevented adequate opening of the upper lid. When

4

See footnote 9, p. 262.
272 NEUROSURGERY

the plates were inlaid only to the edge of the orbit, this difficulty was corrected. Revision was also necessary in a third case.

The preoperative and postoperative use of penicillin became fairly routine

procedure in these cranioplasties. No operative or postoperative deaths occurred in this series, and the morbidity rate of all tantalum repairs was surprisingly low.

CASE REPORTS

The following case reports represent special experiences with cranioplasty

at the neurosurgical centers at Hoff General Hospital, Santa Barbara, Calif.,

Birmingham General Hospital, Van Nuys, Calif., and Hammond General Hospital, Modesto, Calif.

Nontraumatic Skull Defects

Case 1.-A soldier with a history of intermittent attacks of upper respiratory infection

and sinusitis since April 1944 was admitted to Letterman General Hospital, San Francisco,

Calif. In New Caledonia, a diagnosis had been made of possible osteomyelitis of the left

frontal bone secondary to sinusitis. A subperiosteal abscess in this region was incised on

23 September 1944, and a sequestrectomy of the left frontal bone was carried out on 7

October 1944.

The patient was subsequently evacuated to Hammond General Hospital, where, in

January 1945, physical and roentgenologic examination revealed a large circular defect

involving the major part of the left frontal bone in its lateral superior portions. The edges

of the defect were irregular, but there was no evidence of a spreading bone infection.

A tantalum cranioplasty was performed on 6 April 1945. The inlay technique was used

over the frontal area and the onlay technique elsewhere, with fixation by means of tantalum

wires. The plate was hammered out on a basic dental cement model. The postoperative

course was uneventful, and the cosmetic result was satisfactory. The patient was given a

disability discharge in August 1945.

Traumatic Skull Defects

Case 2.-An officer in the Army Air Forces was admitted to Hoff General Hospital

because of a large skull defect in the left frontotemporal region, resulting from the removal

of fragments from a compound comminuted, depressed fracture and of foreign bodies in that

area. He had been struck in the left naso-orbital region by a shell fragment from an antiaircraft battery during a bombing mission on 13 June 1943 and had become unconscious

immediately. On his return to the base, depressed bone fragments, met dlic fragments, and

embedded pieces of his oxygen mask were removed from the wound. His condition was

critical during the first 24 hours after operation. Thereafter, he recovered uneventfully

and was later returned to the United States for further observatiou and treatment.

When he was admitted to the Hoff General Hospital on 21 September 1943, his overseas

operative report described a large laceration of the dura in the left frontotemporal region

with clots of blood and herniation of cerebral tissue. Beneath the skull fragments was a

large, rectangular metallic foreign body, about 1.5 cm. by 5 cm., and there were several

smaller foreign bodies, about 0.5 cm. by 2 cm., resembling pieces of rubber tubing. There were

multiple lacerations of the nose on the left side, and a large laceration of the left nasofrontal

region of the skull medial to the left eye was filled with clots of blood and cerebral tissue.

Examination at Hoff General Hospital revealed a large frontotemporal cranial defect

(fig. 50) measuring 7.6 cm. by 12.7 cm., with destruction of 3.8 cm. of the left orbital bone.
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-i .~ ( l I: IIl ,i 1444 1 1.1 ,4'- 1 lilT.:I 44,- II I il i f I if I 11if 1414IllI..
274 NEUROSURGERY

On 23 February 1944, a repair of the cranial defect was carried out, with the patient

under Avertin with amylene hydrate and ether anesthesia. It was believed that sufficient

time had elapsed to preclude the possibility of further infection. An accurate tantalum

plate of the defect was prepared by means of impressions, molds, and models. The previous

scalp incision was reopened and carefully dissected laterally, exposing the skull defect. The

scar tissue and dura had regenerated over the brain and were surprisingly normal in appearance. After adjustments had been made in the plate, drillholes were perforated around the

edge of the bony defect with an electric drill, and the plate was wired firmly in place with

tantalum wire. The scalp flap was then replaced, and the subcutaneous tissues were approximated with interrupted sutures of medium black silk. The skin was closed with interrupted

end-on mattress sutures of fine black silk. Before closure, a small amount of powdered

sulfathiazole was sprinkled in the wound. At the conclusion of the procedure, the patient

was given a transfusion of 500 cc. of citrated blood. HIe was taken from the operating room

in good condition.

The postoperative convalescence was uneventful and the cosmetic result was good

(fig. 50A and B). Roentgenograms of the skull on 6 March 1944 showed the previous

defect in the left frontal and parietal region covered by a perforated metal plate held in position by several wire loops.

Jacksonian convulsions had developed before the operation in the Zone of Interior, and

after operation the patient continued to have convulsions about every 2 months. They

were never fully observed. This was one of the cases handled before adequate appreciation

of the technique of the direct or secondary method of cranioplasty had been developed.

Case 3.-A 34-year-old officer was struck by machinegun bullets on 16 April 1945, in

Germany. He sustained a severe lacerating wound involving the scalp, skull, dura, and

brain, with an associated left hemiparesis, and a compound comminuted fracture of the skull

which led to a large deformity of the right parietal region.

Primary debridement was done on the day of injury. A piece of fascia lata from the

left thigh was sutured over the dural defect, and the scalp wound was closed in layers.

When the patient regained consciousness, he was found to have an almost complete leftsided paralysis. The cranial wounds healed without difficulty, but a large skull defect was

left. A gradual improvement in the paralysis ensued.

Roentgenograms of the skull disclosed a defect of the right parietal region measuring

11 by 5 by 4 cm., with evidence of old fracture lines extending into the lateral border of the

right orbit. On 16 October 1945, a tantalum cranioplasty was performed, the inlay technique being used along the upper portion of the plate and the onlay method elsewhere.

Tantalum wedges were used for fixation of the plate.

The patient made an uneventful recovery, and the cosmetic result was satisfactory.

After operation, he had one major convulsive seizure, an adequate description of which was

not obtained. When he was last seen, in November 1946, he looked quite well; he had put

on weight; the hemiparesis had greatly improved, and the cranioplasty had caused him no

trouble.

Case 4.-This soldier sustained penetrating, bifrontal wounds of the head as the result

of machinegun fire on 30 November 1944, near Metz. He had a compound comminuted

fracture of the skull and a laceration of the brain in the area involved. Debridement wasr

carried out at an evacuation hospital, and he reached Hammond General Hospital on 14

January 1945.

Roentgenograms of the skull on 22 January 1945 revealed a large bony defect affecting

both frontal bones. In addition to the skull defect, the patient had loss of memory and an

incomplete type of motor aphasia.

Tantalum cranioplasty was carried out on 4 April 1945 by the inlay technique, with

fixation by means of tantalum wires. The plate was prepared by hammering it out on a

dental cement mold. The postoperative course was uneventful and the cosmetic result

good. The patient was given a disability discharge on 22 August 1945.

Case 5.-A soldier sustained a rifle-bullet wound of the right eye and frontal lobe of the
CRANIOPLASTY 275

brain, with an associated comminuted fracture of the supraorbital ridge, 30 July 1943, on

Munda. Debridement and enucleation of the right eye were performed on 31 July at a

station hospital in New Caledonia. He was evacuated to Hammond General Hospital,

2 September 1943. Petit rial seizures became evident in February 1944, and there was a

grand real episode on 23 July 1944. These major seizures continued until they were controlled by phenobarbital medication.

General physical examination disclosed nothing unusufl other than the defect of the

right frontal region and right anophthalmos. Roentgenograms of the skull revealed a large

bony defect involving the right anterofrontal bone and extending inferiorly from the coronal

suture to the right orbit.

A tantalum cranioplasty was performed on 31 October 1944 by the onlay technique,

with fixation by means of tantalum wire. The plate was preformed by the indirect method

and was hammered out on the dental mold.

The postoperative course was uneventful, and the patient was transferred to Dibble

General Hospital, Menlo Park, Calif., on 14 December 1944, for fitting of an artificial eye

and any further plastic procedures necessary. Photographs 17 days after operation revealed

"a satisfactory cosmetic result.

Case 6.-A soldier received a penetrating injury to the right supraorbital region from

"a shell fragment in October 1944, in Italy. The injury resulted in a compound comminuted

fracture of the affected area, as well as a laceration of the right frontal lobe of the brain.

Craniotomy, with removal of the comminuted bone fragments and devitalized cerebral

tissue, was carried out overseas.

Except for the skull defect in the right frontal region (fig. 51A), examination at Hammond

General Hospital in December 1944 disclosed nothing unusual. A tantalum cranioplasty

was performed on 12 February 1945. The plate was prepared by the indirect method and

was hammered out on the dental mold. The onlay technique was used, and fixation was

carried out by means of tantalum wire.

A good cosmetic result was obtained, and the patient was given a disability discharge on

30 May 1945. Anteroposterior and lateral roentgenograms of the skull before and after

cranioplasty with tantalum are shown in figure 51B and C, and the postoperative appearance

of the patient is shown in figure 51D.

Case 7.-A soldier who was injured by a bomb fragment on 24 September 1943, in New

Guinea, sustained a compound comminuted fracture of the skull and an underlying laceration

of the parasagittal region of the brain. Debridement was performed overseas. A tantalum

cranioplasty with the inlay technique and fixation by means of tantalum wires was carried

out in the Zone of Interior on 22 May 1944. The scalp overlying the defect was rather thin

in two areas, but, at this stage of the experience with tantalum cranioplasty, the likelihood

of subsequent pressure atrophy was not sufficiently appreciated. The plate, however, had

to be removed on 19 July 1944 for this reason. Granulation tissue had filled in the dead

space beneath the tantalum plate and also had filtered through the perforations in it, thus

holding it firmly in position.

A second attempt at repair was carried out on 3 October 1944. Although it had been

believed that skin grafting would be required, the condition of the scalp appeared sufficiently

satisfactory to make it appear that a plastic procedure of this sort might be unnecessary.

The patient made an uneventful recovery, and the procedure seemed to be successfi.l.

Some time before cranioplasty, convulsive seizures had developed. The patient was

given a disability discharge on 18 January 1945. About a month later, an area of necrosis in

one of the thin areas of the scalp necessitated his return to a Veterans' Administration

hospital for further treatment.

Case 8.-A 33-year-old soldier received a severe pentrating wound of the right frontoparietal region of the skull and brain from an enemy shell fragment on 14 November 1944,

in Germany. An associated compound comminuted fracture resulted in a large residual skull

defect (fig. 52A). With the patient under local anesthesia, debridement of the wound, with

removal of bony fragments, was carried out overseas on 14 November 1944.
.176 N11 IIt U L~ I. I '

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278 NEUROSURGERY

the patient had a convulsive episode. A tantalum cranioplasty was performed on 5 April by

the onlay technique, with fixation by means of tantalum wire. The plate was preformed by

the indirect method and was hammered out on the dental cement mold rather than by means

of a pressing cylinder.

The postoperative course was uneventful, and the cosmetic result was satisfactory (fig.

52D). The patient was discharged to a Veterans' Administration hospital for separation

from the service on 7 September 1945. A letter dated I May 1947 indicated that he did not

even realize that the plate was in his skull, since his head "felt fine all of the time." He was

apparently continuing to have occasional convulsive episodes.

SUMMARY AND CONCLUSIONS

In World War II, the experience with Vitallium, Ticonium, and tantalum

for cranioplasty left little justification for the employment of other metallic

materials, and, at the end of the war, most of those familar with the subject considered tantalum the metal of choice for the repair of the larger defects. While

acrylic plates may have certain advantages, in that they lack temperature

changes and are inert to electric phenomena, their preparation is more difficult,

and it is doubtful that they are as satisfactory in large defects as tantalum.

Autogenous bone or cartilage continues to offer an adequate means for the

repair of the smaller skull defects, particularly those involving the frontal sinuses

and the region of the glabella. Final selection will probably remain somewhat

the personal choice of the surgeon who is more familar with, and more enthusiastic about, one technique than another.

It is generally agreed that indications for cranioplasty include the following. (1) The repair of deforming and unsightly defects; (2) the danger of trauma

at the site of the defect; (3) pulsating and painful defects; and (4) headaches

and other symptoms of the syndrome of the trephined, including discomfort at

the site of the defect. The relief of an associated convulsive state has also been

considered as an indication, but it is not believed that the cranial defect is the

cause of convulsive seizures or that its repair alters their incidence appreciably.

Secondary intervention for tantalum plating in the presence of infection or

immediately following wound healing cannot be justified on the basis of scattered

successes. It is believed wise to consider a minimum delay of 3 months after

primary healing before a secondary procedure to cover a cranial defect is performed, and to allow 8 months after healing if frank infection has been present.

Complete coverage with good scalp is essential to successful tantalum cranioplasty; if the cranioplasty is not successful, the tantalum plate should be

removed promptly.
CHAPTER XIII

Posttraumatic Epilepsy

A. Earl Walker, M. D.

ADMINISTRATIVE CONSIDERATIONS

In November 1945, Cushing General Hospital, Framingham, Mass., was

designated as a center for the treatment of posttraumatic epilepsy, and arrangements were made for the transfer to it of all patients with this disease then under

treatment in Army general hospitals. Convoys began to arrive early in December, and patients continued to be received at irregular intervals for the next

6 months.

In all, 246 patients were treated for posttraumatic epilepsy at this center.

A few others who were admitted with this diagnosis were found, on examination,

not to be suffering from the disease.

To process so large a number of cases within a short time would have been

impossible without the organization developed in the course of the war by Lt.

Col. Frederic H. Lewey, MC, and Lt. Col. W. P. Van Wagenen, MC, which

provided functionally united, although administratively distinct, sections of

neurology and neurosurgery (p. 21). The existence of this organization made

it feasible to utilize at once all the aptitudes and special skills available in the

hospital and to begin the study of patients immediately without waiting for

specially trained personnel. The plan may not have been ideal, but without it

the posttraumatic epilepsy program would have encountered grave difficulties.

All patients were admitted to the neurologic service, on which they were

worked up by the staffs of the neurologic and neurosurgical sections, under the

supervision of Maj. F. A. Quadfasel, MC. Clinical and electroencephalographic

studies were madn, autonomic functions were investigated, psychologic examinations were conducted, and vocational counseling was provided. The

American Red Cross assisted in the securing of social histories and in the

rehabilitation of the patients.

CLINICAL INVESTIGATION

Anamnesis and General Physical Examination

Because the histories which accompanied the patients on their transfer

to Cushing General Hospital were of varying degrees of completeness, it was

found necessary to adopt a standard form for the clinical history. This form

was prepared after a careful investigation of the epilepsy history outlines in

current use at the neurologic centers in Montreal, Boston, New York, and

279
280 NEUROSURGERY

Chicago. T'ie form (appendix C, p. 411) was designed as a guide for ward

officers to insure that all pertinent data would be elicited and recorded in definite

order. It also made it possible to analyze the clinical history with comparative

ease.

Each patient was given a complete physical examination in conformity

with Army general hospital procedure.

Neurologic Examination

Bec4use almost all of these patients had neurologic deficits, the majority

of which were quite severe, it was considered advisable to have the neurologic

examination follow a more flexible form than the Army neurologic examination

sheet (55-E-10-A), which was set up for patients with few abnormalities.

Accordingly, a special outline (appendix C, p. 414) was formulated for the recording of the neurologic examination.

Officers who had had considerable experience in neurology obtained the

detailed neurologic history and carried out the examination. Both history and

examination were doubly checked for accuracy and completeness by the

neurologist and the neurosurgeon.

Other Special Studies

Roentgenologic examination.-Routine roentgenograms of the head were

made at the time of admission. All previous films of the skull were reviewed.

Pneumoencephalograms were reread and a note concerning them was incorporated in tile history.

Examination of spinal fluid.-Unless the patient had had a recent, complete

examination of the spinal fluid, a lumbar puncture was performed. Careful

observwttions were made of the spinal fluid pressure under normal conditions

and following jugular and abdominal compression. Cytologic, serologic,

bacteriologic, and chemical studies were made on the spinal fluid.

Ophthalmologic examination.-An ophthalmologic consultation was requested on each patient, with particular emphasis on visual field disturbances.

Otolaryngologic examination.--The otolaryngologic consultant was asked

to emphasize hearing and vestibular disturbances.

Aphasic examination.-Each patient was given an examination designed

to reveal possible disturbances of speech (appendix C, p. 417). In normal individuals, this examination served as a rough test of the individual's intelligence

and could be completed in a few minutes. In aphasic individuals, it indicated

the type and severity of the impairment and could be used for comparative

purposes at a later time.

Psychologic examination.-A number of tests were used as indicators of

psychologic performance, as follows:

1. The Wechsler-Bellevue test was considered to give a general rating of

the individual's intellectual ability.
POSTTRAUNMATIC EPILEPSY 281

2. The revised Binet vocabulary test was somewhat more dependent

upon a special form of learning.

3. The Wechsler memory scale was also a test of somewhat special aptitudes.

4. The Bendei Visual Motor Gestalt test was used as a possible indicator

of brain damage.

5. The critical fusion frequency test was included as a criterion of focal

brain damage.

6. The Goodenough test was included for evidence of brain damage.

It was hoped that these tests, each serving a special function, would constitute a battery which might differentiate a patient with cerebral injury from

a normal individual and might indicate whether a return to normal or a

progression of the cerebral process could be expected.

Autonomic function.-Since vasomotor disturbances were often present

in individuals suffering from posttraumatic epilepsy, the autonomic examinations included the following: (1) Sweat tests, (2) plethysmograms, (3) electrocardiograms of oculocardiac reflex, (4) electrocardiographic alterations, and

(5) oscillomet ry.

Electroencephalograms.-Routine electroencephalograms were made of

each patient after he had had no medication of any kind for 3 days. Standard

hyperventilation tests were carried out at the end of the routine run. If an

abnormal focus of activity was present, extra electrodes were placed and an

accurate localization was made.

Social history.--With the assistance of the American Red Cross, the

family of each patient was interviewed in order to obtain more specific and

accurate information of his childhood. Red Cross workers were given a suggested outline of the social history desired (appendix C, p. 419).

Evaluation of Findings

These studies constituted the basic workup of each patient admitted to

the hospital. When complicating factors were present, they were taken care

of by appropriate means. Not a few patients were suffering from osteomyelitis or fractures of bones and required orthopedic treatment. Some required

plastic reconstruction of the face. Otherm presented special otolaryngologic

problems. As the result of their cerebral wounds, a few were paraplegic and

needed special care.

When the case had been fully worked .mp, it was presented to a combined

neurologic-neurosurgical conference in which the problems were reviewed and

medical and surgical therapy was decided upon and initiated.

ANALYSIS OF CLINICAL FINDINGS

The records of the patients suffering from posttraumatic epilepsy and

treated at Cushing General Hospital have been extensively analyzed in the

hope of identifying factors which influence the development of the convulsive

state.
282 NEUROSURGERY

Age distribution.-The age incidence of this series corresponds well with

the age distribution in the wartime Army. There were 96 patients between

19 and 25 years of age, 83 between 26 and 30, 54 between 31 and 35, and 13

were over 35.

Type of injury.--Of the 246 patients in this series, 236 had open wounds

and 10 had closed injuries of the head. Bilateral or multiple wounds were

present in 40 cases. Thie open injuries were variously caused by shell fragments

(154), bullets (58), shell fragments and bullets (2), blunt objects (15), a knife

(1), and unknown agents (6).

Location of wound.-The sites of cranial and cerebral wounds in this

series were scattered over the entire head, with a predominance of lesions in

the parietal region of the skull. In a number of cases, perforating wounds were

present with extensive damage. to more than one lobe of the brain and in some

cases to both hemispheres (table 12).

History of unconsciousness.-The period of impairetd consciousness varied

greatly (table 13) and did not seem to be directly proportional to the extent

of the apparent cerebral wound. Shell fragments appeared to cause a greater

and more prolonged impairment of consciousness than bullet wounds of the

brain, but the difference is probably not, very significant. It is noteworthy

that almost a quarter (23.4 percent) of the patients with craniocerebral wounds

for whom this information is available had no period of unconsciousness.

Debridement.-The patients who comprise this group were more severely

wounded than the patients who would comprise a random sample of head

injuries (fig. 53).' The figures are not biased, however, by the factor of late

TABLE 12.-Location of head injury in 240 patients with posttraumatic epilepsy

Lobes involved

Locat ion of injury

Right side Left side Side unknown! Total

Frontal lobe ------------------------- -'------ 13 20 3 36

Frontoparietal lobe -------------------------- 9 14 4 27

Frontotemporal lobe ----------------------------- 2 3 1 6

Parietal lobe ------------------------------------ 27 38 4 69

Parietotemporal lobe .-------------------------- 9 8 2 19

Temporal lobe ---------------------------------- 4 6 0 10

Parieto-occipital lohb -- -------------------------- -16 2 25

Occipital lobe ------ -------------------------- 1 5 2 8

Both frontal lobes ----------------------- ----------------- 3

Both parietal lobes -----------------------.-----------.--------.---------- 4

Both temporal lobes .....--------.-.-- ----------

Vertex --------------- - -. - -.--.--- ---------.-------- . ------------------- - 4

Other combination -------------- ------ --------------------- ----------- 28

Total -----.---------------------------- 72 110 18 240

I Maitby, G. L.: Penetrating Cranioeerebral Injuries: Evaluation of the Late Results In a Uroup of 200 Consecutive

Penetrating Cranial Wounds. J. Neurosurg. 3: 239-249, May 1946.
POSTTRAUMATIC EPILEPSY 283

"IrABLE 13.-OQuration of impairment 6f consciousness after head injuries in 237 patients with

posttraumadic epilepsy

Period Unconsciousness Confusion

None ----------------------------------------------- 46 23

1 day ------------------------------------------------ 51 38

More than I day ------------------------------------- 99 151

Unknown ------------------------------------------- 41 25

debridement, for, in the 168 cases in which the time of initial wound surgery

was known, the operation was done within 24 hours of wounding in 132 cases,

between 2 and 4 days afterward in 28 cases, and after 5 days in only 8 cases.

The severity of the injury may be judged by the extent of debridement.

In at least 154 of the 178 cases in which the extent of the debridement was

known, dural penetration had occurred. Debridement of the skull and scalp

was necessary in 4 cases and debridement of the dura in 12. Surgery was

limited to the scalp in only eight cases.

Infection.-In spite of the early treatment which most of these patients

received, infection occurred in 82 of the 186 cases in which the character of

wound healing was known. This is an unusually large proportion. Age may

have played some part in the rate of infection, for secondary wound healing

occurred in 30.5 percent of the patients over 25 years of age against only 15

percent in patients under 25 years. The type of chemotherapeutic or antiRELATIVE FREQUENCIES

FACTORS (PERCENTAGES OF TOTAL KNOWN CASES)

0 10 20 30 40 50

NOT UNCONSCIOUS

.POSTTRAUMATIC EPILEPSY

NORMAL NEUROLOGICAL PENETRATIN G WOUNDS

EXAMINATION

INFECTED WOUND

FOREIGN BODIES

TIME OF DEBRIDEMENT:

24-100 HOURS

OVER 100 HOURS

FIGURE 53.-Relative frequencies of various factors in selected series of

posttramnatic epileptics and in a nonselected series of patients suffering from

penetrating wounds of head.
284 NEUIR)SURIt(GERY

biotic therapy did not seem to influence the rate of infection. About the same

numbers of infected and noninfected patients received sulfonamide drugs and

penicill!n.

Intracranial foreign bodies.--'1'his study supplies no evidence that the

presence of intracranial foreign bodies is a factor in the production of epilepsy.

Thite majority of the patients (141) had no d(emonstrable foreign bodies within

tile brain.

Neurologic defects.--The severity of tile cerebral wounds in these cases

is evident from the fact that, at the time of their admission to ('ushing General

Hospital, all but 14 of the 246 patients presented one or more neurologic

abnormalities.

Electroencephalographic abnormalities.-A preliminary survey of the

electroencephalographic records in this series indicated that the tracings were

normal in only 31 cases. A generalized dysrhythmia, such as is seen in the

idiopathic forms of epilepsy, was present in 25 cases. localized or focal abnormalities occurred in 180 cases. hite great majority of the records showed

slow wave foci (one-half to 6 per second) about the site of tile cranial defect

and brain wound (fig. 54). A much smaller number showed spiky waves or

spikes confined to the defect.

For comparison, all analysis was undertaken of tile records of a control

series of nonepileptic patients admitted to ('ushing General Hospital for the

treatment of craniocerebral injuries.' This series was composed of patients

with somewhat less severe wounds of the head than the group with posttraumatic epilepsy. It is not surprising, therefore, that a slightly smaller

percentage of focal abnormalities was found in the control group than in the

epileptic group. The generalized dysrhythimias were of about equal frequency

in both series. The incidence of localized spiky waves or spikes, which are

usually considered indicative of epileptic activity, was the same in both.

Serial electroencephalographic examinations were made in a number of cases

in both groups, but, it was not possible to predict from these examinations an

epileptic diathesis or to tell if the patient had had convulsive seizures. From

this investigation, it was concluded that the electroencephalogram was not.

ari adequate indicator or prognosticator of the convulsive state in cases of

penetrating brain wounds.

Posttraumatic syndrome.- Although the posttraumatic syndrome is

usually thought to be associated chiefly with mild head injuries, both headaches and dizziness were complained of by 54 patients in this series.

Epileptogenic Factors

The statistical analyses suggest that a number of factors predispose to

posttraunmatic epilepsy, as follows:

1. The severity of the local injury seems to be important, as may be

2 Kaufman, 1. C.. and Walker, A. E : The Electroencephalomram After Head Injury. J. Nerv. & Merit. Dis.

109: 383-395, May 1949.
POSTTRAUMATIC EPILEPSY 285

assumed from the high incidence of dural penetration (87 percent), electroencephalographic changes (86.8 percent), and neurologic damage (94.3 percent)

in this series.

2. Sepsis in the wound may be a predisposing factor in epilepsy. It was

present much more frequently, according to Nlaltby, in this series than in an

unselected series of penetrating head wounds.

3. The location of the wound seems to play a role in the production of

posttraumatic epilepsy. If the incidence of craniocerebral wounds in the

different parts of the head was the same in World War II as in the First World

War, tie distribution of wounds in any unselected series would be 27 percent

frontal, 25 percent parietal, 17 percent temporal, and 15.5 percent occipital.

In this series, the majority of injuries were in the parietal region of the head;

approximately 18 percent were in the frontal area and about 5 percent in each

of the temporal and the occipital regions. Posttraumatic epilepsy thus seems

to occur much more frequently with lesions in the central region than with

lesions elsewhere. On the other hand, the frequency of attacks, once the

attacks were established, did not seem to be related to the site of the wound or

to the presence of foreign bodies.

4. It was the clinical impression that convulsions were precipitated by a

cranial operation, such as cranioplasty. The impression was borne out by

the fact that 45 patients had convulsions within a week after this operation.

This analysis does not support some of the previous hypotheses concerning

the causation of posttraumatic epilepsy, as the following data show:

1. Heredity (lid not appear to be an important factor in its development.

In this series, only 4.5 percent of the patients' relatives had -'onvulsions, as

compared to an incidence of 3.4 percent in normal families and an incidence of

17 percent in epileptic families.'

2. Intracranial foreign bodies did not seem to predispose to epilepsy.

Tile majority of the patients in this series had no demonstrable foreign bodies

within the brain, andi the incidetwe of such objects was no higher in this series,

according to Mfaltby, than in an unselected series.

3. Cerebral dvsrhythmias did not appear to be an important consideration

in posttraumatic epilepsy. The percentage of cases exhibiting these phenomena

was not appreciably greater in this series than in the normal population.

Time of onset of epilepsy.-The time after injury at which the epilepsy

occurred varied greatly. In 27 percent of the cases, the seizures came on within

3 months and, in another 30.7 percent, between 3 and 6 months after injury.

The delayed onset of attacks did not seem to have prognostic importance nor

was it related to the anatomic site of the injury.

3 Kerr, H.: A Statistical Analysis of Gunshot Wounds of the Head. In The Medical Department of the United

States Army in the World War. Washington: Government Printing Office, 1927, vol. Xi, pt. 1, p. 842.

SLennox. W. 0.: Personal communication.

455735--58----20
286 NEUROSURGERY

THE EPILEPTIC ATTACK

Auras

The type of seizure in this series did not, in general, differ from tile type

seen in idiopathic epilepsies. It is true that focal manifestations (present in

75.8 percent of the cases) were more common than in an unselected group of

patients suffering from convulsive seizures. The most common localizing

sign was an aura-motor, sensory, or visual-which ushered in the attack.

The types of aura in 239 patients with posttraumatic epilepsy are shown in

the following tabulation:

Number of

Type of Aura: patients

None -------------------------------------------- 63

Motor ------------------------------------------- 64

Somatosensory ------------------------------------ 54

Visual ------------------------------------------- 23

Complex ------------------------------------------ 17

Vertiginous ---------------------------------------- 8

Auditory ----------------------------------------- 5

Epigastric ---------------------------------------- 4

Diplopic ----------------------------------------- 1

Total ----------------------------------------- 239

The occurrence of an epileptic warning seemed to be related to the location

of the injury. In the patients who had no aura, there was a high incidence of

frontal wounds; in those with motor aura, there was a high incidence of frontal

and parietal injuries; and in the group with sensory aura there was a high

incidence of wounds in the parietal region.

Motor aura.-The motor phenomena preceding a fit were usually present

in the upper extremity, less commonly in the face, and only occasionally in the

leg. An entire half of the body was occasionally involved. The predominance

of auras in the arm is probably only a correlate of the extensive cortical representation of the arm and hand. Both inhibitory and excitatory phenomena

occurred as auras. A weakness or heaviness of the arm was occasionally encountered, and an inability to speak was not infrequently stated to be the first

manifestation of an attack. Excitatory phenomena were more common;

they consisted of twitching of the face, eye, or fingers; jerking of the arm or

leg; or turning of the head and eyes away from the side of the cranial wound.

The motor manifestations persisted either for a very short period or for

many minutes. They might or might not be followed by a generalized seizure.

Some patients found that massage of the twitching part stopped the progress

of the attack. In a few cases, the aura started in one member and spread to

another, but a true Jacksonian march was seldom encountered. In only a

single case did the patient describe a motor aura followed by a sensory hallucination, although the reverse was common.
POSTTRA UMATIC EPILEPSY 287

3 4 

3 

9 9

78

4 -13

5-7

7- 8

2-9

9 -7 - ---

FIGURE 54.-Electroencephalogram of patient with penetrating wound of left temporal

region 23 months before this record was made. The slow wave out of phase activity in the

third and fourth tracings is due to a focus umder point 5.

Somatosensory aura.-Just as with motor phenomena, sensory auras

were referred to the face, hand, or arm, and, less often, to the trunk and leg.

Occasionally, the neck, axilla, abdomen, or spine was the site of the parasthesia. The individual parts of the foot were not singly involved as were the

thumb and fingers.

The usual type of paresthesia was a sensation of numbness. It was sometimes described as a "funny feeling," "as if the hand were off," "a tickling sensation," "a tingling," or "a pins and needles" feeling. One patient bad a

kinesthetic aura as if the right arm were swinging in a circle, and another a

feeling as if the arm and leg were about to move. "Burning" was seldom used

to describe the sensation; only one patient complained of the hallucination of

coldness. Pain as an aura was encountered in only two cases. One patient

stated that his warning consisted of the "going to sleep" of the right hand and

then the right leg, followed by painful abdominal cramps and spasms of the
288 NEUROSURGERY

right hand and leg. Frequently, the sensory aura was followed by motor

phenomena such as twitching or jerking of the paresthetic extremity. Occasionally, olfactory, auditory, and visual hallucinations rounded out the

aural cycle.

Visual aura.-The common visual aura consisted of a blurring of vision

in one or both visual fields. The impairment of sight was frequently described

as dots, a black ball, a circle, or a curtain moving across the visual field in an

undulating or pulsating fashion. Frequently, the scotoma began in the periphery of a hemianoptic sector and proceeded across the vertical meridian to

involve the normal field, causing a complete loss of vision for a few minutes.

With the onset of blindness, a generalized attack sometimes developed.

The visual aura often consisted of white or colored "lights" in the affected

visual fields. Occasionally, the patient described his warning as a pyrotechnic

display with all the colors of the rainbow. The hallucination might develop

in an hemianoptic field. Occasionally, a blinding light preceded a grand mal

attack. One patient described his aura as "little yellow stars followed within

a minute by blindness," either lasting 2% hours or followed within a few seconds

by a generalized seizure. Another patient maintained that he saw blue

flashes of light in his right lower quadrantanoptic visual field and then "bedpans, ducks, books, trains, and magazines" moving to the left. When lateralized, the hallucination occurred in the visual field contralateral to the cerebral

wound. It might be followed by numbness of the face, arm, or hand on the

side of the aura, and, less commonly, by twitching. One patient complained

of his "eyes going out of focus" and another of seeing double at the onset

of the attack.

Complex aura.-These are bizarre auras. One patient spoke of his attacks

beginning with a confused feeling, a sizzling noise, and then a cry as the tonic

phase started. "Sweating and blackouts" were the words used by another

patient to describe his aura. Dreamy states occurred but were unassociated

with gustatory and olfactory hallucinations. Although the patient was always

asked about it, a full-blown uncinate attack was not encountered. A patient

with a bilateral inferior frontal lobe injury was warned of his attack by "a

funny feeling in the stomach, smell of burnt almonds, and a droning noise like

an aeroplane." A number of patients had auras composed of auditory, visual,

and motor components. A ringing of bells, flashes of light, and movement of

the right arm ushered in the attacks of a patient who had a wound in the left

occipital region. The onset of tie epilepsy in another patient was characterized

by ringing in the left ear, followed by a feeling of coldness of the left side of the

lip and face, and burning of the fingers of the left hand. Still another noted

that, before the attack, sounds became fainter, the left side of his face, lips,

teeth, and tongue burned, and his jaw muscles tightened, so that he could not

talk. These are but a few examples of the varied complex auras encountered

in this series of patients with posttraumatic epilepsy.

Vertiginous aura.-A number of patients complained of dizziness just

before the generalized attack. It is usually difficult to assess this sensation,
POSTTRAUNMATIC EPILEPSY 289

but in some cases there appeared to be a true vertiginous element in the

dizziness. One patient stated that objects spun around and he became

nauseated.

Auditory aura.--Uncomplicated auditory auras were encountered infrequently in this series. Usually, a sonic warning was accompanied by a visual,

motor, or sensory hallucination. One patient "heard voices, saw bright lights,"

and then became unconscious. Humming in both ears ushered in the attack

in one case. A sound of "motors running followed by a stinging sensation in

the right hand" constituted another aura. Usually, the aura was not lateralized, but one patient maintained his auditory premonition was in the left ear.

Epigastric aura.-The epigastric auras consisted of a feeling of uneasiness

in the pit of the stomach, nausea, a choking sensation, cramping abdominal

discomfort, and, occasionally, vomiting. Such visceral auras were infrequent.

Occasionally, the attack was initiated by other manifestations such as sweating.

Although in some cases the attacks consisted only of focal manifestations,

generalized seizures developed in 87 percent of the cases in this series. Other

variants of the epileptic diathesis were less commonly seen. Fifteen patients

had petit mal attacks, and two had psychomotor episodes. In none of these

cases was there an electroencephalographic spike and dome pattern characteristic of petit mal or psychomotor epilepsy.

MEDICAL MANAGEMENT

As a general rule, all patients were treated by nonsurgical measures before

surgical procedures were considered with the exception of those suffering from

such conditions as uncontrollable status epilepticus, infections of the scalp,

or cranial defects which required repair.

Anticonvulsant Medication

It had been hoped that medical therapy could be regulated by determinations of the blood and spinal fluid levels of the anticonvulsant agent used, but

this did not prove practical. Without this information such therapy was

clearly empiric, but it was nonetheless employed and gave good results.

In the first cases encountered, treatment was begun with small doses of

phenobarbital (0.1 gin.) at night, the dose being increased if an attack occurred.

When this regimen proved inadequate, phenobarbital was given in 0.1-gm.

doses twice daily and Dilantin Sodium (diphenylhydantoin sodium) was given

in the same dosage 3 to 6 times daily.

In 16 of the 20 cases in which this regimen was tested, daily doses of

Dilantin Sodium (5 capsules or more) proved toxic. Ataxia and dizziness were

the most frequent side effects, but in three instances extreme ataxia, vomiting,

weakness, and nystagmus developed after this treatment had been carried out

for several weeks. Complete investigation of the neurologic status of the

affected patients, including pneumoencephalographic studies, disclosed no
290 NEUIROSURGERY

other cause for the symptoms. Tie patients slowly improved when Dilantin

Soxdium therapy was discontinued, but, in one case, it was more than 3 months

before the nystagmus disappeared.

If epileptic seizures were not controlled by a reginen of phenobarbital in

dloses of 0.1 gin. 2 or 3 times a day (the administration being regulated according

to the degree of drowsiness it produced), combined with Dilantin Sodium in

doses of 0.1 gin. 4 times a day, inedical management was regarded as unsuccessful

and surgical measures were considered.

Results of Anticonvulsant Therapy

The results of medical management, in spite of the difficulties just related,

were on the whole quite good. One evidence of its results is the fact that at

the beginning of the program practically all of the hospital personnel observed

one or more seizures, while after a few months nurses were sometimes on the

ward for months before they witnessed an epileptic attack.

Of 238 patients submitted to this regimen, seizures were controlled by it in

110 patients for periods of at least. 6 months. In 64 of these 110 cases, the

results were achieved by phenobarbital alone, usually in doses of 0.1 gmi. daily.

in 26 cases, Dilantin Sodium, usually in doses of 0.3 gin. daily, combined with

phenobarbital in (loses of 0.1 gin. daily, proved sufficient. In nine cases,

Dilantin Sodium was used alone in (loses of 0.3 gin. daily. The remaining

patients were treated by various combinations of these drugs. It is quite

possible that in many of this group I)ilantin Sodium alone would have proved

adequate, but the routine required did not permit testing.

In 22 cases, attacks were controlled from. 4 to 6 months by the measures

described. At the end of these periods, the patients were either discharged or

were transferred to other institutions. In 40 cases, the patients were transferred

to other Army hospitals or to Veterans' Administration hospitals before they

had been treated long enough to warrant conclusions.

In the remaining 66 patients, the attacks were not controlled by anticonvulsant medication. Forty of the patients later underwent cortical resection. The other 26 patients were not operated on chiefly because of neurologic

defects, infected wounds, or unwillingness to undergo surgery; no patient was

operated on if he did not wish to be.

As this analysis indicates, the chief reliance in the medical management. of

these patients was upon phenobarbital and Dilantin Sodium. Tridione (trimethadione) was used in a number of cases but had no apparent, effect oil

psychomotor seizures.'

3 In all, 130 patients were discharged from Cushing Oeneral Hospital with their epileptic attacks controlled either

forf 6months or more (110) or for 4 to 6 months (20D. At the end of 12 to 18 months after their discharge, 51 had had no

convulsions, 19 had had only I seizure, and 22 had had several seizures. Few of them had continued taking the medication

as prescribed and about 10 percent had discontinued it enthely. Under the circumstances. complete control of seizures

in almost half of the 130 patients was regarded as distinctly encouraging. Social and economic tesults were, however.

distinctly les promising. (Walker, A. E. and Quadflasel, F. A.: Followup Report on a Series of Poattraumatic Epileptic.

Am. J. Psychiat. 104: 781-782. June 1948.)
POSTTRAUNMATIC EPILEPSY 291

General Measures

An extremely important phase of the treatment of these patients had

to do with counseling them about their condition. Many had been unduly

alarmed by gossip and rumors. Their morale was invariably much improved

when their status was discussed with them tactfully but frankly. They were

told that there was no ground for the stigmata so often attached by the laity

to the epileptic state; that the seizures were simply an indication of the brain

injury; that they could be controlled to a large extent if not entirely eliminated;

that epilepsy does not lead to insanity, does not necessarily prevent marriage,

and should not be kept secret from fiance, wife, or family; that unless attacks

were very frequent, they were not incapacitating; and that the drugs used for

the control of epileptic seizures are not habit forming. These explanations

and their frank discussion (lid much to restore self-confidence and improve

morale.

Patients were also advised about their general activities and way of life,

the following facts being emphasized:

1. An epileptic must take certain precautions, exactly as do patients

suffering from many other medical diseases.

2. Because of the danger of injuring himself in an attack, he should not

bathe in deep water unattended or work around moving machinery into which

he might fall in a fit.

3. Driving an automobile is dangerous not only to himself but to the

public.

4. If the patient had frequent attacks, he was advised to carry with

him a padded tongue depressor to place between his teeth when he felt an

attack beginning.

General hygiene.-Experience has shown that epileptics are less likely

to have seizures if their general physical condition is good and if they are

mentally and physically active. A regular routine of exercise, wholesome

meals at the usual hours, and adequate sleep each night was therefore provided in the hospital. A special diet was not used, but excesses were discouraged. Because seizures are frequently associated with constipation, the

patients were advised to cultivate regular evacuation habits. Moderate

smoking was allowed, but all alcoholic beverages, which tend to precipitate

attacks, were forbidden.

Management of Seizures

It was found that the relatives of a patient and even hospital attendants

(lid not have a healthy attitude toward patients subject to convulsions.

The whole situation was discussed with them, and they were instructed in

the proper care of a patient having a seizure. If the patient is prevented from

injuring himself, they were told, the attack, while terrifying to behold, does

not endanger life. Because the seizure is usually self-limited, the observer

can be of more assistance by following a few simple directions than by rushing
292 N EU"SURl;G EItY

to telephone a doctor. The clothing about the patient's neck should be

loosened. To prevent tongue biting, a padded tongue depressor can usually

be inserted between the molar teeth without using force. l)uring tihe clonic

phase of the attack, the patient. should notl be restrained, but he should be

protected from injury by removing him from the proximity of radiators anti

furniture andi by placing a pillow or other soft, object, under his head to prevent

bruises and lacerations. During this (lonic stage, tire attendant should not

leave tile patient. It lasts only a minute or two following which he relaxes.

Then, to maintain a patent. airway, he may be turned on his side so that the

saliva may drool from tile corner of his mouth. lie may now be moved to a

bed, preferably one with sideboards.

Since anl observant nurse or relative can give valuable information about

the mode of onset ani progress of the patient's attack, it, was worthwhile

instructing these persons in the points to note during and following an attack.

These included the mode of onset of motor phenomena; the spread of the

attack; the type of movement; involvement, of one or both sides; the state

of consciousness; tongue biting; incontinence of urine or feces; cyanosis;

injury; duration of the attack; and, following the (lonic phase, tile period

of confusion or excitement, weakness of an arm or leg, disturbance of speech,

or any other unusual occurrence.

SURGICAL MANAGEMENT

Surgical treatment was considered entirely as an adjuvant to medical

therapy for post traumatic epilepsy. It, was not. regarded as a substitute for

it, and most. patients were not, operated upon until intensive medical treatment

had failed to control the attacks.

Indications

The most frequent. indications for surgical intervention for epilepsy were

the fbilowing: (1) Sizable bone fragments or other foreign bodies in the brain,

especially if they were superficial and near the motor cortex; (2) a cranial

defect larger than 2 cma. in diameter; and (3) convulsions not. controlled by

nontoxic amouitts of anticonvulsant niedication.

Intracerebral foreign bodies.-At, the primary debridenlent of a wound of

the head, all foreign bodies, bone fragments, and necrotic material were usually

removed. If, however, a foreign body had been overlooked and was discovered

months or years after an uneventful convalescence, it, was diflicult to decide

whether it. should be removed. The role of intracerebral bone fragments and

foreign bodies in post t raumnat ic epilepsy has still not been clearly demonstrated,

but there is no doubt that their presence in the brain is usually associated with

greater pathologic reaction than occurs after surgical wounds.

If, therefore, convulsive seizures had developed and if foreign bodies

present, were superficial and readily accessible without, damaging normal brain

excessively, it was the practice at Cushing General Hospital to remove themu,
POSTTRAUMATIC EPILEPSY 293

with adjacent diseased tissue. If, however, tile particles were small and if the

patient's attacks could be controlled by anticonvulsant medication, they were

usually left in situ.

Cranial defects.-Defects in the skull smaller than 2 cm. in diameter,

unless they were situated in the frontal region and were disfiguring, usually

required no surgical treatment. Such defects, especially in young individuals,

gradually decrease in size because of bony proliferation at the margin of the

defect, and in the course of a year or two they may be completely filled in by

a thin layer of new bone. If there is no bony regeneration, a thick, firm,

fibrous membrane covers the opening so that even the pulsations of the brain

may not be palpable. These defects were therefore not usually repaired.

Defects larger than 2 cm. in diameter were usually repaired, since cranioplasty by protecting the underlying brain and eliminating the constant pulsations of the cerebral tissue may decrease or even eliminate convulsive seizures.

Persistent seizures.-Inability to control convulsive seizures by medical

treatment constituted the most frequent indication for surgical therapy for

posttraumatic epilepsy. If convulsions persisted in spite of therapy with

Dilantin Sodium and phenobarbital in doses just below the toxic level, surgical

intervention was considered justifiable.

Contraindications

A surgical procedure on the brain must be considered as carrying a certain

risk. This danger must be weighed against the possible advantages of any

operative procedure. Because epilepsy is not usually a lethal disease, no method

of treatment should be employed that is attended by a heavy risk to life,

especially if the results of the procedure are not well established. There were,

therefore, certain contraindications to the surgical treatment of epilepsy at

Cushing General Hospital.

Extensive neurologic disturbances.-It appeared unwise to subject an

individual who was hemiplegic, paraplegic, or quadriplegic to a serious operation

for the relief of convulsive seizures if the seizures played a very minor role in

his disability. The condition of severely aphasic patients was also carefully

evaluated before operation. Only if it seemed likely that the elimination of

their attacks would enable them to lead a relatively normal existence were

they subjected to operation. If they would still be seriously handicapped,

even though they would no longer have attacks, the danger of aggravating the

aphasia and the risk of operation were considered to overweigh the possible

gain from the procedure.

Mental disturbances.-If the patient was mentally disturbed, the advisability of operation was always doubtful. Psychoneurotic tendencies leading

to alcoholic excesses constituted, for instance, a poor background for surgery.

Mental impairment to a degree which rendered the patient incapable of following

medical advice and treatment was likewise regarded as a contraindication to

surgery.
294 N EVIROSURG ERY

Chronic infections of scalp or cranium.-Infection as a contraindication

to exploration of the cerebral cortex is self-evident. Appropriate medical and

surgical measures were instituted ini all such cases to clear up the infection.

General debility.-Because a cortical resection is a major surgical procedure, and one of considerable magnitude, surgical intervention was delayed

in any instance of debility until the patient's general condition was improved.

Timing of Surgery

If foreign bodies were present in the brain or if a cranial defect existed in

the skull at the time of the patient's first convulsive seizure, the optimum time

for surgical intervention depended upon the time which had elapsed since the

original brain injury. If less than 6 months had elapsed, immediate removal

of the foreign bodies, with cranioplasty, was considered advisable because of

the excellent chance that the epilepsy could be controlled medically. If,

however, the attacks had begun more than 6 months after the injury or if the

patient was first seen at a later time, it was thought wiser to await the results

of a test of medical therapy before carrying out any surgical procedures. If

the attacks persisted, as previous studies indicate they usually do, the cortex

could be more extensively explored at the time the foreign bodies were removed

and the skull defect was repaired.

If the patient's primary wound had healed by first intention, the cortical

exploration was carried out whenever it was decided that medical management

had failed. If the primary wound was infected, a cortical resection was not

considered to be advisable until the wound had been completely healed and

free of drainage for at least 6 months and preferably for a year.

Special Preoperative Examinations

When cortical excision was to be undertLken, it was considered advisable

for additional psychologic examinations to be made before operation so that

any alterations following operation might be more readily evaluated. Certain

of the tests previously made were repeated, and a Rorschach examination was

always carried out.

Accurate localization of the area of cerebral cortex giving rise to the convulsive manifestation in posttraumatic epilepsy was necessary for surgical

treatment of the condition. Since it seemed possible that an epileptogenous

focus might be more susceptible than normal cerebral cortex to a convulsant

agent, an attempt was made to stimulate the focus selectively by altering the

chemistry of the blood. An attempt was made to locate the focus without

inducing a generalized seizure by using electroencephalographic recordings to

determine the activation before clinical manifestations appeared.

Activated eectroencephalography.-Electroencephalograms were made

with electrodes placed conventionally upon the scalp, with additional electrodes

about the site of the healed wound or cranial defect, and with at least one
POSTTRAU MATIC EPILEPSY 295

electrode on a comparable position on the opposite side of the head. For

monopolar recording, an electrode attached to the ipsilateral ear was used as

,I common lead. All anticonvulsant medication was eliminated for 3 days

before the electroencephalographic recordings were made.

Hyperventilation.-It is well known that alterations of the acid-base

equilibrium of the blood will accentuate or diminish the likelihood of convulsive

izures. The usual hyperventilation technique induces a buildup in 20 to

percent of epileptic patients. The attempt to measure the respiratory

\change was found to be too exacting for epileptics with neurologic disorders.

in a group of seven patients, all of whom seemed willing to cooperate, an

attempt was made to obtain standard hyperventilation at a rate of 15 cycles

per minute, each cycle representing an exchange of 20 cc. of air per pound of

body weight. Kymographic recording of the respiratory exchange showed

that the individual patients achieved from 40 to 112 percent of the standard.

In one patient (breathing 14.2 cc. of air per pound of body weight 15 times a

minute), a Jacksonian convulsion developed (luring the hyperventilation. The

other six did not, have significant alterations in the electroencephalograms.

Hyperventilation, therefore, did not seem to be a consistent, satisfactory

method for activating an epileptic focus.

Forced hydration.-While clinical convulsions may be induced by forced

hydration in 25 to 40 percent of individuals subject to epilepsy, it is a difficult

procedure to control quantitatively. In 8 patients, 4 of whom had posttraumatic epilepsy and 4 posttraumatic encephalopathy without seizures, the

hydration test described by Penfield and Erickson 6 was carried out after

anticonvulsant drugs had been withheld for a few days. Under this regimen,

such severe nausea and vomiting developed within 24 hours in all but one

of the patients in the epileptic group that the test had to be discontinued.

Gains in weight from 1.5 to 5.5 pounds were noted. None of the patients

showed electroencephalographic changes, although one had a generalized

seizure 2 hours after the test. Gastrointestinal disturbances did not occur

in the nonconvulsive group, and none of the patients showed electroencephalographic alterations.

Alcohol.--Clinical experience shows that seizures are prone to occur a

(lay or two after an epileptic has indulged in alcoholic beverages. In view

of this fact, electroencephalograms were made on a group of 16 patients, 12

of whom were epileptic, after the rapid (within 2 to 3 minutes) intravenous

administration of 40 to 150 cc. of 10 percent alcohol. The studies were made

during administration, immediately after, and at intervals up to 72 hours

after the alcohol had been injected. In the four instances in which blood

alcohol levels were determined, they ranged between 100 and 150 mg. percent.

In the nonepileptic group, the alpha rhythm became more prominent, and the

amplitude of the previous abnormal activity decreased. All the patients

6 Penfield, Wilder, and Erickson, Theodore C.: Epilepsy and Cerebral Localization. Springfield: Charles C

Thomas, 1941.
296 NEUROSURG ERY

showed clinical evidences of intoxication, although none were unable to walk.

No clinical or electroencephalographic manifestations of epilepsy were observed.

Tridione (trimethadione).-Because grand mal had developed in some

patients under treatment with Tridione for petit mal, 12 patients with posttraumatic epilepsy were tested with this drug; the (loses, which ranged from

50 to 500 mg. each, were given variously from 1 to 3 times (a total of 26 trials).

In no instance was there any appreciable effect on the electroencephalogram,

but one patient, about 30 minutes after receiving the drug and after the electroencephalographic recording had been completed, had a focal epileptic attack

which did not become generalized.

Electric shock.-Because electric shock has proved to be such a simple and

relatively innocuous convulsant, it was used in a group of 11 patients with

posttraumatic epilepsy. Seven patients were given 200 milliamperes for 0.05

to 0.15 second with a 60-cycle sine wave current. They had only startle

reactions or mild tonic spasms at the instant of application of the stimulus.

Four patients who received 2 to 5 milliamperes of square wave pulsating direct

current for 2 to :1 seconds felt only a sensation of warmth. The electroencephalograph was turned off just before the shock and was turned on again

immediately afterward. In no instance was there significant alteration in

the electroencephalogram 5 seconds after the stimulus.

Penicillin.-Since penicillin had been shown to have a convulsive effect

when applied to the cerebral cortex, 100,000 units were given intravenously

to 5 patients, 4 of whom had organic brainh disease. The electroencephalographic

record was followed for 35 to 50 minutes. In no instance was any change

noted.

Sodium cyanide.-Because the cytochrome-oxidase system is impaired in

advanced paretics in whom convulsive manifestations are common anld because

cyanide is a specific poison for these enzymes, it was thought advisable to

determine its effect upon patients with posttraumatic epilepsy. A 2-percent

solution of sodium cyanide was therefore administered intravenously to 17

patients, 14 of whom had seizures. Three patients were given 0.3 mg. per

kilogram of body weight, and the remainder were given 0.4 mg. per kilogram

of body weight. One patient in the first group had no clinical or electroeneephalographic reaction. In all the other patients, a respiratory gasp

occurred 8 to 20 seconds after the injection, andi there appeared a progressive

slowing of the predominant activity of the electroencephalogram. In one

patient, for example, the gasp occurred 20 seconds after the injection in tile

antecubital vein. The predominant rhythm in all leads 5 seconds later, was 8

per second; in another 5 seconds, it was 6 per second, and 8 seconds later it

was 2 per second. Fifty seconds after the injection, widespread muscular

twitching occurred throughout the body. Within 70 seconds after inhalation

of two ampules of amyl nitrate, the slow waves had disappeared. In some

cases, the head and( eyes turned to one side without constant relationship to

the site of injury. Occasionally, opisthotonos developed. The reaction to

the cyanide was the same in patients with epilepsy and in those without it.
POSTTRAUMATIC EPILEPSY 297

Acetylcholine.-Since it had been suggested that acetylcholine may be

related to epileptic states, 18 patients, 15 of whom had epilepsy, were given

100 to 300 mg. of this drug at rates of injection varying from 20 to 60 mg. per

minute. No change in the electroencephalogram was noted in any case except

that in one instance, there was a decrease in amplitude of the waves for 2

minutes after tile injection. The patients experienced a feeling of warmth

and occasionally coughed, but they had no other clinical manifestation related

to the injection.

Metrazol (pentylenetetrazol).-It had been known for some time that clinical seizures could be induced in patients subject to epileptic attacks by a smaller

dose of Metrazol than that needed to cause convulsions in normal individuals.

For activation of the epileptogenous focus, Metrazol, usually in 2-cc. doses

(200 mg.), was injected as rapidly as possible into the antecubital vein while

an electroencephalogram was recorded (fig. 55). The needle was left in place,

and as soon as alterations were seen in the tracing, which was usually within

30 to 60 seconds, phenobarbital sodium (0.26 gin.) was administered intravenously in an attempt to prevent the development of clinical convulsions.

In one group of patients, the Metrazol was given by intramuscular administration, 0.6 rag. per kilogram of body weight being injected into the deltoid muscle.

Phenobarbital sodium was given intravenously or intramuscularly as soon as

changes were seen in the electroencephalogram, which was usually 3 to 4

minutes after the drug had been given.

In tile majority of cases, the changes occurred predominantly or solely

in the tracings from one region (localized electroencephalographic alterations).

The results of Metrazol activation in tests of 97 patients with posttraumatic

epilepsy are shown in the following tabulation:

J'alients

showing

these

Findings fi ndi ngs

Generalized electroencephalographic alterations --------------------------------- 7

Localized electroencephalographic alterations ---------------------------------- 58

Localized and generalized electroencephalographic alterations. - ----- ----- 10

Generalized slow waves ------------------------------------------------------ 5

Localized slow waves -------------------------------------------------------- 33

Generalized spikes --------------------------------------------------------- 6

Localized spikes ------------------------------------------------------------ 31

GeneraliAe'd electroencephalographic seizures ----------------------------------- 6

Localized electroencephalographic seizures ------------------------------------- 18

Clinical generalized convulsion ----------------------------------------------- 14

Clinical focal convulsion ----------------------------------------------------- 10

I Although a number of patients were activated more than once, in this table a positive result in any tategory is stated

only once for each patient. Some patients had positive results on repetitions of the tests, which were sometimes carried

out 4 times.

These alterations took the form of slow waves or humps with a frequency less

than the alpha rhythm, or of single or multiple spikes, at times occurring rhythmically and giving the pattern of a localized electroencephalographic seizure.

Abnormalities present before activation were usually aggravated by the Metra-
298 NEUROSURGERY

zol. Such localized electroencephalographic alterations occurred in 60 percent

of 97 patients tested (fig. 55).

In a smaller number of cases, generalized electroencephalographic alterations consisting of single or multiple slow waves or spikes were present simultaneously in tracings made from several parts of both sides of the head. It

PLATE

P LATYE

A ;12-10 2CC. MUTRAZOL I.V.

10-14

14.4

START B

75 SEC. AFTER I-,TRAZOL C

135 SEC. AFTER METRA ZOL t --

FIGURE 55.--Electroencephalogram taken during Metrazol activation. The electrodes

were placed on the scalp about a plate in the right frontal region. A. Record taken during

intravenous administration of 2 cc. of Metrazol (200 mg.). B. Spiking seen in all records 75

seconds after injection, most pronounced and out of phase in tracing. from electrode 14.

C. Spikes of greater amplitude 135 seconds after administration of Metrazol.

some instances, the rhythmic waves and spikes occurred simultaneously in all

parts of the head recorded, giving the pattern of a generalized electroencephalo

graphic seizure.

In a small number of cases, the patients experienced sensory or motor

phenomena such as they usually had at the onset of their spontaneous seizures.
POSTTRAUMATIC EPILEPSY 299

In approximately half of these cases, tile attack consisted only of this aura.

In the remainder, tile attack began as, or developed into, a generalized seizure

involving all parts of the body and associated with loss of consciousness. Thle seizures induced by Metrazol had the characteristics of thle patient's

ordinary attacks. The fit was ushered in by the same aura, progressed in the

usual ord(r, and was associated with identical motor phenomena. The severity

of the seizure was comparable to that of the spontaneous convulsion. There

was, however, no relation between the frequency and number of attacks which

the patient had had and their occurrence on Metrazol activation.

Because a single Metrazol activation gave positive localizing electroencephalographic findings in less than half of the cases studied, examinations were

repeated on a number of patients whose primary examination had been negative. About a third of this group had localized electroencephalographic

alterations on the second test. Reexamination was also done on a number of

patients who had had focal electroencephalographic alterations on the first

test. Although the majority again had focal abnormalities, some showed

no electroencephalographic alterations on the second test. It was therefore

concluded that focal activation was not consistently found in the same patient

on repeated examinations, although, when it was present, the focus appeared

to be at the same locus.

If the activation was carried out while the patient was taking anticonvulsant medication, the incidence of activation was lower. In a series of 40

such activations, 3 patients (7.5 percent) showed generalized electroencepbalographic changes, and 15 patients (37.5 percent) showed localized alteration,

but none of the patients in this group had clinical convulsions.

In a group of 11 patients, 6 mg. of Metrazol per kilogram of body weight

were administered intramuscularly. Only 1 patient had a clinical generalized

seizure, and only 2 showed localizing ele.:troencephalograplhic changes. After

9 of the 11 patients in this group were given 2 cc. of Metrazol intravenously,

all showed focal electroencephahograplii(' alterations. It would seem, theni,

that, though the intramuscular method of administration of Metrazol was less

apt to produce clinical seizures, it was much less efficient in activating an

epileptogenous focus.

On the whole, activated electroencephalography by Met razol was concluded

to be a useful diagnostic procedure and of real value in localizing an epileptogenous focus.

Pneumoencephalography.- -In order to ascertain the amount of brain substance lost and the degree of ventricular distortion, pneumoencephalograms

were raade routinely before a cortical exploration (table 14). One hundred and

nine patients were thus studied from 3 months to 3 years after the head injury.

A few patients had more than one pneumoencephalographic study. In the

entire group, only 14 pneumoencephalograms were reported as normal. Four

of these patients had closed injuries of the head. In only three patients did tile

ventricular system fail to fill. In 9 patients, 3 of whom had closed injuries of

the head, the ventricles were symmetrically dilated. The pneumoencephalo-
300 NEUROSURGERY

TABLE 14.-Pneumoencephalographic observations in 109 patients with penetrating wounds of

the head

Unilateral Bilateral Bilateral

Normal find- Nonfilling of ventricular ventricular ventricular

Series ings ventricles dilatation dilatation dilatation with

outpouching

Percent Percent Percent Percent Percent

Posttraumatic epilepsy series - - 12. 8 2. 8 1& 3 & 2 57. 9

Nonselected series ------------ 27. 2 5. 8 29.0 16. 5 29.0

STroland, 0. E., Baxter, D. H., and Schatzki, K.: Observations on Encephalographic Findings in Cerebral Trauma.

J. Neurosurg. 3- 390-398, September 1946.

grams of all patients suffering from closed injuries of the head were either normal

or showed symmetrical ventricular dilatation.

The most common finding in cases of penetrating head injuries was a bilateral ventricular enlargement with an outpouching at the site of the skull

defect (fig. 56). This finding was present in 63 patients. In 12 patients, unilateral ventricular enlargement with an outpouching was present on the side

of the lesion, and in 8 patients, a simple unilateral ventricular dilatation was

present on the side of the lesion (fig. 57).

Fi.URE 56.-Pneumoencephalograms of patient with posttraumatic epilepsy, showing

mild generalized ventricular dilatation, somewhat more pronounced on left side, and retraction of entire system to left. The enlargement of the third ventricle is well demonstrated.

A. Anteroposterior view. B. Posteroanterior view.
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302 NEUROSURGERY

intervals after pneumoencephalography and by clinical auscultation of the

shaken head; the splash of the water was quite audible until the air was absorbed.

Dye (phenolsulfonphthalein) was injected into the lateral ventricles of

eight patients, and the rate of excretion in the urine was determined. Almost

all seemed to have slow rates, but, since normal patients vary so greatly, it

cannot be stated with certainty that this phenomenon indicated an impairment

of the absorbing mechanism.

Preoperative Medication

Because the majority of patients with posttraumatic epilepsy had had

infected wounds of the scalp and brain, prophylactic chemotherapy was given

before secondary craniotomy. Sulfadiazine (2 gm. every 4 hours) was given for

24 hours before operation, and penicillin (30,000 units every 3 hours) was given

for 12 hours. This regimen was continued for 5 days after operation.

ANESTHESIA

Intravenous Pentothal Sodium (thiopental sodium) was used in the first

craniotomies for posttraumatic epilepsy, but the cortical activity was observed

to be markedly depressed. Afterward, therefore, local anesthesia was secured

by infiltration of the scalp with 1 percent procaine. Morphine (0.015 gm.),

given as preoperative medication, did not appear to affect the cortical activity.

It is a tribute to the determination and stamina of these patients that under

these circumstances, only one lost his courage during the course of the operation, although the procedure occasionally lasted 5 hours.

TECHNIQUE OF OPERATION

Incision

The site of the epileptogenous focus, the size and shape of the skull defect,

and the extent and position of scalp scars were important considerations in

planning the incision. Frontal foci were exposed adequately by a bifrontal

incision behind the hairline, which left a perfect cosmetic result. For central,

parietal, temporal, or occipital exposures, a horseshoe-shaped incision was used

unless a previous incision prevented it..

A skin flap was not reflected across a previous scar for fear of ischemic

necrosis of the distal scalp. When a scar passed transversely in the temporal

region, it was necessary to use an S-shaped scalp incision, and to reflect two flaps,

in order to gain sufficient exposure. If a previous horseshoe-shaped incision

had been made but was too small to provide adequate exposure, the anterior or

posterior limb was carried farther out, leaving at least 3 cm. of scalp between

the two incisions to prevent ischemic necrosis. If a tripod sear was present,

it was converted into a modified horseshoe incision.
POSTTRAUMATIC EPILEPSY 303

Incisions circumscribing cranial plates were preferred to those passing

over the plate. It was thought that slight tension on the suture line due to

previous loss of scalp substance might cause the incision to disrupt and expose

the plate. If the incision skirted the plate, granulation tissue from the periosteum would soon fill in the gap, and there would be less danger of losing the

plate.

If the skull defect was small, the bone flap was planned to incorporate the

entire defect. If the hole was large, an appropriate flap was made anterior,

posterior, superior, or inferior to the defect, to expose the previously determined epileptogenous focus. The flap was hinged, if possible, by temporal

muscle.

Two-Stage Surgery

Usually, the craniotomy and cortical exploration were done in one stage.

If, however, the epileptogenous focus lay near the midline, it was considered

wisest to expose the cortex in two stages. In one patient with a focus near the

midline in the frontal region, status epilepticus developed during a cortical

exploration. Bleeding from openings into the longitudinal sinus due to avulsion

of pacchionian granulations assumed alarming proportions and could not be

controlled during the seizure by fibrin foam or manual compression.

A two-stage operation was therefore devised to minimize the future development of such a serious complication. At the first procedure, the bone

flap was turned down and all bleeding from the longitudinal sinus was controlled. Tantalum foil or plate was laid over the sinus, so that a secondary

craniotomy could easily be done without causing further hemorrhage. The

two-stage procedure had the added advantages that the first stage could be

performed under general anesthesia and that the discomfort of the patient at

the second operation was greatly shortened.

Exposure of Field

If a plate was present in the cranial defect, it was inspected for evidence

of infection as soon as the scalp flap was reflected. In many cases, a small

amount of clear fluid was present between the scalp, the dura mater, and the

plate. The thin membrane over the plate was usually white, smooth, and

glistening, but if infection was present the membrane appeared yellow and

granular. Yellow fluid about the plate suggested infection. If there was any

question, a piece of the membrane was removed immediately for bacteriologic

study. At times, organisms were found on smears, although cultures remained

sterile probably because of the inhibitory action of the preoperative chemotherapy.

If a plate was not present, the dura mater was separated from the margin

of the defect and from the scalp over the defect to prevent lacerations of the

brain when the bone flap was lifted.

After reflection of the bone flap and control of all bleeding, the cortex
304 NEUROSURGERY

was expose(d by incising the dura mater and carefully elevating it from the

underlying arachnoid to avoid tearing fine adhesions and causing subpial

bleeding. In many cases, a subdural membrane was found firmly adherent

to the dura mater. If the meningocerebral scar was small, the dura mater

was separated from it by sharp dissection. If the scar was extensive, the dura

mater was cut only from the margin adjoining the suspected epileptogenous

focus. The exposed brain tissue was carefully inspected and photographed so

that, in case subsequent operative procedures had to be undertaken, the area

would be objectively recorded. A rough sketch of the exposed area was found

useful for orienting points of stimulation.

Appearance of brain.-In many cases, when the dura mater was opened,

a subdural membrane firmly adherent to the dura mater was encountered

(fig. 58). In some cases, the membrane was 2 to 10 mm. in thickness and quite

extensive, overlying as much as half of a hemisphere. In other cases, the

membranev was of filamentous thinness. The meningocerebral scar, whether

small or large, was firm an(d tough and had to be cut by sharp dissection. The

adjacent brain appeared normal in some cases, but frequently it was yellow

FIGURE 58.-Exposed cortex showitig severe arachnoidal proliferation adjoining

meningocortical sear.
POSTTIIAUMIATIC EPILEPSY 305

/,'(/

A4PpCd,"dnCC o'COPlCX

Upon rcmovel o.

Acne adnd Cdrel flap / fJ'ord lion

FticURE 59.--Fxposed cortex showing -rachnoidal proliferation with eystlike formation at

site of meningoeortical sear.

or brown, softened, and cystic. The arachnoid was often thickened and translucent and occasionally contained white calcified plaques. Because of atrophic

gyri, arteries and veins, which are usually concealed in sulci, appeared on the

surface of the brain (fig. 59). Traction of the scar produced distortion of

superficial channels (fig. 60).

Studies on Cortex

An electrode holder, devised by Capt. Curtis Marshall, MC, was used to

place leads on any portion of the exposed cortex and to group as many as 10

leads about a small focus (fig. 61). For routine examinations, the leads were

placed at regular intervals over the entire cortex. The cortical activity was

usually tested, 8 points at a time being led into the 4 channels of the electroencephalograph. If an area of abnormal activity was found, this focus was

more closely analyzed by grouping the electrodes about the abnormal point

and using serial recording (fig. 62).
306 N Ei UllOI$" It( GEIKY

Electrocorticograms.- -Slow wave fovi W.re prt'.senlt iII plact ically all Csaes,

but iiey were not colisideredt as of ov.alizilig valuet so far as tilie epilelpy was

coniceried. ,Spoutaneolts focal elhetrical alt erat ions suchi as i•solated spikes,

Iuir-sts of spikes, or sp)iky wavaes (epileptic jiimanifestatit ios) were preisenl ii 14

of 31) clases thus txaiiil. Thlese, foji wtT&,r adjac.ent to, buIlt illt i, Ilie vereblral

scat.a. Ihiev were, uiually coutii ed to atil aru',al of coit ,x nothimoire :3 to 4

,'•I. ('II1. alld wer-e oftenl confinetd to oile c'Onll\'iltil~l.

Stimulation of cerebral cortex and electrocorticographic activation.- 'I'li c•,

lype.t of electriic sttlitilaitorPS wvere t(ried. Tlht ofdihlriitI. Site, Vtt Vt t)-4.'-c,,

FI':; i0o.---( vrehral cortex atdjacent to large sear which has t':used traction

oil SYlianl vessels.

stinmlator with awt output voltage from 0.1 to 20 volts proved quite satisfactory. A stimulator having a variable saw-tooth form (kindly loanied by I)r.

Percival Bailey, Illinois Neuropsychiat rI Institute, Chicago, I11.) gave adequaite results. Because til electroencephalograph was used immediately after

tilte stitnulatiou, at direct pulsating current stimulator, such as the square wave

stimulator of Pollock, which cauised polarization of tie tissues blocking tile

amplifiers, was not satisfactory.

After the spontaneous activity of the cerelral cortex was tested, an attempt

was malde to induce the focus to fire artificially. Because of previous experiel'lees (p. 297), Metrazol was tried its an activator, but the fear of inducing a,
POSTTRAUMATIC EPILEPSY 307

4 4

FIGURE 61.-Electrode holder clamped to margin of calvarium with

electrodes placed upon cortex for recording.

FIGURE 62.-Spontaneous electrocorticograms of epileptogenous foci in right inferior

frontal region. The record shows out-of-phase spiking in the first three leads, indicating

two foci, one at point 0 and one at point 9.
308 N EURIOSUltGE RY

generalized seizure, as well as the ease of activating the cortex by electrical

stimulation, led to abandonment of the Ilethod.

The usual method of electroactivation consisted of serial stimulation of

representative points of the cerebral cortex by ineans of a sine-wave current

from 1.5 to 2.5 volts for 5 seconds, followed by observation of the electrical

activity of the cerebral cortex, the motor responses, and questioning of the

patient regarding induced sensory phenomena. If no change was observed

in the electrocorticograin after 1 minute, another point was stimulated, and

so on until the entire cortex had been mapped (fig. 63A). An afterdischarge

PDT. $ STIMUL.ATErD

b

SC;W- STIMULATEDO

7,, {S

SCAN STIMULATED

--- • IIdUAT ----- __--

Fi, RF 63.-A. Electrocorticograms in case of psychomotor and grand mal epilepsy:

a. Spontaneous electrocorticograin from points indicated; b. record taken after stimulation

of scar (2 volts sine wave current for 5 seconds) (electrocorticogram has remained normal);

c. record taken after stimulation of point 3 (note slight afterdischarge in the first tracing);

d. record taken just after stimulation of point 8. B. Record taken after stimulation of

point 5: e. Afterdischarge in third tracing; f. record of same area I minute later; g. record

of same area 2 minutes later (the patient, who was operated on under local anesthesia, felt

quite normal. The triangular gyrus was removed by subpial dissection); h. record after

removal of triangular gyrus and stimulation of same area with 2 volts for 5 seconds. There

is no afterdischarge, nor could any be obtained by stimulation of the adjacent cortex. The

horizontal line at the base indicates an interval of 1 second, the vertical line a calibration

of 50 microvolts.
POSTTRAUMATIC EPILEPSY 309

would occasionally occur for a few seconds at tile point stimulated, but this

phenomenon was considered within physiologic limits. Generally, however, an

area of cortex adjacent to the scar could be found which, oil stimulation, caused

a long-lasting spiky afterdischarge (fig. 63B). This epileptic discharge might

persist for as long as 30 minutes. In many cases, the sensory or motor aura

which preceded the patient's spontaneous attacks was associated with this

afterdischarge. Occasionally, tihe elect rocort icographic attack would progress

to a clinical seizure, but in some cases tle patient did not have any motor or

sensory concomitants during the electrocorticographic (lischarge. Of 29 patients in whom such activation was used, 11 had no clinical phenomena associated with the afterdischarge. The remainder had sensory or motor focal

manifestations which, in seven patients, progressed to a generalized seizure.

Most of the 11 patients who had no motor or sensory phenomena associated

with the epileptic afterdischarge had had no aura with their spontaneous

attacks.

Epileptogenous foci localized in this maimer were adjacent to tile evre bral

scar in 18 cases and were in a gyrus slightly removed from, but parallel to,

the scar in 4 instances. In eight cases, the foci were separated from tile scar

by one or two nonepileptogenous convolutions. The extent of tile focus could

be determined by triangulation or push-pull arrangement of electrodes. TILe

foci activated by electrical stimulation were located at approximately tile site

predicted by tihe electroencephalogranm recorded after Metrazol activation. In

those cases in which spontaneous epileptic electrocorticographic alterations

were present in one area of the cortex, electroactivation brought out a long

afterdischarge from that cortical focus.

Multiple epileptogenic foci were present in very few cases, but occasionally

a focus migrated from one cortical area to another within a period of minutes.

On one occasion, the epileptogenous area wandered around a scar through an

arc of 1800 within a perio(d of 28 minutes.

The threshold of excitability appeared to be fairly constant, but it was

elevated for I to 4 minutes after a long afterdischarge. The activation usually

occurred at the site of stimulation, but, in 15 percent of tile cases, epileptic

activity was initiated in adjoining gyri, which were sometimes removed as

much as 2 to 3 cm. from the point of stimulation.

These observations seemed to indicate that certain cortical areas adjacent

to cerebral scars could be excited by the production by normally subliminal stimuli

of a local state of hypersynchrony characterized by epileptic electrocorticographic manifestations. Athough these phenomena had many of the characteristics of cortical afterdischarge, their lower threshold, more localized activity,

and longer duration suggested that they were different at least in degree That

areas capable of such activity were potentially epileptogenous seemed highly

probable. That they were the foci from which spontaneous epileptic attacks

originated lacked demonstration, though this seemed a reasonable inference

in those instances in which the electrocorticographic attack was associated

with an aura identical to that, in the spontaneous attacks. If the focus was

455735--58 -21
310 NEUROSURGERY

some distance from the scar, the suspicion was entertained that another, and

perhaps primary, focus was located nearer the injury.

By the use of this technique, it was possible in many cases to locate both

the motor cortex and an epileptogenous focus without inducing a generalized

seizure. Without the aid of the electrocorticogram repeated stimulations

might have precipitated a seizure as the result of facilitation of repetitive

excitations. If a generalized seizure occurred during exploration of the cortex,

it was usually difficult to locate an epileptogenic focus because of the marked

depression of cortical activity which persisted for hours after a particularly

severe seizure.

It was often difficult to find the precentral cortex by stimulation techniques

in patients suffering from posttraumatic epilepsy. Many had a hemiparesis

due to a subcortical lesion, in which event little response could be expected

from cortical stimulation. As cortical reorganization and recovery proceeded,

the excitability of the cortex probably increased. The longer the time after

injury, therefore, the better were the responses induced by electrical stimulation.

p V..

Condition of cortex on Jf..Dura Tnater

removal of bone flap, and alalon of cerebral aore defect in Jura miater. to Ji dhor'n lat anterioro 

of left ventricle.

FIGURE 64.-Surgical field showing extensive left frontal cerebral scar containing bone

fragments. The scar was removed to the ventricle.
POSTTRAUMATIC EPILEPSY 311

In those cases in which the clinical aura and electrocorticographic manifestations of an attack could be simultaneously induced, it seemed probable

that the stimulated focus was responsible for the patient's spontaneous attacks.

In those cases in which only the electrocorticographic epileptic manifestations

could be elicited, the evidence that the focus stimulated was responsible for

the attacks was not conclusive. There was no doubt, however, that such areas

were functioning abnormally and were potentially, if not actually, epileptogenous.

Surgical Removal of Sear and Focus

After the epileptic focus had been located and its extent determined by a

secondary application of the electrodes about it, it was removed by one of

several techniques, as follows:

1. The focus and the scars were excised down to the ventricle (fig. 64).

2. The focus and the scar were removed down to white matter (fig. 65).

3. The focus was ablated by subpial dissection (fig. 66).

Several considerations determined which of these techniques would be

employed. If there were foreign bodies in the scar, the scar and the focus

shad ing iiichitco*

Central area of subpial

Appearance

acar. Dottiec '"va' line indicae Abaion

•area. ablatelie.

FIGuRE 65.-Surgical field before and after removal of sear and epileptogenous focus.

The wound was a bullet "crease" of the parietal bone, without fracture of the bone. In

spite of the absence of penetration, a large scar was present in the parietal region.
3 12 N L1 It (S [I' (

1 ,ItI y

CC

5hatdecl area in-dicaics arca,

of sulbpial rresectio-n

-tiowi hY da~irk lminiltg.

\V411 Ie eCISeti. Thei tla11oiig of coiIIl)lIca'ii I 1i8was lessenedie Iif I the i'l "CiI 'It

not olut'titt If th le 8t'1i wa WIIShi gi an ad1t jacen CtoI the' loot~l 41'UI~T'U t'xte1181 Vt

Ir~est''t olS WNT't U VOlte bet UcaIuse of1 lhe fear- of t'xaicellba Ing lim a i al .N.S1 01,' 1111

a1 j)hUISiU n. t5)t(Iit of thlie I)V-ott't ii~'cUl-lt'( Iv out. iiie1)10 bloo pplyII~ tothle

Ait Ct'rt' 1 ichni (tIt I 'NWSOI \VliSt 1i rdet II the litcum It'-IoI next tot)5(lit,

SCnIII, 11i( d the Inivolve Vt(gl WU5 s II'ioNtt ( C(ii 'IfIly fro Jii t roIij to Iritl

Ualjawenlit ('ovt tx 10) (ltch IlIt'- corn plt't eiess of' th vt xt ir1lnIion by st iii int loll1

Wit il t lit 51 Sjiii(' St Irti(vtII of (hiIIetl it 1'(d Im ) it' otilIy . III someit cases, .it \\'Is

foiiund thlit dw lit' tor t'hU lnct'ii to tIl(. fottis, ~r i-St' t ( o I isv'1)1I 'i

III somei castes. befoi'' 41ll conivullsive net iv it v could IbIe ('I I in letI.It atP I li('r.

t'xt t'sivt' Sl~b)jiIII disset'ttion of 5t've'I'ii gvri, itil11illug Inito thle scm. hadi( to be
POSTTRAVNIA i EPIEPSY 313

Te mpora

-p~ra5uhpia[ reseclLon- , Cross- sechion shoiing

hdaCed alea , ubpial resection•. Heavy

inaicate5 cortex " dark line inicat:s part of

rernovea. cortex removed.

FI(;URE 67.-Teehiique of od)pkial res-ectioin. The cortical iliatiomi is carried to the

depth of the suletos.

carried out. During the ablation, speech anl motor power were checked

frequently. A defect in the d(ura mater was repaired by temporal fascia or

pericranium.

After closure of the dura mater, the bone flap was replaced. If a tantalum

plate formerly covered the defect, it, was replaced by a Lucite plate to make

subsequent roentgenograms of the skull more revealing (fig. 68).

PATHOLOGIC EXAMINATION OF EXCISED TISSUE

The microscopic examination of the tissues removed (fig. 69) showed that

the cerebral scars consisted of connective and glial tissue with numerous capillaries and had a varying amount of inflammatory cellular reaction. Neurones

were not present in the center of the sc,". The scar did not. seem to possess

any histologic characteristics different from those of scars in nonepileptie individuals.

The removed epileptic foei, even when they appeared grossly normal,

were in all instances composed of abnormal cortical tissue. The cytoarchitecture
N V' I tO i aE tN

Fl; IS lt d~ -ll h i-enno hiIv. A (h-cialo (fý-,txv

Ilo l )*v ~ u kil.1111p il. -av Of TlcAf h c
POSTTRAUIMATIC EPILEIPSY31

I. .%

FRE69.-Photoinicrograph of cortex adjacent to scar show~ing inivasion of cortex

by reticular tissue. The arachiioid is markedly thickened over this area. (Perdrau preparation X.)

of the cortex was disturbedl, andl the neuirones were decreased in number.

Those present were (lark staining, andl the nucleus, nucleolus, and cytoplasm

were distinguished with dlifficulty. Glial tissue was increased, and ill some

cases the connective tissue was also inlcreasedI, particularly about capillaries.

The araclinoid usually was thickened and occasionally contained chronic

inflammatory cells.

POSTOPERATIVE CARE

The~ patijent usually withistood the operative procedure well. In some cases,

plasma and blood were giveil during the operation. If not, a transfusion wvas

always started wheni he was brought b~ack to the ward.
316 NEUR()SURIGERY

III some instances, the patient was anesthetized with intravenous Pentothal

Sodium during tile closure of the wound. As soon as lie began to wake up,

sodium phenobarbital (0.2 gin.) was given by hypodermic injection. Phenobartital (0.1 gin.) was then prescribed 3 times a day. On a few occasions, when

orders for such postoperative medication were oImitted, convulsions occurred

within the first few days after operation. Apparentl, although there was

greater likelihood of attacks at this time, their occurrence was not an indication

of therapeutic failure; after these few days, the patients might have no further

attacks.

Fluids were limited to approximately 1,500 ce. per (lay for the first 3 or 4

(lays to prevent postoperative nausea and vomiting, The patient was allowed

up as soon as he desired, which was usually by the third or fourth (lay.

Ordinarily, there were few problems following the craniotoiny.

CRANIOPLASTY

Those patients who had a cranial defect but whose attacks were controlled

by anticonvulsant medication required only a cranioplasty. Although sheet

tantalum proved to be easily shaped, its radiopacity was undesirable, since

epileptic patients may require repeated roentgenographic examinations.

Acrylic plates, although more troublesome to form, were preferable to tantalum

for this reason. The surgical technique of cranioplasty (p. 261) is so well standardized that no comment on it is required.

After operation, the patient was given phenobarbital, 0.1 gm. 3 times a

(lay, to prevent the attacks otherwise likely to occur within a few days after

operation. In a week, the medication was reduced to the preoperative level.

POSTOPERATIVE EXAMINATIONS

At the end of 1 month, and again at, the end of 3 months after craniotomy,

the patient had complete neurologic, psychologic, and electroencephalograptuc

examinations. In general, his neurologic status was not appreciably altered

by the operative procedure. Several patients had an increase in hemiparesis

or aphasia lasting for a few weeks, but in most instances these disturbances

returned to their previous level within 3 months. All patients were advised to

continue anticonvulsant medication for 3 to 5 years.

It is recognized that the results of any procedure for the relief of convulsive

seizures are usually good or excellent for tile first few mo;.dis, or even for the

first few years, after operation. Immediate results suggest that surgical measures may have a limited place in the management of posttraumatic epilepsy

which has not responded to medical measures (tables 15 and 16).

OCCUPATIONAL THERAPY AND REHABILITATION

A patient who was under treatment for posttraumatic epilepsy at Cushing

General Hospital was rehabilitated as quickly as possible, in order to improve
POSTTRAUMATIC EPILEPSY 317

his mental outlook. To this end, he was seen by a vocational counseling group,

whose responsibility was to assess his individual problems and potentialities.

A form was used for this purpose (appendix C, p. 420). Advice concerning

future activities was predicated upon the results of this investigation, the

Army Classification Test score, and psychologic examinations.

TABLE 15.-Early results of cortical excision in 39 patients with positraumatic epilepsy

Scar Excision of Excision

Results Scar resection epileptogenous of Total

resection to locus subdural

ventricle membrane

-No attacks for 3 months after

operation ------------------- 9 3 9 2 23

Attacks only during first 3 days

after operation --------------- 0 2 2 0 4

Aura only --------------------- 1 0 3 0 4

More attacks, much as before-- 0 2 6 0 8

Total ------------------ 10 7 20 2 39

TABLE 16.-Later results of cortical excision in 36 patients with posttraumatic epilepsy'

"Scar Excision of Excision

Results Scar resection epileptogenous of Total Control

resection to focus subdural group 2

ventricle membrane

No attacks ----------------- 2 3 7 0 12 1

Aura only or 1 attack ------ 1 1 4 1 7 2

More than 1 major attack_ --- 6 3 7 1 17 17

Total ---------------- 9 7 18 2 36 20

SAll investigations were carried out approximately a year after operation.

This group consisted of patients who were not controlled by medical management and who, because of neurologic

Incapacity, infection, or personal prejudice, were not considered suitable for operation.

In some cases, training for a job was begun in the hospital, or high school

credits were obtained for schooling carried out in the hospital while the patient

was under treatment. In this way, his rehabilitation was started before lie

left the hospital. After discharge, he was assisted in obtaining suitable work.

Many commercial firms had a sympathetic comprehension of the difficulties

of these patients and were quite willing to employ them in certain positions.

The social service organizations in the community, the American League

Against Epilepsy, and the American Red Cross all assisted in occupational

and social adjustments. Thus, for some patients, at least, the ultimate goal in

the treatment of posttraumatic epilepsy-a return to a normal social and

economic life-was successfully reached.

455735v-58-22
CHAPTER XIV

Speech Disorders Resulting From Gunshot

Wounds of the Head and Neck

William G. Peacher, M. D.

HISTORICAL NOTE

Rehabilitation of Army personnel with speech defects was carried out in

World War I at a single center, General Hospital No. 11, located at Cape May,

N. J.' Speech reeducation was given at this center to a total of 54 patients;

the defects of 37 of them were subsequently classified in the following categories:

Aphasia, 14; imperfect phonation, 13; stammering, 3; aphonia, 2; stuttering, 2;

aphasia and stuttering, stammering and stuttering, and multiple neuritis, 1

each. When this installation was closed on 7 July 1919, facilities for therapy

and the 20 patients still in the hospital were transferred to General Hospital

No. 41 at Staten Island, N. Y. When the last report was made on the subject,

1 November 1919, 14 soldiers were still hospitalized with speech defects, but

it was anticipated that their treatment would be completed by the end of tile

year.

Not a great deal of information exists concerning the incidence of speech

disorders following craniocerebral injuries in World War I or concerning the

method of treatment of these defects. Frazier and Ingham 2 reported in the

official history of the Medical Department that among 200 patients with craniocerebral injuries observed at General Hospital No. 11, 16 had residual speech

defects 6 months after injury. Ten of these defects were of the motor or

dysarthric type, and three were of the sensory type, with alexia as the most

prominent symptom. The remainder were of the mixed type. Improvement

was noted in all, following speech reeducation. In 1919, Ingersoll, in a paper

concerning the management of wounds of the nose and throat on the otolaryngologic section at Base Hospital No. 11, stated that vocal therapy was beneficial

in injuries of the jaw, pharynx, and larynx, but lie gave no statistics.

IThe Medical Department of the United States Army in the World War. Washington: U. S. Government Printing

Office, 1927, vol. XIII, pt. 1, pp. 181-188.

3 Frazier, C. H., and Ingham, S. D.: Neurological Aspects of the Effects of Gunshot Wounds of the Head. In The

Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927,

vol. Xi, pt. 1, p. 801.

3 Ingersoll, J. M.: Injuries of the Nose and Throat Due to Bullet and Shell Wounds I aryngoscope 29: 624-632, No.

vember 1919.

319
320 NEUROSURGERY

CONCEPTS OF SPEECH DIFFICULTIES

EARLY IN WORLD WAR II

Between the World Wars, although considerable progress was made in the

treatment of speech defects, the main emphasis was on the dysphasias. The

study of all speech disorders was accelerated by the magnitude of the fighting

early in World War II, as well as the large numbers of head and neck wounds,

but considerable time passed before the full importance of the problem was

appreciated and adequate methods of examination and treatment were evolved.

Until April 1943, no comprehensive program for the management of speech

disorders existed in the United States Army. Several unofficial attempts,

however, were made earlier. Medieal officers interested in the subject treated

functional disorders, such as stuttering, articulatory disorders due to poor

habits, and speech defects due to foreign dialects. Darley and Spriestersbach, 4

for instance, reported improvement, after only 3 weeks of individual and group

therapy in 22 soldiers treated in the spring of 1942 at Fort Riley, Kans. A

similar brief program was conducted at Fort Storey, Va., as part of the rehabilitation program, but detailed results are not available.

ESTABLISHMENT OF THE ARMY PROGRAM FOR

THE CORRECTION OF SPEECH DEFECTS

Complete diagnostic and therapeutic facilities for soldiers with both

organic and functional speech disorders were first set up under Army auspices

on 7 May 1943 at Brooke General Hospital, Fort Sam Houston, Tex. It is

fortunate that they were provided at that time, for casualties were just beginning to be received from the fighting in North Africa and in the Solomons.

It is also fortunate that the speech clinic was attached to the neurosurgical

service, since the majority of patients evacuated from overseas with speech

defects were admitted to this section for cranioplasty and for treatment of

various neurologic residuals. This clinic was operated until 22 February 1945,

when the necessary facilities, including personnel and patients, were transferred

to McGuire General Hospital, Richmond, Va.

In contrast to the centers later designated for speech training, the speech

clinic at Brooke General Hospital remained attached to the neurosurgical

service as long as it was in operation and was never made an adjunct of the

neurologic service.

In April 1945, The Surgeon General took official cognizance of the need for a

program of speech training for military casualties and delegated the responsibility to Army hospitals with specialized neurologic and neurosurgical centers.

Speech therapy was made the responsibility of neurologic sections, following

definitive surgery, and the patients were to be retained in hospital until maximum benefits had been achieve(l. 5 Speech clinics were developed in all but two

4 Darley, F., and Spriestersbach, C.: War Notes. J. Speech Disorders 8: 189-190. June 1943.

3 War Department Technical Bulletin (TB MED) 155, 25 Apr. 1945.
SPEECH DEFECTS 321

of the designated installations; patients assigned to those two hospitals were

transferred to other installations in the same service command when they were

ready for speech training.

MANAGEMENT OF SPEECH DISORDERS

IN OVERSEAS THEATERS

The exigencies of modern warfare permitted no formal speech therapy in

combat zones, and treatment was limited to the causative injury. Thorough

debridement of all craniocerebral wounds and the institution of supportive

therapy not only saved lives and decreased morbidity but also prevented complications which might subsequently have influenced the speech mechanism.

Treatment of the speech defect at this time would not have been desirable

because of the presence of an acute pathologic reaction, which usually took

several weeks to subside.

No organized program for the correction of speech defects was developed

in communications zones because of the necessity for early evacuation of

patients for further specialized reconstructive therapy, including repair of

scalp and skull defects and, as necessary, resection of cerebrodural and cortical

scars. Facilities for detailed neurologic, neurosurgical, and psychologic

investigation were frequently available; however, the pressure of hostilities, the

ensuing casualty loads, and the need of definitive surgical treatment for such

urgent conditions as hematemas, meningitis, brain abscess, and retained bone

and metallic fragments, as well as the frequent necessity for redebridement,

secondary closure of wounds, and skin grafting, made it impossible to undertake

the prolonged studies and treatment necessary in speech defects.

In spite of the circumstances, however, interested fellow patients and

Red Cross workers were able, in some cases, to begin the work of reeducation

and psychotherapy by teaching the patients such familiar and useful words

and sentences as "Hello," "Good morning," and "I am hungry, cold, tired."

Some patients were also taught the alphabet and were taught to count before

they reached the Zone of Interior.

ADMINISTRATIVE CONSIDERATIONS OF SPEECH

CLINICS IN ZONE OF INTERIOR

Assignment to Hospitals

Patients evacuated to the Zone of Interior with speech defects were returned on the basis of their wounds rather than on the basis of residual speech

disorders. In the Zone of Interior, they were assigned to hospitals on the basis

of the major medical or surgical defect present, the speech disorder again being

regarded as incidental. The assignment was, in general, as follows:

Neurosurgical centers received patients with (1) gunshot wounds of the

head and neck which had resulted in cranial defects and such neurologic
322 N EUI{)SIRGERY

residuals as hemiplegia, parietal lobe signs, convulsions, and visual fiel disturbances, and (2) cranial nerve injurics. Gunshot wounds of the head and

neck were sometimes accompanied by dysphasia, dysarthrophonia, or both.

Injuries of the facial (peripheral) nerve could be accompanied l)y dysarthria,

injuries of tile vagus (recurrent laryngeal) nerve by dysphonia, and injuries of

tile hypoglossal nerve by dysarthria.

Plastic surgery centers received patients with, (1) maxillofacial wounds,

including involvement of the tongue, lips, and floor of the motith, which were

sometimes accomipaniied by d(yslalia; (2) gunshot wounds of tile larynx, which

were sometimes accompanied by dysphonia: and (3) palatal defets, which were

likely to be associated with rhinophonolalia.

Neuropsychiatriic centers received patients suffering from (1) anxiety

states, sometines accoinpaanied by stuttering; (2) conversion hysteria, sometimes aiccoinpipaed by aphonia and dysphonia; and (3) other neuroses and

psychoses, sometimes accomnpanied by dyslogia.

Aural rehiabilitation eenters received patients suffering from deafness

resultinig from , ironic middle-ear infection,. heavy gunfire, and skull trauma,

in which dysaudia was the usual speech defect.

At Brooke General Hospital, where tile first speech clinic was established

in World War II, the most common speech disturbances encountered as a

result. of gunshot wounds of tile head an(d neck were dysphasia, dysarthria,

dyslalia, and dysphonia. Some instances of aphonia and stuttering were on a

functional basis and had resulted from exposure to enemy action. Remedial

speech training, which was deferred until the completion of specific neurosurgical procedures, was carried out by speech pathologists and psychologists

under medical supervision. All speech defects encountered were treated except

such common functional defects as articulatory and vocal disturbances arising

from poor habits, low educational training, and use of foreign dialects. Trained

personnel were insufficient, and all facilities were devoted to patients whose

speech disorders were on an organic rather than on a functional basis.

War Department Technical Bulletin entitled "Aphasic Language Disorders" (TB MED 155), published on 25 April 1945, recognized the need for

therapy in the field of speech but contained recommendations for the management, study, and classification of only the dysphasias. The program in each

designated center of treatment was made the direct responsibility of tile

medical officer locally in charge.

Function of Speech Clinics

The primary function of Army speech clinics was the diagnosis of speech

disorders in military casualties and their reeducation, with the object of returning them to useful military duty or to civilian life after maximum benefits had

been received from hospitalization for other disqualifying neurologic or physical

sequelae of injuries or both. Every effort was made to restore the soldier to an

adequate social, mental, and economic status in his community before he was
SPEECH DEFECTS 323

discharged from the hospital. A secondary purpose of the speech clinic was

to disseminate information derived from experience by ward rounds, conferences, lectures, and publications, for tile benefit of other centers and other

patients.

Personnel of Speech Clinics

In each designated center for speech training, a psychologist, preferably

with a background of training in speech, was assigned to the neurologic service

to assist in evaluation of patients as well as in their reeducation. Except at

Brooke General Hospital where a neurosurgeon was in charge, the director of

each clinic was a neurologist whose responsibility it was to organize tile program, maintain a close liaison with all personnel participating in it, and evaluate

and interpret the results of all examinations so that correct treatment could be

outlined. Teachers of speech were in short supply throughout the war, and no

technical school for their training was ever developed. It was therefore often

necessary for the neurologist in charge of a speech clinic to train the workers in

the installation himself. These workers consisted of occupational therapists,

American Red ('ross workers, members of the Women's Army Corps, and

similar personnel who were selected for the positions because of their previous

background and their interest in the problem. Students and instructors in

speech from adjacent colleges often volunteered to assist in the program, during

the school year as well as in vacation periods.

DIAGNOSTIC AND THERAPEUTIC REGIMEN

Diagnostic Regimen

When a patient with a speech defect was admitted to one of the designated

general hospitals in the Zone of Interior, he was examined by the director of the

speech clinic (a neurologist), who supervised all subsequent medical and surgical

therapy and directed the program devised for speech rehabilitation. When

all definitive treatment had been concluded, the patient was interviewed by the

speech therapist, who, after conferring with the neurologist and neurosurgeon,

outlined the specific program for his care and reeducation. It was the rule to

discuss the situation intimately and at an early (late with the patient's relatives also in an effort to secure an early psychologic adjustment, to allay tensions and anxiety, and to present as encouraging a picture as was justified of

the results to be expected from treatment.

The routine of diagnostic study began with the examinations usually carried out on any neurologic patient. In addition to the history and physical

and neurologic examinations, routine laboratory tests were made, consultations were requested, and other studies were carried out as indicated, including

roentgenologic examination, special studies of the blood and spinal fluid,

laryngoscopy, audiometry, psychometry, electroencephalography, and similar

measures. In the occasional case in which cranioplasty or craniotomy was
324 NEUROSURGERY

necessary and the dura was entered, inspection, palpation, biopsy, and stimulation of the cortex added to the completeness of the study. In some instances,

these manipulations actually produced improvement in speech by the release of

cerebrodural scars and improvement in the cerebrospinal fluid circulation.

Diagnostic studies always included those listed in TB MED 155, in addition to those preferred by the particular neurologist in charge of the speech

clinic. All analyses were based on the principles previously established by

Jackson, Head, Goldstein, and Weisenburg and McBride. In general, the

dysphasic patient was subjected to the following battery of tests in addition to

the basic examinations already listed:

1. Psychometric studies.-Wechsler-Bellevue; Kent EGY; Rorschach;

Bender Visual Motor Gestalt; thematic apperception test; Minnesota multiphasic test; Shipley-Hartford test; measurement of abstract behavior, including

the Goldstein-Scheerer cube and stick tests; Weigl-Goldstein-Scheerer color

form sorting test; and mechanical aptitude and vocational preference studies.

2. Language studies.-Head, Weisenburg and McBride, Chesher, and Halstead and his associates. Specific testing of the cognitive functions, such as

reading, writing, arithmetic, and spelling, was included in this group. Because

of the overlap of various speech disorders, investigations for dysarthria and

dysphonia most commonly associated with the dysphasias were not overlooked.

3. Nonlanguage studies.-Various form boards (Seguin, two-figure, casuist,

etc.); Pintner nonlanguage tests, drawing tests, and Knox cube tests, among

others.

Therapeutic Regimen

Patients with speech defects could I)e centralized on special wards, with

adjacent classrooms, at four of the special centers (Bushnell General Hospital,

Brigham City, Utah, Kennedy General Hospital, Memphis, Tenn., O'Reilly

General Hospital, Springfield, Mo., and McGuire General Hospital). Similar

arrangements were made at Percy Jones General Hospital, Battle Creek, Mich.,

at the convalescent center (Fort Custer Annex). Officers lived in separate

quarters but attended classes with enlisted men.

The individualized program outlined for each patient took into consideration his previous experience, education and environment, the results of diagnostic studies, the opinions of the various consultants, and the need for a possible change in his occupation because of residual disability. Training further

took into account residual function and was directed along lines of substitution

through other association pathways. An active reconditioning program was a

part of every individual program. In some instances, with due regard to the

condition of the individual patient, arrangements were made for credit in advanced subjects with local high schools and colleges. United States Armed

Forces Institute courses were also extensively utilized.

Equipment used during the rehabilitation of dysphasic patients included

all material supplied by occupational therapy departments in the arts and
SPEECH DEFECTS 325

crafts selected for the individual; magazines and comic books for picture and

word stimulation; flash cards; textbooks on spelling, arithmetic, reading,

writing, and other subjects; stimulus letters, words, and numbers made of

cardboard, wood, or metal; playing cards (numbers), crossword and jigsaw

puzzles; miniature objects; coins; calendars; ward telephones, to improve conversation and aid psychologic adjustment; dlocks; blackboards; phonograph

recordings; tachistoscopes; and a variety of other items, which, with those

already listed, were adapted to the needs of the individual patient. Recording

machines, of the recorder-playback type, which were available at DeWitt

General Hospital, Auburn, Calif., Thomas M. England General Hospital,

Atlantic City, N. J., Percy Jones General Hospital, McGuire General Hospital,

and Wakeman General Hospital, Camp Atterbury, Ind., proved most useful

in permitting comparative studies of the patient's progress as well as providing

opportunity for him to recognize and correct his own errors.

The time devoted specifically to speech therapy depended upon the characteristics and degree of the speech disorder in the individual case. At first,

half an hour twice daily was as much as the usual patient could tolerate. Later,

as improvement occurred, practice sessions could be lengthened. Although

individual training was emphasized throughout, group therapy proved valuable

in such fields as writing, reading, arithmetic, and spelling. Frequent examinations were given, and records were maintained to determine progress. Conferences and seminars were held to discuss common problems, disseminate information, and adopt new suggestions.

The usual individual schedule was maintained on an 8-hour basis but was

entirely flexible. A typical program follows:

0800 to 0830: Ward work detail.

0900 to 1000: Physiotherapy; classes in writing, reading, and arithmetic.

1000 to I100: Orientation and education program (moving pictures, concerts, lectures, etc.).

1100 to 1200: Speech therapy.

1300 to 1400: Physical training.

1400 to 1600: Occupational therapy; speech therapy; diversional and

recreational activity; educational activities, including

classes in reading, writing, arithmetic, and spelling.

1900 to 2100: Local night courses for credit.

Furloughs.-All patients with speech defects, if their physical condition

permitted, were given furloughs immediately after completion of the initial

studies made on their entrance into the centers. Periodic leaves were also

given at 2- to 3-month intervals. Instructions were given to the patient himself

and to members of his family, so that lessons could be continued while he was

away from the hospital. The psychologic values of these leaves more than

balanced the loss in training time which resulted.
326 N E U ROSURG ERY

CLASSIFICATION AND MANAGEMENT OF SPEECH

DISORDERS

The chtsitication of speech disorders adopted ill Army treatment centers

was based oil categories already well known to physicians interested in them.

Additions were made as military necessity required. The defect was listed

according to the major disorder Present, with full recognition, of course, that

more thanl one (lefect often existed in the same patient. Dysphasia and dysarthria, for instance, oft en coexisted. Patients with palatal perforations presented impairment of both phonation and articulation, while those with maxillofacial wounds not infrequently showed concontitant structural and neurologic

involvement of the peripheral speech apI)aratus.

Dysphasia

Patients in this category were classified into I of 5 possible groups, depending upon tile predominating defect revealed by examination. These defects

included the following: (1) Motor or expressive dysplasia ; (2) sensory or receptive dysphasia; (3) amnesic dysphasia; (4) mixed or expressive-receptive dysphasia; and (5) aphasia, which might be total or complete.

The term "dysphasia" to denote impairment of language was first used by

Head 6 and was in general use by British speech pathologists. It was preferred

in Army speech centers as being more characteristic and more accurately descriptive than the fornier term "aphasia," which was reserved for complete

loss of speech.

Since, owing to delays in evacuation, Army patients usually were not ohserved until 4 to 8 weeks after injury, subclassification into such groups as

transcortical and subeortical dysphasia was not possible. For the same reason,

when the patients were first seen, usually only one major defect was present,

such as impairment in comprehension of speech an(i writing (sensory or receptive dysphasia); difficulty in expression of language and writing (motor or expres.sive dysphasia); or inability to name objects, qualities, and conditions

(amnesic dysphasia). Sometimes the defects were mixed. It was believed that

soon after injury the majority of speech defects could be regarded as mixed

(expressive-receptive), all language processes being involved. During tie same

period, complete loss of speech (aphasia) might be present, but it was unlikely

to be permanent unless severe, irreparable cerebral damage existed. Lesions

such as those described by Wernieke, Gerstmann, and others were occasionally

observed.

Dysarthria

The term "dysarthria" was used to denote a disorder of articulation on the

b)asis of a lesion of the central or peripheral nervous system. It could occur

(1) with injuries of the central nervous system, including the pyrami(lal tracts

I lead, Ilenry: A phasla and Kindred ilsorder. of Speech. New York: Macmillan Co., 1926.
SPEECHt DEFECTS 327

(corticobulbar and eorticospinal), extrap.yrainidal tracts, frontopontocerebellar

tracts, and cerebeliar pathways; or (2) with injuries of the peripheral nervous

system, including the facial nerve, the palatal branches of the vagus nerve, and

the hypoglossal nerve. Although articulatory defects assumed the major role

in such cases, phonatory problems were associated with most central nervous

system lesions. For this reason, the term "dysarthrophonia" is now being

suggested as a more descriptive term than dysarthria in this type of case.

Since dysarthria was usually the result of a craniocerebral injury, patients

suffering from it were admitted to the neurosurgical sections of designated

general hospitals. It was usually associated with such other neurologic residuals as dysphasia, heiniplegia, and cerebellar manifestations. Only occasionally, in spite of the large numbers of gunshot wounds of the head which

occurred in World War II, was it associated with central nervous system damage. The majority of cases were the result of lesions of the cranial nerves,

chiefly of the facial nerve and the hypoglossal nerve. Lesions of the facial

nerve caused impairment of accurate production of bilabial sounds. Lesions of

the hypoglossal nerve interfered with the production of linguadental and

linguarugal sounds. Lesions of the vagal an(l recurrent laryngeal nerve,

although theoretically incorporated with this group, were classified wit h1

dysplionias.

Disorders of articulation due to central nervous system lesions were

less frequent in the Army than in civilian life. When they occurred, they were

usually associated with cerebellar injury alone or were present in conjunction with pathologic changes productive of dysphasia. Defects which

occurred under the latter circumstances were grouped with the dysphasias.

In a supratentorial lesion, therefore, dysarthria was commonly found with

other evidence of central nervous system involvement. The infrequency

of dysarthria in the presence of extensive damage to the frontal, parietal, and

temporal lobes is interesting, especially in view of the high incidence of

articulatory disturbances in the pyramidal and extrapyramidal disorders in

childhood. The explanation is undoubtedly the site of the lesion: dysarthria

is usually manifest in bilateral involvement, and is much less common on a

unilateral basis. It should be emphasized that these conclusions are derived

from examinations made 1 or 2 months after injury. It is quite conceivable

that minor defects were initially present and were overlooked by both examiner

and patient.

In examinations for dysarthria and dyslalia, although long test phrases

and sentences (such as Methodist Episcopal, Third Riding Artillery Brigade,

round the rock the ragged rascal ran) are commonly mentioned in the

neurologic literature, their use was discouraged, as they occasion difficulties

even in normal persons. Standardized words, phrases, and sentences weighted

with the individual sounds to be tested were found far more useful and

practical.

A-nother important fact learned in the speech clinics concerned the previous recording of a patient's speech defect according to the examiner's ir
328 NEIUROSURtGER:Y

t erpret at ioi of hiis !t.-sI)olist to qjues't tiolls. Inid ivid tildt diffret'iMitwe ' foundI

to maake this sys-teni lacking in uiniformilt y and therefore very' unsatisfactory.

Ani accurate phionetic analysis of thet defects present by thle uise of ffi lilt' iiienatijonal p~honet ic alphabet largely compensated for tills lack of unliforniiltv.

Speechi deftects due' to lesions of tilie perip)heral facial andi hv.Poglosstil

nerves only occasionallyN required specific therapy. Adiequate compensation

by substitution had often b~een achieved by thle twit' thle lpatient'; wvere seena In

Zone of Interior hospitals. C1en trail nervous s 'Nst cii d vsarthlria, however.

almost always reqIuiretd active treatment. Accurate' Producitiion of tile vllriolfuý

soundts and their strengthening was an tesstential p~art of the training. Exploratioii of thet involved nerves, Which waIs SAMIitt inIes nlect'SSarv, oftenI anaeio0-

ratedI the sp(Tech tdefects. 'lThe treatmetnt of associatted sp~eechi disordetrs was

part of therapy.

Dysphonia

Under thet hieadling of tIh*ysphouna w~ere includetd cases tof voice implairmienit.

tiuc( to inivolvenment of tilie laryngteal mnechanismn. Tlhe caustes might be organic.

such as tumiors, traumas, `>Jlammatory processe's, ~tmi congenital albnoruinalitiets,

or functional, such ats p)oor vocal habits antd aphouiia onl the basis of -oilversion hysteria.

Only occasional cases of tlysphonia of traumatic origin wt're ob,;ervetl

at thle sp(echl clinics inl thle Zone tof Interior. Patienits withi gunslot wounds of

the neck often dietd. If t hey survived, thberte wtere multiple syniptoms- becauste of thle mnany closely related vital structurtes inl this rtegion.

Dysphonia r(esultetd from thet following causes: (1) D~irect trauima to thle

larYnx; (2) paralysis of the vagus nervte or of its recurrent laryngeal branch;

and (3) indirect trauima to the larynx or tilet vagus nterve or its recurrtent

laryngeal branch, withI resulting te(mporary edlemla, htemorrhage, anti simnilarc

manifestations. Late extrinsic contract ure of scars occasionually causetd (ysplioaiia by (distortion of tile laryngeal mnechanism.

Laryngeal parailysis of cenit ral nervous system. origin was observed only

infrequently. C1erebellar lesions usually resulted in) errors of both articulation

anad phonation (dysarthroplaonia), with the former predominating. The

Ia r~ngeal syndIromes of Jackson, ('ollet-Sicard, Vt'rnet, antiI rapia were also

infrequent. A few cases wer(e observed following chronic inflamimatory

processes, chemical antd thermal trauima, injury at thyroidectomy, bilateral

'ortd involvement, paralysis of the superior larv *iageal nerve, anti excision of

tumiors from thle vocal cords. P~atie'nts wit h functional dysphionlia Onft lthe

basis of conversion hysteria were treatetd at neuropsyciiiatric, not, neurosurgical, centers.

]ii addition to routine stutdies, the complete examination of a patient, with

tlysphonia inicluded laryngoscopy, vocal recording, antd tilie. invest igat ion of

associated speech defects. Specifitc questions to the patient, concerning pitch,

intensity, quality, and rate' were found tessential for detcisive concldusions.

Formerly, when reliance hath beten placed onl thlit replies to such gene(ral ques-
SPEECH DEFECTS 329

tions as whether hoarseness or voice changes had been noticed, negative

answers were often received, even in the presence of obvious changes in the

quality of the voice.

Vocal exercises resulted in considerable improvement in most cases of

neurologic or structural damage to the laryngeal mechanism. Esophageal

speech was preferred to all artificial larynx in avulsion injuries and after laryngectomy for tumors. The resection of intrinsic and extrinsic scars distorting

the larynx occasionally resulted in improvement, and a patient was occasionally

benefited by exploration of tie vagus or recurrent laryngeal nerves. Physiotherapy, in the form of beat, massage, and electrical stimulation over the course

of the involved nerve, often expedited recovery in traumatic speech defects.

Medical and surgical measures were used as necessary. Patients with aphonia

on a hysterical basis were placed under the care of the neuropsychiatrist.

Dyslalia

In the category of dyslalia were included disorders of articulation due to

actual structural involvement of the organs of articulation (the lips, tongue,

and palate). These disorders might be due to congenital defects, such as cleft

lip and palate, or might be acquired, such as tumors of the tongue and palate,

palatal perforations, and gunshot wounds of the tongue with loss of substance

and late cicatricial contracture between the tongue and the floor of the mouth.

Functional causes of dyslalia, such as low educational standards, sigmatism

(lisping), foreign dialects, and the regional differences apparent in American

speech were obviously not of wartime importance and were excluded from this

category. Dyslalia and dysarthria often coexisted in the same patient as the

result of the anatomic location of maxillofacial wounds.

Because lesions of the palate are associated with impairment of both

articulation and phonation, the term "rhinophonolalia" has been suggested

as a substitute for rhinophonia, which is in use by the British school, and for

rhinolalia, which is advocated by the American Speech Correction Association.

Patients with dyslalia, which was usually the result of structural damage

to the articulatory mechanism following maxillofacial injuries, were ordinarily

admitted first to plastic surgery centers. Because of anatomic relationships,

dysarthria due to injuries of the seventh and twelfth cranial nerve in their

peripheral courses was often associated with dyslalia.

Dyslalia was observed after all of the following injuries and conditions,

in sone(' .A which, as note(I, other speech disturbances also occurred: (1) Injuries

to soft tissues, particularly the lips and cheeks; (2) loss of various portions of

the tongue; (3) wounds of the floor of the mouth with late cicatricial contracture,

usually involving the tongue; (4) maxillofacial fractures with concomitant

soft-tissue injury which. when occurring in tracheotomized patients, were also

at times associated with dysphonia; (5) mandibular fractures with deformity

accompanied in some instances by vocal changes related to intensity and rate

but with pitch and quality usually not, affected unless laryngeal damage was
330 NEUROSURGtERY

also p~resenit ; (6) loss of teeth, Ipart icuilarl .v tihe incisors; (7) trismuts ; (8) cranijal

nerve injuries, with injuries of the peripheral port ion of the facial 1111([ hypogrlossal nlerves lit t inies accomplaniedl lw dvNsart hrial 1111d1 injuries of tihe facial

ne~rve anld its recurrent laryngeal branch hy (lyspiolilia : (9) Perforations of thle

hard andt soft palates, which wvere associatedl with rliiioplioiolalia ; and (10)

structural damage to thle lar 'ynx, with dysphonia present if tile (alamage wits

inicomplete ltiid with aplionia if the (lanage wats complete.

Facilities for correcting speech defects wvere not availabl)e ait plastic suirgery

ceeiters, unless these centers had also been dlesignatedl as special centers for

neurology andl neurosurgery. If theY had not been, either patients needing

spehtraining~ were transferred to a speech cne tttcnlso frcn

st ruct ive surgery or local arrangemtents were miadle for inst~ruct ion byv civilians.

Methods of examination were similar to those carried out for dlyS1arthria,

both (lYslalia andl (lsarthrira b~eing disordlers of articulat ion. Because (lyslalin

was so often associatedl with maxillofacial wounds, specific speech therapy

sometimes had1( to be postponed for as long ats 12 to 24 months. 'Satisfactory

comphenisationi wats achiievedl iii many cases of fracture wvithl soft-tissuie damage

by replacement of misýi ng portions of thle lips, cheeks, and ot her tissues with

local and (distant flaps. L ater speech reedlucat ion was sometlines necessary,

part icllarlv.N inl the following cases: (1) Cicatricial contractutres biet ween tlie(

tongue and~ thle floor of thle mouith inl whichi inicreased1 lingual mob0ilit v achiievedl

bsurgical release of adhesions often facilitated thle soluition of thile sub~sequent speec'hi problemi, (2) loss of considerable portions of thle tongue, and (3) Strulctura-Il and neurologic damlage or both to the( laryngeal miechaniasin.

Therapy uisuaflly consist ed ill strengthening the various Iinvolve'd comploieints of tilie art ictilatorY ap~paratuts b),y approlpriate exercises, wvith tilie sublst ittittion of compensating niovelnients. to achieve thle dlesiredl soundl~s whieit there

was tissue loss or repilacemlent. Imnutat ion, mnechanical (direct ion, mirrorwork,

ear. training. chewing" met hodls, pushing exercises, kinesthetic st imulat ion, andl(

similar (devices were iisedl as nlecess'ary. Once the correct sound~ was pirodulced,

it wats strengthened bY approp)riate exercises. Esophageal Speech wvas taught

whlen avullsionl wvoun(1s of thle larynix were associatedl with maxillofacial inijuries.

Occasion allY, after corrective surlgerY of pala tail Perforations, residual ta1sal it v

necessi tatedl add~it ional thI erapy.

Dv~spheinia

"The categor-y of (lv sphkemnhi or stutattering inicluded instances of obvious

hiesitat ion and~ repetition inl tilie sp~eecha pat tern Wvit h occasional seconidary ,manialfestations. The cause wats uslually' jpsy'chiologic, but dvsplvhiemin wats also noted

following craniocerebral inj uries.

I)y:Nsphlenmin a classified accordling to whet her. it had existedl before

induict ion or h~ad dlevelop~ed ini service. A fairly, large number of pat ieints inl

this categor-y were observed ait speech clinics (durinig t reatmenit of other medical

and surgical cond~itioins. The usual cau11se was sonie mild eamot ional conflict,
SPEECH IE.FECTS 331

personality (lisorder, or reaction to a(ivelse environmental circumstances.

These patients were not considered to have severe enough disabilities to be

classified as psychoneurotic. In general, they performed their routine duties

faithfully and competently. Many of them saw action and adjusted as well

as any other randomly selected group of nonstutterers. Stuttering did not

prevent their l)romotion in the enlisted ranks, and some of them received

commissions.

Postinduction stuttering was usually the result of some intense emotional

experience, such as exposure to repeated enemy bombing, prolonged campaigns,

and severe wounds. The etiology was listed as combat fatigue when the symptom disappeared within a few weeks following rest, psychotherapy, and specific

medical and surgical measures. When the anxiety state continued to recur,

even after therapy had been continued over a long period of time, the patient

wias classified as psychoneurotic and was transferred to a neuropsychiatriC

center. In most cases, insufficient neurologic evi(lenice was present to suggest.

that an organic factor was responsible. Some patients with dysphasia exhibited

hesitation in their speech, as well as occasional secondary manifestations such

as facial grimacing, but true stuttering could not be said to be present.

Large numl)ers of stutterers in the Army were not treated at all. Patients

who were admitted to the hospital for investigation, however, were studied

intensively and were given individual and group therapy. A detailed history

was taken, and the personality structure was observed, particularly in relation

to the patient*' reaction to his symptoms and environment. PYsehlometric

studies included the Wechsler-Bellevue intelligence scale, projection techniques

such as the Rorschach method, and thematic apperception and Bender Visual

IMotor Gestalt tests. Therapy was directed toward the underlying emotional

(lisordler. Specific treatment of the stuttering complex was not attempted.

Principles of general semantics and mental hygiene were stressed. Individual

and group psychotherapy was practiced daily and was coordinated with active

reconditioning. The patient was encouraged to verbalize his fears and anxieties

and to objectify them in relation to his early childhood experiences. Projection

techniques, with the reenacting of common problems, were employed. Narcosynthesis was helpful in the occasional carefully selected case. Negative

practice was also sometimes helpful; by this method, the patient is taught to

stimulate his blocks with later introduction of the new pattern to normal,

everyday situations.

Dyslogia

The term "'dyslogia" was use(d to include disorders of articulation accompanying various neuroses, with the exception of aphonia on the basis of conversion hysteria and psychoses.

Patients with dyslogia were usually under the supervision of the neuropsychiatrist at a neuropsychiatric center; p)sychiatric rather than articulatory

principles of training were followed, though analyses applicable to the

dysarthrias anti (lyslalias could sometimes be applied. Methods of examination
332 NEUROSURGERY

and treatment, however, were usually directed toward the various neuroses

and psychoses with which the symptom was associated and were not directed

primarily toward the articulatory defect.

Dysaudia

The term "dvsaudia" was used for cases of impairment of articulation due

to defective hearing, whether it was congenital or followed craniocerebral

injuries, acoustic trauma, aural infections, and similar conditions.

Patients with dysaudia were treated at the Army aural rehabilitation

centers for the deafened and hard of hearing, where therapy was directed

chiefly toward improvement of hearing and prevention of speech deterioration.

This was accomplished by the provision of a hearing aid, speech reading,

phonetic stimulation, and psychotherapeutic techniques. Methods of examination and other principles of therapy used in dysarthria and dyslalia were also

applicable to dysaudia.

DISPOSITION

The length of hospitalization of patients with speech defects depended

upon the severity of the disorder, the adaptability of the individual to treatment,

and the associated disabilities, which were often of far greater consequence

than the speech difficulty. Dysphasia was usually associated with other

neurologic residuals, such as cranial nerve injuries, hemiplegia, convulsions,

hemianopsia, astereognosis, and varying degrees of intellectual impairment, including confusion, loss of recent memory, disorientation, impairment in learning

capacity, defects in cognitive abilities, loss of visual-motor coordination,

personality disorders, and delirium.

From the standpoint of the speech difficulty only, patients with minor

defects were usually ready for disposition within 2 or 3 months after admission

to the hospital. Those with more serious defects sometimes required hospitalization for a year or more before any improvement was noted. Occasionally,

even though spontaneous speech appeared adequate, further reeducation was

necessary in such subjects as reading, arithmetic, and writing. In such cases,

arrangements were made for additional training through the Veterans' Administration. In January 1947, 2 centers were designated for this purpose, 1 at

Van Nuys, Calif., the former Birmingham General Hospital, and 1 at

Framingham, Mass., the former Cushing General Hospital. It was also made

possible for veterans to obtain speech therapy on a local contract basis if the

arrangements were approved by the Veterans' Administration and did not

conflict with the organization of existing centers.

As a rule, the presence of a speech defect, if there were no other injuries

and disabilities, did not disqualify a man for some form of useful military duty.

Spontaneous speech and comprehension of speech adequate for ordinary conversational purposes were interpreted as indicating maximum hospitalization

benefits in patients with dysphasia. On this basis, had the necessity continued,
SPEECH DEFECTS 333

they !ouIld have beeni retuirned to dluty. As alread * noted, however, most of

them were separatedl from service onl thle basis of associatedl disab~ilities and

neurologic residluals.

STATISTICAL DATA

Surveys made ait intervals (luring the -war and in October 1945 (tables 17

and 18) give some idea of tile patient load and of the (list ri)u t ion andl managemaent of cases at the speech centers. The majority of the (centers fouind

dlvsphasia, the most comm~fon de(fect.

Final figures from Percy Jones General Hospital for thle entire periodl

durinig which it operatedl as a speech center (November 1944 to November

1946) show that during this time the hiopsital received 107 patients with

dlysphasia, 28 with dysphernia, 6 with (Iysarthria, 2 with dysphonia, andl~ 4

with emotional (difficulties associatedl with poor articulation and foreign accent.

TABLE 17.-Sum~narized data on Armpy program for speech disorders at Zone of Interior

generaIl hospitals

General hospital Date of organization of clinic Personnel in chiarge Average

case'loaid

Cuhng 6 ur.144Pcologist___ 80

DeWitt-_-- 21 Jan. 1945--- Speech thierapist---------40

Halloran__ 3 Apr. 1945- - ---------------------------- 647

Haiuod 8 ug.195---------- do------------------- -6

Kennedy. --------- December 1944- Neurologist --------------- 20-25

McCloskey- 1 Mar. 1945- -- ----- Neuropsychiiatrist- 15

McGuire '~7 'May 1943 ----------- Neurosurgeon-----------20-30

Northington -------- 24 July 1945 --------- r Neuropsychiiatrist----- 25

O'Reilly--- - _----June 1944___ Neurologist ------ -------- 15-25

Percy Jones --------------- 6 Nov. 1944 --- -------- d---------- -------- 15-25

Thomas M. England -------- 1 June 1945 ---- Psychologist---------20

Wakeman-----------February 1945----- Neurologist ---------------- 6

IFormerly at Brooke Gleneral Hospital.

TABLE 18.-Dislribution of speech disorders at Brooke and McGuire General HospitalI

speech disorder

Cases Wounded ___________ ______________

Period treated in action

1) Y,4- Dys- Dys- Dys- DysP111VL~a arthria phonia lalial phemia

7 May 1943-31 Aug. 1944______---120 16 32 47 12 5 24

1 Sept. 1944-31 Dec. 1944------- 97 25 16 26 16 14 25

1 Jan. 1945--30 Sept. 1945 ..... 243 I205 81 42 37 27 56

1 Oct. 1945-4 Oct. 1946 ------- 263 205 32 40 16 164 11

Total ----------------- 1 723 .151 161 155 81 210 116
334 NEUROSURGERY

In January 1946, the results of a survey of dysphasic patients still in Armhospitals, which was carried out by the Office of the Surgeon General, constituted a central register for patients with this disorder. In November 1946,

11 patients with dysphasia were still receiving speech reeducation at Halloran

General Hospital, Staten Island, N. Y., but they were expected to be ready for

final disposition when the installation was closed on 31 December 1946.
CHAPTER XV

Clinicopathologic Aspects of Fatal MissileCaused Craniocerebral Injuries

(An Analysis of 24 Cases)

Eldridge H. Campbell, Jr., M. D., Hartuig Kuhlenbeck, M. D., Robert L.

Cavenaugh, M. D., and Aage E. Nielsen, M. D.

The clinicopathologic study of fatal missile-caused injuries to the head

upon which this chapter is based was undertaken for two reasons. The primary

purpose was to establish criteria that would serve to indicate to the clinical

neurosurgeon which of these wounds is apt to be lethal and to which, to express

it very bluntly, lie should not devote the time and effort which could be ex.

pended, with a better chance of success, upon wounds that are potentially less

lethal. The secondary purpose was to set up a collection of carefully documented pathologic materials on this type of head injury for permanent storage

and use in the Army Institute of Pathology (now the Armed Forces Institute

of Pathology), Washington, D. C.

As with many another research project, the secondary of these two objectives proved to be the easier of fulfillment, as well as, perhaps, the more

important. Not a great deal that was conclusive was established about the

lethality of head injuries as a result of this study. On the other hand, the

protocols of each of the 24 cases investigated, together with the gross and

microscopic specimens, all carefully photographed, were deposited with the

curator of the Army Institute of Pathology early in 1947. They constitute a

truly invaluable collection, and, as with all other specimens entrusted to the

Institute, the materials are available at all times to students of pathology and

to other physicians interested in the particular field of head trauma.

MATERIALS AND METHODS

This study was based upon 24 extensive craniocerebral injuries, all of which

were caused by missiles and all of which terminated fatally. Ten patients

died without operation; the other fourteen were treated surgically. The

materials were obtained during the last phase of the Italian campaign, through

the cooperative efforts of the 8th, 13th, 16th, 28th, 94th, 170th, and 171st Evacuation Hospitals.

In all instances, autopsies were performed at these forward hospitals,

either by a pathologist or by a neurosurgeon. All possible clinical material

335
336 NEUROSURGERY

was collected, and(l all details of the gross injuries of the scalp, the skull, and tile

brain and its coverings were carefully recorded.

The brains were fixed in formnalin for a period of 10 days and then. were

forwarded to the 2d Medical Laboratory. Here the gross specimens were

photographed, to show the extent of tile surface injuries, before the brains were

sectioned coronally. Photographs were made of the most important levels,

and representative blocks of tissue were cut for histologic study. The microscopic sections were cut, stained, ald([ studied at the Army Institute of Pathology. Clinical and autol)sy data were forwarded with the specimens.

In 10 of the 24 cases, the cranial and cerebral injuries were associated with

injuries of other parts of the body. In at least 3 of these 10 cases, the other

injuries were severe and may have played a contributory part in the fatal

outcome. In every instance, however, the cerebral injury was thought to be

the primary cause of death.

The anatomic location of tie destructive lesions in each case, together

with the survival time after wounding, is summarized in table 19. Space does

not permit the publication of the protocols of all 24 cases in this chapter, and

repeated references will therefore be made to this summarized table throughout

the ensuing discussion. The listing is according to the hours of survival and

not according to the chronologic order in which the cases were handled. Certain case reports are also reproduced in detail, to illustrate certain of the fundamental surgical implications of the study.

Survival time in these 24 cases -anged from 30 minutes at one extreme

to slightly over 10 days at the other. In nine instances in which the time of

wounding could not be ascertained with certainty, the period of survival was

estimated on the basis of the interval between the time of tagging by the medical

aidmen and the recorded time of death. In four instances in which the information concerning the survival time was particularly vague, the approximate

period could be deduced from other sources which were regarded as reliable.

This study includes wounded men who survived long enough to reach a

forward hospital. Battlefield deaths were excluded, since the time factor in

such deaths is necessarily unknown. It is of interest, however, that in 1,000

autopsies performed by Capt. William W. Tribby, MC, on casualties found

dead in the field between the Salerno landings and the crossing of the Arno,

craniocerebral injuries alone accounted for 133 deaths. In another 268 cases,

in which there were injuries of other parts of the body in addition to the head

injuries, the craniocerebral wounds were of such severity as to have been a

possible, if not probable, cause of the fatality. In other words, in 40.1 percent

of 1,000 battlefield deaths, head injuries were the actual or the probable cause

of the fatal outcome.

CRANIAL LESIONS

Five of the twenty-four head injuries which make up this series represented

perforating (gutter) wounds of the cranium. The remainder were penetrating

wounds. The characteristics of the wound of entrance, as well as of the wound
CLI NICOPATHOLOGIC ASPECTS 3:37

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338 NEUROSURGERY

of exit (if there was a wound of exit), were essentially the same in all cases.

Bone fragments of varying size, depending upon the size of the missile, were

carried to various depths below the inner table of the skull. In certain throughand-through wounds, bone fragments were found throughout the path of the

missile. In one instance of penetrating injury, an everted fracture was observed

at the point of intracranial ricochet of the missile. The linear fractures which

radiated in a variety of patterns from the wounds of entrance seemed to have

no particular clinical significance.

One type of fracture, however, the so-called discontinuous fracture, seemed

of quite special significance. This term implies the existence of one or more

fracture lines in the base of the skull which do not in any way connect with the

primary fracture. These fractures were usually multiple, and they were most

often seen in the region of the cribriform plates, the orbital roofs, and, to a

lesser extent, in the sphenoidal ridges and tegmental plates of the petrous bones.

Fractures of this type were present in 9 cases; 3 were instances of perforating,

and 6 were instances of penetrating, wounds of the skull.

The exact mechanism of discontinuous fractures is not yet clearly understood. It has been suggested that they result from great internal pressure

suddenly produced within the cranial cavity by the effects of a high-velocity

missile. On the other hand, the wavelike deformation spreading through a

cranium struck by a missile may be a significant factor. These shock waves

were studied in 1945 by Harvey, Butler, McMillen, and Puckett.'

Regardless of the mechanism of their formation, it was necessary to bear

in mind the possibility of discontinuous fractures as an important feature of

all penetrating or perforating missile wounds of the cranium. They could

produce hemorrhage and cerebral damage at a considerable distance from the

missile track, and they also could permit the entry of air or infection or both.

There was definite evidence of injury to t hat part of t he brain which corresponded

to the site of the discontinuous fracture in 4 of the 9 cases in which this type

of fracture was present (cases 1, 4, 10, and 21) and less conclusive evidence of

injury of the brain in a fifth case (case 2). The base of the frontal lobe, including

the region of the olfactory bulb and tract, was invariably the area involved.

In two cases, the dura was torn at the site of the discontinuous fracture,

and it may also have been torn in a third case. In one instance, and possibly

in another, the brain was also damaged at the site of the discontinuous fracture.

The findings suggest that in this type of injury, the brain and tile dura may be

involved together or independently.

PATHOLOGIC CONSIDERATIONS

Gross Damage

In 18 of the 24 head injuries in this series, the ventricular system was

directly involved by a laceration of the ventricular wall. In 17 of these 18

I Harvey, E. N.. Butler, E. G., McMillen,j. L., and Puckett, W. 0.: Mechanism of Wounding. War Med.8:91-104.

August 1945.
CLINICOPATHOLOGIC ASPECTS 339

cases the lateral ventricle was affected. The third ventricle, however, was

affected in only one instance (case 10). Intraventricular hemorrhage was

present in every instance in which the ventricles were wounded, the degree

varying from a small amount of liquid blood to a complete cast of blood which

filled the entire system. In one case, in which there was no apparent gross

lesion of the ventricular system, a solid blood clot was found blocking the sylvian

aqueduct; presumably it resulted from rupture of a subependymal vessel.

The lateral ventricle was damaged 17 times, the frontal and temporal

lobes 16 times each, and the occipital and parietal lobes 13 times each (table

19). No other structures were damaged with such high degrees of frequency.

The insula was injured in four cases.

Of the other telencephalic structures which suffered direct injury by the

missiles, the corpus striatum was damaged in 8 cases, the corpus callosum in 7,

and the septum pellucidum in 4. The diencephalon was directly involved in

7 cases, including 3 cases with damage to the thalamus alone (cases 12, 20,

and 21), 3 cases with damage to the thalamus and hypothalamus (cases 7,

10, and 24), and 1 case with damage confined to the hypothalamus (case 8).

In one instance, the lesion of the thalamus and hypothalamus was combined

with damage to the mesencephalon in the diencephalomesencephalic border

zone. This was the only case in which a gross lesion of the mesencephalon was

evident. Gross damage to the cerebellum was noted in six cases. There was

no evidence of a gross lesion in the region of the fourth ventricle, including

the pons and the medulla oblongata, in any case in this series. The assumption

seems reasonable that wounds of these structures resulted in death on the

battlefield and that they therefore would not be represented in a series which

excludes battlefield deaths.

Multiple injuries were the rule in all cases, and in only 1 instance (case 15)

was gross damage confined to as few as 2 structures.

Histopathology

Since the survial periods in the 24 cases of severe brain injury in this

series ranged from 30 minutes to approximately 10 days, the material was

well suited for a study of early tissue changes and reactions in the central

nervous system. The survival periods, however, did not extend to the stages

in which Wallerian degeneration or retrograde cell reaction can best be demonstrated. They also did not extend to the stages at which reparative processes

were in full development.

Microscopic examination of the brain lesions always revealed a central

zone of hemorrhage and necrosis in the path of the missile, with immediate

and complete destruction of tissue elements. Adjoining this zone was a zone

of hemorrhage and edema, in which there were severe alterations of the ischemic

type in the nerve cells, with less apparent damage to glial elements. In some

instances, the elements of the mesodermal vascular structures in this zone

showed few cellular alterations, but occasional necrosis of the walls was observed,
'140 N E I U P; I t (1 V R V

Wvith e'xudaltioni of 111)1 ii or of at coaigilatitig proteinl precipitate. Tlhese fiilidings

accord with p~re'viously record(edl observa tin b yS lv agg'iistiss. Kertioliati, and

1)rapiewski " anud H~and 1 (n Courv ille.1'

lit till 24 cases, thle dlefiinite zone of efdeitia 1111(1 hemiorrhage ext ended allong

tile missile track for dist ances varYing from 3111111u. to I cmli. or more. Ileniorrhlage andt othter vascuilar (latnage, however, also occurred l ii foci of apparenthl

irregular and ulnpredicjt aide patterms, lit varY i ig, 11nd often conisidlerabl)e.

dlistanlces fromitilte missile truck, andl diffu~se edveina not conitiguouis with tlie(

primary Wound was noted lii iiaiiY inistanices. It is necessarY to bear lit initid,

therefore, that inl penlet rating" wollids of the braiti. inl addition to tie local

(lalliage a~long thle missile track andl in its immnedliate vi('ilit *v, there are other

and more (listaht lesions of t lie type found inl cereb~ral cont usioni. It is ftirt hermore p~ossib~le, ats Miller I pointe~d out inl 1927, that cerebiral conicussion alone,

Withlouat microscopic clianlges demtonst rable bY present teI(chlical met hods,

might give rise to various sy ipijtonlls. D amlage caused byV laceraion 1(1 li(I

contuiton501 niav lead to tilie Series of traunliat ic react ions dlescrib~ed l)V Betitiett

and (1 11hit , ill 1933: andi~ designated1 as traumilatic encephalitis. ( oncissuonl,

however, is believed to give rise to changes Which are of a m1ore rapidlY tranlsienlt

nlat tire.

Another poinit to lbe emp~hasizedl is the )o5ssililit ,v aldvanlced( 1) * Scheinker

anid Evanls, that ill headl inljuries lilt('rat 10115 inl the paretiehvivua 11111 be

secondlarY to Vascular (list uirhances. C entral vasoparal~vsils, aCcorditig to thlese

aut hors, is of special inllzprtance, andl vascular alterations are initerprete'd ats

duet( to local re'tardlation or immlob~ilizaltion of thle blood( flow, associatedl withI

fiiilhl(HIT('115 ill thile permevalilit N -of tilie Vessel wvalls for serous fluid land redl

blood( ce'lls. lin the case's ill thins series, it wa-Is difficult to ('valuiate accurately,

the relative im Port atcie of JprimarY mlechaliviial impact, andl thle 1)O-ssih)ilit *

e'xist ed thaiit second(ary isehemiia mnight be dl tie to mnehanical vascular lesions,

such Its rupture, ats wvell as to funcltional vasojiaral -ysis.

Edema.- -lI ri n iure , as llassiln poilitedl out inl 194:3, t he( ce(la

pareiich vima. miaiv assume a. si(evelike appearance, inl which vacuiola t ed aerolae

aire separatedl by thin trabeculae. Edematous fluid fills thle advent itial spaces,

of Virchow-Robin and1( may, lin add~it ion, cause ruptunre of tile glial pedlicles,

at tac'hied to th(' miembraiia limlitans perivascularis, which remains firmnly

adhe(rentt to tile a(Ivenititiail t i5ssue. A s'con~d space' filled with fluid is thuls

found exte(rnal to the perivascuilar limiting m~emfbrane' and1 wit hini thle cereb~ral

iiarenchyma if; this space, Which re'prese'nts the perivascular spaces of His and

2 Baggenstuss, A. Ii., Kernohan, J1. W., and IDrapiewski. J. F.: rhe Hlealing i'rwet~b in W~oundis of the Brain. Am.

J. Cliii. Path. 13:=-33348, July 194..

3 and~. C. W., andt Courvili,', C. B.: flistologic Studies of tilt Brain in Cases of Fatal injury to tilt fleadt. V1.

Cytoarchitectovic A4lterations. Arch. Neurol. A- Psychiat. 34:1277-1294. lDecetnher 19316.

4miller. (o. (I.: Cerebral Concussion. Areh. Surg. 14:891-916, April 19Y27.

5Bennett, A. F.. and Hunt, ff. B.: Traumatic Fncephalitis: Case Reports of So-Called Cerebral Concussionl WIith

Encephalographic Findings. Arci. Surg. 26:397-406. March 19Mu.

S cijeinker, 1. M., and Evans. J. P'.: IHistoiogic Studlies of the Brain Following Head Trauma. V. Alterations ill

the Vessels of the Central Nervous System Following i'raurna. A ewarch Nerv. & AMent. iDis., l'roc. 24:94-130, 195.

7 limasin. 0I. B.- (heneral Pathological Considerations in Birain Injury. In Injuries of thle Skull, Brain and Spinal

Corti dited hy Samuel Brock. Baltimore: William,. Ar Wilkins Co., 1943. pp1. 14-40.
CLINICOPATIIOLO(GI(' ASPECTS 341

A FlP 1tEXM)

Fw~unE 70.-Arteriole in head of caudate nueieuis evn~t'iinii~g coaglibiurn an~d

with predominantly niononuclear round-cell infiltration of Virchow-Itohin

space. There is pronounced perivascular edenia. A perivascular space of

His and Held has been created. Hei-atoxvlin and eosin stain. (X 210)

Held, may lbe traversed by broken or elongated glial processes (figs. 70, 71,

and 72). These spaces are artificial and (-an result from tissue shrinkage but

may also be causedI in cerebral trauma bv the pressure of edlema in a locus of

lesser resistance. Edematous fluid also surroundled the ganglion cells in thle

central parenchmyma, giving rise to the periganglionic spaces of Obersteiner

(figs. 73 and[ 74), which are not present. in normal tissue. Damage to the

synaptic structures surrounding the nerve cells, plus interference. with their

function, must be considered a likely result of the formation of these periganglionic spaces.

Although edema, which represen tedI one of the characteristic zonal feat ures

of cerebral injury, was usually most pronounced in the immedliate vicinity of

the injury, it could also be found at a considerable dlistance from the, site of

injury and often involved the leptomeninges. There was no apparent regularity in its extent andl (istribut~ion, these considerat ions seeming to dIependl uponl

a number of variable factors, among which the central vasoparalysis emphasized

by Scheinker and Evans may be included. Thus, edema was present, but was

not conspicuous, in a patient whose survival time was :30 minutes. It was

pronouncedI in a second patient with a survival period of 5 hours, and it was

still present in a third with a survival period of about 10 days. The wide

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4 ist ril)1l t loll of cer'ebral 11a11( 1 h])t (lilell iligen I1 e icillia a5li'1vvioisl p v bel)(1 v~Ini

lplinsize( by I lassiji, andh lilsI b% (snaia anid (rvlii'911dBok'

A\ vascu'1laU c ('huhge 0('('uIioIIuIiv 1noted ill ('(elluzI tol a15 11en.5 4CohhlstIIe of

('0111 jse(I (cap1111iay 100j)8 which lppl:l)('u-vd( as solid, Ii vai liiized Ihands dihg. 75.

Hemorrhage. -Avi nordiwagc lesions \\(TVe 0I varnilus but interre iated Iyl

Ma zl55ive heivi'll iage11" whilichliiililtria I (I Ilee'I'ct tI issue andil lelpt llielli ihges \Vits

associate 1 '1Widt act uial laceratI'ions)1. Pet erb'hill IieiilOJl'l HIngs of thle rill- typ

andh so-caUlled( baill lieiiiai'i'liages Were ob)served1 eslpeciailiv ill tilie ihlil~ll('(Ii teI

vi f Iliv lizll o (olipee (destrucetion1. Scat ivi pe('l (techiiui lieillrilaghhipes ~'i(11 0 itV at I Il' /me 

and111(Io1' 111111 itv CIe~llaI'l-lag('se. wvrie found1( at. conhsideralea 1)1(ist a aces front tile

missile traick a 111 pro)babIly result ed elither froln. actiun I In cernt loll of I he vessels

ill d iv Iiiiisile traick or. fronut cart ti'vecaip. Othler Iteinorrhtage"s wven re PI'f'5Ulyfb

(file to riJlpt ure of vessels sub~ject ed to Ii iecilianiea 1 stress ait thle tili ofe at ipact.

"Thle st ness iuuight talke tilie form of at pull oi at' sihea -i'ig force of. evenl smddeln

l 0ST1oat M., and G ;ilibti t i, V. 'tScsttnctsioitf Nteuro sis: 'Traniat la ic Ence'; ttllhi is: A ('Oneept ionl Of 'ostCOllCUSSi0T1

P'henomeina. Arch. N euro, & I 'sviihia. 1ISAXI-214. A uglst 1927.

9 G reenfieltd, J. G;.. Someit Obitservat ions onr Ceirebtral Inojurie's. P rit-. Royv. Stx' Medt . 32:43-52, Nove'rii er 1083.

lu Brock, S.: Gew'nral C'onside[ra! tions ini 1 jurits of thet S kullI, ftrainano! 5

l inat C'tird. lit In hint's o f the Skull, Biraiun

antd Spina Cji.i ord, t't it (' by Sanieittl Birock. , Ha.1tlt I Or: W~illiaxits A Wilkins C o.,I 1913. lil. 1- 13.
CLINICOPATIIOIA)(1CI( A.'PECTS 343

A;i~:,

Fim-RE 72.-1Perivasei-iiar edema in medullary vciaetir of heis niphere.

Tratisuidate with prlotein precipitatte is filling both tile X ircholv -Robin

space miid the space of His mid Held. Arrow shows outer lining of

Virchow-Robiii space. fctnatoxyliii aiia eosiii staini. (X 160)

r-t S00-0

edema and ishei iier. c(I hm sincrexajcett wud

Roi ~csand athusdisrlvsuptred che t-P ne FIP 0001
3144 N ,UI ) tEI

%F Imn

I-i(i m 1.Edmaou corie nvcnivo aealo ihsl Ito

nrliddmgd) 1-r ~aid(vl hspcm4 iggssnioohga *eao~i an1' it ti. Y 55 4,P

Fi ri-u.; 75. 1 isiolw 0141cy4lorcllitvar eetia1 )t i (I, 4)4rivasculhr hemlorrhiage andI( edvlna in co(rtex adjmicit to) mnissile woundI(. Thev pyramnidal

(-(-]s arep (riellied it varions anizles. (Col~lap~sed capillair v loo)p, ap)Jl'U as,

liyaliiized bands. I leniat (xylill and( vosill Stain. ( .' 210)

lPet ecitial1 heTHllTl-apres val~lsev l)v fait vilbolislu l1Ii ve beeii ciilpill)i5'A'(

hv ii1 ifllber of a lit hors, inclichling I assin and 'Martlhind( and Beling." There

Wits lit tle evidelev of fatl ciuholisnli ill this seri-es, however, except ill at Single

inst anice (case I I), 1i1i1d eveni ili it tilie ew~vlncev was not concluisive. ihere

wer nmeou fait drop~let s ili vessels inl regionis *in which no hvemorrhageýs were

' It lrflandIt~*1. S., and lieling. C, C.: Trauinatie; Cerebral Hemorrhage. Arch. Neurol. & Phychiat. 922:l1iW)-i02:i,

Novembier 1tr29.
CLINICOPATHOLOGIC ASPECTS 34A5ý

present, while the hemorrhagic areas did not. differ froin similar areas ini other

cases in which there was ino definite evidence of fat emnbolism.

Thle findings in this series of cases indicate the importance of (list ingilishing

bet ween hiemorrhiages cau~sedl by dhirect traumna andl those caused by concussion

at a (list ance from the trauma.

Changes in nerve cells.-Ini this series, the nierve Cells in the zone of comipie t de stru1ct~ion were entirely cruishied and dI(isinit egra te(](. Except, for poorly

staining granular (letrituis, there were no traces left o" structures.

In the zone of edema andl hemorrhage, the chiangi. .e frequently

dlescribedl as due to ischemic cell (disease. The cells were shrunken and stained

darkly withI both hemiatoxylin-eosin andI Nissi stains. The nuclei were pyknotic

and the cell processes, especially the apical dendrites of pyramidal cells, were

wavy or tortuous (figs. 76, 7:3, 77, and 74). The changes described ranged in

A FIP 9M99

FIGURiE 76.-Nerve cell changes of ischemnic cell disease type

in cortex adjacent to missile wound. Shrinkage, homogeneous

staining, pyknosis of nucleus, and tortuous dendrites are

characteristic. Slight pericellular edema has caused the socalled spaces of Obersteiner. A few collapsed capillary loops

can be recognized. Hemnatoxylin and eosin stain. (X 235)
N IKI k( SlI(IIY

a *

- .9

I I.

p ** * * .*

* - '.

* 9 9 .. J *

'-/' I" . .

4,.. 1'' "I,-

* I 9.,

9,. .9-,'

9 9 9

494'9'. 

.9 9 9 '*'*/ £i; * .9 * *-* i,-,,' * 1 - r. *. -

* 9 a - * '

I -4 -'V * * ''

*9 -9.

.9. 1 -

A I Ii

uliI1iie staII)ii)52 I'I('t lot). Ia ('Xl lelije 'liiiila' tiz-. 78 a)I4l 79). Large,

'h'I)iat()IIM j)1'I'ie'llIIlar )ee4)11141 i'e see)) :1 io1II)41 the sliiuiiikeui *elk. '(ucuoli-

I 14)1) 4)1 I lit e'Jls, XVii I) h).S 4)1 aIlillil V 14W sI aiil5, Was soulel iI))'' 4)l)4'I'Vu'4l

(liSj)III('CI1IC1)t at 1II(' IllI4'IeII,4. anti 1 iZI'0lV5iS. was 114)1 14)111141 14) lIt' ('lJ (l('4'I4)j)d'4l

ithis series. ( )ii liii' basis (II I lie l4'siaI)s aI)served III it, t Ins is hot a 4'I)sl)ieIIaIIS

('('Ii ('IIUtig4' ill I lit' ('iPlV 5IaL('5 4)1 a'hlle lrain iauiaa.

lI'I)4)II))''d eell lI1Iieat I Ii'' h.4'I)eI))ie tVj)4' wei'e 14)111)41 bIllowing IL

5lII'Vl*Il f)4'114)41 ol 4)111 v 31) mninulo's. ( )n 11)4' whale. iii I Ins selies. I hey W4'I'('

flit tier delitilt elV e4)111i114'4l to 1114' iIi)Ine(hia I e \i4'il)it V at' the 1 i'a tuna I t/A'(l t'eioti,

I l14)iigli llit'y Well' 4)eeasio)lUtllV observed It) 1)111)4)1' 4l4'r4'4' ii) r4'l4)ll5 at a t'atlsleI'Ul)l4' (li51a114't' It'4d)) tIle ;tet tial I tailina. ( )l) I lie other ll;ll)(l, it iS 4)1 it)Iei'4'5t

that iii 1)lItlil)4'r 4)1 lt)51111i('4'5 II) WI)i4'h) 41i1'4'eI I iattti)a WaS 4'Ohllit)4'(l to I lie teI'li4'4'I)ll1lOt), ('('II tlat))iio' 4)1 Iaii'lv 4'(Il)Sj)i4'tl4)Il'. (14'gl't'4' vas l'nial ill the inferior

aliail'' Ii)I('14'115 4)1 1 lit' 1114'4l111

lZ1 0l)l4)I)gata fig. NI)). ( oIIUph't4' (liSal)l)4'iIt'Zit)4'4' alIt1

lesion vli('ti4'V4't' 1114' 4't'I'4' bellar ('4)I'14'X walae'rat4'4l (It' ('4)1)1 II'('(l (1k>. 81 alIll 82),

whit'li 'eiiis (4) it)(li('atl' (I) that I h)('54' ('('1k I'4'l)I'4'54'tIt 4'14'I)lI'11IS es)4'4'ialIV ensiI lV(' to Inlililia aild 2 I hat 1114' ('('1k 4)1' 1114' inferior olivajy 1i114'14'us alt' aI)l 14)

(liI't'4'tlV illV4)l V4'4 I.
% ~

AFII' 100119i

Fic;t.Rn, 78.-I (Iato necrosII~is ( o-. f cortex inl parjeto.-occipitaI regiont

wvith hi.,bly shrunk inerve cels Tni Ihere are a few infiltrating I~olymlorpho.

nuclear 1eitkoeytes and monotioticlear cells in addition to glia nuclei and

collapsed Caipillaries. fletnatoxylin and e'osin stain. ( X 400)

III ltIddit ionl to (lalililgve to ilidiviuld cells(11, N(lollreclikei (lt ura I clia ilgs

resulting from la1cera ition of tihe cortex were recorded, dule to t ie( immllediate.

effect of the traurnlaltizilltg ag(ent. They included distort ioi.. of t ie( lamiiniar

P~attIern and1 irregula 11iities IIiI lie( a i.1.afigemlenit of thle (lisplaced coitletil cells, Which oippc U redl orient ed iat varliouls (Iivergreti t angles. Tlhese chaniiges, which had

lprevioislY lbevii relportq ed by aind alild ('ourville ill I1):w, were designiated as

primarY or early, ill colit radlist ilnetionl to Owli secondwary or hitv e.V oyil1 rcliitect. ur-ll

chlanges resulting from the 1)1111 of coirtical scarls. The cas'es reportedl ill this

chapter presented, of course, o ily primary chainges because the longoest period

of survival was Inl thle nieighiborhood of I 0 (blys.

Changes in nerve fibers.-1 n aireas of complete (lestruct ion, the( aixoms had

lost their property of being sI atined Iby Silver imlpregniationl and liplu'eared its

finle gmranll ti detrmitIus, jindicatitiug t ha t ininietliatIe necrosis 1111( occurredl. lit

the surrounldingo Zone, (lamag11(e to nerve fibers was inhicat ed by swelling and thie

formation of varicosit ies (figs. 8:3, 84). Swollen fibers, occasionally shIowedl a

ret icular nietwork of nuelrotilbrillae with vacuolated, ehongaitedl mieshes, and

file swollenl myielili shlea ths had1( acquliredl a certamn afhinit v for diffuse i mpregnail- tionl wit Ii sil\ver sailts (fig. 85A anrd 1B). Swollen aixons wvere also fairly (itstiiictly outliniedl by dipb use of hiemattoxylini-vosin and Nissi,- stainls. The axonis

aisulflned a sintiious course, with himany 1loops, and appletired fragmiented, though
3~48 X I I I sI tI .I 

A IAlV 1IMI2112

1i ii~il; I t1,79.. 11 va IiriztI diost iw-ve tiIIs in, twierotic artvt

it Is (IifiI('Ilt to sa , whletherlii . tile. pc c Iv prv esvilt('( varlY actunal I'lagIllenttaltIOll

Or wihether tihe lillt errpt lowll'l' "(PPlle to thle ext Cll-(Imi (if Owluortliml.li l(1ps

bevoitl (the 1)lalles ()f thle Sectmi d01 i-". S6A\ and B). E'lIl bulbs ()f globlitil.,

flisiforl~l. andi chllllike apperwiii ce (figs. S7 , SS) andI olteii of1 ioticiilateo textilre

resent 1)1e CthIt ose (ucsd1 be( Iv Ram'), jl2 I~ii~l 1 a111b ai ii iril. 3

The gel icra I fit id I I gs, of I Ilese. a IIt hiors, as well as t lie cm l l('isious \\-I jll I I e d. Irew

cotltl be0 colt fulmed III t LNs Inal tvit'llt , but1II iIlost 1wtalice is it wits not possible

to lascervtaili wihetcl .11 a 51rilch re ()f culd-blulb t pe \\as .1 true end~ 1)1111) oi- was

mnerely: aI I a rtificial bl-calk resultliug" because tihe planle ()f (li1scto had vut o41,

ava rico;i t V I a tilcoit I' n110115 a xoI. TIhere wa5 Ito) cvvidetIc of regehiera ti

p'0 0 0 '

5 5 0 '5 bu11t it liltist be kept Il ind liiiml thattle jerio Is of suirvival Illn t Illis ser-ies

Were cmItjlparat i vel short , nione exeec Iiig' It0 daYs. Fu rt tier st inlies, oil fiber

2 I~iuu'n V('u~u. ant:~i: ),uuivratiuit11:11i lzwraivnt imflth Nviv('uIS 54%S1,tiui trnsiut-hI bv lO:aui Mt. May.

Newv Yirk: ( )Owell Unikersit l'icss. 11121.

.1 Rl;i.t. ( . WV. :111.1 ( 'uoiIr% iliii . B'. II II ýStiilfuc SI~i ill the ltr:1iji ill ( ';Miv o~f F':11:11Ii h m %m T I h Ii Iv:.ld V. (Changes

hil the Nvr~v Flwjtsq A.im. Niuirol. N I's\00eh I:31: 527 -7,5.7 Ma:relh 1931.
A IIA P 19

milu.N is-j ', siii 21(0)

p .pýIN'~jr

4A

4td.* a- 4vz A

7. io .

40 6

SS

A. FI P I 12

Fif; i i8. ( '.rebeIlar corlvx atdjacenit lo lacerntvd areai. Infilt ration

of mol)(eculatr Ia y 'r with Ii l ' viyuorp)IomuicIear IcuukoevI vs . \Iost Pmukinije's

cells ha~ve (Iisaplj~)artAr, b~ut tw~o scelfros.e( (cells ill I Ili.en (isl ap. of ischii'iiic cell

dlamuage: are indicated hY !irrow~s. I IeiuiatOXvlill :mold CO~ill SI aill. (X I I (M)

4557::15'"-- 5 .4-- -2 4
'VAV

or

de'

kill 1111_1 I<

\ ~ ~ ~ i ~ ii W ~ i ~ it 1 ~ ~ ~ ~ i!t~ FI itil (i N\II t)~

FI~ va S3. SNvIn , 11*1(~1 , :1d j s-bv fajl-1 1i l

Modinn~~- r-im in sil21 im 315)li
CLINICOPATlIOLOGIC ASPE1CTS 351

.%F I P' 100MY3

FIi;URE 84.--Varicositics, possible end bulbs, and edensa in white

substance of damaged parietal lobe. Bodian silver impregnation.

(X 315)

degeneration and possible later abortive regenerative processes were thus

precluded.

Changes in the ependyma and choroid plexuses.-The changes described

by Rand 4 and by Rand and Courville i5 as occurring in the choroid plexus

almost immediately after injury to the brain could be clearly recognized in

the cases in this series. They consisted of edema of the stroma, hydropic

swelling of the choroid epithelium, and increased vacuolization of these epithelial cells (fig. 89A and B). Although hyalin bodies were frequently found

in the strotna of the villi, it is doubtful that their presence represented a change

due to trauma, since such degenerative changes are occasionally seen in otherwise normal material. These structures may be regarded as precursors of

psainmonia bodies.

Severe subependymal edema was frequently seen. Sometimes it resulted

in distortion of ependynmal cells (fig. 90). Numerous pyknotic nuclei were seen

within the cells of the ependymal lining (fig. 91). The changes in both the

ependyma and the choroid plexus frequently occurred at, a considerable distance front the site of direct lesions. In many instances in which the wound

was in the telencephalon, they were found in the fourth ventricle.

Changes affecting glial tissue.-The reaction of the astrocytes was rather

inconspicuous in early stages in the cases in this series. These cells were found

disintegrated in the zone of complete destruction, but in the surrounding zone

swelling of astrocytes was notice([ after approximately 18 hours (fig. 92). This

I1 Rand, C. W\.: Histologic Studies of the Brain in Ca"es of Fatal Injury to the Head. I. Preliminary Report.

Arch. Stig. 22:738-753. May 1931.

13 Rand, C. W., and Courville, C. B.- Histologic Studies of the Brain in Ca.s of Fatal Injury to the Head. II.

Changes In the Chorold Plextus and Ependymna. Arch. Surg. 23: 357-425, September 1931.
Irmo
CLINICOPATriiojA)(dI(' ASPIK(,s .353

1'i I Rt 86. -A andir B. Swellinig, tortuiosit% and11( possible fragmentaUtioni

of axonls inl white sliist aiwe: of damfagedI pariet al Iobv. There is also

evidence of eleni~a. Bodiaii silver inpregmat ion. ( X 27-5)
354 N Itri ()S.IU(;EILY

lboi -00 

EbV 1 ~10;

LI'I'L4I

'iw-mi.. 8S. -'arivo."ities and possble enld bulbs of ax~ons ill Inedtilhtry eeInter of dlamangedI parietal lobe. Bodian silv'er imp~rent'gii~ont.

(X 4.5(0)
('INIOAIII) CASPEC:(TS 355

2 -

be03

03

..... ~ .... 0
44

4 o

A F1,11X59 LN

a to

UF I mI21

1' X4w9It J. P~I~~ ykoicimvi wistit, thei ef enidviiai fiiiim~ of the I

lateal ponoictd entrck-nd stlwpndyial dema HeatoviI

and (X vsin 5045 taiii 
CLINICOPATIIOLO(.UC ASPECTS 357

finding wits int erpreŽted its rep-esenlt ing thle oniset of so-calledl afleboi( changes.

Further accentuation of the regressive p~rocess was nioted1 in cases in which

the survival period was longer. In add~itionl, the presence of constrict ion of

nuclei an([d (ouble nuclei indicatedl a mild degree of amlitot ic cell dlivisioni, but

conispicuious proliferation was not observed. These ob~servationis were in accord

with the findings of Baggenstoss, Kernohian, amtd Drapiewski, who statedt that

astrocytes play a minor role iii the reparative pr~ocess ill brain injuries. Olig(odendlroglia Cells showed1 a strong reaction, indicat'A by swelling (fig. 93), occasional pv-kiosis, ainitotic dlivision (fig. 94), and a granular or- vacuiolated apwP.

A FI' 100109

FIGURE 92.-Edema in white sub~stance of dlamaged parietal lobe.

The cytopla-sm of astrocytes has become homogeneous aud their nuclei

are pkynotie. This swelling of perinuclear cytoplasm is believed to

represent an early stage of so-called ameboid transformation. Hemnatoxylin and euifl;i stain. (X 545)

pearance. In several cases, dlefinite evidence of accumulation of oligodendroglia

cells around dlamagedl nerve cells suggestedl neuronophagia or' at least increased

satellitosis (figs. 74, 95). The changes of oligodendroglia were thus both regressive and progressive in charact-er.

Microglia (mesoglia) cells showed swelling and iransforrnat~ion into rod

cells (fig. 96). Evidence of amitotic cell (division could also he found. Time

changes in these cells were essentially progressive. Their activity (luring tile

stages studiedI in this series was, however, rather inconspicuous, an(1 the findings mfenltionled are in accord with Hassin's observations.
, -. - -

or

C CL

mil cd l ia ald p- m lieIicvl

:110!
CIA N1('(PATriIOOGA(I( ASPEA-rsT 3~59

Liut RF; 5 -~ Aschenfic nerve 'ell changes in fron tal co~rt ex ntear Wounid

airea. T here is somne suzggestioni of nticironophaigiat. Ifermatoxyliii an~d

i\Iarginai ghiosis, as described byN Winkelman and Eckel,' la ot a Coll

slpicUous feat nre inl this series of Cases, al111thogh inl two inlst ances t-here was,

observed a very mild1 inldicat ion of increase iii glia, Cells inl thet first, cortical

lat* er. lit theseI cases, Ilarginlal ghiosis Conisisted of anl incerease of aill three

forins of ghia cells mid~ was purely a local phienomnenon (figs. 97, 98). Inl a few

Cases inl whinch the survival period was several days, there were, inl additionl

to ilitotic figuires of pm'oliferat ing" euudotihetiaf cells, somle nultot ic figulres ill tile

brain suibstiance which Could not be (lefihuitelY idenitifiedl ill resp~ect to cell type

but, which minight have beeni dividing glia, Cells (figs. 99, 100, anid 101). It is

thus not. impossible that glial elenents may uindergo imitotic as well ats ainiitotic

cell division inl thle early stages of react ioni followinig t'raumlla.

Changes in the histogenous and hematogenous elements of the vascular

apparatus.-Othier important, vascuilar chianges found lin this, series, inl add~ition

to rupture of blood vessels, hiemorrhlage, and edlema, whiicht already have

heeii discussedl, inceluded severe congestion of the veins and Cap~illaries. Extremle (distention was associatedl witli stasis. Fibrin t luronibi, andl necrosis and

hivalinfizatioii of tlie vascular walls, were also not ed. th'lese chanuges occasionally

occurredl not onily* inl tile viciniitY of traumllatic lesionls but1 also at at conlsiderable

(distance from them11.

Scheuukr a~l ')jjju,17 hos u%%iI,( vasclar chan11ges inCerebral traumail,

described vasoparalvsis, genieral mid~ local, associa t ed wit il i uucrelsed perlieabil60 Winkelman:, N. W ..nd Eckvl. J. 1.: Braiin Trauzzza; 1[Ist~oplthology During thp Eairly Stages5. Arc-h. Neirol. &

I'sychlat. 31: WA,-9$6, Maky 19P34.

""Ree toot note 6, P. 3*?.u
360 X 1' -1N)-I*;Fi

4...

W- Vo-v

t P,

.. .7

4N.

111ingf.' oc4ia ~ i-. Iolcl a t 1s ffs-1.ll an oo i O .( :5 4i.A 
CLI NTCOPATIIOoi~mmC ASPE'CTS 361

ity, (legeileratiloll, alld( necrosis of tilhe vessel wall, aiill ciroliuc Vascular chanlges.

All t he act ual histologic alteratiotis observed 1)* S.cleiiiker and Evanls

were also observedl in tilie material In this series except for chiromei vascular

Changes, which could1 not have dleveloped( within thle surlvivial periods of thiese

Casualties.

Perivascular inifiltration, whlichi Was founld to b~e presenlt a few hour's after

inljt iv, relpreselltedl tile most conlspiculous tissue reaction to traumila if) this Series

(figs. 102, 71, and 10:). Tereacting cells were polvmorph onutclear leukoc t es,

smnall noiononuclear cells (presumably lvYm plocv Ies), and1( large 1111 omi clear cells

7-a

QIP1101

4ltR S7--ortcl. fhf aitlloelg~ v fnagt

g~io~i. 1Iei~to~yizi an vo~iista40. (>

(monocvt or lust e icvt es). PolvmorplioUcla.elsfeunlypeoi

IiateRl whic seeeoltoiicate oet thva aarepar tta atb lugeastv of tmergacinal cll

w~ere of hematogenous origin. On the other hand, it app~earedl likely that

histogenous elements present in adventitial tissue took part in the reaction.

"I'lese Vai-olls cells, originating 1)0t1 from thle 1)100( stream and~ tile walls of tile

Vascular apparatus, infiltrated into tile b~orders of the zone of necrosis and

throughout the neighboring zone of edemia and( perivascular h iemorrh ages (figs.

104 and( 105). NMacrophages with 1)100( pigment were seen Ini the leptomeniiiges

when thet survival period was more than :3 (lays andl in thle brain substance

when it was about 5 or 6 days.
:162 NIEKURost, IM RY

C omlpoundi~ pg11tiul1ar ('orIplscies were foundm whlei tlie( sur-vivall period wvas 3

(la 's or more (figs. 1 06, 107, anid 108), whiichi Is III accordl withI the observat tOlls

of Baggeiistoss. Keriiolaii, anid 1)rapiewski."1 As thlese ant hors poinit ed out,

most of thlese cor-puscles aippearied to arise froii ad veni it ial cells an id froum large

IllololllivivaiV (cel11, whic possib0511ly were of livinlatogetiolis orligi i. There was,

lit tle evidenlce thalt mi1croglia1 cells contribuiited siguilifica iit lv to thle format ion

of compuj)tnd grait itila il cor-puscles ait thIese si agces, alt bolugh solile gi tvIe cell."

z1i'digt have beenl formed bX theml.

46":e" . ' .

4 %,

-tab,

4W.,

-' - *

S St

AFIP IM3~3

11(1 l.R ¶).-Sliglit marginal glmosis ill miolecular Ia.,e(r of frontal cortex

ill fimmed(iate VicinIityv of wvolund area. Hin 'at oxylin and eosin stain.

(X myO)

1Proliferalt loll of ca pillaries, ill (Ialua12gedl areavs of lhe brinil becamei ntot iceablel( after a1 silrvival period of more thanii 5 dayvs (figrs. 109.A and 11, 110, and1(

111). O bviously, only- the early stageVs of this pr1oce'ss could be followed ill

this series. Ill t hese5 cases, tit( endothelial cells were liyleertropl~hied and formed

one-Iavere(I, but thick, enidotlhelial tubes or s-olid elid~ot belial sprouts. M\itot ic

figures wvere frequent (fig. 11 2A and11( ). Fairly dense ne(t works of newly

gr-own caipifllaries were11 sleen whenl thle sur1vival timei was a11)01210 It)tavs. ProliferatIionl of capillarie's oc-cuirr-e( ill dama112ged areasl of both1 white and1( g-raly sILstallice but1 was5 Illore pronounci11ed inl the latter. Fibr-oIliist e proliferat ion also

occulTled( butit Wals less predolomililt lit Inlt l2('s( earlly st ages.

is Sce footiiott 2. p. 3M1.
CIANICOPATHiOIA)(IC ASPET 363T

>. 0

IFI

itvlft. Am
0 . I 

4'

stai. 5) B.L- 60A. 
CLINICOPATHtOLOGI(C ASPECTS 365

AFIP 100346

Fli'RE lOl.-Mitosis (equatorial plate) of reacting glious

element in damaged frontal cortex. Hematoxylin and eosin

stain. (X 1600)

AFIP 100002

FICURE 102.-Small artery in region of diagonal band of

Broca, with necrotic wall and perivascular infiltration. Infiltrating cells are polymorphonuclear leukocytes and small as

well as large mononuclear cells. Hematoxylii and eosin stain.

(X 210)
166

.. - , 'I, &

** 40 V

t-~i a n d 

0oi l S a i .4
CLINICOPATHOLOGIC ASPECTS 367

AFIP 100201

FIGURE 105.-Marked infiltration with polymorphonuclear

leukocytes in necrotic area of cortex adjacent to parietal lobe

wound. Hematoxylin and eosin stain. (X 500)

Leptomeningeal changes.-The most striking alteration in the leptomeninges was hemorrhage followed by a cellular reaction. The erythrocytes

in the meshes of the subarachnoid space were intermingled with polymorphonuclear leukocytes, histiocytes, large mononuclear cells, and lymphocytes.

Proliferating fibroblasts could also be recognized, and red blood cells were

occasionally seen enclosed within macrophages. The findings in this series

corresponded to the changes in the leptomeninges described by Hassin 19 as

the result of brain injury.

Infection.-A meningeal reaction of varying degree was observed in most

cases in this series, but in only two cases (cases 14 and 24) was there definite

evidence of pronounced purulent meningitis. In one of these cases (case 14),

the ventricular lining also showed evidence of purulent ependymitis (fig. 113).

In only one other instance could the unusually marked infiltration of the brain

substance with polymorphonuclear leukocytes possibly be interpreted as an

indication of infection. A certain amount of infection of the brain substance

"is See footnote 7, p. 340.
368 NELUROSURGOERY

1j DEPRESSEDý1

... ::HEMATOM

Fic u HE 106.-A and B. Approximate patterni of skull fracture.

AFIP 100335

FIGURE: I07.--Conipouimd grainular corpuscles in vicinity of

sulcus torininalis near anterior end of damaged thalarnus. Hematoxviin and eosin stain. (X 315)
CLINICOPATHOLOGIC ASPECTS 369

AFIP 10342

FiruR 108.-Compound granular cells in white matter of

damaged occipital lobe. The grouping of such elements along

a proliferating vessel is conspicuous. There is also some perivascular infiltration with mononuclear cells. Nissl's stain. (X 250)

was probably present in several other cases also. Although the material in

this series differed in this respect from the practically aseptic cases studied by

Baggenstoss, Kernohan, and Drapiewski, it is remarkable that the findings in

both series were so similar, especially in respect to the predominance of polymorphonuclear leukocytes.

Sequence of reactive and other changes.-Generally speaking, the reaction

of the brain tissue to trauma is far more sluggish than the reaction of tissues

in other organs. The reactive processes during the early stages following

injury, as they appeared in this series, were essentially carried out by the mesodermal components. The ectodermal elements showed only limited activity.

Summary of Pathologic Findings

On the basis of the observations made in the 24 mortal brain wounds

reported in this chapter, the sequence of reaction and other changes in the

cerebral tissue after trauma may be summarized as follows:

1. The early traumatic stage was characterized by disintegration of tissue

in the path of the missile, hemorrhage and edema in the zone adjacent to the

path of the missile, changes of the ischemic type in the nerve cells, and changes

in the choroid plexus.

2. Within a few hours, perivascular infiltration set in, with a conspicuous

participation of polymorphonuclear leukocytes. Thrombosis and necrosis of

blood vessels proceeded as additional circulatory changes resulted from spread-
70 NIN E U R(OSURGERY

*• . . 4 

I~t ",r 5 4*

AS

* ,'iih,, ;4 h" 

.. '.'.

* WA

i ," ,:•' ". Jr, . .,.

~J- kki

k 8 

, ,y,€ !

Fi( URE 10O.).-A an(1 B. Prolif(,rat io'. of (endothelial cells,

capillaries, and solidl endothelial sIprouts in daifagedI cortex of

frontal lobe0. Hematoxylin andl eosin stain .A. ( X 160) ]i. (K

27.5)
CIAN1COPATIIOLOGIC ASPECTS 371

AFIP 100)341

FIGURE 111.-Conspiuo~i eusapoiallr prliferaio in sagedo damy 

cneofdmgdoccipital cortex Hemnatoxylin and eosin stain.( iS
-17 NV'VItr Ost-RGI:RY

4

IS A

4m

k FI I'I M1004, I M313

Fcunp: 112. -A and 1 B. AMitosis of endlot heliat cell of p)roliferaIt~ing capJillarv in dalIIag(A vortex :idjaceent to wotindc. JIVIeIIatoxyliii and eOsill st aml.

A. ( / 800)) 11. (X/ 1900)
CLINICOPATHOLOGIC ASPECTS 373

r, - 0%- aos,1'0 €

AFIP 100539

FIc.uRE 1 13.-Ependymitis in right lateral ventricle. A venule

with perivascular infiltration is seen in an ependymal granulation.

A fibropurulent exudate adheres to the ventricular wall. Hematoxylin

and eosin stain. (X 210)

ing edema and hemorrhage. In damaged areas, axons began to swell, appeared

sinuous, and showed varicosities.

3. Increased infiltration of hematogenous and histogenous elements took

place into the cerebral parenchyma within the following period. Affected

axons sometimes underwent fragmentation, and bulbs appeared.

4. After about 18 hours, swelling of oligodendroglia, microglia, and early

ameboid transformation of astrocytes became noticeable, and pyknotic

nuclei were observed within the ependymal lining. Glial elements of all three

types displayed signs of occasional but extremely limited amitotic division.

5. After the second day, patchy areas of early demyelinization were

observed in the regions of white matter affected by edema and hemorrhage.

6. After the third day, compound granular corpuscles made their appearance, and there was also, at this time, some inconspicuous evidence of neuronophagia.

7. After the fourth day, definite proliferation of capillaries set in.

SURGICAL CONSIDERATIONS

The implications of the preceding presentation, although it is entirely

pathologic, are far more than academic. Most of the neurosurgeons in the

Medical Corps at the beginning of World War II had had little, if any, firsthand experience with cerebral injuries caused by high-velocity missiles. Many

of the younger men, in fact, had been trained in an atmosphere in which most

455735T58-25
374 NEUROSURGERY

neurosurgery was ' ive and in which patients with severe head trauma were

seldom seen.

As a result, these neurosurgeons were placed in forward hospitals,

they had to learn the hard way, by trial and error, the practical details of

military surgery. One of the most difficult of their problems was the correct

selection of patients for operation. There were few rules to guide them, and no

authoritative publications on the subject.

The fact that patients with severe damage to large parts of the brain,

including the ventricular system, may survive for relatively long periods of

time raises the question how one can distinguish, on the basis of the location

of the anatomic lesion, between a mortal and a nonmortal brain injury. From

a purely theoretical standpoint, it might seem that any injury of the brain

would be directly mortal only insofar as it affected the function of the centers

of the medulla oblongata which control respiration and cardiac action. Oil

the other hand, extensive damage to higher parts of the brain, such as the

cerebral hemispheres, diencephalon, mesencephalon, and cerebellum, can

weaken the activity of the vital centers in a number of ways. Mechanical

factors include the disruption of synaptic structures in the rhombencephalon

through the pressure wave in the cerebrospinal flid of the ventricles, through

ventricular hemorrhage, and also through gc 1 cerebral edema. Hemorrhage and edema, combined with vasopai .ay lead to anoxia of the

vital centers. The toxic effects of devitalized ti _. and of infectious processes,

even if they are mild, are additional factors which may endanger the function

of these centers and may contribute to the formation of a vicious circle. These

are all variables, many of which may escape observation, n-nd the distinction

between a mortal and a nonmortal brain wound therefort c, nnot be bfsed

exclusively on the extent of damage that is grossly, let alone c!i ' -ally, appaf'eOt.

The whole situation was confusing. All too frequently, a nC.aiher .

soldiers with head injuries would be received in the preoperative wards at tp,•

same time. The neurosurgeons, whose numbers were limited and whose time

and strength were also limited, would be forced to decide which of these pati.nts

could most profitably be submitted to operation. Many times, craniotomif-s

which were performed to be certain that wounded men be given every possible

chance for life were found, at autopsy, to have been useless from the start

because the cerebral injury had been lethal and beyond surgical relief from the

moment if was sustained. Meantime, other patients with head injuries, less

seriously wounded and with better prospects for survival, might have had

their chances of life jeopardized by the delay in treatment.

By the time this particular study was undertaken, almost all of the neurosurgeons who participated in it were no longer inexperienced. All of them

associated with the evacuation hospitals from which this material was derived

had been through two or more active campaigns and had acquired the sound

clinical judgment which, for most surgeons, can be acquired only by extensive

experience. They were considered competent by this time to handle any type

of trauma involving the nervous system. That competence probably accounts
CLINICOPATHOLOGIC ASPECTS 375

for the fact that in these 24 cases, there was only one instance in which lesions

were found at autopsy which might possibly have been corrected successfully

by a more skillful surgeon.

The patients who made up the material for this investigation are logically

divided into two groups. In the first group are the 10 patients who were

recognized as hopeless surgical problems from the beginning and in whom no

surgery was attempted. In the second group are the 14 patients for whom

surgery was attempted and for whom, although their state seemed hopeless,

there was a sufficiently reasonable doubt of the lethality of their wounds to

warrant the attempt at operation.

GROUP I (NONSURGICAL)

In every one of the 10 cases in this group, autopsy studies revealed the

soundness of the surgical decision to withhold operative intervention. The

two cases presented here in detail represent a fair sample of the entire group.

The first patient survived 30 minutes. The second survived 31 hours.

Case I

Clinical History

A soldier who became unconscious immediately after being struck by a

bullet from a pistol fired at close range presented a wound of entry in the

right temple and a wound of exit in the left parietal region. Cerebral herniation was present in both. Vigorous arterial bleeding in the right temporal

wound had been partly controlled by a pressure bandage. The blood pressure

was unobtainable. The pupils were dilated and fixed. No movements of any

of the limbs were observed, and no reflexes of any type were obtained. Breathing ws stertorous, and pulmonary edema was progressive.

Death occurred 30 minutes after wounding. Autopsy was performed 2

hours later.

Protocol

GROSS ANATOMY

Skui.--An oval opening about 7-9 cm. in diameter, with sharply cut

edges, was present in the right temporal region, about 3.5 cm. above the

external auditory meatus and 5 cm. posterior to the lateral corner of the right

eye. Bloody fluid oozed from the wound. The skin and the scalp around the

opening were free from burns, and no foreign particles (gunpowder) were

observed. Another opening, between 12 and 15 mm. in various diameters,

was present in the left temporoparietal region, about 9 cm. above the left

external auditory meatus and 15 cm. from the lateral corner of the eye. The

shape of this opening was stellar, due to the irregularly torn scalp. A small

blood coagulum was seen in this wound, mixed with small particles of brain

substance and of bone.
376 NEUIX )SURGERY

('NTR , XIT

A B

AFIP 140781

-\ FicGURE 114.--A. Approximate position of

cranial wound of entry. B. Approximate

,, 0 position of cranial wound of exit. C. Apz proximate pattern of discontinuous fractures

"0 in anterior cranial fossa and sella turcica.

(

Openings on both sides of the skull (fig. 114A and B) corresponded to the

openings in the scalp. The opening on the right, which was located in the

anterior third of the temporal squama, was sharply cut, oval, and of the same

size as the opening in the scalp. Several fracture lines radiated from it for a

distance of approximately 3-5 cm. The opening on the left, which passed

through the suture between the temporal squama and the parietal bone, was

also oval and sharply cut and was about twice as wide as the opening on the

right. Through this opening, a fracture line ran in a nearly horizontal plane

for about 4-5 cm. both anteriorly and posteriorly.

The anterior portion of the sella turcica and the entire lamina cribrosa,

although these structures were not in the direct path of the projectile, were

shattered into small fragments (fig. 114C), but no cuts were detected in the

optic nerve.
CLINICOPATHOLOGIC ASPECTS 377

Brain.-The point of entry of the projectile into the brain substance was

in the right superior temporal gyrus, near the pole of the temporal lobe and

approximately basal to the junction of the trunk and the posterior ramus of the

sylvian fissure. The wound, an irregular tear, slightly over 1.0 cm. in diameter,

was roughly funnel shaped, with the apex directly inward. It was filled with

small, intimately intermingled fragments of brain tissue and coagulated blood.

The point of exit, of the projectile from the brain was situated in the

posterior part of the left inferior fiontal gyrus, this location corresponding to

the triangular and opercular portion of Broca's convolution, just above the

dorsal end of the trunk of the left sylvian fissure. The wound was a nearly

circular tear, somewhat over 2.0 cm. in diameter.

The leptomeninges showed widespread hemorrhage, particularly in tie

regions of both cerebral wounds. There was also some coagulated blood in

the subdural space on the left. Tile base of the brain was contused and

lacerated in the region of the medial orbital convolutions and of the gyrus

rectus of both frontal lobes, this area corresponding to the area of the discontinuous fracture.

Coronal sections of the brain showed the course of the missile to be at a

level slightly rostral to the anterior commissure. The track was rather clear

cut, gross destruction of the brain substance being limited almost entirely to

the path of the projectile, in a zone between 1 and 2 cm. wide (fig. 115). Severe,

AFIP 100825

Fjc.uRE 115.-Coronal section through brain showing missile track.
378 NEVROSUIIGERY'

grossly recognizablte hemorrhagic lesions extended fromn the level of thle rostrum

of the cor nus eallosum to thle, level of the mnassa intermiedia of (lie thalamus.

There was also considlerab~le diffuse hemorrhage along the fibers, of the right

internal capsule in thle pes pedunculi, as far eaudhid as the miost caudlal levels

of the thalanmus.

In addition to the cortical areas already nIentioiiedl, thle brain structures

located in the path of the projectile included, from right to left, tile anterior

portion of the right insula, the right lentiforin nucleus, the right internal

capsule (anterior limib), the base of the head of tile right caudlate nucleus, thle

septum pelluciduni, the b~ase of the he'ad of the left caudate nucleus, thle left

internal capsule (anterior limb), the left lentiformi tucleuis, thle claustrum, and

tile insula. Both anterior liorns of the lateral ventricle were perforated, aild

the entire ventricular system was filled witiL b)100(.

AFIP 100010

FIGURE 1 16.-Petechial hemorrhages in cerebral cortex

adjacent to missile wound. The hemorrhages are jperivawcular and many arc of the "rinIg" type. Ilenmatoxylin and

cosin stain. (X 70)
CLINICOPATHOLOGIC ASPECTS 379

MICROSCOPIC ANATOMY

Tilhe cortex surrounding the site of both tile entry and tile exit of tile

projectile showed lacerations and numerous petechial hemorrhages of the

perivascular, ball hemorrhage, and ring hemorrhage type (fig. 116). Although

tile patient survived for only about 30 minutes after wounding, the cortical

nerve cells displayed definite alterations. The cell bodies appeared elongated,

narrower than normal, densely stained, and homogeneous. The processes,

especially the apical dendrites, were tortuous and corkscrew shaped; the nuclei

were pyknotic (fig. 76). These changes have been described both as chronic

cell alterations and as ischemic cell disease. In this case, they must be interpreted as rapidly occurring acute changes, possibly titue to mechanical trauma

as well as to ischemia. On the other hand, there was no evidence of any glious

or mesodermal reaction. A slight, degree of edema was present.

The lacerated cortical areas at the bas- of both frontal lobes presented

identical histologic pictures. There was also considerable subarachnoid

hemorrhage in the neighborhood of entry and exit of the missile and ill tile

area of the laceration of tho basal part of the frontal lobes.

In the areas of the basal ganglia traversed by the missile, the hemorrhages

and cellular changes, which were similar to those ill the cortex (fig. 117), inAFIP 100009

FIGVRE 117.-Nerve cell changes of ischemic cell disease type in head of

caudate nucleus adjacent to missile track. Slight edeema of subependyifal

cell plate. Perivascular hemorrhage and perivascular edema along venule

of nucleus caudatus. Hematoxylin and eosin stain. (X 160)
380 NEUROSURGERY

cluded subependymal hemorrhages in the vicinity of the projectile track and

perivaocular hemorrhages in the white substance of the region of the internal

capsule. Although the ventricular system was filled with blood, there was no

conspicuous histologic alteration of the ependlymal lining. The choroid plexus,

however, showed some evidence of early changes, corresponding to those

described by Rand 20 after 2 to 4 hours (fig. 89A and B). The stroma was

moderately edematous and the villi were ballooned, so that in some places the

fibers of the stroma bad become separated from the blood vessels. In addition,

hyalin or fibrinoid bodies were seen in the stroma, though such findings are

occasionally observed in normal cases. The choroid epithelium appeared

swollen and hydropic, with irregular margins and increased numbers of vacuoles.

Case 10

Clinical History

The time of wounding was not known in this case. The patient had sustained a penetrating wound in the right parieto-occipital region, with moderate

cerebral herniation and was in coma when he was admitted to an evacuation

hospital 3 hours after tagging.

He was slightly restless and moved all limbs on painful stimulation. The

temperature was 1020 F., the pulse rate 100, and the respiration 28. Breathing

was stertorous. The pupils were somewhat constricted and fixed. The deep

reflexes were all more active on the left, and the Babinski and Hoffman reflexes

were positive on that side. Superficial reflexes were absent. Roentgenologic

examination revealed a severe comminuted fracture in the right parietooccipital region; a large metallic foreign body lay near the sella turcica.

During the period of observation in hospital, the blood pressure rose to

180/50, the pulse to 130, and the respiration to 40 to 60. The temperature

remained approximately 102' F. until death. No operation was undertaken.

Death occurred 31 hours after tagging, and autopsy was performed 10

hours later.

Protocol

GROSS ANATOMY

Skull.-There was a round opening, about 1.2 cm. in diameter, in the upper

part of the right parieto-occipital region, about 1.5 cm. from the midline (fig.

118A). The defect was mainly in the occipital squama but also involved thtv

right, leg of the lambdoid suture. There was a discontinuous fracture in the

medial portion of the right lesser sphenoid wing and the right cribriform plate

(fig. 118B). There was some coagulated blood in the epidural as well as in the

subdural space.

"I' See footnote 14, p. 351.
LINICOPATHOLOGIC ASPECTS 381

'--•• " ";'SITE OF 6ASILAR

ENTRANCE OF MISSIlF

IGURE 118.-A. Approximate location of wound of entry in skull. B. Approximate site

of discontinuous fracture of cranial basis.

Brain.-An irregularly torn wound of the right hemisphere in the region

r the junction of the occipital and parietal lobes, which involved the lobulus

arietalis superior and the supramarginal gyrus (fig. 119), corresponded to the

ole in the skull. The wound track led deep into the right hemisphere and made

s exit in the region of the substantia perforata anterior. A thin, curved,

regularly shaped shell fragment, with sharp edges, measuring about 1 by 1.2

.n. in diameter, was found in the vicinity of the substantia perforata anterior.

,ilaterally, there w as an area of laceration and contusion on the orbital surface

r the frontal lobe, corresponding to the gyrus rectus, the olfactory bulb and

"act, and the adjacent orbital gyri. This lesion measured about 3 by 4 cm.

tid was presumably related to the area of the discontinuous fracture.

Sections of the brain revealed extensive destruction of the right cerebral

ePrisphere with damage to the ventricular system and the corpus callosum

igs. 120 and 121). The structures involved were the third ventricle, the right

ialamus, including the diencephalomesencephalic border zone, the anterior

art of the right hypothalamus, and a large part of the right striate body.

Iassive intraventricular hemorrhage had occurred, and a cast of clotted blood

lied the entire ventricular system. Widely scattered petechial hemorrhages

ere seen throughout the entire brain substance, and there v ere small lacerations

k the right cerebellar hemisphere.

MICROSCOPIC ANATOMY

In the area of laceration at the base of the frontal lobes was a very marked

Lfiltration with polymorphonuclear cells throughout the edematous cortex,

455735"-58---26
dflc'p : It l 1 ~ i1 11 1

0111111% t

I 'it i it 121. (a irm id - i la i -llm ill--- #.\Icltll \j o Iraaa~ iaa, li

fllaa aaf i )IitI11: 1 li :kll ft I i ta1a\ ali it I l O i il Ilrd aaI \t-1tr-icIe.
CLINICOPATIIoIA)( IC ASPECTS 383

possibly due to it beginning infection. In the region of the parieto-occipital

wound were cortical areas of edemaltous iiecrosis, giving the picture of a foamy

ground substance in which the highly shrunk necrotic nerve cells, glial elements, and polymorlphonuclear cells were enclosed (fig. 78). The walls of the

sylvian aqueduct were edematous and displayed so-called aiel)oid glia cells

in the silel)endylmal cell plate (fig. 122).

.14

AFIP 100224

FiWRE 122.-Edema and hemorrhage in wall of sylvian aqueduct, with

swollen astrocytes. Blood cells are also present in the lumen of the aqueduct.

Ilematoxvlin and eosin stain. (X 400)

The cerebellar• cortex in the region of the lacerations of the right cerebellar

hemisphere showed dense infiltration with polymorplionuclear cells in the

molecular layer (fig. 81). There was marked leptomeningeal reaction in the

basal frontal and the cerebellomedullary regions, with large masses of polymorphonuclear leukocytes.

Comment

In the first, of these cases (case 1), in addition to petechial hemorrhages and

grosser hemorrhages from lacerate(d larger vessels into the missile track, subarachnoid space, and entire ventricular system, early changes of the ischemic or

chronic type were conspicuous in both the cortex and the basal ganglia. There

were also mild changes in the choroi(l plexus. The lesion of the cranial bones
384 NEUROSURGERY

included so-called discontinuous fractures of the lamina cribrosa and the sella

t urcica.

In the second case (case 10), the conspicuous features were widespread

destruction of internal structures of the right hemisphere, basal lacerations of

both frontal lobes, including the olfactory bulb, due to discontinuous fracture,

and, in the histologic picture, very marked infiltration with polymorphonuclear

cells. The temperature of 102' F. may have resulted from involvement of the

centers in the anterior hypothalamic region but may also have resulted from

infection. The fracture in the right cribriform plate and medial portion of the

right sphenoid wing was discontinuous in a sense, although, in this instance, it

may have been caused by direct impact of the missile.

In view of the intraventricular bleeding and the extensive destruction of

the diencephalon, it is indeed remarkable that this patient did not die immediately after he had been wounded.

These two cases demonstrate, both clinically and pathologically, the

intrinsically hopeless character of such head wounds. Both patients were

practically moribund when they were admitted to the hospital. No experienced surgeon would have been tempted to operate upon either of them, for

their vital signs were never stabilized. The most remarkable feature of both

cases is that the patients survived the initial trauma.

The comparison between the anatomic areas of destruction in the two

cases is interesting (table 19). In the first case, the destruction involved the

frontal and temporal lobes, corpus striatum, corpus callosum, septum pellucidum, and both lateral ventricles. The patient survived 30 minutes. In

the second case, the destruction was even more widespread than in the first.

The injured structures included the frontal, parietal, and occipital lobes; the

corpus striatum and corpus callosum; the lateral ventricles and the third ventricle; the thalamus and hypothalamus; and the mesencephalon and cerebellum. The brain showed far greater mutilation than the brain in the first

case, yet this patient survived for about 31 hours. Both cases are excellent

illustrations of the futility of attempting to postulate the lethality of mortal

wounds of the brain solely upon the anatomic areas destroyed by thvi missile.

As has been pointed out previously, one can say with finality that a

wound of the brain is mortal only when the lesion involves, directly or indirectly, the cardiac and respiratory centers of the medulla oblongata. Probably most of the wounded who died immediately on the battlefield had suffered

direct damage to these structures. As table 19 shows, not a single case in this

series presented gross evidence of damage to either the medulla or the pons.

GROUP II (SURGICAL)

In each of the 14 cases in the second group, the neurosurgeon, by operation, attempted to convert what appeared clinically to be a hopeless situation

into a more favorable one. The following protocols illustrate both the type

of cases in this group and the type of surgery performed in them.
CLINICOPATHOLOGIC ASPECTS 385

Case 7

Clinical History

This soldier was found unconscious on the battlefield early in the morning; no definite history could be obtained, but it was believed that he had

been wounded several hours before. When admitted to an evacuation hospital at 5:30 that afternoon, he was semicomatose but could, with assistance,

carry out simple commands. He would not or could not phonate. It was

recorded that he had left hemiplegia, left hemianesthesia, and, probably, left

hemianopsia. The pulse rate was 120, the respiration 40, and the blood pressure 110/70. There was a penetrating wound in the medial portion of the

left orbital ridge. The globe of the left eye was preserved.

A lengthy debridement of the missile track through bilateral osteoplastic

flaps was commenced at 9 o'clock that evening. Troublesome bleeding was

encountered from the longitudinal sinus. Both cribriform plates and the

adjacent dura and brain were extensively involved in the wound of entry.

Repeated attempts to tap the anterior horn of the lateral ventricles were

unsuccessful. Because of the rapid deterioration of the patient's condition,

efforts to find a hematoma farther back along the track were abandoned.

He died 25 hours after tagging, hence between 25 and 30 hours after

wounding. Autopsy was performed 7 hours later.

Protocol

GROSS ANATOMY

Skuli.-Few details were available concerning the skull injury. A bullet

wound had its entry at the left nasal bridge, causing damage to the left frontal

sinus and the wall of the left orbit. The tip of the bullet was found in the

right occipital lobe of the brain. The ethmoid bone, including the cribriform

plate and the crista galli, were shattered. The dura was extremely tense.

The opened longitudinal sinus was free of thrombus formation. There was

a considerable amount of clotted blood in the posterior cranial fossa, and

blood surrounded the cervical part of the spinal cord. The source of this

hemorrhage was not determined.

Brain.-The brain was rather firm. A small amount of subarachnoid

hemorrhage was noted. The orbital surfaces of both frontal lobes, including

the olfactory bulbs and tracts, were lacerated. Coronal sections of the brain

showed damage to the medial and basal frontal cortex of both frontal lobes.

The missile track (fig. 123) could be followed into the right hemisphere, where

extensive destruction of the right striatum, pallidum, and internal capsule

was found (fig. 124). The septum pellucidum was involved anteriorly, the

laceration including both right and left lateral ventricles. The anterior parts

of the right thalamus and hypothalamus were also involved, without direct

damage to the periventricular diencephalic structures. Farther caudad, the
386 NE UILOSURGERY

ENTRY

FioURE 123.-IDitgrain of miissile track through

EIT

I1;*14ý

FIGURE 124.-Coronal section showing damage to right striatum, pallidum,

and internal capsule.
CII NICOPATtIO1,O;I(, ASPI.ECTS :187

track ran laterally and spared the thalamic centers, destroying, however, the

posterior lini) of the right internal capsule and the caudal parts of the

lenticuilar nucleus.

In the right occipital lobe, the track ran dorsal to the posterior horn of

the lateral ventricle (fig. 125), almost reaching the occipital pole. There were

AFIP 1039fd)-33a

Fim-RE 125.--Coroial section showing missile track in right occipital lobe.

massive hemorrhages into the ventricular system, and numerous petechial

hemorrhages were scattered throughout the entire brain substance.

MICROSCOPIC ANATOMY

The histologic findings corresponded, in general, to the findings described

in the previous case in which survival time was about 31 hours. The usual

zones of hemorrhage and edema were found around the large areas of destruction of the basal ganglia. Numerous polymorphonuclear cells and a few large

mononuclear elements were scattered throughout the hemorrhagic regions

(fig. 104). The zone of manifest changes extended to a depth of about 8 mm.

along the missile track. In addition, the ependyma, including that of the

fourth ventricle, showed edema. The choroid plexus displayed moderate

edema, and in some of the villi the epithelial cells appeared flattened. In

this case, as in others, the zone of complete destruction of nerve fibers was

characterized by a disintegration of the axons, which had lost their property

of being impregnated by silver salts. A fine granular detritus was interpreted

as indicating immediate primary necrosis. In this case, however, the secondary changes in the nerve fibers in the marginal zones of the lesions had

become very conspicuous, especially among the large fibers in the hemorrhagic
388 N EU ROSURG ERY

zones of the internal capsule. Affected axons displayed a tortuous course,

with varicosities and occasional fragmentation. End bulbs, as described by

Rand and Courville, 21 could be found (fig. 87). In some instances, the swollen

myelin sheaths showed affinity for diffuse. impregnation with silver salts (fig.

85A and B). The leptomeninges showed a mild reaction; the meshes of the

arachnoid were in many regions filled with erythrocytes and white blood cells.

Case 12

Clinical History

This patient, as the result of small-arms fire, sustained a perforating

wound running from the right frontal to the right occipital region. The huge

compound comminuted fracture involved the right frontal, temporal, parietal,

and occipital bones; lacerated cerebral tissue herniated through a large defect

present in its center. The patient was said to have been in coma and in shock

when he was admitted to the hospital, but no record of his vital signs was

available. After 24 hours, he became restless, and left hemiplegia was evident.

The right pupil was dilated and fixed. The neck was stiff. The left arm and

leg were flaccid; the left biceps and triceps reflexes were hypoactive as compared

to those on the right, while the left knee and left ankle jerks were relatively

hyperactive. The Babinski and Hoffmann reflexes were positive bilaterally.

Abdominal reflexes were not obtained on the left. Roentgenologic examination

disclosed a large bony defect which involved all the bones on the right side

of the calvarium. Widely separated fissures ran both forward and backward,

as well as across into the left temporal region.

The condition remained essentially unchanged, and the wound was

debrided 52 hours after injury. The operator's note follows:

Under ether anesthesia the wound of the right cerebral hemisphere was debrided, the

herniations of pulp brain at the wounds of entry and exit having first been excised. Within

the cranium devitalized masses of right cerebral hemisphere were removed, together with

numerous bone fragments and large blood clots which were found in the extradural, subdural,

intracerebral and intraventricular portions of the wound. Wounds of entry and exit were

thus connected. After removal of pulp brain, the futility of any procedure was seen. The

extensiveness of destruction was markedly out of proportion to the clinical signs, save for

depth of coma. The brain wound extended into the body of the lateral ventricle, superiorly

to the longitudinal sinus, posteriorly into the occipital lobe, and deep into the temporal lobe.

It was necessary to clip large branches of the right middle cerebral and the main trunk of the

right posterior cerebral arteries. The open ventricle was washed as free of clots and debris

as possible. The dura was not sutured; scalp closed by plastic procedure. Four thousand

cubic centimeters of whole blood were required during the operation to compensate for the

blood lost.

Death took place 12 hours after operation and 65 hours after wounding.

Autopsy was performed 9 hours later.

21 See footnote 13, p. 34&
CLINICOPATHOLOGIC ASPECTS 389

Protocol

GROSS ANATOMY

Skull.-There was an irregular opening in the parietal and temporal

bones on the right side, measuring from 12 to 15 cm. in different diameters

and involving adjacent parts of the occipital, frontal, and sphenoidal bones

(fig. 126). Irregular fracture lines from the borders of this defect radiated

in all directions.

FIGURn 126.-Approximate outline of skull defect.

The large opening was covered by adjacent mobilized tissues held together

by sutures, and there was free and interstitial hematoma formation in the

wound area. In the dura mater was a large, irregular opening, and several

silver wire clips were in the edge of the dura. In the occipital region, the subdural space contained a massive, loose hematoma.

IGrain.--The right parietal lobe of the brain was severely lacerated, and

the shreds of brain tissue were covered by blood coagulum. The brain wound

extended dorsad into the occipital lobe and rostrad along the sylvian fissure

into the temporal lobe and the base of the frontal lobe.

Coronal sections of the brain showed destruction of the greater part of

the right parietal lobe (fig. 127), except for the region of the gyrus cinguli and

neighboring structures on the medial surface. The right occipital and temporal

lobes were also severely damaged, while the lesion of the frontal lobe was chiefly

cortical and for the most part involved the right inferior frontal gyrus. The

lesion reached the body and the inferior horn of the right lateral ventricle.

The destructive lesion inolved also the right half of the diencephalon, including
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CLINICOPATIIOLO(1 R ASPE~CTS 391

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392 NEUROSURGERY

mentation was the result of actual interruption of the axon or of extension

of the loops beyond the plane of the sections (fig. 86A and B). Marked edema

and hyalinization were observed in the choroid plexus.

Case 17

Clinical History

This soldier was struck in the right temple, right flank, and buttocks by

shell fragments. When he was admitted to an evacuation hospital 5 hours

later, he was dazed, very restless, and uncooperative. The blood pressure was

62/40. He moved all four limbs, in each of which moderate extensor spasm

was observed. The deep reflexes were equally hyperactive; the superficial

reflexes were absent. No pathologic reflexes were present. The pupils were

equal and reacted promptly to light. Roentgenologic examination disclosed

a metallic foreign body measuring 3 by 2 by 1.5 cm. embedded in, and depressing,

the right temporal bone, just above the external auditory canal, for approximately 1.5 cm. Small shell fragments were also visible in the buttocks and in

the right side of the twelfth dorsal vertebra.

After repeated whole-blood transfusions, the patient had improved to

such an extent that the wounds in the flank and buttocks could be debrided,

and the right kidney, which was found to be shattered, could be removed.

By this time, he had received 2,500 cc. of type 0 blood. The temperature was

99.20 F., the pulse rate 100, the respiration 28, and the blood pressure 116/76.

The following day, the vital signs were unchanged, but the patient

remained disoriented and confused. The pupils were equal and reacted to

light. Spasticity of all extremities had increased, as had hyperreflexia.

Fifty-one hours after wounding, the head wound was debrided, the

indriven bone and metallic fragments were removed, and the dural defect

was repaired by a graft of temporal fascia. An additional 2,000 cc. of whole

blood were administered during the 2-hour operation. The right trigeminal

nerve was found to be lacerated. No note was made concerning the ventricle.

By the following day, the temperature had risen to 102'-1040 F., the

pulse rate was 120, and the respiration was 20-26. The blood pressure was

135/84. The patient became more stuporous. The lungs were filled with

coarse rales, and cyanosis was quite evident. His condition continued to

worsen; that night, the lumbar spinal fluid pressure was 580 mm. H20, although

the temporal flap was said to have been pulsating.

Death occurred 85 hours after wounding. Autopsy was performed 2

hours later.

Protocol

GROSS ANATOMY

SkulI.-A defect in the right temporal squama measured 2.5 by 4.5 cm.;

its posterior margin involved the external anditory canal (fig. 130). There
CLINICOPATHOLOGIC ASPECTS 393

FIGuRE 130.-Approximate location of defect in right temporal squama.

was also a defect resulting from craniotomy in the right parietal bone. Its

anterior margin was at the coronal suture, and its medial margin was 6 cm. from

the midline. A bone flap was found in the defect. A large defect in the dura

of the floor and lateral wall of the right middle cranial fossa had been incompletely repaired with a fascial graft.

Brain.--A laceration measuring about 7 by 7 cm. and covered by a blood

clot was found in the inferior and lateral surface of the right temporal lobe.

Coronal sections of the brain showed extensive damage to the right

temporal lobe, with involvement of the inferior horn of the lateral ventricle

and ventricular hemorrhage. The brain appeared generally hyperemic, and

there were many scattered petechial hemorrhages throughout the brain

substance. There was marked generalized swelling of the brain.

MICROSCOPIC ANATOMY

The histologic changes in this case did not differ essentially from those

found in other cases with a survival period of more than 3 days. In the vicinity

of the laceration, there was still considerable edema with severe ischemic

changes in the ganglion cells and a distribution of glia cells suggesting so-called

neuronophagia (fig. 74). Occasional compound granular cells and numerous

ameboid glia cells were found in the areas of hemorrhage and necrosis.

Polymorphonuclear cells were also widely distributed through the damaged

areas and their surroundings. Blood vessels in some regions of cortex and

white substance were filled with rod-shaped micro-organisms, a few of which

were also found in the brain substance around the vessels. Some of these
394 N EIlROSURGERY

micro-organismns had round spores at one end. It is likely that they represiteted post morteni containianation. This view is supported by the fact that

the tissue reaction in contamiinated areas did not show any difference from

that of noncontamninated areas or that of other cases in which mnicro-orgainisnis

were not found in tile brain.

Cominent

In the first of these cases (case 7), the histologic pietture did not show new

details or further developments of the reaction of tile tissues to traunia except.

for thie very conspicuous secondary changes in the nerve fibers. From ilthe

standlpoint of localization, tile extensive defect of the corpus striaturn throughout, the length of the right hemisphere is noteworthy. Left henmiphlgia and

left henmianesthesia were doubtless the result, of the complete involvement of

the right internal capsule, including the retrolenthicular portion. Exact data

concerning tihe temperature were not. available, but. a note iaade upon the

patient's admission to the evacuation hospital was to the effeet that he was

warmi. It, is possible that this statement referred to a liyperthermnia resulting

from a lesion of the rostral hypothalamus.

While nothing could have saved this patient, many experienced neurosurgeons would question the wisdom of using bilateral osteoplastic flaps to

expose the intracranial structures, as was done in this ease. Such a procedure

is far more time consuming than the more conventional procedure of rongeuring

away enough bone at the site of entry of the missile to expose tihe traumatized

areas.

Both ventricles were filled with clotted blood, which explains why neither

could be tapped. While the lethal outcome in this case would appear to have

been both inevitable and merciful, it, would probably lbe better, when a ventricular clot is suspected at such an operation, to expose the ventricle for direct inspection and for debridement, if necessary. Wounds of the ventricle could somnetimes lbe diagnosed, or their presence at least suspected, by the apparent

path of the missile or by the escape of cerebrospinal fluid from a wound in the

cerebrum.

The second of these cases (case 12) represents a noble effort onl the part of

a surgeon who dealt skillfully with what. was perhaps a lethal wound from the

beginning. It is another extremely striking example of relatively long survival

(2/12 days) following a very extensive wound of the right diencephalon with

intraventricular hemnatoma. In view of the damage to the right. pretectal area,

it is significant that the right pupil was found dilated and fixed.

In this case, very definite foci of beginning demyelinization could be

recognized in the white matter. Compound granular corpuscles, however, had

not, yet been formed.

The third of these cases (case 17) is the only one in the series in which the

evidence at post mortem examination might indicate that. with more skillful

surgery, applied at the right, time, the patient's chances of survival might have

been materially enhanced. Here, again, the surgeon elected to employ a bone
MLINICOPATHOLOGIC ASPECTS 395

lap for exposure, whereas the conventional practice is to endarge the cranial

lefect at the point of entry of the missile. Furthermore, the patient's condition

vas allowed to deteriorate without any measures being employed to control the

,bviously mounting intracranial pressure. This criticism, however, is made

vithout knowledge of the circumstances under which the surgeon was working,

ior is there any possibility of knowing just what part the associated injuries

)layed in the fatal outcome.

The histologic changes present in this case corresponded to those present

it other cases of more than 3 days' duration. The intravascular and extravas-

,ular presence of micro-organisms was interpreted as post mortem containnation.

The clot found at autopsy over the temporal lobe and the wound entering

lie right temporal horn of the ventricle with the contained blood suggested

hat hemostasis at operation had not been complete. Inadequate hemostasis

,oull also account for the steadily downhill course, the mounting intracranial

)ressure, and the final fatal outcome.

Since retrospect is always better than prospect, it is easy for the neuroiurgical armchair strategist to sit back, read the clinical and pathologic records

of these 14 surgical cases, and remark that they represent a perfectly useless

,ffort. They do. But they seem less useless when one remembers that experi-

!nced neurosurgeons were handling them, surgeons who had seen and operated

)in dozens of similar patients who presented similar clinical findings. Then the

notivation of the surgical effort becomes apparent. These surgeons had seen

nany similar patients survive appropriate surgery. This is not a fact which

*an be substantiated statistically, but it is well known to every neurosurgeon

vho gained his experience in World War II.

The conclusion of the whole matter is that there must be an extraordinarily

iarrow zone which divides nonmortal from mortal wounds of the brain. Many

'actors influence the outcome. Some are known. Some are not. Among the

mown facts, the three which follow seem particularly pertinent to this study:

1. Speed of transport to a hospital installation in which proper equipment

mid experienced personnel are available for expert medical and surgical care is

isually essential for the best results in serious crnniocerebral injuries. In 14

if these 24 cases, it is known that from 5 hours to 3 days were required for the

)atients to reach the level of the evacuation hospital. In 4 other cases, the

ýxact hour of wounding was not recorded, but the evidence indicated that the

imelag was more than 5 hours. Thus, in 19 of the 24 fatal cases in this series,

lie timelag was unduly prolonged, so prolonged in 3 cases, in fact, that the

atients arrived in evacuation hospitals with active meningitis and cerebritis.

It is the first hours after wounding which are often of the greatest imporance in craniocerebral injuries because it is during this period that intracranial

dleeding is occurring and intracranial pressure is mounting, often to the point

if irreversible cerebral damage from anoxia. Speed of evacuation, however, is

ometimes not controllable. In every military campaign, it depends to a large

-xtent upon the character of the fighting and the terrain. These factors were
396 NEUROSURGERY

undoubtedly responsible for much of the delay in transit observed in these and

other cases during the last phase of the Italian campaign.

2. T'ie skill of the surgical team is unquestionably an important factor in

the outcome of craniocerebral injuries. Surgery of this kind requires teamwork.

Every member of the team- tihe surgeon, the assistant surgeon, the sterile

nurse, the circulating assistant--must know his or her job and must perform it

with speed and skill. The surgeon must have learned that many of the timeconsuming rituals of the civilian neurosurgical operating room have no place in

a military hospital. He must operate with great accuracy, but he must lose no

time about it. Most important of all, he must have learned how to achieve

perfect hemostasis before the wound is closed. The most frequent evidence of

surgical error observed in these 24 autopsies was the presence of intracranial

blood clots, undoubtedly to be explained by imperfect hemostasis at operation.

3. A capable anesthetist ranks in importance second only to the surgeon.

His skill in maintaining a free airway, in using just the right amount of the

anesthetic drug, and in administering intravenous fluids and blood in just the

right amounts at just the right time is a factor of inestimable value in the end

results of intracranial surgery for combat-incurred wounds.

SUMMARY AND CONCLUSIONS

This chapter is based upon a clinicopathologic analysis of 24 mortal craniocerebral injuries caused by high-velocity missiles. The survival after wounding

varied from 30 minutes to approximately 10 days. The analysis of this series

of cases warrants the following conclusions:

1. The majority of the cerebral lesions in this series directly involved the

ventricular system. Damage of the cerebral hemispheres was present in all

cases, but comparatively few lesions of the diencephalon and the cerebellum

were observed, and the mesencephalon was involved in only a single case.

Penetrating missile wound- of the brain caused local damage of the lacerating

and contusing type along the track of the missile and in its immediate vicinity,

as well as additional damage of the contusion type at varying, and often at

considerable, distances from the wound.

2. In the studies made of the reaction to trauma and the histopathologic

changes of traumatic encephalitis affecting the various ectodermal and mesodermal components of the central nervous system, of particular note was the

relatively sluggish reaction of the brain to injury as compared with the reaction of other organs of the body to trauma.

3. Hemorrhage, edema, degenerative processes, and infiltiation with

hematogenous and histogenous elements were the predominant features during

the first 4 days after wounding. After the fourth day, proliferation of capillaries marked the beginning of reparative processes. Compound granular

corpuscles began to appear after 3 days.

4. In cranial lesions connected with penetrating and perforating wounds

of the head, so-called discontinuous fractures are an important complicating
CLI NICOPATHOLOGIC ASPECTS 397

feature. When such fractures occur iii the region of the cribriform plate and

orbital roof, which is a common location, the suprajacent dura and brain are

frequently damaged. It is thus easy for cerebrospinal fluid and blood to

escape and easy, at the same time, for infection, air, or both, to gain entrance.

The overlying dura and brain may be torn or contused. These injuries, together with contusions, hemorrhages, and occasionally lacerations at some

distance from the primary wound, serve to emphasize the fact that, in injuries

caused by high-velocity missiles, the resultant lesions are by no means always

confined to the missile track.

5. Severe injury of the brain tissue and of its envelope is not necessarily

confined to the missile track but may occur at a considerable distance from it,

in the form of laceration, contusion, and hemorrhage, alone or in combination.

In this series, clots of varying size were almost invariably present in the missile

track. If the ventricles were injured, blood in -arying amounts was almost

invariably found in the ventricular wounds also. Extradural hemorrhages

were common but in most instances were small and of little clinical significance.

Subdural hematomas, while sometimes large, were for the most part relatively

small.

6. The pathway of a high-velocity missile is not smooth but is ragged and

irregular and is often made multiple by the fragmentation of the missile or the

propulsion of bone fragments. These circumstances usually render complete

operative removal of devitalized tissue a practical impossibility. In this same

connection, it is noteworthy that much of the brain tissue destroyed by injury

is not immediately softened and is not readily distinguishable from uninjured

tissue if operation is performed promptly or even within a period of 24 hours.

Areas of this kind probably correspond to zones of delayed disintegration.

7. The primary purpose of this investigation was to establish the clinical

criteria of mortal brain wounds. Neither its results nor the results of any other

military experience, so far as is known, have established criteria to indicate to

the clinical neurosurgeon the particular craniocerebral wounds which are apt

to be lethal.

ADDENDUM

The following case history is as good an illustration as could be found of

the practical impossibility of determining when an injury of the head is lethal

and when it is not. It was related, on request, by Dr. Francis A. Carmichael,

Jr. (formerly Major, MC, AUS), who served in the European theater, and it is

published as lie related it, without editorial revision.2

As I recall, I encountered this patient, who was then an infantry lieutenant, during

the Battle of the Bulge. This particular evening I was making rounds of the new casualties,

as I had instructed my various assistants to do, and in order to set a good example I thought

I would make a few myself on the way toward my hut in the evening.

This patient presented a striking picture from the start, inasmuch as he was swathed in

a very voluminous turban type of bandage completely encircling his head, the bandage being

22 This patient visited me in 1955, and he is, as Dr. Carmichael intimates in his case history, a most remarkable illustration of what can be accomplished by neurosurgery and plastic surgery.-R. (. S.
398 NEUROSURGERY

liberally soaked in blood. Upon removing this turban, I was utterly and completely horrified at the underlying mess which was a conglomeration of mud and blood, but by gentle

palpation with the gloved finger I was able to ascertain that there was virtually no skull in

this mass of debris since everything beneath the finger was soft over a very wide area.

Having no idea what to do about the situation and wishing some time to regroup my own

thoughts on the matter, I quickly applied a fresh turban and retreated to the privacy of my

nissen hut for meditation oil the subject.

The patient himself was able to talk, although he was hemiplegic on the left side. He

was disoriented as to time and thought that he had been wounded a day or two previously in

France. As a matter of fact, as I ascertained later from Colonel Spurling, he had been

wounded that very morning, and Colonel Spurling had come upon him in France and

ordered his immediate evacuation, not knowing, of course, at which hospital he might arrive.

On the subsequent days, the lieutenant was able to tell me this story; namely, he was

going down a road with his platoon and a German tank came into view. It was terrifically

muddy and slushy that day, and he remembers that the turret gun of the tank was pointed

directly at him at rather cloý . range. The gull was discharged, there was a deafening concussion, and the patient rein, inbered nothing until some time later when he was awakened

by the stretcher bearer. He was unable to say definitely whether the 88-mm. tank gun

discharged or struck him directly or whether it concussed him and he fell into the muddy

road where his head was run over by the treads of the German tank. From the resulting

traunma, I would judge that the latter theory was probably the more correct.

The following morning, having the lieutenant on the schedule, I uncovered the wound

again under better circumstances in the operating room. Here, after copious lavaging with

saline and cotton pledget manipulation, I was able to uncover the wound in its entirety and

effect some sort of a toilet of the entire debris.

The situation was as follows: The scalp, the skull, and the dura had been completely

and cleanly avulsed front an area about three-fourths of an inch above the superciliary ridge

on the right side, extending to beneath the zygoma laterally up to the sagittal suture in the

midline and back to encompass the lambdoidal suture behind so that this area of the brain

was completely exposed, being denuded of the dura, of the skull, and of the scalp, all of which

were missing so that, in essence, the rather intact cortex was presenting itself to the atmosphere. The cortex was not badly damaged but was ecchymotic and bruised here and there

with minor lacerations.

O)n this occasion, I accomplished nothing more than debrideinent; there was nothing to

repair, nothing to sew to, and no way to cover the wound. So, again, I enclosed the patient

in the customary turban dressing, after having overlaid the cortex with petrolatum-impregnated strips of gauze.

Another onslaught to the problem was made the following morning, at which time, with

the patient in the upright position, I uncovered the wound and prepared his back, thinking

that perhaps I should be able to swing some sort of a covering flap up from the intrascapular

or deltoid area of one side in order to cover the wound. This also proved to be a failure,

since there was no way to acquire enough coverage or skin by my meager methods to even

start to close the wound.

()n the third morning, another attempt was made, and this time, by some scalp-releasing

incisions and splitting of the scalp areas, it wias possible to cover approximately one-third of

the denuded area but no more. There was nothing with which to make a dural repair and,

again, a similar dressing was applied.

This patient was with us some time, I should say over all at least 6 weeks, and in the

course of this time there was, as might be expected, some rather superficial abscess formation

in various sectors of the cortex, which responded quite well to incision and drainage and to

continuous wet packs of Azochloramid (chlorazodin).

Finally, in utter despair and panic, on one occasion, with the aid and abetment of the

plastic surgery department, we took off split-thickness grafts from the abdomen and applied

them directly to the exposed and now granulating surface of the cortex, there being no
CLINICOPATHOLOGIC ASPECTS 399

intervening arachnoid or dura. To my astonishment, these grafts took, and we were able

in a relatively short time to accomplish complete closure, flimsy as it was, by this method

of split-thickness grafting.

As might be expected, as soon as coverage was obtained, the problem of edema and

abscess formation vanished quite rapidly under the antibiotic treatment and local packs of

Azochloramid which had been instituted. Coincidentally, with this favorable turn of

events, the patient's memory cleared quite well and he showed some recovery of strength in

the heretofore hemiplegic left extremities. I do remember a personal touch at this time,

when we were in the throes of getting this patient over such a grievous injury, that word

arrived at the hospital that his father had suddenly died in the States. For this reason, we

redoubled our efforts and without any hesitation sent the patient to the Zone of Interior.

I was, of course, at this time worrying what the plight of the next surgeon would be when he

attempted to remove the split-thickness grafts which we had applied directly to the cortex

of the brain. There had been, in my experience, no precedent for this type of frantic operation such as we had done.

Dr. Malvin F. White (formerly colonel, MC, AUS) had the courtesy to write me some

years later, saying that when it came his turn to remove the split-thickness grafts which we

had applied to very great areas of the right cerebral hemisphere, he found the subarachnoid

space had re-formed, that the brain or cortex on that side was bathed in a layer of spinal

fluid, and that the grafts were removed with considerable ease, more or less as if they had

been designed in that fashion. Dr. White was thereafter to carry out some very brilliant

reconstructive work on this patient.

The patient had apparently been quite grateful to all concerned and, I understand (as

he does to me) remembers us with a kindly letter each Christmas. He once visited Kansas

City, Mo., and called me, but unfortunately, I was out of town that weekend and did not

get to see him.

The patient now has almost virtually recovered from the left hemiplegia; he is quite

well and happy, has been promoted to captain, and has been retired on full disability. It

has been deeply gratifying to me and I know of interest to you, that this patient has not in

any way suffered any psychiatric complication from this mutilating and somewhat horrifying

wound, the most spectacular that I encountered during my military career.
APPENDIX A

Course of Instruction in Neurosurgery

Phase I

Fundamentals of Neurosurgery (192 hours), Neurological Institute,

College of Physicians and Surgeons, Columbia University

i. Neuroanatomy, 64 hours, didactic lectures, amphitheater exercises.

Scope: Relations of skull to brain; of spinal column to spinal cord and nerve roots;

external and internal anatomy of brain; blood supply of brain; dissection of brain, spinal

column, and principal nerve trunks.

References: Mettler, F. A.: Neuroanatomy, St. Louis, C. V. Mosby Company, 1942;

Krieg, W. J. S.: Functional Neuroanatomy, Philadelphia, Blakiston Company, 1942.

2. Neurophysiology, 16 hours, didactic lectures, amphitheater demonstrations.

Scope: Fundamental activity of nervous tissue; results of lesions of various regions of

brain and at various levels of spinal cord.

Reference: Fulton, J. F.: Physiology of the Nervous System, New York, Oxford Press,

1938.

3. Cadaver surgery, 24 hours, didactic lectures, amphitheater demonstrations.

Scope: Simulated types of head and nerve injuries; surgical approaches and techniques

of repair.

4. Neuropathology, 14 hours, didactic lectures, amphitheater demonstrations.

Scope: Reaction of nervous tissues to injury; examination of gross specimens of brain

and cord injuries; suppuration; histopathology of traumatic lesions.

5. Medical examiners' demonstration, 4 hours.

Scope: Autopsies on head and nerve injuries from accident cases at large city hospitals.

Officers will attend in small groups.

6. Neurological examination, 10 hours, lectures, amphitheater demonstrations.

Scope: Physiologic significance of pathologic signs; individual drill in standard neurologic

examination; principles of localization.

References: Spurling, R. G.: Practical Neurological D)iagnosis, with special reference to

the Problems of Neurosurgery, Springfield, Charles C Thomas, 1940; Monrad-Krohn, G. H.:

The Clinical Examination of the Nervous System, London, H. K. Lewis, 1938.

7. Principles of clinical neurosurgery, 16 hours, lectures, demonstrations.

Scope: Physiologic principles underlying neurosurgical technique; didactic instruction

in care and treatment of acute head injuries and of injuries to spinal column; prophylaxis of

meningitis; care of bladder, tidal drainage; physiology and pathology of spinal fluid.

References: Neurosurgery (Military Surgical Manuals, National Research Council, vol.

6), Philadelphia, W. B. Saunders Company, 1943; Rowbotham, G. F.: Acute Injuries of the

Head, Baltimore, William Wood and Co., 1942; Ehrlich, W., and Gross, S. W.: l)iagnosis

and Treatment of Head Injuries, New York, Paul B. Hoeber, 1940.

8. Neurologic and neurosurgical clinics, 16 hours, lectures, demonstrations.

Scope: Demonstration of wide variety of medical and surgical cases exhibiting nerve and

brain injuries.

9. Examinations, tests and inspections, 10 hours.

10. Open time, 18 hours.

401
402 NEUROSURGERY

Phase II

Technical Training in Neurosurgery (576 hours),

Selected Army General Hospitals

1. Pathology, 36 hours, conferences, amphitheater exercises.

Scope: Autopsies and examination of tissues, with particular attention to traumatic

lesions of nervous system. Study of gross surgical specimens with an accurate written

description of each. Microscopy of all neurosurgical specimens studied under the direction

of the Chief Pathologist.

References: Rand, C. W., and Courville, C. B.: Histological studies of the brain in cases

of fatal injury to the head, Arch. Neurol. & Psychiat. 27:1342-1379 (June) 1932 (reprints

supplied).

2. Clinical pathologic conferences and staff conferences, 24 hours.

Scope: Review of neurologic and neurosurgical cases. Officers to present and take part

in discussion of neurosurgical material at weekly staff and clinicopathologic conferences.

Special assigned reading, directed by preceptor, covering the important data of each

case presented at conference.

3. Neurologic examination and care of patients, 264 hours, conferences, amphitheater

exercises.

Scope: Students will be stationed upon the neurosurgical wards, where they will act as

clinical clerks and dressers. They will perform complete neurologic examinations of all

assigned cases. Records will be carefully checked and graded by neurosurgical preceptor.

No student will have fulfilled the requirements of the course until he shall have demonstrated

to the preceptor his ability to perform, record and interpret a complete neurologic examination. Postoperative care of patients.

References: Spurling, as listed; Fulton, as listed.

4. Neurologic clinic, 24 hours, conferences, amphitheater exercises.

Scope: Study of neurologic cases. The preceptor will hold once each week a 2-hour

conference or ward walk clinic in which the important phases of diagnostic neurologic

problems are stressed.

5. Neurosurgery, 144 hours, amphitheater exercises.

Scope: Operating room assignments. Each stuaent will be a member of the operating

team in the capacity of an assistant in his proportional number of neurosurgical cases.

Particular stress will be placed upon the technical problem of hemostasis, the use of the

electrosurgical unit, suction, etc. No student will have finished his course until he shall

have demonstrated to the preceptor his technical ability to perform a thorough debridement.

References: Davis, L. E.: The Principles of Neurological Surgery, Philadelphia, Lea &

Febiger, 1942; Bailey, Hamilton: Surgery of Modern Warfare, chapters 42, 43, 47-50,

Baltimore, Williams & Wilkins, 1941; Neurosurgery, in Military Surgical Manuals, as listed.

6. Roentgenology, 36 hours, conferences, amphitheater exercises.

Scope: Study of X-ray films of head and spine injuries. The Chief of Roentgenology

will teach all students a minimum of 3 hours weekly the interpretation of skull and spine

films, particular attention being placed upon the localization of foreign bodies, depressed

fragments of bone and linear fractures into the accessory nasal sinuses.

References: Technical Manual (TM) 8-275, paragraphs 27-34; Technical Manual (TM)

8-240.

7. Physiotherapy, 12 hours, conferences, amphitheater exercises.

Scope: Physiotherapy in peripheral nerve lesions. The Chief of Physical Therapy will

teach all students the care of paralyzed muscles, and splinting for prevention of deformity

in group muscle paralysis.

8. Open time, 36 hours.

Scope: Assigned reading. It is expected that the students will follow the example of

the preceptor in answering all night emergencies and attending such off-hour exercises as

would contribute to their knowledge of neurosurgery.
APPENDIX B

Extracts From Manual of Therapy

European Theater of Operations

SURGICAL EMERGENCIES. SECTION A

PRIMARY SURGICAL TREATMENT

II. WOUNDS OF THE CENTRAL AND PERIPHERAL NERVOUS SYSTEM

a. CRANIOCEREBRAL INJURIES

1. Diagnosis:

a. Signs of critical brain injury.

(1) Profound unconsciousness with failure to respond to deep supraorbital pressure.

(2) Rapid or irregular respirations.

(3) Rapid pulse with a rising blood pressure.

(4) Decerebrate rigidity.

(5) Dilated fixed pupils.

b. Intracranial hemorrhage is a potential factor in every case of head injury. The

common signs of acute localized intracranial hemorrhage are:--

(1) Deterioration in condition of patient.

(2) Convulsive seizures, particularly when localized to one side of body.

(3) Hemiplegia or hemiparesis.

(4) Unilateral dilated fixed pupil, particularly after a lucid interval of consciousness.

(5) Signs of increasing intracranial pressure (slowing of the pulse, elevation of

blood pressure, changes in the respiratory rate and deepening unconsciousness).

c. Small lacerations of the scalp may be associated with penetrating wounds of the

skull and extensive intracranial injury. All scalp wounds should have serious implicationsuntil proved otherwise.

2. Treatment:

a. Early evacuation to field or evacuation hospital where a neurosurgical team is available. The sole objective of emergency treatment should be to improve the condition of the

patient sufficiently to permit transportation.

b. Treatment of cerebral concussion and edema by spinal fluid drainage and intravenous.

hypertonic solution are of questionable value and should only be used in exceptional cases.

c. The wound should be treated as follows:-

(1) Clip hair for several inches about lacerations.

(2) Control bleeding from scalp wounds with pressure dressings. If bleeding cannot be controlled with pressure, use through-and-through mattress suture.

(3) Scalp wounds should not be irrigated, debrided or sutured.

(4) Dust sulfanilamide crystals into the wound, care being taken to distribute

them uniformly. More than 5 gins. is seldom required.

(5) Do not place sulfathiazole or sulfadiazine directly into the wound, particularly

if there is brain tissue exposed.

403
404 N EU ROSU{GAERY

(6) )ncet thlt dressing is placed, do Knot change it uant il the patijent reache-s a hospital

where definitiv e treat ment call be given. The dressing may he reinforced as

necessary.

d. Blood loss front scalp) Wounds is seldoiti severe~ enouigh to requiire early transfusion.

e. Bleeding froml the ear 511001(1 be treated onily with a (riresilig over tile external ear.

D~O not attemlpt to StO;) the b)leeding. IN) not e'XjIlore. cleanse or irrigate the auditory canal.

f. Shock rarely results front tilconllplicatedi cranial injuries. If thet p~atienlt is in shock.

search carefully for associated injuries. p~articularly chest and abdomiunal wounds, or extenisive

injury to the long bones. When shock is present, the usual treat ment of this state takes precedence over all other considerations.

g. An unconscious p)atient should not be placed onl his back or in an upiright posit ion.

Aspiration of secretions from the nose and throat into the bronchial tree is promoted in these

positions andi the platient may literally drown in his own secretions, Hie should be placed onl

his side, the foot of thle litter or lwd elevated so that secretionls roln fronm his mlouthi by

gravity (pokst oral drainage).

It. Medicationl. Morphine suippresses thet state of conlsciousness, and depresses the

respiratory centers, and its uise- should be discouraged in cranioceerebral traumna. Head

WOUllnds accomupanied by painful wounds of other p~arts may require morphine, bult it Iluist

lit used judicionsly.

L. Early recording of the following data is important for thle mlost efficient future treat-

"it-lit of thet patient:-

(1) Time of injury.

(2) State of consciousness when first seen.

(3) Paralysis of one or more extremities.

(4) Pulse rate counted for onle-half minute.

(5) Respiratory rate and rhythmn.

(6) Blood pressure.

3. Evacuation:

a. liead inljury patients without serious associated injuries stan~d tratisjortation well.

The usual dictums of good first aid care should be followed whether evacuation is by air,

ambulance, boat or hospital trainl. High priority evacuiation is always indicated.

1). FRACTURES OF THE SPINE WITH NEUROLOGICAL INVOLVEMENT

Cervical.

1. D~iagnosis:

a. When all injured mall complains of severe pain ill his nleck, suspect a fracture or fracture-dislocation of the cervical sp~ine; if his arms alnd legs are paralyzed the diagnosis is

certainl.

b. Cervical -%pille fractures are ulsually associated with forward dislocationl alnd allterior

anlgulatioll at tilt- level of the lesion. D~etermination of the exact level of the fracture is

unlimportanlt for emergency treatment.

Do not manipulate the head in an attempt to establish the level of the injury.

2. Treatment:

a. The most important principle of treatmenlt is to prevenlt ant increase in the bony

deformity. IDo Ilot mnove the patienlt unitil the conditions are favorable. Make every move

count. IDo Ilot raise thet- head unlder ally circumstances. Do Ilot put a rolled blanket or

pillow benleath thet head.

1). With the patienlt oil his back, p~lace a folded blanket (not more than 3 inchies thick)

benleath the shloulders, thus permittinlg tile head to fall backward alnd downward. Place
APPENDIX B 405

and fix folded blankets or articles of clothing on either side of the head to reduce lateral

movemnent.

c. When patient is picked tip to transfer to a litter or solid support, maintain strong

traction at both the head and feet ini the longitudinal axis of the body.

d. Keep pressure off the sacruim and heels, and where possible transfer patient to soft

mattress to minimize danger of pressure sores.

e. An indwelling catheter should be introduced before distention of the bladder occurs,

especially before evacuation of patient to distant points. Never clamp the catheter.

f. Give morphine cautiously to cervical injuries for fear of respiratory paralysis; in

many cases the diaphragm will have been paralyzed by the damage to the cervical spinal

cord.

3. Eracuation:

a. High priority evacuation to General or Evacuation hospital is indicated.

Lumbar.

1. Diagnosis:

a. If an injured patient complains of severe local pain in the lumbar region, fracture

of the spine in this area should be suspected. Paralysis of the legs below the knees makes

the diagnosis certain.

2. Treatment:

a. Again the fundamental principle in handling fractures or fracture-dislocations of

the lumbar spine is to prevent an increase in the bony deformity, thus avoiding further

injury to the spinal cord.

b. There are two acceptable positions for transportation of patients with lumbar

spinal fractures:-

(1) With the patient on his back, make a roll with folded blankets, about 12 to

18 inches in circumference, and place beneath the mattress near the site of the

injury. This position produces hypertension of the spine.

(2) With the patient face down, some extension of the spine is automatically

produced; in all circumstances further flexing is prevented.

c. When transferring patient from ground to litter, traction should be maintained at

the feet and axilla and he should be slid or rotated to the litter and not lifted.

d. Keep pressure off sacrum and heels and wherever possible transfer to a soft mattress.

e. An indwelling catheter should be introduced but it should not be clamped.

f. Do not attempt to reduce the fracture in the field or in the intermediate dressing

stations.

3. Evacuation:

a. High priority to a Field, Evacuation or General hospital is indicated.

c. INJURY TO PERIPHERAL NERVES

1. Diagnosis:

a. Fifteen percent of extremity wounds are complicated by injury to one or more major

nerve trunks. Simple tests for motor and sensory function will usually indicate accurately

which nerve is involved.

b. At the primary inspection of the wound, observe carefully the exposed nerves and

record their condition on the EMT tag or on the cast. This information greatly facilitates

later treatment.

2. Treatment:

a. Extremity wounds with nerve injuries should receive exactly the same treatment

as soft tissue wounds elsewhere * * * Most patients with nerve injury will have

455735r-58- 27
406 NEUROSURGERY

injuries to one or more of the long bones, so splinting will be a preliminary requirement for

transportation. In those cases with bone injury, the extremity should be immobilized in

the most favorable position, to prevent deformity. This can usually be accomplished

with bandages or rolls of clothing and blankets. Casts or elaborate splints will usually

not be required for satisfactory evacuation. Remember to protect from pressure a part

that has been deprived of sensation.

3. Evacuation:

a. Low priority evacuation is usually indicated.

SURGICAL EMERGENCIES. SECTION B

DEFINITIVE SURGICAL TREATMENT

II. WOUNDS OF THE CENTRAL AND PERIPHERAL NERVOUS SYSTEM

a. CRANIOCEREBRAL INJURIES

The following statements are intended as a guide for medical officers who, by force

of circumstances, are required to treat neurosurgical patients before they arrive at a hospital

where trained neurosurgical teams are available. (See also section on Emergency Treatment * * * .)

1. Care of the Unconscious Patient:

a. Keep the patient in optimal position for postural drainage. Never permit him

to lie on his back or be in an upright position. Place on side with face rotated forward

and, if necessary, elevate the foot of the bed or litter to facilitate drainage of secretions

from mouth by gravity.

b. Maintain fluid intake to 1500 cc. daily and increase proportionately during hot

weather or in case of high fever. Fluids should never be put into the mouth of a stuporous

or semiconscious patient. They should be given per rectum, subcutaneously or intravenously. Never use more than 1000 cc. of physiological saline in 24 hours because of the danger

of salt retention in the tissues of the brain. If unconsciousness persists after 24 hours

feed nourishing liquids by nasal tube.

c. Turn the patient from side to side every 3 hours to prevent bed sores and hypostatic

pneumonia.

d. Avoid morphine and other opium derivatives for restlessness. Paraldehyde, administered by nasal tube, rectum or intravenously is the safest and most satisfactory sedative

for the patient with head trauma.

2. Intracranial Hemorrhage:

a. Extra Dural: The classic signs of extra-dural hemorrhage are:-

(1) A lucid interval of consciousness.

(2) Deepening stupor.

(3) Unilateral dilation and fixation of the pupil on the side of the lesion.

(4) Slowing of the pulse rate.

(5) Rising blood pressure.

(6) Focal convulsions or paralysis.

Extra-dural hemorrhage requires immediate surgical evacuation with ligation of the

main trunk of the middle meningeal artery. A straight incision extending from the midportion of the zygoma upward into the temporal region should be used. The temporal bone

exposed by separating the fibres of the temporal muscle is trephined. The bony opening

may be enlarged as necessary to evacuate the clot and ligate the middle meningeal artery.

The dura should not be opened, except when a sub-dural hemorrhage is suspected. If the
APPENDIX B 407

main artery cannot be found and small bleeding points completely controlled with the facilities available, place a light gauze pack over the dura and compress until all bleeding has

stopped. Dust sulfanilamide crystals throughout the wound and close the incision with

the tip of the packing presenting through the lower angle. Fractional removal of the pack

may be begun after 48 hours.

b. Sub-dural hemorrhage: Acute sub-dural hematomas of size sufficient to cause profound symptoms are frequently arterial in origin. They are usually associated with profound brain injury and prognosis is always grave. They are often clinically indistinguishable

from extra-dural hematomas. The technical details for evacuating the clot are similar to

those described for extra-dural hematomas.

Chronic sub-dural hematomas are of late occurrence and should always be suspected

when recovery from a relatively minor closed head injury is retarded. These are not emergency lesions and can always await evacuation to hospitals where trained neurosurgeons are

available.

c. Intracerebral bleeding, if arterial, is apt to be quickly fatal. If venous, localized

intracerebral hematoma may form and stop spontaneously. The usual location is in the

anterior half of the temporal lobe. These clots produce characteristic neurological symptoms and signs. They are seldom emergencies and will usually await evacuation to the rear.

In general, surgical exploration for intracranial hemorrhage should be carried out early

only as a life-saving measure when the patient is deteriorating rapidly.

d. Scalp wounds: Carefully debride the scalp to conserve as much skin and subcutaneous tissues as possible, otherwise the wound cannot be closed. Sulfanilamide powder

(not over 5 gins.) should be dusted into the wounds and the edges of the skin meticulously

approximated. Do not use drains. If there is extensive loss of tissue and the edges of the

scalp cannot be approximated, a split-thickness skin graft should be placed over the exposed

bone (fig. 1).

PERICRANIUM TO BE

SKIN GRAFTED

FIGURE 1.-Method of closing defect in scalp.

3. Fractures:

a. Simple linear fractures require no treatment.

b. Compound linear fractures into the accessory nasal sinuses or external auditory

canal are important, chiefly because they afford portals of entry for infection. In such cases

sulfadiazine therapy (administered intravenously or by mouth) should be instituted at once.

c. Simple comminuted depressed fractures of bone should be removed and the edges of

the defect smoothed with rongeurs. These defects can be most satisfactorily repaired with

tantalum plate at a subsequent operation. In certain instances the bony fragments will be

large and may be elevated into position, thus restoring the contour of the skull.

d. In compound comminuted fractures the wound should be thoroughly cleansed of

dirt and foreign matter. If the bony fragments have torn the dura and damaged the brain,
408 NEUROSURGERY

all devitalized ti,,tue, including the brain, should be meticulously removed. Openings in

the dura should be closed, if neces,,,ary by free transplants of fascia frotm the temporal intiscle

or fascia lata. Drains should never bei used uinless available facilities do not permit thorough

control of hemorrhage. All tissues, including the brain, shouhld be dusted with sulfanilamide

crystals. Primary closure should be attempted up to 72 hours in wounds treated locally

with sulfanilamide at time of injury. All compound skull fractures should receive adequate

sulfadiazine therapy systematically.

In penetrating wounds of the brain it is important that all fragmented bone be removed.

Smiall metallic fragments, unless producing symptoms, may be left. especially if their r,-

intoval requires traversing relatively normal brain tissue.

b. SPINAL INJURIES WITH NEUROLOGICAL INVOLVEMENT

(Refer to section on Emergency Treatment, * * *

1. Fracture Dislocation of the Cerrical Spine:

a. The best form of treatment is skeletal traction applied by ('rutchfield tongs. If

tongs are not available, skeletal traction may be applied by wires passed through two small

burr holes made on either side of the skull, or by barbhless fish hooks placed beneath the midportions of the zygomatic arches. In the absence of all facilities for skeletal traction, halter

traction is the method of choice. At least 15 pounds of weight should be applied. Open or

closed reduction by manipulation should never be attempted, for fear of further damaging

the spinal cord.

2. Compression Fractures of the Lumbar Spine:

a. Reduction is best accomplished with the patient on his back and a blanket roll, apl)roximately 12 inches in diameter, placed beneath the mattress at the point of fracture.

(fig. 2.)

b. Care of the Bladder. Treat the paralyzed bladder by tidal drainage as soon as practicable (fig. 3). If after 6 weeks there is no evidence of recovery, a cystostomy should be

done. Keep urine acidulated with animnonium chloride or ammonium mandelate. Change

catheter at least once a week.

c. INJURY TO PERIPHERAL NERVES

In view of the irreparable degenerative changes that occur in the end plates of severed

nerves, early surgical repair is essential for best results. Primary suture is theoretically

desirable but experience has shown that in battle wounds where there is contusion of the

nerve, immediate suture is not desirable. However, it is essential that the severed nerve

ends be approximated as nearly as possible to prevent retraction. This greatly facilitates

early end-to-end secondary suture.

When the wound is debrided, exposed nerve ends will often be visualized. Approximate the ends if possible but if the gap does not permit approximation, anchor the nerve

ends snugly to surrounding soft tissues to prevent subsequent retraction. Thin stainless

steel wire cr tantalum wire should be used for nerve repair. These suture materials are ideal

as they serve a useful purpose in identifying by subsequent X-ray examinations the location

of the nerve injury or the extent of the nerve defect. Do not attempt elaborate primary nerve

Suture.

Dust the wound thoroughly with sulfanilamide crystals and close the muscles or fascia

loosely over the exposed nerve trunks. Never place a pack on a minor nerve trunk. Do not

attempt primary closure of the wound. Delayed or secondary sutures are recommended.
APPENDIX B 409

S• BLANKET

FRACTURE BOARDS

SOFT (AIR) MATTRESS HARD (HAIR) MATTRESS

PILLOWS

,' ', • • •SOFT

S•.-,/"'• L'--,' •PILLOW

FRACTURE BOARDS

FIRM PILLOW

BED PAN. IMPLO

FIRM PILLOW FIR PILLO

FRACTURE .BOARDS

FIGURE 2.-Proper position for patient with compression fracture of the lumbar spine.
410 NEUROSURGERY

BLADDER ... .

CLAMP ,

Figure 3.-Simple type of tidal drainage. The essential point in successful operation

is that the rubber tubing alongside the yardstick empty more slowly than the bladder.

This is accomplished by means of a small screw clamp shown in the drawing.

\
APPENDIX C

Special History and Examination Forms

HEAD INJURY-HISTORY

Patient Date of exh'nination

Date of birth Marital state: S M NV D

Home address

Family history History of:

Patient's Fainting Other nervous or

parents Xt present Seizures spells Migraine mental disease

Living Yes Yes Yes

Father

Dead No No No

Living Yes Yes Yes

Mother

Dead No No No

Number with history of:

Patient's Total Fainting Other nervous or

siblings number Seizures spells Migratine mental disease

Male

Living

Female

Male

Dead

Female

Spouse

Patient's

children

Male

Living

Female

Male

Dead

Female

Patient's number in order of birth (excluding foetal Seizures in other relatives

deaths)

Past History

Birth date

Delivery (normal-proionged-instrurnental-injury-circumstances unknown)

Development

Walked at

Talked at

Stuttering

Accidents

Head injuries

Broken bones

Operations

Illnesses

Migraine

411
412 NEUROSURGERY

Past History-Continued

Illness-Continued

Meningitis

Chorea

Other illnesses

Personal habits

Tobacco Number Per Day

Cigars

Cigarettes

Chewing tobacco

Alcohol Amount Per Week

Beer

Hard liquor

Frequency of intoxication

Sleep

Personal hygiene (care of teeth, body and clothing, bowel movements)

Nature of Head Injury: Open

Closed

Type of missile

Place (street, field, etc.)

Location (frontal, occipital, parietal, etc.)

Period of unconsciousness

Period of confusion and disorientation

Other wounds

Bleeding

Time debrided after injury

Extent of debridement (scalp-skull-dural laceration-brain laceration-ventricle opened)

Local drug therapy

General chemotherapy

Time of healing

Secondary procedures (debridement-abscess-cranioplasty-scalp plastic)

Immediate neurological sequelae (weakness of arm or leg-aphasia-motor and sensory

disturbance)

Convulsive Seizures (list all attacks)

Dates (Day or month Night Under medication? Type Remarks (alcohol, exciteand/or day) ment, other factor)

Status epilepticus (duration and date)

Typical Attack

Prodromal symptoms

Aura

Olfactory

Gustatory

Auditory

Visual

Sensory

Gastric paresthesia

Motor

Vertiginous

Dreamy state

Automatism

States of confusion or furor

Petit mal

Automatic seizures (pallor-flushing)

Cry
APPENDIX C 413

Typical Attack-Continued

Attack

-tonic (cry-loss of consciousness)

-clonic

Clonic

Beginning with

1) turning of head and eyes

2) movements of face

3) movement of arm

4) movement of leg

Generalized

Unilateral

Biting of tongue

Frothing at mouth

Wounds (location)

Urinary incontinence

Cyanosis (duration)

Duration

Post-epileptic states

Period of confusion

Sleep

Excitement

Headache

Weakness of arm or leg

Aphasia

Vomiting

Minor Attacks

Pallor

Staring

Loss of consciousness

Blackouts

Epileptic Equivalents

Dreamy state

Sleepwalking

Emotional fits

Allergies Personal Familial

Hay fever

Asthma

Migraine

Urticaria

Food

Childhood Manifestations of Convulsions

Enuresis

Fugues

Nocturnal crying

Temper tantrums

Fainting spells

Petit mal attacks

Seizures

Present Complaints (spontaneous):

Question regarding:

Attacks (frequency, severity, and duration)

Headache (local, generalized, associated with emotional upset, type, frequency

and duration)

455735-58----28
414 NEUROSURGERY

Present Complaints (spontaneous)-Continued

Question regarding-Continued

Dizziness (type, frequency, aggravated)

Irritability (constant, aggravated)

Impaired mentation (give examples)

Lack of concentration

Easy fatigability

Insomnia (initial, nightmares)

Effect of alcohol

Other changes

Previous Medication Amount Duration Effect

Bromides

Phenobarbital

Dilantin

Tridione

Other drugs

HEAD INJURY-EXAMINATION

Height Weight

Psychiatric Evaluation

General behavior (appearance, activities, attitude, cooperation)

Emotional reaction and mood tendencies:

Manner (distant. expansive, hopeless, indifferent)

Mood (depressed, moody, unstable, seclusive, suspicious, anxiety, fear)

Judgment (discrimination)

Insight

Orientation

Memory address, 4962, 53817, 738294, 82961475

Mental ability and intelligence:

100-7; 93, 86, 79, 72, 65, 58, 51. 44, 37, 30. 23, 16, 9. 2.

Name months backward

Began school at

Age and grade at finishing school

Occupational training

Social adjustment (arrests, AWOLS, occupational, sexual, sociability)

Neurological Examination

Cranial Nerves Right Left

I Perceives odors (use cigarette)

Identifies odors

II Vision

Fundi

Fields

III IV and VI

Extraocular movements

Convergence

IV Nystagmus

Ptosis

Endophthalmos or exophthalmos

Pupils

Size

Shape

React to light

React to convergence

Consensual
APPENDIX C 415

Neurological Examination-Continued

Cranial Nerves-Continued

V Sensation Right Left

Cotton

Pin prick

Corneal reflex

Motor

Masseters

Lateral motion of jaw

Deviation of jaw

VII Facial weakness

Forehead

Eyes

Mouth

VIII Acuity

Weber

Rinnd

IX and X

Sensation of palate and pharynx

Movement of palate

Pharyngeal reflex

Phonation

Swallowing

XI Sternocleidomastoids

Trapezius

XII Movements of tongue

Tremor

Atrophy

Fibrillations

Motor

Involuntary movements

Atrophy

Fibrillations

Tonus

Upper extremities

Lower extremities

Strength and motility

Upper extremities

Lower extremities

Co-ordination

Finger to nose

Heel to knee

Each finger to thumb

Rapidly alternating movements

Reflexes Right Left

Biceps Abdominal

Triceps Upper

Radial Lower

Knee Hoffmann

Ankle Rossolimo

Plantar Oppenheim
416 NEUROSURGERY

Sensation Right Left

Pin prick

Cotton

Warm

Cold

Deep pain

Vibration

Localization

Position sense

Fingers

Toes

Two point discrimination

Figure writing

Palms

LAgs

Stereognosis

Nerve status

Tenderness

Excitability

Size

Station and gait

Romberg

Gait

Associated movements

Hopping

Walking tandem

Head, spine and neck

Scalp (position, size and condition scalp wounds, depressed areas, etc.)

Stiff neck

Kernig

Lasdgue

Patrick

Macewen

Naffziger

Additional observations
APPENDIX C 417

EXAMINATION FOR APHASIA AND RELATED DISTURBANCES

Name Grade ASN Ward

Age Date_

1. Sidedness: Hand (Catches ball) (Kicks ball)

Eye (Cone)

2. Spontaneous speech: "How did you get here?" (Stenographic record of one minute)

3. Automatic speech: Greetings

Cursing

4. Repetition: "I am at Cushing General Hospital."

"This is a wonderful day." "Man" "Dog" "Chair" "Table"

A EO. U P____

B T D M N

7 11 5 24 341 -

5. Singing: (My Country) Humming!

Whistling:

6. Serial speech: a-alone; b-with help

1-21

Week days

Months

Seasons

Alphabet

Lord's prayer

Poem: (Mary Had a Little Lamb)

7. Naming: Seeing: Feeling: Handling:

Key

Pencil

Button

Comb

Hammer

Safety pin

Scissors

Eraser

8. Selecting objects: Tactile Auditory Visual

Key

Pencil

Button

Comb

Hammer

Safety pin

Scissors

Eraser

9. Commands Visual Auditory

1. Point to your teeth

2. Point to your chin.

3. Point to your eyebrows.

4. Point to your eyelashes.

5. Point to your eyelids.

6. Smile.

7. Get up, close the door, turn on the light, and then

come back and sit down.

8. Point with right hand to left eye.

9. Point with left hand to left ear.

10. Point with right hand to right elbow.
418 NEUROSURGERY

10. Reading out loud:

Story: (Page 58, Mental Examiner's Handbook,' par A)

Words: (Page 50, Mental Examiner's Handbook 1)

Letters: A F - Z Q L

a f sz q I

Numbers: 7 11 5 24 341

11. Writing: a. Spontaneous: "How were you injured?"

b. Dictation: "I am at Cushing Hospital."

"This is a wonderful day."

"Man" " Dog" "Chair" .. "Table"

A E 1 - 0 U_ P_

B T d in - nn

7 - 11 - 5 - 24 - 341

c. Copying: "Don't count your chickens before they are hatched."

I1A. Drawing of a man

12. Calculation: (Oral) 2 + 2 = 7 + 8 = 12- 5= 10- 2 =

3 X 4 = 6 - 9 = 8 2 24+ 4 =

(Written) 14 + 13 = 18 + 76 382 - 241

234- 169 = 72 X 8= 21 X 14-

148-.- 4 = 357 -1- 17=

13. Spelling: (From dictation) (From sight of object)

Key

Pencil

Button

Comb

Hammer

Safety pin

Scissors

14. Rhythm: Right Left

15. Stereognosis: (See Number 8)

16. Apraxia: (See attached form)

17. Agnosia: (Single objects) (See Number 7) (Pictorial representation)

18. Optic Constructional Agnosia: (Apraxia)

Right Left

19. Spatial orientation: "How do you get to the lab from this ward?"

20. Right-Left Differentiation: (See Number 9)

21. Finger agnosia: Name fingers:

Index finger

Ring finger

Thumb

Little finger

Middle finger

Show me the index finger of your hand. My hand.

Ring finger

Thumb

Little finger

Middle finger

Summary and evaluation of language function:

I Wells, F. L., and Ruesch, J., Mental Examiners Handbook. New York, N. Y., The Psychologlesl Corporatkn, 1st

EdFltUM
APPENDIX C 419

SUGGESTIONS FOR SOCIAL HISTORY IN CASES WITH SEIZURES

About the patient:

1. Birth (normal, prolonged, instrumental, injury, circumstances unknown)

2. Early development

Walked atTalked at3. Schooling

Began school atFinished grade at years

4. Occupational training

Number of jobs in years

Longest job

5. Social adjustment: arrests, number of friends: male, female

6. As a child or later:

Bedwetting (frequency, up to what age)

Temper tantrums

Fainting spells

Blackouts or dreamy states (did something which he did not remember)

Fits (describe them: onset in face? Does one arm or leg move first? Are

they unilateral or generalized? Convulsive? Duration? Unconscious?

Incontinent? Tongue-biting? Face pale or flushed? Injuries during

attacks?)

After attacks: Confused? Excited? Sleepy?

Weakness of arm or leg?

7. Head injuries, diseases?

8. Drinking

9. Personality: depressed, overactive, moody, unstable, seclusive, egocentric, suspicious,

irritable, rigid, worrisome, carefree, overreligious

About the family:

Immediate-mother's and father's family and their children

1. Fits, attacks.

2. Is any member of the family institutionalized?

3. Alcholism.

4. Drug addiction.
420 NEUROSURGERY

OCCUPATIONAL COUNSELING

Head Injury Patients With Post-Traumatic Epilepsy

Section I Patient Identity

1. Name of patient 2. ASN

3. Rank 4. Branch of service

5. Location of home or residence (City and state)

6. Age 7. Marital status

(Single, married, divorced, separated, widowed)

8. Children (specify number, age, and sex)

9. Does family visit patient? (Yes or no) 10. Frequency

Section 11 Physical and Mental Status

A. Physical status

1. Motor impairment

a. Not incapacitated by loss of motor power or by incoordination

b. Paralysis of: Right Left Mild Severe

(1) One leg

(2) One arm

(3) Arm and leg

(4) Two legs and one arm

(5) Other

c. Ambulation Well Poorly

(1) Walks:

(a) Without support

(b) With cane

(c) With crutches

(2) Stands indefinitely

(3) Sits indefinitely

(4) Wheelchair patient

(5) Bed patient

d. Handedness

(1) Right-left handed

(2) Paralyzed hand is right-left

(3) Uses paralyzed hand (well, poorly, not at all)

(4) Uses non-paralyzed hand (well, poorly, for writing only, not at all)

2. Impairment of speech Mild Severe

a. None

b. Impairment of

(1) Speaking

(2) Understanding

(3) Finding words

(4) Writing

(5) Reading

(6) Arithmetic

3. Loss of senses

a. None

b. Blindness

(1) In one eye

(2) In both eyes

(3) To one side (right-left)

c. Deafness

(1) One side (right-left)

(2) Bilateral
APPENDIX C 421

A. Physical status-Continued

3. Loss of seeses-Continued

d. Loss of sensation (location)

e. Astereognosis (right-left)

4. Attacks

a. None

b. Petit mal

c. Convulsive attacks

(1) Frequency

(2) Aura (does patient have forewarning)

(3) Loss of consciousness

(4) Duration

(5) After effect (type, time)

(6) Controlled by medication

d. Psychomotor attack

e. Headaches, dizziness

5. Operations

a. Cranioplasty

b. Craniotomy

c. Plastic

6. Associated injuries

a. (describe)

b. Operations Done Indicated

(1) Nerve suture or neurolysis

(2) Orthopedic

(3) Plastic

B. Mental status

1. Previous records show:

a. No neuropsychiatric disorder

b. Psychoneurosis

c. Psychosis

d. Other

2. Present psychiatric condition

a. Good adjustment

b. Psychoneurosis

c. Post-traumatic behavior disorder

d. Mental deterioration

e. Mental deficiency

3. Present emotional status

a. Normal affect

b. Indifferent

c. Euphoric

d. Depressed

e. Resentment toward Army, society

4. Attitude toward present disability

a. Insight, with constructive plans

b. Partial insight-no plans

c. No insight into condition

C. Work tolerance

1. Normal

2. Easily fatigued

3. Concentration (good-poor)
422 NEUROSURGERY

Section III Probable Disposition

A. Eventual Disposition

1. Discharge

a. To his own care

b. To his family

c. To VAF

2. Ability of family to care for patient on a domiciliary basis

a. Can care for the patient satisfactorily

b. Cannot care for patient. Reason:

c. Ability indeterminable

3. Probable date of final disposition

Section I V Education

Education Highest Graduation, degree or Major Age at

grade diploma course completion

Elementary

Secondary

College

University

Other training or schooling (other than occupational)

Course Date Duration

Interests in further schooling:

Section V Occupational Background and Interests

1. Trade school, art school, apprenticeship

2. Major civilian occupations

3. Number of jobs in years

4. Longest job

5. Usual reason for leaving

6. Army training

7. Army assignments

8. Does he want further training in a suitable occupation?

9. What kind of work is the patient interested in doing?

Section VI Aptitudes

1. Army General Classification Test

2. Mechanical Aptitude Test

3. General Educational Development Test

4. Radio Operators Aptitude Test

5. Other aptitude or ability tests

a. Wechsler-Bellevue

b. Rorschach

c. Bender

d. Kuder

6. Types of work patient is now doing in Occupational Therapy

a. Diversional

b. Functional

7. Attitude toward present work

8. Hobbies and other avocational interests
APPENDIX C 423

Section VII Summary

1. By attending medical officer and clinical psychologist:

a. Evaluation of current physical and mental condition

b. Prognosis and probable disposition

2. By vocational counselor:

a. Appraisal of aptitudes, abilities and interests

b. Evaluation of vocational potentialities

c. Specific types of training recommended as suitable
APPENDIX D

Battle Wounds and Battle Injuries of the Head and Brain

The statistical data presented in tables 1, 2, 3, and 4 were prepared by the Medical

Statistics Division, Office of the Surgeon General.

The term "admission," as used in these tables, refers to cases in which a battle wound or

a battle injury of the specified site was reported as the primary cause of admission to hospital

or quarters. With respect to multiple wounds recorded on admission, only one, the more

serious, would have been recorded as the admission diagnosis. Data pertaining to patients

who incurred head or spinal injuries but were admitted to treatment primarily for wounds or

injuries of other sites are not available. With respect to KIA (killed in action) data, the

anatomical region indicated is that associated with the primary cause of death. The variables, causative agent, nature of traumatism, and anatomical location pertain to the primary

diagnosis tor admissions and CRO (carded for record only) cases and to the principal cause of

death for the KIA.

TABLE 1.-Battle wounds and battle injuries of the head (including brain and ear) in the

United States Army, by causative agent, combined years, 1942, 1943, and 1945

[Preliminary data based on tabulations of individual medical records]

Nonfatal Deathr Case

Causative agent KIA I CRO Admis- among fatality

cases sions 3 those ratio

admitted 4

Number Number Number Number Percent

Bomb and bomb fragments -------------- 130 171 657 35 5. 3

Shell, shell fragment, and flak ----------- 5, 779 2, 011 12, 500 886 7. 1

Bullet, machinegun, rifle, etc ------------ 3, 945 465 2, 714 465 17. 1

Land mine, boobytrap ------------------ 226 232 1,406 83 5.9

Grenade and grenade fragments ---------- 56 88 490 23 4. 7

Explosion of ammunition, weapon, etc .... 99 87 1,076 11 1.0

Incendiaries --------------------------- 2 22 41

Firearms, mechanism or effects of discharge of ----------------------------- 10 24 272 13 418

Aircraft, excluding aircraft weapons ------ 459 12 334 36 10. 8

Parachute jump ------------------------ 28 4 50 2 4.0

Boat sinking and accident ------------------- 3 50 1 2.0

Tank, tractor, caisson ------------------- 21 4 66 2 3.0

Motor vehicle, passenger and cargo ...... 13 2 102 5 4. 9

Vehicle, other and unspecified -------------- 1 3 20 3 15. 0

Cutting or piercing instruments ---------- 32 5 26

Fire, hot liquid, or objects -------------- --------- 3 5 ----------------

Fall or jump, twisting, turning, lifting,

slipping, etc ------------------------- 2 3 112 1 .9

Other and unspecified ------------------- 967 141 532 119 22.4

Total -------------------------- 11,773 3, 277 20, 453 1,685 8. 2

I KIA for whom a wound or injury of the head was reported as the primary cause of death.

2 CRO cases with a wound or injury of the head as the primary diagnosis.

' Due to wounds or injuries of the head.

4 Consists of all cases which ended in death, not necessarily due to wound or injury of the head nor necessarily occurring during the years indicated. 425
426 NEUROSURGERY

TABLE 2.-Battle wounds and battle injuries of the head (excluding brain and ear) in the United

States Army, by causative agent, combined years, 1942, 194J. and 194.5

[Preliminary data based on tabulations of indiNdual nedical recordsl

Nonfatal Deat hs Case

Causative agent KIAI CRO Admis- among fatalhty

cases 2 sions 3 those rat o

admitted

Ni mber Nu mber Nu n•er Nu mber Perceni

Bomb and bomb fragments --------------- 124 121 240 35 14.6

Shell, shell fragment, and flak ------------ 5, 754 1,291 4, 667 882 18. 9

Bullet, machinegun, rifle, etc ------------- 3, 929 343 1,689 462 27 -4

Land mine, boobytrap ------------------- 217 96 305 80 26. 2

Grenade and grenade fragments ---------- 54 49) 188 22 11.7

Fxplosion of ammunition, weapons, etc - 79 35 68 5 7. 4

Incendiaries ---------------------------- 2 14 21

Firearms, mechanism or effects of dis- 10 7 59) 12 20. 3

charge of.

Aircraft, excluding aircraft weapons ------ 451 10 213 33 15. 5

Parachute jump ------------------------- 28 3 18 2 11. 1

Boat sinking and accident ---------------- 2 22 1 4.5

Tank, tractor, caisson -------------------- 21 3 34 2 5. 9

Motor vehicle, passenger and cargo 1.... !3 2 4) 2 4. 1

Vehicle, other and unspecified ------------- -- 2 I 1 3 27. 3

Cutting or piercing instruments ----------- 31 4 17

Fire, hot liquid or objects ------------------------ 2 4

Fall or jump, twisting, turning, lifting, 2 2 51 1 2. 0

slipping, etc.

Other and unspecified -------------------- 949 94 225 117 52. 0

Total -------------------------- 11,667 2,078 7,881 1,659 21. 1

SKIA for whom a wound or injury of the head was reported as the primary cause of death The number of KIA cases

is markedly affected by the lack of detail In describing the anatomical location In most of the KIA cases shown in this

table, the anatomical location of the wound or injury causing death has been recorded as "head, generally." 2 CRO casem with a wound or Injury of the head as the primary diagnosis.

3 Due to wounds or injuries of the head.

4 Consists of all cases which ended In death, not necessarily due to wound or injury of the head nor necessarily occurring during the years indicated.
APPENDIX D 427

TABLE 3.-Battle wounds and battle injuries of the brain in the United States Army, by causative

agent, combined years, 194;2, 1943, and 194.5

(Preliminary data based on tabulations of individual medical records]

Nonfatal Deaths Case

Causative agent KIA' CRO Admis- among fatality

cases - slons 3 those ratio

admitted

Nui mber Number Number Numtber Percent

Bomb and bomb fragments -------------- 6 6 248

Shell, shell fragment and flak ------------- 20 100 5,345 2 0.0

Bullet, machinegun, rifle, etc ------------- 8 2 721 2 .3

Land mine, boobytrap ------------------- 9 29 447 3 .7

Grenade and grenade fragments ---------- 2 3 150

Explosion of ammunition, weapon, etc -.-- 20 19 747 5 .7

Incendiaries ---------------------------.----------------- -1

Firearms, mechanism or effects of dis- -- __- 3 66 1 1.5

charge of.

Aircraft, excluding aircraft weapons ------ 8 97 3 3. 1

Parachute jump --------------------------------.-------- 32

Boat. sinking and accident ------------------ 1 17

Tank, tractor, caisson ---------------------------.-------- 23

Motor vehicle, passenger and cargo ------- --------.-------- 46 3 6. 5

Vehicle, other and unspecified ------------------------------ 9--

Cutting or piercing instruments ------------- -1 5

Fire, hot liquid or objects ....

Fall or jump, twisting, turning, lifting, - ------- 1 54-

slipping, etc.

Other and unspecified ------------------- 17 11 242 2 .8

Total ---------------------------- 92 174 8,250 21 .3

I KIA for whom a wound or injury of the brain was reported as the primary cause of death. The number of KIA

casts is markedly affected by the lack of detail in describing the anatomical location. This accounts for the relatively

small number of KIA cases shown.

2 CRO cases with a wound or injury of the brain as the primary diagnosis.

SDue to the wounds or Injuries of the brain.

4 Consists of all cases which ended in death, not necessarily due to a wound or injury of the brain nor necessarily occurring (luring the years indicated.

NOTE.- The low case fatality ratios are probably due to the relatively minor nature of many of the cases which reached

medical treatment facilities: many serious cases are killed instantly or die before arriving at a treatment facility.
428 NEUROSURGERY

TABLU: 4.-Admissions for battle wounds and battle injuries of the head, by location of traumatism,

United States Army, 1942-43

[Preliminary data based on tabulations of individual medical records]

Nonfatal Deaths among

Anatomical location CRO cases Admissions those

admitted'

Number Number Number

Brain and coverings --------------------------------- 29 1,295 21

Cranial nerve and pituitary gland ------------------------------ 2 ----------

Ear- ---------------------------------------------- 61 295 1

Skull ------------------------------------------------------- 387 94

Scalp, occipital, parietal, or temporal regions ----------- 225 947 10

Head, generally ------------------------------------ 37 228 133

Total --------------------------------------- 352 3, 154 259

1 Not necessarily due to the wound or injury causing admission nor necessarily occurring during 1942-43.
INDEX

A 14 KOTT, W. 1)., 234, 237 Air blast concussion, 223-224, 237-240

Abdomen, wounds of, 40, 83, 128, 138, 182 Air blast shock wave, 220-222

from blast concussion, 227, 243, 251 Air-containing viscera, damage to, in blast

Abscess. See Brain abscess, other types, concussion, 227, 253-254

Abscess formation, in transventricular Air evacuation, 63-64, 65, 111, 121, 180, 212

wounds, 184-189, 191, 192, 198 Air mattresses, 79

Acceleration-deceleration in blast concussion. Airway, maintenance of215, 237 during head surgery, 139, 396

Acceleration-deceleration theory of blast in craniocerebral injuries, 128, 130, 159,

concussion, 250, 252-253 176-177

Accessory nasal sinuses, 113 in epileptic seizures, 179, 292, 299

Acetic acid, 118 in wounds of dural sinuses, 159

Acetylcholine, 297 AITA, J. A., 224, 240, 244, 246, 247, 256

Acoustic trauma, 332 Alcohol, in posttraumatic epilepsy, 291,

Acrylic cranioplasty, 93, 96, 261-262, 268- 295-296

269, 278, 316 Alexia, 319

Acrylic resins, 28, 91 ALLEN, Col. K. D. A., 103

Activated electroencephalography, 294-295 Allied Forces, liaison with, 48

Adjunct therapy. See Blood replacement, Alpha activity in encephalography, 247-248,

Fluid balance, Antimicrobial therapy, etc. 249, 252, 257, 297

ADLER, A., 259 Alpha waves in posttraumatic epilepsy, 297

Administration of- Alveoli, rupture of, in blast concussion, 228

auxiliary surgical groups, 55-56 Ameboid changes, in craniocerebral injuries,

neurosurgical centers, 16-17, 21 257, 373

neurosurgical services, ETOUSA, 69 American Board of Neurological Surgery,

posttraumatic epilepsy center, 279 5, 7, 15, 19, 24-25

speech reeducation program, 321-323 American League Against Epilepsy, 317

Administrative difficulties, in reassignment American Red Cross, 22, 279, 281, 317,

of personnel, 57, 59-60 321,323

Administrative considerations, in head in- American Speech Correction Association, 329

juries, 3-4, 91-92 Amitosis, in craniocerebral injuries, 357, 373

Administrative policies, in World War I, Amnesia3-4 after craniocerebral injuries, 10

Administrative separation of neurologic and in blast concussion, 215, 226, 238, 242, 256

neurosurgical sections, 17 See also specific types.

Aerial bombs, 228 Amnesic dysphagia, 326

Aerocele, 117-118

Affiliated hospitals, 25 Anesthesia, in- 2

Afterdischarge induced by cortical stimula- blast concussion, 238

tion, 308-309 craniocerebral injuries, 137-139, 266, 396

Age, influence of, in wound healing, 283 craniofacial wounds, 173

Age incidence, in posttraumatic epilepsy, 282 peripheral nerve surgery, 35

Agnosia, 242 surgery for posttraumatic epilepsy, 302,

Air: 303

entry of, in discontinuous skull fractures, wounds of dural sinuses, 159

339, 397 Anesthetists:

in cerebrum, 103 importance of, in head injuries, 396

in subarachnoid space, 103 on neurosurgical teams, 55, 59, 126

in subdural space, 103 Anglo-American Medical Mission to Soviet

in ventricular system, 103 Union, 48

429
430 NEUROSURGERY

Anoxia- Areflexia, 130-131

during head surgery, 139 Armed Forces Institute of Pathology, 335

in head injuries, 374, 395 Armistice, in World War I, 3, 89

Antibiotic therapy, in head injuries, 172, Armored units, 110

191-192, 283-284 Army Air Forces, 50, 56, 60, 109

Anticonvulsive drugs, 97, 289-290, 292, 293, Army areas, collection of statistical data in,

316 81, 82-86

Antimicrobial therapy, in- Army consultants, inbrain abscess, 209, 212, 213 ETOUSA, 47

cerebrospinal fluid fistula, 175 MTOUSA, 41

craniocerebral injuries, 119-120, 125, 202, surgery, 81

203-204 Army Dental Corps, 95

craniofacial wounds, 175 Army Institute of Pathology, 335

fungus cerebri, 119 Army Medical Museum, 230

meningitis, 117, 206-207 Army Neurological Laboratory, 90

transventricular wounds, 199 Army of Occupation, ETOUSA, 68, 69

See also Antimicrobial therapy, specific Army Pictorial Service, 81-82

agents, etc. Army program for correction of epeech

Anuria, 84, 85 defects, 320-321

Anxiety neuroses, in shellshock, 217 Army regulations for duration of hospitaliAnxiety syndrome: zation, 24

a's indication for cranioplasty, 269 Army surgeons, ETOUSA, 45, 46, 81

differentiation of blast concussion from, Army surgical consultants, ETOUSA, 55

259-260 Arno River, 336

in aphasia, 322, 323, 331 Arteriograms, 13

in blast concussion, 215, 234, 238, 239, 241 Articulatory disorders, 320, 322, 326, 327,

Anzio, 40, 42 328, 333

Apathy, in blast concussion, 240, 241 Artificial larynx, 329)

Aphasia, 22, 37, 91, 96, 97, 130, 158, 159, ASCROFr, P. B., 145, 157, 181, 228, 229, 270

163, 197, 319-334 Asphyxial convulsions, 252

after cranioplasty, 96 Aspirationafter epileptic seizures, 292 in brain abscess, 211, 212

after surgery for posttraumatic epilepsy, in craniocerebral injuries, 146

312 in craniofacial injuries, 173

assignment of patients with, to hospitals, in transventricular wounds, 183

15, 321-322, 327 of subgaleal fluid, 179

classification of, 326-332 of trachea, in head surgery, 139, 177

disposition in, 332-333 Assignment of neurosurgeons, 5, 53, 101, 109

elect roencephalography in, 323 in ETOUSA, 46-47, 48-60, 66-68

in blast concussion, 242, 257 in MTOUSA, 42-43

in posttraumatic epilepsy, 280, 286, 293, to forward hospitals, 101, 123

316, 319 to neurosurgical centers, 5-6

in World War 1, 90 Associated injuries. See Injuries of specific

management of, 321, 326-332 structures.

psychotherapy in, 321 Associated wounds, in head injuries, 101,

studies on cortex in, 324 108, 125, 138, 181-182, 199, 203, 336

See also specific types. Association pathways, 324

Aphonia, 319, 322, 328, 329, 330, 331 Astereognosis, 332

Apnea, 139 Astrocytes, 125, 351, 357, 373

Apraxia, in blast concussion, 257 Ataxia, 289

Aqueduct of Silvius, 339 Atelecta.is, 86

Arachnoid, 103 ATKINS, H. J. B., 227

in posttramnatic epilepsy, 304, 305, 315 Audiometry, 323

Arachnoiditis, 207 Auditory auras, 289
INDEX 431

Auditory components of complex auras, 288 Basingstoke, 72

Auditory hallucinations, after somatosensory Battalion aid station, management of head

auras, 288 injuries in, 127

Aural rehabilitation centers, 322, 332 Battlefield deaths, from head injuries, 182,

Auras, 286-289, 309 336, 339, 384

induced by Metrazol in posttraumatic Belgium, 58

epilepsy, 298-299 BELING, C. C., 344

Australia, 13 BELL, R. C., 229, 243

Autogenous bone cranioplasty, 90, 94, 261, Bender Visual Motor 6estalt.test, 281, 324,

278 331

Autonomic functions, 279, 281 Benghazi, 228

Autopsy attendance, in professional training Benign cerebral fungi, 107, 181

program, 29 BENNETT, A. E., 340

Autopsy findings, in- Binet vocabulary test, 281

blast concussion, 218, 219, 227, 228, 231, BiSKIN, G., 230

234, 236, 258 Bizerte, 42

craniocerebral wounds, 101, 116, 181 Bladder, care of, after craniocerebral surgery

mortal head injuries, 335-397 in paraplegia, 27

Auxiliary surgical groups, 25, 50, 55-56, 58, Blast concussion, 215-260

59-60, 67, 68, 70, 74, 75, 125 abdominal injuries in, 227

equipment of, 74, 75 acceleration-deceleration in, 215, 237

teams from, 74, 75, 77-78 acceleration-deceleration theory of, 252-

training of, 55 253

workload of, 84-86 amnesia in, 215, 226, 238, 242, 256

Auxiliary Surgical Groups: anesthesia in, 238

1st-56, 84 anxiety syndrome in, 215, 234, 238, 239,

2d-39 241

3d-39, 48, 55-56, 83-84 apathy in, 240, 241

Avertin (tribromoethanal), 138 autopsy findings in, 218, 219, 227, 228-231,

Avulsion wounds of scalp, 155 234, 236, 258

Axons, changes in, in mortal head injuries, causes of death in, 217, 219, 227-228, 230,

347-348 252, 259

cerebral contusion from, 242-243

Babinski sign, 131 changes in nuclear groups in, 216

Back disabilities, 17, 28, 31 clinical picture of, 237-244

Bacteriologic studies of spinal fluid, 280 coma in, 234

Bacteriology of- combat exhaustion in, 227, 260

brain abscess, 116, 209, 210, 212 compression theory of, 253-255

craniocerebral injuries, 117, 202, 203 damage to blood vessels in, 216

fungus cerebri, 118 damage to central nervous system in, 227-

meningitis, 84, 117, 118, 206, 207 228, 230-231,252-253, 260

BAGGENSTOSS, A. H., 340, 347, 362, 369 definition of, 215-222

BAILEY, 0. T., 150 delayed cerebral hemorrhage in, 234-236,

BAILEY, P., 241, 306 256

BAKER, G. S., 264, 266 diagnosis of, 218-219, 223-224, 225-227,

Ball hemorrhages, 342 234, 237, 259-260

Barbiturates, in- edema of brain in, 254

craniocerebral injuries, 129, 177 electroencephalography in, 216, 223, 224,

meningitis, 208 242, 243, 244-250, 256-258, 260

postoperative convulsions, 180 etiology of, 215, 224, 225-227, 250-259

Bar-le-Duc, 53 experimental studies in, 219, 227, 230. 250-

BARRow, D. W., 221, 240 252, 257, 259

Basal cisternae, 116 functional neurogenic approach to, 255-

Basal ganglia, 101, 102, 129, 181, 257 256
432 NEUROS URGERY

Blast concussioii-Contiinued Blast oioneussion--('outinued

headache in, 215, 226, 234, 237, 238, 242, unconsciousness in, 215. 216, 223. 233,

258, 260 237-238, 240, 242, 244, 248, 255, 257-

hemorrhage in, 226, 228, 230, 234-236, 258

237, 241, 254, 258 vegetative disturbances in. 256

high-explosive missiles in, 217, 219, 223, vertigo in, 215, 226, 238, 239, 258, 260

225, 226, 237, 241 Blast injuries, 91. 97

history taking in, 223 Blindness in visual auras, 288

hyperacusis in, 215. 238. 239, 242, 256, 260 Blood chemical changes, in posttraumatic

hysteria in, 223-224 epilepsy, 294

in civilians, 225. 226-227 Blood in spinal fluid, in blast concussion.

in closed head injuries. 224 216, 242

incidence of, 222-225 Blood pressure, in head injuries, 102, 110

insomnia in. 234, 257 Blood replacement, inmanagement of, 255, 259- 260 brain abscess, 213

mechanism of, 252-255 craniocerebral injuries. 123, 127, 128, 203,

microscopic studies in, 218, 227-228. 229, 396

229-230, 231, 236, 250-251, 252 craniocerebral surgery, 177-178

nerve cell changes in, 216 craniotacial injuries, 172

neurologic examination in, 218. 223, 242 meningitis, 208

neurologic sequelae of, 216. 237, 238, 239- posttraumatic epilepsy, 315

240 transventricular wounds, 166

neurosurgieal evaluation in, 239-242, 260 wounds of dural sinuses, 159. 162

nomenclature of, 215-219 Blood stream, passage of compression waves

organic neurologic theory of, 256-259 through, 253-255

paralysis in, 238 Blood studies, in aphasia, 323

pathogenesis of, 215 Blood supply:

pathologic process in, 215, 217, 227--236., of brain, 305

241, 243, 250-251 of scalp, 95

physiopathologic theory of, 256-257 protection of, at operation, 312-313

pneumoencephalography in, 239, 240, 260 Blood vessels:

post mortem findings in, 218, 219, 227, 228. damage to, in blaost concussion, 216

231, 234, 236, 258 rupture of, in craniocerebral injuries, 340,

psychiatric approach to, 218, 237, 258-259 342. 359

psychiatric studies in, 256-257, 258, 260 Bone flaps, 77, 261, 303, 313. 394-395

psychometric studies in, 223, 256, 258, 260 Bone fragments:

psychoneurosis antecedent to, 259 as cause of brain abscess, 208, 211

psychopathologic theory of, 256-257 as foreign bodies, in head injuries, 91, 92,

pulmonary injuries in, 227, 228, 254 93, 110, 112, 114, 126, 131, 134, 140.

pupillary changes in, 237, 239 145, 146-147, 201, 321, 338, 397

reflexes in, 237, 239 in cerebral fungi, 107

relation of psychosomatic trauma to, 226 in scalp wounds, 140

research studies in, 222-225, 237-240 in transventricular wounds, 103, 167, 168

roentgenologic examination in, 237 189, 190

rupture of tympanum in, 226 in wounds of dural sinuses, 159, 161

shock in, 227 influence of, in posttraumatic epilepsy, 98,

sound waves in, 219 292

statistical errors in, 218-219 See also Foreign bodies.

subdural hematoma in, 233-234 Bone-nerve injuries, 18, 20

timelag in, 223, 224 Bone wax, 126, 143, 203

Boothby-Lovelace-Bulbulian mask. 128

tinnitus in, 215, 226, 238, 242, 258 BOTTERELL, Lt. Col. H., RCAMC, 71

tremors in, 238, 239, 240, 256 Bovie electrosurgical unit, 77-78, 126
INDEX 433

Bovine thrombin, 77 British hospitals, 60, 77

Braceshops, 79 British medical meetings, 71-72

BRADEN, Lt. Col. S., 6, 7 British Ministry of Pensions, 270

BRADFORD, F. K., 262, 270 British mobile surgical units, 93

Brain: British Neurological Society, 72

blood supply of, in posttraumatic epilepsy, British neurosurgeons, 60,71, 107 112, 113, 148

305 in World War I, 100

contusions of, 164, 181, 340, 396, 397 liaison with, 71-72

damage to, in discontiatious fractures, 339, British neurosurgical center.;, 67, 71

397 British Society of Neurological Surgeons, 71

edema of, in blast concussion, 258 British speech therapists, 329

hyperemia of, in blast concussion, 230 BROCK. S., 342

incidence of wounds of, 120 Bromides, in meningitis, 208

lacerations of. 216, 227, 342, 396, 397 Bronchoscopy, 139

scars ot, 7 BRowwN, J. C., 262, 268

through-and-through wounds of, 171-172 Btucy, P. C., 211

tumors of, 7, 28, 37 Bull) suture, 35

See also Cerebral, Craniocerebral. Bulletin of the U. S. Army Medical DepartBrain abscess, 7, 9, 15, 58, 86. 91, 93, 108, ment, 73

115-117, 146, 208-212, 213, 321 BRaKE, G. L., 261

antimicrobial therapy in, 209, 212, 213 Burma 13

bacteriology of, 212 Bursting fractures, 156

diagnosis of, 210-211 BUTLER, E. G., 338

etiology of, 208-209

exploration of, 211 Cadaveric neurosurgery, 25, 26, 27, 29

foreign bodies, as cause of, 93. 146, 208, Caffeine sodium benzoate, in craniocerebral

210-211 injuries, 177

fungus cerebri with, 118 CAIRNs, Brig. H., RAMC, 71, 148

management of, 4, 93, 105-106, 112, 211- Calvarium:

213 application of tantalum plate to, 266, 267

meningitis with, 117 cranioplastic material from, 94

pathologic process in, 209-210 fractures of, 100-101, 173

penicillin therapy in, 93 CAMERON, G. R., 227

resection of, 116, 211, 212-213 CAMERON, J. E., 262, 268, 269

roentgenologic examination in, 212 CAMERON, Col. J. M., MC, 7

symptoms of, 210-211 CAMPBELL, Col. E. H., Jr., MC, 146, 147, 182

Brain stem: Canadian hospitals, 60, 71

damage to, in blast concussion, 240, 251, Canadian neurosurgeons, 60

256 Capillary changes, in mortal head injuries,

wounds of, 102, 129, 181. 197-198 362, 396

Brain surgery, use of tantalum foil in, 37 Carbon monoxide poisoning, 217, 225

BRENNER, C., 258 Cardiac center, in medulla oblongata, 374,

BRICKER, Col. E. M., 111 384

British, purchase of equipment from. 74, 78, CARMICHAEL, Lt. Col. F., 118, 119, 397

79 CARNEY, H. M., 261

British Army, 61, 112, 147 Carotid artery injuries, 119

British Army consultants, 71 Casablanca, 107

British Army Emergency Medical Service, Case fatality rates, in60, 61 craniocerebral wounds, 99, 120-122, 123,

British Army experience- 124, 135, 147, 180-182

at Dieppe, 82 in forward hospitals, 83, 84, 99

in head injuries, 110 in World War 1, 90, 123, 201

with local penicillin therapy, 203 German prisoners of war, 83

with sulfathiazole, 148 meningitis, 117, 208
434 NEUROSURGERY

Case fatality rates, in -Continued Cerebellum, wounds of, 230, :127, 328, 3:19,

neurosurgical casualties, in ETOUSA, 84 374, 384, 396

neurosurgical centers, 32-33 Cerebral blast syndromne. See Blast conpenetrating craniocerebral wounds, 8:3-84, cussion.

85-86 Cerebral circulation, damage to, in blast

spinal cord injuries, 86 concussion, 254

transventricular wounds, 83, 165-166, 183, Cerebral concussion, 107, 111-112, 340, 345

189, 192, 199 early ambulation in, 107

in World War 1, 18:1 Cerebral contusions, 112, 216, 242-24:3

See also Statistics. Cerebral dysrhythmias, in--

Case histories: blast concussion, 249

abscess formation in transventricular posttraumatic epilepsy, 284

wounds, 184-189, 192-198 Cerebral fungus, 58, 65, 85, 107-108, 112, 270

apparently lethal head injury, 397-399 after brain abscess, 105

blast concussion, with delayed cerebral in craniofacial wounds, 172

hemorrhage, 2:14-236 in World War I, 90

blast trauma, with- prevention of, 101

intracerebral hematoma, 2:11-233 Cerebral headrest, 75

subdural hematoma, 233-234 Cerebral hemispheres:

brain abscess, 115-116, 208 epilepsy after wounds of, 270

cerebral blast concussion, 228-231, 240 wounds of, 130, :174, 396

cerebral contusion from blast, 242-24:1 Cerebral petechiae, 217, 225, 227, 230-231,

craniofacial wound, 175 2:14, 345, 383

depressed fracture over occipital cortex, Cerebral scars, 94, 97, 148

159 in posttraunmatic epilepsy, 313-315

electroencephalography in blast concus- reconstructive surgery of, 90

sion, 248-249 resection of, 92, 97-98, 267

immersion blast concussion, 242 Cerebritis, 93, 94, 107, 116, 395

intracortical hematoma, 163 Cerebrodural scars, :321, 324

mortal head injuries, 275-283, 284-294 Cerebrospinal fluid circulation, 324

retained foreign bodies, in transventricular Cerebrospinal fluid fist ula, 7, 84, 86, 103-104,

wounds, 184-189, 192-198 112, 113, 117-118, 120, 135, 148, 166-

subcortical hematoma, 165 167, 168, 175, 204, 206, 207-208, 212

tantalum cranioplasty, 272-278 evacuation of casualties with, 180

through-and-through wound of brain, 172 penicillin therapy in, 178

transventricular wounds, 169-170, 184- Cerebrum:

189, 192-198 air in, 103

wound of longitudinal sinus, 16:3 wounds of, 102, 142

Cassino, 42 Chemical studies of spinal fluid, 280

Casts, in peripheral nerve injuries, 18, 79 ChemotherapyCasualties with neurosurgical injuries. See after craniocerebral surgery, 179

Neurosurgical casualties, during evacuation, 180

Cathode-closing tetanus, 22 in craniocerebral wounds, 127, 172, 283-

Causalgia, 8, 23 284

Cavernous sinus, 174 in craniofacial wounds, 172

Celluloid cranioplasty, 90, 94 in dural wounds, 135

Central nervous system, damage to, in blast in peripheral nerve injuries, 86

concussion, 226-228, 2:30-231, 252-253, in scalp wounds, 140

260 in skull fractures, 157

Central vasoparalysis, 340, 341 in transventricular wounds, 191-192

Cerebellar cortex, 124, 346 See also Antimicrobial therapy, specific

Cerebellar pathways, 327 agents.

Cerebellar tract signs, in blast concussion, Cheyne-Stokes respiration, 83, 130, 136

240 CHILDE, A., 10
I NDEX 4:35

('hills, inl meningitis, 2M)4 Con u, C. A., .Jr., ! 54)

C'hloral hydrate, 177, 208 Cognitive futtiie , -ting of, 324

Choked disk, 211 ('oim, It., 230)

('horoid plexuis, 189), 351, 369, 383 C'oif%, E. J., 7 7

('hromatolvsis, 254), 251 (Collecting 4tations, onl NormanaI(v beach-

(Circular Letters: head, 615

No. 75, Offiee of Chief Surgeon, ETOI'MA, College of Physicians and Surgeons, ('oltimi4 D~ecemtber 1942-611 bin University, 25, 26, 27

No. 81, 0411cc of Chief Surgeon, ETOUSA, C'olon, wounds of, 84

17 May 1944-5I (Coma, ill ---

Civiliani-type head injuries, 48, 60, 61 Mlast concussion, 234

(Civilians, blast concussion inl, 225, 226 227 craniocerebral injuries, 83, 128, 129), 131,

CLA~RK, Lt. (Col. A. Gr., 7 134, 135, 138, 139)

Classification, of-- t rnnsventiricular woundIs, 103

ap~hasia, 326--332 (Combat exhaustion, 226, 227, 260

head injuries, 140 Combat neurosis, 218, 2261-227

transventricular wounds, 183 (Combat zone, assignment of neurosurgeon.-t

Clearing stations, 58 to, 53

('left lip (palate), 3290 Combined bone-nerve surgery, 231

Cli nical piet tire, in--- C'ombined nerve injuries, :17-:38

blast concussion, 237-244 Combined nerve-vascular lesions, :16

brain abscess, 210-211 (Combined pl)astic-flerl'e surgery, 2:1

head injuries, 26 Complex auras, 288

subdutral heinatoma, I11 Compression of skull, ill blast concuission,

transvent ricuilar wounds, 103 215-21(6

See also Specific signs and1 symptoms. Compression theory of blast concussion, 250,

(Clinical policies, 45, 46, 61 254-255

inl World War 1, 3 CoNE-,, W. V., 9, 2:30, 241

Clinical research, 24, 82 (Conference(s), on- -

Closed head injuries, 11, 20, 58, 83, 91, 99, aphasia, 323

IM101)li, Ill- 112, 120, 140, 254 neurosuirgery 1942, (-

b~last concussioni inl, 224 pantient management, ait Cuashing General

conservative managenment of, 109) Hospital, 234

disposition of patients with, 10)8 See also Meetings.

elect roencephalographic finadings inl, 247- Confrontation testing, 1:11)

248 Congenital abnormualit ies of larynx, :128

infect ion inl, 1461 Conjunctival hemorrhage, 244

post~traumat ic epilepsy after, 282 Connective tissue format ion, after tantalum

See also Fractures of skuill, specific types cranioplasty, 94, 95

of fractures. Consciousness, state of inl epilelpitic seizures,

(Closed head injury syndromne, 240 292

Closuire, of- Consultant(s) inl surgery:

craniofacial wounds, 174 First IT. S. Army, 47, 66;

donor site, inl scalp wounds, 153-154 Fifth U. S. Army, 431

dura, 104, 113-11l4, 126, 127, 148-150, 20)3 'MTOUSA, 41

ill brain abscess, 1161, 212 Consultations, 28, 31, 40), 49), (15, :32.1

inl cerebrospinal fluid fistula, 103-104, Contamination, fronm repeated wound dress117-118. inigs, 202

inl transventricular wounds, 1(68, 191 Cotnt,4,553 45,6:,7,172 galea, 179 otnn,4,5,53 4 5 3 7 1 2

scalp-- 80, 82, 110, 112

at cranioplasty, 267 (Continuous skull fractures, 101)

iii fungus cerebri, 213 Contract. service for neurosurgical patients,

scalp wounds, 99-100), 127, 202, 203 4, 5, 6
436 NEUROSURGERY

Contraindications, to-- Corticogangliar function, 257

cranioplasty, 270, 278 Corticospinal tract, 327

local anesthesia, in craniofacial wounds, Cosmetic indications for cranioplasty 262.

17:3 269, 278

surgery in posttrauinatic epilepsy, 293-294 Cotton sutures, 126

Contrecoup, 243, 342 COtVRVILLE, C. B., 340, 347, 348, 351

Control of hemorrhage, in craniocerebral in- CRAIG, Rear Adm. W., (MC) USNR, 7

juries, 26, 77, 105, 124, 142, 143, 146, 156, CRAMER, F., 224, 234, 2:16, 256, 258

192, 395 Cranial nerve disturbances, in blast conContusions, of- cussion, 240

brain, 164, 181, 340, :396, 397 Cranial nerve palsies, 131

dura, 157 Cranial nerves:

Convalescent hospitals, :35 exploration of, 328

Convalescent wards, in neurosurgical centers, wounds of, :122, :427, 3:132

17, 18 See also specific nerves.

Conversion hysteria, 237, :322, 328. 331 Cranial perforator, 126

Convulsions: Craniocerebral injuries, 8, 21-22, 29, 31, 34,

after craniocerebral surgery, 179-180 35, 50. 61, 71, 78. 83-84, 89-399

after surgery for posttraumatic epilepsy, adjunct therapy in, 321

316 administrative considerations of, 91-92

depression of cortical activity after, :310 in World War I, 3-4

in blast concussion, 241, 244 amnesia after, 10

in brain abscess, 210 anesthesia in, 137-139, 396

in craniocerebral injuries, 86, 131, 1:14 associated with other wounds, 101, 108.

with antimicrobial therapy, 148 125, 128. 138, 199, 203, 336

Convulsive states, 20 blood replacement in, 127, 128, 203, 396

Cordotomy, 36 bone fragments in, 91, 92, 103, 110, 112.

CoRFY, E. L., 219, 251, 252 114, 126, 131, 134, 140, 145, 146-147.

Coronal incisions, in cranioplasty, 266 167, 168, 189, 190, 201

Corps areas, neurosurgical centers in, 6 case fatality rates in, 83-84, 99, 120-122,

Corpus callosum, 85, 339, 384 123, 124, 135, 147, 180-182

Corpus striatumn, 339, 384, 394 in World War 1, 90, 123

Cortex: caused by explosion waves, 215-260

cytoarchitecture of, 313, 347 causes of death in, 83-84, 85-86, 101-102,

damage to, in blast concussion, 257 166, 181-182, 192, 199

depression of activity of, 302, 310 in World War I, 183

exposure of, at operation, 303 cerebrospinal fluid fistula in, 7, 84, 86,

reference of neurologic signs to, 158 103-104, 112, 113, 117-118, 120, 135,

studies on- 148, 166-167. 168, 175, 204, 206, 207-

at operation for posttraumatic epilepsy, 208, 212

305-311 chemotherapy in, 127, 283-284

in aphasia, 324 classification of, 140

wounds of, 130, 149 clinical signs in, 26

Cortical dysrhythmias, in blast concussion, coma in, 83, 103, 128, 129, 131, 134, 135,

248 138, 139, 234

Cortical electric activity, 270 complications of, 105-108, 115-119, 120,

Cortical hemorrhage, in craniocerebral in- 127, 179, 321

juries, 124, 135, 143, 146, 171 convulsions in, 86, 131, 134

Cortical representation, of arm and hand, 286 deaths on battlefield from, 182, 336, 339,

Cortical resection, in posttraumatic epilepsy, 384

290, 294, 299, 311-313, 321 debridement in, 11, 22, 85, 86, 90, 102,

Cortical scars, 321, 347 106, 111, 123, 124, 125, 126, 130, 137,

Cortical stimulator, 78 138, 143-146, 149, 156, 157-158, 178,

Corticobulbar tract, 327 179, 181. 201-202, 203. 271, 321, 394
INDEX 437

Craniocerebral injuries-Continued ( raniocerebral injuries--Continued

delirium in, 134 prognosis of, 10, 83, 130, 135

diagnosis of, 103 reconstructive surgery in, 92--98

of sequelae of, 92 records in, 110, 126

disposition of casualties with, in MTOUSA, redebridement in, 105-106, IM3, 321

108 reparative process in, 339, 357

drainage in, 179 respiration in, 83, 102, 129-130, 135, 138

dressings in, 156 resuscitation in, 81, 102, 103, 110, 121,122,

dysaudia after, 332 128, 134, 190

early ambulation in, 10, 112 return to duty in, 10, 109

evacuation of patients with, 65, 180 roentgenologic examination in, 26, 128,

exploration in, 115, 116, 126 131-134, 145, 164

eye signs in, 130, 131 role of neurologist in, 91-92

followup of, 22 secondary wound closure in, 321

foreign bodies in, 84, 86, 91, 92. 93, 100. sedation in, 128

110, 112, 114-115, 124-125, 126, 131- selection of patients for surgery in, 374-375

132, 134, 140, 145, 146-147, 168, 184, sequelae of, 91, 92-93

189, 190, 284, 338 397 shock in, 102, 129, 133-134

hematoma formation in, 83-84, 102, 115. state of consciousness in, 129, 131

135 stuttering after, 330

hemorrhage in, 102, 124, 127, 129, 135, subdural hematoma in. 11

143, 146, 171, 189, 206, 395 sulfonamide therapy in, 128, 284

in Army Air Forces, 109 technique of debridement in, 143-146

in ETOUSA, 50, 109-122 time of death in, 101, 181-182, 201, 241,

in forward hospitals, 26, 101,102, 120, 121, 336, 339, 341, 346, 348, 359, 362, 374,

125, 157, 181, 199, 202 384, 394, 395

in general hospitals, 112, 199, 212 timelag in, 101-102, 110-111, 202, 204,

in MTOUSA, 41, 99-108 395-396

in neurosurgical centers, 37 in World War I, 89-90

in World War I, 89-90, 110, 123 timing of surgery in, 135-136, 138

in Zone of Interior, 28, 91-98 vascular changes in, 340, 342, 345, 347,

incidence of, 82, 157 359-362, 369, 396, 397

incidence of meningitis in, 204 visual field disturbances after, 322

infection in, 86, 92, 93, 105, 124-125, 135, wounding agents in, 132, 204, 271

148-149, 201, 271 wounds of entrance (exit) in, 336-338

intracranial pressure in, 129, 395 Craniofacial wounds, 172-175, 177

ischemic changes in, 340, 345, 346, 369, 383 Cranioplasty, 8, 86, 91, 112, 142, 208, 261-

lethality of, 101-102, 335-399 278, 320

management of, 123-182 anesthesia for, 37, 266

at Cushing General Hospital, 21-22 complications of, 96

before D,day in Europe, 109 contraindications to, 278

in ETOUSA, 109-122 electroencephalographic studies at, 269-

in MTOUSA, 99-108 270

meningitis with, 117, 178-179, 204-208 experimental studies on, 261-262

neurologic examination in, 127, 129-131 in aphasic patients, 323

neurologic sequelae of, 321-322, 332 in brain abscess, 212

occupational therapy in, 10 in World War I, 90, 94

pain in, 177 incision in, 95

paralysis in, 130, 131 indications for, 27, 92, 94, 269-271. 278,

penicillin therapy in, 106, 128, 178, 284 285, 316

plasma replacement in, 128 infection after, 96, 303

postoperative management of, 175-180 inlay (onlay) technique of, 266-267

posttraumatic epilepsy after, 282 performance of, overseas, 93

priorities of surgery in, 134-136 reactions after, 94

455735-58--29
438 NEUROSURGERY

Cranioplasty -Continued Debridement, in-Continued

technique of, 92, 93, 94-96 wounds of dural sinuses, 159-162

timing of, 270, 278 Decerebrate rigidity, 102, 103

with autogenous bone. 90 Decubitus ulcers, 36, 38

See also specific types. Dehiscence, of scalp wounds, 99, 105, 191,

Craniotomy, 83, 86, 266, 323 202

case fatality rates in, 83-84 Dehydration, in transventricular wounds,

in World War I, 90 190

Cribriform plate, 103, 104, 207, 338, 384, 397 Deiter's nucleus, 250

CRICHTON- M ILLER, H., 218 Delayed evacuationCRISLER, Col. A., 47, 56. in peripheral nerve injuries, 92

Cristi galli, dural flaps from, 104 of neurosurgical casualties, ETOUSA, 63

Critical fusion frequency test, 281 Delayed neurosurgical care, ETOUSA, 64

Curvilinear incisions in scalp wounds, 001 Delayed posttraumatic cerebral hemorrhage,

CusHING, H., 89, 90,118, 123,126, 140, 165, 183 in blast concussion, 256

CUTLER, Brig. Gen., E. C., 55 Delayed surgery, in head injuries, 11, 101-

Cyanosis in epileptic seizures, 292 102, 105-106, 111

Cysts of subarachnoid space, 301 Delayed suture, of peripheral nerve injuries,

Cytoarchitecture of cortex, 313, 347 11

Cytologic studies of spinal fluid, 280 Delerium:

aphasia in, 332

DANDY. W. E., 5 in craniocerebral injuries, 128, 134

DARLEY, F., 320 DEMITTH, E. L., 257

DAVIs, Col. L., 7, 10, 11, 45, 48, 53, 60, 109 Demyelinization of white matter, 373, 374

DAVISON, C., 257 DENNY-BROWN, D., 215, 218, 250, 252, 253,

D-day, 46, 47, 49, 53, 54, 55, 56, 61, 62, 63, 254, 258

64, 69, 70, 71, 72, 77, 81, 82, 109, 110, 111 Dental compound, for cranioplasty, 263, 264

Deaths: Dental technicians, assistance of, in craniofrom shock, 39 plasty, 95

on battlefield, from head injuries, 182, 336, Dependents, neurosurgical care of, 7

339, 384 Depressed skull fractures, 100, 111-112, 140.

time of, in head injuries, 101,181-182, 201, 157-159, 180

241, 336, 339, 341, 346, 348, 359, 362, Depression, of cortical activity after convul374, 384, 394, 395 sions, 310

Debility, in posttraumatic epilepsy, 294 DEY, F. L., 250

Debridement, in- Diagnosis, ofantecedent wounds, in posttraumatic aphasia, 323-324

epilepsy, 282-283 blast concussion, 218-219, 223-224, 225-

craniocerebral injuries, 11, 22, 57-58, 70, 227, 255, 258-260

85, 86, 90, 102, 106, 110-111, 112, 123, brain abcess, 116, 210-211

124, 125, 126, 130, 138, 140-147, 148, cerebrospinal fluid fistula, 103

149, 156, 178, 179, 181, 201-202, 203, craniocerebral injuries, 41, 92

271, 321, 394 meningitis, 206

craniofacial wounds, 173-174 subarachnoid hemorrhage, 179

depressed skull fractures, 112 transventricular wounds, 103, 189--190

dural wounds, 143, 167-168 Diagnosis, routine of, in neurosurgical cenmortal head injuries, 397 ters, 21-23

scalp wounds, 100, 111, 140-142, 143, 157, Diagnostic surveys, 19, 20

159, 167-168 Diagnostic wards, in neurosurgical centers,

skull injuries, 112, 142-143 17

through-and-through wounds of brain, Diencephalomesencephalic border, 339

171-172 Diencephalon, 257, 374, 384, 394, 396

transventricular wounds, 166-170, 183, Dieppe, 82

184-189, 190-191, 199 Diet, in posttraumatic epilepsy, 292
INDEX 439

Dilantin Sodium, in posttrauniatic epilepsy, Dura--Continucd

289-290, 293 exploration of, 65, 95, 324

Dilated pupils, 394 in depressed skull fractures, 158

Diploic hemorrhage, 143 incidence of wounds of. in posttrauiatic

Disabilities, of back, 17, 28, 31 epilt.psy, 270, 283, 285

Discontinuous skull fractures, 101, 33S, 384, involvement of, in transventricular

396-397 wounds, 189

Dislocation, of inner table of skull, 101 lacerations of, 93, 103

Disposition boards, 80 management of wounds of, 83, 104, 11,

Disposition, of - 113-114, 125, 143, 148-150, 174, 267

aphasic patients, 332-333 in fungus cerebri, 118

casualties with- in posttraumnatic epilepsy, 303-304, 313

head injuries, 17, 18, 31, 92, 108 in skull fractures, 157-158

herniated nucleus lulposus, 8 in transventricular wounds, 168, 183

neurosurgical casualties, 20 nonclosure of, 107

after V-E Day, 67 priority of wounds of, 135

Distention of scalp, by salt solution, 113 Dural fistulas, 86

Division clearing stations- Dural grafts, 113, 168

in MTOUSA, 39 Dural sinuses, wounds of, 83, 84, 102, 124,

on Normandy beachhead, 65, 66 127, 135, 140, 159-163

Division of Head Surgery, Surgeon General's Dural-cortical adhesions, 37

Office, in World War I, 3-4 Dypshemia. See Stuttering.

Division of Medical Sciences, National Dysarthria, 319, 322, 324, 326-328, 329, 330,

Research Council, 25 331, 332, 333

Division of Neurology and Psychiatry, Dysarthrophonia, 322, 327. 328

Surgeon General's Office, in World War I, 3 Dysaudia, 322, 332

Doctor-patient relation, in neurosurgical Dysl:tlia, 322, 327, 329-330, 331, 332

centers, 20 Dyslogia, 322, 331-332

DON AOHY, Capt. R. M. P., 86 Dysphasia, 320, 322, 324, 326, 327, 332, 334

Donor site, on scalp, 153-155 Dysphonia, 322, 324, 328-329, 330, 333

Doetr. N.. 71 Dysrhythmias, inDouble vision in visual auras, 288 blast concussion, 257

Drainage- posttraumatic epilepsy, 284

in brain abscess, 112, 116, 211, 212

in craniocerebral injuries, 93, 104-105, 127, Early ambulation, in head injuries, 106-107,

156, 179, 203 112

in craniotacial wounds, 175 Ears, damage to, in blast concussion, 227,

in dural wounds, 148 244, 258

of bladder, after craniocerebral surgery, East Anglia, 56, 61

179 ECKEL, J. L., 359

DRAPIEWSKI, J. F., 340, 357, 362, 369 ECKER, Major A. D., MC, 113, 114, 117, 119,

Dressings, after craniocerebral surgery, 156, 149

179 Ecker technique of dural repair, 113, 114

DuF, F. 0., 234 Economic factors, in etiology of blast conDura: cussion, 259

closure of, 104, 126, 127, 148-150, 203 Ectodermal components of brain, 369, 396

in brain abscess, 116, 212 Edema, ofin cerebrospinal fluid fistula, 103-104, brain, in117-118 blast coneiission, 254, 258

in transventricular wounds, 168, 191 craniocerebral injuries, 102, 128, 189.

contusions of, 157 213

damage of, in skull fractures, 142-143, 339, mortal head injuries, 339, 342, 347, 351,

397 357, 359, 369, 373, 374, 396

debridement of, 143, 167-168 larynx, 328
440 NE UROSURGERY

Edinburgh, 71 Ependyuiitis, 367

Eggshell fractures, 156 Epidural hematoma, 179

Eighth cranial nerve, palsies of, 131 Epidural infection, 104

Elective neurosurgery, 5, 49, 78, 374 Epigastric auras, 289

Electric shock, in posttraumatic epilepsy. Epilepsy. See Posttraumatic epilepsy.

296 Epileptic diathesis, 284, 289

Electric stimulation of nerve fibers, at opera- Epileptic seizures, 286-289, 291-292

tion, 23 Epileptogenic factors, 284-285

Electric suction, in craniocerebral injuries, Epileptogenic foci, 92, 96, 97, 294, 302, 303.

126 306-309, 313-315

Electrocardiography, in posttraurmatic epi- resection of, 310-311

lepsy, 281 Epiphenomena, 256

Electrocautery, 40 Epistaxis, in blast concussion, 241

Electrocorticography, in posttramnatic epi- Equipment:

lepsy, 306-311, 312-313 at Walter Reed Genera! Hospital, 14-15

Electrodiagnosis, 20, 22, 34, 38, 79 for head surgery, 126-127

Electroencephalograph%, 22, 34. 35, 37, 38, for neurologic examination, 129

92, 96, 97, 98 for speech rehabilitation program, 324-325

at Walter Reed General Hospital, 5 improvisations of, .50

effect of forced hydration on, 295 in ETOUSA, 47-48, 54, 74-79

effect of hyperventilation on, 295 of auxiliary surgical groups, 74, 75

effect of Metrazol injection on. 297-299 of auxiliary surgical teams, ETOUSA, 55,

effect of sodium cyanide induction on, 296 60, 74, 77-78

in aphasia, 323 of evacuation hospitals, ETOUSA, 74, 75,

in blast concussion, 212, 243, 244-250, 78-79

256-258, 260 of field hospitals, ETOUSA, 78

in cranioplasty, 269-270 of general hospitals, ETOUSA, 74, 75,

in experimental blast concussion, 251-252 77-78, 79

in posttraumatic epilepsy, 271, 279, 281, of neurosurgical centers, 34, 35

284, 285, 289, 294 -295, 296, 297, 298, 299, of station hospitals, ETOUSA, 77-78

305-311,316 shortages of, inElectromyograms, 222 ETOUSA, 75-79

Electroneurosurgery, 50, 147 neurosurgical centers, 35, 38

in transventricular wounds, 166 United Kingdom, 47-48, 50, 74-75

Electrophysiologic studies, 24 F]ICKMýO%, T. C., 295

Electrostimulation, 21, 23, 28 Esophageal speech, 329, 330

Electrosurgical units, 26, 50, 77-78, 146 Essential Technical Medical Data,

Electrotherapy, II ETOUSA:

ELKINS, C. W., 262, 268, 269 22 August 1943-109

ELVIDGE, T. C., 295 17 August 1944-120

Embolic origin, of neningitis, 206

Emergency Medical Tag, 80 Ethnoid, wounds of, 83, 104, 139, 173, 174

Emotional conflicts, in aphasia, 330, 333 Etiology, ofEmotional trauma, relation of, to blast con- blast concussion, 215, 224, 225-227, 250-

cussion, 226 259

Emphysema, in blast concussion, 228 brain abscess, 208-209

Encapsulation of brain abscess, 105 disorders of articulation, 327

Encephalography, 13, 81. 86, 91, 97, 256 dysarthria, 326-327

in blast concussion, 216, 223 (lysaudia, 332

Encephalopathy, 226, 240, 256 dyslalia, 329-330

England. See United Kingdom Base. dysphonia, 328

Enlisted personnel in neurosurgical assign- shellshock, in World War 1, 225

ments. 14, 51, 55-59, 69, 126 stuttering, 330-331

Ependyrna, 189, 351. 373 Europe. See Continent.
INDEX 441

European Theater of Operations: Exploration -Continued

head injuries in, 109-122 in spinal cord injuries, 65

neurosurgery in, 45-86 in subdural hematoma, 237

Evacuation. See also Air evacuation, of cranial nerves, 328

Evacuation, of-- of dura, 158, 324

casualties with head injuries, 123, 156, 1 S0, Explosion waves, head injuries caused 1y,

395-396 21.--260

neurosurgical casualties, to - Expressive (motor). dysphasia, 326

United Kingdom, 47; 51, 53, 62-64, 67 Expressive-receptive (mixed) dysphasia, 326

Zone of Interior, 53 Exteroceptive nerve endings, 226

psychiatric casualties, 260 Extradural bleeding, in mortal head injuries.

Evacuation hospitals- 397

in ETOUSA, 46, 47, 51, 53-54, 57, 64, 65, Extradural hematoma, 83, 156, 164, 171-172

67, 68, 69, 83, 109 Extradural space, injuries of, 102

neurosurgeons in, 25, 53-54, 58-60 Extradural surgery, in cerebrospinal fluid

in MTOUSA, 39, 40-41 fistula, 104

neurosmugeons in, 40 Extrapyramidal tract, 327

on Normandy beachhead, 65--66 Extremities, wounds of, 26, 83, 128, 138

Evacuation hospitals: Extrinsic contracturc of larynx, 328

blast concussion in, 222 Eye signs, in head injuries, 130, 131, 136

case fatality rates in, 83-84 Eyes, injuries of, 83

deaths from head injuries in, 182

equipment of, ETOUSA, 52, 53, 74, 75, FABING, H. D., 215, 223, 244, 255, 256

77-78, 79 Face, wounds of, 83, 281

head surgery in, 26, 101, 120, 121, 125, Face-down position, in head surgery, 137

157, 181, 202, 374 Facial bones, fractures of, 173

peripheral nerve surgery in, 26 Facial motor tic, 238

recommendations for use of neurosurgeons Facial nerve, wounds of, 322, 327, 330

in, 59-60 Facial palsy, 130

roentgenology in, 103 Falx, hemorrhage from, 146

surgery of spine in, 26 Faradic current, 78, 79

transit hospitals serving as, ETOUSA, 54 Fascia lata grafts, 83, 104, 113-114

workload of, 82, 125 in cerebrospinal fluid fistulas, 104, 118, 208

Evacuation policies, in North Africa, 39 in dural wounds, 149-150, 174, 191

Evaluation, of- Fat embolism, 344

equipment, ETOUSA, 75-79 Fatigue, in blast concussion, 226, 241

findings, in posttraumatic epilepsy, 281 Fever, inneurosurgical care, ETOUSA, 64-66 blast concussion, 241

neurosurgical personnel, ETOUSA, 46-47. brain abscess, 211

70 craniocerebral injuries, 102, 206

neurosurgical personnel, in Zone of In- meningitis, 206

terior, 34, 36 mortal head injuries: 284, 294

progress in peripheral nerve injuries, 21, 22 Fibrin exudation, in craniocerebral injuries,

EVANS, J. P., 340, 341, 359, 361 340

Everted fracture of skull. 338 Fibrin film, 113, 150, 191

Exercise, in posttraumatic epilepsy, 292 Fibrin foam, 77, 126, 143, 146, 162, 163, 174,

Exophthalmos, 7 208, 303

Experimental studies, in- Field block, 138

blast concussion, 219, 227, 230, 250-252, Field hospitals:

257, 259 case fatality rates in, for head injuries,

cranioplasty, 261-262 83-84

Exploration- deaths from head injuries in, 182

in brain abscess, 211 equipment of, 78

in craniocerebral injuries, 115, 116, 126 head injuries in, 26, 101
442 NEUROSURGERY

Field hospitals--Continued Forward hospitals, 80

in ETOUSA, 58, 64 assignment of neurosurgical personnel to,

in MTOUSA, 39-40 123

on Normandy beachhead, 65, 66 head surgery in, 199

peripheral nerve surgery in, 26 neurosurgery in, MTOUSA, 40-41

recommendations for use of neurosurgeons roentgenologic examinations in, 134

in, 59-60 See also Evacuation hospitals, Field

surgery of spine in, 26 hospitals.

Field medical record, 129 Fourth ventricle, 339, 357

Fifteenth U. S. Army, 66 Fox, C. A., 250

Fifth U. S. Army, 41, 43, 99, 182 Fractures, 83, 281

FINCHER, Maj. E. F., 6, 7 Fractures, ofFirst aid: calvarium, 100-101

in craniocerebral injuries, 127-128 ethmoid, 103

in U. S. Army, 45, 47, 53, 54, 65, 66, 89, facial bones, 173

120, 121, 181 long bones, 130

training in, 70 mandible, 329

Fistula. See specific types. pelvis, 85

Fixed pupils, in head injuries, 83, 102, 130, petrous pyramid, 85

169, 394 radius, 85

Flaccid paralysis, 130 sinuses, 103

Fluid balance- skull, 130, 131, 156, 157-159

after craniocerebral surgery, 177-178 See also Closed head injuries, specific

after surgery for posttraumatic epilepsy, types.

316 vertebrae, 82

in craniocerebral injuries, 203 France, 58, 63, 398

in meningitis, 208 FRAZIER, C. H., 319

Focal abnormalities in electroencephalog- Free grafts, 83, 100, 143

raphy, in posttraumatic epilepsy, 284 FREER, Col. A., 7

Followup of casualties, with- French casualties, care of in U. S. hospitals,

head injuries, 22 71-72

posttraumatic epilepsy, 316 French neurosurgeons, 71-72, 116

Followup records, 60-61, 80-81 FRIEDMAN, A. P., 258

Foot suction pump, 78 FRISHMAN, A. J., 181, 182

Foramen of Monro, 168, 189 Frontal lobe:

Forced hydration, in posttraumatic epi- epileptogenous foci in, 302

lepsy, 295 wounds of, 85, 156, 173, 174, 177, 285,

Foreign bodies, 83, 85, 86, 91, 92, 93, 100, 286, 327, 338, 339

110, 112, 114-115, 124-125, 126, 131- Frontal sinuses, 83, 103, 104, 139, 173-174,

132, 134, 140, 145, 146-147, 284, 338, 278

397 Frontoparietotemporal wounds, 85

as cause of brain abscess, 115-116, 208, Frontopontocerebellar tracts, 327

210-211 Frozen hands, 38

as indication for surgery, in posttraumatic Frozen joints, 23, 92

epilepsy, 292-293 FULCHER, 0. H., 261

in contralateral hematomas, 164-165 FULTON, J. F., 225, 253

in scalp wounds, 140 Functional basis of aphasia, 322

in tfansventricular wounds. 168, 184, 189, Functional neurogenic approach to blast

190 concussion, 255-256

in wounds of dural sinuses, 159-161 Functional paralysis, 340

role of, in posttraumatic epilepsy, 284, 285, Functional speech defects, 328, 329

311 Fungus cerebri, 118-119, 135, 136, 148, 155,

See also Bone fragments. 163

Foreign-body reaction to acrylic resin, 262 management of, 212-213
INDEX 443

Furlough system, in- Grand mal, 288, 296

neurosurgical centers, 20, 28 GRANT, F. C., 27, 211,261,269

speech program, 325 GRANTHAM, Lt. Col. E. G., 6, 7

Graphic records, 22, 31, 336

Galea: Graphic representation of exposed brain, in

closure of, 179 posttraumatic epilepsy, 304

undernmining of, in scalp wounds, 100 Gray matter, 125, 243

Galvanic current, 79 GREENFIEI.D, J. G., 342

GANADO, W., 230 GRINKER, R. I., 234, 255

GARAI, 0., 242, 243, 248, 249 GROAT, It. A., 250, 251

GAYNOR, WV. C., 181, 182 Group therapy, in stuttering, 331

Gelatin foam, 77, 126 GRUNAGLE, J. F., 232

General anesthesia, 35, 266, 303 GRUNTHAL, E., 259

General hospitals: G URDJIAN, E. S., 250, 255, 262, 268

blast concussion casualties in, 222, 223 GURWITT t I Si 182

cranioplasty in, 94 Gu> W. A., 119

disposition boards in, 80 Gust., ,i.ttions, in complex auras, 288

evacuation front, 114 Gutter wounds, of head, 83, 124, 140, 149,

head surgery in, 112, 199, 202 204, 336

in ETOUSA, 48-49, 51,53, 54, 56, 57, 6(1, Gynecologists, 27

66, 75, 109 Gyri, atrophy of, 305

equipment of, 74, 75, 77-78, 79

in MTOUSA, 41 HAMLIN, H., 233, 237, 242

in Zone of Interior, 28-29, 107 Hard palate, 330

meningitis in, 117 Harvard University Medical School, 77, 113

neurosurgical teams from, 55 HARVEY, E. N., 338

transventricular wounds in, 184-189 HAssii, G. B., 340, 341,342,357,367

General measures in posttraumatic epilepsy, HAVERFIELD, NN. T., 211

291-292 HAWLEY, Maj. Gen. P. R., 10, 51, 58, 60,

General surgery, use of neurosurgical per- 68, 73, 74

sonnel for, in MTOUSA, 42 HAYNES, Capt. W. G., 6, 7, 135, 147, 166,

GERMAN, W. J., 104 170, 181, 183, 201

German Army, 112 HAYS, Maj. Gen. S. B., 75

German neurosurgeons, 107, 114 HEAD, H., 324, 326

German prisoners of war, 83, 84, 118 Head injuries. See Closed head injuries,

German technique, in cerebrospinal fluid Craniocerebral injuries, Mortal head

fistula, 104 injuries.

Germany, 58 Head Surgery, Division of, Surgeon General's

Ghost cells, 346 Office, in World War I, 3-4

GILIBERTI, V., 342 Head surgery, positioning on operating

Gitter cells, 362 table in, 137

Glabella, 278 Headache:

Glial elements, in mortal head injuries, 339, after craniocerebral surgery, 96, 179

340, 341,359, 373 as indication for cranioplasty, 94, 269, 278

Glioblastoma, 9 in blast concussion, 215, 226, 234, 237,

Gliosis, 125 238, 242, 258, 260

Goldstein-Scheerer cube and stick test, 324 in brain abscess, 210

Goodenough test, 281 in craniocerebral injuries, 91

Grafts- in posttraumatic epilepsy, 284

in dural closure, 104, 116, 149-150, 174, psychiatric factors in, 258

191, 212 Hearing aid, in aphasia, 332

in repair of scalp wounds, 266 Hearing impairment, in posttraumatic

See specific types. epilepsy, 280

Gram-negative bacillary meningitis, 117, 207 Helmet, 124
444 NEUROSURGERY

Hematogenous changes, in mortal head Histogenous changes, in mortal head injuries,

injuries, 259-262, 373, 396 359-362, 373, 39C,

Hemiatoma. See specific types. Histologic studies, inHematoma formation: mortal head injuries, 335-399

cerebral fungi after, 107 posttrautnatic epilepsy, 313-315

convulsions with, 108 History taking, inin craniocerebral injuries, 83-84, 102, blast concussion, 223

115, 135 posttraumatic epilepsy, 279-280

Hematoxylin staining of nerve cells, 345, 347 Hoarseness, 329

HEMBERGER, A. J., 263, 267 Holding period, in forward hospitals, 40

Heinisnesthesia, 394 Holland, 58

Hemianopsia, 158, 332 Homonymous hemianopsia, 130, 159, 163,

Heiniparesis, 130, 310, 316 197

Hemiplegia, 22, 130, 293, 332, 394 Homonymous visual field defect, 159

in World War I, 90 HOOKER, D. R., 227

Hemniplegic anesthesia, 238 Horn cells, of spinal cord, 241

Hemisphere changes, in carotid artery HORRAX, G., 166

wounds, 119 Horseshoe flap, in scalp wounds, 100

Hemoperitoneum, 228 Hospital centers:

Hemoptysis, in blast concussion, 241 12th, Malvern Wells, Worse., 62

Hemorrhage, control of, 26, 77,105, 124, 142, 15th, Cirencester, Glos., 62, 86

143, 146, 156, 192, 395 No. 4108, Musgrove Park, Taunton,

Hemorrhage, in- Somerset, 62

blast concussion, 226, 228, 230, 234-236, No. 4124, Odstock, Nr. Salisbury, Wilts, 62

237, 241,254, 258 No. 4140, Hermitage, Nr. Newbury,

eraniocerebral injuries, 102, 124, 127, 129, Berks., 62

135, 143, 146, 171, 189, 206, 395 No. 4144, Churchill, Headington, Oxon, 62

craniocerebral surgery, 146, 303, 304 No. 4166, Frenchay Park, Bristol, Glos., 62

discontinuous skull fractures, 339 No. 4204, Diddington, Nr. St. Neots,

mortal head injuries, 339, 340, 343-345, Hunts., 62

383, 396 No. 4209, Redgrave Par, Nr. Botesdale,

transventricular wounds, 169-170, 183, East Suffolk, 62

189, 190, 192, 195-197 No. 4210, Norley Hall, Nr. Wymondham,

wounds of dural sinuses, 124, 135, 159, 162 Norfolk, 62

wounds of scalp, 77, 142 No. 4211, North Mimms Park, North

wounds of skull, 142, 143 Mimms, Herts., 62

Hepatitis, 28 No. 6810, Whitchurch, Flintshire, 62

HEPPENSTALL, .M. E., 246 Hospital centers, ETOUSA, 47, 61-63, 66-67

Heredity, role of, in posttraumatic epilepsy, Hospital trains, 64

285 Hospitalization policies, in World War 1, 3-4

Herniated nucleus pulposus, 31, 36, 38, 50, Hospitals. See specific types.

61, 86 Hospitals, evacuation:

as military problem, 7, 8 8th-107, 335

indications for surgery in, 10 13th-335

record forms for, 8 16th-335

separation from service for, 8 28th-335

surgery for, 8, 9, 10 34th-83

High-explosive missiles, in blast concussion, 45th-83

217, 219, 223, 225, 226. 237, 241 67th-83

HILL, D., 246 94th-335

HILLER, F., 259 95th-83

Hindbrain, 257 96t h-83

Histiocytes, in mortal head injuries, 361, 367 97th-83
INDEX 445

Hospitals, evacuation--Continued Hospitals, general-Continued

102d-83 numbered--continued

103d-83 91 st-62

128th-83 98th-62

170th--335 100th-62

171st-335 158th-62

Hospitals, field: 160th-56, 62, 115, 212

13th-83 184th-212

45th-83 Hospitals, station:

47th-83 named:

51st-83 Fort Bragg, 6

Hospitals, general: Fort Sam Houston, 6

named: numbered:

Ashford, 12, 13 49th-61, 62

Billings, 6 231st-61, 62

Birmingham, 12, 13, 332, 372 Hospitals, various:

Brooke, 12, 13, 18, 320, 322, 323 Canadian Neurological Hospital No. 1,

Bushnell, 12, 13, 324 Basingstoke, 71

Cushing, 12, 13, 98, 279-317, 332 Deuxnouds, 89

DeWitt, 12, 13, 325 Hill End Hospital, London, 71

England, 12, 13, 32, 325 H6pital de la Pitid, Paris, 72

Fitzsimons, 12, 13, 96 Hospital for Peripheral Nerve Injuries,

Halloran, 12, 13, 18, 32, 334 Oxford, 71

Hammond, 13, 95, 272 Johns Hopkins Hospital, 5

Hoff, 6, 12, 272 St. Hugh's Hospital for Head Injuries,

Kennedy, 12, 13, 95, 97, 324 Oxford, 71

LaGarde, 6 Hospitals, visits of neurosurgical consultant

Lawson, 6, 12, 13 to, inLetterman, 3, 6, 12 ETOUSA, 46-47, 49-51, 64-66

Lovell, 6, 12 Zone of Interior, 34-38

McCaw, 12, 13 HUNT, H. B., 340

McCloskey, 12 Hyalin bodies, inMcGuire, 18, 320, 324, 325 craniocerebral injuries, 351

Mayo, 13 mortal head injuries, 359

Newton D. Baker, 13, 96 Hydromite, 263

Nichols, 12, 13 Hyperacusis, in blast concussion, 215, 238,

Northington, 13 239, 242, 256, 260

O'Reilly, 6, 9, 12, 13, 16 Hyperemia, ofPercy Jones, 6, 9, 10, 12, 13, 15, 324, brain, 230

325, 333. leptomeninges, 230

Schick, 12, 13 Hyperostosis of skull, 261

Tilton, 6, 12 Hyperreflexia, in blast concussion, 239

Wakeman, 12, 13, 325 Hypersynchrony, in electroencephalogral)hy,

Walter Reed, 5, 6, 7, 8, 9, 11, 12, 13, 17, 257, 309

18, 82, 106. Hyperthermia, 84, 135, 181

numbered: Hyperventilation, in posttraumatic epilepsy,

1st-62 281,295

11 th-319 Hypoglossal nerve, 327, 328, 330

21st -105

33d-42, 43 Hypoproteinemia, in41st-319 brain abscess, 213

55th-62 infected head injuries, 203

65th-62 Hypotension, in blast concussion, 241

8&3d-62 Hypothalamus, 257, 339, 384, 394

455735-58---30
446 NEUROSURGERY

Hysteria, in- Indications for-(Continued

blast concussion, 223-224 opening dura, in spinal cord injuries, 65

shellshock, 217 Pentothal Sodium anesthesia, 139

roentgenologic examination, in head inIdentification of mortal head injuries, 101- juries, 131, 134

102, 335, 373-375, 394-396 surgery, inIdiopathic epilepsy, 284, 286 brain abscess, 93

Ilium, cranioplastic material from, 90, 94 herniated nucleus pulposus. 10

Illinois Psychiatric Institute, 306 penetrating craniocerebral wounds, 101-

Immersion blast concussion, 227, 233-234,242 102

Inadequate debridement, 93, 105, 114, 119, posttraumatic epilepsy, 97-98, 292-293

183, 189 Inductorium, 78

as cause of brain abscess, 208 Infection:

as cause of cerebral fungi, 107 after cranioplasty, 93, 96, 271, 303

as cause of infection, 124 after drainage in penetrating craniocerIncidence of-- ebral wounds, 104

blast concussion, 222-225 after inadequate debridement, 58

bone-nerve injuries, 18 as cause of death in transventricular

craniocerebral injuries, 82, 157 wounds, 183, 192-193, 199

dysarthria, 327 as contraindication to cranioplasty, 270,

fungus cerebri, 17 278

beli-atoma formation, 102 cerebral fungi after, 107

infection, 84, 105, 146, 147, 183, 184, 201 in closed head injuries, 146

meningitis, in head injuries, 117, 166, 204 in craniofacial wounds in World War

neurologic defects, in posttrauniatic epi- 1, 90, 172

lepsy, 284 in head injuries, 104, 105-106, 110-111,

penetrating craniocerebral wounds, 112 120, 124-125, 135, 148-14q, 201-213, 271

peripheral nerve injuries, 82, 120 in mortal head injuries, 367-369, 384

posttraumatic epilepsy, 97, 117, 270 in peripheral nerve injuries, 86

posttraumatic syndrome, 107 in scalp wounds, 86, 100

retained foreign bodies, 114 in skull fractures, 142, 339

scalp wounds. 99 in spinal cord inijuries, 86

skull fractures, 157 in transventrieular wounds, 166, 183, 184,

spinal cord injuries, 82, 120 189, 190

ventriculitis, 166 incideiice of, 84

wounds of-- management of, 203-204

dural sinuses, 159 of antecedent wound in posttraumatic

paran-Pl si!uses, 174 epilepsy, 283-284, 285, 294

Incisions, in- prevention of, 2'6, 201-202

craniofacial wounds, 173 See also Residutl infection, st,,cific types.

cranioplasty, 9,5 Inferior olivary nucleus, 346

craniotomy, 266 INGERSOLL, J. M., 319

peripheral nerve injuries, -75 INGHAM, S. D., 319

repair of cerebrospinal fluid fistula, 104 INGRAHAM, F. D., 77, 113, 150

scalp wounds, 99, 100, 150-153, 155, 202 Initial wound surgery. See Debridement.

surgery for posttraumatic epilepsy, 302- Inlay technique of cranioplasty, 95-96,

303 266-267, 269

through-and-tbroagh wounds of brain, 172 Inner table of skull, fractures of, 101, 157

Incontinence, in epileptic seizures, 292 Insomnia, in blast concussion, 234, 257

Indications for-c

cranioplasty, 92, 94, 269-271, 278 Intercurrent causes of 1rans- death, in 

debridement in penetrating craniocerebral ventricular wounds, 183

wounds, 112 Inter-Hospital Letter, 8-10, 26

lumbar puncture, 179 Internal hydrocephalus, 191-192, 301
INDEX 447

Intestine, perforation of, in blast concus- KING, J. F. J., 211

sion, 227 KLaMm, R. A., 241

Intracerebral hemorrhage, in blaet conl- Knox cube test, 324

cussion, 258 KOZOL, H. L., 259

Intracortical hernatomais, 163, 171-172, 183 KROHN, P. L., 251, 252

Intracranial hematomas, 124, 140, 163-165,

321 Laboratory examinations, in aphasia, 323

slow respiration as sign of, 130 laboratory studies of nerve regeneration, 20

Intracranial pressure-- Lacerations, ofafter craniocerebral surgery, 179 brain, 216, 227, 342, 396, 397

during head surgery, 139 dura, 93, 103

in blast concussion, 254 scalp, 58, 63, 86, 140

in brain abscess, 210, 211, 212 Lamina cribrosa, 384

in cerebrospinal fluid fistula, 103-104 Laminectomy, 58, 83, 84, 86

in craniocerebral injuries, 102, 124, 129, Land mines, 123-124

135, 395 Laryngeal syndromes, 328

in fungus cerebri, 107, 119 Laryngectomy, 329

in meningitis, 208 Laryngoscopy, 323, 328

in transventricular wounds, 190--191 Laryngospasm, 139, 173

Intratracheal anesthesia, 137, 138, 139, Larynx:

159, 173 aphasia after wounds of, 319

Intrathecal antimicrobial therapy, 103, 119, 204 trauma to, 322, 329-330

in brain abscess, 116, 120 tumors of, 328, 329

in meningitis, 117, 120, 206-207 Lateral ventricles, 168-169, 339, 384

in transventricular wounds, 191-192 changes in, in blast concussion, 239

Intravenous fluids, in head injuries, 58, 128 instillation of penicillin into, 178

Intraventricular chemotherapy, 207 Lateralization of pathologic changes, 131

Intraventricular hemorrhage, 181, 183, 339, Leptomeninges, 124, 341, 342, 367

383, 394 damage to, in blast concussion, 230

Irrigation, in debridement of craniocerebral Lethality of head injuries, 101-102, 168,

injuries, 126, 145-146, 168, 169, 183 335-399

Isehemic changes, in- See also Mortal head injuries.

craniocerebral injuries, 124, 340, 345, 346, LEVICH, L. A., 261, 263

369, 383 LEwEY, Lt. Col. F. H., 279

nerve cells, 339 Liaison between professional services,

wounds of carotid artery, 119 ETOUSA, and Office of Surgeon General, 72

Ischemic necrosis, of scalp, 151, 302 Liaison functions of senior consultant in

Isle of Man incision, 151 nenrosurgery, 48

Italy, 182, 222, 335, 396 Liaison with Allied neurosurgeons, 71-72

Liege, 13

Jacksonian convulsions, 108, 134, 179,286,295 Linear fractures, of skull, 140, 157-159, 338

Jaw, wounds of, 319, 329 Lipiodol myelography, 10

JEFFERSON, G., 61, 71, 257 Lips, wounds of, 322

Liver, wounds of, 84

KAHN, E. A. 212 1W;VINGSTON, K. E., 261, 270

KANE, Lt. Col. J. W., 7 1heal analgesia, 22, 59

KENNARD, 'M. A., 257 (ontraindicated, in craniofacial wounds,173

Kent EGY test, 324 in craniocerebral injuries, 137, 138-139

KERMAN, W. Z., 224, 240, 24-1. 246, 247, 256 in cranioplasty, 37, 266

KERNOHAN, J. W., 340, 357, 362, 369 in peripheral nerve surgery, 35, 37

KERR, A. S., 262 in spinal cord injuries, 65

Kerr's compounds, 263, 266 in surgery for posttraumatic epilepsy, 302

KIMBROUGH, Col. J. C., 51, 64, 66 Local antimicrobial therapy, inKinesthetic aura, 287 craniocerebral injuries, 126, 147-148
448 NEURlOSURG ERY

Local antimicrobial therapy, in--Continued Management, of ('ontinued

craniofacial wounds, 175 dura, in-continued

transventricular wounds, 166 skull wounds, 142-143, 157-158

Local penicillin therapy, in-- surgery for posttrauniatic epilepsy, 303-

brain abscess, 212 304, 313

craniocerebral injuries, 119, 203- 204 dural injuries, 81, 111, 113-114, 148-150

transventricular wounds, 168, 191-192 in World War 1, 183

Local prep)aration, in craniocerebral injuries, epileptic seizures, 291-292

136 infection, in head injuries, 105-106, 203-204

Local sulfonamide therapy, in - intracranial heanatonias, 163-165

brain abscess, 116 meningitis, 117, 206-208

craniocerebral injuries, 10, 11, 106, 109, neurosurgical casualties, ETOUSA, 60-63,

111, 119, 128, 202 66-67

dural wounds, 135 paraplegics, 74, 79

peripheral nerve surgery, 11 peripheral nerve injuries, 4, 22-24

Localization of focus, in posttraunatic posttraumatic epilepsy, 289-317

epilepsy, 91, 286, 294 scalp wounds, 111

Location of-- skull defects, 9-10, 92, 93-96

antecedent wounds, in posttraumatic spinal cord injuries, 4, 64

epilepsy, 282, 285, 286 through-and-through wounds of brain,

motor auras, 286 171-172

somatosensory auras, 287 transventricular wounds, 183, 190-192

LOFSTROM, J. E., 173, 174, 201 tumors, 4

London, 56, 71, 74 wounds of dural sinuses, 159-163

Lon• bones, fractures of, 130 Manchester, 71

Longitudinal sinus, 83, 159, 161-162, 303 Mandible, fractures of, 329

Lucite cranioplasty, 313 Manpower losses, from herniated nucleus

Lumbar puncture, 118, 119, 179, 206, 207 pulposus, 8

Lymphocytes, in mortal head injuries, 361. Manual of Therapy, ETO, 65, 73-74, 110

367 MARCHAND, W. E., 219, 226

LyN,,, ,. G., 242 Marginal gliosis, 357

MARSHALL, Capt. C., 305

Macrophages, in mortal head injuries, 367 Marsupialization in brain abscess, 106

Malaria, 28 Masked facies, in blast concussion, 240

Malignant cerebral fungi, 107 Mastoid, 83, 127, 131, 139, 172, 208

Malignant neoplasms, 10 MARTIN, J., 147, 182

Malingering, 217 MARTLAND, H. S., 344

Management, of-- MATSON, Maj. D. D., 84, 115, 159, 164, 168,

aphasia, 321, 326-332 173, 174, 178

blast concussion, 255, 259-260 Maxilla, injury of, in air blast, 222

brain abscesses, 47, 93, 105-106, 112, 115- Maxillary sinus, 83, 139, 174, 175

117, 211-213 Maxillofacial surgery, 40, 62

cerebral fungus, 108, 212-213 Maxillofacial wounds, 99, 322, 327, 329, 330

cerebrospinal fluid fistula, 103-104 MAYFIELD, Lt. Col. F. H., 6, 7, 10, 261. 263

closed head injuries, 100-101, 109, 111- MCCARTHY, W. D)., 261, 263

112, 157-159 N' CRAVEY, Lt. Col. A., 6, 7

convulsions, after craniocerebral surgery, MCMILLEN, J. H., 338

179-180 Measurement of abstract behavior, 324

craniocerebral injuries, 4, 101, 109-122, Mechanical aptitude studies in aphasia, 324

123-182 Mechanism, ofat Cushing General Hospital, 21-22 blast concussion, 252-255

dura, in- damage to vital centers, in mortal head

craniofacial wounds, 174 injuries, 374

fungus cerebri, 118 discontinuous fractures, 101, 338
INDEX 449

Mechanism, of-Continucd Meningitis-Continued

vascular rupture, in head injuries, 342-343 sulfonamide therapy in, 206-207

Mediastinal hemorrhage, 228 urea therapy in, 207

Medical Bulletin, Officer of Theater Chief Meningocerebral scars, 125, 304

Surgeon, ETOUSA, 109, 111 Meningccoccic meningitis, 206

Medical Field Service Training School, Mental disturbances, inShrivenham, Berkshire, England, 70-71 brain abscess, 211

Medical laboratories: posttraumatic epilepsy, 293

1st-81-82 Mental hygiene, in stuttering, 331

2d-336 MEREDITH, J. M., 211

Medical Research Council, 71 MERRITT, H. H., 258

Medical supply depots, United Kingdom Mesencephalon, 257, 339, 374, 384, 396

Base, 74 Mesodermal components of central nervous

Medical therapy, in posttraumatic epilepsy, system, 339, 369, 396

90, 91, 289-292 Mesoglia, 357

Mediterranean (North African) Theater of Metastatic brain abscess, 209

Operations, 11, 13, 25, 39, 41, 58, 74, 82, Metencephalon, 257

107, 255, 320 Methyl methacrylate cranioplasty, 94, 262

craniocerebral injuries in, 99-108, 112, 148, Metrazol, effect of, in posttraumatic epilepsy,

183 297-299

field hospitals in, 39-40 Metrazol activation, in posttraumatic epineurosurgery in, 39-43 lepsy, 306-308

Medulla oblongata, 339, 346, 374, 384 Microglia, 357, 362, 373

Meetings, of- Microscopic studies, in blast concussion, 218,

Allied neuropsychiatrists, 218 227-228, 229-230, 231, 236, 250-251, 252

British medical societies, 71 Midbrain, 101, 257

neurosurgeons, in- Middle meningeal hemorrhage, 11

ETOUSA, 71, 72-73, 113, 114 Migration, ofUnited Kingdom Base, 71, 116, 117. 118, epileptogenous focus, 309

119 foreign bodies, in head injuries, 190

U. S. armies, ETOUSA, 73 ventricle, 118

Membrana limitans perivascularis, 340 Military Occupational Specialty (MOS)

Meninges: rating, for neurosurgery, 47, 48, 60, 67, 68

hemorrhage into, in blast concussion, 258 MILLER, G. G., 340

wounds of, 142 Minnesota multiphasic test, 324

Meningismus, 206 Missile track, in head injuries, 131-133

Meningitis, 84, 86, 208, 209, 321 Mitosis, in mortal head injuries, 359, 362

adjunct therapy in, 208 Mixed aphasia, 319, 326

after brain abscess, 105 MIXTER, J., 8

antimicrobial therapy in, 206-207 Mobile neurosurgical teams, 54

as cause of death in craniocerebral injuries, Mobilization, of181 frozen joints, 23

bacteriology of, 206, 207 nerves, 35

case fatality rates in, 117, 208 Mobilizing radial splints, 38

diagnosis of, 206 Mold, preparation of, in cranioplasty, 263-

etiology of, 204-206 264, 268-269

in craniocerebral injuries, 117, 178-179, Monoplegia, 130

204-208 Monoplegic anesthesia, 238

in craniofacial wounds, 172 MONRoD-KROHN, G. H., 27

in mortal head injuries, 367, 395 Montenovesi rongeurs, 142

in transventricular wounds, 166, 189 Montreal, 9, 97, 279

management of, 117, 206-208 Moralepenicillin therapy in, 206-207 in paraplegia, 38

spinal puncture in, 206, 207 of neurosurgical personnel, 57, 67, 69, 71
450 NEUROSURGERY

Morphine: MUNRO, D., 146

in craniocerebral injuries, 110, 128,129,177 MUNSLOW, R. A., 148, 181

in surgery for posttraumatic epilepsy, 302 MURPHY, Lt. Col. F., 6, 7, 9

preoperative use of, 138-139 Muscle atrophy, in peripheral nerve inMortal head injuries, 181-182, 197-198, juries, 11

335-397 Muscle implants, 26

amitosis in, 373 Muscle stamps, 146, 162

associated injuries in, 336 Muscular power, technique of determination

attempts at identification of, 335-397 of, 22

autopsy findings in, 335-397 Muscular twitchings, in blast concussion,

causes of death in, 336 241,242

changes in axons in, 347-348 Muzzle blast, 216, 220, 224. 232

changes in capillaries in, 362, 396 Myelin sheaths of nerve fibers, 247

changes in nerve cells in, 369 Myelography, 7, 8, 9, 10, 13, 75

changes in pupils in, 394 Myoclonus, 241

criteria of, 335, 396-397

debridement in, 397 Nancy, 53

edema of brain in, 339, 342, 347, 351, 357, Naples, 42

359, 369, 373, 374, 396 Narcosynthesis, inhematogenous changes in, 259-262, 373, blast concussion, 256, 260

396 stuttering, 331

hemorrhage in, 339, 340, 342-345, 383, 396 Nasal bones, comminution of, 173

histogenous changes in, 359-362, 373, 396 Nasogastric alimentation, 178, 208

histologic studies in, 335-399 Nasopharynx, wounds of, 139

infection in, 367-369, 384 National Research Council, 10, 25, 113

intraventricular hemorrhage in, 339, 383, Nausea394 after forced hydration, 295

mechanism of damage to vital centers in, after surgery for posttraumatic epilepsy,

374 316

meningitis in, 367, 395 in epigastric auras, 289

necrosis in, 339, 342, 347, 359, 361 in vertiginous auras, 289

pathologic studies in, 335-399 Naval hospitals, 223, 271

surgery in, 335, 374-375, 394-399 Naval Medical Center, 9

time of death in, 336, 339, 341, 346, 348, Neck, wounds of, 119, 328

359, 362, 374, 384, 394, 395 Necrosistimelag in, 397 in craniocerebral injuries, 105, 107, 124

Mosquito forceps, 75 in mortal head injuries, 339, 342, 347, 359,

Motion sickness, 10 361,369

Motor aphasia, 130, 319 of corpus callosum, 85

Motor aura, 286 of scalp, after cranioplasty, 271

after Metrazol injection in posttraumatic of scalp incision, 99, 156, 2C6

epilepsy, 298-299 Neoplasms, paraplegia caused by, 18

Motor components of complex auras, 288 Nerve cells, changes in, inMotor (expressive) dysphasia, 326 blast concussion, 216

Motor hallucinations, in auditory auras, 289 mortal head injuries, 339, 345-346, 369

Motor phenomena- Nerve fibers:

after somatosensory auras, 288 changes in, in mortal head injuries, 347-

in epileptic seizures, 292 351,394

induced by stimulation of cortex, 309 electrical stimulation of, at operation, 23

Motor weakness, in posttraumatic epilepsy, Nerve grafts, 21, 24

108 regeneration, 22, 29, 35

MoTr, F. W., 217, 225 repair, 24, 86

MULFORD, Capt. E. H., 107, 150, 181, 182 scars, 22

Multiple neuritis, 319 stretching, 35
INDEX 451

Nerve-bone injuries, 86 Neurorrhaphy, 21, 28

Nerves: Neuroses, with--

mobilization of, 35 aphasia, 322

transposition of, 37 dyslogia, 331

Neuroanatomy, 25, 26, 27, 29, 30 Neurosurgery:

Neurogenic symptoms, in blast concussion, as specialty in World War II, 3-4

238 between World Wars, 4, 89

Neurologic aftereffects of surgery, in brain British consultants in, 71

abscess, 212 case fatality rates in, ETOUSA, 82-86

Neurologic changes, in cerebral fungi, 107, conference on, 1942-6-8

213 in European Theater of Operations, 45-86

Neurologic defects, signs. See specific de- in Mediterranean Theater of Operations,

fects, signs. 39-43

Neurologic defects, in- in World War I, 3, 25, 89-90

craniocerebral injuries, 92 in Zone of Interior, 3-38

posttraumatic epilepsy, 280, 284, 290, 293 on Normandy beachhead, 65-66

Neurologic disturbances, after cranioplasty, professional training in, 24-31

96 senior consultants in, ETOUSA, 45-86

Neurologic examinatien, 26, 27, 127, 129- standardization of, 7, 8

131 Neurosurgical care, of--

in aphasia, 323 dependents, 7

in blast concussion, 218, 223, 242 French casualties, in U. S. hospitals, 71-72

in posttraumatic epilepsy, 280, 316 Neurosurgical casualties:

Neurological Institute, College of Physi- air evacuation of, 63-64, 65, 111, 121, 180

cians and Surgeons, Columbia University, assignment of, to specialized centers, 5-6,

25, 26, 27 321-322

Neurological Institute, Montreal, 97 critique of management of, 66-67

Neurological personnel, shortages of, 19 definition of, 11, 61

Neurological sections, in neurosurgical cen- disposition of, 17, 18, 67

ters, 17, 34-35 estimates of, 82

Neurological sequelae of- evacuation of, in ETOUSA, 47, 53, 62-64,

blast concussion, 216, 237, 239-240 67

craniocerebral injuries, 271, 321-322, 332 in North Africa, 25

signs, in- transfer of, to Veterans' Administration

craniocerebral injuries, 131 hospitals, in World War I, 4

intracortical hematoms, 163 triage of, in ETOUSA, 11-12, 63

skull fractures, 157-159 Neurosurgical centers:

transventricular wounds, 189-100 administration of, 16 17

Neurologists, 17, 20, 32, 36, 53, 91-92 backlog in, 34

Neurology: chiefs of section in, 15, 16

British consultants in, 71 convalescent wards in, 17, 18

training in, in World War I, 3 equipment of, 34, 35, 38

Neurology and Psychiatry, Division of, Sur- evaluation of personnel in, 34, 36

geon General's Office, in World War I, 3 freezing of personnel in, 16

Neurolysis, 21, 28, 86 furlough system in, 20

Neurones, in posttraumatic epilepsy, 313, 315 in corps areas, 6

Neuronophagia, 357, 373 in ETOUSA, 51-53, 61-63, 64, 66-67, 78,

Neuropathology, 27, 35, 38 80

Neurophysiology, 25, 26, 27 photography in, 81-82

Neuropsychiatric casualties, 46, 223 in MTOUSA, 41-42

Neuropsychiatric centers, 322, 328, 331 in service commands, 6

Neuropsychiatric Institute, University of in United Kingdom Base, 67, 69, 82, 119

Illinois, 25 in Zone of Interior, 5-24, 69, 89, 91, 113,

Neuropsychiatrists, 222, 329, 331 328, 330
452 N EURIOSUItG ERY

Neurosurgical centers--C('ottitued Neturosurgical personnel--(C'ontiitiud

neurological sect'ions ill, 34-35 training of, in - organization of, ill Brit ish ieurosurgical facilities, 71

ETOU)USA, 51-53 ('anadian, neurosurgical facilities, 71

Zone of Interior, 18-24, 34-35, 36-37 ETOUSA hospitals, 6M-70

oft hol4'dic-nellrourgical wards ill, 36 utilization of, in World War I, 3

paraplegic wards in, 17, 18 wastage of, ill

refresher courses in, 16 ETOUSA, 46, 59-60, 66

rouitinle of - MTOUSA, 41, 42-43

admission to, 21 workload of, 58, 59-6t0

diagnosis in, 21-23 Neurosurgical planning, in 1942, 5-Il

staffing of, ill - Neurosurgical policies:

ETOUSA, 51-53 dis.sei•kllatioll of, 8--I1

Zone of Interior, 5, 6-7, 12, 19, 21 evohuition of, il MTIOUSA, 39

statistics of, :14, 36 Neurosurgical procedure's:

student officers in. 16 duration of, 15-16

workload of, 5-6, 7, 11, 12-13, 15-16, 18-19, standardization of, 6, 7, 9

20ý-24, 26, 28, 32, 56, 66-67 Neurosurgical teams, 25, 67, 68, 125-126.

Neurosurgical evaluation, in blast concus- 180

sion, 239--242, 260 equipment of, 60

Neurosurgic:al injuries, register of, 21 in MTOUSA, 41

Neurosurgical kits, 74-75 in transit hospitals, in ETOUSA, 55

Neurosurgical patients, management of, by on Normandy be-achhead, 65-66

contract service, 4, 5, 6 workload of, in--

Neurosurgical personnel: ETOUSA, 66, 82-86

administrative difficulties in assignment MTOUSA, 41

of, 59-60, 66, 67, 70 Neurosurgical-orthopedic wards, 18

assignment of, in - New vessel formation, in head injuries, 125

ETOUSA, 46-47, 48-64) Nightmares, in blast concussion, 242

forward hospitals, 58-60, 101, 123 Nims, L. F., 257

MTOUSA, 40, 42-43 Ninth U. S. Army, 66, 73

Zone of Interior, 5, 6-7, 12, 19, 109 Nissl bodies, 250

contacts of consultants with, 74 Nissl stains, :145, 347

evaluation of, in--- Nitrous oxide-oxygen-ether anesthesia, 1!7-

ETOUSA, 46-47, 70 1:38

Zone of Interior, :14 Nomenclature, of

global (list ribut ion of, 124 blast concussion, 215-219

in affiliated hospitals, 25 speech disorders, 326, :127, 329

in speech clinics, 323 Nontransportable casualties, :19, 40, 64, 66,

meetings of, in ETOUSA, 72-73 84, 101

morale of, 57, 67, 69, 71 NORvROtSs, N. C., 261, 269

recommendations for assignment of, 66-68 Normandy, 6:3, 64, 65-66, 120, 226

recruitment of, 24-25 North African Theater of Operations. See

redeployment of, from ETOUSA, 617-619 Mediterranean Theater of Operations.

rotation of, in NORTIIFIELD, I). W. C., 211

ETOUSA, 57-58, 69, 80 Nose:

MTOUSA, 41-42 aphasia after wounds of, 3:19

shortages of, in -- hemorrhage from, in blast concussion, 244

ETOUSA, 46, 48-49, 56 NOSIK, W. A., 234

MTOUSA, 40, 42-43 Novocain block of stellate ganglia, I Ill

World War I, 3, 4 Nuclei, changes in, in head injuries, 216, 345,

Zone of Interior, 15, 19, 22, 24-25 :351

statistics of, oil V-E Day, 68-69 Nurses:

temporary duty for, after V-E I)ay, 67 in neurosurgical cent{ers, ET(O)USA, 51
INDEX 453

Nurses -Continued OSNATO, M., 342

on neurosurgical teams, 55, 59, 126 Osteomyelitis, 209, 261, 281

rotation of, 70 Osteoplastic flap, in cranial surgery, 104

training of, in ETOUSA, 69, 70 Otitis media, 322

with neurosurgical training, 13-14 Otolaryngologists, 53, 173, 280, 281

Nursing care--- Otorrhea, 206, 207, 208

by enlisted personnel, 14 Outer table of skull, fractures of, 157

in craniocerebral injuries, 22, 175, 396 Oxford, 71

in paraplegia, 18, 36, 38, 79 Oxidized cellulose cotton, 77

on recovery wards, 17 Oxygen, inNutrition, in-- Pentothal Sodium anesthesia, 139

eraniocerebral injuries, 203 resuscitation, 128

meningitis, 208

paraplegia, 18, 38 Pacific Ocean areas, 67, 110, 223

Nylon sutures, 126 Pain--

Nystagmus, 289-290 as indication for cranioplasty, 94, 269, 278

in craniocerebral injuries, 177

Obsessive-compulsive states, 241 in craniofacial wounds, 177

Occipital lobe: Painful stimuli, response to, in head injuries,

damage to, in blast concussion, 251 129

epileptogenous foci in, 302 Palate, defects of, 322, 326, 329, 330

wounds of, 37, 130 Pantopaque myelography, 7, 8, 9, 10, 15, 75

Occupational therapy, 10, 317, 323 Paraldehyde inO'CONNELL, J., 71 craniocerebral injuries, 177

Office of the Surgeon General, 5, 12, 16, 25, meningitis, 208

26, 28, 65, 69, 72, 320 posttraumatic epilepsy, 180

chief surgical consultant in, 5, 34, 64-65 Paralysisconsultant in neurosurgery in, 5, 34-38 after surgery for posttraumatic epilepsy, 312

Olfactory bulb, 251, 338 in blast concussion, 227, 238, 243, 257

Olfactory hallucinations, 288 in craniocerebral injuries, 130, 131

Oligodendroglia, 357, 373 in peripheral nerve injuries, 86

Onlay technique of cranioplasty, 266, 267, 269 of larynx, 328

Ophthalmologists, 53, 173 of vagus nerve, 328

Ophthalmology, 27, 40 Paranasal sinuses, 83, 127, 139, 140, 149,

Opisthotonos, 296 172, 173-174, 175, 178, 206, 207, 208

Optic chiasm, 174 Paraplegia, 8, 11, 20, 35-36, 38

Optic nerve injury, 240 association of, with posttraumatic epiOran, 39 lepsy, 281

Orbit, injuries of, 139, 140, 172, 173, 175, 206, caused by neoplasms, 18

208, 338, 397 evacuation in, 64, 65, 74, 79

Organic neurologic approach to blast concus- in posttraumatic epilepsy, 293

sion, 256-259 management of, 74, 79

Orthopedic casualties, 79 morale in, 38

Orthopedic representation, at staff confer- nursing care in, 18, 36, 38, 79

ences, 23 nutrition in, 18, 38

Orthopedic services, neurosurgery on, be- reconditioning in, 38

tween World Wars, 4 urologic care in, 27, 35, 38

Orthopedic surgeons, in neurosurgical cen- Paraplegic program, 8

ters in ETOUSA, 53 Paraplegic wards, in neurosurgical centers,

Orthopedic surgery, use of neurosurgeons for, 17, 18

in MTOUSA, 42 Parasagittal wounds, 130

Orthopedic-neurosurgical wards, 35, 36-38 Paresis, 158

Oscillatory phase of shock wave, 219, 220 Parietal lobe, 285, 286, 322, 327, 339

Oscillometry, in posttraumatic epilepsy, 281 epileptogenous foci in, 302
454 NEUROSURGERY

Paris, 53, 72 Pentothal sodium anesthesia:

PASTER, S., 224, 234, 236, 256 contraindication to, in craniofacial

Pathogenesis, of blast concussion, 215 wound!, 173

Pathologic physiology, of contralateral he- in craniocerebral injuries, 137, 138-139

nmatoma, 164 iii surgery for posttraumatic epilepsy, 302

Pathologic process, ill- in wounds of dural sinuses, 159

blast concussion 215, 216, 217, 226, 227- Pentothal Sodium narcosis, in blast concus236, 241, 243, 250-251, 256, 257 sion, 256, 260

brain abscess, 209-210 Pentylenetrazol. See Metrazol.

cerebral fungi, 107-108 Peptic ulcer, 257

craniofacial wounds, 174 Percy Jones splint, 35

transventricular wounds, 189 Perforation of--

Pathologic studies, on mortal head injuries, intestine, in blast concussion, 227

335-397 palate, 329, 330

Pavement skull fractures, 100 Pericranial grafts, 104, 113, 118

Pavlovian theory of blast concussion, 256 in dural wounds, 149, 174, 191

Pearl Harbor, 11, 13, 110 in skull injuries, 143

Pedicle grafts, 100, 118, 149 Periganglionic spaces of Obersteiner, 341

Pelvis, fracture of, 85 Periosteal elevator, 126

Penetrating craniocerebral injuries, 11, 49, Peripheral circulation, status of, in head in..

65, 78, 81, 82, 83, 99, 101-104, 112-119 juries, 129

case fatality rates in, 83-84, 85-86 Peripheral nerve injuries, 8, 9, 11, 15. 17, 20,

causes of death in, 85-86 22-23, 26, 28, 31, 35, 37, 50, 58, 61, 71,

delayed debridement in, 105-106 75, 78, 81, 83, 86, 89

drainage in, 104-105 anesthesia for, 35, 37

foreign bodies in, 114-115 chemotherapy in, 11, 86

grafts in, 104 civilian type, 48

indications for surgery in, 101-102 delayed suture of, 11

infection in, 104, 105-106 errors in management of, 92

management of, 104, 111 evaluation of progress in, 21

redebridement in, 105-106 graphic records in, 21, 22-23

resuscitation in, 102 in World War 1, 4

time of death in, 101 incidence of, 82, 120

Penetrating wounds of spine, 82, 84- incision for, 35

PENFIELD, W., 9, 97, 125, 295 infection in, 86

Penicillin therapy, 27, 29 management ofeffects of, in posttraumnatic epilepsy, 296 at Cushi,)g General Hospital, 22-24

in brain abscess, 93, 116, 210, 212, 213 between World Wars, 4

in cerebrospinal fluid fistula, 103 muscle atrophy after, 11

in craniocerebral injuries, 106, 111, 119- paralysis in, 86

120, 123, 128, 177, 178-179, 203-204, physical therapy in, 11, 79

284 postoperative immobilization of, 18, 35,

in cranioplasty, 272 37, 79

in meningitis, 117, 206-207 primary suture of, 11

in surgery for posttraumatic epilepsy, 302 prognosis of, 23

in transventricular wounds, 168, 191-192 regeneration in, 20, 22, 24, 29, 35

Penicillin, resistant organisms, 116, 118, 209 rehabilitation in, 18

Peninsular Base Section, MTOUSA, 42 spontaneous recovery in, 21, 24

tantalum in repair of, 8, 37, 86

Pensions, in posttraumatic epilepsy, 270 timelag in, 86

Pentobarbital sodium, 138, 316 work furloughs in, 24

Pentothal sodiun,, control of postoperative wound healing in, 86

convulsions by, 180 Peripheral Nerve Registry, 31, 37
INDEX 455

Vc-ivascular space of His and Held, 340-341 P111me, ofPersonality disorders, in aphasia, 330, 332 air blast, 222

Personality factors, in etiology of head in- shock wave, 254

juries, 259 I"iyniouth, 63

Personnel of speech clinics, 322, 323 Pneumatocele, after cranioplasty, 96

Petechiae of brain, 217, 225, 227, 230-231, Pneunmoencephalography, 92, 96, 97, 119

234, 345, 383 in blast concussion, 239-240, 260, 262

PETERSON, Col. L. T., 7 in posttraumatic epilepsy, 280, 299-300

Petit mal, 289, 296 Pneumonia, 183

1Petrous bone, 85, 207, 338 POLLOCK, L. J., 225

Pharyngeal reflexes, loss of, 176 Pollock stimulator, 306

Pharynx, aphasia after wounds of, 319 Polyrnorphonuclear leukocytes, in mortal

Phenobarbital, in posttrauniatic epilepsy, head injuries, 361, 362, 367, 369, 384

289-290, 293, 316 Pons, 339, 384

Phenolsulfonphthalein studies of ventricular PORTER, Lt. Col. W. L., 7

changes in posttraumatic epilepsy, 302 PositioningPhonation, defects of, 319, 326 after head surgery, 176

Photography, 38, 81-82 in peripheral nerve injuries, 37

Physcial examination, in- on operating table, in head surgery, 137

aphasia, 323 Postoperative dehydration, in fungus cerebri,

blast concussioz. 2339 119

posttraumatic ):hepsy, 280 Postoperative edema, in craniocerebral inPhysical factor-, in etiology of blast con- juries, 156

cussion, 259 Postoperative lumbar puncture, in fungus

Phyvsical therapists, in neurosurgtcal centers, cerebri, 119 ETOUSA, 51 Physical therapy equipment, 79 Postoperative management, in- Physiologic thery to central nervous craniocerebral injuries, 175-180 in blast injury tonsystem, posttraumatic epilepsy, 315-316 inbatconcussion, 226-227

Physiologic salt solution, in head injuries, i28 Postoperative wards, in neurosurgical centers,

Physiopathologic theory of blast concussion, 17-18

256-257 Posttraumatic epilepsy, 22, 37, 92, 94, 96,

Physiotherapy, in- 97-98, 108, 271, 279-317, 322, 332

dysphonia, 329 after brain abscess, 117

frozen joints, 23 anesthesia for surgery in, 302, 303

peripheral nerve injuries, 11, 35, 38, 79) anticonvulsive medication in, 90, 91,

Pictorial records, 81-82 289-292, 293, 316

Pineal gland, 237 aphasia in, 293

Pinprick tests, 129 association of, with paraplegia, 281

Pintner nonlanguage test, '24 auras in, 286-289, 309

Plasma transfusion, in- blood supply of brain in, 305

craniocerebral injuries, 128, 177, 178 cerebral scars in, 313-3i5

posttraumatic epilepsy, 315 changes in ventricles in, 299b 302

Plaster-of-paris head caps, 156 clinical picture in, 286-289

Plastic surgeons, 23, 53 convulsions after surgery for, 316

Plastic surgery centers, 62, 322, 330 cranioplasty in, 285, 316

in craniocerebral wounds, 397 debility in, 294

in craniofacial wounds, 173, 281 Dilantin Sodium in, 289-290, 293

in dural wounds, 174 effect of acetylcholine in, 297

in scalp wounds, 140, 142, 156, 266 effect of alcohol in, 295-296

Pleocytosis, in cranio2erebral injuries, 211 effect of Metrazol in, 297-299

Plethysmography, in posttraumatic epi- electric shock in, 296

lepsy, 281 electrocorticography in, 306-311, 312-313
456 NEUROSURGERY

Posttraunmatic epilepsy ---ontinued 4 Preoperative dehydration, in fungus cerebri,

electroencephalography in, 271, 279. 281, 118

284, 285, 289. 294-295, 296, 297, 298, Preoperative examinations, in posttraumatic

299, 305-311 316 epilepsy, 294-302

evaluation of findings in, 281 Preoperative p)reparation, for craniocerebral

examination(s) in, 279, 280, 294, 316, 317 surgery, 128-129, 136-137

familial influence in, 285 Preoperative spinal puncture, in fungus

followup studies in. 316 cerebri, 118

forced hydration in, 295 Preoperative wards, in neurosurgical centers,

general measures in, 291-292 17

headache in, 284 Pressure dressings, in craniocerebral injuries,

histologic studies in, 313-315 156, 267

history of unconsciousness in. 282 Pressure phase of shock wave, 219-220

history taking in, 279-280 Prevention of--

hyperventilation in, 295 cerebral fungus, 104

in World War I, 90 infection, in head injuries, 26, 201-202

incidence of, 97, 270 Primary suture, in peripheral nerve injuries,

indications for surgery in, 97-98, 292-293 11

infection of antecedent wound in, 294 Primary wound closure, in transventricular

influence of foreign bodies in, 292-293, 311 wounds, 191, 199

localization in, 91 Priorities of--

location of antecedent wounds in, 286 evacuation, in head injuries, 110, 134-136

management of, 289-317 surgery, it! transventricular wounds, 167

mental disturbances in, 293 Procaine infiltration anesthesia, 59, 137,

neurologic defects in, 280, 293 138-139

neurones in, 313, 315 Proctologists, 27

occupational therapy in, 317 Professional Services Division, Office of

physical examination in, 280 Theater Chief Surgeon, ETOUSA, 45, 46,

pneumoencephalography in, 280, 299-300 51, 60, 64, 66, 70

postop)erative management in, 315-316 Professional training program:

preoperative examinations in, 294--302 results of, 25, 2%-30

psychologic counseling in, 291 selection of candidates for, 29, 30

rehabilitation in, 279, 316-317 Prognosis, ofrel)lacement therapy in, 315 craniocerebral injuries, 10, 83, 130, 135

roentgenologic examination in, 280, 313, occipital lobe injuries, 37

316 perip)heral nerve injuries, 23

sedation in, 289-290, 293, 316 posttraumnatic epilepsy, 285

surgery in, 279, 290, 292, 294, 302-313 trairsventricular wounds, 169, 170

Tridione in, 296 Projection techniques, in stuttering, 331

two-stage surgery for, 303 Prophylactic antimicrobial therapy, invocational counseling in, 279, 317 cerebrospinal fluid fistula, 120

Posttraumatic epilepsy center, Cushing Gen- craniocerebral injuries, 202

eral Hospital, 98, 279-317 Prophylactic redebridement, 208

Posttraumatic head injury syndromes, 8, 10, Prop)hylactic resection of cerebral scars,

37, 1(7, 109 97-98

Postural drainage, in head injiirles, 110, 111 Prophlaxis, of--

Practical training, in neurosurgery, 25, 26, cerebral scars, 148

28-29, 30-31 postt raumnatic epilepsy, 90

Preinduction stuttering, 330-331 Protein t)recipitate, in craniocerel)ral inPreoperative case fatality rates, in cranio- juries, 340

cerebral injuries, 121-122 Psammomna bodies, 3551

Preoperative chenmotherapy, in craniocere- Psychiatric al)p)roach to blast concussion,

bral injuries, 136, 302, 303 218, 237, 255, 258-259
INDEX 457

Psychiatric battle casualties, 91, 257 Pyramidal cells, 345

Psychiatric factors, in headache, 258 Pyramidal tract, 242, 326, 327

Psychiatric studies, in blast concussion,

256-257, 258, 260 QUADFASEL, Maj. F. A., 279

Psychiatrists, 17, 218, 222 Quadriplegia in posttrauniatic epilepsy, 293

in speech clinics, :122, 323 Quadriplegic anesthesia, 238

Psychiatry:

sections of, 17 Radial nerve-humerus injuries, 37

training in, in World War I, 3 Radial nerve splint, 35, 37

Psychic improvement, after cranioplasty, 96 Radiating fractures of skull, 156

Psychogenic disturbances, in shellshock, 217 Radius, fractures of, 85

Psychologic counseling, in Dosttraumatic RAM6N y CAJAL, S., 348

epilepsy, 291 RAND, C. W., 340, 347, 348, 351

Psychologic examinations, in posttraumatic Raney clips, 77

epilepsy, 279, 280, 294, 316, 317 RANEY, Maj. R. B., 6, 7

Psychologic origin of stuttering, 330 Rank, relation of, to blast concussion, 223

Psychometric studies, in blast concussion RANKIX, Brig. Gen. F. W., 5, 7, 11, 64-65

223, 248, 256, 258, 260 ReactionsPsychometry, in aphasia, 323 after cranioplasty, 94

Psychomotor activity, decrease in, in blast to intrathecal penicillin, 207

concussion, 240 to tantalum foil, 37

Psychomotor epilepsy, 289 Receptive (sensory) dysphasia, 326

Psychoneuroses, confusion of with blast Reconditioning, inconcussion, 237, 244, 255, 259-260 paral)legia, 38

Psychoneurosis, antecedent to blast concus- speech rehabilitation program, 324

sion, 259 Reconstructive surgery, 7, 28, 29, 30, 90,

Psychoneurotic origin of stuttering, 331 92-98

Psychopathic tendencies, in blast conct:.- Record forms, 31

sion, 248 for herniated nucleus pulposus, 8

Psychopathologic theory of blast concussion, Record of wound data, on plaster cap, 156

256-257 Records, 11, 31, 80-81

Psychoses, 244 in craniocerebral injuries, 110, 126

with aphasia, 322, 331 of neurological examination, 131

Psychosomatic traunia, relation of to blast Recovery wards, in neurosurgical centers,

concussion, 226 17-18

Psychotherapy, 260, 321, 331, 332 Recruitment, of neurosurgical personnel,

PUCKETT, W. 0., 338 24-25

PUDENZ, Lt. Comdr. R. H., 7, 9, 261 Recurrent laryngeal nerve, 322, 327, 328,

Pulmonary edema, 83, 84, 111, 181 329, 330

Pulmonary infarction, 86 Redebridement, inPulmonary injuries, in blast concussion, 227, brain abscess, 208

228, 254 craniocerebral injuries, 104, 105-106, 112,

Pulsating defects, of skull, 269, 278 114, 115, 203, 321

Pulse: orbitocranial wounds, 173

in blast concussion, 241 Redeployment plans, in ETOUSA, 67-69

in brain abscess, 211 REEVES, Lt. Col. D. L., 6, 7, 261, 267

in craniocerebral injuries, 102, 110, 211 Reflexes, inpressure in ventricular wounds, 103 blast concussion, 237, 239

Pupillary changes, in- craniocerebral injuries, 130-131

blast concussion, 237, 239 Refresher courses. 16, 30

mortal head injuries, 294 Regional consultants in neurosurgery.

Purkinje cells, 346 ETOUSA, 47, 49

PUTNAM, T. J., 27 Rehabilitation, inPyknosis. in mortal head injuries, 345,351,357 aphasia, 322-323
458 N EUROSURG ERY

Rehabilitation, in--Continued Roentgenologic examination -Continued

peripheral nerve injuries, 18 in posttrauxnatic epilepsy, 280, 301, 313,

posttrauniatic epilepsy, 279, 316-317 316

World War I, 90 in through-and-through cerebral wounds,

Relaxing incisions, in scalp wounds, 100, 172

150-156, 202 in transventricular wounds, 103, 166, 190

Reparative neurosurgery, in MTOUSA, 41 in wounds of dural sinuses, 159

Reparative process, in head injuries, 339, 357 Roentgenologists, in neurosurgical centers,

Replacements, blast concussion in, 223 ETOUSA, 53

Research studies, in- ROGERS, Brig. Gen. J. A., 65

blast concussion, 222-225, 237-240, 241- ROGERs, L., 231, 241

242 Rohrschach test, 294, 324, 331

ETOUSA, 82 Rotation, ofmortal head injuries, 335-397 nurses, 13-14, 70

Resection, of - ward officers, 16

brain abscess, 93 Rotation flaps, in scalp wounds, 151-153

cerebral scars, 267 Rotation of neurosurgical personnel, inepileptogenous foci, 311-313 ETOUSA, 57-58, 69, 80

Residual infection in head injuries, 92, 93 MTOUSA, 41-42

Residual nasality, 330 ROULHAC, Capt. J., 105

Residual neurologic changes, 108 RowE, Lt. Col. S. N., 86, 146

Resistant infections, 116, 118, 209 Royal Army Medical Corps, 72, 79

Respiration, in- Royal Canadian Army Medical Corps, 71

blast concussion, 241 Royal Society of Medicine, 71

craniocerebral injuries, 83, 102, 110, 129- Rupture, of130, 131, 135, 138, 139, 181 alveoli, in blast concussion, 228

transventricular wounds, 103, 169 blood vessels, in mortal head injuries,

Respiratory center, in medulla oblongata, 340, 342, 359

374, 384 tympanum, in blast concussion, 244

Resuscitation, 84, 102, 103, 110, 121, 122, Ruptured intervertebral disk. See Herniated

128, 134, 190, 321 nucleus pulposus.

Retinal detachment, 227 RuSSELL, C. K., 230, 241

Retrograde amnesia, 215

Revision of tantalum cranioplasty, 271 Sagittai sinus, 130

REYNELL, J., 248 Satellitosis, 357

Rhinophonolalia, 322, 329, 330 Scalp:

Rhinorrhea, 206, 207, 208 blood supply of, 95

RHOADS, H. T., 221, 240 gutter wounds of, 124

Rhombencephalon, 374 ischemic necrosis of, 302

Ribs: lacerations of, 58, 83, 86, 140

cranioplastic material from, 90, 94 scars of, 266, 302-303

fractures of, in blast concussion, 227 undermining of, in craniofacial wounds, 174

ROBERTSON, Lt. Col. R. C. L., 6, 7, 261 Scalp wounds, 65, 99-100, 110, 111,283, 321,

ROBINSON, C. S., 219 336

Roentgenologic examination, 27, 29 chemotherapy in, 140

after tantalum cranioplasty, 10 closure of, 95, 99-100, 127, 150, 202, 203,

in aphasia, 323 213, 267, 302, 321

in blast concussion, 237 debridement of, 140-142, 143, 157, 159,

in brain abscess, 212 167-168

in cerebral fungi, 107-108 dehiscence of, 105, 191, 202

in cerebrospinal fluid fistula, 103 disposition of casualties with, 99, 108

in craniocerebral injuries, 26, 128, 131- hemorrhage from, 77, 102, 142

134, 145, 164 incidence of, 99

in forward hospitals, 134 incision in, 99, 100
INDEX 459

Scalp wounds-Continued Serumn albumin, 119

infection in, 86, 100, 289 Serum protein levels, after craniocerebral

management of, in brain abscess, 116 surgery, 178

metastatic brain abscess after, 2W.) Service commands, neurosurgical centers in,

repair of, 86, 140, 142, 150-156, 266 6

roentgenologic examination in, 131 Seventh cranial nerve, 131, 329

Scapula, cranioplastic material from, 94 Seventh U. S. Army, 66, 67, 72, 120, 122,

SCARFF, Lt. Col. J., 45, 48, 74 181, 182

SCHEINKER, I. M., 340, 341, 359, 361 SHEARBURN, Maj. E. W., 107, 150, 181, 182

SCHORSTEIN, J., 93 Shellshock, 6, 217, 218, 225

SCHNEIDER, I. C., 173, 174, 201 Shipley-Hartford test, 324

SCHNITKER, Lt. Col. M., 7, 261, 263 Shock, 39, 85

SCHWAB, I. S., 216, 223, 224 in blast concussion, 227

SCHWARTZ, Lt. Col. H. G., 105 in craniocerebral injuries, 102, 110, 128-

Sciatic nerve injuries, 35, 38 129, 133-134

Sciatic nerve-femur injuries, 37 in transventricular wounds, 190

Sciatic pain, 8 in wounds of dural sinuses, 159

Scotonma, in visual auras, 288 Shock Waves, 215, 216-217, 219, 338

SCOTT, W. W., 250, 255 air blast of, 220-222

Secondary contamination, after local penicil- SHORT, R. H. D., 227

lin therapy, 204 Shrivenham, 71

Secondary debridement. See Redebride- Sicily, 58

ment. Side effects, ofSecondary infection, in scalp wounds, 202 anticonw'lsive medication, 289-290

Secondary neurosurgery, in World War I, 4 forced hydration in posttraumatic epilepsy,

Secondary repair, of skull defect, 263 295

Secondary wound closure, 86, 321 Sigmatism, 329

Sedation- Sigmoid sinus, 159

after craniocerebral surgery, 177 Silk sutures, in head surgery, 105, 126

in craniocerebral injuries, 128, 129) Silver clips, 15, 26, 40, 126, 146, 162

in meningitis, 208 Silver staining of nerve fibers, 347

SEDDEN, H., 71 SIMON, C. P., 71

Segregation of neurosurgical injuries, 17-18, Sinus. See specific sinuses.

19-20, 37 Sinusoidal current, 78, 79

Seguin test, 324 Sixth cranial nerve, paesies of, 131

Sella turcica, 384 Skin, conservation of, in scalp wounds, 140-

Semantics, 331 142

Senior consultant in neurosurgery, ETOUSA, Skin grafting, in head injuries, 321

functions of, 45-48 Skin temperature test, 23

See also DAVIS, Col. LOYAL; SPURLINC,, Skull:

Col. R. G. autogenous bone graft- of, 261

Sensorimotor cortex, 270 comminution of, in transventricular

Sensory aphasia, 319 wounds, 189

Sensory auras, 286 compression of, in blast concussion, 215,

induced by cortical stimulation, 30) 216

induced by Metrazol injection, 298-299 continuous fractures of, 101

Sensory hallucinations- debridement of, 142-143

after motor auras, 286 depressed fractures of, 100-101, 111-112

in auditory auras, 289) discontinuous fractures of, 101, 338, 384,

Sensory (receptive) dysphasia, 326 396-397

Separation from service. See Disposition. everted fractures of, 338

Septum pellucidum, 339, 384 fractures of, 131, 140, 156, 252, 283

Sequelae of head injuries, 34, 91, 92-93 gutter injuries of, 124

Serologic studies of spinal fluid, 280 hyperostosis of, 261
460 N E URtOSUIRGERIY

Skull-C('ontinued Spinal cord injuries--Continued

linear fractures of, 3138 in World War I, 4

osteoomyelitis of, 261 mnanagemlent of, in transit, 64

p)avement fractures of, 100 See also Paraplegia.

Skull defects, 7, 15, 37, 77, 91, 108, 244, 261- Spinal drainage, in262, 263, 264, 278, :121 fungus cerebri, 213

as indication for cranioplasty, 94, 269, 278, meningitis, 208

292, 293 Spinal dura, 104

See also Cranioplasty. Spinal fluid:

Skull defects: blood in, in blast concussion, 241, 242

correction of, by bone flaps, 261, 303 passage of shock wave through, 254

management of, 8, 9-10, 92, 93-96 survey, 22, 280

secondary repair of, 263 in aphasia, 323

SLEMON, II. V., 147, 181 in brain abscess, 211

Sliding flaps, in scall) wounmds, I 11, 151-153 in craniocerebral injuries, 206, 280

Smoking, in posttrauinatic epilhpsy, 291 in posttraunmatic epilepsy, 280

SNYDER, Col. H. E., 4:3 Spinal p)ressure, in brain abscess, 211

Social factors, in etiology of blast concussion, Spinal puncture, 206, 207

259 Spine, injuries of, 8, 11, 58, 65, 71, 82, 83

Social studies, in posttraunmatic epilepsy, 281 between World Wars, 4

Sodium Amytal (amobarbital sodium), 1:38 in forward hospitals, 26

Sodium cyanide, effect of, in posttraunmtic Splinting, in peripheral nerve injuries, 23,

epilepsy, 296 35, 79

Soft palate, 330 Split-thickness grafts inSolution M, 35 closure of donor site of scalp. 153-155

Solomons, :120 closure of dura, 212

Somatic factors in blast concussion, 259 craniofacial wounds, 174

Somatosensory auras, 287-288 scalp wounds, 100, 155

Sound waves in blast concussion, 219 Spontaneous closure of cerebrospinal fluid

Southampton, 63 fistulas, 103, 117

Southern Base Section, ETOU-SA, 55 Spontaneous healing, in intracranial infecSoviet Union, 48 tions, 105

Spastic paraplegia, 1:30 Spontaneous recovery, inSpeech clinics, 320, 321, 322-'323, :328, 330 fungus cerebri, 107

Speech defects, :37, 320, 322, 333. See also l)eripheral nerve injuries, 21, 24

Aphasia. SPRIESTERSBACH, C., 320

Speech deterioration in dysaudia, 332 SPURLING, It. G., 5, 6, 7, 10, 13, 15, 17, 26,

Speech disorders, nomenclature of, :326 45, 47, 48, 51, 53, 55, 58, 59, 62, 64, 65,

Speech rueducation, in World War I, 319 67, 73, 74, 78, 82, 114, 120, 261, 263, 269,

Speech rehabilitation program, 322, 32:1, 270, 271,398

325-326, 333-334 Staffing, ofadministrative considerations of, 321-323 auxiliary surgical groups, in ETOUSA, 55

equipment for, 324-325 evacuation hospitals, in ETOUSA, 53-54

Speech therapists, 322, 32:3 neurosurgical centers, inSphenoid. 1:19, 173, 3:18, 384 ETOUSA, 51-53

SPIEGEl,, J. P., 2:14, 255 Zone of Interior, 5, 6-7, 12, 15-16, 19

Spinal cord: transit hospitals, in ETOUSA, 54-55

civilian-type injuries of, 18 Stammering, 319

dlamage to, in blast concussion, 241Samrig 1 incdene 

incidence 

tof 

of 

wndblast 

wounds c 

of, 

11 

12089iof, Standardization of neurosurgical policies, 7,

tumors of, 7 8,9

Spinal cord injuries, 8, 11, 29, 58, 61, 65, Staphylococcic meningitis, 205

71, 81, 86 Starvation, relation of, to blast concussion,

case fatality rates iii, 86 226
INDEX 461

Station hospitals, in - Stupor, in brain abscess, 210

ETOUSA, 61, 77-78, 84 Stuttering, 319, 320, 322, 330-331, 333

MTOUSA, 41 Subarachnoid block, 207

Zone of Interior, 29 Subarachnoid hemorrhage, 131, 179

Statistics: Subarachnoid space, 103, 173, 206, 367, 383

aphasia, 333-334 changes in, in posttraumatic epilepsy, 301

in World War 1, 319 instillation of penicillin into, 178, 204, 207

blast concussion, 218-219, 223-224, 241- Subcortical dysphasia, 326

242, 243 Subcortical hematoma, 115

closed head injuries, 223 Subdural hematoma, 7, 11, 83, 110, 115,

craniocerebral injuries, 120-122, 180-182, 157, 164, 171-172, 179, 237

336 in blast concussion, 233-234

before D-day, 109 in mortal head injuries, 297

in ETOUSA, 83, 85, 86, 115 in transventricular wounds, 183

in MTOUSA, 99 Subdural membrane, 304

in World War I, 23 Subdural space, 102, 103

cranioplasty, 93, 96, 97, 271-272 Subependyinal edema, 351

infection in head injuries, 105, 146, 147 Subependymal vessels, 339

meningitis, 118, 208 Subgaleal fluid, 191

mortal head injuries, 336, 338-339, 395 Subgaleal hematomna, 156

neurosurgical casualties, in- Subgaleal infections, 86

ETOUSA, 82-86, 120-122 Subpial hemorrhage, inWorld War I, 4 blast concussion, 251, 258

neurosurgical centers, 31-33, 34, 36 surgery for posttraumatic epilepsy, 304

neurosurgical personnel, in ETOUSA, Sucrose, 119

68-69 Suction apparatus, 26, 40, 78

penetrating craniocerebral wounds, 101, in brain abscess, 212

112 in craniocerebral injuries, 145

pneumoencephalography in posttrauniatic in transventricular wounds, 166

epilepsy, 299 in wounds of dural sinuses, 162

posttraumatic epilepsy, 270, 281-284, 290 Sulfadiazine therapyretained foreign bodies, 114-115 after craniocerebral surgery, 178

skull defects, 271-272 in craniocerebral injuries, 119, 203

tantalum cranioplasty, 271-272 in meningitis, 117, 207

transventricular wounds, 165-166, 170, in surgery for posttraumatic epilepsy, 302

183, 199 in transventricular wounds, 191

in World War 1, 183 Sulfathiazole, in craniocerebral injuries, 148

wounds of sinuses, 159, 174 Sulfonamide therapy, 27, 29

See also Workload. in brain abscess, 116

Status epilepticus, 289, 303 in cerebrospinal fluid fistulas, 103

Stellate ganglia, 119 in craniocerebral injuries, 4, 5, 10, 11,

STEPHENSON, C., 224, 234, 236, 244, 246, 106, 111, 123, 128, 177, 178-179, 202,

247, 248, 249, 256, 257, 258 203, 284

Stereoscopic roentgcnograms, in head in- in meningitis, 206-207

juries, 131 in peripheral nerve injuries, 11

STEWART, 0. W., 230, 241 Supply. See Equipment.

STIER, E., 258 Supraorbital notch, 129

Straight sinus, 83, 159 Supratentorial lesions, 327

Strength-duration curve, 22 Supreme Commander Allied Forces, 48

Streptococcic meningitis, 206 Supply Depot G-30-74

Streptomycin, 207 Supply Division, Office of Theater Chief

Surgeon, ETOUSA, 74, 75

STUCK, W. G., 261 Surgeon(s):

Student officers in neurosurgical centers, 16 First U. S. Army, 65, 66
462 NEUROSURGERY

Surgeon(s) -Continued Tantalum cranioplasty--Conttinued

MTOUSA, 41 radiotherapy after, 10

Peninsular Base Section, MTOUSA, 42 revision of, 271

Southern Base Section, ETOUSA, 55 technique of, 94-96, 262-266

Surgeon General's Office, in World War I, 3-4 Tantalun foil, reactions to, 37, 77, 84, 94,

neurosurgical consultant in, 89 262, 303

Surgery, in - Tantalum plate, removal of. 96, 271-272

cerebrospinal fluid fistulas, 207-20S Technique ofdecubitus ulcers, 38 acrylic cranioplasty, 262

herniated nucleus pulposus, 8, 9, 10 activated electroencephalography, 294-

mortal head injuries, 335, 373-375, 394- 295, 306-311

397 closure of scalp wounds, 99-100

posttraumatic epilepsy, 289, 290, 292-313 cortical resection, 311-313

anesthesia for, 302, 303 cranioplasty, 92, 93, 94-96

subdural henatomas, 234 debridement, inSurgery, indications for: brain abscess, 106

in penetrating craniocerebral wounds, craniocerebral injuries, 143-146

101-102 dural wounds, 143

in posttraumatic epilepsy, 97-98, 292-293, scalp wounds, 140-142

302-303 skull wounds, 142-143

technique of, in posttraumatic epilepsy, determination of muscular power, 22

302-303 dural closure, 113-114, 149--150

timing of, in epilepsy, 292, 294 dural grafting, 149-150

SI-THERLAND, M. W., 219, 254 hyperventilation, in posttraumatic epiSuture material in- lepsy, 295

craniocerebral injuries, 105, 126 local anesthesia, 138

dural closure, 149, 174 local penicillin therapy, 147-148, 203-204

peripheral nerve injuries, 86 Metrazol activation of epileptogenous foci,

scalp wounds, 155-156, 202 297-299

wounds of dural sinuses, 162 operation forSWANK, H. B., Jr., 229, 230 cerebrospinal fluid fistula, 118, 208

Sweat test, 23, 281 fungus cerebri, 118

Sweating, 21, 243, 289 intracranial hematomas, 164-165

SWEETZER H. B., Jr., 229, 230 posttraumatic epilepsy, 302-313

SYMONDS, C. P., 216 skull fractures, 157-159

Sympathectomy, 23 transventricular wounds, 169-170

Sympathetic ganglia, injection of, 23 pantopaque myelography, 9

Syndrome of trephined, 269, 278 Pentothal Sodium anesthesia, 139

repair of scalp wounds, 150-156

Tables of- resection of brain abscess, 212

equipment, 40, 78, 79 tantalum cranioplasty, 37, 94-96, 262

organization, 41, 46, 57, 66, 67-69 Teeth, role of loss of, in dyslalia, 330

Tachistoscope, 325 Tegmental plates of petrous bone, 338

Tactical situation, relation of, to- Telencephalon, 339, 351

blast concussion, 223-224 Temporal fascia grafts, 83, 104, 174, 191

management of craniocerebral injuries, Temporal horn of ventricle, 395

123-124 Temporal lobe:

Tangential wounds, 149 epileptogenous foci in, 302

Tantalum, in peripheral nerve injuries, 8, wounds of, 85, 156, 177, 285, 327, 339, 384

37, 86. Temporary duty for training purposes, 30,

Tantalum cranioplasty, 8, 9, 22, 28, 37, 77, 67, 69-70

91, 112, 114, 213, 261-262, 266-267, 278, Tendon reflexes, 131

303, 313, 316 Tensile strength of repaired nerves, 24

in fungus cerebri, 118 Tests. See specific tests.
INDEX 463

Thalamus, 256, 258, 339, 384 Timing ofTheater Chief Surgeon, ETOUSA, 10, 27, cranioplasty, 270, 278

45, 46, 47, 51, 55, 57, 58, 60, 61, 68, 70, grafting, in scalp wounds, 154

72, 74, 75, 78, 82, 109, 111, 112, 120 redebridement, in craniocerebral injuries,

chief consultant in surgery to, 55 105

senior consultant in anesthesia to, 78 surgery, insenior consultant in neurosurgery to, 8, brain abscess, 105-106

10, 23, 45-86, 114 cerebrospinal fluid fistulas, 103-104

senior consultant in plastic surgery to, 111 craniocerebral injuries, 135-136, 138

See also HAWLEY, Maj. Gen. PAUL R. craniofacial wounds, 173

Thematic apperception test, 324, 331 posttraumatic epilepsy, 292-294

Thiopental sodium. See Sodium pentathol. Tinnitus, in blast concussion, 215, 226, 238,

Third cranial nerve, palsies of, 131 242, 258

Third U. S. Army, 54, 66, 73 TINSLEY, M., 181

Third ventricle, 168, 339, 384 Tongue, wounds of, 329, 330

Thirst, relation of, to blast concussion, 226 Tongue biting, in epileptic seizures, 292

Thoracic injuries, 81, 83, 128, 130, 138 Torcular Herophili, 163

in blast concussion, 243, 251 ToVELL, Lt. Col. R. M., 78

Thoracic pain, in blast concussion, 226 Toxemia, effect of, on vital centers, 374

Thoracic surgery, in- Trachea, aspiration of, during head surgery,

ETOUSA, 62 139

field hospitals, 40 Tracheotomy, 329

Thoracoabdominal wounds, 83 Transcortical dysphasia, 326

Thorotrast, 212 Transfusion reactions, 84

Throat, aphasia after wounds of, 319 Transit hospitals, in ETOUSA, 54-55, 63, 64

Thrombin, 77 staffing of, 54-55

Thrombosis- Transportation:

in mortal head injuries, 369 deaths from shock during, 39

of cortical vessels, 146 ot casualties with heaci injuries, 110

of longitudinal sinus, 83 of paraplegics, 74, 79

Through-and-through craniocerebral wounds, Transposition of nerves, 37

140, 171,-172, 338 Transventricular wounds, 83, 135, 165-170,

Thyroidectomy, 328 183-199

Tibia, cranioplastic material from, 90, 94 abscess formation in, 184-189, 191, 192-

Ticonium cranioplasty, 278 198

Tics, 4 antibiotic therapy in, 191-192

Tigrolysis, 346 case fatality rates in, 183, 189, 192, 199

Tirnelag, 30, 63, 84 chemotherapy in, 191-192

in blast concussion, 223, 224 debridement in, 168, 170, 183, 184-189,

in craniocerebral injuries, 101-102, 110- 190-191, 199

111, 112, 127, 180-181, 202, 204, 282- dehydration in, 190

283, 395-396 diagnosis of, 189-190

in World War I, 89-90 evacuation of casualties with, 180

in mortal head injuries, 397 fibrin film in, 191

in peripheral nerve injuries, 86 foreign bodies in, 184, 189, 190

in transventricular wounds, 183-184, 189 hemorrhage in, 129, 169-170, 183, 189,

in World War I, 183 190, 192, 195-197

to electroencephalography, in blast con- inadequate debridement in, 189

cussion, 244 infection in, 189, 190

Time of death, in- management of, 183, 184-189, 190-192

blast concussion, 241 meningitis in, 189

craniocerebral injuries, 101, 181-182, 201 pathologic process in, 189

mortal head injuries, 336, 339, 341, 346, penicillin therapy in, 178

348, 359, 362, 374, 384, 394, 395 primary closure of, 191
464 N EUROSURGERY

Transventricular wounds--Continued United States Armed Forces Institute, 324

prognosis in, 169, 170 U. S. Army Medical Department Bulletin, 37

resuscitation in, 190 University of Illinois Neuropsychiatric Instiroentgenologic examination in, 190 tute, 25

timelag in, 183-184, 189 University of Pennsylvania, School of Mediwounding agents in, 189 cine, 27, 29

Transverse sinus, 83, 159 Unnecessary exploration, 80

Traumatic encephalitis, 340, 396 Urea-sulfadiazine treatment of meningitis,

Traumatic origin of dyslalia, 329-330 117, 207

Tremors, in blast concussion, 238, 239, 240, Urinary sepsis, in paraplegia, 38

256 Urologic care, in paraplegia, 35, 62

Trephined, syndrome of, 269, 278

Triage- Vacuolization, ofat Bizerte Medical Center, 42 choroid epithelium, 35

of neurosurgical casualties, 11-12, 51, 62, nerve cells, 346

65, 66 Vacuum phase, of shock wave, 219

TRIBBY, W. W., 182, 336 Vagus nerve:

Tridione, in posttraumatic epilepsy, 290, paralysis of, 328

296 wounds of, 327, 329

Trigeminal pathways, in blast concussion, 258 VAN NVAGENEN, ILt. Col. W. P., 6, 7, 9, 279

Trimethadone. See Tridione. Vascular changes, in mortal head injuries,

Tripod incision, 100, 151, 302 340, 342, 345.347,359-362,369,370,396,397

Trismus, 330 Vascular surgery, in field hospitals, 40

TROLAND, C. E. 301 Vasomotor disturbances, in posttraumatic

Truloid, 263 epilepsy, 281

Tube drainage, in brain abscess, 116, 212 Vasoparalysis, 340, 341, 359, 374

Tumors, 4, 15 Vasospasm, in wounds of carotid artery, 119

of larynx, 328, 329 V-E Day, 59, 67, 81, 83, 114

of spinal cord, 7 Vegetative disturbances, in blast concussion,

of vocal cords, 328 256

TUN'BRIDGE, R. E., 228, 240 VENABLE, C. S., 261

Tunisian campaign, 39, 101, 105 Venous system, transmission of shock wave

TURNER, 0. A., 146, 261 by, 254

Twelfth cranial nerve, 329 Ventricles:

Two-stage surgery, in posttraumatic epi- changes in, in posttraumatic epilepsy,

lepsy, 303 299-302

Tympanum, rupture of, in blast concussion, damage to, in blast concussion. 251

222, 226, 244 infection adjacent to, 116

migration of, 118

Uncinate attacks, 288 wounds of, 102-103, 140, 339-340, 374,

Unconsciousness: 383, 394, 395, 396, 397

history of, in posttraumatic epilepsy, 282 See also Transventricular wounds.

in blast concussion, 215, 216, 223, 233, Ventricular cannula, 126

237-238, 242, 244, 248, 255, 257-258 Ventricular drainage, in meningitis, 208

Undermining of galea, in scalp wounds, 100 Ventricular fistula, 118, 191

Underwater explosions, 222 Ventricular system. 103, 127

United Kingdom Base, 46, 47, 48, 51, 53, Ventriculitis. 166, 168, 189, 191, 192-193

54, 56, 58, 61, 63, 64,65, 66, 67, 69, 71, Ventriculography, 118-134

72, 74, 79, 80, 81, 82, 107, 109, 110, 112, Vermis, hemorrhage from, in blast con113, 114, 116, 117, 118, 119, 120, 121,212 cussion, 230

neurosurgical centers in, 67, 69, 82, 119 Vertebrae, fractures of, 82

neurosurgical conferences in, 71, 72, 116, Vertiginous auras, 288-289

117, 118, 119 Vertigo, 91

United States. See Zone of Interior. after cranioplasty, 96
INDEX 465

Vertigo--Continued War Department Technical Bulletin:

as indication for cranioplasty, 94, 2f ') No. 74, 27 July 1944-92

in blast concussion, 215, 226, 238, 239, No. 155, 25 April 1945--322, 324

258, 260 War neurosis, 237

in Dilantin Sodium therapy, 289 Ward officers, 16

in posttraumatic epilepsy, 284 Ward rounds, 17, 18, 323

Vestibular disturbances, in- Wardinasters, 17

":.,st concussion, 258 WEEAvER, T. A., Jr., 181, 182

posttraumatic epilepsy, 280 W\EBsTER, J. E., 16, 173, 174, 212, 262, 268

Veterans' Administration hospitals, 4, 290, WEBSTER, J. W., 250, 255

332 Wechsler-Bellevue test, 280, 322, 324, 331

VINCENT, C., 72 Wechsler memory scale test, 281

Vincent-David technique, in brain abscess, WVeigl-Goldstein-Scheerer color form sorting

116 test, 324

Virchow-Robin spaces, 340, 343 Weymouth, 63

Vision: WHITCOMB, B. B., 263

effect of retained foreign bodies on, 93 W\HITE, Capt. J. C., USNR, 7

impairment of, in visual auras, 288 WHITE, Cap. M. C., SN9 Visul cmponntsof cmplx auas,288 WHITE, Col. M. F., 399

Visual components of complex auras, 288 White matter, changes in, in mortal head

Visual field defects, in- injuries, 373

head injuries, 37, 322

posttraumatic epilepsy, 280 WHITTERID(E, D., 251

Visual hallucinations- \WILLIaMS, D., 248

after somatosensory auras, 288 WindsoN, J. V., 228

in auditory auras, 289 Wind of explosion, 217

Visual-motor coordination, loss of, 332 WINKDLE, W. F., 250. 251

Vital centers: WINKELMAN, N. W., 359

damage to, in blast concussion, 228 WOLKIN, J., 164

lethal damage to, 197-198, 374 WOOD, H., 229, 230

Vitallium cranioplasty, 94, 278 WOODHALL, B., 261, 263, 268, 270, 271

Vitamin deficiency, 203 WOOLF, J. I., 261

V-J Day, 69 Workload ofVocal cords, tumors of, 328 auxiliary surgical teams, 41, 66, 82-86

Vocal exercises, in dysphonia, 329 evacuation hospitals, 82, 125, 374

Vocal recording, 328 neurosurgical centers, inVocational counseling, in posttraumatic ETOUSA, 56, 66-67

epilepsy, 279, 317 Zone of Interior, 5-6, 7, 9, 10, 11, 12-13,

Vocational-preference studies, in aphasia, 15-16, 18-19, 20-24, 26-28, 31-33, 36

324 neurosurgeons, in ETOUSA, 58, 59-60

Vomiting- See also Statistics.

after forced hydration, in posttraumatic World War I, 100

epilepsy, 295 administrative management of head inafter surgery, for posttraumatic epilepsy, juries in, 3-4

316 aphasia in, 319

in Dilantin Sodium therapy, 289 craniocerebral wounds in, 4, 89-90, 110,

in epigastric auras, 289 123, 201, 285

VON HAAM, Maj. E., 236 craniofacial wounds in, 172

VON STARCH, T., 222, 224, 244, 248, 249, 257 cranioplasty in, 90, 94

Division of Head Surgery, Surgeon GenWAKELEY, C. P. G., 227 eral's Office, in, 3-4

Wallerian degeneration, 339 fungus cerebri in, 118

WALKER, Maj. A. E., 98, 148, 168, 261 hospitalization policies in, 3-4

War Department Memorandum No. W40- incidence of posttraumatic epilepsy in, 270

9-43, 6 March 1943--11 neurosurgery in, 3-4, 25
466 NEUROSURGERY

World War I -Continued Xanthochromic spinal fluid, 241

peripheral nerve injuries in, 4

professional training in, 3 YOUNG, M. W., 255

scalp incisions iii, 151

shellshock in, 217, 218, 225 Zone of Interior, 58, 68, 69, 80. 108, 113

shortages of neurosurgical personnel in, 4 air evacuation to, 64

specialized hospitals in, 3-4 blast concussion in, 224, 225, 236. 237, 244

spinal cord injuries in, 4 craniocerebral injuries in, 28, 91-98

timelag in head injuries in, 89-90 early ambulation in head injuries in, 107

transventricular wounds in, 165-166, 183 evacuation of neurosurgical casualties to,

wounding agents in, 124 53, 114

Wound dehiscence, in head injuries, 105, 191, freezing of neurosurgical personnel ini, 16

202 mission of hospitals in, 91, 92

Wound healing: neurosurgery in, 3-38

in penetrating craniocerebral wounds, 114 neurosurgical centers in, 5-24, 69, 89, 113,

in peripheral nerve injuries, 86 328, 330

in scalp injuries, 99, 156 personnel in, 5, 6-7, 12, 19), 109

influence of age on, 283 professional training program in, 24-31,

Wound infection. See Infection. 54, 70

return of overseas consultants to, 72

Wounding agents, in- speech clinics in, 320, 321,322-323, 328, 330

craniocerebral injuries, 123-124, 132, 271 unnecessary explorations in, 80

posttraumatic epilepsy, 282 Zirconium cranioplasty, 94

transventricular wounds, 189 ZUCKERMAN, S., 251

Wounds. See specific types and areas. Zygomatic bones, fractures of, 173

U. S. GOVERNMENT PRINTING OFFICE: I95&