War Surgery and Medicine
LATE RESULTS: PENSIONS SURVEY
LATE RESULTS: PENSIONS SURVEY
A survey of 953 cases of head injury was made by Dr. D. Macdonald Wilson in 1950. It covered men who were discharged from the services on account of symptoms relating to head injury, and also those who have applied for pensions. They comprised: (a) simple concussion, 600 cases; (b) fracture of skull not due to penetrating missiles, 157 cases; and (c) fractures of skull due to penetrating missiles, 196 cases.
In the simple cerebral concussion group 268 applied for pension, but they were mostly found to have no physical sequelae and nearly all were cases of pure neurosis. Their few physical disabilities were:
Vision: 8 cases of diplopia (3 transient).
Hearing: 8 cases of blast or concussion deafness.
Speech: 2 cases of motor aphasia (1 transient).
Facial paralysis: 4 cases.
Hemiplegia: 2 cases.
Subdural haematoma: 1 case.
Trigeminal neuralgia: 1 case.
Epilepsy: 16 cases.
Of 868 admissions to hospital in the Middle East in 1942–45 for cerebral concussion, only 117 applied for pensions.
Amongst the Maoris there were very few cases of neurosis, and of the 10 cerebral concussion cases only 2 were on pension. One of these had hemiplegia and the other subarachnoid haemorrhage. Of the Maori cases on pension, 57 per cent complained of sequelae due to penetrating missiles, although these battle casualties constitute only 20.6 per cent of the total cases under review.
Attention was drawn to four cases of concussion associated with symptoms due to local injury of the motor cortex. These cases occurred when the head was struck tangentially by a fast-moving missile, causing a gutter wound in the scalp without injury to bone. In addition to general concussion there was evidently a local contusion to the brain immediately beneath the point of impact of the missile with the head, resulting in symptoms due to injury of motor cells in the cortex. Two such cases suffered from hemiplegia, one temporarily and one partially recovered, while the other two still have symptoms of motor aphasia and one has developed Jacksonian epilepsy.page 156
High-velocity missiles striking the head tangentially can produce these symptoms without injury to the skull, but in other cases with similar symptoms there may be fracture of merely the outer table without any depressed bone. Two such cases occurred, and one case has developed Jacksonian epilepsy.
Fractures of Skull, other than those due to Penetrating Missiles
Of the 153 cases, 23 were due to pre-service injuries, 104 were fractures of the vault, 40 of the base, and 10 of both. The following sequelae have occurred:
|Vault||Base||Vault and Base|
|Motor Aphasia (temp)||1||0||0|
|Paralysis 5th nerve||0||1||0|
Of these 153 fractures, 68.5 per cent remained on pension in 1950—50 per cent of base and 73.5 per cent of vault fractures.
Fifty per cent of those on pensions were assessed at not more than 20 per cent. Four cases received a total disability pension, 1 for hemiplegia, 1 for epilepsy, and 1 for psychosis.
Fractures of Skull due to Penetrating Missiles
Of the 196 cases, 147 had penetration of the dura and brain.
The types of missile causing injury were recorded as being:
|Shell, shrapnel||96 cases|
|Shell, high explosive||30 cases|
|Shell, mortar||27 cases|
|Land mine||6 cases|
In addition to the subjective symptoms complained of, physical sequelae occurred as follows:
Vision: Homonymous Hemianopsia (18 cases, two temporarily).
Defective Vision due to concussion of eyeballs (16 cases).
Diplopia (6 cases, one temporarily).
Evisceration of eyeball due to direct destruction by missile (12 cases).
Hearing: Concussion Deafness (12 cases).
Rupture of Tympanic Membranes (6 cases).
Tinnitus: 8 cases.
Speech: Motor Aphasia varying from hesitant or slurring speech to marked aphasia (25 cases, four temporarily).
Visual Aphasia: 1 case. Motor Agraphia: 1 case.
Anosmia: 2 cases.
Asteriognosis: 2 cases.
Trismus: 1 case.
Mental changes, varying from dulling of intellect to emotional changes, were noted in 12 cases.
Hemiplegia occurred in 56 cases, resulting in:
Temporary paralysis or paresis with complete recovery: 11 cases.
Slight residual weakness and paresis: 12 cases.
Marked hemiplegia with spastic arm and leg, 33 cases, two showing paraplegia of both legs.
Facial paralysis without limb involvement: 4 cases.
Ptosis: 3 cases.
Arterio-venous Aneurysm on brow: 1 case.
Chronic latent Cerebral Abscess occurred in 5 cases.
Epilepsy had occurred in a number of cases, and is discussed below.
Associated injuries received simultaneously with the head injury were fractures (12 cases), GSW Abdomen (3), GSW Chest, penetrating lung (2), GSW with peripheral nerve injury (1), and below-knee amputations (2).
Four deaths had occurred in civil life directly attributable to the head wounds, two following epileptic seizures, and two from cerebral abscess. One case died of cerebral abscess developing after rupture of the tympanic membrane and middle ear disease. The other case is quoted as it illustrates certain aspects in treatment of these head wounds.
26.11.41: Admitted with shell wound to left of occipital protuberance. X-ray revealed a puncture fracture with depressed fragments of bone lying within the cranium. The wound was cleansed, but no excision of wound, debridement, or craniotomy was carried out. The scalp became infected, and patient developed a temperature with disturbance of vision. Papilloedema was noted. Lumbar puncture produced a blood-stained cerebro-spinal fluid free of pus cells. Expectant treatment with “sulpha” drugs resulted in a good recovery. He was returned to New Zealand and discharged on 31.5.42. Subsequently from time to time he complained of poor vision, depending upon the severity of headaches, but fundi were page 158 always normal. As there had been a discharging sinus off and on in the occipital region since 1941, he was on 20.2.45 admitted to hospital for exploration of the wound. Finding a couple of sequestra in the skull gap, the surgeon evidently considered them sufficient to account for the sinus, which was excised. However, the patient was not relieved, and was re-admitted to hospital later, where, on 15.9.45, he died of a ruptured cerebral abscess.
The danger of the silent chronic cerebral abscess following these compound fractures is well illustrated by the following cases:
(1) Case 89:
On 29.5.41 suffered a gunshot wound with penetration of skull and dura mater in the parieto-frontal area. Treated routinely, his wounds soon healed, and towards the end of 1941 he was able to proceed to New Zealand as a convalescent walking case. He returned in a hospital ship under the eyes of the medical staff and walked ashore at Wellington, where he was examined by a Medical Board, but no complaint of headache or other symptoms was made. Proceeding home that night he arrived the next day apparently well, but before the end of the day he complained of headache and rapidly became drowsy. He was taken to hospital, and a subdural chronic abscess was evacuated. He made a rapid recovery, but since 1943 has suffered from Jacksonian epilepsy.
(2) In August 1952 a soldier died who had sustained a penetrating wound of the frontal lobe in Libya on the same day, 26 November 1941, as Case 832. He had little in the way of symptoms after being unconscious for not more than fifteen minutes following the wound, for which he had no primary operative treatment. X-rays at the base hospital in Egypt disclosed several in-driven fragments of bone, and he was first operated on twenty-four days after wounding. He then contracted diphtheria followed by polyneuritis. A freely-discharging sinus persisted, and two further operations were performed in June 1942 and the in-driven bone fragments removed, but the wound did not finally heal till December, shortly after which he was evacuated to New Zealand. In July 1943 a chip bone graft was inserted to close the skull defect. In the succeeding years he complained of recurrent headaches, and in May 1950 had epileptic seizures, but neurological, including X-ray, investigation showed no indication for surgery. Chronic spasms of the left hand and arm were noted in July 1952, followed by vomiting, increasing headaches, and mental confusion. A ventriculogram disclosed a lesion of the frontal lobe, and at craniotomy an abscess was found which was aspirated and penicillin injected several times. He died a fortnight after craniotomy, and the presence of a right frontal lobe abscess was confirmed.