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SECTION III
NEUROSURGERY
CHAPTER VI
A
STATISTICAL ANALYSIS OF GUNSHOT WOUNDS OF THE
HEAD
General
statistics concerning gunshot wounds of the head are Included in the
tables on the
various kinds of battle injuries sustained by members of the American
Expeditionary Forces, in
Chapter III of Section I of this volume. The data referred to show that
of the 174,296 battle
injuries, 10,452 were gunshot wounds of the head, a percentage of 5.99.
Eleven hundred and
forty-six of these head injuries (10.89 percent) resulted fatally.
For
purposes of a more detailed statistical study of these gunshot wounds
of the head,
about 1,100 clinical records, pertaining to such injuries, were
selected and studied. Tabulations
were made therefrom according to the regions involved, the symptoms
presented, the operations,
complications, persistent symptoms, dispositions, and causes of death.
At this point it might be
well to add that some of the clinical histories were remarkably
complete and accurate; others
were lacking in detail. However, considering the adverse conditions
under which the original
entries often were made, the preponderance of good case records is
surprising. The material thus
made available, representing approximately one-tenth of the whole, and
being about 75 percent
adequate for the purpose, gives a fairly accurate cross section of all
the cases.
In
the analysis of these clinical records the grouping of Cushing is used.
Since this
grouping is given in detail in other chapters of this volume no further
explanation of it is deemed
advisable here.
CLASSIFICATION
OF WOUNDS
Table
1 records the cases as to regions of the head involved according to the
depth of the
injury or severity. It will be noted that bursting fractures of the
skull, listed in Class IX are
relatively rare, the number of cases recorded being too small to be of
value. Penetration of the
ventricular system was also only occasionally noted. The largest total
is in the frontal region, the
smallest in the suboccipital. Probably the great majority of such
injuries succumbed before
admission to a field or evacuation hospital. When admitted alive and
dying shortly after, they
were probably recorded as fractures of the skull without further
qualification. Therefore the
largest group is that of Class II,
simple fracture of the skull.
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TABLE 1.- Classification of gunshot wounds of
the head, according to depth of injury, or its severity a
SYMPTOMS
In
Table 2 are the symptoms presented by the cases. The discrepancies are
many no doubt
from lack of opportunity carefully to examine and record the findings.
This is evidenced by the
preponderance of records of outstanding symptoms such as blindness (85
cases) over such
symptoms as amnesia, which was certainly more common than these records
show (18 cases).
Thus there are eight cases of extraocular paralysis recorded, but only
two of diplopia. Again it is
surprising to find that there were only 13 cases with hemianopsia,
while we see in Table I 99
cases of occipital injury with definite cerebral injury.
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TABLE 2.–Symptoms b
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PRIMARY
OPERATIONS
Table
3 shows the primary operations performed. Since 1,056 are recorded, it
is evident
that many of those who were wounded had more than one primary
operation. The zeal of the
surgeon in noting what he did is in marked contrast to Table 2 of the
symptoms his patients
presented. It is interesting to note that 162 cases were treated by
primary closure. In 195 the
foreign body was removed at this time and only 33 were cleaned and
dressed.
TABLE 3.- Primary
operations performedc
SECONDARY
OPERATIONS
Table
4 records the secondary operations performed. Bone fragments and
foreign bodies
had to be removed in 50 cases only, while drainage had to be
established in only 32. Abscess
occurred 15 times. This is an excellent indication of the thoroughness
and success of the primary
operations. In this table the record of 48 cranioplasties and 34 bone
grafts shows the need of
plastic repairs for cranial defects.
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TABLE
4.- Secondary operations
performedd
COMPLICATIONS
In
Table 5 the complications are recorded. The most frequent complication
was
hemorrhage, probably not of much moment in the great number of cases
but dramatic when
occurring and therefore more frequently noted. Infection of the wound
was quite common (59)
while meningitis and abscess were surprisingly infrequent. It is
interesting to note that these
records show only six cases of psychoneurosis.
TABLE
5.- Complications of head
injuriese
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DISPOSITION
OF CASES
The
disposition of the cases of head injuries is shown in Table 6. Only 23
percent died;
43 per cent were returned to duty; 26 percent were judged to be unfit
for further military duty; 5
percent were sent to convalescent camps.
TABLE 6.- Disposition of head injury cases f
PERSISTING
SYMPTOMS
Table
7 shows the persisting symptoms. This table is interesting when
compared with
Table 2. Of 127 cases that presented some form of paralysis its a
primary symptom, in only 66
did this paralysis persist, without considering the 23 percent
mortality that must have affected
these figures. There are other discrepancies: Though 55 cases of facial
palsy were recorded in
Table 2,only 1 case of facial paralysis persisted or survived. Other
cerebral symptoms were
recorded as more careful studies were made, such as astereognosis and
nystagmus.
TABLE 7.- Persisting
symptoms g
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TABLE 7.- Persisting symptoms-
Continued
CAUSES OF DEATH
Table
8 shows the causes of death as recorded. If "Not associated" and"Not
stated" are
disregarded, the preponderance of septic complications, accounting for
72 percent of the deaths,
is very striking. Of these meningitis was much the most common.
TABLE 8. - Causes
of death h
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