Contents

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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 performed^c

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 performed^d

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 injuries^e

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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