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Chapter I INTRODUCTION A. HISTORICAL BACKGROUND War, which seems to date far into antiquity, and man's proclivity acci- dentally to hit his head, have been prolific sources of brain injuries since the beginning of time. That man has been very much interested in the exciting events which follow blows upon the head would seem evident from his early art, the relics of primitive trephining, and the importance which this subject is given in the earliest medical records (133). In the prehistoric skulls discovered in the caves of France, there have been found manmade holes, presumably bored for the relief of symptoms caused by head injuries, of which the still visible fracture lines bear mute testimony. The tombs of Paracas in the New World also contained cracked skulls, with bony defects presumably trephined for the effects of cranial violence. And in the earliest extant manuscripts of Egyptian medicine, explicit directions are given for the care of head wounds (22). It therefore seems likely that for thousands of years man has been aware, not only of the primary effects of head injuries but of the longer lasting and sometimes permanent damage which may be inflicted by a blow upon the head. Yet, the fact that the phenomena were recognized by early physicians is no indication that there was a real under- standing of their nature. Indeed, it has only been in the past century that the physiological principles involved have been suggested. Just 200 years ago Beckett (13), in a surgical textbook, wrote that "to explain the cause of a person's falling to the ground immediately on the reception of a blow, we ought to observe that the blow caused a violent commotion of the whole brain, and so consequently put the spirits in a great confusion and disorder; which making irregular incursions into the several parts of the body, with- out the direction of the will, could not be confined to the nerves, whose office it was to distribute them into those muscles that keep the body in an erect posture; for which reason the machine must unavoidably fall to the ground." Irrespective of the bizarreness of the explanation, the fact that blows upon the head would render an individual unconscious has been known through- out history, and is unquestionably the reason for the early adoption by soldiers of various types of protective headgear. The chronic ill effects pro- duced by such blows upon the head have also been noted, both in legend and in historical records. Although little emphasis is placed upon headache and dizziness as the result of head injuries, the fact that convulsive attacks might follow a head injury was observed. In the 14th century Valescus de Tharanta (129) described a patient who had seizures seven or eight times a day following a penetrating head wound. Berengarius (16) gives an inter- esting description of a patient who, about 2 months after an injury, de- veloped epileptic paroxysms. He was strung feet up, the head wound

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opened, and a large quantity of milky material evacuated, whereupon the convulsions stopped. Duretus (67) was aware that fits might appear many years after a head injury, for he had observed the convulsions of an 18-year- old youth whose head some 6 years previously had been cracked, depressing a bony fragment. Duretus related how he perforated the bone, elevated the depression, and cured the condition. Even in the 19th century, although physicians considered head injuries a possible cause of epilepsy, their etiological role was not regarded as very important. Echeverria (39) concluded that almost 10 percent of his cases of epilepsy had a traumatic origin, but other authors did not find such a high correlation. Bouchet and Cazauvieilh (19) found only 1 in 69 cases, and Leuret (79) 1 in 67 cases in which a blow to the head was thought related to the convulsions. Hammond (61), in his textbook, does not refer to head injury as a cause of seizures. To some extent this may be due to the lethal nature of compound wounds of the head in those days. If the initial shock and blood loss did not kill, the victim usually succumbed to infection. This was so serious that many surgeons gave up trephining for head injuries. In St. Bartholomew's Hospital between 1860 and 1867, the tre- phine was not used once, and in all France in this period only 4 trephina- tions were performed. Obviously, under such circumstances, patients with serious brain injuries rarely survived, so that posttraumatic epilepsy was not often observed. With the introduction of antiseptic and later aseptic surgical techniques, however, many brain-injured patients survived. Accordingly, our statistics for the chronic effect of head injuries date from the time of Lord Lister. Since that time there have been many reports of the incidence of post- traumatic epilepsy following wounds incurred in war and peace. From the Franco-Prussian, Russo-Japanese, and Boer Wars, and partic- ularly the war of 1914, have come many series of head-injured patients, emphasizing not only the special problems in diagnosis of brain injury but also the difficulties in treatment of the neurological deficit, and in vocational and social rehabilitation. As the surgical care of these wounds improved, the number of survivors increased and the severity of the neurological deficit was greater, so that the subsequent care of these patients became a greater problem. Since it was early recognized that the State was obligated in case of war injuries, disability compensations or pensions were more thoroughly studied. B. LEGISLATIVE PROVISION FOR DISABLED SOLDIERS The principle that the State was morally obligated to care for its disabled soldiers seems to have been accepted from colonial times (40). In 1636 the Pilgrims enacted a disability pension law to die effect that any man engaged as a soldier, who was maimed, should be cared for by the colony during his life. Regular meetings were held in Boston to hear the applica- tions of wounded soldiers. Shortly after, disability pension laws were passed in Virginia, Maryland, New York, and, somewhat later, in Rhode Island. The first national pension law of August 26, 1776, provided half pay during disability to any member of die forces losing a limb or being so disabled in the services of the United States as to render him incapable of earning a living. However, at the conclusion of the Revolutionary War the Con-

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federation had no funds, and the commutation certificates given soon dwindled to a mere 12.5 cents on the dollar. In June 1785 a uniform method of handling disability pensions was adopted by the States, which were reimbursed from the Confederation, but because of certain limitations of time invoked subsequently, veterans were generally dissatisfied. The general pension law of 1792 was not much better, for it imposed upon the Circuit Courts of the United States the duty of examining applicants for pensions and determining the nature and degree of disability. The judges questioned the constitutionality of this law to impose upon them duties which were not properly judicial. Although some judges, as commissioners, did hear claims under this law, the issue was so controversial that Congress in February 1793 repealed the objectionable sections and issued new regulations. These provided that claims be presented to the judges, but Congress reserved the final action on their allowance. However, disability or invalid pensions of the Revolutionary War were not numerous; in 1792 only 1,472 men were on the rolls. In the next 100 years, service pensions and pensions for widows and dependents of soldiers and sailors were frequently modified by Congress, but the disability pensions were little changed until the Civil War. An act of 1862 provided pensions for disability incurred in the line of duty since March 4, 1861, while in the service of the United States. The rates for total disability ranged according to rank from $30 (colonel) to $8 (non- commissioned officers and privates). Partial disability was pensioned proportionately. Subsequently, the pension rates were gradually increased and the specific disabilities better defined. In February 1811 there was established by legislation the Naval Home in Philadelphia, which, however, was not occupied by disabled members of the Navy and Marine Corps until 1833. Realizing the need for further homes for invalided soldiers, Congress passed an act in March 1851 creating two military asylums, one at Harrodsburg, Ky., which was disposed of by public sale in 1860, and the odier in Washington, D.C., which is now known as the Soldiers' Home. A few years later a further enactment on March 3, 1865, authorized the establishment of the National Home for Disabled Volunteer Soldiers (53). This was erected in Togus, Maine, in 1866, and additional branches were built in various parts of the country, so that by 1930, when the National Home for Disabled Volunteer Soldiers was con- solidated with the U.S. Veterans' Bureau, there were 11 such homes. The next major change in disability pensions came shortly after the declaration of war against Germany in 1917. At that time, legislation was introduced to amend the War Risk Insurance Act of 1914 to allow a pro- gram of allotments and allowances for dependents of the fighting men, monetary insurance against death or permanent total disability, pensions or compensation for disability of a veteran, awards to his dependents for his death due to injury or illness as a result of service, medical treatment and supply of required orthopedic appliances for service-connected disability, and vocational rehabilitation. On August 9, 1921, the U.S. Veterans' Bureau was created by uniting the Rehabilitation Division of the Federal Board of Vocational Education, the Bureau of War Risk Insurance, and certain hospitals, caring for vet- erans, which were previously controlled by the U.S. Public Health Service.

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Some 9 years later a further consolidation of the activities of the Bureau of Pensions, the National Home for Disabled Volunteer Soldiers, and the U.S. Veterans' Bureau established the Veterans Administration (65). C. SPECIAL PROBLEMS OF BRAIN-INJURED MEN This brief survey of the development of modern systems for the care and rehabilitation of military casualties, especially the head injured, would not be complete without some mention of the special problems of the brain- damaged individual. Such patients were not simply hemiplegics, epileptics, or aphasics, alone or in combination, but presented a more general problem requiring a holistic view of the individual. This situation was early recog- nized in certain European countries where special institutes with well- organized staffs highly specialized in various neurological, psychological, therapeutic, and rehabilitation techniques were set up to study and treat head-injured patients. In Germany the "Institut zur Erforschung der Folgeerscheinungen von Hirnverletzungen" carried out such a program (55). As a result of these enterprises and the activities of the various veterans' pension boards, in stimulating studies of the biological course of head injuries, islands of data are available on certain aspects. In order to obtain a longitudinal view of the head injury problem, a project was set up after World War II, under the auspices of the Veterans Administration, to follow up a representative group of head-injured patients in order to deter- mine the natural history, the stresses, social and biological which may modify it, and the fate of such a group. It was hoped that in a period of 5 to 10 years the general trends might be apparent. This report is the result of such a study of a series of head-injured veterans of World War II. No attempt has been made to review or cover the voluminous literature on the subject of head injuries and their sequelae. The occasional ref- erence in the text to other studies we hoped might place the results of this follow-up in a proper setting and give a perspective to the whole. This monograph is a presentation of data rather than an exhaustive discussion of the subject of head injuries.