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VA Medical Monograph A FOLLOW-UP STUDY OF HEAD WOUNDS IN WORLD WAR II A. EARL WALKER, M.D. It Professor of Neurological Surgery The Johns Hopkins University Baltimore, Maryland and SEYMOUR JABLON, M.A. Statistician, Follow-up Agency Division of Medical Sciences National Academy of Sciences-National Research Council Washington, D.C. 1 AUGUST 1961 The work reported herein is part of the program of studies of the Follow-up Agency of the National Academy of Sciences- National Research Council developed by the Committee on Veterans Medical Problems in cooperation with the Veterans Administration and the Department of Defense. This investigation was supported by the Veterans Administra- tion upon the specific advice of the Committee on Veterans Medical Problems and by the National Institutes of Health under grant B-2153. The work was carried out at The Johns Hopkins Hospital in Baltimore, the Montefiore Hospital in New York City, the Long Beach (Calif.) Veterans Administration Hospital, the Gushing Veterans Administration Hospital in Framingham, Mass., and the Follow-up Agency in Washington, D.C.

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W LIST OF VA MEDICAL MONOGRAPHS In Print A Follow-up Study of World War II Prisoners of War Tuberculosis in the Army of the U.S. in World War II A Follow-up Study of War Neuroses Peripheral Nerve Regeneration: A Follow-up Study of 3,656 World War II Injuries A Follow-up Study of Head Wounds in World War II In Preparation Sequelae of Acute Viral Hepatitis Late Effects of Arterial Interruption in Battle Casualties of World War II Late Effects of Cold Injuries (Ground Type) Sustained in World War II For sale by the Superintendent of Documents, U.S. Government Printing Office Washington 25, D.C. - Price J1.7S

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Preface The volume before you is the fifth in a series of monographs pre- pared under the sponsorship of the Veterans Administration by the Follow- up Agency of the National Academy of Sciences-National Research Council. In cooperation with the Veterans Administration and the Depart- ment of Defense, the studies reported here have been directed toward a longitudinal view of the head injury problem. The work represents several years of careful examinations, statistical evaluations, and correlations of clinical data from four centers in the United States. The authors have focused their attention chiefly on the presentation and validation of findings. They have not undertaken an exhaustive discussion of the subject or review of its voluminous literature. In a highly condensed (largely tabular) form, the monograph brings to the profession one of the most extensive and complete studies of its kind. We hasten to note that these records and conclusions have importance .well beyond the circumstances of war. Indeed, the diabolical talents of warmaking are hard pressed to exceed the risks of modern civil life as a potential source of trauma. Quite aside from its important topic, the monograph is a veritable gold mine of information, direction, example, and commentary on the collection and evaluation of medical data. Working under the severe handicap of any retrospective survey, the authors have with circumspection and precision handled an elusive and capricious body of information. By examining their sources of error and exposing every artifact of observation, they have created a valuable sourcebook for those who wish to conduct researches of a similar nature. BENJAMIN B. WELLS, M.D., Assistant Chief Medical Director for Research and Education in Medicine. Ill

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MEMBERSHIP OF COMMITTEE ON VETERANS MEDICAL PROBLEMS Division of Medical Sciences, National Academy of Sciences-National Research Council Dr. H.Glenn Bell, 1950-51 Dr. David A. Boyd, Jr., 1956-58 Dr. Francis J. Braceland, 1946-49 Dr. W. Edward Chamberlain, 1956r-57 Dr. Edward D. Churchill, 1946-49 Dr. Winchell McK. Craig, 1946-50 Dr. Wilburt C. Davison, 1950-59 (Chairman, 1950-56) Dr. Michael E. DeBakey, 1946-62 Dr. Louis I. Dublin, 1946-48 Dr. Jacob E. Finesinger, 1952-59 Dr. Fred J. Hodges, 1957-62 Dr. A. Leroy Johnson, 1951-54 Dr. Chester Scott Keefer, 1948-51 Dr. Paul V. Lemkau, 1959-62 Dr. Esmond R. Long, 1952-62 (Chairman, 1956-59) Dr. Perrin H. Long, 1946-54 Dr. Currier McEwen, 1956-62 Dr. Donald Mainland, 1953-54 and 1956-62 Iv Mr. Herbert H. Marks, 1948-54 Dr. William C. Menninger, 1946-49 Dr. Morris Fishbein, 1946-52 Dr. A. McGehee Harvey, 1952-62 Dr. Hugh J. Morgan, 1946-48 Dr. Benedict Nagler, 1960-62 Dr. O. H. Perry Pepper, 1946-51 (Chairman, 1946-50) Dr. I. S. Ravdin, 1949-51 Dr. C. P. Rhoads, 1946-47 Dr. Gordon H. Scott, 1960-62 Dr. William S. Stone, 1956-62 (Chairman, 1959-62) Dr. H. Houston Merritt, 1952-54 Dr. J. Roscoe Miller, 1946-54 Dr. Roy H. Turner, 1951-52 Dr. C. J. Watson, 1948-49 Dr. John C. Whitehorn, 1949-51 Dr. Milton C. Winternitz, 1946-50 Dr. Stewart G. Wolf, Jr., 1951-52 Dr. Harold G. Wolff, 1949-51 Dr. Barnes Woodhall, 1951-52

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ACKNOWLEDGMENTS During the formulation of this study the advice was sought of the late Dr. William G. Lennox and of Dr. Johannes M. Neilson, both of whom graciously gave their time, experience, and encouragement. For the more arduous tasks of conducting follow-up examinations we are greatly indebted to our colleagues, particularly to Dr. John D. French, Dr. Arnold P. Fried- man, and Dr. Jerome K. Merlis, who organized supporting follow-up centers in their areas. Dr. Friedman and his associates have also contributed some supplementary material on headache. Dr. Curtis Marshall not only read the electroencephalograms of the Baltimore center but analyzed selected records from the other centers. We also acknowledge with appreciation the help of the many neurosurgical residents of the Johns Hopkins Hospital, who assisted in preparation of records, examination of patients, and compila- tion of data. To Dr. James W. Markham, who worked on the pilot proj- ect during its most active phase, we are particularly grateful. The Medical Statistics Division, Office of The Surgeon General, U.S. Army, kindly provided duplicate punchcards on World War II head in- juries to serve as the sampling base. Similarly, the Veterans Administra- tion provided lists of veterans receiving disability compensation in 1950 for residuals of head injuries and resident in the areas of study. Records offi- cials of the Department of Defense and the Veterans Administration have generously provided access to the records needed for the research. The American Red Cross extended its helping hand in each study area, taking on the difficult task of interpreting to the subjects the nature and purpose of the study, and obtaining their cooperation when the personnel of the follow-up center had exhausted their resources. We also owe particular thanks to Mr. A. Hiram Simon, who supervised the statistical processing in the Follow-up Agency; to Miss Vivian Heiden- blut of his staff, under whose direction the demanding task of abstracting and coding the medical records was performed; and to Mrs. Myrtis E. Hill- man, without whose devoted editorial efforts this report could not have been completed.

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ORGANIZATION AND PERSONNEL OF THE CLINICAL CENTERS Baltimore Center The Johns Hopkins University and Hospital, Baltimore, Md. A. Earl Walker, M.D., Director James W. Markham, M.D. Curtis Marshall, M.D. Los Angeles Center The Long Beach Veterans Administration Hospital, Long Beach, Calif. John Douglas French, M.D., Director Ralph W. Ban-is, M.D. J. Sloan Berryman, M.D. Irla Lee Zimmerman Boston Center The Gushing Veterans Administration Hospital, Framingham, Mass. Jerome K. Merlis, M.D., Director C. Grossman, M.D. B. Matzilevich, M.D. Anthony Varjabedian, M.D. Angela Folsom, Ph. D. P. Pruyser, Ph. D. New York Center Montefiore Hospital, New York, N.Y. Arnold P. Friedman, M.D., Director H. Mikropoulos, M.D. John A. Passoni, M.D. A. Siegelaub vl

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Foreword Great wars between nations are a part of the history of man, deciding nothing permanently. The prospects for their outlaw are as dim as they have ever been, and military preparations for the next mount with increasing seriousness, demanding more and more sacrifices from citizens of all nations. If one looks for a modicum of contribution to the welfare of man from war, it is to be found only in the benefits he may receive from the medical and surgical experiences gathered during war at an expensive price. The facts gained from the treatment of chest wounds, injuries to the peripheral nerves, the control and prevention of contagious diseases, and infections are examples of the application of advancements made in medicine and surgery during wartime. This volume, a post hoc study, made under servere obstacles, of a group of patients who received craniocerebral injuries, is the result of several years of careful examinations, statistical evaluations, and attempted correlations of head trauma, symptoms, and objective findings at four centers in the United States. This monograph is a part of the program of studies of the Follow-up Agency of the National Academy of Sciences-National Research Council developed by the Committee on Veterans Medical Problems in cooperation with the Veterans Administration and the Department of Defense. It is the companion of a similar study, under the same auspices, of the results of peripheral nerve injuries received during World War II. It is regrettable that this study and that of peripheral nerve injuries were handicapped by the absence of a prepared plan of observations which should have been outlined between World Wars I and II. The lessons learned during World War I were not utilized to the fullest extent during World War II, an outstanding example being the treatment of peripheral nerve injuries. Missing are data which might easily have been obtained even under the stress of battle and evacuation problems if, during the brief intervals between wars, thought had been given and work expended upon how the greatest future good could be obtained from the terrible sacrifices asked of men. Aside from the data which have been so carefully collected and evaluated, it is to be hoped that this book will stimulate thought about plans which can be put into effect during any future conflict, so that future evaluations of medical and surgical experiences can be improved beyond the costly record of the past. LOYAL DAVIS, M.D., Professor and Chairman, Department of Surgery, Northwestern University Medical School, Chicago, III. vH

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Table of Contents Page Chapter I. Introduction 1 A. Historical Background 1 B. Legislative Provision for Disabled Soldiers 2 C. Special Problems of Brain-Injured Men 4 Chapter II. Method and Materials 5 A. Sampling Plan and Organization of Study 5 B. Characteristics of the Sample as Determined From Army Records 6 C. The Follow-up Examination 14 D. Differences Between Men Who Reported for Follow-up Examinations and Those Who Did Not 16 1. Characteristics of the Injury and Status at the Time of Separation From Service 16 2. Information From VA Claims Folders 16 3. Data From Telephone Interview 18 4. Conclusions 19 E. Follow-up Results and Variability Between Centers 19 F. The Injury Score 28 G. Roster-Injury Groups 31 Chapter III. The Chronic Neurological Deficit 35 A. Introduction 35 B. General Survey 35 C. Neurological Symptomatology 36 D. Mental Status 46 E. Aphasia 54 F. Apraxia 59 G. Olfactory Disturbances 59 H. Visual Disturbances 59 I. Acoustic Disturbances 63 Other Cranial Nerves 65 Disturbances of the Motor System 66 L. Somatosensory Disturbances 70 M. Urinary Disturbances 73 N. Sexual Disturbances 73 O. Discussion 75 Chapter IV. Electroencephalography, Pneumoencephalography, and Psychom- etry 77 A. Introduction 77 B. Electroencephalograms and Neurological Deficit 77 1. Variability in Interpretation 77 2. Characteristics of the Wound 80 3. Neurological Deficit 85 4. Pneumoencephalogram 87 5. Early Electroencephalograms 88 6. Rehabilitation 88 7. Clinical Abnormalities 90 8. Epilepsy 91 9. Intelligence 93 10. Discussion 93 C. Pneumoencephalography 96 1. Findings 96 2. Discussion 99 D. Psychometry 100 1. Intelligence as Determined by the Wechsler-Bellevue Test 101 2. Minnesota Multiphasic Personality Inventory 108 3. The Goddard Form Board Test Ill 4. Discussion 113 ix

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Chapter V. Epilepsy 115 A. Introduction 115 B. Types of Attacks 116 C. Incidence of Epilepsy 119 D. Time of First Attack 122 E. Antecedent Factors in Epilepsy 125 F. Factors at the Time of Wounding Which May Modify the Probability of Epilepsy 127 1. Severity of Wounding 127 2. Location of the Wound 129 3. Repair of the Wound 131 G. Posttraumatic Factors in the Probability of Epilepsy 133 H. Course of the Epilepsy 138 I. Treatment of Epilepsy 142 J. Discussion 143 Chapter VI. Social and Economic Rehabilitation 145 Bibliography 155 Appendix 1. Posttraumatic Headache—Arnold P. Friedman, M. D., and H. Mikropolous, M.D 165 Appendix 2. Code Sheets, Outline of Code for Acute Injury 169 Appendix 3. Examination Booklet, Outline of Booklet for Follow-up Examina- tion 173 Appendix 4. Letters to Veterans 177 Author Index 181 Subject Index 183