Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon (1961) / Chapter Skim
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The Chronic Neurological Deficit
The Chronic Neurological Deficit
Pages 35-76
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From page 35... ...
B GENERAL SURVEY A glance at the summary table 40 of the chronic neurological deficits indicates that even years after injury few men who suffered a head wound considered themselves perfectly normal, although almost half had no abnormal findings on neurological examination.
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From page 36... ...
Cedrmark (27) stated that 25 percent of patients suffering various civilian head wounds considered themselves well in 10 days, and 50 percent were free of symptoms in 3.5 weeks and 75 percent in 10 weeks.
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Accordingly, patients considered to have the posttraumatic syndrome often have many more than three of the above complaints. This arbitrary definition of the syndrome vitiates analysis of the individual complaints.2 Examination of the present series of head-injured patients for these general symptoms at the times of discharge and of follow-up (table 41)
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From page 39... ...
On analysis of the 309 men who were asymptomatic at discharge, it is found that only 40 are so at follow-up, 136 have the posttraumatic syndrome, 80 suffer headaches, and lesser numbers suffer other posttraumatic symptoms. On the other hand, only 24 (6 percent)
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. men receiving compensation from the Veterans Administration for residuals of a head wound, so it is not surprising that few of them are without symptoms.
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. Even the immediate neurological deficit does not seem to be related to symptomatology or the posttraumatic syndrome at follow-up.
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3 I a i o 1 2 3 (I "a O 3 i J i 9 if *
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The percentage for the subgroup with symptoms differs from that in the symptom-free group with P <\05. Table 46. -- Correlation of Mental Deterioration, Determined by Wechsler-Bellevue Intelligence Scale, With Neurological Symptomatology at Follow-up Abnormally deteriorated for age Number tested Symptom Number Percent 57 237 389 4 40 102 7.0 16.9 '26.2 One or 2 symp Posttraumatic s ,oms yndrome Total...
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From page 44... ...
maintains that this is typically quite distinct from the posttraumatic syndrome, being characterized by mental alertness, emotional depression, exaggeration of preexisting personality defects, elaboration of symptoms both in statement and behavior, the presence of hysterical components, and the multiplicity, changeability, and indefiniteness of the symptoms. The two conditions -- posttraumatic syndrome and posttraumatic neurosis, Strauss and Savitsky (120)
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From page 45... ...
It has been suggested that cranioplasty might prevent the syndrome of the trephine, which is practically identical to the posttraumatic syndrome. Gardner (51)
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D MENTAL STATUS A rather large number of mental aberrations were noted, although the majority of the patients had no complaints referable to their mental status.
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3 1 •fr 'B ^ A O m JO a O CM en in c g in CM CM D in en *
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71 100.0 100.0 25.4 73.2 64.0 1.4 10.0 50 26.0 Table 53. -- Relationship of Mental Status to Mental Deterioration as Determined by Wechsler-Bellevue Abnormally deteriorated for age Mental status Number tested Number Percent Total 683 145 21.2 Normal 562 71 50 90 38 17 16.0 i53.5 '34.0 Impaired judgment or mentation Other and unknown .
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O NO »-H CO § 8 ifi f^ r~*
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-- Correlation of Memory With Location of Wounding Location of wounding Memory Frontal Parietal Temporal Occipital Number Percent Number Percent Number Percent Number Percent Total 251 100.0 372 100.1 187 100.0 176 100.0 0 -- 2 errors . 192 51 76.5 20.3 287 75 77.2 20.2 148 31 79.1 16.6 133 38 75.6 21.6 Test not done or unsatis8 3.2 10 2.7 8 4.3 5 2.8 Toble 58.
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. However, the 7 left-handed persons suffering head wounds who had aphasia also had left-sided lesions.
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From page 55... ...
tion of speech is the most prevalent form of cerebral organization in sinistrals. In general, wounds of the left hemisphere were more disabling than comparable wounds of the right side of the brain; of 286 patients with right hemispheral wounds, 61 percent had no immediate neurological deficit, whereas of 312 patients with left hemispheral wounds, only 48 percent were without deficit.
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3 I I a | •5
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. Although diplopia and blurred vision did not seem to be related to wounding of any particular part of the brain, blindness, as would be expected, was much more commonly found with wounds of the frontal region since these implicated the optic nerve and tract; hemianoptic defects were found in patients having injuries of the posterior parietal, temporal, and particularly the occipital region (table 70)
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Table 66. -- Olfactory Symptoms at Follow-up Symptom Number of men Symptom Number of men None 684 Unknown 6 11 Anosmia 25 Total 739 Other 13 Table 67. -- Correlation of Olfactory Disturbances With Location of Wounding Location" of wounding Symptom Frontal Parietal Temporal Occipital Number Percent Number Percent Number Percent Number Percent Total 251 100.0 372 100.0 187 100.0 176 100.0 None 223 6 88.8 2.4 6.8 2.0 344 7 7 14 92.5 1.9 1.9 3.8 176 1 5 5 94.1 0.5 2.7 2.7 164 2 93.2 1.1 1.7 17 5 3 7 4.0 Table 68. -- Visual Disturbances Subjective complaint Number of men Objective findings Number of men 578 Normal 645 18 Blind1 7 Blurred vision -- bilateral 38 Vision impaired 23 27 Homonymous hemianopsia, 6 contralateral 63 Field defect 55 Homonymous hemianopsia, Other 17 3 5 Other 5 Unknown 3 Total number of cases.
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From page 63... ...
Blurred vision does not seem to correlate with specific factors of wounding nor with objective evidence of impaired vision since 29 of 39 patients so complaining had normal vision. However, it may be a manifestation of the posttraumatic syndrome, for every one of the 39 men complaining of blurred vision had posttraumatic symptoms, and 29 had the full-blown syndrome.
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From page 64... ...
Table 71. -- Auditory Disturbances Disturbances of hearing Subjective complaints Objective findings None 456 587 Tinnitus: Contralateral to side wounded 36 Ipsilateral to side wounded 80 Bilateral 81 Impaired hearing: Contralateral to side wounded 32 27 Ipsilateral to side wounded 71 89 Bilateral 26 19 Deafness: Contralateral to side wounded 5 5 Ipsilateral to side wounded 20 9 Bilateral 1 1 Other and unknown 5 4 Total number of cases 739 739 Table 72. -- Correlation of Auditory Findings With Severity of Wounding R-I group Finding 1 2 3 4 Number Percent Number Percent Number Percent Number Percent Total .
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J OTHER CRANIAL NERVES Nerves to the extraocular muscles were rarely involved; in 18 cases only was there such impairment -- 14 times in the ipsilateral and 4 times in the globe contralateral to the injury (table 74)
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From page 66... ...
The 9th and 10th cranial nerves were involved in only two cases in this series, causing impairment of deglutition. Table 74. -- Impairment of Other Cranial Nerves Nerve and type of impairment Number of men Nerve and type of impairment Number of men Ocular motor nerves: Impairment extraocular movement: 14 Contralateral to wound ....
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From page 67... ...
However, motor impairment at the time of wounding was either overlooked at that examination or developed later, for 160 patients were noted to have some paresis at the follow-up examination.
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From page 68... ...
It was hoped that an analysis with reference to the status at follow-up, of the 148 patients noted to have a hemiparesis at the time of wounding, would give some indication of factors favorable and unfavorable in prognosis. For the purpose of this study, a residual weakness at follow-up of at least 20 units difference in dynamometer readings of the 2 grips, or a difference of 10 units in favor of the nondominant hand, was arbitrarily taken to be the 68
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From page 69... ...
Disturbances of the motor system may be manifested by weakness, spasticity, atrophy, or changes in reflex activity. Because in wounds of the brain the involvement of the motor system is of the upper motor neuron type, spastic paresis with increased deep reflexes and pathological superficial reflex responses is usually found.
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From page 70... ...
Table 79. -- Correlation of Motor Power With Tone Finding Tone, side contralateral to wound Hypotonia Hypertonia Rigidity Normal Other and unknown Total 3 9 28 39 1 2 2 3 1 34 124 578 2 1 Normal 1 73 574 2 Other Unknown 1 Total 13 70 5 648 3 739 Tone, side ipsilateral to wound 1 33 112 34 124 578 2 1 7 5 1 575 2 Other 2 1 Total 10 6 720 3 739 Muscular atrophy was less commonly found than hypertonicity or hyperreflexia, being noted in only 62, or approximately one-fourth of the paretic patients (table 80)
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From page 71... ...
. 21 8.4 54 14.5 14 7.5 8 4.5 Table 82. -- Somatosensory Disturbances Impaired Impaired Impaired stereognosis Location Paresthesias superficial sensation deep sensation None 584 561 618 634 Face: Contralateral ...
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From page 72... ...
1 44 45 8 3 3.0 10 5.5 54 14.9 51 53. 1 Table 84. -- Correlation of Sensory Disturbances With Location of Wounding Location of wounding Disturbance Frontal Parietal Temporal Occipital Number Percent Number Percent Number Percent Number Percent Total 251 100.0 372 100.0 187 100.0 176 100.0 Contralateral: 35 41 13.9 16.3 96 99 25.8 26.6 37 33 19.8 17.6 25 25 14.2 14.2 Hypesthesia Paresthesias may or may not be associated with demonstrable sensory alterations.
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It is apparent that disturbances of deep sensibility and astereognosis closely parallel those of the superficial sensibilities. Of 154 men with superficial sensory disturbances, 101 had impaired deep sensibility, and only 11 with normal superficial sensation had impairment of deep sensibility.
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From page 74... ...
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From page 75... ...
In fact, certain disabling symptoms seem to be more dependent upon the general than the local injuries. Thus the posttraumatic syndrome, the mental disturbances, certain cranial nerve impairments, and sexual alterations, correlate with general rather than local factors.
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