Brain injury

“ On recovering from the immediate effects of the injury—concussion of a greater or lesser degree of intensity—the patient does not regain complete mental and bodily convalescence. He suffers from symptoms suggestive of brain irritation—headaches, photophobia, mental irritability, insomnia, loss of appetite, the pulse accelerated, and the temperature slightly raised. ”

“ A very small amount of damage at this central part, or base, of the brain will produce a very large amount of paralysis. We may have large pieces of the bones of the skull driven into the outer surface of the brain, or considerable masses of our upper brain removed, or destroyed by tumors or disease, without very serious injury. But any disease or injury which falls upon the base of the brain, where these stalks run and big nerve-knots (ganglia) lie, will cause very serious damage, and often death. ”

“ True, there are certain parts of the brain which are exceedingly delicate, and in which the point of a needle would inflict at once a fatal injury. But the brain-substance itself is utterly non-sensitive, as every hospital-surgeon can tell us. Persons may actually recover from serious injuries of the brain in which several ounces of brain-substance may have been lost, and recover with good effect, and in many cases without any perceptible alteration of their mental peculiarity. ”

“ The differentiation of these conditions as suggested in the statistical manual of the American Psychiatric Association is as follows:—
"The diagnosis should be restricted to mental disorders arising as a direct or obvious consequence of a brain (or head) injury producing psychotic symptoms of a fairly characteristic kind. The amount of damage to the brain may vary from an extensive destruction of tissue to simple concussion or physical shock with or without fracture of the skull. ”

“ But when the fright or fear or nervous shock produces a bodily injury, then there may be recovery for that bodily injury, and for all the pain, mental or otherwise, which may arise out of that bodily injury. The brain and the nervous system are so closely connected with the mind, are the instruments by which the mind communicates with the body and operates upon it, that we sometimes deal with the nervous conditions as if they were mental conditions, and possibly the testimony has to some extent treated them as one. ”

“ These latter cases are generally fatal, and are accompanied not infrequently with meningeal and ventricular hæmorrhage’ (Bowlby) . [59]
The worst degrees of brain-injury arise when the injury is inflicted at close range, more especially at the site of emergence of a perforating bullet, the damage to the soft parts being there magnified by the waves and vibrations set up by the bullet during its passage across the brain. In many cases also the brain is dashed as a whole against the opposing osseous barrier (laceration by contre-coup) . ”

“ The anatomical appearances after early death from concussion of the brain are often insufficient for us to comprehend the fatal result, for we know that the organ will bear, both from disease and other kinds of injury, vastly greater inroads upon its structure and surroundings without causing death. Often there is mere localized cerebral congestion, with no ruptures of vessels; then there are slight extravasations shown as points or dots of blood in the nerve-matter; and, again, there is what is called the bruised brain. Sometimes there is nothing abnormal whatever to be found. ”

“ In fact, death itself may result though the marks of contusion are very slight or even imperceptible. Intracranial hemorrhage, laceration with ecchymosis of the brain, on the same or opposite side to the injury, and concussion of the brain may result. ”

“ The upper part of the brain may bear pressure to a considerable degree without bad consequences ensuing, but compression at the origins of the nerves is always highly dangerous and generally fatal. Bleeding from the nose, mouth, and ears, when attended with other circumstances and symptoms evincing a violent injury and consequent cerebral disturbance, has been considered as decisive of fracture at the base having occurred. ”

“ In all cases of head injury, the questions that dominate the whole clinical outlook are, whether the brain is directly damaged or not, and whether it is likely to become the seat of infection.
It is impossible to consider separately in their clinical aspects injuries of the cranium and injuries of the brain. It seldom happens that one is seriously damaged without the other suffering to a greater or less extent. Sometimes the skull suffers comparatively little, while the brain is severely damaged, but it is rare for a serious injury to the bone to be unaccompanied by definite brain lesions. ”

“ So far as my observation goes, the injury to the head, supposed to be the cause of general paralysis, often has appeared to probably come from an accident due to the impaired physical strength and to the vaso-motor disturbance in the brain incident to the early stage of the disease and while it was still unrecognized. Cases are observed in which no predisposing or exciting cause is found by the physician. ”

“ After such consideration of local complications, it would appear that the middle fossa of the skull presents the greatest dangers. Another factor must, however, be taken into consideration—injury to the brain—the commonest cause of death in all head injuries. ”

“ Then, too, in the act of falling from the occurrence of a cerebral hemorrhage due to disease the head may be injured and show marks of violence. It should be borne in mind that an injury to the head may be inflicted when disease of the brain, vessels, or membranes already exists. In such a case a slight blow might cause extensive hemorrhage, but as that which accelerates causes, death, even though it might sooner or later have occurred in the same manner without injury, is due to the injury inflicted. ”

“ Cases of head injury are often more grave in their consequences than in their immediate symptoms. Sometimes the patient appears to be getting better when really he is worse. Rest and quiet should be observed for several weeks after an accident which has in any way affected the brain. ”

“ Diseases and injuries of the brain are notoriously difficult to diagnosticate. This may well be because it has always been so well protected by the skull that there have been evolved within it few tell-tale self-protective responses, so that in the presence of injury and disease within itself the brain remains remarkably silent. It should occasion no surprise that there are in the brain no receptors, the mechanical stimulation of which can cause pain, because its bony covering has always prevented the adaptive implantation within it of contact pain receptors. ”

“ When an injury is not immediately fatal, and life, although for a time in imminent danger, is not destroyed, yet fluctuates on the verge of destruction, gradually to be restored, again to fail, and at the end of several days to be eventually extinguished, the changes which take place in the functions of the brain during this period are accompanied by alterations which are observable in its appearance. The assemblage of phenomena which have taken place constitute inflammation ”

“ An alteration from the ordinary state of the pupils does not prove the absence or presence of any serious general injury, but only that a particular part of the brain has been more or less affected. The breathing at this period is free, and not in the least noisy or stertorous, unless the concussion be complicated with irritation occurring from lesion of the brain or its membranes, or of the medulla oblongata. ”

“ It is unnecessary to enter into details with regard to the symptoms arising from bullet-wounds of the skull and brain, for they closely resemble those previously enumerated in the chapters dealing with fractures of the skull and injury to the brain. There are, however, a few special points to which attention should be directed.
1. External hæmorrhages are seldom profuse.
2. The escape of cerebro-spinal fluid is of infrequent occurrence, probably due to the fact that the apertures of entry and exit are blocked up with scalp, fragments of bone, and pulped and swollen brain. ”

“ If he fall upon his head and be stunned, he will look deadly pale, very much as if he had fainted. He will in a few minutes, in all probability, regain his consciousness. Sickness frequently supervenes, which makes the case more serious, it being a proof that injury, more or less severe, has been done to the brain ”

“ Insomuch as all evidence tends to prove that general cerebral irritation, as resulting from injury, implies a condition of contusion or superficial laceration, a prolonged period of bodily and mental rest is essential before the patient is discharged from treatment and allowed to return to work—a period of not less than six months. ”

“ In young persons the brain will bear a greater degree of pressure and of irritation with impunity than it will in persons of mature age. By far the greater number of cases in which recovery has taken place after fracture and depression of the skull with injury of the brain, and even loss of its substance, have occurred in children or in persons under the adult age ”

“ The brain of the infant is equally—if not more—liable to bruising and laceration, but the results are far less definite than in adults. There can be no question that extensive cerebral injury may exist in the child without leading to the development of any definite localizing symptoms. ”

“ There are cases in which responsive actions take place under very abnormal conditions—as after a rupture of part of a man’s spinal cord, or the removal of the whole brain in lower animals, such as the frog. A man so injured may have utterly lost the power of feeling any stimulation—pricking, cutting, or burning—of his legs and feet, the injury preventing the conveyance upwards to the brain of the influence necessary to ordinary sensation, and stopping short at the spinal cord below the point of injury. ”

“ Although the general proposition seems to be established, that the brain is not immediately necessary to the action of the heart, yet it must not lead us to the conclusion that the heart is therefore incapable of being affected by violent impressions on the nervous system; the fact is quite otherwise, for although the brain may be removed, and the circulation be nevertheless maintained by artificial respiration, yet an injury of another kind inflicted on the brain, may be followed by those immediately fatal consequences which decapitation itself would not produce ”

“ That whether the heart is exposed or not, its action continues long after the brain and spinal marrow are destroyed; and still longer when the brain is removed without previous injury to its substance. ”

“ On a dissection of the brain in a pure case of this kind, no trace of injury or even of derangement of any part of it can be perceived. Life is extinct, but the brain is intact. The immaterial has been separated from the material part, by an injury apparently inflicted on the very seat of life, with as little apparent derangement of its structure as if death had occurred in a secondary manner from the abstraction of blood by a rupture of the heart. ”

“ Biomedical research is also the source of increased hope. Investigators supported by the National Institute of Neurological and Communicative Disorders and Stroke are acquiring new information about what happens to the brain as a result of head injury. Leads from these studies will help scientists develop effective treatments to limit or prevent brain damage. With the combined support of voluntary health agencies and the Federal Government, the tragedy of head injury can be substantially reduced. ”

“ After recovering, his intellect fully developed itself in a mind endowed with a lively imagination, an amazing memory, and a zeal for study rarely equaled.' Such instances can be accounted for by the brain having previously been poorly nourished by a defective blood supply, which defect was remedied by the increased circulation afforded by the head-injury. ”

“ Irritability gives place to fatuity; there is less manifestation of temper, but more weakness of mind. Recovery is slow, but though delayed, may at length be perfect....”
The treatment consists in keeping the patient quiet, in a darkened room, on much the same lines as for concussion.
Compression of the Brain.—This term is used clinically to denote the train of symptoms which follows a marked increase of the intra-cranial tension produced by such causes as hæmorrhage, œdema, the accumulation of inflammatory exudate, or the growth of tumours within the skull. ”

“ It is unreasonable to ask one to believe that the milder cases of concussion, cases in which the patient merely suffers from loss of consciousness for a few minutes, from which he rapidly recovers and is discharged from treatment within a few days, and from which he suffers in the future from no remote ill effects whatsoever, it is unreasonable to ask one to believe that such cases have experienced so severe a lesion as brain contusion or laceration. ”

“ In his later years he devoted himself especially to the study of injuries of the brain following fractures of the skull and of pistol shot wounds of the head, and his book, "Traumatic Injuries of the Brain," remains today a standard work. ”

“ This affords a partial explanation of the fact that wounds of the brain are far less dangerous than those of the spinal cord. It is always a great wonder, even to us physiologists, every time we convince ourselves on living subjects that the brain is without feeling. Men have been seen who suffered great portions of their brain, which protruded from the skull, to be cut away, and sick drunkards or madmen, who, through the wounds in their head, seized hold of the brain with their hands and destroyed it. ”