Brain lesion

“ The trephine is applied, the disk removed, and the gap enlarged with the craniectomy forceps in the forward and backward directions. The hæmatoma is evacuated and the bleeding arrested after the methods enumerated above.
Results. The ultimate result of operation for middle meningeal hæmorrhage depends on two factors—the time at which operation is carried out, and the question of brain lesion. There is every reason to believe that, when treated early and when uncomplicated by brain injury, the prognosis, both immediate and remote, is wholly satisfactory. ”

“ 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. ”

“ With regard to the extensive character of the brain destruction in the region of the aperture of exit, it must be borne in mind that this lesion corresponds in position with one which would exist even if the injury were of a non-penetrating degree. A large proportion of the contusion and destruction is therefore explained by violent impact of the projected brain with the skull prior to the passage of the bullet, and not to the direct action of the bullet on the tissues. ”

“ In the functional mental diseases there is no characteristic lesion of the brain as yet recognizable, even in the latest stages, more than is to be found in the brains of persons dying from other causes. When apparently local injuries or diseases cause insanity, they probably do so through a general disturbance of the brain or through diffuse disease resulting therefrom and for the most part affecting both hemispheres. ”

“ That a similar pathological condition occurs in the cerebral mechanism, and may serve to explain many psychic symptoms, is very probable.
On the other hand, a destructive lesion may be so placed in the spinal cord or brain as to allow centripetal impressions to reach healthy spinal gray matter in the normal way, but preventing their passage frontad (upward) to be recognized by consciousness. In such a case we observe normal, or more commonly exaggerated, reflex action in parts which are insensible in the ordinary sense of the term. ”

“ Injure the brain, and consciousness is lost. 'Lost' is the right word—not 'destroyed.' Repair the lesion, and consciousness may be restored, i.e. normal manifestation of consciousness can once more occur. It is the display of consciousness, in all such cases, that we mean when we speak of the effect of brain injury; the utilisation of bodily organs is necessary for its exhibition. If the bodily organs do not exist, or are too damaged, no normal manifestation is possible. ”

“ Neither medicine nor physiology opposes the use of the clinical method in cerebral localization. But only circumscribed lesions that have little or no tendency to become general, or to act at a distance by compressing the brain, or otherwise, can come to the aid of our theory. When there is a lesion of the cortical region of the brain which fulfills these conditions, the resulting symptoms may be of two orders—either stimulative or paralytic of the true function. ”

“ The autopsy showed slightly congested lungs; no other lesion except a sharply defined hemorrhage in the cervical spinal meninges and over the meninges of the temporal and occipital lobes. Microscopic section of the brain failed to show any hemorrhages within the brain substance.
Here is a case of death following explosion without external wound. The meningeal hemorrhages are hardly enough to explain the death. The explanation of the death must probably be made after histological examination. ”

“ They should always lead the physician to carefully consider the great probability of a lesion in some way involving the motor area.
Tumors of the cerebellum, pons, and medulla oblongata sometimes give rise to general convulsions which closely simulate attacks of grave epilepsy. These convulsions or general spasms are among the most important symptoms of intracranial neoplasms. More than paralysis, they may be regarded as general symptoms, as they are more likely to occur from tumors situated in different and distant regions of the brain than paralysis. ”

“ Sometimes they show automatic movements and have to be fed. The conversation is often incoherent and meaningless. They are inclined to be emotional. Sleep is usually interfered with and they are restless at night. The appetite is lost. Occasionally evidences of brain lesions appear with paralyses, speech disturbance or epileptiform seizures. The duration is usually a matter of a number of months. At autopsy grave cell alterations and glia reactions are common. Rod cells are also found. Endothelial proliferation is frequently observed in the vessel walls. ”

“ We should observe notwithstanding, that these different causes of death, may act with various degrees of intensity. If they act but feebly, they affect the intellectual functions only, for these functions are always the first to be altered, in all lesions of the brain however small. If the lesion be greater, the affection extends to the muscles of the limbs, and convulsion or palsy ensue. Lastly, if the [304] lesion be very great, the whole of the muscles of the animal life, the intercostals and diaphragm, as well as the others, are paralyzed, and death follows. ”

“ The lesion in these cases is usually chronic meningitis, though it is possible that in some instances the gray matter rather than the membrane of the brain may be affected, and in severe cases the gray matter is of course more or less compromised. ”

“ The chief elements for the formation of the diagnosis are the slow and interrupted progress of the affection, persistent headache, tendency to prolonged slumber, and final coma; the absence of paralysis of the cranial nerves, of vomiting, and of general convulsions; the age of the patient, the coexistence of alcoholism, chronic insanity, or acute rheumatism, and traumatism. The diseases for which hæmatoma would be most likely mistaken are acute inflammation of the meninges, apoplexy from cerebral hemorrhage, tumor in the substance of the brain, and necrobiosis from thrombus or embolus. ”

“ The diagnosis of cerebral tumours is very difficult, particularly when attempts are made to indicate their exact seat, but that of other cerebral lesions is somewhat easier.
The prognosis is very grave, and in the case of domestic animals nothing can be done. In the ox intra-cranial operations are difficult, by reason of the presence of the sinuses which obstruct the approach to the brain cavity; economically surgical treatment is seldom advisable. ”

“ To this course, however, there are two great objections: (1) the exposed cortex most commonly includes the motor area, herniation of which will lead to disastrous effects on the extremities of the contra-lateral side—spasticity, paralysis, aphasia, &c.; and (2) the herniation of brain-matter including, or closely related to, an irremovable tumour tends to lead to œdema of the brain tissues and softening of and hæmorrhage into the growth, with subsequent rapid development of the outwardly protruded mass. ”

“ But when all these conditions have been excluded and when the symptoms are apparently due to a cerebral affection, there is one group of cases in which localizing brain symptoms are absent and in which the chief indications of disease are headache, double optic neuritis, and often vomiting. In most of these cases syphilis can be also excluded. A diagnosis of brain tumor is given, and the growth is thought to be situated in some region in which the localizing symptoms are at first indefinite—cerebellum, temporo-sphenoidal lobe, or prefrontal region. Such a diagnosis often proves to be correct. ”

“ The cerebral turgescence and disturbance, therefore, in whatever degree they may exist, are only, when sympathetically produced, to be considered as morbid causes, whose presence, where the predisposition prevails, may lead to a serous inflammation of the tissues of the brain, but which do not form, in any sense, parts of the disease itself; since, under every degree of them, they are so frequently remediable, by means which are alone available, for the removal of their distant and sympathetic cause. ”

“ At the same time it is only logical to conclude that any morbid condition of the cerebral circulation or of the brain or membranes which leads to a corresponding amount of ventricular effusion, or atrophy or destruction of the nerve centres already designated, will produce the symptoms characteristic of this disease. Thus the different forms of meningitis, traumatic injuries to the cranium, chronic encephalitis, cerebral softening or degeneration, sclerosis, neoplasms of all kinds affecting the brain (cysts, cholesteatoma, psammoma, melanoma, etc.) , and parasites may occasion this disease. ”

“ 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. ”

“ At autopsy there are often no evidences of any great injury to the brain. Occasionally extensive areas of softening may, however, be found. Usually there is a widespread destruction of the nerve cells and their associated fibres. There is often a proliferation of the glia, with changes in the vessel walls which may be thickened and dilated, with capillary hemorrhages and softenings. Extensive areas of the cortex may be involved. Bleuler's description of the traumatic psychoses is not essentially different from that of Kraepelin. ”

“ In a few cases the enormous irritation of the cerebral growth suddenly or gradually inhibits the heart's action through the impression made on the pneumogastric. Apoplectic attacks which may or may not terminate fatally sometimes are the result of a sudden giving way of necrosed brain-tissue, the necrosis having resulted from the obliteration of numerous blood-vessels by the advancing growth. Blood-poisoning occasionally takes place from abscesses in proximity to the tumor. ”

“ It is of great interest to reflect upon the methods by which students of brain disease are enabled to determine so exactly the location of tumors, abscesses, hemorrhages, clots, scars, and other alterations of tissue giving rise to epilepsy and brain disorders, and which afford no indication of the diseased locality by any changed condition of the surface. ”

“ INSANITY FROM GROSS LESIONS OF THE BRAIN (tumors, new growths of all kinds, exostoses, spicules or portions of depressed bone, embolisms, hemorrhages, wounds, injuries, cysticerci, etc.) is attended with the usual indications of those conditions which may determine diffuse disorders of the brain, giving rise to any of the symptoms of the various psycho-neuroses and cerebro-psychoses. The lowered mental and moral tone after cerebral hemorrhages is a matter of common observation, and after one an individual is rarely observed to be fully himself again. ”

“ When the first of these causes appears to have been instrumental, in occasioning this condition of the brain, it is plain that it must be removed, and the obstructed emunctory corrected,—the suppressed evacuation promoted, or a new and artificial one substituted. When there exists any structural disease within the head, or a relic of a former state of excitement, a serous inflammation may be reasonably apprehended, and to avert it, the most rigid and undeviating attention [Pg 100] must be paid to regimen, whilst cupping and leeching must be employed, and a seton fixed in the neck. ”

“ Such disease, when the patient does not soon succumb to its virulence, advances to a frightful extent, affecting a large surface, destroying the whole thickness of the bone, and even exposing the internal parts. In a case of this description, which occurred in the Royal Infirmary under my care, the anterior half of the cranium was totally destroyed, the left orbit contained a putrid mass, consisting of the disorganised eye mixed with pus and bloody fluid; the dura mater was exposed, and sloughed at several points, and the unhealthy discharge from the parts lodged on the surface of the brain. ”

“ They tend to diffuse and invade neighboring groups of muscles. “They have never the localization, the measured and purposed character, of the contractions which belong to the lesions of the cortex. They frequently become transformed into permanent contractures.” The application of these facts and conclusions to brain tumors is evident. As neoplasms are so frequently connected, either directly with the dura mater or with the fused membranes, it is evident that the convulsive attacks from which the patient suffers may occur from tumors located anywhere within the cavity of the skull. ”

“ 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. ”