Traumatic brain injury

“ S06.2x Diffuse traumatic brain injury S06.2x0 Diffuse traumatic brain injury without loss of consciousness S06.2x1 Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less S06.2x2 Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes S06. ”

“ It is important to remember that there were no diagnostic imaging examinations, which began in the 20th century with x-rays, angiography, pneumoencephalography, computed tomography and magnetic resonance. Likewise, neurological surgeries were not performed at that time, and it is interesting to note that today, a patient presenting with a motor deficit due to encephalic trauma and intracranial hematoma is usually operated upon, reversing deficits in some cases of early hospital admission. ”

“ Wounds of the brain vary very widely in their immediate results according to the part of the brain injured. Thus sometimes a slight wound of the brain may be instantly fatal and often a severe wound in another part is not so. Extensive wounds may occur especially in the frontal lobes with remarkably slight disturbance. If a person with a wound of the brain survives the first effects of the injury the danger of inflammation remains. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ Middle meningeal hæmorrhage, uncomplicated by brain injury, is of infrequent occurrence, the associated injuries to bone and brain confusing the diagnosis. Moreover, the special pressure effects are dependent not only on the absence of serious brain lesion, but also on the non-existence of a safety-valve, such, for instance, as is afforded by a comminuted fracture of the bones entering into the formation of the temporal fossa, or of the roof of the middle and external ears. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ In the present state of our knowledge respecting concussion or cerebral shock it may, I think, be accepted (1) that concussion is dependent on an acute inhibition or paralysis of the vaso-motor centre; (2) that the milder cases are unassociated with any pathological visible changes; (3) that the prolongation and severity of the depression stage are directly proportionate to the extent of the brain lesion, such lesions varying from œdema and contusion to extensive hæmorrhages and lacerations. ”

“ 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) . ”

“ 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. ”

“ In the most severe cases, such as are included in class I., the exit wound often possessed in the highest degree the so-called 'explosive' character. From an opening in the skin with everted margins two or more inches in diameter a mass of brain débris, bone fragments and particles of dura-mater, skin, and hair, bound together by coagulated blood, protruded as a primary hernia cerebri if the patient survived the first few hours after the injury. ”

“ It may come on after the paralysis is apparent, and in fact is more commonly gradual than sudden in its onset. The classical instantaneous shock is the rare exception. In the celebrated case where a tamping-iron was driven completely through a man's skull and brain, he himself was able to give a clear description of the accident to the surgeon who first attended him. Several other instances of severe and sudden injury to the brain without loss of consciousness have been recorded. ”

“ 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. ”

“ The loss of memory may be marked and the intellect temporarily weakened, while the weakness and anæsthesia of the extremities persist longer. The external injuries, burns, and wounds are liable to be more severe.
In the fatal cases where death is directly due to the electricity it is usually instantaneous or at least without recovery of consciousness. It may be caused by shock or by apoplexy, i.e., intracranial hemorrhage or by the direct effect of the electricity on the brain. Of course death is often due to burns or to indirect traumatic injuries. ”

“ 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. ”

“ Its effect is observed in the function of an organ and especially in the brain. Concussion of the brain causes stupidity, loss of consciousness, amnesia, coma. The intracranial lesion most often associated with concussion is ecchymosis and laceration on the surface of the brain, but there may be no lesion visible even if the case is a fatal one. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 ”

“ 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. ”

“ 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. ”

“ Therefore the lower end of the cord is never again in functional connection with the brain. These injuries are more rapidly fatal the higher up they are. If the injury is above the fourth cervical vertebra death is nearly immediate, for then even diaphragmatic breathing is impossible, and the injured person dies of asphyxia. Fracture of the odontoid process of the axis, which regularly occurs in hanging, may occur from falls on the head, etc., and is not always immediately fatal. ”

“ 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. ”

“ In the more severe cases the vaso-motor depression is unduly prolonged, or persists till death, the patient remaining concussed for a considerable period of time, or dying in that condition. In these fatal cases the post-mortem examination usually reveals brain laceration, but always evidences considerable engorgement of superficial cerebral veins, increase of cerebro-spinal fluid and œdema, both of the pia-arachnoid region and of the brain substance itself. ”

“ Head injury is a very serious national health problem. As many as 700,000 Americans are hospitalized every year for head injuries caused by motor vehicle accidents, sporting mishaps, and falls. Of these patients, roughly 100,000 die. Another 50,000-mostly under the age of 30-suffer permanent brain damage that prevents them from returning to schools, jobs, or normal lives. ”

“ The speech areas are implicated if the injury be situated on the left side. Paralysis limited to the lower extremity is exceedingly suggestive, such a palsy occurring only with the greatest rarity in extra-dural hæmorrhages (from the middle meningeal artery) .
If the pressure be unrelieved by operation the patient passes from the excitatory to the paralytic stage of brain compression, gradually falling into a condition of coma, the pulse increasing in frequency and the respiration becoming more and more embarrassed. ”