Ain’t That A Kick In The Head?

My husband has a fondness for what I generally call “testosterone movies.”

These are usually loud and fast-moving with lots of car chases (ending in crashes and explosions), gun fire (preferably automatic weapons) and huge gouts of flame erupting just as the hero is fleeing in slow motion.

One of the features of these movies is the “mano a mano” scene – where the good guy confronts the bad guy and they duke it out.  Fisticuffs. Knuckle sandwiches.  There are so many colorful phrases these tough guys use.

However, I have seen all too many of the real life victims of such confrontations, and as John Wayne might have said, “It ain’t pretty.” I’m thankful that my husband has not developed a taste for a relatively recent development in televised sports – Mixed Martial Arts.  This is an “anything goes” type of combat where opponents can punch, kick, bite, pinch, slap and do whatever else they want.

Maybe it is too much reality.  The fantasy violence is more attractive to some people.

But plenty of people will pay-per-view for these sanctioned slug fests. The world may be stopped in wonder with the idea of a knockout punch to the jaw.  To me, it has a sort of ring of familiarity as I have seen this before in the emergency room when I was a neurological surgeon.

This seems to be common-place in the world of neurotraumatology.

Frankly, I have also seen a lot of folks with jaws wired to fix fractures from injuries incurred at the same time as the blow to the head.  But here there is no jaw injury reported specifically, so we can only assume that all of the force that went to the jaw was transmitted to to the skull directly. The brain is not fixed rigidly to the skull. There is a phenomenon called “contrecoup” (a French word, what else??) which means “blow against.” When there is force to the skull, there is force to the brain.  But there are layers of membranes, including a relatively rigid outer one, the “dura mater,” and an inner “pia mater” or soft, vascular layer.  There are spaces, more virtual than real in normal life, but life-threatening when they expand by getting filled with blood.

Which explains why most of the illustrations on the net are meant for lawyers,to use in court. The brain goes back and forth, like a ball within a sealed container of water. The “contrecoup” thus affects the opposite side of the head from where the blow is struck. I actually like the rule they have in the type of combat described — that the fight is stopped the moment someone cannot defend himself, rather than waiting for the victim to become unconscious. A single injury may or may not be a “concussion.” Classifications of trauma obscure one amazing fact. There may be a total non-correlation between injuries to the skull and injuries to the brain, because this piece of rigid bone that is the skull encases a movable brain. I have seen skull x-rays that look like mixed-up pieces of a jigsaw puzzle, where the brain is quite intact and its owner is smiling at me, saying “Gosh, Dr. G., what happened?” On the other hand, I have seen perfect skull x-rays, with no visible sign of fracture, where the owner lies in an intensive care unit, barely clinging to life. Getting the jaw on the side, where it attaches to the skull, seems to be secret of getting a circular sort of torsion to the blow.  If Steven Segal does indeed know the exact angle at which to do this, then he is keeping it secret.  In a world where there is no question of causing humans head injuries for the sake of research (we are humane and do function under all sorts of international congresses and research review boards), it has been many years since I have heard of research on head injury being done to animals.  Of course, the people who do this have their own research review boards.

But for the time being, I can only think of this; I have no directions for anyone who wants to exert a blow to the head and have someone just be “shaken” from it and come back to exactly the way they were.  No ways to make it a single fireworks of stretched vessels and an explosion of neurotransmitters that would end up with what us scientist types like to call “restitutio ad integrum,” a catchy Latin phrase for getting back exactly the way you were, although this reporter actually seems to have it a little more on the ball than the first article.

There is a lot more known about the chronic results of being in the ring and taking one’s “lumps;” something that has been of interest to neurologists since the 1920’s, and that is known generally as “dementia pugilistica.”

Whether people are calling for the complete abolition of boxing or simply regular MRI assessments, it seems that boxers can end up with something that includes slurred speech, incoordination, and can progress, even when they stop, to something that looks like Alzheimer’s or Parkinsonism.  Refer to any recent interview with Muhammad Ali. Problem is lack of knowledge of what it takes to make this happen. After all, nobody knows for sure how much or how many blows to create what, and if it is “subclinical,” when do people get in neurological trouble? As with almost everything else, I can admit to a personal anecdote. My “uncle” Eddie was an alleged “prizefighter.”  Now I never saw him fight but I did see one photo of him wearing boxing gloves that he used on his business cards.  I was very little and I don’t even know what he was trying to sell, except that it had something to do with memberships in a “prizefighting museum.” I know he was not my uncle by any sort of family relationship, but he came to visit me when I was small (preschool) with his wife, my aunt “Charlotte,” who was not my aunt either. They were neighbors at one time, and had moved to Florida, but came back to visit briefly after they had moved.  It seemed funny to me even then that he could not seem to remember my name. He called me “Senorita/can’t be sweeter” which may be a good generic name for little Spanish speaking girls, but was exotic for moi in suburban Boston. Physically, he was kind of hunky for an older Jewish guy.  Aunt Charlotte walked him around by the hand and occasionally had to remind him what state he was in.  I remember a little tremulousness, resting and maybe Parkinsonian, but I was admittedly diagnostically incompetent at the time.

They claimed he never had a knock out.  Nobody claimed he never got hit. They were happy and I was smart enough not to ask any questions until after they left. My parents told me that Charlotte’s first husband had been a real loser, and that Eddie was an improvement. I suppose how much you like what you have depends on where you started from. Still, I am hard put to recommend any kind of pugilism as a profession, given the immense evidence that it causes some kind of brain damage, which may be quite evident chronically.

As for action movies, I defer to my loving husband who heartily recommends the original “Die Hard” movie for fist fights, gun fights and explosions.  He claims it is a classic, and I bow to his expertise in this field.