Concussion of the brain

“ 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. ”

“ The organ in these cases has been merely disturbed and shaken, without visible rupture or hurt having occurred. Again, many patients are supposed to labour under concussion only, in whom fracture of the base of the cranium, or extravasation of blood on the surface, or into the substance of the brain, are discovered after death. It is always difficult to distinguish between the effects of mere concussion and those of compression of the brain by extravasated fluid; for, in the greater number of cases, the symptoms of both affections are blended together. ”

“ When the fracture is associated with severe concussion. In the event of persistence of concussion symptoms of a severe type the prognosis is decidedly unfavourable. This prolongation of cerebral shock is undoubtedly dependent in its persistence on severe vaso-motor depression, and in the majority of cases ending unfavourably it will be found that the brain is generally œdematous and regionally contused or lacerated. ”

“ It has, however, been demonstrated that a slighter injury of the kind, giving rise to long-continued symptoms, need not necessarily be fatal; in which case it is supposed that the cure is effected by adhesion, and not by granulation accompanied by the secretion of purulent matter.
247. When a concussion of the brain has rendered the sufferer insensible and motionless, the countenance is deadly pale, (the reverse of what takes place in sanguineous apoplexy;) the pulse is not discoverable: the man does not appear to breathe. ”

“ MacKelcan introduced the subject of concussion of the brain. After remarking on the several symptoms, and mentioning the other affections of the head with which concussion is apt to be confounded, Mr. M. directed the attention of the society more particularly to the treatment in the stage of collapse, adopted by Professor Andrini of Florence. ”

“ Concussion induces affections of the brain and of its membranes of an equally serious nature, at a more distant period of time, when the stage of stupefaction and insensibility is wanting; it is to guard against such an occurrence that persons who suffer from falls or severe blows on the head usually lose blood. ”

“ Experience of the character of the lesions observed after severe concussion by the ordinarily somewhat coarser forms of violence common to civil life, fully explains the severity of the damage to the brain tissue met with in injuries due to bullets of small calibre. Viewing the elaborate arrangements which exist for the preservation of the central nervous system from the moderate vibration incidental to ordinary existence, it is easy to appreciate the harmfulness of such exquisite vibratory force as that transmitted by a bullet of small calibre travelling at a high rate of velocity. ”

“ In general, the existence of concussion is more often overlooked than the coexisting alcoholism, so that if there is any doubt in a given case it should be treated as one of cerebral injury. The injury which causes the concussion in such cases is often due to the alcoholism. We may be able to verify this supposition if the injury is such as would be likely to be caused by a fall. There may be nothing found in the brain after death to distinguish between concussion and alcoholism. ”

“ When it follows a superficial course, its track is marked by a wheal, or elevation of the skin with discoloration. At one time, it was believed that the most serious consequences resulted from a ball passing close past the body without even touching it—that in this way violent concussion of the brain, proving instantly fatal, was produced ”

“ 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. ”

“ Pathology.—Concussion produces laceration of the brain, or at least a jarring of the nervous elements, which, if not sufficiently severe to produce sudden death, may lead to softening or inflammation, with their respective symptoms of functional derangement. ”

“ Thus we see that the cord is much more securely protected from the effects of external violence than the brain, and we can understand that there is reason for the doubt of the sceptics as to the frequency of the injury described as concussion of the spine. ”

“ 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. ”

“ Remarkable effects sometimes result from commotion of the brain; the patient may suffer loss of vision or of hearing, either partial or complete; or partial paralysis may occur; of the muscles, for instance, supplied by the portio dura. In many cases such affections may be supposed to arise from compression of nerves, or other læsion subsequent to and caused by the effects of concussion, and probably connected with fracture of the base of the cranium. ”

“ It should be noted, however, that the anterior fontanelle supplies evidence as to increase or decrease of intracranial pressure. In concussion the fontanelle is depressed, in compression it is tense and [50] pulsation is absent or diminished. Irritation of the brain is evidenced by irritability and general convulsions.
Treatment. In the absence of symptoms, or when the fracture is associated with concussion or irritation, operative measures are contra-indicated, the patient being treated after the general principles laid down for those conditions. ”

“ The patient vomited at the instant of the blow, and symptoms of compression, mixed with some of concussion, soon followed. He died eleven hours after the injury. At a post-mortem examination, the superior longitudinal sinus was found to be ruptured, and about four ounces of coagulated blood were lying on the brain. Two darkly-congested spots were observed in the cerebrum, one on each hemisphere, corresponding with the line of direction in which the ball had passed, and these, when cut into, presented the usual characters of ecchymoses. There was no fracture of bone. ”

“ Every one knows that the surest way to fasten the head is to knock the handle on the ground, as the concussion drives it further in; so that if the human head were carried on a straight support, similar concussions would be caused to the brain and other vital organs, to their serious if not fatal injury. Of course extra muscular strength is required to support the increase of weight caused by those curves; and this is effected by an extra stress on the muscles of the back. ”

“ The spine should be examined in all fatal cases of supposed injury. Concussion of the spinal cord is a fertile source of differences of opinion in railway cases. In no case should a hasty decision be given as to the probable future result to the patient from the injury.
Wounds of the face are not generally dangerous, unless they penetrate the brain. There is always the possibility of injury to the eye causing detachment of the retina, or inflammation leading to blindness. Punctured wounds in the neighbourhood of the orbit may become septic and lead to secondary meningitis. ”

“ 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. ”

“ Now [195] the death of those of the first class, in consequence of lesions of the red-blooded auricle and ventricle, is caused in two ways, and first, because the brain in such case is rendered inert from want of impulse, and can neither have sensations, nor exercise an influence over the locomotive and vocal organs.
Accordingly, all this order of functions is stopped, as when the encephalic mass has experienced a violent concussion. It is in this way that a wound of the heart, or the bursting of an aneurism, annihilate all our relations with external objects. ”

“ The contents of the head, like the contents of all hollow forms, receive the vibratory influence of force externally applied. The brain receives the concussion of the force applied to its osseous envelope; and when this latter happens to be fractured, the danger to life is not in proportion to the extent of the fracture here, any more than elsewhere in the skeleton fabric, but is solely in proportion to the amount of shock or injury sustained by the nervous centre. ”

“ As the brain is overcharged with blood, the vessels pressing on that part are very liable to burst, from the least accidental concussion; and the unfortunate victim of such folly may expire, while he remains insensible of his danger. ”

“ The analogous injuries termed generally in Chapter IX. nerve contusion, although frequently accompanied by tissue destruction, may be followed by reparative change, and are capable of complete or almost complete spontaneous recovery; while the lesions in the spinal cord are permanent, and complete recovery is only witnessed in the parts affected by the remote pressure or irritation from blood extravasation, or in those influenced by concussion. ”