Concussion

“ 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. ”

“ The term concussion is very aptly and forcibly illustrated by the homely but striking expression in use in the sister country, when a man has been suddenly killed by a fall on the head, “that the life has been shook out of him.” ”

“ The different points of practice which have been noticed are well illustrated by the following case, in which the symptoms of concussion were complicated by those which are commonly observed in compression of the brain:—
An old man, when cleaning windows, fell from some steps on his forehead, which he slightly cut and bruised, the left temporal artery being divided by another small cut: it bled profusely until the hemorrhage was arrested by a surgeon. ”

“ Concussion of the brain may arise from falls on the nates, or from blows on the head. The face becomes pale, the pupils contracted, the pulse weak and small, the extremities cold, the respiration scarcely perceptible, and the sphincters relaxed. The tendency to death is from syncope. Reaction may then occur: the pulse quickens; the skin is hot and dry; there is great confusion of thought, from which the patient ultimately recovers; vomiting is present in most cases. Concussion often passes into compression, due to hæmorrhage from the lacerated cerebral vessels. ”

“ In slight concussion the usually transient effects of the [Pg 320] injury, and its happy tendency not to destroy life, place us in a state of uncertainty as to the occurrence of anatomical changes, since no opportunity of post-mortem examination occurred. The clinical condition included under this term corresponds with that implied in 'spinal concussion' in civil practice. ”

“ 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. ”

“ As the cord is so well protected from injury, it must be extremely rare to have concussion of the cord without some actual lesion of its substance. As concussion of the cord is not often the result of the injuries of which we are treating, but rather of railroad injuries and the like, it will not be considered at length in this connection. As a result of a blow or fall on the spine or communicated to it, hemorrhage may occur in the substance of the cord or around it between or outside its membranes. ”

“ The symptoms of concussion may nevertheless continue for days, more particularly the insensibility, or that state which is approaching to it, complicating the case and embarrassing the practitioner. In a child or young person the symptoms of compression or irritation, when they appear even at a secondary period, may pass away under further moderate depletion; but in an adult any undue delay in giving the necessary relief, by the removal of the depressed portion of bone, will in general be destructive to the patient. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ The touch could not but have been slight, but to me the concussion was dreadful, and almost made me scream with the surprise and pain; the sensation being very similar to that which a heavy person feels on touching the ground, when he has jumped from a higher place than he ought. ”

“ If it be pricking, the Wound is deeper, but of small Moment: If it be a battering or bruising Instrument, the Wound is accompany'd with Contusion, producing a great Suppuration, besides the Concussion and Commotion of the Part, which are inseparable, and often cause very dangerous Symptoms.
Inferences may be made also from the disposition of the wounded Person; for a strong robust Man may better bear the Stroke than a weak one ”

“ Concussion.—Temporary loss of function was often observed in the limbs, corresponding to the distribution of one or more nerve trunks when wound tracks had passed in their vicinity. Interference with function sometimes amounted to loss of sensation alone: in others to loss of both sensation and motor power. Such symptoms were of a transitory character, lasting for a few days or a week; if both sensation and motion were impaired, sensation was usually the first to be regained. ”

“ 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. ”

“ The SYMPTOMS of concussion of the brain range from a mere daze or stunning to those of deep unconsciousness. There is no paralysis of the extremities in pure cases. Often the patient is very restless, and throws his limbs about in all directions. When these are quiet there is response to irritation and electricity. ”

“ 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. ”

“ TREATMENT.—Absolute simple rest in bed is all that is necessary in mild cases of concussion. The patient should be well watched for any symptoms which might supervene and show that the injury was more severe than at first supposed. On the other hand, serious symptoms may be present without indicating any great gravity in the case. Children, for example, often have convulsions from the slightest cause. I have attended them when these set in immediately after the injury, but in a day or two there was entire recovery. ”

“ Symptoms of nerve lesion.—These differed little in character from those common to such injuries in civil practice, except in the relative frequency with which they assumed a serious aspect. After all in civil practice nerve concussion is most familiar to us in the degree common after knocking the elbow against a hard object, and the same may be said in regard to the allied injury of contusion. It is in small-calibre bullet wounds alone that the occurrence of such severe and sharply localised injury to deep parts as was observed is possible. ”

“ Lacerated wounds as a rule bleed less freely than those which are incised. Symptoms of concussion would favour the theory of the injury having been inflicted by a heavy instrument. Again, it is often difficult to decide whether the injury which caused death was the result of a blow or a fall. A heavy blow with a stick may at once cause fatal effusion of blood, but this might equally result from fracture of the skull resulting from a fall. ”

“ Everyone 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 person may die from the concussion, or he may slowly or quickly recover. The insensibility may be for a time complete . The pulse may be small, quick and imperceptible, and, no blood being pumped up by the enfeebled heart, the face will be pale and the surface of the body cold. ”

“ In severe concussion a far more highly destructive action is exerted. This condition may be followed by complete disorganisation of the cord, accompanied or not by multiple parenchymatous hæmorrhages into its substance. Either or both of these pathological conditions are produced by the impact of the bullet with the spine, given a sufficiently high degree of velocity, and it is difficult to separate clinically the resulting symptoms. ”

“ 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. ”

“ 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. ”

“ The reaction from what may be called pure concussion is generally slow. The patient is apt to be dazed for some time, although the pulse and temperature may be normal. When there is a rebound with fever, and florid complexion, and suddenly or gradually another but deeper unconsciousness supervenes, it is almost certain that positive lesion took place at the time of injury, and that the reaction has brought with it great congestion if not extravasation. ”

“ 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. ”

“ Pure concussion of the spinal cord may, I believe, be studied from a better standpoint in the case of small-calibre bullet injuries than in any others, since in many instances it is, I think, possible to exclude any complications such as wrenches and strains of the vertebral column, and ascribe the symptoms to the pure effect of extreme vibratory force communicated to the cord by its enveloping bony canal. ”

“ 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. ”

“ The reporter was immediately struck by the complete stupor in which Herbert lay, a stupor owing either to the hemorrhage, or to the shock, the ball having struck a bone with sufficient force to produce a violent concussion. ”

“ Concussion of the Spine." - Occasionally one hears persons, whose professional education should have taught them better, speaking or writing of concussion of the spine as if that were in itself a disease. It is an expression which is not infrequently used in an equally comprehensive and incorrect way when the ill-informed person is speaking of the injuries, real or imaginary, of which an individual makes complaint after having met with a severe shake when travelling on a railway. ”

“ 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. ”