A system of practical medicine. By American authors. Vol. 5

by Unknown

This, in fact, is the point of controversy, for there are those who seem to deny that there can be a jarring or shaking of the cerebro-spinal mass sufficient to cause positive symptoms without producing positive lesions, whilst others are as firm in their convictions that pronounced symptoms may follow a mere disturbing ripple of the nervous elements. How is the question to be settled? The slightly shocked or injured recover rapidly, whilst some who only appear to be as slightly injured or shocked at first, go on to death, during the progress to which event there is no doubt as to the existence of lesion and no difficulty in finding it at the autopsy. Hence, say the lesionists, the first ones had it, but got well, whilst the non-lesionists affirm that it never existed in them.

The logician would think that these differences in opinion were only differences in degree about the same thing, but, nevertheless, the question is one for serious discussion, and is of much greater importance than would appear to be the case to the average layman.

This importance lies in the medico-legal aspects of the suits arising out of the alleged injuries and their consequences. Judges, lawyers, and doctors know them well. In doubtful cases authorities of equal eminence are quoted, and the results of trials are equally as doubtful as to whether justice or injustice has been done. These remarks, as will be seen, are especially applicable to injuries of the spine, but they also may have place in the consideration of consequences arising from concussion of the brain.

Concussion of the Brain.

Whatever doubts there may be as to concussion of the spine, there are none, I believe, who deny the appropriateness of the expression as to the brain, it being, by its anatomical relations, so much more exposed to shock than the spine.

We understand that pure concussion, uncomplicated with fracture, refers to a condition caused by external violence, direct or indirect, which communicates a jar or shock to the cerebral mass, and which expresses itself by certain well-defined symptoms. The nervous system and the circulation are most manifestly involved, but in a pure case it may be said that all of the symptoms arise from central nervous disturbance. Even could it be shown that they were dependent on temporary congestions, these congestions, I think it will be admitted, would be due to vaso-motor derangements.

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. Most of these cases, under modern criticism, have been justly shut out from the record as having no value; for it has been shown that the post-mortem examinations of them have been very imperfect, the brain only having been inspected, whereas the chest, the abdomen, or the spine might readily have revealed the cause of death.

It is fair, however, to assume that there must be a capacity for serious results in the vibratory jar, as the discoverable lesions in many well-examined cases have been in themselves insufficient to kill. The rapidity of recovery of those who get well also bears weight on this point.

Of nineteen cases of recovery from concussion of the brain of which I have record, the average stay in hospital was eight days. The range of stay was from one to twenty-five days. Many of these were at first profoundly shocked, some of them apparently hopelessly so when we compared their symptoms with those who died. As they recovered, however, in so short a time, there surely could not have been any gross lesion to account for their symptoms. What else, then, can account for them than vibratory jar? and if this can produce such severe results within the line of recovery, why cannot the degree of it be so extended as to involve, for example, the respiratory centres, and so kill without leaving perceptible sign?