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

by Unknown

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. Loud speaking to him may elicit some attention, but the answers are mostly incoherent. There is pallor, often extreme, coldness of surface, and sweating. Vomiting is usual, and may come on immediately or later, and it continues as long as there is anything to discharge; sometimes there is retching. In favorable cases the cessation of vomiting is accompanied by a slow return to consciousness, which may be preceded by delirium. This return is never sudden, and the method of it serves to distinguish the case from that of some forms of epilepsy. The pulse is generally frequent and feeble, often irregular; in extreme cases it may be slow and feeble, very rarely, if ever, strong or bounding. After reaction it becomes more natural, and if recovery follows it will not show much variation. The temperature is depressed at first. In one characteristic case it was 98° on the first day, reached 101° on the third day, and receded to 98½° on the eighth day, when the brain symptoms disappeared.

There may be retention of urine and sluggishness of the bowels, but in bad cases coincident with the vomiting there is sometimes involuntary discharge both of feces and urine. The respiration is irregular, sometimes almost ceasing, and then returning with great rapidity.

Much has been said and written about the condition of the pupils in concussion of the brain. I have made this matter a subject of observation, and am convinced that the state of the pupils is of no diagnostic value whatever as to determining the existence of concussion or compression. Their state is of great value in telling us that the functions of certain brain-centres are partially or wholly impaired. The progress of the case will tell us whether the impairment is due to clot or effusion, congestion or jar.

It is wrong, therefore, to say that the pupils are one way in compression and another in concussion. It is right to say that in either case they are sluggish or wholly irresponsive to light. In one person they may be dilated, in another contracted, and in the same person the eyes may present marked contrasts.

In the light of modern physiology this is what might be expected. The condition of the pupils is dependent on that part of their nerve-connections which is involved in the injury, and also upon the method of that involvement. Clinical experience, I think, amply sustains this view.

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.

Now, really, compression to be followed by inflammation is the condition demanding attention.

DIAGNOSIS.—The history of the case and the symptoms as detailed will enable us to reach a conclusion in most cases as to the existence of concussion of the brain. There are some conditions, however, from which it is to be carefully distinguished. These are simple fracture, with or without depression, compression from any cause, drunkenness, and epilepsy.

There may be such profound shock with fracture that at first concussion symptoms mask those of the lesion, or even keep them for a time completely in abeyance. The head bruises are often very deceptive to the touch in the search for fracture.