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.
{910} I am in the habit of directing students to feel their own
scalps, in order that they may appreciate the fact that the touch
gives no sensation whatever of the natural thickness of the cranial
covering. It seems as though something like a piece of thin parchment
only intervenes between the fingers and the bone. The fact is, the
scalp varies from an eighth to a quarter of an inch thick, differing
in different places, and where muscles, as the temporal, for example,
are beneath it, the bone is much deeper. The importance of this
observation lies in the fact that a pulpefied bruised mass of scalp
will cause the edges of its healthy surrounding part to feel almost
precisely like bone around the borders of a depressed fracture. The
accompanying general symptoms will mostly not be in accord with this
condition, but in some cases the deception is so complete that it is
very difficult to persuade those not familiar with the fact that a
fracture does not exist, and to induce them to refrain from rash
proceedings.
One case I can call to mind where the opinion of the attending
physician was only changed by the ultimate favorable result, which
left no sign of permanent injury of any kind. These cases are
particularly apt to occur with children.
I remember also another source of deception. A boy was severely
injured by a blow upon the forehead. Concussion was marked. There was
a lacerated wound reaching to the edge of the orbit; fractured bone
could be felt, and at first sight what appeared to be brain-matter was
oozing from the wound. A hasty unfavorable prognosis was given to the
parents. On closer examination it was found that the fracture was of
the external wall of the frontal sinus, and the supposed brain-matter
was the delicate fat-lobules of the orbit. The patient recovered
rapidly.
There is a marked distinction between the ordinary symptoms of
concussion and those of compression, whether from depressed fracture
or effusion, as of blood in apoplexy. Here there are flushed, often
swollen, countenance, stertorous breathing, slow and it may be strong
pulse, deep or absolute insensibility, and fixed pupils. The injury,
if there is one, is mostly palpable and explanatory. If it is
concealed, the other symptoms point to the true nature of the case.
The diagnosis from drunkenness is not always easy, although deep
intoxication is more apt to be accompanied with compression than with
concussion signs. Drunkards often have bruises on their heads caused
by falls, and some of them are pale and sick after debauch. The smell
of liquor is not always reliable, for it is so common after accident
for friends to administer stimulants before the patient is seen by a
medical man that he might be easily misled into too hasty a judgment.
The general appearance of the old stager is well known, but in cases
where there is the least doubt the patient, whether in hospital or in
private, should be kept a sufficient time under observation for the
effects of drink to pass off. Then it will be seen whether this has
masked a more serious condition. Too hasty conclusions in this matter
have led to most unpleasant occurrences. These are well known in
police administration and to hospital men.
The convulsions of the epileptic, the foaming mouth, and the quick
return to partial or complete consciousness will generally serve to
distinguish the case from one of concussion, but at times there are
those who {911} require also to be kept under observation for some
hours, and even a day or more, in order to come to a correct
conclusion.
The PROGNOSIS in concussion is generally favorable, but if complete
unconsciousness is present it is doubtful as to the individual so long
as this lasts, for, as before intimated, the cases which recover may
present as marked symptoms at first as those which prove fatal.
Recovery is mostly complete, but not suddenly so. The after-effects in
any case may prove serious.
There is, however, an unwarranted tendency to attribute any defect in
character, and even criminal lapses, to a blow upon the head,
especially should the history or marks of one be discovered as having
occurred at any time, no matter how long, previous to the inquiry.
The blow may be the cause of subsequent epilepsy, chronic
inflammations, and insanity or imbecility. These cases have, however,
an almost continuous history of trouble from the date of the injury,
the manifestations varying in severity from time to time as
pathological changes go on or as exciting causes develop them.
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.
The more serious cases equally require rest, but also something more.
To bring about reaction from shock, sinapisms to the extremities, to
the nape of the neck, and over the stomach should be used. Hot-water
bags should be placed along the sides of the body and limbs. Alcoholic
stimulants must be sparingly used, if at all: they are rarely
necessary. The stomach will often reject them unless in minute doses.
If too much is absorbed, unpleasant consequences to the brain may
follow. In extreme cases hypodermic injections of brandy or ether may
be administered. Ammonia, camphor, and other diffusible stimulants may
be useful, either externally or internally.
If the reaction is regular, with gradual restoration to consciousness
and no noticeable rise in temperature, nothing further is required but
a continuance of the rest and the use of cooling drinks and spare
diet. The bowels and bladder must be attended to; the catheter may
have to be used.
Restlessness, with or without delirium, is not unusual, but it
generally subsides under full doses of bromide of potassium.
When reaction is followed by high fever, and especially when there is
with it a passing on into secondary unconsciousness independent of
true sleep, we have almost surely internal compression from
congestion, effusion of serum, or hemorrhage to deal with. Now, blood
may be taken generally or locally with great benefit. Cups, both dry
and wet, to the temples and back of the neck are very useful. Leeching
also is an efficient method of depletion. Ice in bags or towels, or
cold water, should be applied to the head. Hot water, say about 120°
to 130°, to the head is often of great service and very soothing.
{912} The choice between cold and hot water is to be determined by the
effects produced. Sometimes surprisingly good results come from
alternating their use. Hot mustard foot-baths may be given in bed
while the patient is kept lying on his back with the limbs flexed.
The result only in these severe cases will determine whether the
symptoms were due to great congestion or to extravasation, possibly
with brain lesion. Complete recovery takes place in the first
condition. In the latter a fatal termination is much more probable,
and if there is recovery it is apt to be only partial, and the patient
may be the victim of nervous troubles more or less pronounced
throughout a long life.
Concussion of the Spine.
John G. Johnson of New York is authority for the statement that
English railways paid in five years two million two hundred thousand
pounds, or eleven million of dollars, as damages awarded by juries in
cases of concussion of the spine. The statement appears almost
incredible, but the facts are ample to sustain it.
It also illustrates the powerful influence of one great authority
(Erichsen) better than anything I know of in the history of the
medical profession. After this celebrated surgeon's lectures and work
on concussion of the spine, etc. were published, dating back to 1866,
the great body of medical men received them as the standard and guide
in all such cases. They were a godsend to plaintiffs and prosecuting
attorneys, and the defendant had a poor chance with juries when the
possible miseries of any one who claimed compensation for injury to
the spine was pathetically pictured to them.
That the defendants have suffered injustice in a great number of cases
I think there can be no doubt. Is it any wonder, therefore, that a
reaction has occurred of late, and that the views formerly held by
professional men have been subjected to sharp criticism founded upon a
much more scientific and practical knowledge of the subject at issue?
As in all reactions, extreme views have been reached by certain
observers, and there are those who seem to hold that concussion of the
spine cannot occur. By spine here is meant the spinal cord or marrow.
It has been well remarked, I think by Page, that we do not speak of
concussion of the skull. We always say concussion of the brain. The
use of the term spine has given rise to much confusion, but the
professional man will understand what is meant when so-called
concussion of the spine is under discussion.
The advocates of the rarity or even impossibility of the injury call
attention with much force to the anatomical facts. First, to the
immense strength, pliability, and cushioning of the bony and
ligamentous encasement or column; then to the ample calibre of the
canal in which the nervous cord is suspended, and to the pliant
structures intervening between its inner walls and the cord itself.
From without inward, in the canal, we have fat, watery connective
tissue, and the plexus of spinal vessels; then comes the dura mater,
loosely investing the cord and unattached to the bone, not forming
here, as in the skull, the internal periosteum. Within the dura mater
is the arachnoid, its visceral layer {913} separated by a wide
interval from the viscus or cord, which interval contains the
cerebro-spinal fluid; then the pia mater or vascular membrane, which
closely invests the cord.
Besides these structures there is the ligamentum denticulatum passing
from the dense pia mater to the parietes of the canal and supporting
the cord and roots of the nerves in the most efficient way—pliable
enough to yield and break the force of vibrations, and strong enough
to sustain.
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.
Clinical observation is, I think, of far greater value in determining
questions of the kind than any theory, however strongly supported by
anatomical facts. Does transient concussion of the spine occur as
transient concussion of the brain occurs? Page, if I understand him,
says not. In his work on _Injuries of the Spine and Spinal Cord_
(London, 1883), in criticising a well-known case as to the claim of
persistent paraplegia without discoverable lesion, he says: “We
italicize the word persistent, for simple concussion of the brain may
give rise to a transient unconsciousness, and, if the analogy holds
good, concussion of the spine should per se produce a transient
paraplegia. _We know of no case, nor can we discover the history of
any case, where this has happened._”
I italicise the last sentence. In 1881 a boy came under my care who
was shot in the back three inches to the right of the third or fourth
dorsal vertebra. He at once had characteristic symptoms in the legs of
being wounded in the spine in such a way as to affect the cord
somehow. There was partial paraplegia, with pains in both limbs. Under
rest these symptoms soon disappeared. In a few days I made a deep
incision and removed some clothing and fragments of bone, and then
from the depths of the spinal gutter I took a large conical ball which
was resting against the bony bridge of a vertebra. The boy recovered
rapidly. I saw him some months afterward perfectly well.
Surely, this was a case of spinal shock or concussion with transient
paraplegia, and the cause of it could have been nothing else than the
impact of the ball against the column, producing vibratory jar
sufficient to affect the cord. The immediate symptoms and the rapid
and complete recovery are, in my opinion, inconsistent with any theory
of congestion or pronounced lesion of the medulla.
Here is another case of transient paraplegia also occurring in 1881,
and, to my mind, still more significant: A man fell from a height of
about twenty feet and landed directly on his feet. He was immediately
paraplegic. On examination no injury to the spinal column could be
detected, but there was fracture of both calcanea. The spinal symptoms
were thoroughly marked. Besides the paralysis of the limbs there was
loss of control of the bladder and bowels, and the other accessories
in such cases. But all went on to recovery. Pari passu with the
fractures the spinal symptoms improved. It is not necessary here to
give further details, but simply to state that in four months, the
time required being chiefly due to the fractures, the patient was
discharged able to walk and well in every other respect.
If this is not a case of transient paraplegia owing to spinal shock or
{914} concussion, I am willing to admit that I do not know the
requirements of the critics when they ask for such cases. I think that
it is no matter how the blow or shock to the column is received,
whether direct or indirect, so that it is shown that the medulla is
influenced within the line of recovery, without having suffered fairly
presumable lesion.
President Garfield surely suffered from transient spinal shock
produced immediately by impact of the bullet upon the column. The
symptoms soon passed off, and at the post-mortem the cord was healthy
in every respect. The differences between his case and the others I
have mentioned were those of degree only, his concussion not being
severe enough to cause paraplegia.
Spinal concussion or shock from railway collisions does not differ
from forms of the same injury received in other ways. It is absurd,
therefore, to give a peculiar pathological history to so-called
railway spine. That the injury occurs, I have no doubt; that the
medulla is seriously affected in the vast majority of cases, I have
very great doubt.
I cannot now, after thirty years of hospital and private practice,
call to mind a single case of concussion of the spine arising from
other accidents than on railways which has had the terrible
after-history that is so often attributed to them; and I have seen in
that time many cases of spinal injuries of all kinds.
There is another fact of personal experience. I have examined many
cases of claimed irreparable or serious injury to the spine in
private, both for plaintiff and defendant, in impending suits, but I
cannot remember a single application of a patient for admission to the
hospital to be treated for the after-effects of concussion of the
spine, the original injury having been received in a railway
collision.
As all sorts of people ride on railways, it is strange that the
numerous recipients of concussions of the spine are pecuniarily
independent of hospitals. One old fraud I do remember who fell from a
street-car and claimed lasting injury to the upper part of the spine
and the head, and adequate compensation for it in court. I was not
called as a witness at the trial, and the plaintiff recovered very
heavy damages. These were afterward reduced to a much smaller amount
when it was discovered what I knew about the case.
Other structures of the spine besides the medulla are much more
subjected to injury than it is, and their consequences often mislead
both patient and doctor, especially the former.
The ligaments and muscles are exposed to contusions, strains,
ruptures, and twists which are wrongly attributed to concussion. From
these injuries and from so-called concussions the patient recovers
rapidly or slowly according to their extent. If damages are looked for
from a corporation, he is in a state of what may be called expectant
pecuniosity, and shows no amendment until the question is settled.
Otherwise, he gets well, as those do who are injured but have no
expectations.
There is a striking want of confirmation by post-mortem examination of
the terrible effects which are said to follow concussion of the spine.
In fact, the records of such examinations are so few, notwithstanding
the immense number of those who have claimed to have the injury that
the sceptics are somewhat justified in attributing the few cases which
have shown great pathological changes in the cord and its membranes to
the {915} coincidence of disease, as myelitis or syphilis, or to much
graver injuries than concussion.
I have reported a case in full in the _Medical News and Abstract_
(Philada., Nov., 1881) which illustrates how coincidence might easily
play its part in a supposed concussion. This feature of it is not
alluded to in that paper. A gentleman began to complain of pain
posteriorly at the root of the neck. Paralytic symptoms gradually
developed. It is unnecessary to repeat the details here, but the
history was a most dreadful one, and precisely that of the few serious
ones described in the works on concussion. Within a year the patient
died. The autopsy revealed a meningitis and softening and destruction
of the cord to the extent of two and a half inches of its brachial
enlargement. There was no other disease. Now, this patient frequently
travelled on railways, and if he had been subjected to the slightest
accidental shock it would have been received on all sides as the cause
of the disease. There was, however, no such history, nor was anything
ever known to account for the fact that a man in otherwise perfect
health should have two and a half inches of his spinal cord as it were
spontaneously destroyed.
I will state in passing that this case did not confirm the views of
Johnson and others as to there not being any severe pain on pressure
in myelitis. It showed also that clinical observation is not always in
accord with plausible anatomical facts or reasoning.
Thus, Johnson says: “It is a mistake to suppose that meningitis or
myelitis is accompanied by pain on pressure: the spinal cord is
surrounded by a bony wall thicker than the bones of the skull, and you
might as well press on the head to see if the brain is diseased.”
Now, in this case the pain was simply atrocious and greatly increased
by pressure. To relieve both it and the disease the actual cautery was
applied on both sides of the spinous processes; and some estimate may
be made of the sufferings of the patient, who would not take ether,
when he exclaimed as the hot irons were burning through his tissues,
“Oh, that is better than the pain.”
To sum up, then, I think I have shown that concussion of the spinal
cord proper occurs. I also believe it may occur in a railway collision
just as it occurred in the man who fell twenty feet. Why should not a
traveller sitting in a peculiar position—with his feet, for example,
firmly against a partition or wall of the car—suffer it in a
collision.
On the other hand, the great majority of those who after accidents
claim injury to the spinal cord as the cause of their disabilities are
wholly mistaken. The question is of great importance, for upon it
depends the testimony as to whether the patient has sustained
temporary or permanent injury.
Each case must be studied on its own merits. There is no class of
injuries so full of opportunity for the exaggerator or malingerer. The
history of many of them is by no means complimentary to human honesty.
Those interested can study the special works on the subject: space is
not given to detail them in this paper.
The SYMPTOMS and PROGNOSIS of concussion of the spine may be almost
inferred from what has been written above. There are tinglings, pain,
and sometimes cramps in the limbs; there may be partial or complete
paraplegia which is transient in character. Complete paraplegia is
{916} very rare, and when it exists it almost always indicates a more
serious injury than concussion. The case I have cited is an
exceptional one.
The bladder is almost always affected; there is either suppression or
incontinence. The bowels are sluggish for a time. The pulse is mostly
quickened; the temperature does not vary much from the normal.
Priapism, which is so frequently present in wounds involving the
spinal column and cord, is not present in concussion.
I have in the _Medical News_ (Nov., 1881) given my reasons for
believing this symptom to be due to a coincident impression or
laceration of the sympathetic nerve when there is a fracture or other
injury of the vertebra. This view I have been able to sustain by a
case reported in the _Medical News_ (Philada., Feb. 25, 1882).
The PROGNOSIS of concussion of the spine is generally favorable. The
recovery is slow in pronounced cases. Where such terrible consequences
follow as are described in some of the cases which have been caused by
railway collision, there is reason to believe that the original injury
was either too severe to come under the head of concussion, or that
some coincident deterioration was present at the time of the accident.
The DIAGNOSIS from fractures and dislocations is mostly easy. In these
cases the local and general symptoms are nearly always so definite as
to give no trouble in coming to a conclusion as to their nature. In
obscure cases time will develop the truth.
In the TREATMENT of concussion of the spine the great remedy is rest.
Under this alone the slight cases will rapidly recover. The more
severe ones will require other aids, such as cupping, both wet and
dry, to the spine over and about the chief seat of complaint.
Sinapisms, blisters, and iodine are useful in the order named. Opium
will be borne much better for the relief of pain and restlessness than
in like injuries of the head. The natural functions must be looked
after. Both the catheter and enemata may be required. Great care must
be taken to provide against chafing of the skin and bed-sores. For
this I know of nothing better than repeated sponging with alcohol, and
drying the surface at once by a good rubbing. The points of pressure
should be frequently changed by shifting the patient.