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In one case there is no deviation from the natural condition; the brain and its membranes are perfect in all their parts. In another case there is a deep congestion of the cerebral vessels. In another case there are minute points of extravasation throughout the brain substance, and in another case there is a laceration of the brain substance, and in another case there is a large clot producing pressure upon the brain. In each, the case is said to have been by this particular school of teachers one of concussion of the brain. There is another class of teachers, just as eminent in their profession, standing just as high in authority, who do not give so broad a range to this term concussion. On the contrary, they limit it to those cases wherein there is no visible lesion of the brain or its membranes. Indeed, they teach that it is extremely doubtful whether a man ever died from simple concussion without any visible injury of the brain or spinal cord.

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It is natural for the student to cling to one or the other of these two ideas, and especially will he embrace one strongly if he has had any experience in the treatment of this class of injuries. By a careful reading of a list of reported cases, and by a close study of a number of cases which have come under my own observation, I have cast my lot with that school of teachers who say that it still remains to be demonstrated whether concussion without any lesion to the brain or its membranes may result in death.

I can very readily understand how death may follow an injury producing laceration of the brain or its membranes, but to say that a mere shock from a blow upon the head produces death is a difficult idea to conceive. However, surgical literature upon this subject is full of reported cases in support of this doctrine, and upon a first reading the argument seems to be conclusive, but upon a second and a more careful research the errors and want of thoroughness in the examinations render the reports without value so far as that side of the question is concerned, while on the other hand they become a power in support of the doctrine of the lesionist.

The only available means whereby these differences of opinion may be made to coalesce is to carefully make after-death examinations, and whenever a death from a blow or fall upon the head by an examination reveals the brain and its membranes, spinal cord and heart perfect in all their parts then it can truly be said that

simple concussion may result in death. A century and a half ago the celebrated Littre believed that he had met with a case which would settle this question for all who might come after him, but like many of his time as well as many of the present day, he was satisfied to examine one part only, the brain. This case has ever been pointed to by those who believe in the doctrine with great confidence as being a case of simple concussion. This case, although an extremely familiar one, one which has been recited by many writers upon this subject, still so bountifully serves my purpose that I reproduce it in full. It is as follows:

"A criminal who had been sentenced to be broken on the wheel determined to destroy himself. Having placed his hands behind him, he ran a distance of fifteen feet dashing his head against a stone wall and fell down dead. The cranium was opened and the brain and its membranes were found to be perfect in all their parts, except that they did not fill the cranial cavity as usual, and the brain substance seemed to be closer and more compact than is

common.

"By way of explaining the sudden death, Littre himself adds that the violence of the shock was so great that the brain. had shrunk, and possessing but little elasticity 'it could not recover itself, in consequence of which the distribution of the nervous influence throughout the whole body failed in an instant.”

This reasoning of Littre sounds well, but does it really prove that there was not some lesion more formidable? I undertake to say that there is not a lesionist or a non-lesionist of the most sanguine type who would accept for a moment so limited an examination. It has been suggested that in all probability this criminal died of a broken neck. The very fact that he ran a distance of fifteen feet, dashed his head against a stone wall, and fell down dead would substantiate such a doctrine, and his death could have been explained without ever having opened the cranium. Had Littre examined the spine and heart of this criminal then his report would have been of some value, but as it is, it does not prove anything, nor does it explain the cause of death.

Since the days of Laennec and his followers, who have pointed out the organic diseases of the heart, we now know that many cases of so-called concussion said to be due to falls upon the head are not concussions at all, but they are the result of a sudden failure of a diseased heart.

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Coming down a period of time an hundred years, I find another case reported by an English surgeon which speaks volumes in favor of the theory of the lesionist. This is the case: "A man having fallen from a great height on to a pavement was picked up and carried into a hospital. He was collapsed and in a state of perfect insensibility. There was no paralysis, neither were there any spasms of the muscles. In this state he remained some hours and then died. The head was examined, and not a single trace of an injury was detected in any of the cranial contents; everything was perfectly healthy."

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The case was set down by all those who had seen the man while living, and by all those who were present at the examination, as a case of death from simple concussion of the brain. Now what makes this case of so much value in illustrating my point is the fact that a second examination was made. A visiting surgeon in going his rounds in the same hospital heard of the examination and recognizing the fact that the examination was incomplete, he repaired to the dead-house with his assistants and had the spine laid open, and there was found a most extensive extravasation of blood completely filling up this canal in its whole length, and extending upwards even beyond the point where the spinal marrow was cut across in removing the brain. Now, had this surgeon been so easily satisfied as those who preceded him in the examination, this case instead of being recorded as one of extravasation into the spinal canal would have gone to swell the number of deaths from simple concussion of the brain. This case illustrates too, how important it is, in making a post-mortem in this class of injuries not to stop short of a complete examination of brain, spinal cord and heart. I renew the broad statement that in all cases of sudden death from injury these organs should always be examined, but if these parts are not examined it can not fairly be said that the death was due to simple concussion of the brain.

To show how little we sometimes know of the condition of these parts, and how guarded we should be in our diagnosis of these cases of injury, I relate the following: "A boy, having fallen from a great height, was found with urgent symptoms of concussion, and died in a few hours. The head was examined and, with the exception of a little extravasated blood beneath the arachnoid

on the surface of both hemispheres, with slight bruising of the brain in two places at its under surface, the brain and its membranes were perfectly healthy. The heart was also examined, and there was found a rupture of the muscular part of the ventricles, leaving only the serous covering unbroken, which alone prevented the blood being poured into the pericardium." Now, had this boy lived, this thin serous wall would have soon parted and there would have been added a complication, perhaps immediately fatal, superadded to the injury of the brain. It is interesting to note that there was not the slightest injury of the chest ; no ribs were broken, and the rupture of the heart would have gone entirely unnoticed had it not been for the examination of this organ. Many cases similar to the above could be related which would afford incontrovertible evidence in support of the lesionist, but, suffice it to say, I have not seen the report of a single case wherein death could fairly be attributed to concussion of the brain.

The following is of greater interest because it came under my own personal observation, and it shows that we of the present day are not free from the errors that were practiced more than one hundred years ago:

Major McCoy being thrown from his wagon while in rapid motion fell upon his head, became immediately unconscious and died in a short time. The cranial contents were not examined, but it was given out that his sudden death was due to concussion of the brain. I did not see him until two hours after his death, when I was called upon by the undertaker to embalm his body by the arterial process. In the course of this operation I discovered. that his neck was broken. There may have been some visible injury to the brain or its membranes, but had not the broken neck been discovered this case, like that of Littre, would have gone on record as being one of concussion of the brain.

A second case which came under my immediate observation is conclusive evidence to my mind, that in all cases of concussion which amount to more than a stun for a shorter or a longer period there is more or less visible injury to the brain or spinal cord.

The case is so full of interest, and it tells the story of an injury to the brain so perfectly that I give it in brief. This case in the case beginning was said by all who saw it to be concussion of the brain,

and I believed it was myself, but upon a careful observation of the case from day to day, it became evident that there was more than a vibratory jar battling with the life forces of my patient, and I was driven to the conclusion that if an after-death examination could be had a most formidable lesion of the brain or spinal cord could be made visible.

But this, my great desire, I was not permitted to enjoy, although my patient succumbed to the inevitable. Hence I am called to depend upon the thirteen days of history for the evidence in support of such a theory. It was this case that led me to doubt the doctrine of sudden death from concussion. This is the case: Mr. King, a countryman, having been thrown from his wagon onto the solid street, was picked up insensible and carried into the Windsor Hotel. I saw him in an hour afterwards, when consciousness seemed to be returning. His pulse was intermittent, about forty per minute, breath slow, but regular and smooth. Pupils about normal. In a short time he could speak, and the use of his limbs gradually returned. In about one hour after I saw him he became conscious of a desire to move his bowels and got up on a vessel and did so. He voided his urine without any assistance. Afterwards he became very drowsy, and soon lost the ability to recognize his friends. Within four or five hours from the time of the accident he vomited a considerable quantity of blood, and quite a good deal of blood ran from his nostrils and his left ear. The stupor became more profound and the ability to recognize his most intimate friends was almost entirely lost. It became necessary to draw his urine, and this paralysis lasted until a short time before his death. On the following morning the stupor was so profound it was feared there might be depression of bone. There was a depression in the region of the posterior fontanel which had been declared congenital, but, fearing a mistake, Dr. M. Sexton was called to examine, and he agreed that the depression was a natural one, and said that the urgent symptoms depended upon concussion, and we would be compelled to wait further developments.

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There now appeared on the back part of the head and left and back side of the neck all about the region of the mastoid a continued deep ecchymosis, and a thin serous oozing was kept up over this surface for several days. There were some slight symptoms of

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