Concussion: Then and Now

Someone recently asked me about the treatment of concussion for a Pride and Prejudice-related fan fiction story.  I misinterpreted her question and gave her a long exposition on Regency medical practice for head injuries.  Then I found out that the story takes place in modern times.  It occurred to me that a comparison of medical treatment for concussion in the two eras would provide a good comparison of the differences in all medical practice for those two historic periods.

Concussion 2011:  Scenario 1.   The patient is a young man in his early 20s who falls from a horse and is unconscious for four hours.  He, fortunately, is wearing a helmet, but the Emergency Medical Technicians who accompany the ambulance are concerned about a cervical spine injury (the section of the spine in the neck), so they immobilize his head and neck, carefully slide a backboard under him and onto the gurney, then lift the gurney into the ambulance.  Because he seems to be breathing well and there are no obvious broken bones or internal injuries, they drive him to the hospital swiftly but cautiously, trying not to do anything that will jostle his head and neck.

When they arrive at the Emergency Room he is immediately evaluated by the ER doctor, as well as a neurosurgeon and a neurologist and has an emergency CT scan of his head and neck.  He has not yet regained consciousness, but his pupils are both the same size and respond to light, his reflexes are normal. His CT scan does not show any injury to his cervical spine or evidence of bleeding in or around the brain.  He is admitted to the Critical Care Unit where his respiration and ECG are monitored and the nurses frequently check his pupils with a penlight to make sure they are the same size and react to light, and look in his eyes at the optic nerve to see if there is any increased pressure in the brain.

After a few hours he awakens with a severe headache, dizziness and nausea, but his mental status seems to be normal.  They do not give him any pain medications except Tylenol, because aspirin and ibuprofen-like drugs can increase the risk of bleeding and narcotic pain relievers will put him to sleep and they will not be able to evaluate his mental status.  Overnight they awaken him every hour to do a mental status exam and recheck his pupils.   By the next day, he is feeling a little better and his headache is not quite as bad, but because of the length of time he was unconscious they keep him in the hospital for a few days for observation.  At this point his risk of a bleed in the brain is rapidly decreasing and they allow him to have some hydrocodone (an opium derivative) for his headache.  After that time he is allowed to go home with instructions to be careful, stay at bedrest as much as he can over the next 2 weeks and avoid activities which might make him dizzy or be dangerous if his coordination is not yet back to normal.  He is given an appointment with the neurologist for 1 week later for followup.

Concussion in 1811: Scenario 2:  A young man in his twenties is thrown from a horse during a fox hunt and is unconscious.  The other riders and servants who see the mishap run to a nearby farm and take a door off its hinges and bring it back to carry him back to the farmhouse.  The bystanders have straightened him out to make sure he can breathe well and one is tending to his horse, which has a badly strained hock.  The unconscious young man is lifted onto the makeshift stretcher and carried at a jog to the farmhouse and moved carefully onto a bed.  A servant is sent for the physician and the farmer’s wife nervously watches the young man and keeps cool compresses on his head until the doctor arrives several hours later.

When he arrives, the physician finds that the patient has awakened for brief periods, but is now unconscious again.  He takes his pulse and finds that it is strong and regular, then he presses on his fingernails and sees that the blood perfusion seems good.  Next he waves a candle back and forth in front of his patient’s pupils and sees that they are round and the same size, and reactive to light; he checks his reflexes, which are normal.  He tests the man’s sensation with a pinprick and he reflexively draws back in spite of being unconscious.

He comes down and talks to the men who brought him in and to the farmer’s wife: he says that he is still unconscious, but seems to be only lightly so.  There is no evidence that he broke his neck but they must just wait until he awakens to be sure.  The wife, who will be nursing him is given instructions to give him some laudanum (tincture of opium) in wine if he wakes up with a headache or is restless, and he is to be watched all night carefully.  He warns the man’s friends that it is a matter of time whether  they will know if he has seriously injured his brain, but they must keep him quiet because there is a risk of bleeding in the brain from such an injury.  If he awakens at all and is thirsty they may try to give him lemonade or gruel. He will probably be in bed at the farmer’s house for a couple of weeks before he can go home.

After four hours the man awakens with a severe headache and double vision and he stays in the farmhouse and is nursed by the farmwife until he is able to get up and around and to tolerate the jostling of a carriage to take him home.  The doctor comes to see him daily and is happy to see that his patient seems to be progressing well; the headache and diplopia have resolved and his coordination seems to be improving.  He will be followed by his own physician once he is home.

One comment on “Concussion: Then and Now

  1. Thank you for this excellent comparison on concussion treatments. It was exactly the information I needed. I find it interesting that the primary difference in treatment seems to be whether or not they keep the patient awake. I’d had that wrong in my current wip – thank you!!!!
    I’m very glad to have found your site.

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