Railway spine: The advent of compensation for concussive symptoms

The introduction of railway transportation in Great Britain in the early-nineteenth century saw an increased frequency of trauma cases involving persisting symptoms without objective evidence of injury. In 1866, a prominent surgeon, Sir John Eric Erichsen, attributed such symptoms to concussion of the spine (popularized as "railway spine") that involved an organic pathology, inflammation of the spinal cord in the absence of spinal fracture, with potential psychological overlay. This was widely accepted within the medico-legal context throughout the 1870s, whereby passengers sought compensation for collision-related injuries. In 1883, a railway surgeon named Herbert William Page countered the assertion that many of Erichsen's cases likely had sustained direct physical injury to the spine, the cord, and/or the spinal nerves; and in cases without such injury, the symptoms were psychogenic, as in traumatic neurasthenia and/or hysteria. Similarities between Erichsen's and Page's medico-legal positions, such as conscious and unconscious forms of symptom exaggeration that would both resolve upon settlement of the case, ushered in the era of medical injury compensation.

The first concussion crisis: head injury and evidence in early American football

In the early 21st century, sports concussion has become a prominent public health problem, popularly labeled "The Concussion Crisis." Football-related concussion contributes much of the epidemiological burden and inspires much of the public awareness. Though often cast as a recent phenomenon, the crisis in fact began more than a century ago, as concussions were identified among footballers in the game's first decades. This early concussion crisis subsided-allowing the problem to proliferate-because work was done by football's supporters to reshape public acceptance of risk. They appealed to an American culture that permitted violence, shifted attention to reforms addressing more visible injuries, and legitimized football within morally reputable institutions. Meanwhile, changing demands on the medical profession made practitioners reluctant to take a definitive stance. Drawing on scientific journals, public newspapers, and personal letters of players and coaches, this history of the early crisis raises critical questions about solutions being negotiated at present.

Birth and Evolution of the Football Helmet

OBJECTIVE

To review the advent and evolution of the football helmet through historical, physiological, and biomechanical analysis.

METHODS

We obtained data from a thorough review of the literature.

RESULTS

Significant correlation exists between head injuries and the advent of the football helmet in 1896, through its evolution in the early to mid-1900s, and regulatory standards for both helmet use and design and tackling rules and regulations. With the implementation of National Operating Committee on Standards for Athletic Equipment standards, fatalities decreased by 74% and serious head injuries decreased from 4.25 per 100,000 to 0.68 per 100,000. Not only is the material used important, but the protective design also proves essential in head injury prevention. Competition among leading helmet manufacturers has benefited the ultimate goal of injury prevention. However, just as significant in decreasing the incidence and severity of head injury is the implementation of newer rules and regulations in teaching, coaching, and governing tackling techniques.

CONCLUSION

Helmet use in conjunction with more stringent head injury guidelines and rules has had a tremendous impact in decreasing head injury severity in football. Modifications of current testing models may further improve helmet design and hence further decrease the incidence and severity of head injury sustained while playing football.

A flask full of jelly: the first in vitro model of concussive head injury--1830

IN 1830, THE French Military Surgeon Jean-Pierre Gama reported an experiment planned to unravel the mechanical events caused by head injury. His model was a round glass flask with a long neck filled with a gelatinous substance that resembled the consistency of the brain. Thumping the walls of the flask caused the movement of thin wires embedded in the "brain-like" material, thought to represent the spread of forces within the brain. Gama thought that he could thus observe oscillatory and vibratory movements of the wires representing the effects of concussion without visible structural brain lesions. Although it was crudely constructed, entirely subjective as to evaluation of results, and lacking the essential instrumentation that only modern technology can provide, this hypothesis-driven pioneer experiment should be regarded as the first to use the novel approach of physical modeling of the brain. Even today, this approach has not been fully exploited.

Concussion: the history of clinical and pathophysiological concepts and misconceptions

Concussion is a well-recognized clinical entity; however, its pathophysiologic basis remains a mystery. One unresolved issue is whether concussion is associated with lesser degrees of diffuse structural change seen in severe traumatic brain injury, or is the mechanism entirely caused by reversible functional changes. This issue is clouded not only by the lack of critical data, but also by confusion in terminology, even in contemporary literature. This confusion began in ancient times when no distinction was made between the transient effects of concussion and severe traumatic brain injury. The first clear separate recognition of concussion was made by the Persian physician, Rhazes, in the 10th century. Lanfrancus subsequently expanded this concept as brain "commotion" in the 13th century, although other Renaissance physicians continued to obscure this concept. By the 18th century, a variety of hypotheses for concussion had emerged. The 19th century discovery of petechial hemorrhagic lesions in severe traumatic brain injury led to these being posited as the basis of concussion, and a similar logic was used later to suggest diffuse axonal injury was responsible. The neuropathology and pathophysiology of concussion has important implications in neurology, sports medicine, medicolegal medicine, and in the understanding of consciousness. Fresh approaches to these questions are needed and modern research tools, including functional imaging and experimental studies of ion-channel function, could help elucidate this puzzle that has evolved over the past 3,000 years.

The physiological basis of concussion: 50 years later

In this brief narrative, the author compares what is known today about the physiological basis of concussion with the results of studies described 50 years ago in the Journal of Neurosurgery. The author was a member of the team that originally reported these findings in the first volume of the Journal of Neurosurgery.