nosis in fracture of the skull is serious, mainly on account of the danger of inflammation, which is greater in compound fractures, and also on account of the more remote danger of irritation from depressed fragments causing epilepsy, insanity, etc., at a later period.

A circumstance that Taylor' says is connected with fracture of the skull with depression-namely, that the person, sensible as long as the object producing the fracture remained wedged

FIG. 13.-Several Fractures of the Left Half of the Base of the Skull, Running Paral. lel to One Another and Approaching One Another, also Separation of the Mastoid Suture. The injury was caused by a fall on the left side of the back of the head.

in, became insensible and began to manifest other fatal symptoms as soon as it was removed-must be extremely exceptional. It may be explained, if it occurs, by the occurrence of hemorrhage after the object which occluded an open vessel by its presence or its pressure was removed. For it should be remembered that the symptoms of compression in a depressed fracture of the skull are very rarely due to the compressing effect of the depressed bone, but rather to an injury of the brain, intracra"Med. Jurisprudence," 11th Amer. Ed., 1892, p. 334.

nial hemorrhage, or a local and temporary interference with the circulation.

We may truly say that wounds of the head are dangerous in proportion as they affect the brain. The existence of affection of the brain may be hard to tell from the appearances, for an injured person may recover from the first effects of a comparatively slight wound and yet die suddenly later.

66

Concussion is the name applied to one of the effects on the brain of a more or less violent blow directly on the head or transmitted indirectly to the head. Though the term concussion" implies a functional rather than an organic lesion, yet in the majority of cases it is equivalent to laceration of the brain. With laceration of the brain there is usually more or less effusion of blood which may be limited to a very thin layer. Concussion may exist without laceration of the brain. Even death has been known to occur from concussion of the brain without any visible signs of injury to the brain, so that the concussion

Lower Part of the Rim of a Round-
Headed Hammer. The blow was

struck from the right side.
natural size.

must have been functional and the fatal result due to shock of the nervous system. Fatal concussion does not, therefore, necessitate the existence of compression or visible injury of the brain. Concussion may sometimes be due to a violent fall upon the feet, in which case the shock is transmitted through the

spinal column to the head with or without fracture of the base of the skull. It was in this way that the Duke of Orleans, the son of Louis Philippe, died.

The symptoms of concussion show all degrees of severity. Thus the injured person may become confused and giddy with or without falling, he may become pallid and nauseated and may vomit, but after a short period he recovers gradually.

With a more severe injury, with which there is generally some laceration of the brain, the injured person falls and lies quiet and relaxed, apparently unconscious, though often he can be partly roused.

Paralysis and anæsthesia are absent.

The

FIG. 17.-Fracture of Parietal Bone with Depression, caused by the Blow of an Axe.

heart is feeble and fluttering, the skin cold and clammy. The pupils, as a rule, react to light, but otherwise vary considerably. Urine and fæces may be passed involuntarily. As he begins to regain consciousness, vomiting usually occurs. Consciousness usually returns within twenty-four or forty-eight hours, when headache and indisposition to exertion are complained of, and this may last for a long time. Occasionally the symptoms instead of abating increase, and coma supervenes, often indicating meningitis, encephalitis, or intracranial hemorrhage. In other cases the person may die almost immediately on the spot where he fell, while in still others apparent recovery takes place and death occurs later either suddenly or after a reap

ABSCESS OF THE BRAIN.

563

pearance of symptoms. In such cases, abscess of the brain may occur and be the cause of the fatal result. These abscesses are the result of the injury, which may be almost anything from a compound fracture to a slight contusion not leaving any scar. The abscess may occur within a week' or not until after months or years. This interval of apparent recovery may lead to the false supposition that death was not due to the injury, but to some intervening cause. It is well to bear in mind that about half of the cases of abscess of the brain are not trau

FIG. 18.-Wounds of the Vault of the Cranium caused by Artillery Side-Arms, followed by Death shortly after.

matic. A large majority of these are due to suppuration in the middle ear, a few to septic diseases or tuberculosis. The situation of the abscess often distinguishes between the traumatic and non-traumatic varieties. The traumatic variety is usually found beneath the injury or sometimes directly opposite, where the brain is injured by a kind of focussing of the radiated effects of the blow. The cases of abscess of the brain due to ear disease are usually found in the temporal lobe of the brain lying over the position of the ear or in the cerebellum behind it. The uncertainty of the nature and the extent of the cerebral injury 'London Lancet, 1873, i., p. 697.

of the body, erysipelas is found lit similar wounds elsewhere. The de that the redness and swelling acco comparatively slight. If erysipela the head, there is some reason to su position or careless treatment. Fr of the scalp abscess or diffuse celluli as well as erysipelas. The constitu. case may be marked or even severe, ble. In very rare cases necrosis of inflammation may even extend to tl lacerated wounds of the scalp are u by another; they are rarely self-in contused wounds are the most com head. These two kinds of injurieflicted by another or are accidenta that contused wounds of the scalp closely resemble incised wounds in should be borne in mind, as caref distinguish them if they are fresh a ulate. These wounds are liable to incised wounds, in fact more liable, wound more susceptible to inflamma apt to be infected at the time of the

One of the results of contusions sation of blood, most often betwe occipito-frontalis muscle and the p asations are usually in the form of tomata often present a hard circula centre, and may readily be mistak with depression. The diagnosis b pressed fracture is not usually d hematoma the ridge is elevated abov is movable on the surface of the ski often pit on pressure. With depre hand, the edge is at or about the lev it is sharper, more irregular, and les sions and the resulting hematoma suppurating, but this event is rare. wounds may occasionally show the 1