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.

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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.

in so-called contusion of the brain renders it necessary to be very careful in giving a prognosis. Any injury should be considered serious which has produced unconsciousness, for such an injury may produce enough laceration of the brain to render serious danger possible or even probable. We have seen that as a rule the symptoms of concussion come on immediately, but it is possible that symptoms at first so slight as to escape notice may become serious in a few hours or days. A gradual hemorrhage may sometimes account for this. The knowledge of certain acts performed or a conversation held at the last moment before the injury may be retained after recovery from concussion of the brain. This is not necessarily the case, for instead of remembering up to the moment of the injury, the injured person may remember only up to a certain time shortly before, or a part and not everything may be remembered.

The diagnosis of concussion of the brain from alcoholism is sometimes a matter of medico-legal interest or importance. Concussion may be so slight as to simulate intoxication. The history often clears the case up. The history of a blow or a fall or the presence of marks of violence on the head indicates concussion, though the blow or fall may not have caused the symptoms, which may be due to alcoholism. The odor of the breath may indicate alcoholism, but here too we may have both present and the concussion may be responsible for the symptoms. Or again the alcohol may have been given as a heart stimulant after the accident. This combination often occurs. If there is no odor in the breath, the presumption is in favor of concussion. As mistakes are still not infrequently made in diagnosis, those cases in which there is any ground for doubt should be carefully watched for developments. In general, the existence of concussion is more often overlooked than the coexisting alcoholism, so that if there is any doubt in a given case it should be treated as one of cerebral injury. The injury which causes the concussion in such cases is often due to the alcoholism. We may be able to verify this supposition if the injury is such as would be likely to be caused by a fall. There may be nothing found in the brain after death to distinguish between concussion and alcoholism. A bruise on the head only indicates a probability of concussion, for the bruise and alcoholism may both be present, the former perhaps due to the

EXTRAVASATION OR EFFUSION OF BLOOD.

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latter. The presence of alcohol in the stomach would indicate the existence of alcoholism.

Another effect of an injury which has caused concussion of the brain is an extravasation or effusion of blood. Extravasation of blood in or on the brain is one of the commonest causes of death from injury to the head. It may occur with or without marks of external injury. A person suffering from such an extravasation of blood may recover from the first effects of the injury, and at a varying time afterward the symptoms may return and increase so as to result fatally. In such a case the opening of the bleeding vessel may have become plugged until some exertion, emotion, or excitement on the part of the injured person has loosened the plug. A hemorrhage may have ceased from partial syncope and return with a stronger heart action due perhaps to the administration of alcohol. This effusion may occur on the surface of the brain in connection with a superficial laceration of the brain or just beneath or outside the dura mater and not involving the brain directly. The latter cases are almost always due to the effects of violence, though there is at least one case of apparently spontaneous rupture of the middle meningeal artery. The violence which causes a rupture of the branches of this artery may be so slight as to leave no bruise or so severe as to cause fracture of the skull. The most important symptom of such extradural hemorrhage is a period of consciousness after recovery from the first effects of the injury, then stupor may appear and deepen into coma. A subdural hemorrhage may cause almost the same symptoms, though the injury is usually such as has produced a depressed fracture. This hemorrhage is most often due to the rupture of a number of small vessels under the fracture, though if one larger vessel is ruptured it is most often the middle cerebral. A thin layer of hemorrhage in connection with a superficial laceration of the brain is of frequent occurrence with or without the other two forms of intracranial hemorrhage. If the brain is lacerated we may have convulsions in addition to other symptoms. Death occurring during or soon after a prize-fight may occur from some of the above classes of intracranial extravasations. It may be questioned whether the blows or a fall caused the hemorrhage. It is generally due to a fall in such cases, but may be due to blows, but the guilt is