From the above considerations we see that spontaneous cerebral hemorrhage and that due to disease are not always easily distinguished from that due to violence. In severe injuries the structure of the brain is plainly bruised, etc., but the greatest difficulty exists in cases of slight violence where arteritis of the cerebral blood-vessels coexists. The spontaneous extravasation of blood in or upon the brain from excitement does not usually occur except with diseased vessels, old age, or alcoholism. It is rare, therefore, in the young and healthy. If there is any doubt as to the origin of the hemorrhage, the medical witness should state the cause most probable in his judgment. Taylor[663] supposes the case of a man excited by passion, alcohol, or both, who becomes insensible and dies after being struck a blow so slight that it would not have affected a healthy person. If examination reveals a quantity of blood effused into the substance of the brain, there can be little doubt in the mind of the medical man that the excitement was the principal cause of the effusion. On the other hand, if a severe blow or a violent fall on the head had been received in a personal conflict with another and it is found that death was due to an effusion of blood upon the surface, there can be little doubt in the mind of the medical examiner that death was due to the blow, which would satisfactorily account for the conditions found without reference to coexisting excitement, etc. In fact, in all cases where a question is raised as to the cause of the hemorrhage, it is most important to consider whether the violence was not sufficient to account for the hemorrhage without the coexistence of disease or excitement. It is also most important to bear in mind that after severe injuries, as after a fall, causing extensive fracture of the skull, followed or not with extravasation of blood, the injured person may walk about and die some distance from the place of the accident and where no chance for a similar accident exists. In this way the suspicion of murder may be occasioned, as illustrated in the following case cited by Taylor:[664] A man was accused of the murder of his companion, who was found dead in a stable with fracture of the temporal bone which had caused rupture of the middle meningeal artery. The accused stated that the deceased had been injured by falling from his horse the day before. After the fall, however, the deceased had gone into a public-house, where he remained some time drinking before returning to the stable. The extravasation had here taken place gradually, as is characteristic of hemorrhage from the middle meningeal artery, and perhaps the excitement due to the drinking had influenced it.
The date of an effusion of blood may sometimes be a matter of importance in determining whether a given extravasation of blood in or on the brain was caused by a recent blow or had existed previously. The color and consistence of these effusions indicate whether they are old or recent; the precise date we cannot state, but the information we can give is often all that is required. The color of recent effusions is red, which changes after some days to a chocolate or brown, which generally turns to an ochre color (see Plate I.). This latter color may be met with from twelve to twenty-five days after the injury. The consistence of the coagula also becomes firmer with age, and as the coagula become firmer they are more or less laminated and the expressed lymph may lie between the laminæ or around the coagula.
MEDICAL JURISPRUDENCE—PLATE I.
Extravasations in several portions of the Arachnoid, with hemorrhages in neighboring portions of the brain. Death in four days.
Cerebral abscess. Epilepsy, Paresis. Death 3¼ years after the injury.
RECENT AND OLD CEREBRAL EFFUSIONS.
On account of the many layers of the brain coverings, a rough diagram of the coverings as given by Taylor[1] may be of much use to the medical expert in illustrating his evidence so as to make it clear to the court (see Fig. 19).