The _extremities_ are investigated with respect to unilateral palsy, a condition only present in trauma and apoplexy. General convulsions point to injury, uræmia, and epilepsy. Resistance to manipulation is suggestive of alcoholic excess. Unilateral palsy may be associated with corresponding alteration in the deep reflexes. The _pulse_-rate and the condition of the arteries supply valuable evidence. The coats may be atheromatous, whilst the slow, full pulse is strongly suggestive of compression, apoplexy, and alcoholism. The _temperature_ should be taken on both sides of the body. A rise of temperature is usually dependent on brain injury, apoplexy, and alcoholism. In opium poisoning, uræmia, and epilepsy the temperature is more likely to be normal or subnormal. In pontine hæmorrhage, hyperpyrexia is commonly observed. Some difference in the temperature on the two sides of the body points to injury or apoplexy. The _depth of the coma_ is often of the greatest assistance in the differential diagnosis. Thus, in concussion, alcohol poisoning, and in the minor grades of epilepsy and uræmia, the patient may often be sufficiently aroused by shouting in the ear, digital pressure over the supra-orbital nerves, or by the application of the battery, as to give some account of the accident, &c. In compression, in the deeper states of uræmic and diabetic poisoning, and in the status epilepticus, the patient can seldom be aroused from the deep coma into which he is sunk. In all cases of doubt the patient must be kept under careful observation. [26] _Syst. of Pract. Surg._, vol. ii. [27] _Deutsche Zeit. für Chir._, Bd. 4, vols. i and iii. [28] _Guy’s Hosp. Reports_, 1885-6. [29] Bergmann’s _System of Surgery_, vol. i. [30] _Ruptures de l’Artère méningée moyenne._ [31] _Guy’s Hospital Reports_, vol. lix. [32] _Traumatic Injuries of the Brain._ [33] _Traumatic Injuries of the Brain_, p. 138. [34] _System of Surgery_, vol. i, p. 179. [35] _American Practice of Surgery_, Bryant and Buck. CHAPTER VI THE REMOTE EFFECTS OF HEAD-INJURY =General considerations.= It is often stated that a patient who has received a severe head-injury is ‘never the same man afterwards’. Before accepting such a sweeping statement--the gravity of which is obvious--it is essential that an extensive survey should be made into the remote effects of head-injury, and, in their consideration, the surgeon must not be biased by those cases that seek hospital relief. It is the unfavourable cases that present themselves for examination, the more favourable are usually lost to view. Furthermore, whether the early results are completely satisfactory or not, but little guide can be obtained into the more remote results unless, as a routine procedure, an attempt be made to trace all such cases in their after-history. The more remote results can then be estimated at their true value.