Hemorrhage (Apoplexia Sanguinea; Apoplexia Gravis) is a very common disease in the brain, and is often suddenly fatal. I class it with hyperaemia, although it is not necessarily accompanied or caused by striking congestion.

Cerebral hemorrhage consists in an extravasation of blood into the substance of the brain, and a solution of its continuity corresponding in extent to the amount of the bleeding; the latter injury consists generally of breaking-down, laceration, or contusion of the cerebral substance.

The intensity of the hemorrhage, the number of the bleeding vessels, and the nature and extent of the disorganization of cerebral substance occasioned by the extravasation, produce many marked varieties in the form of the seat of hemorrhage.

Sometimes a spot of gray or white cerebral substance, varying in extent, is speckled or striped with a small number of dark red dots and streaks of extravasated blood (ecchymosed): the streaks run parallel to the nervous fibre, the intermediate cerebral substance preserves its normal color and consistence, and, where the fibres of the brain run in one direction, it seems to the naked eye merely drawn asunder, some few only of the elementary parts having suffered an actual solution of continuity.

At other times the number of these extravasations is more considerable: they lie closer together, and some of them having coalesced, are thereby increased in size. The cerebral substance appears to be uniformly suffused, and colored with various shades of red: it is of a soft pulpy consistence; and, apparently, in consequence of the number of original small extravasations, and still more by the confluence of larger ones, it is broken into shreds, and softened to a red pap.

When this is the case, the small extravasations become more numerous, and, still coalescing, produce more and more extensive destruction of the intermediate cerebral substance; and thus, as the other extreme, we find all the primary small extravasations united in a single great one, which includes the broken-down interstitial substance of the brain, and is itself contained in a cavity of lacerated, and bruised cerebral tissue.

This, therefore - the apoplectic cavity (Herd) - proceeds from hemorrhages occurring at several points at once, - from the confluence of many small cavities. The form first described has received the name of Capillary Apoplexy.

An extensive cavity is, however, sometimes formed in another manner, viz., by the independent enlargement of a single small extravasation in consequence of the continuance of the hemorrhage; for there are some single and very small extravasations, of the size of a poppy- or millet-seed, which, when the hemorrhage continues or recurs, increase rapidly or by degrees, and tear and separate the surrounding cerebral substance in various directions. Though the tissues composing the walls of such a cavity, may resemble the broken-down structures already described, yet the extravasated blood which it contains is, in its interior strata, at least, free from all admixture of cerebral tissue.

It is not clear whether one form of the hemorrhagic cavity may, from any particular morbid cause, be occasioned by the other; but it appears, nevertheless, as if that described second, were principally dependent on hypertrophy of the left ventricle, and gave rise to the large (foudroy-antes) cavities which prove suddenly fatal.

The apoplectic cavity, whether produced in one way or the other, presents varieties, when recent, which are important in several respects.

Seat Of The Hemorrhage

It happens in the cerebrum far more frequently than in any other portion of the brain. The cerebellum is comparatively very seldom attacked, and the pons yet more rarely. Its occurrence in the corpora quadrigemina, the pons, and the medulla oblongata is quite exceptional, and it almost never happens in the corpus callosum, the fornix, and the hippocampi. There is, however, pretty frequent exception to this rule: for when a large cavity is formed in the cerebrum, one or more small secondary cavities are found also in other parts of the brain, especially in the cerebellum and the pons.

In the cerebrum, the situations in which hemorrhage principally occurs are the optic thalami, and corpora striata; from them the white substance of the hemispheres is invaded: the gray matter of the convolutions also is a common site. The cavity is less frequent in those fibrous parts of the hemispheres which are distant from the seats of gray matter.

From this it is evident that the masses of gray matter, and those portions of the brain which contain considerable quantities of gray matter, are eminently the seat of apoplexy. It is unnecessary, after stating these general facts, to prepare a scale of frequency.

The distinction of apoplexy into peripheral (that of the cortex of the brain), and that occurring in the central parts is worthy of notice, inasmuch as the former is followed by physical changes and functional disturbances of considerable importance. When spontaneous it almost always occurs only on the convexity of the hemisphere-Hemorrhage into the lateral ventricles, - not the rupture into the ventricles, which so frequently happens to apoplectic cavities in the corpus striatum and optic thalamus, but hemorrhage from the lining membrane, and the vessels ramifying near it, - is an extremely rare occurrence. I once met with it, as others also have done, in a very large congenital hydrocephalus.

The cavity varies in size from that of a poppy, or millet-seed, to that of a man's fist, and even beyond, so that at length it may include an entire hemisphere of the cerebrum. This part is of course the seat of the largest cavities. It not unfrequently happens that they burst through the brain, either outwards on its surface, or more commonly inwards, into the cavity of the lateral ventricle, as might, indeed, be expected from their being more usually situated in the optic thalami and corpora striata. The consequence in the former case is extravasation, first, into the tissue of the pia mater, and then between it and the cerebral layer of the arachnoid, to a greater or less extent. Not unfrequently the whole of the pia mater surrounding the diseased hemisphere is suffused, and free extravasation is poured out even into the ventricles. In the latter case, the first and immediate result is the effusion of a large quantity of blood into the collateral ventricle; it passes into, and fills, the opposite ventricle, producing at the same time, much laceration of the septum and fornix. The effusion proceeds into the third, and thence into the fourth ventricles, and from the ventricles into the pia mater all round the brain, but especially at the base. The size of the rent varies; it may be an inconsiderable fissure, or a large cleft, gaping into the ventricle; the latter is especially the case in the corpora striata and optic thalami.

In peripheral apoplexy, or apoplexy of the superficial part of the brain, the cavity is covered in, and closed by the pia mater, and the tissue of that membrane is suffused. In superficial extent, peripheral apoplexy usually includes the space of about a square inch.

The smallest cavities occur in those parts of the brain, in which apoplexy is, in general, less frequent, although some cavities, of the size of walnuts, are not very rare in the pons, and even larger still in the cerebellum.

The number of recent cavities is also various. Usually but one is found, though to this there are frequent exceptions. With very large and suddenly fatal cavities in the cerebrum, one or several others, in different parts of the brain, are very commonly associated, which are secondary to the former in point of size. It is also interesting to observe, sometimes, in the very atrophied brain of old persons the simultaneous, or nearly simultaneous, occurrence of very numerous small cavities: they equal millet-seed, hemp-seed, and even beans in size, and occur in different parts of the brain.

It is also remarkable that two symmetrical cavities are sometimes found in corresponding organs of the brain, for instance in the corpora striata.

The form of the cavity, when small, is generally round or elliptical; in fibrous parts, like the pons, it is very often a slit parallel to the fibres: larger cavities are more irregular, and are dilated into pouches in various directions.

The parts around, constituting the walls of the cavity, consist of cerebral substance more or less extensively suffused, red, and broken down into a soft and very moist pulp: in large cavities, ragged shreds of it hang into the cavity.

The contents of the cavity, too, the extravasated blood, present numerous varieties. In the first place, as has been already explained, it may, or may not, enclose shreds of the destroyed cerebral tissue. Its quantity corresponds with the size of the cavity, and may amount to six, eight, or even ten ounces.

There are many diversities both in the degree and the manner of its coagulation. Sometimes the whole extravasation becomes one uniform thick, blackish-red mass; at other times it is partly fluid, and partly in clots of various consistence: occasionally there is a more marked separation into a fluid portion and one coherent cake; or the entire mass has congealed into a sort of placenta that fills out the cavity and assumes its form. Here and there, moreover, the fibrin may be separated in the form of clots, or cords, or membranes, which pervade the blackish-red cake. It is of much importance to remark those forms of coagulation, not hitherto observed, in which the fibrin, when in considerable quantity, is deposited around, and encloses the clot and serous portion - the peripheral form, - or is lodged as a central clot, in the interior of the coagulated mass. Each form opposes permanent obstacles to the healing, that is, the contraction and closure of the apoplectic cavity.

Lastly, a brain, which is the seat of apoplexy, suffers not only a solution of continuity at the part itself, but also some displacement corresponding to the size of the cavity. The cerebral substance surrounding the cavity is stretched and torn, the segment of the brain containing it is enlarged, swollen, and more or less altered in form, and a portion of brain swollen by a large cell is found to fluctuate, when much of the effused blood has not coagulated. The pons is thus enlarged around a cell in its centre, especially in breadth; but the changes are most striking when one of the cerebral hemispheres is occupied by a large apoplectic cell. It is forced against the dura mater and cranium, and inwards against the opposite hemisphere; it becomes prominent and convex towards the falx cerebri; it feels quaggy (schwappend, - wabbling); and if it enclose a very large cavity, it ruptures on the removal of the dura mater. The inner membranes are thin; the serum which had been previously infiltrated through them, is removed; their vessels are compressed; the convolutions are driven close together, flattened and diminished in size; the structures at the base of the brain are flattened, the opposite ventricle is narrowed, and its contents are displaced. When a cavity of this kind opens into the ventricle, the opposite hemisphere also shares in the enlargement, etc, as much as is possible.