The Cerebrum

The Cerebrum affords the best opportunity for observing the healing process just described. Very large cavities close in this part, and even in the cerebellum also, at least so far as to leave merely a small cavity, or cyst, which in itself is not injurious. In many portions of the organ, especially in the pons, where, on the whole, apoplexy is not very rarely observed, only very small cavities heal completely. It is generally believed that cavities, the greater diameter of which is parallel to the course of the fibres of the brain, and in which, therefore, the mass of cerebral matter is more thrust asunder than really destroyed, heal, that is, close, more readily than those which are oppositely situated. The observation made above (p. 297) may be connected with this, that the contraction of the apoplectic cyst takes place especially in the diameter which is parallel to the direction of the contiguous fibres.

Although the process of healing may be going on, and a cavity be in a favorable state, it may yet prove fatal secondarily at any period. The further terminations and consequences of apoplexy may, therefore, be introduced here.

a. Apoplexy may be fatal at once, primarily, and suddenly (apoplexie foudroyante), or after a short time, some hours, or a few days: and death, in such cases, results from the extensive destruction of the brain, and from pressure. Of this kind are large central cavities, those of the size of a hen's egg, and even smaller. Still more certainly fatal are larger ones, which burst into the meshes of the pia mater without, or the cavity of the ventricles within. In certain parts of the brain, again, as the pons, medulla oblongata, corpora quadrigemina, a cavity which is not absolutely of inordinate size, may prove fatal by its suddenly withdrawing the influence of the brain from vital functions.

b. Apoplexy is fatal secondarily after a short interval, when, a reactionary process having been established in the neighborhood of the cavity, the inflammation becomes excessive, and is accompanied by yellow softening of the brain around. This is, moreover, occasionally associated with a very acute softening of the stomach.

c. Another secondary, and more remotely fatal result may ensue at any stage of the healing process when already commenced and advanced; its symptoms are those of paralysis and imbecility, marasmus and tabes, anaemia, and so forth. This latter secondary mode of death is partly occasioned by those diseases of the brain which are developed in consequence of apoplexy and its healing process. They are as follow.

a. The first effect of apoplexy is a permanent loss of a portion of the cerebral mass.

B. A very frequent, if not an invariable, consequence of this, is a manifest atrophy extending to considerable distances, in the course of those fibres which are included in the apoplectic spot. Large peripheral apoplexies are particularly remarkable in this respect.

y. This atrophy itself, together with the diminution and closure of the apoplectic cyst, gives rise to a corresponding amount of vacuum within the cranium; and the vacuum becomes greater as repeated attacks of apoplexy gradually involve the whole mass of the brain in the atrophy.

d. The atrophy of the brain, if not followed by oedema, is constantly combined with induration (sclerosis - condensation, and leather-like shining and toughness) of the white substance, and with the discoloration of the cerebral substance already described in the atrophy of the brain of old persons: and it gives rise to premature marasmus of the brain, and early failure of its powers. Doubtless the induration is principally due to the atrophy itself; it increases with the number of the apoplectic cavities; but it may also further arise from the whole brain participating in the inflammation and healing process of repeated attacks of apoplexy. At least, increase of density and adhesions of the superficial parts of the brain to the pia mater, are very commonly produced by an extension of the process of reaction much beyond the seat of peripheral apoplexies.

E. The vacuum in the skull produces congestions of the brain, and, thereby, repetitions of the apoplectic attack; as well as chronic, and even acute, oedema, if it should be occasionally increased.

C. A varicose state of the cerebral vessels sometimes comes on in the neighborhood of the apoplectic cyst and cicatrix.

All these appearances, either singly or together, are more developed in proportion to the size of the apoplectic cavity, and still more in proportion to the number of attacks. But extensive, and frequently repeated, peripheral apoplexies are, as has been already noticed, most remarkable in this respect; and it is in these that the most marked examples of imbecility and weakness of intellect occur.

In the few cases I have observed of primary hemorrhage into the lateral ventricle, the extravasation had always coagulated into a rounded cake, and was either loose or lightly adherent to the wall of the ventricle.

In conclusion, I turn to the pathogeny of hemorrhage in the brain. It is, in my opinion, entirely within the scope of anatomical inquiry.

The source of the hemorrhage is the finer vessels and the capillaries of the brain, one or several of which are ruptured. The rupture, however, of so large a number of vessels as we observe even in a cavity of only moderate size, is far from being entirely primary; by far the greater number are torn secondarily in the common destruction of cerebral tissue, by the increasing effusion.

The first that meets us in the search for the causes of apoplexy is -

1. Manifest External Violence

Manifest External Violence, producing traumatic apoplexy; it may act either directly upon the skull, or indirectly through the trunk,, and produce concussion of the brain: in the former case, wounds of the soft parts of the head, and injuries of the skull itself, are usually associated with it. Most frequently these forms of apoplexy are rapidly fatal, by the general paralyzing effect of the concussion upon the whole brain. The mode of their origin is evident.

2. A Second Class Of Apoplexies

A Second Class Of Apoplexies are those which result from different pre-existing anomalies, the mode of action of which may be more or less clear: they are named spontaneous apoplexies.

The mode in which these spontaneous apoplexies arise remains now to be examined; and, in order to omit none of their causes, all the circumstances under which they occur, may, I think, be so arranged as to afford a useful survey of the most important facts.

Cerebral hemorrhage is not unfrequently observed in the course of convulsions, especially puerperal convulsions and epilepsy. It is generally very extensive and rapidly fatal.

It occurs also sometimes in the neighborhood of tumors, tubercle, and cancer of the brain.

Occasionally, inflammation and obstruction of the venous trunks of the pia mater, or of the longitudinal sinus, are attended with hemorrhage in the contiguous substance of the brain; it occurs also in the neighborhood of inflammation (red softening), as well as in the inflamed spots themselves.

Sometimes it takes place in pregnant females, and persons with distorted spine, when the lungs are morbidly dense.

In some very rare cases in which congenital hydrocephalus is increasing rapidly after birth, blood escapes either into the cerebral substance or into the cavity of the ventricles from the vessels ramifying on their dilated walls.

Sometimes it occurs in the course, or as the consequence of fevers, particularly the typhus and typhoid.

And occasionally during the progress of Bright's disease of the kidneys (albuminuria).