720o NERVOUS SYSTEM. (NERVOUS CENTRES. ABNORMAL ANATOMY.) 



heart, oppressed by some disease affecting its 

 own structure, fails to propel the blood with its 

 proper force to the brain. The delirium which 

 comes on in rheumatic fever, when pericarditis 

 or endocarditis commences, is indicative of an 

 anaemic state of the brain ; and in some in- 

 stances in which I have had the opportunity of 

 examining the brain, when the patient died in 

 this delirium, I have found marked and obvious 

 anaemia of this organ. 



Anaemia of the brain, according to my ob- 

 servation, is of two kinds, general and partial. 

 In the former, pallor prevails throughout the 

 brain. This is met with, as before mentioned, 

 in ill-nourished children ; and it is also present 

 to a remarkable degree in persons, house- 

 painters and others, who have largely imbibed 

 the poison of lead, as if the presence of that 

 poison interfered greatly with the process of 

 haematosis. Partial anaemia is where the defi- 

 ciency of blood is observed chiefly in the grey 

 matter. I have frequently seen the grey matter 

 of the convolutions perfectly bloodless, and the 

 white matter of the hemisphere covered with 

 bloody points of congested veins. This is the 

 condition generally met with after death from 

 rheumatic or gouty delirium. 



When the brain is very anaemic a consider- 

 able quantity of fluid is generally found beneath 

 the arachnoid membrane, with or without a 

 small quantity in the ventricles ; or more rarely, 

 a good deal of fluid in the ventricles, with 

 little or no subarachnoid fluid. 



Of' cerebral hemorrhage. Effused blood 

 from one or more ruptured bloodvessels is 

 found upon the surface, in the substance, or in 

 the ventricles of the brain. Effusion of blood 

 in any or all of these situations constitutes the 

 most common form of cerebral apoplexy. 



The blood is sometimes effused simply upon 

 the surface of the brain ; it is diffused beneath 

 the arachnoid membrane, and even under the 

 pia mater, raising up that membrane and sepa- 

 rating it from its connection with the cerebral 

 substance. Not unfrequently such a diffusion 

 of blood beneath the pia mater is connected 

 with an internal extravasation which has made 

 its way to the surface either through broken down 

 cerebral substance or from the ventricles. 



A recent apoplexy in the substance of the 

 brain is no more than a dark clot of blood, like 

 a mass of black currant jelly, filling a cavity 

 which it has formed for itself in the cerebral 

 substance. Such is the appearance when the 

 examination has been made a few hours or even 

 a few days after the apoplectic fit. If the 

 patient survive this period, we find evidence of 

 changes in the clot and in the surrounding 

 cerebral substance. These changes vary ac- 

 cording to the condition of the brain prior to 

 the apoplectic effusion. 



If the brain has been quite healthy up to the 

 occurrence of the rupture, a condition which is 

 extremely rare, then the changes towards cica- 

 trization take place quickly ; the serum of the 

 clot becomes absorbed ; the torn brain-substance 

 around the clot contracts ; the solid matter of 

 the clot assumes a reddish instead of a black 

 hue; it gradually diminishes in quantity, and 



the brain-substance, not contracting to the savne 

 extent as the clot has done, a cavity remains, 

 which contains serum, and more or less of the 

 remnant of the- clot. The cerebral substance 

 forming the wall of this cavity has a yellowish 

 colour, somewhat of the same hue as that which 

 is seen after extravasated blood in the subcuta- 

 neous tissue, and it is denser than is natural. 

 After the lapse of more time the cavity con- 

 tracts, and nothing remains but a spot of dis- 

 coloured and somewhat indurated cerebral 

 substance. When the apoplectic clot has been 

 of large size, and has occasioned an extensive 

 solution of continuity, the contraction of the 

 surrounding substance is not sufficient to obli- 

 terate the cavity, which in such instances is 

 occupied by a soft, loose, areolar tissue, infil- 

 trated with fluid. In other cases the cavity is 

 lined by a distinct membrane and is filled with 

 fluid, forming a true cyst. Cruveilhier affirms 

 that the most frequent sequel to the apoplectic 

 clot is the indurated and discoloured spot of 

 cerebral substance; next in frequency is the 

 cavity with the loose areolar tissue ; and last, the 

 cavity lined by a membrane or the serous cyst. 



The morbid condition which surrounds the 

 apoplectic effusion is generally that of colour- 

 less softening. This state doubtless precedes 

 the rupture which gave rise to the hemorrhage. 

 Sometimes, however, red softening extends 

 around it more or less; this generally follows 

 the effusion. The existence of either of these 

 morbid states is very unfavourable to the con- 

 traction and cicatrisation of the apoplectic cyst. 



It frequently happens that in the cerebral' 

 substance around an apoplectic clot we find 

 very numerous small points of effused blood, 

 sometimes accompanied by minute streaks fol- 

 lowing the direction of the cerebral fibres. 

 This constitutes what is called capillary apo- 

 plexy. Sometimes this is the only marked 

 appearance present, and no large clot has been 

 formed. This occurs not uncommonly in apo- 

 plexy affecting the medulla oblongata and the 

 mesocephale. \Vhen many such minute effu- 

 sions take place very near to each other, it is 

 easy to understand how by their coalition they 

 may form a large apoplectic clot; and it is 

 most probable that large effusions generally 

 arise in this way, not from the rupture of one 

 or even of a few vessels, but from that of 

 numerous minute ones. 



The size of the apoplectic clot varies consi- 

 derably (excluding the cases of capillary apo- 

 plexy in which no coalition has taken place) 

 from the size of a millet seed to that of a man's 

 fist, the clot sometimes breaking up the fibrous 

 nervous matter of the hemisphere with its sur- 

 rounding grey layer, and completely occupying 

 its interior. There is no part of the brain 

 so favourable for the occurrence of a large 

 apoplectic clot as the hemisphere, because its 

 softness and magnitude afford the least resistance 

 to the flux of blood. 



Apoplectic effusions occur most frequently 

 in the hemispheres of the brain, affecting first 

 the corpora striata or optic thalami, and spread- 

 ing from them into the white substance of the 

 hemisphere, or sometimes breaking up their 



