CEREBRAL APOPLEXY. 219 



down portion of brain is not limited to a new formation of connective 

 tissue, but there is extensive destruction from inflammatory softening, 

 or the apoplectic clot is even transformed to an abscess of the brain. 

 The parts untouched by the haemorrhage are bloodless if the extrava- 

 sation has been considerable, and the more so the larger the extrava- 

 sation ; small capillary haemorrhages have no influence on the amount 

 of blood in the rest of the brain. In large effusions the hemisphere 

 containing the clot is particularly anaemic. The subarachnoid spaces 

 also are empty, the convolutions flattened, and the furrows have dis- 

 appeared. Since the uneven appearance of the surface of the brain is 

 to a great extent due to the presence of cerebro-spinal fluid and of 

 vessels containing blood between the convolutions, the surface of the 

 brain appears very smooth and even when there is a large extravasa- 

 tion. The brain rarely endures the injury from an apoplexy without 

 impairment of the general nutrition. The gradual diminution of men- 

 tal power seen in almost all apoplectic cases corresponds to a general 

 atrophy of the brain ; which, according to the examinations of Turk, 

 is associated with a degeneration, extending into the spinal medulla, 

 of those filaments communicating with haemorrhagic effusion. 



SYMPTOMS AND COURSE. Sometimes apoplexy -occurs unexpect- 

 edly in persons who have previously felt quite well ; in other cases it 

 is preceded by premonitory symptoms that excite in the physician, and 

 even in the laity, the apprehension that the patient is threatened with 

 apoplexy. The patients complain of headache, or of heaviness and 

 fulness of the head, of noise in the ears, flashes before the eyes, and 

 attacks of dizziness ; they sleep badly, are excited and irritable. There 

 are also, as peculiarly ominous symptoms, occasional temporary feel- 

 ings of formication and numbness in certain limbs, momentary loss of 

 memory for some words and figures, or temporary paralysis confined 

 to certain groups of muscles. Thus we see the premonitory symptoms 

 of apoplexy are those that we gave in preceding chapters, as due to 

 general and partial hyperaemia of the brain, and to partial anaemia of 

 the brain resulting from degeneration of the walls of the vessels ; a 

 condition that entirely corresponds with the frequent dependence of 

 cerebral haemorrhages on increased lateral pressure in the cerebral 

 vessels, and on degeneration of their walls. In general it cannot be 

 determined whether the temporary partial paralysis and anaesthesias, 

 the " warnings " preceding the apoplectic attack, depend on throm- 

 bosis of small vessels, or on small capillary haemorrhages. In the 

 latter case, of course they could not be classed among premonitory 

 symptoms. 



The destruction of brain-filaments, whether they be broken up by 

 large extravasations or be softened by small capillary haemorrhages, 



