Nervous influences. The probability of these as a factor was suggested by the writer to explain certain occasional peculiarities, as the onset during sleep, when the blood-pressure is lowest, the absence of aneurisms as a source of haemorrhage in many cases, the asserted occurrence of prodromata at times, and especially the occurrence of symmetrical hinorrhages. It is to the vasomotor control of these parts that such action must be assigned. This principle rests on the close bilateral association of the brain-hemispheres, and presumes that any general influence—as from the abdominal or thoracic viscera, reach ing some centre or part of one hemi sphere—affects at the same time or in immediate sequence its opposite in like manner. Possibly by allowing a dilata tion of the arteries to the respective parts a strain is exerted on the vessels sec ondary thereto, and thus weak points give way. Whether this cause can of itself be sufficient or whether it at most is only an immediate cause cannot be stated.
Two eases of apoplexy which were considered as hysterical. Trophic lesions, such as oedema and hfemorrhage, as ob served elsewhere in the body, may exist in the brain, according to his view. Hys terical hiematemesis, Inemoptysis, ancl eechymosis are well known : there is no reason why similar lesions should not be found within the cranial cavity. There was no autopsy in either of the cases; if there had been, the hysterical nature of luemorrhage could not have been dem onstrated in this way. Gilles de la Tonrette (Bull. et Memoires de la Soe. des HAT). de Paris, June 4, '96).
The changes that old age brings are universally recognized as predisposing to apoplexy. This bas, in times past, lead to the assumption that cerebral hrernor rhage was only a matter of years. Be cause senility is added to the other fac tors this tronble is more frequent in the aged, though it has been found that in the very old cerebral thrombosis is a more frequent result. But, as the pre vions causes are quite as common in the younger or stress years of life, there is no immunity at any period.
Distinct from the above are the im mediate provoking causes, of which there are many: straining at stool, lift ing of heavy weights; plethoric states, as after excessive eating; rag,e, .fright, the sexual act or other great excitement, severe coughing, meteorological condi tions (rise in barometer, fall in atmos pheric temperature), etc., come under this head. These all act by increasing the blood-pressure. Presumably they are, of themselves, insufficient without previous vascular change.
Hereditary influence. C'ase of a man of 25, who had a bilateral cerebral Inem orrbage, whose father and one brother died of left hemiplegia at 58 and 28 years, respectively. and whose sister died
of apoplexy at 25 years. No history of syphilis. Bernard (Bull. de la Soc. Anat., No. 26, '9:3).
Case of cerebral luemorrhage in a woman of 52, with tumors of the parotid and frontal regions, who received 28 cubic centimetres of chloroform, the ame.stlie.sia lasting, one hour and hve minutes. Coma followed at once, last ing eig,ht hours: then she gradually recovered, showing left-sided complete paralysis of the arm, less complete of the leg and right side of the face, with complete insensibility in the left arm, less marked on the entire left side of the body. She slowly recovered. Boureau (Revue de Chiriire.,,ie. July, 1902).
Pathology.—This resolves itself into three questions: (1) as to the vascular changes preceding or attending the rupt ure, (2) as to the blood thrown out, and (3) as to the changes of nerve-tissue re sulting therefrom.
1. In the usual spontaneous cases we find some alteration of the vessel-walh that weakens their resistance. Fatty and atheromatous degeneration is com mon in the aged, and appears earlier in those who have done heavy lifting, indulgence in alcoholics, or for any cause developed premature senility. tis and the uric-acid diathesis lead to arteriofibrosis, which later breaks down.
Specific arteritis leaves an atrophic dition of the vascular wall, and this may-, in time, yield. Aneurisms (miliary) sometimes develop, as found by Bou chard and Charcot, doubtless on the basis of some of the conditions just men tioned, and presently one or the other of these inay give way. Later studies have shown that far from all spontaneous cases are due to the rupture of such aneurisms. We must conclude that weakened spots sometimes give way directly; i.e., without the intervention of such dilatation.
Three cases of multiple lesions of the brain. These are very uncommon, hav ing been the only ones found out of a total of 4000 post-mortem examinations. Clinically they are interesting because the symptoms during life did not lead to suspicion of the presence of the ex tensive lesions found post-mortem. In the first case there was headache, un consciousness lasting two hours, and muscular twitchings, but no paralysis after a luemorrhage consisting of more than an ounce of blood. After the sec ond hiemorrhage there were headache, spasm, but no motor paralysis, hernia nopia, and dementia, and yet the second clot was larger than the first, and it was only after the third attack, when more than five ounces of blood was ef fused, that hemiplegic symptoms and coma. supervened. This case is an ex ample of the adaptability of the brain to rapid increases of intracranial press ure. Freyberger (Edinburgh Med. Jour., Nor., 1901).