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CHAPTER 8: The Federal Bureaucracy
MULTIPLE CHOICE
1. Which term often carries negative connotations of overgrown government, excessive rules and
paperwork, and a burdensome process?
a. Civil service
b. Populism
c. Communism
d. Bureaucracy
e. Washington
ANS: D REF: 201 NOT: factual
2. Most organizations have a common set of rules for carrying out functions that characterize the
operations. These formal rules are called
a. statutes.
b. recommendations.
c. bureaucratic guidelines.
d. standard operating procedures.
e. standardized commands.
3. Sociologist Max Weber, an early student of bureaucratic organizations, identified several common
characteristics of effective bureaucracies. Which of the following would NOT be on Weber’s list?
a. Hierarchical arrangement with a clear chain of command from top to bottom
b. A focus on the professionalism of all employees
c. Hiring and promotional decisions that are normally influenced by local politicians
d. Organization based on a division of labor, expertise, and specialization
e. A common set of rules and regulations for carrying out organizational functions
ANS: C REF: 204 NOT: applied
4. Modern Americans are NOT most likely to encounter government bureaucracy when
a. registering for unemployment benefits.
b. receiving Social Security benefits.
c. receiving orders to report for a pre-induction physical.
d. receiving a driver’s license.
e. checking a product’s safety at the Consumer Protection Agency’s website.
ANS: C REF: 204 NOT: factual
5. What provisions or requirements does the U.S. Constitution make concerning the federal bureaucracy?
a. The bureaucracy must be in tune with the needs of the citizenry and must be structured in
a way to meet those needs.
b. The bureaucracy must be separate from political parties in order that it not fall prey to
political pressures.
c. The Constitution places the president as head of the bureaucracy.
d. The bureaucracy must not be allowed to grow larger than the military.
e. The bureaucracy is an important reality in American federal government, though the
Constitution makes no mention of it.
ANS: E REF: 204 NOT: conceptual
6. The federal government’s bureaucracy is ultimately the responsibility of
a. the President of the United States.
b. the Congressional Business Office.
c. the Oversight Committee of the Supreme Court.
d. the White House chief of staff.
e. the bureaucracy itself.
ANS: A REF: 204 NOT: factual
7. Each bureaucratic unit or agency has a written procedure for carrying out its programs or services.
These procedures are referred to as
a. red tape.
b. regulations.
c. statutes.
d. writs.
e. implementation cycles.
ANS: B REF: 206 NOT: factual
8. Which term refers to the process in which the federal bureaucracy carries out a law passed
by Congress?
a. Rules and regulations
b. Execution
c. Policy implementation
d. Bureaucratic oversight
e. Policy development
9. Regulations are
a. a set of rules that guide employees of an agency in carrying out a program or service.
b. a widely accessible federal government publication.
c. freedom in deciding how to implement a law.
d. Congress choosing not to deal with politically difficult issues.
e. the process of carrying out a law.
10. When a bureaucratic unit or agency drafts a set of regulations to implement a program, those
regulations must be officially published and made accessible to the public. These regulations are
published in the
a. Federal Register.
b. United States Code.
c. Federal Statutes.
d. Supreme Court Reporter.
e. Washington Post.
11. A step included in authoring regulations is

a. asking the Attorney General for an advisory opinion regarding a proposed regulation.
b. asking the courts for a preliminary ruling regarding a proposed regulation.
c. having an open period where the agency accepts comments on a proposed regulation.
d. Options A, B, and C are true.
e. None of the above is true.
12. Policy implementation is

ANS: E REF: 206 NOT: factual
13. What is meant by “administrative discretion”?

a. The federal courts have considerable oversight ability and latitude to steer an agency.
b. An agency is not bound by its written regulations and may adapt its procedures to meet the
particular circumstance.
c. Having enacted the legislation, Congress has reserved the right to create administrative
guidelines for an agency.
d. When laws are vague, a federal agency usually has considerable freedom in deciding how
to implement them.
e. In regard to a federal agency, the president has considerable freedom to dictate to the
agency how a law will be implemented.
ANS: D REF: 206 | 207 NOT: applied
14. The federal bureaucracy that develops workplace safety regulations and enforces them is the
a. Environmental Protection Agency.
b. Department of Commerce.
c. American Federation of Labor.
d. Occupational Safety and Health Administration.
e. Employment Security Commission.
15. One of the reasons for Congress passing vague laws, thus calling for administrative discretion, is
16. Congressional oversight includes

a. placing an artillery round beyond a target for the purpose of adjusting fire.
b. a preliminary scan of proposed regulations to check for logical consistency.
c. a review of the relevant enabling act to assess conformance with the Constitution.
d. regular monitoring of bureaucratic agency performance for the purpose of accountability.
e. asking the Attorney General for an advisory opinion regarding a proposed regulation.
17. What is meant by “administrative law”?

a. Ethical standards for agency employees including all managers and administrators
b. Laws that relate specifically to the authority of an administrative agency, are created by
that agency, and carry the enforceability of law
c. Laws in which Congress dictates how an agency head will conduct his or her business
d. Laws created by the president that all federal agencies must follow but state agencies may
disregard in certain cases
e. Court opinions that carry the weight of law based on Supreme Court rulings that have
stood over time
ANS: B REF: 207 NOT: conceptual
18. What is meant by “delegated congressional power”?

a. Congress delegates limited powers of lawmaking to the president.
b. Congress chooses how it wishes to enforce particular laws and states decide whether to
support these decisions.
c. Congress surrenders its lawmaking powers to the state legislatures.
d. Though Congress has the constitutional power to make laws, it gives an agency the
effective power to make laws related to the agency’s particular sphere of influence.
e. The Supreme Court takes the authority to make laws from Congress and delegates it
instead to the agencies.
ANS: D REF: 207 NOT: conceptual
19. The federal bureaucracy that is charged with regulating air and water quality standards is the
a. National Park Service.
b. Department of the Interior.
c. Environmental Protection Agency.
d. Sierra Club.
e. Occupational Health and Safety Administration.
20. Though Congress may delegate power to the bureaucratic agencies, Congress does not normally give
open-ended power, and it does not relinquish all power. The process of retaining ultimate authority
is called
a. auditing.
b. congressional prerogative.
c. congressional oversight.
d. partial delegation.
e. retention.
21. A common and effective method for Congress to enforce its oversight of a federal agency with which
it is dissatisfied is to
a. abolish the agency.
b. transfer the agency to the executive branch.
c. hold extensive Congressional hearings.
d. reduce or eliminate the agency’s budget.
e. prosecute the agency’s officials.
ANS: D REF: 207 NOT: applied
22. As a bureaucratic agency under direction of Congress, what is the purpose of the General Accounting
Office (GAO)?
a. It manages the U.S. Treasury.
b. It is an auditing agency that investigates the actions or inactions of other agencies.
c. It is an enforcement arm of Congress that prosecutes criminal activity among
agency employees.
d. It acts as a liaison between the president and Congress concerning the federal budget.
e. It is an agency that lobbies Congress for favorable funding or legislation for the
executive branch.
23. As an agency under direction of the Congress, the Congressional Budget Office (CBO) makes budget
recommendations to Congress. What is the other primary purpose of the CBO?
a. It recommends salaries for legislators.
b. It presents a completed budget to the president each year for his/her approval.
c. It conducts research, such as program effectiveness studies, at the direction of Congress.
d. It serves as the treasury for the Congress.
e. It functions as a bank within the capitol building.
ANS: C REF: 207 NOT: conceptual
24. Some federal agencies are given bureaucratic powers to adjudicate cases on behalf of the United States
government. Which of the following is NOT a federal agency with adjudication powers?
a. Equal Employment Opportunity Commission
b. National Labor Relations Board
c. Federal Communication Commission
d. Environmental Protection Agency
e. National Park Service
25. Though it is federal agency and not a court, the Equal Employment Opportunity Commission may take
what action against a company that violates an employee’s rights?
a. The EEOC has authority to adjudicate a case against a company and impose a punishment
and fine.
b. The EEOC has full judicial powers to imprison offenders.
c. The EEOC and other federal agencies have no powers to enforce administrative rules and
must rely solely on the federal courts.
d. State courts have authority over federal agencies that operate within their jurisdictions.
e. The EEOC has does not have original jurisdiction in a case but serves as an appellate level
review for lower federal courts.
ANS: A REF: 209 NOT: applied
26. The federal bureaucracy currently employs thousands of people. Comparatively, during the
administration of President George Washington the total number of agencies was __________ and the
total number of federal employees was ___________.
a. two; ten
b. three; about fifty
c. four; about one hundred and eighty
d. six; more than one thousand
e. twelve; more than fifteen thousand
27. What is meant by the term “administrative judge”?

a. It is a judge that does not preside in a courtroom but handles court-related paperwork.
b. It is a judge who serves as a magistrate.
c. It is a judge who works within a federal agency to hold hearings and make judgments on
cases related to that agency.
d. It is a lower court judge who determines guilt but not punishments.
e. It is another name for an appellate court judge, such as those on the Court of Appeals.
28. Bureaucratic adjudication

a. includes determining the rights and duties of particular parties within the scope of agency
rules or regulations.
b. takes place in the court system.
c. is a process whereby an agency expands its power into subject matter areas adjacent to its
primary area of concern.
29. The Department of Justice was established

a. to increase services and agencies in support of military operations.
b. to centralize the national economic and monetary system.
c. to aid in westward expansion of the nation.
d. to prosecute violators of federal Reconstruction statutes.
e. to manage federally owned lands.
30. The Bureau of Labor was created

a. to help regulate interstate and foreign trade arising from large-scale industrialization and
economic development.
b. as a response to workers’ concerns that arose with the growth of the industrial economy.
c. to respond to severe economic crises.
d. to provide jobs for large numbers of the unemployed.
e. to deal with the nation’s fiscal woes.
31. The Commerce Agency was created

a. to help regulate interstate and foreign trade arising from large-scale industrialization and
economic development.
b. as a response to workers’ concerns that arose with the growth of the industrial economy.
c. to respond to severe economic crises.
d. to provide jobs for large numbers of the unemployed.
e. to deal with the nation’s fiscal woes.
32. President Franklin Roosevelt’s New Deal programs were created to counter the negative effects of the
Great Depression. Which of the following was NOT one of the federal agencies that Roosevelt was
instrumental in creating during his 13-year tenure?
a. Social Security Administration
b. Securities and Exchange Commission
c. Department of the Treasury
d. Civilian Conservation Corp
e. Brownlow Committee
ANS: C REF: 209 | 210 NOT: factual
33. By the 1930s the federal bureaucracy had grown significantly. In response, President Roosevelt in
1936 created the Brownlow Commission. What was the purpose of this commission?
a. To identify funding sources in order to expand the federal government’s reach
b. To investigate ways in which the president could circumvent the powers of Congress
c. To reduce the number of federal agencies
d. To investigate how to make the growing bureaucracy more efficient and more responsive
to the president
e. To expand U.S. military powers throughout Europe and Asia
34. President Johnson’s Great Society programs in the 1960s built upon President Roosevelt’s New Deal
programs of the 1930s as they responded to the growing prosperity in the American economy. Which
of the following was NOT a goal of Johnson’s policies?
a. To promote social justice
b. To create a safety net for the poor
c. To guarantee health care for the elderly
d. To greatly expand educational opportunities for all Americans
e. To force the state governments to assume the responsibility for social assistance
ANS: E REF: 210 NOT: conceptual
35. While expanded federal programs are often popular for Americans, this much larger bureaucracy
suffers during a downturn in economic growth, such as was experienced in the 1970s. Why does an
economic downturn create such challenges?
a. There are fewer citizens for the bureaucracy to serve.
b. Economic downturns often create federal budget deficits that make it very difficult to
continue supporting a large bureaucracy.
c. State governments begin to take away the federal government’s role in providing
social benefits.
d. Downturns in the economy always create international tensions that require a stronger
military presence, which in turn drains off available resources.
e. As the U.S. Constitution requires a balanced budget, the federal government must
eliminate agencies when income decreases.
ANS: B REF: 211 NOT: applied
36. Beginning in the 1980s, the federal government has used a variety of methods to reduce the size and
tax burden of the federal bureaucracy. One such method is privatization. Which of the following does
NOT describe an intended purpose of privatization?
a. To increase the number of employees supported by the federal government
b. To replace government-provided services with services provided by the private sector
c. To keep costs for services lower than those provided by government agencies
d. To allow for less government red tape and fewer civil service restrictions
e. To allow private companies to have more flexibility to compete and adapt to
changing circumstances
ANS: A REF: 211 NOT: conceptual
37. Eliminating government oversight and laws concerning certain activities, resulting in less government
intervention, is referred to as
a. bureaucracy.
b. downsizing.
c. outsourcing.
d. deregulation.
e. privatization.
38. An ongoing debate in American government is the question of which level of government should have
the authority to provide programs and services to citizens. Beginning in the 1980s many of the services
provided by the federal government were relinquished to the state governments. This process is
known as
a. deregulation.
b. devolution.
c. privatization.
d. reinvention.
e. revolution.
39. The federal bureaucracy is made up of a variety of agencies. The 15 major administrative
organizations within the bureaucracy that report directly to the president are called
a. mini-bureaucracies.
b. state governments.
c. judicial branches.
d. cabinet departments.
e. administrative units.
40. Only Congress has the power to create a federal cabinet-level department. The most recent federal
cabinet to be created was the
a. State Department.
b. Department of Education.
c. Department of Homeland Security.
d. Department of Justice.
e. Attorney General’s Office.
41. At the head of each cabinet department is a secretary. How does a secretary obtain his/her position?
a. Nominated by and answers directly to the Senate
b. Nominated by and is subordinate to the judicial branch
c. Nominated by Congress and ratified by three-fourths of the state governments
d. Appointed by the president but must be confirmed by the Senate
e. Appointed by the president at his/her discretion without oversight
42. The sub-agency of the U.S. Department of Labor that develops standards to promote safe workplace
environments and implements regulations to enforce these standards with employers is the
a. Office of Labor-Management Standards (OLMS).
b. Occupational Safety and Health Administration (OSHA).
c. Bureau of Labor Statistics (BLS).
d. Environmental Protection Agency (EPA).
e. Immigration and Naturalization Service (INS).
43. The sub-agency of the U.S. Department of Labor that sets policies for conduct of negotiations between
employers and employees is the
a. Office of Labor-Management Standards (OLMS).
b. Occupational Safety and Health Administration (OSHA).
c. AFL-CIO.
d. Magistrate’s Court.
e. State Department.
44. The federal Cabinet-level agency that has the primary charge of protecting the nation from terrorism
and responding to emergency situations is the
a. State Department.
b. Central Intelligence Agency.
c. Department of Homeland Security.
d. Department of Justice.
e. Department of Defense.
ANS: C REF: 213 | 215 | 216 NOT: factual
45. The State Department

a. protects the federal judiciary, apprehends fugitives, and detains people in federal custody.
b. represents the United States abroad, conveying U. S. foreign policy to foreign
governments and international organizations.
c. is responsible for paying all the bills of the federal government.
d. handles federal relations with Native American tribes.
e. manages patent and trademark protection programs.
46. The Department of Justice

47. The Treasury Department

48. The Department of Interior

49. The Department of Commerce

50. Which of the following is NOT a cabinet department of the executive branch?
a. Department of Defense
b. Department of Education
c. Department of Justice
d. State Department
e. Judicial Branch
ANS: E REF: 214 | 215 NOT: factual
51. The Federal Emergency Management Agency (FEMA) is a primary unit of which agency?
a. Department of Homeland Security
b. Department of Defense
c. Department of Commerce
d. Congressional Budget Office
e. Federal Bureau of Investigation
52. Which of the following is NOT a primary unit of the U.S. Department of Homeland Security?
a. Emergency Preparedness and Response
b. Science and Technology
c. The Secret Service
d. The United States Military
e. Border and Transportation Security
53. Some federal agencies do not have high cabinet-level status but they do report directly to the president.
Such agencies, which include NASA and the Small Business Administration, are referred to as
a. cabinet departments.
b. independent agencies.
c. administrative units.
d. congressional subdivisions.
e. inner circle agencies.
54. Federal agencies that are responsible for implementing rules and regulations with respect to individual
or corporate conduct related to some aspect of the economy are called
a. independent agencies.
b. congressional agencies.
c. executive branch sub-divisions.
d. regulatory agencies.
e. interstate agencies.
55. Which federal regulatory agency was created in 1914 with the authority to implement rules and
regulations that encourage competition in industry?
a. Federal Trade Commission (FTC)
b. Federal Communications Commission (FCC)
c. Securities and Exchange Commission (SEC)
d. Consumer Product Safety Commission (CPSC)
e. Occupational Safety and Health Administration (OSHA)
56. A government corporation

a. is based on the idea that a market exists of customers willing to pay for services provided.
b. relies on revenue primarily derived from payment for services provided.
c. often is kept in business by government intervention.
ANS: D REF: 219 | 220 NOT: factual
57. A government corporation

a. must register and file regular reports with the SEC.
b. is regulated by the Treasury Department.
c. forecasts weather and environmental conditions.
ANS: E REF: 219 | 220 NOT: factual
58. The Executive Office of the President is an agency of the federal bureaucracy that is managed by the
White House Chief of Staff. Which of the following positions or units is NOT included in this agency?
a. White House Press Secretary
b. Office of Management and Budget (OMB)
c. National Security Council (NSC)
d. U.S. Secretary of State
e. White House Counsel
59. The Hatch Act

a. prohibits the dismissal of an employee for political purposes.
b. was a response to the Spoils System.
c. administers the system of federal hiring.
d. was modified by the Shakman decision.
e. established a system for hiring some federal workers based on job qualifications.
60. The Civil Service Reform Act

a. prohibits the dismissal of an employee for political purposes.
b. was a response to the Spoils System.
c. administers the system of federal hiring.
d. was modified by the Shakman decision.
e. established a system for hiring some federal workers based on job qualifications.
ESSAY
1. The term “bureaucracy” normally creates negative images of bloated and ineffective government.
However, the bureaucracy is a necessary part of government and has sometimes been referred to as the
fourth branch of government. Describe some of the ways that the bureaucracy serves a useful and
important role.
ANS:
Answers may vary.
2. What is the role of the cabinet-level departments and why are they important to the president? How are
the heads of these Cabinet-level departments chosen?
ANS:
Answers may vary.
3. What is the purpose of a federal regulatory agency? Give three examples of regulatory agencies and
briefly describe the primary role of each agency.
ANS:
Answers may vary.
4. How does a merit system differ from a system of patronage in the selection of government employees
for the civil service?
ANS:
Answers may vary.
5. What impact did President Roosevelt’s New Deal policies have on the federal bureaucracy during the
Great Depression and into the 1940s? How did the policies of the Roosevelt administration compare to
those of the Reagan administration in the 1980s and the emergence of devolution?
ANS:
Answers may vary.
6. Discuss how the following events have affected the nature of the American bureaucracy: the Civil
War, Civil Service reform, the New Deal, World War II, and the 9/11 terrorist attacks. Give
specific examples.
ANS:
Answers may vary.
7. How do Congress, the president, and the judicial branch make bureaucracies accountable?
ANS:
Answers may vary.
8. Compare and contrast the following methods of getting control of the federal bureaucracy:
privatization, deregulation, and devolution. Evaluate the strengths and weaknesses of each method.
ANS:
Answers may vary.
9. Compare and contrast the activities of political appointees, career professionals, and civil service
employees. Explain how each group is hired and how each function.
ANS:
Answers may vary.
10. Fully explain the processes for developing regulations and bureaucratic adjudication.
ANS:
Answers may vary.
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make a mistake on this basis, he will have the recompense of
knowing that he has assisted in a very rare case, in which it was next
to impossible for him to be right. This condition is said to be found
more frequently when the brain lesion and paralysis are on the right
side.
Severe pain in the head, followed by gradually but rapidly deepening

coma and paralysis of one side, becoming more and more complete,
probably means a hemorrhage into or just outside of the great
ganglia and involving a large extent of one of the hemispheres.
If there have been moderate loss of power or complete paralysis

lasting some hours, with, afterward, sudden loss of consciousness
and general muscular relaxation, with sudden fall, soon followed by
rapid rise, of temperature, it is very probable that a hemorrhage has
broken through into the ventricles or beneath the membranes, and is
still going on.
Rapidly-deepening unconsciousness, with general muscular

relaxation and gradual manifestations of more paralysis on one side
than the other, may come from meningeal hemorrhage.
Very sudden and complete hemiplegia without prodromata, with

deep unconsciousness coming on rapidly or suddenly, but a little
after the paralysis, is likely to denote the occlusion of the middle (and
perhaps anterior cerebral) artery of the opposite side at a point
sufficiently low down to produce extensive anæmia of the motor
centres along the fissure of Rolando as well as the underlying great
ganglia.
Aphasia with hemiplegia, often without the slightest disturbance of

consciousness, is in a considerable proportion of cases connected
with a lesion of the third left frontal convolution, and in a somewhat
larger proportion with the frontal lobes in general and the island of
Reil. This lesion is in a great majority of cases occlusion of the
artery. Difficulty of speech, connected with difficulty of swallowing
and associated with a certain amount of amnesic aphasia, has been
found with lesions of the pons. As aphasia, however, may occur
without any fatal lesions at all, it is not certain in all these cases that
the obvious lesion of the pons is a direct cause of all the symptoms.
Word-blindness is associated, according to a case reported by

Skworzoff and a few others,49 with a lesion of the angular gyrus, pli
courbe (P2 of Ecker), and word-deafness with a lesion of the first
temporal (T1). These localizations agree with those experimentally
determined.
49 West, Brit. Med. Journ., June 20, 1885.
Conjugate deviation is of importance as a localizing symptom, chiefly

because it may be manifest when other signs of hemiplegia are
difficult to elicit. I do not find it mentioned in twenty-seven cases of
cerebellar hemorrhage not included in the table of Hillairet, but it is
not infrequent with lesions of the pons; and when the lesion is in the
lower third, it is in the opposite direction to that described as usual
with lesions of the hemispheres.
Hemianæsthesia involving the organs of special sense, unilateral

amblyopia, and color-blindness is supposed to be connected with a
lesion of the posterior third of the internal capsule, or the thalamus in
its immediate vicinity, sometimes also with a lesion of the pons.
Bilateral hemiopia—blindness of the corresponding sides of both
eyes—is apt to be connected with a lesion of the occipital lobe of the
opposite side. Rendu and Gombault remark that hemianæsthesia of
the limbs and face may be met with in certain lesions of the cerebral
peduncles, but in this case the higher special senses (sight, smell)
remain unaltered. Hemichorea points to the same localization as the
more complete hemianæsthesia.
Alternate hemiplegia is due to a lesion of the pons upon the side of

the facial paralysis, and opposed to the paralysis of the limbs and in
the posterior or lower half. Care should be taken not to confound this
with the accidental addition of a facial paralysis to a hemiplegia of
the other side.
Irregular ocular paralyses are very likely to be due to lesion of the
same region. In some of these forms an investigation of the electrical
condition with reference to the presence of the degeneration reaction
may be of great assistance.
With extensive lesions profound coma and relaxation without distinct

hemiplegia are likely to be due to injury of the pons. A thrombus of
the basilar artery may lead not only to rapid, but even to sudden,
death. A phthisical patient died suddenly while eating his supper, and
a thrombosis of the basilar artery, with softening of the pons, was
found. Of course the lesion must have been of older date.50 Bright51
thought that when symptoms pointing to disease of the intracranial
vessels were present the diagnosis was confirmed, and the location
of the lesion in the vertebral arteries rendered highly probable, by a
persistent occipital pain. In the upper part of one side of the pons the
hemiplegia is not alternate, but of the ordinary form.
50 Bull. de Société anatomique, 1875.
51 Guy's Hospital Reports, 1836.
Any extensive lesion of the medulla must cause death so rapidly as

almost to defy diagnosis, but such rarely occurs. The very rapid
termination of certain cases of hemorrhage into the pons and
cerebellum is due to the escape of blood into the fourth ventricle and
consequent compression of the medulla.
Lesions of the lower and inner part of the crus are indicated by
paralysis of the third nerve of the same, and hemiplegia of the
opposite side of the body.
Obstinate vomiting, severe occipital headache, and vertigo, with or

without a distinct paralysis, render a cerebellar hemorrhage
probable, though no one of these symptoms is necessarily present
or pathognomonic. Vomiting is very much more common with
cerebellar hemorrhage than with cerebral. Ocular symptoms, like
nystagmus and strabismus, accompany cerebellar lesions.
A difference in the temperature of the paralyzed and non-paralyzed
sides, when amounting to one and a half to two degrees and lasting
for a long time, is thought by Bastian to indicate a lesion of the optic
thalamus.
The severe and rapid sloughing of the nates sometimes seen in

rapidly-fatal cases is stated by Joffroy to be most frequently
connected with a lesion of the occipital lobes.52
52 Arch. gén., Jan., 1876.
It is plain, from what has been said about the symptoms of the
different kinds of lesion, that a distinction may be often very difficult,
and at times impossible; and in this connection all observers are
agreed, the apoplectiform shock, the hemiplegia, and the slighter
attacks being common to two or three lesions. The diagnosis can be
made, if at all, only by the consideration of more or less secondary
symptoms and the careful weighing of the various probabilities
against each other. Most of the statements of differences of
symptoms are only relatively true.
A glance at the nature of the pathological processes involved may

serve to systematize our observations.
Hemorrhage is a sudden accident, with a severity increasing as the

amount of effusion increases. It has been prepared for by arterial
disease, but this disease is one which may have no previous
symptoms. It is at first an irritative lesion.
Embolism is a sudden attack which may be as severe at first as even

a few minutes afterward. It is also prepared for by disease of other
organs, which may or may not have symptoms according to the
origin of the embolus. As embolism affects especially those regions
where the motor centres are spread out, while hemorrhage attacks
more frequently the conductors in their locality of concentration, the
paralyses arising from the former affection may be more narrowly
limited.
Thrombosis is a gradual affection, which may, however, manifest
itself suddenly, from the obstruction reaching a certain point and
suddenly cutting off the supply of blood. This also depends on
previous disease which has more or less definite symptoms.
The severity of the attack is not conclusive, though the completely

developed apoplectic attack is more frequent with hemorrhage.
Rapidly increasing severity, especially if there have been
prodromata, is in favor of hemorrhage. Convulsions, early rigidity,
and conjugate deviation of the eyes of the spastic form, especially if
afterward becoming paralytic, are strongly in favor of hemorrhage,
and the latter possibly conclusive. Hughlings-Jackson states that he
cannot call to mind a single case of hemiplegia from clot in a young
person in which there were not convulsions.
Sudden paralysis without cerebral prodromata, unconsciousness, or

pain can hardly be anything else than embolism; but, unfortunately
for diagnosis, the initial paralysis from the embolus may be slight,
and afterward added to by the secondary thrombus, so as to put on
the appearance of more gradual approach.
Aphasia, and especially aphasia associated with but little or no

paralysis, is very much more frequent with embolism than with
hemorrhage.
The temperature, if we could always have it recorded from the very

beginning, might be of value, as the initial depression is said to be
less with embolism than with hemorrhage, but Bourneville,53 who
lays down this rule, gives so many cases where no great depression
occurred with hemorrhage that it cannot be considered decisive.
Besides this, we are not likely to get the information at the time it is
of the most value.
53 Op. cit.
Etiological information may have a very practical bearing on this part

of the diagnosis. Age gives a slight amount of predominance to the
chances of hemorrhage, and youth a considerably greater one to the
chances of embolism. Interstitial nephritis with hypertrophy of the
heart, after the exclusion of uræmia, gives a strong probability in
favor of hemorrhage. Valvular disease of the heart, especially a more
or less recent endocarditis, is strongly in favor of embolism. A feeble
action of the heart, slow and irregular pulse, are more likely to be
connected with thrombosis.
Atheroma and calcification, as detected by examination of the visible

and tangible arteries like the radial and temporal, is a condition either
connected with the periarteritis aneurysmatica which gives rise to
hemorrhage, or one which furnishes a suitable spot for the
deposition of a thrombus; hence it can be considered conclusive in
neither direction.
Arcus senilis, even of the fatty variety, can only show some
probability of arterial degeneration.
Retinal hemorrhage, if present, favors the presence of a similar

cerebral lesion, but nothing can be argued from its absence.
Landesberg54 has reported a case in which embolism of the central
artery of the retina, easily diagnosticated by the ophthalmoscope,
preceded by a few days a similar accident in the middle cerebral;
and Gowers55 another in which the two arteries were occluded
simultaneously.
54 Archiv für Ophthalmologie, xv. p. 214.
55 Lancet, Dec. 4, 1875.
If a sudden paralysis arises in connection with a septic process, we

may diagnosticate an embolus with a good deal of confidence; but it
is not unusual to meet with small abscesses of septic origin which
have given rise to no special symptoms whatever, or only to such as
are covered up by the more general constitutional ones.
PROGNOSIS.—The prognosis quoad vitam of cases of apoplexy still in

the unconscious state is based upon the general severity of the
symptoms as indicated by general muscular relaxation, or, at a later
period, the extent of the paralysis, the amount of affection of the
heart and respiration, and especially the progress during the first few
hours. Too much weight should not be placed upon a very slight
improvement at first, since this often takes place in cases soon to
prove fatal.
Stertorous respiration with perfect tolerance of mucus in the throat,

absolute loss of the reflexes, and immobility of the pupils signifies
profound depression of the organic nervous centres, and is
consequently of unfavorable augury.
The temperature is a valuable guide. In proportion as it moves

steadily and rapidly upward is the prospect of an early fatal result. A
person may die during the initial fall of temperature, but in such a
case there would hardly be need of a prognosis.
In general, the prognosis from hemorrhage, supposing the

symptoms to increase in severity for an hour or two, is worse than
that from occlusion.
Age, aside from the fact that it makes hemorrhage more probable
than occlusion, is not of great importance in prognosis, certainly not
out of proportion to the general impairment of vigor in advanced
years.
A renewal of the hemorrhage within a few hours cannot be predicted.

It may be indicated by another fall of the temperature, which, if it
have been previously on the rise, renders, of course, the prognosis
more unfavorable.
After recovery, more or less complete, from the apoplectic condition

the prognosis is favorable, for a time at least, except so far as one
attack may be looked upon as the forerunner of another. After the
temperature has reached a sort of standstill in the neighborhood of
normal, its subsequent rise will furnish among the earliest indications
of an approaching fatal termination.
Urinary trouble, retention, incontinence, or, much more, cystitis, is to
be looked upon as a complication which materially increases the
gravity of the situation. Bed-sores or abrasions may be placed in the
same class, except that the early and extensive sloughing of the
nates described by Charcot is of almost absolutely fatal significance.
After some days or weeks the progress of the paralysis either toward
better or worse may be exceedingly slow, and as time goes on the
danger to be apprehended from the latter becomes less and less.
When paralysis takes place in young persons and the primary attack
is recovered from, it is doubtful if the chances of a long life are
materially diminished. A case has already been referred to in this
article where the consequences of a cerebral hemorrhage occurring
in infancy were found in a woman of eighty-three in the form of
atrophied limbs and an old pigmentary deposit in the brain.
Hemorrhage into the cerebellum would appear, from statistics, to be

exceedingly fatal, but it is certain from old lesions occasionally found
that it is not absolutely so, and its apparent severity is partly caused
by the fact that it is very seldom diagnosticated except at the
autopsy.
The prognosis quoad restitutionem ad integrum cannot be made to

advantage at an early period. After the immediate danger to life has
passed it is safe to say, if pressed for an answer, that it is highly
probable that some recovery from paralysis may take place, but that
it is highly improbable that it will be absolutely complete, and just
how far improvement may go it is impossible to predict with accuracy
at first. Time must be given, in the first place, for pressure to subside,
compressed nerve-fibres to be restored, and for such collateral
circulation as is possible to be established. How recovery takes
place beyond this it is not easy to say. It is hardly supposable that
any considerable portion of nerve-structure is renewed. A certain
amount of substitution, by which one part of the brain takes up the
functions of another part, is among the most plausible suppositions;
but how this is accomplished it is hardly worth while in the present
condition of cerebral physiology to speculate.
Practically, it may be said that physicians are apt to consider a
paralysis absolute at too early a period, while the patient and his
friends continue to hope for a complete restoration after it is evident
that no really useful increase of power is to be looked for. Weeks,
and even months, may elapse before any return of motion can be
perceived in cases which are really susceptible of considerable
improvement, and a year most certainly does not cover the limit of
the time during which it may go on.
The most unfavorable symptom, one which probably precludes all

hope of useful recovery in the limbs affected, is contracture,
heralded for a time by increase of the deep reflexes, indicating
degeneration of the motor tract in the white substance of the cord.
Until this begins, certainly for many weeks, the patient may be fairly
encouraged that some improvement is possible, though after a few
weeks the chances diminish as time goes on. In the rare cases
where the muscles undergo rapid wasting the prognosis is, if
possible, worse still. The localization of the lesion after the early
symptoms are passed does not greatly influence the prognosis.
A rapid recovery taking place in either hand or foot, and especially of

the hand first, without corresponding improvement in the other limb,
is of unfavorable import for the latter, and, in general, the prognosis
is not exactly the same for both limbs involved. In the rare cases of
hemiplegia from acute brain disease occurring in children the
nutritive disturbances in the form of arrest of growth should be taken
into the account in prognosis, since the result may be nearly or quite
the same as is found after infantile paralysis from disease of the
cord.
In regard to the slighter forms of paralysis, it may be said that the

less extensive the original paralysis is, and the sooner improvement
begins, the better is the chance of complete recovery.
TREATMENT, INCLUDING PROPHYLAXIS.—Cerebral Hemorrhage.—As the

condition upon which the usual form of cerebral hemorrhage
depends is so frequently aneurism, and probably nearly always
some arterial disease, the prophylaxis must evidently consist in such
a mode of life as will least tend to this degeneration, or at least put it
off as long as possible. This, of course, means the avoidance of all
the special causes described under the head of Etiology. It is a
disease of old age, but in a pathological sense old age begins in
different persons after a different number of years. Fortunately for
rules of hygiene, there is little that is contradictory in those to be
given for most chronic and degenerative diseases. Abstinence from
alcohol, as an agent tending at once to paralysis and dilatation of the
vessels, is one of the most important rules and insisted upon by
nearly all writers. The avoidance of over-eating, and especially of
nitrogenous food as tending to lithæmia—a generally recognized
cause of arterial degeneration—is perhaps the next. Over-eating is
of course to be understood as a relative term, and to be estimated
with reference to the habits of exercise of each person. Practically, it
will be decided by its effects; that is, if careful thought be given to the
matter and the statements of the gourmand as to his immunity from
all risk of trouble are not accepted as of scientific value. On the other
hand, insufficient food, producing anæmia, may be a factor in arterial
degeneration. Keeping one's self free from anxiety, and getting
through the world with as little experience of its roughnesses as
possible, might be, properly enough, added in a purely theoretical
point of view if any one ever asked a physician's advice in youth as
to avoidance of the diseases of age, or if any one could or would
profit by this advice if it were given.
Intellectual pursuits have been credited with a special tendency to

apoplexy, but there is no good reason to suppose that healthy
exercise of the mind is otherwise than beneficial to its organ. Hurry,
over-anxiety, and mental tension are undoubtedly potent factors in
general breakdown, but do not necessarily lead to this form. They
are certainly not to be found by preference in those persons who
lead an intellectual life.
Syphilis, one of the most important of the causes of organic cerebral

disease, and that too in the form of thrombosis, is not specially
concerned in the etiology of the forms here under consideration.
If symptoms have occurred that justify the apprehension of apoplexy
or paralysis, such as frequent headaches in an elderly person,
hemiopia, temporary aphasia, or slight and temporary paralyses, or if
one have reached a time of life at which the risk of cerebral
hemorrhage becomes considerable, a stricter attention to the rules
laid down above, and even to some to which but little heed would be
given in health, is not out of place. A certain amount of limitation of
diet, moderate and regular but not violent exercise, clothing suitable
to the season, and especially warm enough in winter, and, most of
all, rest if the patient be doing wearing and anxious work, should be
enjoined. Finally, it should be said that the real prophylaxis of
cerebral hemorrhage is to be begun in early life.
Among the exciting causes to be avoided are those which obstruct

the flow of blood from the head, like tight clothing around the neck.
Increase of the arterial pressure by severe or prolonged muscular
effort, as in lifting or straining at stool, is to be avoided, as well as
violent fits of passion. The condition of the bowels should be
regulated by mild laxatives.
When the apoplectic attack has actually occurred, treatment, though

apparently urgently demanded, is really of little avail. If a patient is
about to die in an hour or two from rapidly increasing pressure,
nothing within the reach of medical science can stop him.
There is one danger, however, easily avoided, but probably often

overlooked. A patient may die from suffocation. The stertor is often a
result of the paralysis of the tongue and palate and of the amount of
fluids collecting in the pharynx from the almost invariable position of
the patient on his back; that is, if he have been seen by some one
who wished to do something for him, but did not know what.
Insensibility and paralysis combine to favor this accumulation, which
obstructs the respiration, and which may find its way to the lungs,
together with brandy and milk, and set up an inhalation-pneumonia.
The simple and obvious thing to do is to place the patient sufficiently
on his side, with the face somewhat downward, for the tongue and
palate and secretions to fall forward, instead of backward into the
pharynx. Swabbing out the pharynx may be of some use, but cannot
be so thorough. An easy position and proper ventilation should be
secured in all cases of unconsciousness, even at the risk of treating
a drunkard with undue consideration. Police-stations should be
provided with rooms where these conditions can be secured, and the
necessity avoided of placing persons picked up in the streets in the
narrow, close, and perhaps distant cells provided for malefactors.
The writer recalls the cases of two young men—one who had been
drinking some time before, and the second roaring drunk—who were
locked up in a suburban station-house in the evening, and found the
next morning—one dying and the other dead.
Artificial respiration may be used to prolong life in some cases until

the nervous centres have sufficiently recovered their functions to
carry on the process without assistance. The condition of the bladder
should be ascertained, and the urine drawn if necessary, though it is
more frequently passed involuntarily.
Although it is manifestly impossible to remove the clot from the

interior of the brain, it may appear that the further flow of blood may
be stopped and the amount of damage done limited. For this
purpose two remedies are proposed—namely, bleeding and
purgatives. Both of these act to diminish arterial pressure, which is
forcing the blood out of the rupture. Though the treatment seems
reasonable, it would not be difficult to imagine a condition where
sudden and premature diminution of pressure in the brain, which of
course exists outside of the arteries as well as inside, would tend to
set going again the flow which has ceased from the very force of the
pressure it itself exerts, very much as if a tampon were prematurely
removed from a bleeding cavity elsewhere. As the conditions are
somewhat complicated, and at the same time only remotely to be
estimated, it is safer to be guided by experience in the use of these
remedies than by abstract reasoning. In some of the cases of
temporary aphasia, as notably that of Rostan narrated by Trousseau,
bleeding seems to have given immediate relief. Trousseau, however,
is no advocate of that method of treatment. Most modern authors
speak of venesection as to be used in cases where the pulse is
strong and full and the face red, but not to be thought of in the
opposite class. When a case presents the appearances of plethora
and an attack has come on suddenly, the loss of a few ounces of
blood can certainly do no harm. Other forms of bleeding, such as
cups and leeches, are not rapid enough to be of great value, though
a large number of leeches about the head might be useful. Some
French writers recommend leeches to the anus as revulsives.
Cathartics may be more freely used, although they should be given
cautiously when there is any tendency to cardiac depression. It can
be clearly shown that a brisk purgative lowers the arterial tension
decidedly. In case of cerebral tumor or injury with occasional so-
called congestive attacks, the relief afforded by cathartics is very
great, and, although the conditions are not exactly parallel, it is fair to
assume a similar action in the congestion accompanying cerebral
hemorrhage. From one to three drops of croton oil may be placed far
back on the tongue or it may be diluted with a neutral oil. Ail enema
may be desirable for the unloading of the bowels, but has a much
less marked effect on the tension of the cerebral circulation.
In most cases of apoplectiform cerebral hemorrhage, and probably in

all of simple paralysis, no very active treatment is called for.
Measures directed to the prevention of another hemorrhage, and to
allay any irritation that may supervene during the changes taking
place about the clot and the formation of its capsule, are of the
simplest, and consist in keeping the head high and cool, the clothing
sufficient for warmth, and offering no obstruction to respiration or
circulation, laxatives sufficient to keep the bowels in good order, and
a diet not highly nitrogenous, but sufficient and digestible.
That which will tax most severely, however, the care and patience of
attendants is the scrupulous and minute attention to cleanliness and
pressure over the bony prominences which is necessary when a
patient is helpless and unable to control the discharges from the
rectum and bladder. Frequent change of clothing, bathing, change of
position, and avoidance of wrinkles and roughnesses in the bed may
be successful in keeping the patient free from bed-sores. Bathing
with alcohol hardens the skin and makes it less susceptible to
pressure.
Surgical interference may perhaps be of value in cases where the

portion of the clot outside the brain can be clearly demonstrated; and
this would apply with special force where the hemorrhage arises
from injury.
Trephining and removal of the clot has been done in a few cases of
meningeal hemorrhage, though with indifferent success (3 cases—2
deaths, 1 unknown.)56 An intracerebral clot is obviously a step
beyond, though possibly in some cases not absolutely without, the
reach of the surgeon.
56 Med. Press and Circular, Oct. 14, 1885.
Treatment of Cerebral Embolism.—The prophylaxis is in the

avoidance of such conditions as give rise to the formation of
detachable vegetations or clots. Unfortunately, these are numerous,
not completely known, and not always avoidable. Arterial disease is
to be looked upon as of some importance, but cardiac valvular
lesions of much greater, and the causes of these, like rheumatism,
scarlet fever, and the puerperal condition, are not always to be
escaped. The presence of a detachable piece of fibrin in the
pulmonary veins, heart, or aorta being granted, nobody can possibly
say what will prevent its being loosened and lodging in one of the
cerebral arteries; so that, practically, the prophylaxis of embolism
consists in the judicious treatment of acute rheumatism and the other
conditions just mentioned. The treatment of the first attack must
consist solely in the relief of respiration, bladder, and bowels, if they
have not taken care of themselves. Stimulants may be of use for a
short time, but there cannot be any call for even the slight amount of
depletion suggested for some cases of hemorrhage. Bed-sores are
to be looked out for, just as in hemorrhage, and the subsequent
treatment conducted on the same principles. As regards the primary
lesion, we can do nothing about it either in the way of removal of the
embolus or restoration of the necrosed brain-tissue.
Treatment of Cerebral Thrombosis.—There being two factors in this
affection, both of which are to a certain extent under control,
something may be done toward diminishing the risk of its
occurrence. Arterial disease and its prophylaxis have already been
spoken of. The other condition which is necessary to the production
of thrombosis—namely, an enfeebled circulation—is to some extent
under the control of general hygienic rules: a nutritious, not too
highly nitrogenous, diet, and especially sufficient exercise and the
avoidance of completely sedentary habits. If there is a crasis which
predisposes to the formation of coagula in the vessels, it is not
known that there is any special treatment, medical or otherwise,
which can prevent it. The attack is to be treated exactly on the
principles already laid down. Bleeding is about the last thing to be
thought of. Stimulants, though they cannot dislodge the clot, may be
of use for a time to sustain the heart under the shock. The secretions
and the condition of the skin are to be looked out for.
After a few weeks of waiting the patient and his friends not
unnaturally feel as if something ought to be done to hasten recovery,
and certain measures may be taken, in addition to careful hygiene,
which have this object in view. It is very doubtful, however, whether
anything really shortens the time necessary for such repair as is
possible or diminishes the amount of damage which is to be
permanent. As has already been said, improvement may go on
slowly for months. In the first place, it is sometimes considered
desirable to practise shampooing and massage of the affected
muscles in order to keep them in as good a condition of nutrition as
possible. This, as well as the regular use of the faradic battery if it be
not begun too early, will prevent a certain moderate amount of
atrophy, but could not have any influence in those rare cases where
rapid wasting depends upon secondary degeneration of the anterior
gray columns. It may be doubted, however, whether it is necessary
to pay much attention to the condition of the muscles, as they do not
ordinarily atrophy to the extent of becoming unsusceptible to the
nervous stimulus from the brain so soon as it shall be transmitted to
them. Faradism, like many other agencies, such as magnets, metals,
pieces of wood, and so forth, is said to produce a transfer of
sensibility in cases of hemianæsthesia.
There is no sufficient reason to suppose that any drug is of any value

in the restoration of the nervous structure. Iodide of potassium may
possibly prove to have some effect as a sorbefacient. Very favorable
results have been claimed for ammonia salts in the restoration of
aged persons to a nearly complete use of paralyzed limbs.
Phosphorus has been spoken of as assisting in repair, but the writer
is not aware upon how wide a basis of facts. Silver and gold have
been said to counteract the sclerosing myelitis. Strychnia is certainly
useless, and probably worse. It may make the paralyzed limbs
twitch, but this does just as little good as the involuntary spasmodic
movements, which have never been considered desirable, except as
awakening in the patient false notions of immediate recovery, and
which are frequently a very annoying symptom. The galvanic current
has been applied with a view to a sorbefacient or restorative action
directly to the brain, or rather to the pericranium.
Something can be done for the comfort of such patients: the rubbing
and kneading of the paralyzed limbs, if they do not hasten the
recovery of motion, relieve many of the painful and unpleasant
feelings. Since we do not know how far one part of the brain may
supplement another, attempts at motion after it has once appeared
to ever so slight a degree should not be abandoned by the patient.
He should walk with crutches frequently as soon as he can, though
not to the point of fatigue.
There is one faculty which seems capable of re-education to some

extent: that is of speech in cases of ataxic aphasia, and even in
others the attempt should be made to teach the patient the names of
things. A very interesting case has been reported by Bristowe57 of a
man who came under his observation after an attack which may
have been anterior poliomyelitis with extensive paralysis, able to
write well and intelligently, but unable to say anything. By gradual
education, first in the sound and formation of letters and afterward of
words, he reacquired the use of language. It is obvious that in this
case there could have been no loss of memory for the words
themselves, but simply the loss of the knowledge of how to produce
them. When his speech returned he spoke with his original American
accent.
57 Clin. Soc. Trans., iii. p. 92.
In short, the therapeutics of hemiplegia from arterial disease in the

brain is good nursing and attention to symptoms, with a moderate
amount of care of the paralyzed muscles.
Capillary Embolism.
It may be remarked, in the first place, that the lesions known by this
name are not necessarily strictly capillary, but are situated in the very
small arteries. The microscope marks the transition from the larger to
these smaller embolisms.
More is known about very small embolisms experimentally than

clinically, since they have been produced by the injection of small
seeds and insoluble particles of various kinds. Embolisms arising
from natural causes and deposited in the minutest arteries may have
very similar origin to the larger ones already described, but there are
also other conditions which give rise to particles which pass through
larger arteries without any disturbance, and are arrested in smaller
ones. The softening of thrombi is undoubtedly one source. The same
thrombus which, if detached en masse, would block the carotid
artery, may, if broken up into a number of minute fragments of fibrin
and fat, pass into the ultimate distribution of the cerebrals. The same
thing may of course happen if the thrombus have already undergone
one transportation.
Cases of localized softening are seen where no cause has been

found, except perhaps a thrombus in the heart, which has
discharged its softened and puriform contents; and it is probable that
the connecting links exist in the form of embolisms so minute as to
escape ordinary observation.
The consequences of capillary emboli if they block every minute

ramification of an arterial branch must be essentially the same as if
the branch itself were stopped; but if only a part are thus affected,
the resulting anæmia is not so complete, since the zones of capillary
congestion surrounding the part the supply of which is cut off may be
sufficient entirely to cover it and make more or less complete
compensation. The experimental emboli, in the form of tobacco-seed
and other insoluble substances, which have been traced into the
brain in considerable numbers, often give rise to no distinct lesions in
the cases where the immediate effects are recovered from.
Among the other sources, ulcerative endocarditis may be mentioned

as of special importance, not from the size but the character of
detached emboli, which will give rise, not to simple anæmia, nor, on
the other hand, to merely negative results, but to septic changes at
the place of lodgment.
Aside from these conditions, which are almost the same on a small
scale as we find with the large emboli, we have several peculiar
substances formed in the body and floating in the blood which lodge
in the capillaries of the brain. These are pigment, fat, lime salts, and
white corpuscles. Every one of these, however, is much better
known anatomically than clinically.
Pigment scales, flakes, granules, or cells containing them, are

formed in the course of severe malarial fever, and deposits
consisting of this pigment are found in the spleen, liver, kidneys,
heart, lungs, and lymphatic glands, as well as the brain and spinal
cord. The brain, when a deposit of pigment has taken place, is of a
slaty-grayish or chocolate color, which is marked only in the cortical
substance, the white being unaffected. The pigment is found in the
capillaries, and, according to Frerichs, fibrinous coagula are often
associated. Punctiform hemorrhages in the brain have been seen, as
well as meningeal hemorrhages, in connection with this
degeneration.
The point at which these masses are formed is still a matter of
theory. If the liver, as has been supposed, is one of the places of
formation, or if they originate in the blood, it is of course easy to see
how they reach the brain. If in the spleen, they must pass through
the wide portal capillaries before they are arrested in the narrower
ones of the brain.
It is by no means certain, however, that pigment reaches the brain in

the form of emboli. It is quite as probable that it is found in many
organs which undergo repeated congestions from the local
destruction of blood-corpuscles and changes in their pigment. The
very general deposition seems to point to a process of this kind
rather than to a local origin and a distribution through the blood. The
punctiform extravasations which may be found with deposits of
pigment are also found without it.
Minute particles of fat have been found in cerebral capillaries, but

are much less common here than in the lungs. They may be derived
from the decomposition of a thrombus, as described above, or they
may come from a fractured bone, when, of course, only particles fine
enough to pass through the pulmonary capillaries can reach the
brain. This form of embolism has an interest in connection with
diabetic coma.
Collections of white corpuscles in considerable number have been

observed to form an embolus. These cannot be considered to differ
very widely in character from the ordinary fibrinous embolus, which
contains white corpuscles. It is, however, not certain that such
emboli are deposited during life.
Calcareous masses formed from the decomposition of bone have

been seen in cerebral arteries.
About the symptomatology of such emboli little is known. An array of

minute emboli from the breaking up of a thrombus in the left auricle,
carotid, or even aorta, might possibly so block up large numbers of
arterial twigs as to give rise to the ordinary symptoms of embolism;
but considering the possibility of the re-establishment of circulation,
provided a certain proportion of the minutest vessels escape,
complete anæmia of a large tract produced in this way must be rare.
It is possible that some of the slighter and more transitory attacks of
hemiplegia or of more or less vague cerebral symptoms may be
referred to a lesion of this kind, the first action of a large number of
emboli being to cause an anæmia, which is compensated for much
more rapidly and thoroughly than would be the case if a single
considerable vessel were obliterated.
Various attempts have been made to connect definite and peculiar

diseases with capillary embolisms. Chorea in particular has been
said to depend upon a lesion of this kind, but, although cases have
been observed where the symptoms and lesion coexisted, yet they
are very far from being the rule, or even from constituting a
respectable minority of cases. The lesion of chorea in the great
majority of cases is not known, although attention has been directed
to this theory long enough to have established its truth.
The same may be said of the relationship between pernicious

attacks of intermittent and pigment embolism. There is occasional
coexistence, but far from invariable. Cerebral symptoms of the same
kind and severity occur without as with the pigment deposit. If
pigment embolism is the cause of coma, delirium, etc. in pernicious
fever, it is difficult to see why such cases can recover so rapidly, and
why no symptoms referable to a localized cerebral lesion are
observed after the primary unconsciousness.
Even less proof can be adduced as to any connection between

leukæmic embolisms and the cerebral symptoms occurring toward
the end of severe acute disease.
Calcareous embolism is a pathological curiosity.
DIAGNOSIS.—In the case of multiple capillary embolism it would be

impossible, if it were complete, to distinguish it from a blocking of the
main branch.

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Severe pain in the head, followed by gradually but rapidly deepening

If there have been moderate loss of power or complete paralysis

Rapidly-deepening unconsciousness, with general muscular

Very sudden and complete hemiplegia without prodromata, with

Aphasia with hemiplegia, often without the slightest disturbance of

Word-blindness is associated, according to a case reported by

Conjugate deviation is of importance as a localizing symptom, chiefly

Hemianæsthesia involving the organs of special sense, unilateral

Alternate hemiplegia is due to a lesion of the pons upon the side of

With extensive lesions profound coma and relaxation without distinct

51 Guy's Hospital Reports, 1836.

Any extensive lesion of the medulla must cause death so rapidly as

Obstinate vomiting, severe occipital headache, and vertigo, with or

The severe and rapid sloughing of the nates sometimes seen in

A glance at the nature of the pathological processes involved may

Hemorrhage is a sudden accident, with a severity increasing as the

Embolism is a sudden attack which may be as severe at first as even

The severity of the attack is not conclusive, though the completely

Sudden paralysis without cerebral prodromata, unconsciousness, or

Aphasia, and especially aphasia associated with but little or no

The temperature, if we could always have it recorded from the very

Etiological information may have a very practical bearing on this part

Atheroma and calcification, as detected by examination of the visible

Retinal hemorrhage, if present, favors the presence of a similar

55 Lancet, Dec. 4, 1875.

If a sudden paralysis arises in connection with a septic process, we

PROGNOSIS.—The prognosis quoad vitam of cases of apoplexy still in

Stertorous respiration with perfect tolerance of mucus in the throat,

The temperature is a valuable guide. In proportion as it moves

In general, the prognosis from hemorrhage, supposing the

A renewal of the hemorrhage within a few hours cannot be predicted.

After recovery, more or less complete, from the apoplectic condition

Hemorrhage into the cerebellum would appear, from statistics, to be

The prognosis quoad restitutionem ad integrum cannot be made to

The most unfavorable symptom, one which probably precludes all

A rapid recovery taking place in either hand or foot, and especially of

In regard to the slighter forms of paralysis, it may be said that the

TREATMENT, INCLUDING PROPHYLAXIS.—Cerebral Hemorrhage.—As the

Intellectual pursuits have been credited with a special tendency to

Syphilis, one of the most important of the causes of organic cerebral