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Cerebral symptoms arising in the course of ulcerative endocarditis
might be referred, with a high degree of probability, to an embolus,
but if they were distinct enough to be referred to a localized lesion,
the probability of a single embolus would be much greater than that
of a multitude of capillary ones occluding the same vascular territory.
The diagnosis of pigment embolism might be a probable, or at any
rate a possible, one if in a long-continued case of paludal fever,
where the liver and spleen were enlarged and the skin had the slaty
hue marking the deposit of pigment, there were decisive cerebral
symptoms. It could not, however, be a positive one.

Fatty embolism might be suspected in a case of diabetic coma,

though even if the condition were found it would not establish the
relation of causation.

PROGNOSIS AND TREATMENT can hardly have a definite basis in the

absence of all ground for a satisfactory diagnosis, but do not differ
essentially from those of the larger occlusions.

Thrombosis of the Cerebral Veins and Sinuses.

It has for centuries been known that coagulation of the blood might
take place in the sinuses in a way different from the ordinary post-
mortem clots, but this was looked upon rather as an anatomical
curiosity than as a fact of practical importance and clinical
significance, and it is chiefly among observers of the present century
that we find a growing knowledge of the conditions under which it
occurs and the symptoms to which it gives rise.

Thrombi in the cerebral sinuses are not essentially different from

those formed elsewhere, and the reader is referred to the account
given in the article on General Pathology for a history of their
formation, growth, appearances, and transformations. For our
purposes it is sufficient to recall that they may be white, red, or
striated, either partly or wholly obstructing, and that they may
become degenerated and partly or wholly washed away. The most
important distinction of all, however, is that into two classes, of which
the first consists of those which are simply depositions of fibrin in a
comparatively healthy vessel, and the second of those which are
dependent on a phlebitis.

In order that a thrombus may form it is necessary that there should

be, in the first place, a special condition of the walls of the veins—not
necessarily, however, inflammation, though this is one of the most
frequent and probably the most active form; second, a slackening of
the blood-current; and, third, perhaps a peculiar state of the blood,
though this latter is not certain. A thrombus tends strongly to grow,
and when already formed furnishes a most favorable point for the
deposition of more fibrin.

The cerebral veins furnish a very suitable place for the coagulation of
the blood for several reasons: they are roomy in proportion to the
amount of blood they carry; they are tortuous and abundantly
anastomosing, so that the current of blood is almost reversed at
some points, and can easily stagnate; the veins of the diploë are
held open by their bony walls, and the sinuses by their stiff
membranous ones, so that they cannot collapse and thus limit the
extension of a thrombus once formed.

The sinuses most frequently affected, though none are free from the
liability, are the cavernous, superior longitudinal, and lateral.

The results of thrombosis of the sinuses and veins are not equivalent
to those of a similar process in the arteries, and they may be said in
a general way to be more diffused, as might be expected from the
much greater freedom of anastomosis. Limited softening is rarely a
consequence of occlusion even of a considerable number of veins,
but it has been observed. A large area of softening of one
hemisphere, not involving the temporal and occipital lobes, has been
seen with thrombosis of the parietal veins58 (the internal capsule and
ganglia were not affected).
58 Gaz. des Hôp., 1880, 1066.
Passive congestion in the brain, as elsewhere, although apparently
entirely incompatible with the normal function, seems to be able to
sustain a low form of structural integrity.

Bleeding may take place from the congested veins behind the
obstruction, constituting a distinct form of cerebral hemorrhage which
does not depend upon an arteritis, although if miliary aneurisms
were present the occurrence of thrombosis would undoubtedly tend
to their rupture. The writer, however, is not aware of such a
coincidence having been actually observed. Hemorrhages are
usually diffuse, composed of or accompanied by a number of small
effusions, and situated on or near the surface of the brain or
distinctly meningeal. Punctiform hemorrhages are exceedingly
common.

Phlebitis of the cerebral veins is very likely to run into meningitis, and
the two affections are often so closely united that it is difficult to say
which was the first. Œdema is a consequence of venous obstruction
in the brain as well as elsewhere, and is seen also around some of
the peripheral veins connected with the sinuses.

ETIOLOGY.—Venous thrombosis in the brain depends chiefly on three

sets of causes, though it must be admitted that there are a few cases
where the origin cannot be distinctly traced and where no previous
disease has existed. In the marantic form, occurring chiefly in the
very old and in children, as well as in cases of wasting and
depressing diseases in adults, a simple thrombosis without
inflammation takes place. Two conditions, and sometimes three, are
combined here to produce the result—feebleness of the blood-
current from a corresponding state of the heart, diseased
endothelium of the vessels from defective nutrition, and possibly,
where profuse watery discharges have been going on for some time,
an increased tendency to coagulation from the inspissation of the
blood.

Rilliet and Barthez and Von Dusch59 give the following tables of ages
at which this form of thrombosis has been observed. The
observations of the former were made in a children's hospital, and
hence do not affect the question of its frequency in later life. Perhaps
the rules of admission may account for the absence of cases under
one year of age, of which Von Dusch collected several:

Rilliet
Von Dusch.
and Barthez.
Under 1 year ... 5
2 years 2 1
4 years 4 1
5 years 1 1
6 years 1
7 years 1
9 years 2
10 years 1
11 years 1
12 years ... 1
14 years ... 1
Adults (20, 23, unknown) ... 3
53 years ... 1
Aged women ... 2

59 Sydenham Society's translation.

The special diseases in which thrombosis is most likely to be met

with are given by Bouchut as follows. The same remark is to be
made about these as about those of Rilliet and Barthez. The table is
given as convulsions from thrombosis of sinuses:60

Chronic enteritis 5
Measles and catarrhal pneumonia 2
Chronic pneumonia 5
Phthisis 8
Anasarca without albuminuria 1
Chronic albuminuria 2
Whooping cough and pneumonia 7
 Scrofula, tubercle of bones, etc. 1
Gangrene of mouth 1
Diphtheritis 2

Von Dusch gives a number of cases of the same kind, as do many

subsequent writers, but without tabulation. Virchow61 reports a case
of congenital variola with thrombosis of the sinuses of the dura
mater, the superior and inferior cava, and vessels of the cord.
60 Gazette des Hôpitaux, 1879.

61 Arch., 1859, 367.

It is probable that simple anæmia may, here as elsewhere, either

alone or with other debilitating influences, lead to thrombosis. Von
Dusch remarks that quickly operating and debilitating influences lead
to thrombosis, and gives as an instance a case where a puerperal
peritonitis, for the cure (?) of which repeated copious abstractions of
blood were made during nine days, was supposed to be the cause.
The puerperal condition seems to have a tendency in this direction in
a way not always to be explained by the ordinary rules of the
transmission of emboli or of phlebitis. Although in those reported by
Ducrest62 phlebitis of the pelvic veins existed or was suspected, in
the first of these five cases the lesion may have been, so far as the
description goes, arterial instead of venous thrombosis; and in the
second it is possible that the succession of events was uterine
phlebitis (with the addition of a large sacral slough), lobular
pneumonia surrounded and traversed by veins which were affected
with phlebitis, emboli in the arteries of the cortex, and consequent
venous thrombosis. In the third, fourth, and fifth the connection
between the uterine phlebitis and the inflammation of the cerebral
veins (in two cases meningitis) cannot easily be made out, except by
the rather vague assumption of a general tendency to phlebitis,
which was shown in one by a similar condition in the vein of the arm
where the patient was bled. Empyema has been followed by
hemiplegia, cerebral softening, and thrombosis of the lateral sinus.
The venous thrombosis in such a case may be secondary.
 62 Archives générales, 1847, p. 1.

Marantic thromboses are more likely to occur upon one side, and
that the side upon which the patient habitually lies.

The second class of cases embraces those where a simple

obstruction, partial or complete, of the current of the blood gives the
starting-point for a thrombus in the veins. Such an obstruction may
be formed by an embolus, but in the veins this cannot be considered
an important factor, although a portion of a thrombus may be
detached and become lodged in a narrower vessel or branch farther
along. In this way the propagation of thrombosis for a short distance
toward the heart may be accounted for.

A tumor or inflammatory exudation may press upon a vein or intrude

into it, but most cases of obstruction-thrombosis are traumatic in
origin. Thromboses arising in connection with tubercular meningitis
may be looked upon as having both an obstructive and marantic
cause. In many wounds of the vertex, gunshot and other, the walls of
the superior longitudinal sinus are pressed upon by pieces of bone,
and sometimes spiculæ have directly penetrated it. This class of
injuries is also likely to cause phlebitis without any actual penetration
or compression of the sinus, simply as a result of the inflammation of
tissues in the neighborhood. The thrombi formed in these cases are
not necessarily completely occluding. Where direct injury to the sinus
or in its immediate neighborhood gives rise to phlebitis and
consequent thrombosis, we have a condition closely resembling that
of the third class, where disease of an inflammatory character in the
tissues of the skull, neck, or face sets up a phlebitis and thrombosis
which are transmitted to the intracranial veins and sinuses.

The most frequent source of this third form of inflammatory

thrombosis is the chronic inflammation of the middle ear with the
mastoid cells. The inflammation may be propagated through a
carious or necrosed portion of the temporal bone to the petrosal and
lateral sinuses, or may, without disease of the bone, be carried by
the small veins which open into the sinuses from the petrous and
mastoid portion of the temporal in this region. Abscesses in the neck
may set up a phlebitis extending up the jugular to the lateral sinuses,
to which a meningitis may possibly be added.

Carbuncles about the root of the nose, face, and so far down as the
upper lip are very prone to give rise to thrombosis propagated
through the ophthalmic vein to the cavernous sinus; and it is
probably this risk which gives to carbuncles in this situation their
well-known peculiar gravity. The divide or watershed between the
regions which drain backward through the cranium and those which
are connected with the facial vein below is apparently situated about
the level of the mouth, so that a carbuncle of the lower lip is much
less dangerous. Billroth, however, gives a case where a carbuncle in
this situation was followed rapidly by cerebral symptoms and death,
and where a thrombo-phlebitis was not improbable. He mentions
another case where a carbuncle upon the side of the head set up an
inflammation which travelled along a vein into the cellular tissue of
the orbit, and thence through the optic foramen and superior orbital
fissure into the skull.

Erysipelas of the scalp apparently causes phlebitis in some cases,

and even eczema in the same situation seems to have done so.
When the erysipelas is situated about the upper part of the face, the
path of transmission is through the ophthalmic vein; but when upon
the vertex, it may be propagated through the small veins that
penetrate the bone. This result is certainly a rare one in facial
erysipelas of the ordinary and superficial kind, which is a notoriously
benign disease for one of such apparent severity. It may, however,
be more frequent than ordinarily supposed, since cerebral symptoms
occasionally appear at a date too late to be accounted for by the
fever and too slight to be referred to extensive interference with the
cerebral circulation; the lesion to account for which, as they do not
cause death, can be only inferred, though it is not unreasonable to
suppose it to be a limited thrombosis.

Dowse63 describes the case of a robust man who fell on the back of
his head, but walked home. After a few days he had a severe
headache, chill, and total loss of vision. His temperature rose; he
had erysipelas and partial coma, but no convulsions. There was
thickening of the scalp, but no fracture of the skull and no adhesions
of the membranes. The superior longitudinal lateral sinuses were
free from thrombi, though there was a roughness about the latter, as
if there had been a fibrinous deposit. The cavernous sinuses were
almost completely occluded with adherent fibroid masses, and there
was hemorrhage in the anterior lobe. There was some degeneration
of the brain-structure, but no disease of the arteries.
63 Trans. Clin. Soc., 1876.

Ulcerations in the nasal passages and ozæna have proved starting-

points for thrombosis.64
64 Med. Times and Gaz., 1878, i. 614.

Thrombosis of the jugular veins and corresponding cavernous sinus,

with paralytic symptoms, has been observed in the horse.

The symptoms produced by venous thrombosis, as might be

supposed from their varying location and extent, and also from the
fact of their being almost invariably connected with other diseases
having marked and severe symptoms of their own, are not always
easy to pick out from among many others, but they are sometimes
very well marked and characteristic. A distinction must obviously be
made between the symptoms of simple thrombosis depending on
interruption of the cerebral circulation and those of phlebitis, which
give rise in addition to febrile phenomena common to phlebitis in any
of the large veins.

The symptoms which indicate venous obstruction, without reference

to its inflammatory or non-inflammatory character, are of two kinds:
first, those dependent upon the disturbance of the functions of the
brain; and, secondly, those which depend upon congestion and
compression of other structures.

According to the locality and completeness of the obstruction we

meet with brain symptoms.
In the marantic thrombosis of children these may be very vague, and
consist either in restlessness, followed by somnolence and coma, or,
most especially, in convulsions. The convulsions may be partial and
involve the face only; they may affect one side only, or, what is more
usually the case, be general. There is almost always strabismus.
There may be conjugate deviation. This latter phenomenon is said
by Bouchut to be of no value in children, as it may take place in
either direction, from or toward the lesion, but possibly the distinction
between the spastic and paralytic forms was not duly observed by
him. The condition of the fontanelles is spoken of as yielding and
depressed, with the edges of the bones overlapping. They may,
however, become again tense in the course of the disease from
exudation or hemorrhage taking place. Paralysis is not so marked as
in adults, but may be present.

In adults delirium takes the place of convulsions, due to a

disturbance of circulation over a considerable area, rather than to a
total suppression in a more limited one. Paralyses are not
infrequently met with, either in the form of a hemiplegia or more
localized. Hemorrhage will naturally be followed by its usual
consequences, according to its location. Headache, often very
severe, is among the early symptoms.

It is evident that none of these symptoms can be considered highly

characteristic. They can only furnish a certain amount of probability
in cases where the general course of the disease has made it likely
that thrombosis may take place.

There is another set, however, which, when present, offer the

strongest kind of confirmation: these are due to the pressure from
the veins themselves.

Œdema about the points at which the intracranial circulation is

connected with that of the face and neck may give rise to protrusion
of the eyeball, conjunctival ecchymoses, swelling of the upper lip,
and even of the upper part of the face, which sometimes becomes
slightly cyanosed from the congestion. Epistaxis has been noted.
Œdema may be noticed about the mastoid process when the
thrombosis is situated in the lateral sinuses, but it would be important
in many cases to distinguish this from inflammatory œdema directly
due to disease of the bone.

Œdema of the optic disc, as shown by obscuration of its outlines,

with large and pale vessels, has been observed by Bouchut.

Veins closely connected with those within the cranium may be

thrombosed, and felt as hard cords by the finger. This may occur in
the facial veins about the orbit, in those around the mastoid, or in the
jugulars. On the other hand, if one cavernous sinus is filled with a
coagulum which does not go down into the jugular, this vein will
naturally be empty or receive only a small amount of blood from
other veins.

When the cavernous sinuses are affected, we are likely to have a set
of phenomena due to the pressure of the clot upon the nerves which
pass through it—i.e. the third and fourth, part of the fifth and sixth—
with filaments of the sympathetic accompanying the carotid artery.
Hence dilatation of the pupil, strabismus, or ptosis, and other ocular
paralyses may be the symptoms observed.

It is possible that a headache upon the side of the affected sinus

may be due to vascular dilatation from paralysis of the sympathetic,
or to a direct pressure upon the first branch of the fifth pair.

DIAGNOSIS.—The diagnosis of venous thrombosis may be almost

entirely a conjectural one in those cases where the cerebral
symptoms are vague or mixed with others peculiar to the causative
disease. Where wasting disease has existed, the patient is much
emaciated, and profuse discharges have diminished the fluidity of
the blood, the rapid supervention of coma with slight spasms or
general convulsions will render it highly probably that thrombosis is
taking place. Unilateral symptoms would greatly increase this
probability, and if any accessible veins about the head, neck, or face
could be definitely distinguished as filled with firm coagula, the
diagnosis would approach certainty.
In cases of this kind the only condition likely to put on the
appearance of thrombosis is the simple inanition or so-called hydro-
encephaloid disease, which comes on in exactly the same sort of
cases. Localized phenomena must be the chief point of difference.
Fortunately, the distinction is practically not an important one.

In wounds of the vertex affecting the longitudinal sinus the question

likely to arise where cerebral symptoms supervene is that of
thrombosis or abscess. Here the more definite localization is likely to
be upon the side of the abscess, although, as is well known, this
may remain latent or nearly so for a considerable time, and in
general is much more chronic in its course than thrombosis.

The swelling of the external veins, epistaxis, œdema of the lid,

protrusion of the eyeball, with œdema of the optic papilla, with only
moderate fever, would favor the diagnosis of thrombosis, while optic
neuritis, if present, with chills, would render the abscess more
probable. Unless the wound were sufficiently severe to fracture a
piece of bone into the sinus, or unless the subsequent inflammation
were of an unhealthy character, the abscess in a person of middle
age and previous good health may be considered the more probable
of the two. In the case of Dowse, already mentioned, the diagnosis
between abscess and thrombus must have been very difficult, and,
as it seems to the writer, would have been more likely to rest upon
abscess or meningitis than upon the condition afterward found to
exist.

Where inflammatory diseases exist which are known to lead to

thrombosis with phlebitis, the practitioner, if on the lookout, can often
make a diagnosis with a high degree of probability in its favor. The
cerebral symptoms with the venous swelling, collateral inflammatory
œdema in the more immediate neighborhood of the lesion, and slight
œdema and congestion at more distant points, and a febrile
movement indicating a distinct inflammatory exacerbation, will point
very strongly to thrombo-phlebitis.

An absolute distinction between such a condition of the veins and a

meningitis arising under exactly the same circumstances may not
always be possible, and is the less important since the two affections
are likely to coexist and form a part of the same disease.

The localization of the thrombus is to be determined partly by the

paralytic symptoms, if such exist, but principally by the situation of
the secondary œdema and from the lesion which forms the starting-
point. It has been said that the jugular vein of the side on which
thrombosis exists is less full; and this point might be of value when
the lateral sinus is affected.

PROGNOSIS.—From the character of the lesion itself, as well as from

the diseases with which thrombosis is usually connected, it will
readily be seen that the prognosis is in general a highly unfavorable
one; but it is possibly regarded as too inevitably so, for the reason
that a positive diagnosis may be in slighter cases a matter of
considerable uncertainty, so that the practitioner, even if attempting
to make an accurate anatomical explanation of obscure cerebral
symptoms, is as likely to think that he has been mistaken as that his
patient has recovered from so serious a disease.

Cases, however, have been reported where the diagnosis seems as

clear as it can be made without an autopsy, and recovery has taken
place.

A case is reported by Voorman65 of a child aged six months who had

diarrhœa and vomiting, much prostration, sunken fontanelles,
overlapping cranial bones, trembling of the tongue, slight spasm of
the right arm and leg, head drawn back, and strabismus. The head
afterward increased in size, the temporal vein was swollen and hard,
with œdema of the skin in its neighborhood. There was gradual
improvement and recovery, though when the patient was four and a
half years old its mental development corresponded to that of a child
two years younger.
65 Centralb. f. d. Med. Wis., 1883.

In another, by Kolb,66 a child of seventeen, well nourished, had a

purulent discharge from the right ear. Besides headache, delirium,
hyperæsthesia, convulsions, and then sleepiness and loss of
consciousness, the following symptoms pointed toward thrombosis
of the sinuses: Chills, inflammatory swelling over the right mastoid,
with fulness of a cutaneous vein passing over it; a purely
œdematous swelling in the neighborhood of the internal jugular or
temporal fossa, forehead, and both upper eyelids, with
exophthalmos on the right side; photophobia, blepharospasm, and
cloudy vision; nose-bleed. There was no elevation of temperature,
and recovery took place.
66 Berl. klin. Woch., Nov. 13, 1876.

A case of thrombo-phlebitis following otitis and terminating in

recovery is reported at length by Wreden.67
67 Archives of Ophth. and Otol., 1874, lii. (translation).

The PROGNOSIS in any particular case can be based only on the

severity of the symptoms and on the character of the preceding
disease.

TREATMENT.—The prophylaxis of this affection evidently consists in

the proper treatment of the diseases upon which it depends, and
might therefore be made to embrace nearly the whole range of tonic,
roborant, antiphlogistic, and antiseptic measures, to say nothing of
surgery and obstetrics. The proper nourishment of infants and
children, the cutting short, when possible, of their acute diseases, or
preventing their debilitating effects, will reduce marantic thrombosis
to a minimum. At a later period of life the proper surgical
management of carbuncle, abscess in the neck, and of the puerperal
condition will tend to avoid this risk.

The most important point of all, however, is undoubtedly the careful

treatment of otitis media and early attention to inflammation in the
mastoid cells, with incision or trephining as may be necessary.

After a thrombus has formed there is little to be done toward its

removal.
It has been claimed68 that the preparations of ammonia are capable
of diminishing considerably the coagulability of the blood when it is
morbidly augmented. Though this cannot be considered proved, yet
since the tendency of these salts is also to quicken the blood-
current, a trial in a case where other indications are wanting is, to
say the least, justifiable.
68 Lidell, Am. Journ. Med. Sci., July, 1874, p. 101.

In a case reported by O'Hara,69 where the symptoms pointed very

strongly toward thrombosis of the cavernous sinuses, recovery took
place under mercurials, iodide of potassium, and purgatives. The
reporter was inclined to consider the cause of trouble specific.
69 N. Y. Med. Record, vol. xvii. p. 617.

Considering the fact that cases with such marked and decisive
symptoms as those last recorded have recovered, it is certainly the
duty of the physician to prolong the life of his patient to the utmost,
that absorption and condensation may go on as long as possible and
collateral circulation be developed. Probably most physicians can
recall cases of obscure cerebral disease going on to recovery
contrary to all expectation, in which thrombosis furnishes an
explanation quite as plausible as any other.

Softening of the Brain

is a name which it is yet too early to omit altogether from a

systematic work, although in treating of it we have more to do with
nomenclature and classification than with pathological anatomy. The
phrase may be said to have both an anatomical and a clinical
signification, which do not coincide at all points. Clinically and among
the laity it is used to express various symptoms and groups of
symptoms more or less referable to the brain, some of them
connected with one and some with another lesion, and many purely
functional—if the word may be used—or at any rate unconnected
with any known or definite lesion.

Vertigo, dull headache, sleeplessness, or, on the other hand,

drowsiness, failure of memory, failure of power of concentration, of
steady application, mental depression, fatigue, and even slight
aphasia or actual slight hemiplegia, may any of them be considered
symptoms or forerunners of softening of the brain. As nearly as
anything, the popular notion of this affection corresponds to general
paralysis of the insane or senile dementia, or even mere exhaustion.
Many of these symptoms may, of course, be connected with the real
softening described as the result of embolism or thrombosis, but it is
hardly necessary to say that a symptomatology based on these
elements alone is either too vague or else too much like that of
diseases already described to be considered useful as a separate
clinical grouping.

On the anatomical side softening of the brain has had a definite

meaning, and for many years a part of its pathology has been well
known. A general softening of the whole brain, such as seems to be
the condition supposed when the phrase is used, does not and
cannot exist, since a vascular lesion sufficient to cause anæmic
necrosis of the whole brain must cause death long before softening
would have time to take place. Nearly all the works and reports on
softening have been based upon cases such as are now referred to
definite lesions of the blood-vessels; and a good idea of the change
in nomenclature and pathological views may be obtained by noticing
the dates given in the extensive literature of the subject in the Index
Catalogue of the Surgeon-General's library, which are nearly all
previous to 1860 or 1865.

Localized softening has already been described under the heads of

hemorrhage, embolism, and thrombosis, venous and arterial.
Whether it may occur from diseases of the cerebral vessels without
actual occlusion is not certain, but, remembering the difficulty of
detecting thrombi in minute vessels, and also the fact that it is not a
great many years that occlusions have been systematically sought
for at autopsies, it is better for the present to assume, in cases
where softening is found in the usual form and the usual situations
for the results of thrombosis and embolism, that one of these
accidents is the cause, even if the actual point of occlusion is not
found.

Softening may take place secondarily from tumors in the brain, and
the name is also sometimes applied to a local encephalitis, which is
an early stage of abscess. When, however, these various forms of
disease are removed from the general heading of softening and
referred to their proper pathological classes, there is a residuum in
which the softening seems to be the primary affection, so far as the
brain is concerned, though depending on other constitutional
conditions.

In new-born infants softening of the brain, besides the rare cases in

which it may be dependent on the same conditions which may cause
it in the adult, is observed in two forms, as described by Parrot:70 A.
White softening in multiple foci, dependent upon fatty degeneration,
of which it constitutes the last stage, is found almost exclusively in
the centres of the hemispheres. B. Red softening, which affects the
same region, but more extensively, and is accompanied by
hemorrhage into the lymphatic sheaths with rupture.
70 Arch. de Phys., 1873, p. 302.

These two forms may exist with each other, and with other
intracranial lesions, such as thrombi of the sinuses and exudation
under the arachnoid and around the veins.

Parrot compares this form of softening to that occurring in the other

extreme of life, dependent on vascular lesions; but although he
supposes the method of production to be unlike in the two cases, it is
by no means so certain, either from his conclusions or his cases,
that it is always so. In some of his cases the vessels are said not to
be abnormal, but in others old thrombi are distinctly mentioned. As
secondary consequences may be observed intracranial dropsy, with
perhaps hydrocephalic cranium and degeneration of the pons, bulb,
and medulla.

Two cases of red softening of the cerebellum have been reported.71

In one of them the pia was adherent, in the other thickened and
covered with exudation. The microscopic details are not given nor
the state of vessels mentioned. They are probably not strictly
analogous to those described by Parrot.
71 Jahrbuch. f. Kinderheilkunde, 1877.

The occurrence of granular corpuscles in the brain of the new-born is

described by Virchow, and it is thought by him to be pathological and
of an irritative character (encephalitis congenita). It is somewhat
doubtful if this process is characterized by any distinct symptoms.

The ETIOLOGY is impaired nutrition, deficient or improper feeding, and

depressing diseases, frequently tubercle.

The SYMPTOMS and DIGNOSIS of this form of softening are even more
obscure than those of venous thrombosis in the same class of
cases. Vague cerebral symptoms arising in an infant poorly
nourished and suffering from acute disease may be due to this
condition, but a positive diagnosis is out of the question. In the two
cases of softening of the cerebellum just mentioned, in one, aged
five, there was dilatation of the pupil, difficulty of hearing, and
vertigo; in the other, aged six, vertigo, inclination to vomit, and clonic
spasm of the left facial muscles. Parrot says that in the greater
number of patients the encephalopathic troubles observed during life
cannot be referred to it (softening), and in no case can it be
diagnosticated.

Under these circumstances it is obvious that remarks upon the

PROGNOSIS and TREATMENT must be purely works of the imagination.

Atheroma of the Cerebral Arteries

has already been spoken of as one of the most important factors in
thrombosis, and perhaps of considerable consequence in embolism
and hemorrhage. Its symptoms, when one of these accidents has
taken place, are hardly to be separately considered; and if atheroma
have produced complete occlusion, even without the assistance of a
clot, the symptoms could not be distinguished from those of an
ordinary thrombosis, and would follow the same course.

In some cases, however, the thickening of the artery may interfere

with, without completely interrupting, the circulation in the part to
which it is distributed, and the degree of the interference may vary
from time to time. If, then, in a person whose age and general
physical condition, as shown by the state of the tangible arteries,
arcus senilis, complexion, and so forth, render the existence of
atheromatous arteries in the brain probable, cerebral symptoms of
an ill-defined character arise, it is very probable that they are the
result of irregularities in the circulation dependent on atheroma.

This state of things is to be distinguished from the more clearly

marked conditions which have already been described, partly by the
incompleteness of the attack, and partly by its changes in severity
and character from time to time—a paralysis undergoing alternations
of improvement and the reverse from day to day, delirium appearing
and disappearing in correspondence with the general health, the
vigor of the heart, and the state of the digestive organs.

The diagnosis between these incomplete anæmias and an almost

precisely similar result of syphilitic endarteritis is to be made chiefly
by the history and age. In middle-aged persons general paralysis
might present a not very different set of phenomena. A tolerably
distinct, but not severe, hemiplegia in an old person, subsiding in a
few hours under the influence of a cathartic, and perhaps returning
more than once, may often be due to a local and temporary anæmia
from atheroma, as well as to slight hemorrhage or a not completely
occluding thrombus.

On the other hand, extensive atheroma may exist without serious

impairment of the cerebral functions, provided it be evenly distributed
and do not interfere with the passage of blood in any one vessel.

The prophylaxis of atheroma has already been considered. We do

not know of any drug that can change the nature or extent of the
processes going on in the arterial walls, but if any influence can be
exerted it is through dietetic and hygienic means.

The consequences of rigidity of the arterial walls, as productive of

resistance to the passage of blood, can be warded off to some
extent by promoting the vigor of the heart. Treatment should
therefore be directed to the improvement of the nutrition of the body
in general and the heart in particular. Heart tonics and laxatives are
the classes of medicaments most likely to be useful. Perhaps it is to
its effect in increasing the force of the heart contractions, like
digitalis, that coffee owes its reputation as a preservative from
apoplexy.

ATROPHY AND HYPERTROPHY OF THE BRAIN.

 BY H. D. SCHMIDT, M.D.

ATROPHY OF THE BRAIN.

INTRODUCTION AND DEFINITION.—Atrophy of the brain may originate

during intra-uterine life or by defective development during the early
periods of childhood, or it may occur during adult life, when the
organ is fully developed. The atrophy is characterized by a
diminution of the normal bulk of the brain-substance, in consequence
of which the latter does not entirely fill the cavity of the cranium, but
leaves a greater or less space to be occupied by a serous fluid.
Generally, the atrophy affects, in a symmetrical or asymmetrical
manner, larger or smaller portions of the brain; an atrophy
symmetrically affecting all parts of the brain has never been
observed, even in microcephalia. Nevertheless, when the atrophy
affects both hemispheres of the cerebrum, it is generally called total,
whilst it is designated partial when it is limited to only one
hemisphere or to other individual parts of the brain, such as the
cerebellum, the large cerebral ganglia, etc.

For the sake of convenience we shall treat the atrophy of the brain
occurring during childhood, when the organ is still developing,
separately from that of the fully-developed brain of the adult.

1. Atrophy of the Brain during Childhood.

When congenital or originating during infancy the atrophy is either

primarily due to certain pathological processes taking place in the
substance of the brain, or secondary, being due to lesions of the
skull, such as premature ossification of the sutures. Total atrophy of