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Copyright © 2018 Verlag Vahlen GmbH, München. All rights reserved.
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Library of Congress Cataloging-in-Publication Data
Names: Lewrick, Michael, author. | Link, Patrick, 1968- author. | Leifer,
Larry J., author.
Title: The design thinking playbook : mindful digital transformation of teams, products,
services,
businesses and ecosystems / by Michael Lewrick, Patrick Link, Larry Leifer.
Description: Hoboken : Wiley, [2018] | Includes bibliographical references and index. |
Identifiers: LCCN 2018011184 (print) | ISBN 9781119467472 (pbk.)
Subjects: LCSH: Creative ability in technology. | Creative ability in business. | Creative
thinking. |
Industrial management–Technological innovations. | Technological innovations.
Classification: LCC T49.5 .L49 2018 (print) | DDC 658.4/094–dc23
LC record available at https://lccn.loc.gov/2018011184
ISBN 978-1-119-46747-2 (pbk)
ISBN 978-1-119-46748-9 (ebk)
ISBN 978-1-119-46749-6 (ebk)
ISBN 978-1-119-46750-2 (ebk)
Design and layout: Nadia Langensand
Cover design and visualization: Nadia Langensand
CONTENT
The Tetris blocks will guide you through The Design Thinking
Playbook. We start with a better understanding of the individual
phases of the design thinking cycle. In the thematic block of
“Transform,” we discuss the best ways to shape framework
conditions and how strategic foresight helps us to create greater
visions. The last part, “Design the Future,” focuses on the design
criteria in digitization, the design of ecosystems and the
convergence of systems thinking and design thinking, and the
options of how to combine data analytics and design thinking.

Foreword
Introduction
1. Understand Design Thinking
1.1 What needs are addressed in the Playbook?
1.2 Why is process awareness key?
1.3 How to get a good problem statement
1.4 How to discover user needs
1.5 How to build empathy with the user
1.6 How to find the right focus
1.7 How to generate ideas
1.8 How to structure and select ideas
1.9 How to create a good prototype
1.10 How to test efficiently
2. Transform Organizations
2.1 How to design a creative space and environment
2.2 What are the benefits of interdisciplinary teams?
2.3 How to visualize ideas and stories
2.4 How to design a good story
2.5 How to trigger change as a facilitator
2.6 How to prepare the organization for a new mindset
2.7 Why strategic foresight becomes a key capability
3. Design The Future
3.1 Why systems thinking helps to understand complexity
3.2 How to apply lean business model thinking
3.3 Why business ecosystem design becomes the ultimate
lever
3.4 How to bring it home
3.5 Why some design criteria will change in the digital
paradigm
3.6 How to kick-start digital transformation
3.7 How artificial intelligence creates a personalized
customer experience
3.8 How to combine design thinking and data analytics to
spur agility
Closing words
Authors
Sources
Index
EULA
Keep up the design thinking mindset and start hunting for
the next big opportunity!

Foreword
Prof. Larry Leifer

- Professor of Mechanical Engineering Design, Stanford University

- Founding Director, Stanford Center for Design Research
- Founding Director, Hasso Plattner Design Thinking Research
Program at Stanford
I am quite delighted with this collection of factors of success in
design thinking. My special thanks go to Michael Lewrick and
Patrick Link. I also want to thank Nadia Langensand, who is
responsible for the artistic implementation. As an interdisciplinary
team, we were able to put together a fantastic book.
I want to express my gratitude as well to all the experts who shared
their knowledge with us and contributed to reflections on the
subject matter. The book that emerged is not only one on design
thinking but also an exciting essay with deep insights into the
application of design thinking beyond the digital context. This
Playbook is entertaining and motivates readers to do it, not just
think about it.
The book stimulates and helps readers
to put well-known and new tools in the right context of the
application;
to reflect on the entire scope of design thinking;
to direct the necessary mindfulness to the personas of Peter,
Lilly, and Marc;
to accept the challenges of digitization in which new design
criteria in the human–machine relationship, for instance, are
increasingly gaining in importance; and
to set an inspiring framework in order to enshrine design
 thinking even more strongly in our companies and generate
radical innovations.
I’m delighted in particular that this book contains contributions
from experts from actual practice as well as from the academic
world. A few years ago, the idea took shape that a stronger
networking of the design thinking actors should be achieved. This
Playbook and the communication in the Design Thinking Playbook
(DTP) community today act as a stimulus for an open exchange of
ideas and materially contribute to enshrining design thinking and
new mindsets in companies.
Design thinking is currently experiencing a surge of interest because
it is a pivotal tool for initiating digital transformation. We have seen
how banks use it to shape the “era of de-banking” and how start-ups
have created new markets with business ecosystem design.
At the ME310, which has become somewhat of a legend by now, I
frequently have the honor of welcoming corporate partners from
different industries from all over the world, who work out exciting
design challenges with our local and international student teams.
Have fun reading!

Larry Leifer
Introduction

Where will the next major market

opportunities emerge?

The hunt for the next big market opportunity is ever present. Most
of us are ambitious company founders and good employees,
managers, product designers, lecturers, or even professors. We all
had cool business ideas at one time, such as the vision to build a
revolutionary social network 3.0 that would outshine Facebook, to
establish a health care system that suggests the best possible
treatment option to patients and gives us health data sovereignty,
and many more ideas.
It’s people like us who develop new ideas with great energy and
tireless commitment, our heads filled with visions. To succeed, we
usually need a (customer) need; an interdisciplinary team; the right
mindset; and the necessary leeway for experimentation, creativity,
and the courage to question what exists.
Across all sectors, it has become increasingly important to identify
future market opportunities and enable the people inside
organizations to work with agility and live creatively. Today’s
planning and management paradigms are frequently not sufficient
to respond appropriately to changes in the environment. Moreover,
many companies have banned creativity in favor of operational
excellence and management-by-objectives.
The old management paradigms must therefore be dissolved. But
they will dissolve only when we allow new forms of collaboration,
apply different mindsets, and create more room to develop and find
solutions.
What are the three things that are important to us?

1) Keep your personality!

“No one needs to mutate into Karl Lagerfeld just because we have
creativity and room for development at our disposal!”
Because we are people with different personalities, it is vital we
remain who we are today and continue to trust our experience and
intentions in order to implement what we have gotten off the
ground so far. And if there is one thing we have learned from Tetris,
it is the fact we too often try to fit in somewhere—with the
unfortunate consequence that we then disappear!

2) Love it, change it, or leave it!

“Use the concepts and tips that you like

and adapt them to your needs.”
We decide on our own which mindset fits our organization, and
whether we like the expert tips in this book or find them absurd and
want to change them or adapt them to our situation. It would be a
shame if all organizations were a clone of Google, Spotify, or Uber.
Each company has its own identity and values. Even in Tetris, we
have the possibility of turning things around at the last second so
we’re successful in the end.

3) Don’t do it alone!

“Get the necessary skills, technologies, and attitudes on your teams

to be successful and think in business ecosystems.”
We cannot develop products today with the mindset, design criteria,
and needs from the past. Both users’ needs and the way we work
together have changed, and we must have the necessary freedom
and the skills to develop products and services, business models,
and business ecosystems with agility in a digitized world. If we do
not transform our organization, failed growth initiatives will pile up.
 What should you expect?

The Design Thinking Playbook will help you in the design of your
transition to a new management paradigm. We all know such
transitions from our customers’ needs. Let’s take as an example the
transition from analog telephony to the smartphone all the way to a
mindphone. While in the 1980s we only occasionally needed to take
work calls at home, today we need to be reachable everywhere and
anytime. In the future, we might want to control simple
communications directly through our thoughts in order to eliminate
the inefficient manual-entry smartphone interface. Successful
companies have also created business ecosystems in which they
closely integrate customers, suppliers, developers, and hardware
manufacturers.
In this Playbook, we make the world of design thinking palpable—
and we want to see you a little happier at the end! Because design
thinking also creates happiness. And when you as readers are
happy, we have been successful!

What was the biggest challenge?

“Do you actually know the needs of your readers

for whom you’re writing the book?”
(Source: Direct quote from the first meeting of the editors and contributors of the
Playbook)

Although we could very well picture ourselves as potential readers

of such a playbook, we complied with the wish expressed in the
question. In the design thinking style, we first determined the
customer needs, created various personas, and developed much
empathy for the work of our colleagues in order to establish a solid
basis. Thus The Design Thinking Playbook is the first design
thinking book that lives the mindset from the first to last page!
Because there is already a lot of design thinking literature on the
market, we felt the need to show how design thinking is used
optimally. We also want to help you professionalize your design
thinking skills. And because the world does not stand still, we
reflected on the digital paradigm and combined design thinking
with other mindsets with the aim of becoming better and more
innovative in a digitized world.
Enough of our introduction. Let’s focus on what’s essential—the
specific and practical application of design thinking and expert tips.
We tried to formulate the tips as comprehensible activities and ways
of working. The “How might we . . .” instructions provided are
supposed to be no more than indications for how we can proceed.
Design thinking is not a structured process! We adapt the mindset
and the approach to the particular situation.
1. UNDERSTAND DESIGN THINKING
1.1 What needs are addressed in the
Playbook?
As described in the Introduction, we wanted to write a book for all
those interested in innovation, for movers and shakers as well as
entrepreneurs who design digital and physical products, services,
business models, and business ecosystems as part of their work.
Regarding our three personas, we were able to identify three very
different kinds of users who apply design thinking in their day-to-
day activities. One thing the three have in common, though: All
three of them want to create something new in a rapidly changing
world.
Which brings us straight to our initial question:

How can we learn more about a potential user and

better uncover his or her hidden needs?

In the individual chapters, we focus on the three personas of

“Peter,” “Lilly,” and “Marc.” We hope this lets us address the needs
of design thinking practitioners as best as possible.
“Who is Peter?”
Peter, 40 years old, works at a large Swiss information and
communications technology (ICT) company. Peter came in
contact with design thinking in the context of a company project
four years ago. Peter was a product manager then. Searching for
the next major market opportunity, he had already tried out
quite a few things. For a while, Peter always wore red underwear
on New Year’s Day, but it didn’t make him any luckier in terms
of successful innovations. After this experience, he doubted at
first whether design thinking was really something for him. It
was hard for him to imagine that something useful could come
out at the end of the described procedure. The approach seemed
just a little esoteric to him.
His attitude changed after he attended a number of co-creation
and design thinking workshops with customers. He felt the
momentum that can come into being when people with different
backgrounds tackle complex problems together in the right
environment. Paired with a good facilitator who provides work
instructions in a targeted manner, any group can be empowered
to create a new experience for a potential user. This positive
experience prompted Peter to take on the role in such design
thinking workshops as a facilitator.
Owing to the workshop experience he had gotten and its
successful implementation in projects, Peter was promoted not
long ago. He now has the privilege of calling himself an
“Innovation & Co-Creation Manager.”
He is glad to meet like-minded spirits at events such as “Bits &
Pretzels” in Munich or design thinking meetings in Nice, Prague,
or Berlin where he can exchange thoughts and ideas with the
who’s who among digitization evangelists.
More about Peter: What is his background experience?
Peter studied at the Technical University of Munich. After
graduating, he held various positions in the telecommunications, IT,
media, and entertainment industries. Five years ago, he decided to
move from Munich to Switzerland. Its location and excellent
infrastructure convinced him to make this daring change. There,
Peter met his future wife, Priya. He has been happily married for
two years. She works for Google at their corporate campus in
Zurich. Priya is not allowed to talk much about the exciting topics
she works on, although Peter would be quite intrigued by them.
Both like to get involved with new technologies. Be it the smart
watch, augmented reality, or using what the sharing economy has to
offer, they try out everything the digital world comes out with. A few
weeks ago, Peter had his dream of getting a Tesla come true. Now he
is waiting for his car to be self-driving soon so he can enjoy the
beautiful landscape while looking out the window. In his new role as
Innovation & Co-Creation Manager, Peter now belongs among the
“creative” ones. He has replaced his suits and leather shoes with
Chucks.
Peter tried to resolve the last crisis in his relationship with a little
design thinking session. Priya was very aloof with Peter all of a
sudden. Peter took the time to listen to Priya and better understand
her needs. Together, they discussed ways to bring more oomph into
their relationship. During the brainstorming, Peter had the idea that
wearing his lucky red underwear might save the relationship. But in
the meantime, he had developed so much empathy for Priya’s
concerns that he quickly dismissed the idea. In the end, they came
up with a couple of good ideas for their relationship. Priya did wish,
though, that Peter would use a different method to learn his needs
besides design thinking.
Up to now, Peter had used design thinking in various situations. He
learned that the approach sometimes worked very well for reaching
a goal, but that sometimes it wasn’t right. He would like to get a
couple of tips from experienced design thinkers to shape his work
even more effectively.
Visualization of the persona
User profile of an experienced design thinker from actual practice:

Pains:
Peter’s employer does not invest much in the further training of
employees.
Although Peter feels quite competent by now in dealing with
design thinking, he is still convinced he could get more out of the
approach.
Peter has noted that, while design thinking is a powerful tool, it
is not always used optimally.
Peter frequently wonders how the digital transformation might
be accelerated and what design criteria will be needed in the
future to be a success on the market.
Peter would like to combine other methods and tools with design
thinking.
Peter is faced with the challenge of having to impart to his team
a new mindset.
He would like to exchange ideas with other design thinking
 experts outside his company.

Gains:
Peter has a lot of leeway in his daily work to try out new methods
and tools.
He loves books and all tangible things. He likes to use
visualizations and simple prototypes for explaining things.
What he would really like to do is establish design thinking in
the whole company.
He knows various management approaches he would like to link
with design thinking.

Jobs-to-be-done:
Peter has internalized the design thinking mindset., but
sometimes, good examples that would help to change his
environment don’t come easily to him.
Peter enjoys trying out new things. With his engineering
background, he is open to other approaches to problem solving
(whether quantitative or analytical).
He would like to become an expert in this environment as well.
He is looking to connect with like-minded individuals.
Peter experiments with design thinking.

Use cases:
A book in which experts report on their experience, in which
tools are explained by way of examples—such a book would be
just the thing in Peter’s eyes. A book he could recommend to his
company at all hierarchical levels. A book that expands the
framework of inspiration and makes people want to learn more
about design thinking.
He would also like to know which design criteria will be needed
in the future, in particular for the development of digital
products and services.
 “Who is Lilly?”
Lilly, 28 years old, is currently working as a design thinking and
start-up coach at Singapore University of Technology & Design
(SUTD). The institute is one of the pioneers in design thinking
and entrepreneurship for technology-oriented companies in the
Asian region. Lilly organizes workshops and courses that
combine design thinking and lean start-up. She teaches Design
Thinking and coaches student teams in their projects. In tandem
with that, she is working on her doctoral thesis—in cooperation
with the Massachusetts Institute of Technology—in the area of
System Design Management on the subject of “Design of
Powerful Business Ecosystems in a Digitized World.”
To divide participants into groups, Lilly uses the HBDI®
(Herrmann Brain Dominance Instrument) model in her design
thinking courses. Productive groups of four to five are formed
this way, each one of which works on one problem statement.
She has discovered that it is vitally important in each group to
unite all modes of thinking described in the brain model. Lilly’s
own preferred style of thinking is clearly located in her right half
of the brain. She is experimental, creative, and likes to surround
herself with other people.
Lilly studied Enterprise Management at the Zhejiang University
School of Management. For her master’s degree, she spent a year
at the École des Ponts ParisTech. As part of the ME310 program
and in collaboration with Stanford University, she worked on a
project there with THALES as an industrial partner, which is
how she became familiar with design thinking. During this
project, she visited Stanford three times. She liked the ME310
project so much that she decided to attend the University of
Technology & Design in Singapore. There, Lilly became known
among faculty for her extravagant flip-flops. SUTD students
were less enthusiastic about them.

More about Lilly: What is her background experience?

Lilly has great in-depth theoretical knowledge of various methods
and approaches and is able to apply them practically with her teams
of students. She is good at coaching these teams but lacks
understanding of actual practice. Lilly offers design thinking
workshops at the Center of Entrepreneurship at Singapore
University of Technology & Design. Frequently, people from
industrial enterprises who want to learn more in terms of their
innovation capability or better understand the topic of
“intrapreneurship” take part in these workshops.

Lilly lives in Singapore and shares an apartment with her friend

Jonny, whom she met during her year in France. Jonny is an expat
who works for a major French bank in Singapore. At first, Jonny
thought Lilly’s flip-flops were somewhat freaky but, at this point, he
likes that little splash of color on her.
To maximize success, Jonny sees great potential in user-centered
design and his bank’s pronounced orientation toward customer
interaction points. He is enormously interested in new technologies.
The thought of what they might mean for banks fascinates and
unsettles him at the same time. He follows events in the fintech
sector very closely and has identified new potentials that might
result from a systematic application of blockchain. He wonders
whether such disruptive new technologies will change banks and
their business models even more fundamentally than Uber changed
the taxi sector or Airbnb the hotel industry—and, if so, when such
changes will take place. The core question for Jonny is whether a
time will come when banks as we know them will cease to exist
altogether. Either way, banks need to become more customer-
oriented and make better use of the opportunities that digitization
offers than potential newcomers. Jonny is not afraid of losing his
job as yet. But still, a start-up together with Lilly might be an
exciting alternative. Jonny would like to see his bank apply design
thinking and internalize a new mindset, but this is nothing but
wishful thinking thus far.
Lilly and Jonny would also like to set up a consulting firm that
applies design thinking to support enterprises with digital
transformation. They are still looking for something unique that
their start-up could offer in comparison to conventional consultancy
firms. In particular, they would like to address cultural needs in
their approach to consulting. Lilly has observed too many times how
the European and American design thinking mindset failed in an
Asian context. She wants to integrate local particularities in her
design thinking approach: the attitude of an anthropologist, the
acceptance of copying competitors, and the penchant for marketing
services more quickly, instead of observing the market for a long
time. Something else makes them hesitant to implement their plan:
They are bit risk averse because next year, once Lilly has completed
her doctoral thesis, they want to get married and raise a family. Lilly
wants three children.
In her free time, Lilly is active and creative. She often meets with
like-minded people she knows from the SkillsFuture program,
which is a national program that provides Singaporeans the
possibility to develop their fullest potential throughout life,
regardless of their starting points; or from events such as
“Innovation by Design,” which was funded by the DesignSingapore
Council. They develop concepts for, among other things, adapting
the space and the environment of the country to the needs of
people. Lilly is especially intrigued by digital initiatives and
hackathons that come into being through real-time data from
sensors, social media, and anonymized motion profiles of mobile
devices. Singapore is a pioneer that brings the design thinking
mindset actively to the entire nation, not least with the “Infusing
Design as a National Skill Set for Everyone” campaign.
Visualization of the persona
User profile of an experienced design thinker from the academic
environment:

Pains:
Lilly is uncertain whether she wants to begin a family or a start-
up after she has finished her dissertation.
Lilly would like to work as a professor in the area of design
thinking and lean start-up in Southeast Asia, preferably in
Singapore, but no such position exists there yet.
She feels confident in design thinking both in theory and in her
Another random document with
no related content on Scribd:
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.