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CEREBRAL  HYPEREMIA


                     THE RESULT OF


  MENTAL STRAIN  OR EMOTIONAL DISTURBANCE


                     the so-cai.i.ed


    NERVOUS PROSTRATION OR NEURASTHENIA
         WILLIAM  A.  HAMMOND, M. D.

Surgeon-General, U. S. Army (retired list); late Professor of Anatomy and
   Physiology in the University of Maryland, Baltimore ; of Diseases
      of the Mind and Nervous  System in the College of Physi-
        cians and Surgeons, New York ; The Bellevue Hospital
          Medical  College, New York ; The University of
            the City of New York ; The New York Post-
             Graduate Medical School and Hospital;
               The  University of Vermont; and
                 Medical Department of the
                  University of Georgetown,
                     Washington, D. C,
                       etc., etc., etc.
SECOND EDITION
ENLARGED AND IMPROVED o>"^ „
                       J6 T.0p-
  WASHINGTON

BRENTANO'S

       '895
JAN  4,

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     Copyright,
        1878,
 By G. P. Putnam's Sons,
      AND 1895,
By William A. Hammond.
'<?
^wn:
DUPLICATE
 /        \  ' 
CONTENTS.
                  CHAPTER I.
                                            Page
[ntroduction..........................................  9

                  CHAPTER II.
Cerebral Hyperemia—Symptoms..................... 17

                  CHAPTER III.
Differential Diagnosis............................... 52

                  CHAPTER IV.
Causes.................................................. 69

                  CHAPTER V.
Prognosis.............................................. 81

                  CHAPTER VI.
Morbid Anatomy and Pathology..................... 83

                 CHAPTER VII.
Treatment............................................ 98

                 CHAPTER VIII.                 \
Animal Therapeutics of Cerebral Hyperemia..... 109 
 
PREFACE.
   The  disease  which is considered in  the ensuing
pages is more common, according to my experience,
than any other affection of the nervous  system.   It
is  especially an outgrowth of our  civilization, and of
that  restless  spirit of  enterprise and struggle  tor
wealth so characteristic of the American people.   It
is an easily preventible disorder, not  for this purpose
requiring extensive hygienic  operations, but  simply
the acts of the individual  in  using his or her brain
with the same regard for its well-being as is ordinarily
extended by the humane carter to the  muscular system
of  his horse.   The  brain of man is strong : it will en-
dure a terrible amount  of ill usage ; but there are limits
to  the abuse which  may be inflicted upon it with  im-
punity, and few there be who do not  pass them.
   It is, perhaps, too much to expect the emotions to
be entirely under the control of  the individual, nor is
it desirable that we should be reduced to the condition 
6                    PREFACE.
of intellectual automata, moved always by reason  and
judgment and  never  by feeling.   But it. is  entirely
within the power of every one, by that self-discipline
so seemly in all, to obtain such a  degree of  mastery
over unworthy or excessive passions, as will  prevent
them dominating over the whole  mind  and body to
the detriment of both.
    Ill-regulated emotions are even  more prolific of
brain disorders than severe mental labor, and many a
person considered to be suffering from what is called
nervous prostration  or exhaustion, is  simply  the sub
ject of emotional  disturbance and  a  consequent con-
dition of cerebral hyperaemia.
    The last few years have witnessed the death  ol
many distinguished persons from the direct results of
excessive brain-work, or the passional excitement so
commonly produced in men and women  by the  mul-
titude  of causes  in  operation  upon  them.   In  the
hope, that what I have written may tend  to  the pre-
vention or alleviation of suffering, I. send out this little
monograph.
                  WILLIAM A. HAMMOND.
43 West Fifty-Fourth  St.,
    New York, January I, 1878. 
PREFACE TO  SECOND EDITION.
  A largely increased experience has served to convince
me that the views expressed in the first edition of this
little book were correct, and that no modification is re-
quired as regards the causes, symptoms, and pathology
of the very common disease considered in its pages.
With the advance of medical science, however, our
means of treatment have undergone considerable ad-
vancement, not only in  this  but in many other diseases,
especially those of the brain and nervous system gener-
ally.  The chapter on treatment, therefore, has been
augmented by additions setting forth the advantages to
be  derived by the use of certain  animal extracts—a
matter to which  during several years past I have given
much attention. 
 
CEREBRAL   HYPEREMIA.
                   CHAPTER  I.

                INTRODUCTION.

    The condition in which the brain *is left after very
intense or protracted mental application, or  as a con-
sequence  of powerful  emotional disturbance, is  one
of very great importance, both as regards the imme-
diate results to the individual, and as predisposing to
subsequent disease.  Up  to the time of the publication
of a monograph of mine  on  Wakefulness,* nearly
twelve years ago, the  subject  had scarcely attracted
any attention ; and even  since then,  the very few ob-
servations that have been made by others have been
from wrong  stand-points, and  hence devoid of satis-
factory therapeutical  results.    In subsequent writ-
   * On Wakefulness, with an Introductory  Chapter on the
Physiology of Sleep.  Philadelphia: 1865. 
10
CEREBRAL HYPEREMIA.
ings * I have insisted upon and  amplified  the views
then enunciated, and in  the present monograph I  pro-
pose to  reconsider at length  the whole  subject, em-
bodying in the discussion the  main points of a greatly
enlarged personal experience as well as the  results of
some interesting observations  recently made abroad.
    That an increased amount of blood flows through
the cerebral vessels during mental activity,  that these
vessels may become permanently over-distended, and
that profound interstitial  changes  may thereby be
eventually produced in  the brain-substance, are facts
in  regard to  which  I have no question.  The first
two  are capable of actual demonstration ;  the  last
is a matter  of inference, but of inference  so  very
decided  in  its character as  scarcely to allow of  the
existence of  a doubt.   What  these  changes  are,
and what relation they bear to the  kind and  degree
of cerebral action,  we  are far  from  being  able to
determine.
    Helmholtz,f  several  years ago,  ascertained for

   * Sleep and  its Derangements.  Philadelphia: 1869.  On
the Effects of Excessive Intellectual Exertion.  Bellevue and
Charity Hospitals Reports.  New York: 1870.   A Treatise on
Diseases of the Nervous System.   New York: 1871, and  sub-
sequent editions.
   f Midler's Archiv., 1843, P- 72-   Also Die Chemie der Ge-
vebe, von Julius Eugen Schlossberger, Erster Band.  Leipzig
& Heidelberg, 1856, p.  186. 
INTRODUCTION.
11
muscles  what we cannot with  equal certainty deter-
mine for the brain.  He amputated the legs of a frog,
and, leaving  one of them  in a state of rest, excited
the other to contractions by means of galvanism, con-
tinuing the  current so long as the  muscles retained
their irritability.  The  flesh of  the two  limbs  was
then submitted to chemical examination with the  re-
sult  of  ascertaining that the  water-extractive  was
from twenty  to twenty-five per cent less in the exer-
cised limb than in the  other, while the alcohol-extrac-
tive was  correspondingly increased.   I have repeat-
edly performed Helmholtz's experiment with similar
results.
   Such experiments show how profoundly the exer-
cise  of an organ modifies its structure.
   Gulliver's observations lead to no important con-
clusion except that muscular rigidity  ensues  at a com-
paratively early period in animals hunted to death.
   The effects of emotion over the solids and fluids
of the body has long been known, and in some of its
phases is a  matter  of  every-day observation.  Thus
we see the vessels  of the face  and chest become sur-
charged  with blood under the  influence of anger or
shame ; the  saliva  of man may be  changed from a
bland fluid to a powerful poison through the effect of
rage, and fear or horror converts  the sustenant milk
of the mother  into a potion of deadly qualities.   In
fact, scarcely an  organ  of  the  body  resists this influ- 
12
CEREBRAL HYPEREMIA.
ence altogether, and some exhibit it in a very marked
degree.   Even  the muscles  are subject to it, and
may be profoundly changed in chemical  constitution
through emotional disturbance or physical suffering.
Doubtless the primary effect  is in all such cases pro-
duced upon the blood, but this  does  not lessen the
value of the examples as  analogical to what we have
ample assurance,  takes place in the structure of the
brain from similar causes.
    The influence of bodily suffering in rendering
the blood poisonous, is  very  strikingly shown in the
following  account:
    " In order to  procure a roast for Easter," says Dr.
Roser, " C. in R.  desired his family to set a snare for
a roebuck.  Accordingly  one of these poor  animals
was caught in the snare, which, as its head and breast
had passed through, held it by the hinder parts of the
body, the abdomen and pelvis being enclosed in the
cord, so that  it must have succumbed after a most
agonizing struggle.   It was found dead the next day.
The master and mistress of the family ate on Easter
day the  best  part of  this dainty ; the servants had
little;  the remainder was laid  in  vinegar  but not
eaten.
    " On the same day all of the family who had eaten
of  the venison observed a striking dryness of the
mouth, oppression of  the stomach  and  nausea ;  all
complained of oppression of  the head, giddiness, and 
                 INTRODUCTION.                13

great weariness of the limbs.  The master lost  his
sight for several days, and in  short, there  now began
a series of remarkable symptoms requiring  in  many
ways the assistance of Dr. Roser.  The husband was
only restored to health in July, but the .wife never re-
covered.  She lingered more  than two years, and  at
last died after  severe  sufferings.  The daughter, the
man-servant, and the maid who had eaten little of the
tortured animal, were soon cured.  The  symptoms in
many respects resembled those of  the  effects  of the
bite of  rabid animals (and of  the  sausage poison  of
Wiirtemburg ?) "
    Dr.  Roser concludes  his communication in  these
words :
    " Many an  animal (for example  in  hunting)  is
tortured to death in the  most  barbarous manner like
the roebuck in  the snare.   Ought not the medical  po-
lice to be  led by cases like this  to adopt the strictest
regulations to prevent the use  as food of animals which
have in any way been tortured to death, and to insure
that the animals  intended for food are  not tortured
before being slaughtered ? " *
    Every one,  too, has noticed the  feeling of fatigue   ♦
experienced after severe  physical exertion.  This  is
   * Dr. C. G. Carus in Der Menschenfreund in  seiner Bezie-
hungen ziir belebten Welt, quoted by Liebig in  his  Familiar
Letters on Chemistry, etc.  Third edition, London, 1851. Ap
pendix, No. 4, p. 531. 
14
CEREBRAL HYPEREMIA.
of course due to structural changes in the muscles as
well as to nervous exhaustion.  It is also well known
that the flesh of animals hunted to death is stringy,
unsavory,  and that microscopical examination shows
the fibrillse of the muscles to be ruptured and separ-
ated from each other  by minute extravasations of
blood.   In addition to  these  evidences  of  muscular
change we have that afforded  by the products of the
waste of the  muscular  tissue—the debris, as it were,
which appear in the urine, and enable us to measure
with considerable accuracy the extent of the decom-
position.
   Now, in regard to the brain, somewhat similar re
suits ensue from intellectual exertion  and emotional
excitement; and, although, as  I have said, we cannot
determine with any great degree of exactness, the na-
ture or extent of the change  produced, we are not al-
together without important data which tend to give us
some conception of what is  going on.   By means of
various physical apparatus we are able to obtain ap-
proximately correct notions in regard to the  quantita-
tive  state  of  the cerebral circulation, and a careful
study of the symptoms aids us still further in arriving
at exact ideas on the subject.  We can also, after the
manner of the chemist—who weighing the ashes left
in the grate will tell us  how much coal has been con-
sumed—measure the waste of the nervous tissues and
thus determine with an approximation to accuracy how 
INTRODUCTION.
15
much brain has been decomposed in a  given period.
The two  conditions  are  apparently inseparably con-
nected.   Whenever  there is an increased amount of
blood circulating in the cerebral vessels, there is at the
same time an augmented waste of the cerebral sub-
stance.
    Thus,  several years ago desiring to ascertain the
effects of  excessive mental labor upon the brain as in-
dicated by the excretion of urine, I performed a series
of experiments  upon myself by which it was clearly
ascertained  that the solid matter eliminated by the
kidneys was  notably increased in direct relation with
the extent to which the brain was worked.   All this
was, for the  time being at least, within  the limits of
health.  But by persevering with the experiments and
carrying the  mental exertion to a still higher point, a
stage would have been reached at which the decom-
position of brain substance would have been greater
than the formative  processes, and then disease would
have  existed.   I would have been  living, as it were,
on my brain capital instead of  the income, and brain
bankruptcy would have been only a question of time,
just as it is in financial matters.  This is exactly what
people do with  their brains continually.  Overwork
causes them  to  use  up their brains  faster than they
make them, and as  a consequence, that  organ which
of all others it  is essential to keep in a healthy con-
dition, becomes  the seat  of  serious disease.  To the 
16          CEREBRAL HYPEREMIA.

consideration of some of  the consequences of  inordi-
nate brain action, I propose to  devote the following
pages. 
CHAPTER II.
         CEREBRAL HYPEREMIA--SYMPTOMS.

   That one of the primary effects of intellectual ex
ertion or emotional disturbance is an  increase in the
amount of  blood circulating through the brain, does
not admit of  a doubt, except from those who, still re-
fusing to learn, contend that the cerebral  circulation
is not  subject to variation  under any circumstances.
Experimental  physiology  has, however, determined
this  point  so positively in the affirmative  that  it is
scarcely necessary to adduce the  evidence in its sup-
port.  It will be sufficient to recall the numerous facts
observed by others and myself with reference to the
immediate  cause of sleep, by which it  is shown that
during the condition of wakefulness the quantity of
blood  in the brain is  much greater than it is  during
sleep; the  first being  a  state  of  intellectual activity,
the latter one of almost complete cerebral  rest. *
   *  Those who desire further information on this and analo-
gous  points  are referred to the writer's  monograph entitled,
Sleep and  its Derangements, and to his Treatise  on Dis-
eases of the Nervous System,  chap, i., on Cerebral Congestion.
                           2               " 
i8
CEREBRAL HYPEREMIA.
    Excessive mental exercise  inordinately augments
 the  activity of the cerebral  circulation.  The blood-
 vessels become over-distended, and if the brain  be
 kept long in a condition of extraordinary action, they
 may be rendered incapable of returning spontaneously
 to their normal  dimensions.   Like a bladder  filled to
 repletion with urine, they become in a manner paral-
 yzed and  unable  to contract  upon  their contents.
 They lose,  to a certain extent, their elasticity, and like
 the India-rubber band,  kept too long  around  a large
 bundle of papers, they do not regain their natural size
 even when the  distension is  removed.  A state  of
 cerebral hyperaemia  is thus  induced which gives rise
 to a  set of  perfectly characteristic  symptoms and
 which is fraught with peril to those in whom it  oc-
 curs.
   In  a monograph  published  some four  years  ago,
 Dr. M. Krishaber * described a disorder of  the brain
and  heart  which is  probably identical with the one
under  consideration,  and to which, under the name of
cerebral hyperaemia,  or the prodromatic stage  of cere-
bral  hyperaemia, I  called attention in the first edition
of my Treatise  on Diseases of the Nervous System,
published  in  1871.  Krishaber's  studies  have very
considerably advanced  our knowledge  of the subject,
and as my own more recent investigations and enlarged
experience  have  tended still further to  the elucidation
   * De la " neVropathie ce'rebro-cardiaque."   Paris : 1873. 
SYMPTOMS.
19
of a very interesting and important condition of the
nervous system, I have thought it would not be out of
place to bring some of the more notable results of our
lah )rs  to the notice of the Neurological Society.   It
may be as well, however, to state here at the outset, that
[ differ with Krishaber  entirely relative to the pathol-
ogy  of the disorder we  have both described, and that
I am of the opinion that the cardiac  symptoms upon
which  he lays great stress  are really of quite  second-
ary importance. In other respects there is no essential
point of difference between us in the representations
of an  affection  studied, independently of each other,
and  from  altogether different stand-points.
   1'he disease is  sometimes developed with  great
suddenness, but ordinarily it  advances little by little
to completeness.   When the former  is  the case the
patient experiences, under the influence of great men-
tal excitement, pain in the head, vertigo, an inability
to speak, or  at least imperfection of  articulation.
There  are noises in  the ears, flashes of light before
the  eyes, and  occasionally for  a  short  time double
vision.  The  heart  beats  with increased force and
rapidity and is more or less irregular in its action ; the
face  is flushed, and a feeling of  suffocation  is ex-
perienced.  If he attempts to walk, his gait is uncer-
tain  or staggering, not  only  in consequence  of the
vertigo present, but from actual loss of power in the ^
limbs.   Numbness  is commonly felt in  some part of 
20
CEREBRAL HYPEREMIA.
the body, and clonic  spasms of the muscles, notably
of those of the face, are generally present.
   With all these physical symptoms there are others
indicating mental  disturbance.   Chief among these
are hallucinations,  or illusions of the  senses, particu-
larly of sight and hearing.   Insomnia is  an  almost
invariable attendant, and what little sleep the patient
obtains is interrupted by unpleasant or even frightful
dreams.  Gradually, the disorder becomes established,
and then other functions, especially those  connected
with digestion, are  deranged.   From  the first  the
urine is loaded with  urates and phosphates.
   As instances  of  the suddenness  with which the
disease may make its onset,  I cite the following cases
from my note-book:
    F. H., a gentleman  engaged  in a manufacturing
business which required all nis attention  to make it
profitable, was informed  one morning by his superin-
tendent that a large lot of material had been spoiled.
He at once  experienced an intense sensation of ver-
tigo, a sharp pain in the head, palpitation of the heart,
and would have fallen had he  not been  supported by
the bystanders.  There were also a roaring sound in
the ears and flashes  of light before the eyes.  On at-
tempting to stand, the vertigo and palpitations were
increased.   There was  at no  time  loss of conscious-
ness, though the ideas were confused  and the speech
thick.   In the course of a few hours  the  severity oi 
SYMPTOMS.
21
these symptoms  diminished,  but  that  night  he was
unable to sleep, and in the morning the morbid phe-
nomena re-appeared, though with diminished violence.
For several months afterward, he was  troubled with
wakefulness, a  sense of fulness and tightness  in the
head, occasional weakness of the limbs, slight  numb-
ness and a total inability to exert his mind in his busi
ness affairs without an increase in all the symptoms.
Under appropriate  treatment he entirely recovered.
    S. L., a book-keeper, after a day of unusually ar-
duous work, left his place of business to go  home.
He had hardly taken half a dozen  steps when he was
seized with vertigo and fell  unconscious on the side-
walk.  He almost  immediately regained his  senses,
but on  trying  to  stand found that he was  paralyzed
in  both  legs,  and that  the  least  motion  of  the
body brought  on a return of the vertigo, which was
now attended  with pain in the head, mostly in the
frontal region, noises in the ears and indistinctness of
vision.  On attempting to speak, his articulation was
so  imperfect that  he  could scarcely be  understood.
There was an uneasy feeling at the pit of the stomach,
but  neither  nausea  nor palpitation of  the  heart,
though  the action  of this  organ was irregular.  He
was taken  home in a carriage, and after a sleepless
night found himself very little better  except in the
fact that though his legs were still weak there was no
absolute  paralysis.  Gradually he got somewhat bet- 
22          CEREBRAL HYPEREMIA.

ter, though walking always produced vertigo, and his
gait was similar to that of a partially-drunken man, as
he found it  impossible to avoid a zigzag  course, or a
decided tendency to  sidle over  to  the edge of the
pavement.   Sleep was almost every night imperfect,
being disturbed by dreams of difficulties from which
he could not extricate himself, such as  the house be-
ing on fire, and on his springing from bed discover-
ing his door to be locked on the outside ; falling into
the water  and being on  the  point of drowning from
inability to divest himself of  heavy boots, and  so  on.
Mental application was impossible without leading to
an  aggravation of  all  his symptoms, and  the least
emotional excitement was sufficient  to augment them
to a high degree.  He  suffered in this manner for
nearly a year, before relief was obtained, being in
that time treated with remedies  directed to  the re-
moval of  cerebral anaemia, when in fact the intra-
cranial condition  was  directly the opposite.
    M. S., a young lady, aged 19, and without notable
predisposition to neurotic disturbances, was  deeply
chagrined at not  being invited to  a ball at which she
had  confidently  anticipated  being  present.   While
talking  the  matter over with some  friends she  sud-
denly experienced a severe pain  in the head, vertigo,
noises in  the ears, flashes of  light alternating with
darkness, and violent palpitation of the heart.  At the
same  time  a  peculiar thrilling  sensation was fell 
                   SYMPTOMS.                 23

throughout the body, especially on the left side.  These
symptoms continued with great intensity all that day,
notwithstanding that  stimulants  and antispasmodics
were  administered in large  quantities by the physi-
cians called to attend her.  During the night, every
attempt  to  turn  over in bed was attended with ver-
tigo and palpitation of  the heart.   For over a year
there was very little improvement, and the  course of
the disease was not essentially different from the other
cases cited.  The most distressing symptom in her case
was the persistence of the insomnia, it rarely happen-
ing that she obtained over an  hour or two of unre-
freshing slumber.  When she came under my care
some  thirteen  months after the  inception of the dis-
ease,  I found that the affection, though mitigated in
the violence of the  attendant phenomena, was still
sufficiently distressing to impair her capacity for en-
joyment  and her usefulness to others.  Recognizing
the existence  of  congestion of  the brain  rather than
anaemia, for which she  had uniformly been treated, I
acted accordingly, and had the satisfaction of seeing
her gradually  improve till, at the end of less than six
weeks, she was as well as  she ever  had been  in her
life.
    These cases are cited not  as exhibiting  perfect
representations of cerebral hyperaemia, but merely for
the purpose of illustrating the suddenness with which
the condition  may be induced.   They are selected at 
24          CEREBRAL HYPEREMIA.

random from  many others occurring in my nospital
and private practice, and detailed in my note-book.
   Eventually, no matter how brusque may be the de-
velopment of the symptoms, the course  of the disease
is not materially different from that of the more grad-
ually established form  next to be described.   Indeed
there are no differences except as regards the order of
sequence in which  the symptoms ensue and in the
fact that in the present form, there is, in the begin-
ning, a greater  degree of intensity  in  the abnormal
manifestations.
   In the majority  of cases, therefore, the affection is
evolved more slowly and the order of appearances of
the phenomena somewhat different.
    Wakefulness is generally the first symptom indica-
tive  of  cerebral disturbance, and this may be of  all
degrees from the loss of an hour or two  of sleep to the
passing of  night after night in a state of  complete
insomnia.   Even if sleep be  obtained in some cases,
it is disturbed by nightmare and frightful dreams, and
the patient accordingly rises feverish, unrefreshed and
entirely unfit for mental or physical exertion.
   Upon  endeavoring to  apply himself  to mental
labor, he finds it difficult to fix the attention, and the
effort to do  so, or  to  obtain correct ideas of even
simple matters, almost invariably increases the pain
or uneasiness felt in the head.  I think these phenom-
ena are especially observable in those  who  have  to 
SYMPTOMS.
25
deal with arithmetical questions.  The most accurate
accountant is unable  to add  up a column of  figures
without making errors, of which in health he would
be  incapable.  Repeated attempts in  this  direction
render the task more and more difficult, and aggravate
the mental confusion and physical discomfort.  Indeed,
so  great  is  the  disturbance thus induced  that at
times,  utter despair takes possession of the mind.
In a case of the disease  under  notice, occurring  in a
gentleman holding a prominent position in a bank of
this city, an attempt  at  suicide was  made, solely be-
cause of the chagrin induced  by the inability to obtain
a correct result  in  the  addition of  a  number of
figures.
    The progress of the affection  is  indicated by ad-
ditional evidences  of mental  derangement.   The
memory in regard to recent occurrences and the names
of persons and places is notably weakened, and oc-
casionally there are other  aphasoid  symptoms, such
as substituting  one  word  for another of similar sound,
or imperfectly pronouncing words consisting of two or
more syllables.  Thus, a  patient spoke of  his slippers
as " flippers," another, well educated, alluded to sexual
intercourse as  " sectional" intercourse, and a third,
who was at the  time suffering also from haemorrhoids,
repeatedly spoke of his fundament as his "condiment."
    The judgment is  weak and vacillating, the most
strongly expressed  determination  is changed  appar- 
26
CEREBRAL HYPEREMIA.
ently without reason, and again, there is an impossibility
of arriving at a decision, in cases where ordinarily, but
little reflection would be necessary.  I have known a
patient suffering from the disorder in  question, take
several thousand  dollars every dav for a  month  or
more, to Wall Street, fully resolved, when he left his
house, how to invest his money, but always returning
with  his  purpose unfulfilled—a prey  to doubts  for
which he could give no sufficient cause even to himself.
   Illusions, hallucinations or delusions, may be pres-
ent, but  are not usually fixed ; and the  patient will
often laugh at the  absurd images he has  seen, voices
he has heard or ideas he  has entertained not five
minutes  before.   Persons  thus affected will  often
reason clearly in regard to  apparitions or voices  of
the unreality of which, they are fully sensible.
   A condition very often present is a morbid appre-
hension  of impending evil, for which there is  no
assignable cause, and the nature of which the patient
can rarely define.  He is sure something will happen
to him, but what,  he does  not know;  or  if he  does
designate the  form of  trouble to ensue,  he changes
from one kind  to  another without any more  reason
than he had for the  erroneous idea in  the first place.
Again, he is afraid that he may do some injurious act
either against himself or others, and is hence  fearful
of being left alone.   One patient was  afraid to cross
the ferry from Brooklyn lest he might  be tempted to 
SYMPTOMS.
V
throw himself off of the boat; another kept away from
railway tracks, fearing that  he might  be led  by the
T>ight of a passing train  to  put himself in the way of
the engine ; another begged his wife  to lock up  his
razors ; and another would not take a warm bath under
the apprehension  that he' might neglect to turn off
the hot water in time.  It would be easy to enumerate
very many more like instances.  They remind us of
" morbid impulse," but the  subjects unlike those of
this last-named condition, never yield to the excitation.
In fact it is not an impulse but the fear of an impulse
by which they are  influenced.
   The emotional system participates  in the general
mental disturbance, and indeed is  often  the part of
the mind most prominently deranged.  The passions
are easily roused  into  activity by  slight exciting
causes ; trifling circumstances produce great annoy-
ance, and the  little  every-day troubles of life appear
of vast importance.  The disposition  accordingly be
comes  suspicious,  peevish and fretful.  Persons  thus
affected are very far, ordinarily,  from  being pleasant
companions.  Many of them avoid social intercourse,
and shut themselves up in their rooms to brood over
their real and  imaginary disorders.   Others, again,
plunge into dissipation and excesses of every kind, in
the vain expectation of being able by such  means to
overcome the disease ; and  again, others strive, by a
constant change of one physician  for another, or the 
28
CEREBRAL HYPEREMIA.
substitution of one quack medicine for another equally
quackish, to get relief from their mental and physical
distress.   In some, there are very few decided symp-
toms  present, except  the inability to  sleep, and the
incapability of concentrating the mind upon an object
of study or labor, without inducing pain or discomfort
of some kind in the head.
   In  all, however, there is  the  same mental  intro-
spection.  Every symptom is exaggerated ;  and if one
with which the patient has suffered should happen to
be absent, he is dissatisfied till it makes its appearance
again, or till he has, by concentration of his mind on
the subject, brought it back, and with it  an aggrava-
tion  of all the other phenomena.  " Doctor," said a
gentleman to me a few days since, " I am afraid  I am
getting worse, for last night I slept several hours, and
if  stupor should set in,  I suppose it would be bad."
Another, who had for several  months suffered from
an almost perpetual pain  in  the head, was quite sure
sensibility was being destroyed when he found  him-
self a whole day without  it.
   This  fixing of  the  attention upon the body, is of
course apt  to develope symptoms which would other-
wise, doubtless, never make  their appearance;  and
scarcely a day passes that instances  in point do not
come  under  my observation.   The experiments  of
Mr. Braid in this direction are very instructive, and
will bear quotation in the present  connection.  He 
                    SYMPTOMS.                 2g

requested four gentlemen, whose  ages varied from 40
to 56 years, and who were in good health, to lay their
hands, palms upwards, on a table, and to look at them
fixedly for a few minutes.   They  were not to  speak,
but were, as far as possible,  to concentrate the atten-
tion on the  upturned palms, and to await the  result.
In about five minutes one of these gentlemen, a mem-
ber of the Royal Academy, said that  he felt a  sensa-
tion of  great cold in the hand ; another, an author of
distinction, said that at first he thought nothing was
going to happen,  but at last he felt a darting, prick-
ing sensation, as if  electric  sparks were being  drawn
from the hand ; the third, late mayor of a large city,
reported that  he felt a very uncomfortable sensation
of heat  come over the hand ;  and the  fourth,  secre-
tary to an  important association,  had become rigidly
cataleptic, the arm being firmly fixed on  the table.*
   Speaking of this subject,  Sir Henry Holland f
says :
   " One limb, for  instance, or even a  single finger,
or a portion of the sentient surface of the body, may
be taken for observation, and the results tested  and
checked by means wholly independent of the subject
   * For many illustrations of the power of the attention over
the body, the reader is referred to the author's "Spiritualism,
and Allied Causes and Conditions of Nervous Derangement.
New York: 1876.
   f Chapters on Mental Physiology, p.  24.  London: 1852. 
30          CEREBRAL HYPEREMIA.
of experiment, a point  often  very important to the
truth of the result.
    " We have  here, as  in  other parts of the inquiry,
to look to the respective  cases of attention  directed
by express  volition, or suggested by some  outward
cause acting on the mind.   In the former  and  more
simple case, if a limb be taken for  experiment, a pecu-
liar sense of weight, with a vibratory tingling, or sen-
sations approaching to cramp, are produced by the
consciousness concentrated upon it.  It is  difficult to
describe by words, feelings of  this nature, evanescent
or changing at each moment, and  different doubtless
in different  persons ;  but probably the closest resem-
blance is to  those produced in ordinary cases by mus-
cular fatigue or stagnant  circulation through the
limb.  There  is reason, indeed, to suppose, that the
muscular structure is actually affected in these cases,
and frequently even by  particular conditions of move-
ment, though not volitional in kind."
   Medical men are said, and doubtless with truth—
as many cases will  occur to the mind of  the profes-
sional  reader—to be particularly liable to be  affected
with the diseases to which they have given  special
attention ;  and  every  winter, during my  course of
lectures on  the nervous system,  I am consulted by
medical students, who imagine themselves to  be the
subjects of the diseases I have brought to their notice ;
and in some cases with  reason.  Under another divi- 
SYMPTOMS.
31
sion of the subject, I shall have occasion to return to
this matter for further consideration.
    It follows from what has  been said, that if well
persons are liable to contract diseases through mental
concentration,  the subjects  of cerebral hyperaemia
must  be peculiarly prone to the extension of  their
morbid symptoms through a like influence, and in fact
this is exactly what occurs.  A slight accidental sen-
sation in some part of the body engages the attention,
and becomes a fixture in the clinical history of the
patient.  Neuralgic pains, numbness, spasm, and even
paralysis, may be  thus induced, to say  nothing of
functional disturbances of the several organs.
    Under  this latter  head there  is none more fre-
quently met with  than what for a want  of a  better
name may be called false impotence.  To the produc-
tion of  this condition  the erroneous ideas  which pre-
vail relative to spermatorrhoea and the fears excited by
the advertisements and books  of unprincipled quacks
largely contribute.   Indeed, it is rarely the case, that a
male  patient affected with cerebral hyperaemia does
not at some time or other of its course imagine that
he is impotent, and the only grounds he has for this
notion are the facts that he has an occasional  noctur-
nal emission, or the exudation of a little urethral mu-
cus under the influence of sexual  excitement.  Still
the fact is not to be overlooked that the predominence
of this idea is extremely prejudicial to the patient's 
32          CEREBRAL HYPEREMIA.
well-being, and it is therefore important that the phy-
sician should, by obtaining his confidence and enlight-
ening his ignorance, dispel the delusion at the earliest
possible moment.
   In addition, there  are  certain physical symptoms
of disordered  cerebral action which  by their promi-
nence force themselves into notice.  Thus there are
pain, heat, a feeling of fulness or of distension in the
head, the sensation as if a tight  band encircled  it
or the impression of a dragging or clawing character
at the vertex.  Vertigo is, however, the most prominent
of all this category of phenomena  in the majority of
cases, and may be so severe as  to prevent the patient
moving  about.   In  one  case  recently  under my
charge, the subject, a  gentleman  of about forty years
of age, was  often  seized with  intense vertigo  while
walking in the  street, and was  obliged at such  times
to seize hold of a lamp-post, or, if this was not withir
reach, to sit down on the  nearest door-step, or even
the curbstone, till the violence  of the attack had in a
measure  abated.
   Again,  the least  movement of  the  body, the
slightest  attempt at mental exertion, or the most tri-
fling emotional disturbance is  sufficient to  excite  it.
At times it is clearly aggravated by indiscretions  in
diet or the injestion of even  a  small quantity of any
stimulating liquor, and at others is present during the
whole period of being awake.   There  are  two  kinds 
SYMPTOMS.
33
of this vertigo.  In  one the patient seems to be in
motion ;  in the other the objects about him appear to
be tumbling topsy-turvey around him.  In  the latter
the ground in front appears to rise up to  meet him,
a id hence he walks as  if ascending a hill.   In some
cases the two conditions  co-exist or may alternate.
Probably no symptom  is more distressing  than this.
It almost invariably  excites more fear of  serious con-
sequences than in reality should attend it, and it pre-
vents the patient taking that bodily exercise  so con-
ducive to his restoration to health.  In  some  cases,
however, it is entirely absent, though  such are,  I
think, rarely met with, and, no  matter how intense it
may be, is scarcely ever accompanied by nausea.
   In other cases headache constitutes the chief phys-
ical feature of the disease, and  even when not pre-
dominant is a more or less  constant attendant on the
morbid  condition.   It may be  very severe, unfitting
the sufferer for the  slightest mental or physical exer-
tion, or may consist  of a dull, aching pain, very wear-
ing but yet bearable.  It is aggravated by any effort
to use the mind or body, and especially by any cause,
such as a dependent position of  the head, the use of
stimulating ingesta, a constriction about the abdomen,
chest or  neck—likely to increase  the amount of  the
intra-cranial blood.
   In some cases there is no actual  pain  except as
the immediate consequence of some one or  other of
                        3 
34
CEREBRAL HYPERAEMIA.
the  existing causes mentioned; but  the patient is
always  conscious of an  uncomfortable sensation  in
the  head, which if not  a  pain, is capable of being
readily  converted  into one.  This  is, as  I have said,
sometimes a mere feeling of fulness or tightness, or
as  if the brain—so a  patient  described it—" were
being gathered together into a  heap,"  or, as  another
said, were " being  scratched with  a claw."  Again
there is the  impression  that the head  is exactly bal-
anced on a very sharp point, and that  some effort is
required to keep it from  falling off.
    Usually the painful  sensations in the  head disap-
pear towards night, or  on  the attempt to sleep, but
resume  their violence as soon  as the patient  awakes
in the morning.
    The special senses could scarcely be  expected to
escape giving evidences  of derangement, and hence
among  the chief manifestations of the intra-cranial
disorder are those  connected  with the  perceptive
organs.
    Thus there are noises in the  ears such as roaring,
rumbling or singing, and  occasionally loud  reports
such as might be produced by the discharge of fire-arms.
A gentleman recently under my care for the affection in
question, informed me that when he first experienced
the sensation mentioned  he  was  sitting in his  library,
quietly reading, when he suddenly heard  a report as
if a pistol had been shot  off within a foot of his head. 
SYMPTOMS.
35
He jumped  to his feet, expecting to see  an assailant
behind  him, but  to his surprise there was no one to
be seen, and it was very evident that no explosion had
taken place.  He  was greatly astonished at this, but
attributed the whole matter to an exaggeration, excited
by his irritable nervous system, of some street noise.
He had no further experience of the kind till the fol-
lowing  morning, when on rising  from  bed  after  a
wretched  night of sleeplessness, he  again  heard the
sound, and this time it was as nearly as possible like
the noise produced  by striking two  stoutly bound
books together  close  to his  ears.   After this  there
was scarcely a day that the sound  was not heard.  It
was entirely subjective, as persons in close proximity
to him at  the time, heard nothing.
    Several such  cases have come  under  my observa-
tion.   It is not in all that the sound appears  to be in
the ears.  In some it has seemed to  be located in dif-
ferent parts  of  the head, generally, however, in the
posterior  region.
    In some cases patients have experienced the sen-
sation as if something .snapped or gave way within the
head,  and  this has, in  a few rare instances, been at-
tended with the sudden disappearance of some of the
more  striking symptoms.  Thus, a young lady, in con-
sequence of an intense emotion,  was seized with sud- \
den vertigo and pain in the head, and fell to the floor
unconscious. Recovering her senses in a few minutes 
36          CEREBRAL HYPERAEMIA.

she found herself unable to speak a word, though  she
uttered in an excited way inarticulate sounds  having
no resemblance to  speech.  This condition continued
for several hours, when she suddenly felt " something
snap " in the head, and she instantly recovered the
power of talking.  The vertigo, pain in  the head  and
other symptoms, persisted  for two  or three months
afterwards.
   In another case the onset of the disease in  a gen-
tleman who had  for many years overworked his brain
was extremely sudden, and was attended  with facial
paralysis.  I  treated him for this latter condition with
electricity, with  but little  benefit ;  but one  day he
struck his head violently against a gas-burner hanging
over his desk, and  shortly afterwards felt something
give way within  his head with a sharp snapping sound,
and  the  paralysis  instantly disappeared, after having
lasted some five  or six days.
   Such cases are in  the present state of our knowl-
edge inexplicable.
   The ear becomes hyperaesthetic, and loud noises
are  therefore disagreeable.  At  times  the sense of
hearing is  morbidly acute,  while   at  others it is
markedly impaired.  Sounds  are misinterpreted with
some persons and. illusions result.  This is espe-
cially the case  at  night, when  the  patient is lying
awake, the mind stretched to its utmost tension.   A
gentleman informed  me that a circumstance  with 
                   SYMPTOMS.                 2,7

which  most  persons  are familiar—the conversion of
the sound of  the ticking of a clock  into some phrase
or other—was to him a matter of agonizing weariness.
Night  after night  as  he lay in bed, the  ticking of a
large clock in the hall seemed  to be the  constant
repetition of the word " farewell."  Not wishing to
reveal' the matter  to others, he endured for many
nights the consequent suffering, till finally he made
an excuse for leaving the city.  But still the'wheels
of the  railway cars  seemed  to be uttering the word
"farewell," and it was only after a fatiguing journey
to  Baltimore and  repose  in  a  quiet room that he
escaped the infliction.
    In  addition to illusions, hallucinations of hearing:
are not uncommon and are  usually in  the  form of
whispered words which the patient hears with as much
vividness as though they were real  utterances.  Like
the misinterpretations of real sensorial impressions,
these are  usually experienced at night,  and may be
excited by any circumstance, mental  or  physical,
which  tends to increase the  amount of blood circula-
ting in the  intra-cranial vessels.   Thus, a  powerful
emotion, an  unusually severe mental  task, a strong
muscular effort, or  a  dependent  position  of  the head
may induce them.   In one case, that of a gentleman
of rather obese development, a whisper of some kind
or other was  always heard when  he  stooped to button
his gaiter-boots.  In  another, straining in the water- 
58         CEREBRAL HYPEREMIA.
closet frequently caused a like symptom.   In one very
interesting instance the  sounds were  like  those of
musical instruments, and were arranged into familial
tunes, to the no small satisfaction of the subject;  and
in another they assumed  the similitude of the bark of
a dog.  Occasionally they are  in  the form of com-
mands to perpetrate  some act  of  violence, such as
suicide.  A patient who  came from Brooklyn to con-
sult me heard a voice whispering in his ear and order-
ing him to throw himself into  the river.   '' What is
the use of your going to see a physician ? " it said.
'' The best thing you can do is to kill yourself.   You
are of  no service to }^ourself  or any one else.   Jump
overboard  and end the  matter at  once."   Though
these hallucinations never imposed upon the reason
of the patient,  they were nevertheless sufficiently dis-
tressing, giving rise as they did to the fear that he
might, some day or other, be influenced by them to
commit an act which he abhorred.
  The aural speculum is almost, if  not quite, as valu-
able as the ophthalmoscope in affording important in-
formation relative to the  affection under notice;  and I
have been in' the habit  for the last five years of  em-
ploying it in every case presenting the more obvious
features of the  disease.   I do not  mean  to  be under-
stood as intimating that positively  affirmative results
are to be obtained in all instances, but neither are they
of any other single symptom.  That the tympanum 
                   SYMPTOMS.                  39

does afford an  indication of the  state of  the  intra-
cranial circulation, is sufficiently evident from a con-
sideration of the experiments performed by my friend
Prof. Roosa and  myself * relative to  the  influence
of the sulphate of  quinine, the results  of which  have
bee.i amply confirmed by the subsequent  investiga-
tions of  Prof. Roosa, as well as by those of  other ob-
servers.
    In the cerebral disorder under notice evident con-
gestion will almost always be observed of  the vessels
over the handle of the malleus, and the  tympanum
will be seen to be of  a light pinkish color.   In some
cases we are prevented making the usual examination
owing to the accumulation of cerumen.   This must be
removed by forceps or by washing, and the  inspection
deferred till next clay.
   I may add that physicians wishing to observe the
connection between cerebral hyperaemia and tympanic
congestion have  a ready  method  of satisfying them-
selves  on this point by examining  the tympanum be-
fore  and after the  subject has inhaled a few drops of
the nitrite  of  amyl.   This was  first done, so far as
I am aware, by Mr. Galton, f and detailed in  his paper

   *The Influence of the Disulphate of Quinine over the Intra-
Crania. Circulation. Psychological and Medico Legal "Journal',
October, 1874, p. 230.
   f West Riding  Lunatic Asylum Medical  Reports, vol. iii.,
1873, p. 258. 
40         CEREBRAL HYPERsEMIA.

entitled, " Notes on the Condition of the  Tympanic
Membrane in  the Insane."
    The faculty of vision is almost invariably more or
less disturbed.  Sometimes there are bright flashes of
light from over excitation of the retina, and these, like
the other symptoms, are rendered more intense upon
mental  or physical exertion.   At  other  times dark
spots, muscce volitantes, render the vision  indistinct;
and again there is  the appearance of an undulatory
vapor, such  as is seen around a hot stove, or on a
plain heated by the sun.
   The  conjunctivae are suffused.   The pupils con-
tracted.   There is intolerance of  light, and motion of
the eye-balls is painful, and the ophthalmic symptoms
are aggravated by the effort to use the eyes.  The
ocular muscles easily become fatigued, and hence pain
is  excited by any attempt to read or to  adjust the
visual foci for  near  objects.
    Ophthalmoscopic examination  shows the arteries of
the retina to be increased in  size and tortuosity, and
vessels which  in health are not visible are now clearly
perceived.  The optic disk is often more or less con-
gested, exhibiting the appearance to which Allbutt
has applied the name " Congestion Papilla," but which
is perhaps more generally known as " choked  disk."
The tint of the choroid is  deeper  than it is when in a
normal condition.
   The  effect  of cerebral congestion in giving rise to 
                   SYMPTOMS.             .    4i

visual hallucinations has  long been known, though it
often happens that in practice the value of the fact as
an indication of the state of the  intra-cranial circula-
tion, is  in a great  measure  disregarded.  In another
work* I have considered the subject of hallucinations
of sighjt at some length, and as showing the influence
of undoubted cerebral congestion, in producing them,
I quote the following case which  occurred in my own
experience :
   " A  gentleman under the  professional charge of
the writer can always cause the appearance of images
by tying a handkerchief  moderately tight around  his
neck, and there is one form which is always the first
to come and  the last to  disappear.  It  consists of a
male figure clothed in the costume worn  in England
three hundred years ago, and bearing a  striking re-
semblance  to the portraits  of Sir  Walter Raleigh.
This figure not only imposes on the  sight but also on
the hearing; for questions put  to  it are answered
promptly."
   " A similar instance is related in  Nicholson's Jour-
nal, f   ' I know a gentleman,' he states, 'in the vigor
of life, who, in my opinion, is not exceeded by any one
in acquired  knowledge  and  originality of deep  re-
search ; and who for nine months in succession was
   * Spiritualism and Allied Causes md Conditions ot Nervous
Derangement.  New York, 1876, p. 8.
   f Vol. vi., p. 166. 
42
CERE BRA L HYPEREMIA.
always visited by a figure of the same man, threatening
to destroy him, at the time of his going to rest.   It ap-
peared upon his lying down and instantly disappeared
when he resumed the erect position.' ''
    A case  somewhat like the first of the two  fore-
going  is  referred to  by De  Boismont,* in which
an  individual was able  to  obtain hallucinations of
sight by inclining his head a little forward.  By this
movement the return of blood from the interior of the
cranium was prevented, and hence a state of repletion
favorable to the production of  hallucinations was in-
duced.
    Now, in the  state of cerebral hyperaemia which re-
sults from excessive brain-work or  intense emotional
disturbance, a condition exists  not essentially differ-
ent from that  present in the case referred to, except in
the circumstance  that  the excess of blood is mainly
arterial instead of venous, and that hence the conges-
tion is  more  active  than passive.  But it  must be
borne in mind that it requires a very great degree of
hyperaemia to cause the production of visual hallucin-
ations, and therefore  that we  are not  to  expect them
to occur in  all patients who are its subjects.  So far
as my own experience extends, only about one in five
exhibits the  symptom  with  any degree of distinct-
ness.
   * History of Dreams, Visions, Apparitions, etc.  American
■edition.  Philadelphia: 1835. 
SYMPTOMS.
43
   Double vision is occasionally a phenomenon of the
disease in  question, though it  is generally transient,
and as Krishaber remarks, ordinarily only manifested
in regard to bright objects.
   This author also speaks of  a peculiarity of sight
which  has not come under my notice.  " A patient,"
he says,  " looks  at himself in a glass with  astonish-
ment, as if he had forgotten his appearance.  Another
is horrified at his  image, which represents a being
altogether of different traits from those which he con-
ceived himself to possess.  But he is not alarmed, for
he knows  that  it  is only his  perception  which  is
changed.   This aberration exists not  only as regards
his own person, but  other objects  as well.   The
patient finds men and  things  changed;  he is aston-
ished,  always astonished, and it seems  to  him that he
is a being transported to another planet." *
   The sense of smell is very often lost, perverted, or
intensely exalted.  Perhaps the second named of these
changes is the one most frequently met with.  I have
a patient now under my care, a gentleman,  who from
over-mental work is  suffering from  cerebral hyper-
aemia,  and who  constantly while  awake smells the
odor of illuminating gas.  So strong is this, that  he is
at times  unable  to  resist the impression that gas is
escaping  somewhere, and he goes from burner  to
burner of his residence and office  seeking for the im-
                  *Op. Cit., p. 168. 
44          CEREBRAL HYPEREMIA.
aginary leak.  Another is  constantly sensible of the
smell of turpentine or new paint, and another has the
odor of mint constantly present in his nostrils.
   The taste is also occasionally affected in like man-
ner, usually, so far as my experience  goes, in the way
of perversion.   " Things don't taste as they used to,"
is a  common  complaint, and the saliva and buccal
mucus  often give the  gustatory impression of other
substances.  It is  not at all  unlikely, however, that
" the bad taste in the mouth,"  so often mentioned by
patients, is due to a real change in the  properties of
the saliva or mucus.   I have  observed  several cases
in which any mental or emotional strain was  sufficient
to cause a bitter  or  other unpleasant  taste in the
mouth, and the same phenomenon is quite common as
a consequence of gastric  disturbance.   Krishaber
cites two  cases in which both smell and  taste  were
entirely abolished.
   Sensation and the power  of motion are usually
affected, and generally,  though not  always, on  one
side of the body only.  Thus,  the arm or the leg feels
heavy,  and a feeling as of ants crawling over it, pins
and  needles  sticking  in it,  or, as  if the limb were
"asleep," is experienced.  Sometimes these sensations
are confined to the face, the  muscles of  which  feel
drawn  or tight and the skin of which has the various
indications of anasthesia, mentioned.   Most  frequent-
ly, however,  they  are, I think, experienced on the 
                    SYMPTOMS.                  45

scalp, giving rise to the  several sensations already
mentioned.
    Again, there  is an exaltation of  the sensibility of
the skin and of the sensory nerves generally, and thus
neuralgic pains are felt in  various parts of  the body ;
or the cutaneous  surface is extremely sensitive to the
impression made upon it, whether  of  heat, cold or
slight pressure.
    Slight  convulsive actions or twitchings  of individ-
ual muscles or groups of  muscles are generally pres-
ent.  Sometimes a few fibres only are affected.   The
face, and  especially the  eye-lids and angles of  the
mouth,  are particularly liable to be thus involved.  The
muscular strength is usually weakened.   The patient
tires after slight physical exertion, and occasionally
certain  muscles, such  as the deltoid  and tibialis anti-
cus, become distinctly paretic,  so that there is an im-
pairment of the ability  to raise the arm from the side
or to elevate the foot sufficiently high in walking, to
clear  ordinary inequalities in  the  pavement.   The
dynamometer shows the grasp of the hand of one or
other side, or of both, to  be weakened, and the line
made by the dynamograph is zig-zag or  uniformly
depressed.
   The appetite is  capricious,  and the  stomach acts
imperfectly and  sluggishly.  The gastric juice is  not
secreted in sufficient quantity for  the purposes of
digestion, and the peristaltic  action  of the stomach 
46          CEREBRAL HYPEREMIA.
being weakened, the food remains within it a  long
time undigested, and undergoing fermentation.  Re-
gurgitations, both of the solid contents and of gases,
are common, and the patient tastes his meals several
hours after they have been  swallowed.  Gases accu-
mulate in the  stomach and give rise to the sense of
fulness experienced even after a very slight repast has
been taken. Such symptoms are usually classed under
the name  of  " nervous dyspepsia," a not improper
designation, if it does not lead us into the error of re-
garding them  as  of primary importance instead of
considering them as they are, merely consequent on
the head trouble.
    The bowels are ordinarily costive, though at times
this condition  alternates with diarrhoea.
    The urine is  in some patients scanty and  high
colored, in others it is profuse and almost as pale as
water.  Oxalate of lime is often  present, and  an ex-
cess of phosphates an invariable condition, so  far  as
my experience extends.   I  have  already spoken of
this circumstance.  Whether or not, the  phosphates
in the urine are  to  be regarded as the ashes  of the
nervous system and hence a measure of  the amount
of nerve tissue decomposed, there is  no doubt  that
they are inordinately increased after intense mental
or emotional strain.
    I have spoken of the heat  of the head of which
the patient generally complains.  That there is a real 
                   SYMPTOMS.                 47*

increase of temperature can often be perceived by the
hand or by the use of an ordinary thermometer.  But
in some cases the actual rise  of temperature is so
slight notwithstanding the feeling of heat which the
patient experiences that we cannot detect it by either
of these means.  In such cases resort should be had
to the thermo-electric differential calorimeter of Lom-
bard, by which very minute changes of temperature
can be detected, and the part of the brain in which
the temperature is highest be readily ascertained.
The experiments of Lombard, performed several years
ago, show very beautifully the  influence of cerebral
action in augmenting the  external heat of the head,
and it may be remembered, that over two years ago I
detailed to  the Neurological Society  the results of
some  experiments  of my own in the same direction.
For several years past  I have never examined a pa-
tient presenting the more obvious features of cerebral
hyperaemia without carefully determining the surface
temperature of various  parts of  the  scalp.  At times
and in some regions the elevation reaches two degrees
of centigrade above the normal standard.*

   * Since the above was written I  have become acquainted
with some recent experiments of Prof. Broca, of Paris, in the
same direction.  As he does not refer to  either Lombard's or
my own experiments, though the former [Experiments on the
Relation of Heat to Mental Work) were published in the New
York Medical Journal, January, 1867, p.  198, and a synopsis 
48           CEREBRAL HYPEREMIA.

   But one of the chief categories of symptoms remains
to be considered—chief at least, so far as the more ob-
vious appearances go, though like the other visceral
derangements, I must regard these as being due to the
brain disorder—and that is  the  group of phenomena
connected with the heart.  To Krishaber, in the work
already cited, belongs the credit  of  being the first to
call attention to this  remarkable series, for in the pub-
lication of my own to which I have referred, it was in
a great measure  overlooked.  As Krishaber remarks,
the  troubles of the  circulation  consist  especially in
an irritability of the vascular system, so  that the least
movement,  such  as  rising erect from  the sitting
posture, or to the sitting from the recumbent, leads to
an acceleration of the pulse of from 20 to 30 or  even
40  beats  a minute.   Besides this, there are frequent
and  violent  palpitations either  spontaneous, or pro-
voked by the most insignificant causes, either mental
or physical.
    Emotional  excitement is, however, the most pro-
of my own  in the Journal of Nervous and Mental Disease,
January, 1876,  I presume he is unacquainted with either.  Prof.
Broca ascertained by means of thermometers, applied to differ-
ent parts of the scalp, that the external temperature was affected
by different internal morbid, and physiological  conditions, and
hence confirmed the previous observations  of Lombard and
myself.  His   experiments  would  have yielded much  more
delicate and accurate results if he had  employed Lombard's in-
strument. 
                   SYMPTOMS.                  49

lific cause of cardiac disturbance in  patients affected
with cerebral hyperaemia, and at times leads to serious
results.   The pulsations of the heart may be so irreg-
ular and the  action of the organ so strong as to in-
duce grave interference with the respiratory apparatus.
Upon one occasion a lady, while  in  my  consulting
room, was seized with a paroxysm of the kind in ques-
tion, of  so severe a character that for a moment or
two I thought  she was about to die.   For  several
months  she had been wakeful, had suffered from ver-
tigo and slight pain in the head, and while  relating to
me her  symptoms, a blast near by, where a cellar was
being excavated, exploded and produced so violent and
sudden  a shock  as to bring on the excessive cardiac
action mentioned.  The heart throbbed with so great
a  degree  of violence that  its  pulsations could be
readily  seen through her dress and heard at the dis-
tance of two or three feet;  her face and neck became
livid, and gasping for breadth, she fell  to the floor in-
sensible.  In a  very short time,  however,  the inordi-
nate movements ceased and she recovered  conscious-
ness.
   Physical examination of the heart fails in these
cases to reveal the existence of any organic lesion.
   In the intervals between the paroxyms of inordi-
nate cardiac action, the pulse is small, often slow, soft,
compressible, but by no means regular, either in force
or frequency.  Intermissions of the  beats  are  com-
                          4 
50
CEREBRAL HYPEREMIA.
mon phenomena, and give rise to anxiety and morbid
apprehensions in the patient.
    Krishaber states that at  the very beginning of the
disorder there is sometimes present a series of pheno-
mena simulating fever, such as a  chill, followed by a
distinct period of febrile excitement. During  this last
stage the temperature of the body is elevated almost
half a degree centigrade, or  nearly a whole degree of
our scale, and may even be double this.  This  acces-
sion may be repeated with some degree of periodicity,
but it soon ceases, and  does not reappear after the full
development of the disease.
    I have observed this condition in about one-third
of the cases that have come  under my observation,
though usually, close questioning is necessary to elu-
cidate the fact  of  its  existence, so  little impression
does it make upon the  mind of the patient.    Some-
times, however, the paroxyms  are of such severity as
to excite  the belief that they are of  malarious origin,
and being treated with quinine they and  the other
symptoms attendant on the  disease are greatly  aggra-
vated.
    During the most intense period of the disease there
are occasionally paroxyms characterized by entire in-
ability to move a  muscle of the body, the  conscious-
ness,  respiration, and circulation not being  materially
disturbed.   I have never had  a case which exhibited
these symptoms, though Krishaber appears to regard 
SYMPTOMS.
51
them as not uncommon.  On the other hand, syncope
with complete loss of consciousness, which he speaks
of as rare, is, according to my experience, by no means
uncommon.  With both of these conditions there is
an  almost  continuous  praecordial  pain,  sometimes
severe enough  to excite the  idea of the existence of
angina  pectoris, and  causing the  gravest  apprehen-
sions on the part of  the patient and his friends.
   If the disease be not arrested it is quite certain to
develop into one or another of the forms of cerebral
congestion, apoplectic, epileptic, paralytic, soporific,
maniacal or aphasic, to which in another place* I have
given full consideration.  I do not dwell upon them
here for the reason that this  essay is concerned only
with a series of phenomena which  I conceive  to be
due to cerebral hyperaemia,  constituting  the first or
prodromatic stage of congestion of the brain.
  *  A Treatise on the Diseases of the Nervous System, 6th
edition. New York : 1876, chap, i., Cerebral Congestion. 
CHAPTER  III.
             DIFFERENTIAL DIAGNOSIS.

   Although the symptoms of cerebral hyperaemia,
such as I have described them, have  been to some
extent known, they have heretofore been ascribed to
very different pathological conditions.   Thus,  they
have been classed under the heads  of  nervousness,
dyspepsia, chlorosis, malatial disease, and even under
the very opposite condition to that to which I assign
them—cerebral ancemia.
   The name by which we designate  a disease  is of
no great consequence so long as it does not  lead us
into erroneous ideas of treatment.  But  it is rarely
the case that this can be avoided, and I am very sure
injury has been done in the nomenclature  of  the af-
fection under notice.   It is  important, therefore, to
have exact conceptions of the character of  the symp-
toms and the general course of  the disease  before we
venture to give it a name.
   Under  the name of nervosisme or " nervousness"
Bouchut,*  several  years ago, described an affection
   * De l'etat nerveux aigue et chronique ou nervosisme, etc.
Paris : 18 )o.
       52 
           DIFFERENTIAL DIAGNOSIS.         53

which, so far as I can determine, does not essentially
differ from that to which from the pathological condi-
tion I call  cerebral hyperaemia.  Among the symp-
toms are fever, general  hyperaesthesia, headache, ver-
tigo,  hallucinations of  sight   and  hearing, insom-
nia,  palpitations of the' heart, dyspepsia,  paralysis,
constipation, etc.   Bouchut, however, almost entirely
ignored the fact of  the occurrence of these symptoms
in  men, and though  recognizing the circumstance
that they are  often the  result  of emotional disturb-
ance, is  more disposed to attribute them to certain
conditions  of female  life—pregnancy,  disorders  of
menstruation, lactation, change of  life, uterine  affec-
tions, etc.   Moreover, he made no observations with
the ophthalmoscope or auroscope  and no determina-
tions of the temperature of the  head, and hence fails
altogether to identify the symptoms  as  being due to
an increase in the amount of blood circulating within
the cranium.    Consequently the  treatment recom-
mended  is  not such as appears to be proper.
    Many of the so-called  menstrual  neuroses are,  in
reality, cases of cerebral hyperaemia,  the result of  in-
ordinate emotional  strain.   To establish this point it
is only necessary to consult the collection of  cases
made by Berthier.*  Thus, for instance, case 34 under

   * Des ndvroses menstruelles ;.ou la menstruation dans ses
rapports avec les maladies nerveuses et mentales. Paris : 1874, 
54          CEREBRAL HYPEREMIA.
the head of hyperaesthesia, is clearly an almost typical
case of cerebral hyperaemia, and is as follows (p. 49) :
    "Jeanne Thillois, aged 51 years, was of strong
constitution and  had never been ill, till at about her
thirty-sixth  year  a violent mental emotion caused a
suppression of the menses, and this was  followed by
heaviness of  the head, wandering rheumatic pains,
then by numbness in the arms,  legs, shoulders, and
scalp and by attacks of  vertigo of so intense a char-
acter as to cause  her to fall  to the ground.  A  year
later there were  headache, delirium, weakness of the
limbs, and pain along the whole length of the spinal
column.   She was treated with the cautery, and  w;th
blisters to the skin.   With time there was a  gradual
amelioration of the pains, but the weakness of  the
limbs, troubles of speech and difficulty of deglutition
persisted."
    Many other cases similar to the foregoing might
be  readily collected from Berthier, and  nothing is
more common  than for  just such  mistakes to be made
in regard to cause and effect, as in the instance cited.
    The affection  known as chlorosis, occasionally pre-
sents features  similar in  some respects  to those  of
cerebral hyperaemia, and indeed there is reason to be-
lieve that the former is  not only a disease  of the nerv-
ous system, as  I pointed out  several  years ago,* but
   * Chlorosis, a Disease of- the Nervous System. Quarterly
Journal of Psychological Medicine.  July, 1868, p. 417. 
DIFFER EA 'TIA L DIA GNOSIS
55
is in no essential respect different from the latter.  A
case occurring in my own experience and reported in
the essay referred to, is so apposite  in the present
connection that I quote it in full :
   " A. G., a young lady aged 18, and in good health,
was  frightened by a  runaway horse which,  dashing
furiously down the road along which she was walking,
scarcely allowed her time to spring aside  and escape
injury.  She managed to  get  home, notwithstanding
the great mental  and  physical prostration which im-
mediately succeeded her terror, and after drinking a
glass of wine, to  all  appearance recovered her usual
good health and equanimity of mind.
    " Previous to her fright she  had never been what
is  called  " nervous."    Menstruation  had begun at
fourteen and had always  been  regular in  every re-
spect.   Her appetite also  had constantly been excel-
lent, and she was strong and well  developed for her
age.   Her complexion  was  ruddy,  her pulse  full
and  strong, her  mind  of  good quality and  of sound
and healthy tone, her temper cheerful and equable and
her character remarkable for its strength and for the
conscientious devotion to duty, which was apparent in
all her acts.
    " But soon after the occurrence of the event refer-
red to, her friends noticed the beginning of a gradual
change in these  respects, but especially in  her sus-
ceptibility to nervous  impressions.   From  having 
56          CEREBRAL HYPERsEMIA.
been cheerful and buoyant  in  mind she became mei-
ancholy and depressed ;  and instead  of being open-
hearted and free from deceit, she began to show evi-
dences of hypocrisy and even of want of truthfulness.
At  the same  time her  temper  grew irritable  and
peevish.  The slightest  sudden noise  caused her to
start; a bright light disturbed her; the least touch was
magnified into a severe blow ; she constantly smelt bad
odors and complained that nothing  tasted as it did
formerly.   Her appetite  became  irregular and capri-
cious.   Things which she once liked she could  not
now eat at  all, and others which she had never fancied
became the chief articles of her diet.   Sometimes she
ate  voraciously, while  at others  she would   go for
several  days scarcely eating enough  to sustain  life.
Severe dyspepsia, attended with pain, heartburn  and
eructations  set in.   The bowels were generally con-
stipated, the liver  was inactive, the heart palpitated
violently on the least exertion, the skin was  dry and
harsh, her  hair began to fall out, her spine  became
tender in  the cervical  and dorsal  regions,  and  her
complexion assumed the greenish color so character-
istic of chlorosis.
    " All these changes were effected within  a month
after the occurrence of the shock  to her nervous sys-
tem already mentioned.   During this period I repeat-
edly examined the blood  microscopically and always
found the normal proportion of red corpuscles to be 
DIFFERENTIAL DIAGNOSIS.
57
present.  The menstrual period came on during the
third week.  The flow was  as good as usual, and was
neither of diminished nor increased quantity.
   " Finding no change in the blood and detecting no
bellows murmur at the base of the heart or along the
course of the great arteries, I did  not suppose the af-
fection to be chlorosis, for I had been taught to regard
this disease as being due to  anaemia and as always
being associated with the signs and symptoms of that
condition.  From  the  history of the case and the
prominent phenomena of its course, I was disposed at
first to regard  it as one of those  hysterical  affections
so frequently met  with  in  young women, and which
in some respects  it actually resembled.  I therefore
treated it for the first two  or three weeks  with anti-
spasmodics and tonics, the latter consisting of quinine
and iron, and recommended good, nourishing food and
moderate physical exercise.  Had the existing condi-
tion been one of anaemia, these measures would have
been  clearly indicated  and would   doubtless  have
proved beneficial.   As it was, the patient showed no
signs  of amendment;  on the contrary, she grew grad-
ually worse,  and a month subsequent to the beginning
of her disease  was in  a condition from which I was
fearful it would be difficult to rescue her.  I now
abandoned the use of  antispasmodics, of which I had
tried a large number,  and though I  could, upon  re-
peated examination, find no  diminution of the red 
58          CEREBRAL HYPEREMIA.

corpuscles, I was certain the disease was chlorosis.  I
therefore  continued to administer iron and quinine,
and in addition prescribed  a bottle of ale every day.
   " About this time, being necessarily absent on one
occasion when I was sent for to see her, another phy-
sician was called in for tbe emergency.   He, conceiv-
ing the case to be one of congestion of the liver, bled
her to the extent of eight ounces and gave her a pow-
erful dose of some cathartic medicine,  of which calo-
mel  formed  the  staple ingredient.  I  returned soon
after he had taken his leave, and while the blood still
stood in a basin  on the table.   Coagulation had taken
place, and the fluid was altogether of perfectly normal
characteristics.   As  to the  patient,  she  was  very
materially weakened.   I took the whole quantity of
blood with me for the purpose of analyzing it.  The
following  table exhibits the  result, Scherer's method
of analysis being employed.   I omit that part of the
table showing the composition of the serum, as having
no direct  bearing on the main points concerned:
      " iooo parts of blood
       Water................................791-27
       Solids ---........... ...............208.73
           Fibrin.....................    2.18
           Blood corpuscles............  131.11
           Albumen...................  65.09
           Extraction...............    3.98
           Soluble salts...............  20.41
             Total. ..
           Difference
212.77
  j.oa 
           DIFFERENTIAL DIAGNOSIS.         59

   " I  had never made an analysis of the young lady's
blood before the accession of her ill health, and there-
fore  I am unable to present a comparison of the com-
position of this fluid in both conditions.  It will, how-
ever, be seen that  there is no abnormal deviation from
the ordinary healthy standard, and that  the quantity
of red corpuscles is fully up to the average of full
health.
   " After the bleeding  and severe  purgation the
patient was greatly reduced in strength, so  much so
as to make me anxious for her life.  I had given iron
and quinine faithfully, and had endeavored to maintain
her strength by nourishing food and the employment
of sound hygienic means ; all, however, had been with-
out avail, and I found my preconceived ideas relative to
the pathology of the disease under which she labored
entirely  confounded  by the repeatedly  ascertained
facts, that there was no bellows murmur at the base of
the heart  or along the course of the great vessels, no
diminution in  the  quantity of red corpuscles  present
in the blood,  and  no derangement of the menstrual
functions.   Under  these  circumstances I carefully
re-studied  the case,  and although I could not avoid
seeing that, while  all the symptoms of  the affection
under  which she  labored were  those of chlorosis, it
was  very evident  that  the signs indicating  anaemia
were absent.  While, therefore,  I continued the use
of a strong nourishing diet and enjoined  moderate 
6o
CEREBRAL HYPEREMIA.
physical exercise and mental relaxation, I substituted
arsenic and strychnia for the other medicines.  I gave
her ten drops of Fowler's solution and the thirtieth of
a grain of strychnia, three times a day.   I decided on
this treatment for the reasons  that the disease ap-
peared to be one in which derangement of the nervous
system formed the most prominent feature, and be-
cause  I had previously, in other affections,  satisfied
myself of  the efficacy of  arsenic  and strychnia in
giving tone to the exhausted nervous centres and in
relieving those functional derangements of the viscera
due to disturbed nervous action.
   " She had not taken  these remedies  longer  than
four or five days before  a change was perceptible in
her condition.  She said  she  felt more  like herself
than at any time since  her fright; her eyes became
brighter ;  she began to take interest in events which
were passing around her  ; her appetite increased and
was natural in its tendencies ;  from having  been ex-
ceedingly wakeful at night, she  now slept well ; the
tenderness along the spine disappeared ;  she was no
longer startled at slight  sudden  noises ;  she became
able to concentrate her mind upon subjects ;  and h.r
abnormalities of  character and disposition became less
and less strongly shown.  Gradually all these  changes
and others  necessary to her restoration to health went
on,  and after taking the arsenic  and strychnia for
about six weeks her recovery was complete, so far as 
DIFFERENTIAL DIAGNOSIS.
I could see, in every respect.   About  a year subse-
quently she married.   She has now five healthy chil-
dren  and is herself  the  type, mentally, morally and
physically of what American women ought to be."
   And it gives  me pleasure to add, that she is now,
twenty years after her restoration  to health and the
mother of eleven  children, more able to endure men-
tal or physical strain than nine-tenths of the women of
half her age.
   Dr. Handheld Jones*  has, under the name of " Hy-
peraemia of the Brain," described a condition bearing
but slight resemblance to that under consideration, but
rather in its main features assimilating with conges-
tion ;  but the disorder which he designates " Cerebral
Excitement " is so very much like what I would term
cerebral hyperaemia, that I am quite sure we refer to
the same  pathological  entity.  Indeed, he expresses
the opinion  that the arterial vessels of the brain  are
in a state  of repletion, but he  regards this state as
secondary  to another  which  he  believes to be  an
" excitation  of the tissue."
   The  cases cited by Dr. Handheld Jones all present
more  or less affinity with  cerebral  hyperaemia, as I
have described  it  in  the  present  essay.  I quote  one
which was under  his own care :
   " H. T., aged  52, admitted November 25th, 1866.

  * Studies on Functional Nervous Disorders.   London: 1870 
62
CEREBRAL HYPEREMIA.
A very  strong-made, large, hardy-looking  man, whc
has achieved well-deserved repute by his able and suc-
cessful management of a well-known life-boat.   I saw
him  first  October 29th, when I made the following
notes :—About six years ago he got a fright while he
was  out with the life-boat, from a  man being washed
overboard.  He felt his  inside  run round and he be-
came giddy, but did not lose consciousness, and went
on with his work.  He never got quite right after that
night: his head has been affected ever since.   Before
this happened, on one occasion  he  was pitched out of
the life-boat into a vessel and hurt  his shoulder.  His
left knee has been injured also  in the same way, but
he does not seem to have hurt his  head at any time.
At present he is quite unnerved, gets no sleep at night,
being troubled with dreaming  and  fancies.  In fact,
has a degree of delirium—does not know what he is
about.  Has much sweating at night, and is either "all
on a work," as his wife describes it, with his arms or
legs, or else he  is busy electioneering or cutting arms
and legs  off, or singing, etc.   The tip of his tongue
gets  very sore, too, at night.  Every morning for years
since he has been ailing, he has vomiting and purging
when he  gets up in  the morning; it does not occur
during the day if he keeps  quiet.  Is so irritable, if he
worries himself at all he  gets  all  in  a tremble.   Is
often obliged to come home and go to bed two or three
times a day.  His limbs are full of aches and pains in 
DIFFERENTIAL DIAGNOSIS.        63
blowy  weather.   His memory fails very  much ; no
paralysis ;  pupils normal; no  strabismus.   Head not
unduly warm [probably Lombard's instrument would
have told a different story]; is not anaemic.  Manner
quiet.  Has always  been temperate.  Appetite bad ;
tongue natural.   Is worse than he was a year ago. At
the time of his admission he was rather better than he
was a month before, since he had kept quite still and
done no work.   An intelligent observer who took great
interest in  his case  described him  as a wreck.  His
urine was of sp. gr.  1020, of full red color, not albu-
minous.  He was ordered strychnia, gr. 2V -f" acid nitric
Mij. -f- tr.  valerian,  3L -f- infus. valerian,  31.  ter die
morph. muriat. gr. \ -J- ext. hyosciami, gr.  iv. 0 n, and
for diet ordinary  cocoa, ale Oj., brandy  jiv.   During
the earlier  part of this stage in  the hospital he com-
plained of trembling, numbness, and  tingling  of arms
and legs,  coming  on  intermittently,  of  bad  head-
ache followed by black spots before his  eyes,  itch-
ing of  head and back of  neck, and  forgetfulness.
The dose of strychnia was raised to gr.  ^  [?] and the
valerian was replaced by quin. disulph.gr. iij., and this
again by gr. viij.  of citrate of  iron  and quinine.  By
January 30th he had recovered so far that he had lost
almost all trace of nervous disorder and returned home
well and  hearty,  though by no means capable of re-
suming his former arduous exertions."
    I should certainly call this a case of cerebral hy 
64          CEREBRAL HYPEREMIA.

peraemia, as I understand it.   It is of course  marked
by " cerebral excitement; " but then  this latter is only
a symptom, while the former is a disease.
   It is often the case that cerebral hyperaemia is con-
founded  with another entirely different  affection—
cerebral  anaemia, or a deficient  circulation of  blood
within the  cranium.   As the  two affections  are the
very opposite of each other, and as  a mistake in the
diagnosis would lead to serious errors in treatment, it
is proper to consider the differential points at  some
length.
   The condition often induced  by some powerful
emotion, and known as shock, presents  some features
of resemblance to cerebral hyperaemia.   Thus,  there
may be loss of  consciousness, irregular  action of the
heart, and  pain in the head.   But the pallor of the
face,  the  dilatation of  the  pupils,  the coldness  of
the  skin and  the  feeble  respiration and  pulse, are
sufficient for the ready  recognition  of  the real char-
acter of  the state in question,  and the subsequent
clinical history only  serves  to make  the  diagnosis
more decided.
   In a somewhat less severe form of cerebral  anaemia
there may  be illusions and hallucinations, and  some
confusion of ideas.   A low form of delirium may also
be present.  But there is again, the  dilated  pupil, the
feeble heart, the pallid face, the cold skin,  so charac-
teristic of a deficient blood supply to the brain. 
           DIFFERENTIAL DIAGNOSIS.         65

   And in chronic cerebral anaemia, no matter what
may be the other symptoms—and frequently they pre-
sent great resemblances to those of cerebral hyperae-
mia,—the distinction can be clearly drawn by attention
being given to the foregoing points.
   When, however, we come, in addition, in all forms
in which  anaemia of  the  brain may present itself,
to bring  to our aid the calorimetor of Lombard—
or in its  absence sufficiently delicate thermometers
applied to the  scalp—the  ophthalmoscope,  and the
aural speculum, errors  in  diagnosis  can  scarcely
occur.
    And to supplement all this,  we have to  recollect
that in cerebral anaemia, vertigo is  scarcely ever a
prominent feature, and that  so far from being wakeful,
the  patient  is,  on the  contrary,  almost  constantly
drowsy.   No diagnostic  mark  is of so great import-
ance as this latter, and I regard  it as of itself sufficient
to determine the question.   Sleep  is the result  of a
diminished amount of blood in the  cerebral vessels,
and when this diminution does not pass a certain nor-
mal limit, natural  sleep results.  If, however, the brain
is to an inordinate extent  deprived of its  circulating
pabulum, drowsiness  is  the consequence.   Wakeful-
ness, on  the  contrary, is  produced  by an excessive
amount of arterial blood in  the brain, and hence it be-
comes a  prominent feature of cerebral hyperaemia
 It is true that in the advanced stage when, instead o4
                        5 
65          CEREBRAL  HYPEREMIA.

hyperaemia there  is rather congestion, stupor may
ensue, but stupor is by no means sleep.*
    Cerebral hyperaemia may be confounded with soft-
ening of the brain, and it is not unfrequently the case
that patients come to me to  be treated for the latter
disease, when  they are  in  fact  suffering from the
former.. I generally tell  such  that when they get to
be  affected with cerebral softening they will not of
their own accords consult a  physician, but will  be
brought  to him by their friends.   In fact,  the  two
conditions have scarcely any but the most  superficial
resemblance.   In softening, the  intellect is seriously
and permanently impaired, and the morbid process
advances sometimes slowly, almost always certainly,
to a fatal termination.   In those cases due to embol-
ism there are often loss of consciousness and persist-
ent hemiplegia coming on suddenly and followed by
death in  a few days ;  or  there is  an equally sudden
aphasia, accompanied by loss of the power of motion,
generally on the right side, and unattended by any de-
rangement  of  the mental faculties, beyond,  perhaps,
emotional  weakness ;  or there  is  delirium without

  * For a fuller description of cerebral  anaemia the reader is
referred to  the sixth  edition of the  author's Treatise on Dis-
eases of the Nervous  System, and for a still more complete
account, to Dr. J. Milner Fothergill's essay on Cerebral Anae-
mia, in the  West Riding Lunatic  Asylum Medical Reports,
vol.  iv., 1874, p. 94. 
           DIFFERENTIAL DIAGNOSIS.         fy .

paralysis or convulsions, but with a  great  degree of
mental and physical prostration.  In these cases, care-
fil inquiry will generally reveal the  pre-existence of
articular rheumatism or  the presence of  organic  dis-
ease of the heart.
   Some of the head symptoms  of  Brighfs disease
are similar to those of cerebral hyperaemia, but* atten-
tion to the clinical history of the case will prevent any
mistake in the diagnosis of the affections.  Thus, the
existence of kidney-disease, as  revealed by a chemical
and microscopical examination of  the urine, the ana-
sarca of the face or  limbs, and the repeated  attacks of
convulsions and  coma,  will  be sufficient  to  deter-
mine the  presence of the former affection and  not
the latter.
    In the vertigo which occasionally results from gas-
tric  derangement,  the fact that it  is  only present
while the stomach  is digesting its contents, and that
other symptoms of dyspepsia  are evident  and unac-
companied by the mental  and physical disturbances
characteristic of cerebral hyperaemia, will prevent in
the  majority of cases any errors  of diagnosis being
committed.  When  to  these we   add  the  results
obtained  by  ophthalmoscopical  and calorimetrical
examination, the liability to mistakes is greatly les-
sened.                                              |
    In auditory vertigo  or Meniere's disease,  as  it is
sometimes called, there are auditory troubles.   The 
68          CEREBRAL HYPEREMIA.
face is pale, and there is almost invariably vomiting,
or at least intense nausea.
    Indeed there are few  diseases so distinctly marked
by their symptoms and clinical  history, as that which
forms the subject of this  essay. 
CHAPTER  IV.
                     CAUSES.

   In the introductory chapter I have  considered, to
some extent,  the most prolific causes of  cerebral
hyperaemia—those of  a mental or emotional char-
acter—and of this category the  emotional are by far
the more frequent. A sudden shock of this description
may, as  we have seen, induce  the  affection instan-
taneously ; but still more common are those instances
in which some  powerful emotion, acting  day by day,
and even night by night, slowly,  perhaps, but with ter-
rible certainty, leads to the more or less permanent in-
crease of the intra-cranial  arterial blood  with all the
inseparable phenomena.
    But, though unduly severe or prolonged intellectual
effort is exceedingly liable to cause the disorder under
consideration, I by no means wish to be understood as
intimating that regular  and full  mental labor is at all
a common factor  in the production of cerebral hyperae-
mia.  The brain of  man  is  constructed for just  that
kind of work, and so far from the organ being injured
thereby, it is developed and strengthened  as certainly 
70
CEREBRAL HYPEREMIA.
as are the muscles  by physical  exercise.   Eight or
even ten hours of the twenty-four may, in the average
individual, safely and advantageously be occupied with
brain-work of as intense  a character as may be neces-
sary.   But occasionally we meet with  persons who are
no more  capable of such exertion than others are of
running a half mile in two minutes, and  who  cannot
be brought to the ability by any amount of training.
For them to  persevere in a contest for great  mental
superiority, or for  accomplishing a  task beyond their
powers, is destruction  of  their cerebral organization.
The walls of  their intra-cranial vessels are weak,  and
hence when once they have become distended, they do
not readily return to their normal size.
   The same effect is produced by inordinate  mental
exercise in those to whom eight or ten hours labor of
the kind  in question is no more than they can  health-
fully perform.   Deprivation of amusement, insufficient
physical exercise, by which the blood is not sufficient-
ly diverted from the brain, and above all, using their
brains during the hours that  should be given to sleep,
will speedily result in  cerebral hyperaemia, and prob-
ably, even, in some more serious  disease.   The indi-
vidual who shortens his normal period for sleep, in
order that he may increase his hours of  intellectual
labor is,  by depriving his  brain  of  the  necessary
amount of repose, in the position of one who is  " burn-
ing his candle at both ends."   He is literally consum- 
CA USES.
7»
ing his brain-tissue faster than' he makes it, and per-
severance in that  course will  certainly lead to brain
bankruptcy.  Few organs in the  body can endure as
much hard usage as the brain  ; but there is a limit to
its power of resistance and recuperation, in every one,
which cannot be passed with impunity.
    Cases of cerebral hyperaemia from excessive intel-
lectual exertion are frequently met with in the young,
whose mental powers are overtasked before their brains
are sufficiently developed.   A  growing brain needs to
husband its powers for the normal formative processes
of the cerebral organization.   The blood which cir-
culates in its substance is charged with no more pab-
ulum than is  sufficient for this growth, and for such
mental labor as will aid in strengthening the various
faculties of the  mind, and if it be consumed  in  the
production of force beyond these requirements, disease
is the necessary consequence.   Cases of the kind in
young men and women who  are striving to cram their
minds with numerous studies  are  of almost daily ob-
servation.  Certainly, my experience goes to establish
the fact that the study of mathematics is  bad  for the
average young woman's mind.   I  have repeatedly had
instances of cerebral hyperaemia under my charge oc-
curing in young ladies of  from fifteen  to seventeen
ye^rs of age, in whom it was directly induced  by the
study of calculus, spherical trigonometry, and civil en-
gineering.   I have now the  care of a young lady, six- 
72          CEREBRAL HYPEREMIA.

teen years of  age,  in  whom the  disease  came  on
rapidly, in  consequence of long-continued and  close
application to the solution of a mathematical problem.
But so long as there are ambitious  women who want
their sex to study all the subjects men do, I suppose
civil engineering will be responsible for many hyperae-
mic brains in young girls.
   Dr. Richardson * says in regard to the subject of
mental work for the young :
   " The extent to  which over-mental strain is injuri-
ous to  the young varies according to the  kind and
character  of work.   The endeavors to fill the  minds
of children with artificial information leads to one of
two results.  Not unfrequently in  the very young it
gives  rise  to direct  disease of  the brain itself, to de-
posit of tubercles if there be predisposition to that
disease, to convulsive attacks or even to epilepsy.  In
less extreme* cases  it causes simple weakness and ex-
haustion of the  mental organs  with irregularity of
power.  The child may grow up with a memory taxed
with technicals and impressed so forcibly  that it is
hard to make way for other knowledge ; and added to
these mischiefs there may be and often is the further
evil that the brain,  owing to the labor put  on  it, be-
comes  too  fully and easily developed, too firm and too
soon mature, so that it remains throughout manhood

   * Discourses on Practical Physic.   London: 1871, p. 15. 
                     CA USES.                   73

always a large child's brain, very wonderful in a child,
and equally ridiculous in a man or woman.  The de-
velopment  in  an excessive degree  of one particular
faculty is also a common cause of feebleness."
   From another work * I quote the following appo-
site case : " A youth of fifteen was brought to me by
his father, on  the  16th of August, to be  treated for
obstinate wakefulness, the  consequence  of  severe
mental  exertion at school several weeks previously.
He had  not attended  school since  the last of June,
but had scarcely slept  more than an hour or two each
night since that time, according to  his own and  his
father's statement.   He was a healthy, well-grown lad,
with a good  appetite,  and  nothing  unusual in his ap-
pearance beyond a slight look of weariness and anxi-
ety in his face.  During the  day there were no hallu-
cinations of  any kind, and towards evening he inva-
riably felt overpowered with sleep.   As soon, however,
as he lay down, he  heard voices  repeating extracts
from  the lessons  he had recently been  reading, and
his mind became occupied with imaginary  scenes in
which the gods and  goddesses of mythology, and the
heroes and poets of antiquity, played prominent parts,
and the whole power of his attention was thus kept
engaged with these and other scenes, which were
formed with astonishing rapidity.   Towards morning

   * Sleep and its Derangements. Philadelphia: 1869, p. 256. 
74          CEREBRAL HYPEREMIA.
he fell  into  an uneasy slumber, and  awoke  feeling
more weary even than when he had gone to bed.
   " Medicines, among which opium was  the chief,
had  been employed without success.   On the con-
trary, his  condition  was manifestly rendered  worse
through their influence.  Laudanum, of which he had
taken large quantities, always caused headache with-
out producing the least amelioration in his symptoms.
Notwithstanding  the palpable connection which exist-
ed between  the wakefulness and his former intense
mental  application, he had been allowed to continue
his studies,  and when  he came to me had a Latin
grammar  in  his  hand which he  had been  diligently
studying in  a street railway car.
   " After some plain  conversation with  the father
relative to the  great danger to which he was subject-
ing his son,  by thus inordinately taxing his mind, I
directed the entire  cessation  of  all  studies for  the
present, and a  complete change of  associations, by a
visit to the sea-shore and free indulgence in bathing,
fishing, and  other recreations.   I likewise advised the
use for a few nights  of small doses  of the bromide of
potassium.  My advice was implicitly followed, and a
few days since I received a visit from the boy's father,
and was told by him that his  son's health  had been
completely restored.   I recommended that  the visit
to the sea-side should be prolonged a week or two,
that the return to  study should be gradual, and that 
CA USES.
7S
the boy's eagerness to learn should be somewhat  re-
strained  by occupations and  amusements requiring
but little mental occupation."
   There are certain occupations which, owing to the
harassing emotions to which they give  rise, are  di-
rectly productive of a tendency to cerebral  hyperae-
mia, and in many cases to  the  disease itself.  And
here 1 am again tempted to  quote from Dr. Richard-
son's  suggestive address  " On Physical Disease from
Mental  Strain" merely premising that his  remarks
are equally applicable to the affection now under no-
tice.
   " First, there is the mere copyist, the man who
sits all day at his desk and transfers copies of writing
or of  a speech  to a piece of  paper.  The clerk, the
compositor, the  reporter,  and the second and third
rate author are  of this class.
   " Secondly, there is the thinker and  writer who
copies also, but not directly from other writings  nor
from  thoughts  expressed by  other minds, but  who
goes to the great manuscripts of the Supreme Author
—to the hills  and  plains  and  oceans, to the living
kingdoms of  all animals  and of all times, and trans-
lates the histories of them in written words, bringing
the vastness of  the Universe, as seen by his  superior
sense, into moderate   compass  and  legible  form  so
that lesser minds may read through him the truths he
sees and unfolds. 
y6          CEREBRAL HYPEREMIA.
   "Thirdly, there is the speculative  man, usually
very selfish and locked up in himself ; who, from day
to day, and night to night, and hour to hour, schemes ;
who walks with his head down, his eyes on the earth,
and thinks;  thinks  how  he shall meet  this obstacle,
waylay that plan, shrewdly anticipate  such and such
events ; a truly business man in the world's common
acceptation.
   " Fourthly, there is  the man who carries on his
shoulders other people's anxieties,  who thinks for
others rather  than for himself, and  must  never be
tired of the  effort; the professional man is here  rep-
resented, the politician, the minister  of religion, the
physician and surgeon, and the accountant.
   " Fifthly, there is the artist who  labors  towards
perfection in producing some given form,  ideal or
real, who, absorbed in his work, forgets the noisy
crowd  around him, and day after day toils on, living
with his  own creations, one in the world but not of
the world.
   " Lastly, there is the student; the child or  youth
whose  will is hardly his  own,  who works when he  is
bidden, and plays when  he  is permitted, who is fed
too often with flattery or blows, and between or by
one and the other, is at length turned out in life  pre-
pared, as it is  thought, by education  and training, to
fight the great and unceasing battle of life."
   And  it may be added as  specially  applicable tc 
CA USES.
77
this country that here all these avocations are pursued
with an intensity unknown in the old world, and that
as the nervous system of the average American is far
more impressionable than that of the average Euro-
pean, the abnormal effects are more certain  and far
more decided.   The man  who goes  down  to Wall
street day after day, after a sleepless night, not know-
ing exactly where he is to get the money to meet his
obligations by three  o'clock, or  even that he  will get
it at  all, is the prey of just  that kind  of emotional
disturbance—anxiety—which is  most  powerful  in
producing  cerebral  hyperaemia,  and  this condition,
sooner or later, is almost certain to be the result.
    There is an occupation followed quite extensively
in this  country, though almost unknown as a  distinct
business in Europe, and that is, inventing  machines
and devices  of  various kinds, for which patents are
obtained. . The inventor who is assiduous in the prac-
tice  of his  profession, is probably more subject  to
mental strain than the followers of any other occupa-
tion.   His mind is constantly engaged in making new
combinations, in seeking to  counteract obstacles, and
in endeavoring, often,  to come as near as possible  to
some one  else's  machine without  infringing the pa-
tent right.  All this requires very intense mental ex-
ertion and strain, and at the same time various con-
 flicting emotions are brought into operation to increase
 the cerebral disturbance.   It is not, therefore, a sub- 
78          CEREBRAL HYPERsEMIA.
ject for surprise that such people break down, are af
fected with wakefulness,  pain in the head, mental
confusion, and the other symptoms indicative of the
existence  of  cerebral hyperaemia.  Sometimes, the
mind becomes manifestly weakened, and sharp, shrewd
men overlook some  important point, to the detriment
or entire ruin of their schemes for acquiring wealth.
    Thus, a man came to me not long since complain-
ing of most of the symptoms I  have mentioned in the
present connection, and who, for several years, had
been intensely engaged in the invention of  an  appa-
ratus for rolling bandages.   The instrument was ex-
ceedingly complicated and expensive, but was capable
of rolling  several thousand bandages  a day. It was
certainly very beautiful,  but his time and money had
been entirely thrown away, for there was not the least
demand for anything of  the kind.   I do not  suppose
he  ever sold a single one.
    Individuals who  are not accustomed to the use of
their  minds in a regular  and  thorough manner, or
who are so circumstanced as not to be hardened, to
some extent, to the  effects of emotional disturbance,
break down under  strains  that would be nothing in
others, who, living in large cities and mixing with the
world, become in a manner used to hard mental work
and temporary excitement or depression, as  the  case
may be.  These things are relative.  The farmer, for
instance, gets a hyperaemic brain from calculating how 
                     CA USES.                   79

much he is going to receive from his few tons of hay
and bushels  of  corn,  while the bank clerk or the
Wall street operator will add up hundreds of columns
of figures, and determine the  results of all kinds of
abstruse financial problems  without the least brain
derangement.  Again, a person  whose whole life has
been passed amid tranquillity, succumbs to an  emo-
tion that the  care-hardened man  of the world resists
with ease.  Some of  the worst  cases of cerebral hy-
peraemia I have  ever seen,  have  occurred in country
people as the results of mental exertion or emotional
disturbance, which  the city-bred  individual would re-
gard with entire indifference.
   But it is not  to be forgotten, that the mass of cases
of cerebral hyperaemia  rests largely with  those in- *
dividuals, who are apparently inured, by repeated ex-
periences, to all  kinds of mental strain and emotional
excitement.   With  them as with  grosser  forms  of
matter excessive use causes excessive decay—
      " Gutta cavat lapidem, consumitur annulus usu,
        Ef teritur pressa vomer adhuncus humo."
   There are other causes of cerebral hyperaemia be-
sides those to which attention has been drawn.  Thus,
very hot weather may induce it by  the general irrita-
tion of mind to which it gives rise.  Cold weather may
cause it by its constringing influence on the cutaneous
vessels, and the  consequent accumulation of blood in
the brain as well as in other internal organs. 
8o
CEREBRAL HYPERCEM1A.
     The direct rays of  the sun falling upon  the ex-
  posed scalp give  rise to  many cases of  cerebral h) •
  peraemia, especially in  large  cities ;  and  artisans
  whose occupations require them to expose their heads
  to direct artificial  heat often suffer in like manner.   I
  have known  two  cases in which it was apparently
  caused  by the use of hot  shower-baths, in which the
  water was allowed to fall from  a height on the naked
  scalp.
     There are many substances which, when taken into
  the stomach or inhaled into the  lungs, increase the
  amount of  intra-cranial arterial blood.  Among these
  are the various alcoholic  liquors, camphor, opium  in
  small doses,  belladonna,  Indian  hemp, quinine, sul-
* phuric  ether, chloroform,  the nitrite of amyl, etc.   A
  like power  is also  exerted by tea and  coffee, and
  probably in some cases  by tobacco.
     Of the causes  inherent  in the  individual, sex and
  hereditary influence are   especially  to be  noticed.
  The disease is certainly more  common in males than
  in females, and there appears in  many cases  to be  a
  decided tendency to hereditary transmission.
     Venereal excess is an efficient cause in both sexes,
  but especially in males.   It is  difficult in general  to
  arrive at the truth in regard to  this point, but the re-
  sults of my experience  are such  as  to establish the
  fact of its influence beyond a doubt. 
CHAPTER  V.
                    PROGNOSIS.

   The  probability of recovery in cases of cerebral
hyperaemia depends on the submission of the patient
to proper treatment, medical and hygienic, and the re-
moval of  the cause.   If  these  means  can be carried
out,  a  favorable result can  almost always be antici-
pated.   A spontaneous  recovery  is, however, a  rare
circumstance, and it becomes impossible  if the patient
continues to do those very things  which  have caused
the disease.  The tendency of the affection is, if it be
not arrested, to pass into one or the other of the fully
developed forms of cerebral congestion  already men-
tioned, and then  the  liability  to  secondary lesions,
such as  softening, cerebritis,  cerebral  haemorrhage,
aneurisms, general paralysis, etc., must be taken into
account.
   The apoplectic form of cerebral congestion is that
to which there appears to be the  greatest predisposi-
tion, and  the  epileptic and paralytic  come next in
order.  The soporific, the maniacal  and  aphasic, are
$nore rare, but  are occasionally met with.
   I have never known a patient to  die of uncom-
                          6                 81 
g2          CEREBRAL HYPEREMIA.

plicated  cerebral hyperaemia.   But  instances  of a
fatal result from some one  or  more  of  the  ulterior
conditions into which it tends to develop, are not very
uncommon. 
CHAPTER VI.
         MORBID ANATOMY AND PATHOLOGY.

   The morbid anatomy and pathology of the disease
exhibiting the phenomena to which the foregoing re-
marks have been applied, must remain to  some extent
a subject for speculation till post-mortem examinations
enlighten us  as  to  its real  nature.   Nevertheless I
am quite sure, for  the  reasons  already  stated and
others presently to be adduced, that the affection con-
sists primarily of an increase in the quantity of blood
circulating in the cerebral arterial vessels ; or of what
I have designated cerebral hyperaemia.
   Briefly these are as follows :
   t. The redness of the face, and throbbing of the
cephalic arteries, indicate an increased determination *
of blood towards the head.
   2. The sensation  of fulness of the head almost
invariably present.
   3. The increased heat of the head, not  only sub-
jectively,  but as indicated  by the  thermometer  or
the thermo-electric calorimeter.                      ^
   4. The persistent insomnia always present—a con
dition now known to be due to cerebral hyperaemia. 
84          CEREBRAL HYPEREMIA.
     5. The aggravation of all the  symptoms by intel-
  lectual exertion or emotional disturbance.
     6. The results of ophthalmoscopic and aural exam-
  ination.
     7. The effect of the sulphate of quinine, strychnia,
  nitrite of amyl,  alcoholic  liquors, and other  agents
  which we know increase the amount of blood in the
  brain, in aggravating the symptoms of the disease.
     8. The speedy  disappearance of the phenomena
  under the influence of mental  quietude, and of those
  therapeutical  agents  which lessen  the amount of the
  intra-cranial blood.
     But it is still the  habit of some individuals in the
  medical profession to declare that the quantity of the
  intra-cranial  blood  is  unalterable.   I may, therefore,
  perhaps, be excused for  quoting from another work *
  the following  remarks on this subject:—
     " In  the  cases  of infants,  in whom the anterior
  frontanelle is still open, the scalp is seen to be elevated
♦  above the level of the skull, when the head is depend-
  ent, and depressed when the head is elevated.
     " The same fact  is observed in persons who  have
  suffered injury of the skull involving  the loss  of  a
  portion of its  substance.  During  strong  emotional
  excitement, or the action of  any cause  capable of in-
  creasing the  force of the  circulation, the scalp is
    * A Treatise on the Diseases of the Nervous System.  New
  York- 1876, p. 49. 
MORBID ANATOMY AND PATHOLOGY.    85
elevated ;  from  the action of opposite  causes, it is
depressed.   Both in infants and in persons who have
received injuries such as those cited, the scalp is seen
to be depressed  during sleep, and to rise  as soon as
the individual awakes.
    " A dependent  position of the head  causes a sen-
sation  of fulness or even  pain ; and blood  may pour
from the nostrils.  The eyes are observed to be blood-
shot, and the  countenance  indicates congestion.   A
tumor, a ligature, or any other cause  capable  of  ex-
citing pressure on the jugular veins, will produce like
effects. Ophthalmoscopic examination under such cir-
cumstances shows  the veins of the  retina to be  en-
larged, indicating that an  obstruction exists to  the
return of  blood  through the sinuses and veins  within
the cranium.  Post-mortem  examination of persons
dying  who, during life, have suffered  interruption to
the perfect return of blood from the head, reveals  the
existence of  intra-cranial congestion.   Animals  sub-
jected to experiments calculated to act in the manner
stated, are  after death found to have  congested brains.
    " In animals bled  to  death, the brain  is  found
anaemic in an extreme degree.
    " Direct  experiment still more  positively  estab-
lishes the fact under  consideration.   If a portion  of
the skull of an animal  be  removed, and  the  aperture
be then securely  closed with a watch-glass, the ves-
sels will be seen to enlarge  and  contract, according 
86          CEREBRAL HYPEREMIA.
to the cause brought into action, and the brain will be
correspondingly elevated or depressed.
   " By means of an instrument devised, independently
of each  other, by Dr.  S. Weir  Mitchell  and  myself,
the degree of pressure within  the  cranium  can be
accurately measured.   It is thus seen that  the quan-
tity of blood circulating in the  brain  undergoes ma-
terial variation.*
   " The anatomical arrangement of the blood-vessels
of the cerebral tissue, is such as to admit of an enlarge-
ment of  their  calibre,  without necessarily subjecting
the perivascular substance to  pressure.   Robin f dis-
covered the existence of sheaths around these vessels,
and his observations were  subsequently confirmed by
His, % who ascertained  that  the  same arrangement
exists in the spinal cord.   According to His, ' Fine
transverse  sections of  a hardened brain, having its
vessels injected or otherwise, show  that all the blood-
vessels,  arteries, veins, and even  capillaries, are sur-
   * " For a more complete argument on the subject, and for a
statement in detail of the experiments of  Mr. Durham  and my-
self, the reader is referred to  the author's monograph, Sleep
and its Derangements, Philadelphia: J. B. Lippincott & Co.,
1870.  The cephalo haemometer here referred to in the text is
described in that work (Appendix), and also in the Introduction
to this treatise."
   f Journal de la Physiologie de  Phomme et  des Animaux:
1859, p. 527.
   % Zeitschrift fiir Wifsenschaftliche Zoologie: 1865, B. & V 
      MORBID ANA TOMY AND PA THOLOGY.   87

rounded by a clear space, prominent in the case of the
largest vessels, but in all cases quite sharply defined
externally.   In transverse sections the vessels are seen
to be surrounded by ring-like  spaces ;  and in  parallel
sections the  space is seen  on each side of  the trunk
of the vessel, and follows its ramifications.
   " These perivascular canals are lined by  a  hyaline
membrane, and are capable of being  injected, and in
case of chronic congestion may become permanently
enlarged, so  as to cause the  appearance referred to
under the heading of " Morbid Anatomy."
   Admitting that there is such a condition as cere-
bral  hyperaemia,  the next  question to be considered
is—Does the fact of the amount of arterial blood in
the brain being increased, account for the symptoms
observed in  the  disease  under notice ?   In other
words, what  are  the effects of  cerebral hyperaemia ?
These questions  have  already been  considered to
some extent,  but  a few more  remarks on the subject
will probably not be considered out of place.
   Every action of the brain,  whether it be a percep-
tion, an emotion, an intellection, or a volition, is the
immediate result  of an increase in the amount of the
intra-cranial blood.  With each manifestation of men-
tal force in  any  one of  the  ways mentioned., there
is a necessary decomposition of a certain quantity of
cerebral  tissue.   Within  certain limits,  these  are
healthy processes.  The brain is so  constituted, that 
88          CEREBRAL HYPERsEMIA.
it can become  hyperaemic ; and  it is a normal act for
its tissue to be consumed, in order that  brain-force—
mind,—may be evolved.   A slight exaggeration in the
ordinary, habitual, every-day  flow of blood  to  the
brain, leads to acuteness  of perception, brilliancy of
thought, excitement of  the emotions,  and strength of
the will.
   Some persons are dull in all their intellectual pro-
cesses till they become  excited,—warmed up to their
work as it were—that is, till the  circulation  in their
brains is rendered more active, and then their thoughts
come thick and fast, and are of good quality.  Others
can never compose prose, poetry,  or music, till they
have excited the action of the  heart, and, as a conse-
quence, increased the amount of  arterial blood in the
brain, by stimulating ingesta, such as opium, alcoholic
liquors,  tea or coffee; others require to make use  of
physical means to augment the vividness of their per-
ceptions, their thoughts  or emotions.   It is said that
the tints of  the landscape are  brighter if  we reverse
the position of the head.   A " tumbler " in a circus told
me not long since  that  everything  around him ap-
peared more brilliant, and that his thoughts were cer-
tainly more intense when he stood on his head.
   Tissot *  cites an  instance  in which position was
taken advantage of to solve a problem in mathematics.
   * Avis aux gens de lettres et aux personnes se'dentaires sur
leur sante.  Paris: 176'j. 
     MORBID A NA TOM Y A ND PA THOL OGY.   89

A gentleman, remarkable for his accuracy in  calcula-
tion, for  a wager, lay  down in bed, and wrought by
mere strength of memory a question  in  geometrical
progression  while another person in another apart-
ment performed  the same operation with pen and ink.
When  both had finished,  the one who had  worked
mentally, repeated his  product, which amounted to six-
 een figures, and  insisting  that the other gentleman
was wrong, desired him to read over his different pro-
ducts.  On this being done he pointed out the place
where the first mistake lay, and which had run through
the  whole.   He paid very dearly, however, for gaining
his wager, as for a considerable time he had a swim-
ming in  his head, pains in his eyes, and severe head-
aches upon attempting any mathematical labor.
   The engineer Brindley used to retire to bed for an
hour or two when he was reflecting on a great or sci-
entific projcet.
   A gentleman informs me that so assured is he of
the  greater activity of  his  mind when he lies down,
that he has  had  constructed a special apparatus by
which he is enabled to write while in  the  recumbent
position.
   Cases such as these are on the border-line of dis-
ease, and sooner or later pass over to the other side.
The same may be said of most instances in which re-
course is had to stimulating ingesta to render the brain
more active. 
go
CEREBRAL HYPERsEMIA.
   The principal subjective symptoms of cerebral hy-
peraemia, when it is of such  a degree of intensity as
to constitute disease,  are wakefulness, pain increased
by mental  exertion;  and  mental aberration of some
kind or other.  Of these the first is the most import-
ant, not only on account of the  suffering and injury
it  is  to the  patient, but because it is  the necessary
accompaniment, the  pathogonomic symptom  of  the
affection in  question.   Without  wakefulness there is
no cerebral hyperaemia, with cerebral hyperaemia there
is  always wakefulness.  To  establish the connection
between the phenomena and the pathological condition
is  a matter of great moment,, and that point I propose
therefore to consider at some length.
   It has  been definitely established  by the  experi-
ments of Mr. Durham and  myself that during sleep
the quantity of the intra-cranial  blood  is  lessened.
Durham made circular perforations in the  skulls of
animals so as to expose the brain, and  then  covering
the openings with  watch-glasses hermetically sealed
around the edges, observed the state of the circulation
below.   Whenever the animal went to  sleep the sur-
face of the  brain became  pale, and the whole organ
was reduced in  size, as shown by the fact that it  no
longer  rose into the hole in the skull.  As soon as the
animal awoke the vessels became full,  and the brain
enlarging in consequence, protruded through the per-
foration in the cranium.  My own experiments, per- 
     MORBID ANA TOMY AND PA THOLOG Y.   91

formed independently of Mr. Durham's, though a short
time afterward, were to the same effect, and by means
of an instrument to which reference has already been
made, the amount  of  expansion with wakefulness and
collapse with  sleep were very accurately measured.
Since then, additional experiments, with like  results,
have been performed.
   But we are not obliged to rely on experimental
evidence, at least not  on such testimony of our own
devising.  Thus, it is stated by Blumenbach * that a
young, man, eighteen  years of age, fell from  an em-
inence and fractured the frontal bone on the right side
of the coronal suture.  After recovery took place, a
hiatus  remained  covered only  by  the  integument.
While the young man  was asleep, this chasm was quite
superficial, but as soon as sleep ensued, it became very
deep.  The change was due to the  fact, that during
sleep the brain was in a collapsed condition owing to
the diminished quantity of blood, while  as  soon as
wakefulness began, the brain,  being  possessed of  an
increased  amount of blood, was larger.
   Dendy f states that there was in  1821, at Mont-
pellier, in France,  a woman who had lost part of her
skull, and the  brain and its membranes lay bare ; when
she was in deep sleep the brain  remained  motionless
   * Elements of Physiology, translated by John  Elliotson, M
D., etc., 4th edition, London: 1828, p. 191.
   t  Philosophy of Mystery, London: 1841, p. 283. 
92
CEREBRAL HYPEREMIA.
beneath the crest of the cranial bones;  when she was
dreaming it became somewhat elevated ; and when she
was awake it was protruded through the fissure of the
skull.
   In 1854, a  man  came  under my observation who
had,  through a frightful railway accident, lost about
eighteen square inches of his skull.  There  was thus
a fissure of his cranium  three inches wide and  six
inches long, the brain being only covered by its mem-
branes and  the scalp.   The lost portion consisted of a
great part of the left parietal, and part  of the frontal
occipital and right parietal bones.   The man, who was
employed as a wood-chopper, was  subject to severe
and frequent epileptic fits.  In the course of my treat-
ment of him I soon became acquainted  with  the fact,
that  at the beginning of the comatose condition which
succeeded the fits, and during which, the brain was
gorged with blood, there was  invariably an elevation of
that  portion of the scalp covering the deficiency of the
cranium.  As the stupor passed away and natural sleep
ensued,  the scalp gradually became depressed.  When
the man was awake, the region of scalp in  question
was  almost always on a level with  the  upper surface
of the cranial bones.  I also noticed on several occa-
sions, that during natural sleep, the fissure was deeper,
and  that on the instant of awaking, the  scalp covering
it rose to a much higher level.
   Recently, I had occasion in the performance of  an 
     MORBID ANA TOM Y AND PA THOLOG Y.    93

operation on the cranium of a boy about twelve years
of age, to remove, with the  trephine, saw and pliers,
about six square inches of  the skull, the centre of the
removed part consisting of the posterior  superior an-
gles of both parietal bones, and the posterior angle of
the occipital bone.   Owing to the fact, that the dura-
mater remained intact, the  surface of the brain was not
visible, but as the edges of the scalp were not brought
together for several hours on account of a little oozing
of blood which existed, I had  the  opportunity of ob-
serving that when  the boy slept, the brain  sank away
from the fissure, while as soon as he awoke it arose far
up into the hole,  so that at  the centre it was higher
than the outer surface of the skull    As the superior
longitudinal  sinus  occupied  this situation,  I was en-
abled to perceive, that there  was no apparent increase
in its  size during wakefulness, and that therefore the
augmentation in the size of the brain was  due to an
increased afflux of  arterial blood.
    If  the scalp covering  the  anterior frontanelle  of
very young infants be observed while  they  are asleep,
it will be noticed that it is depressed, and that when
they are awake it is elevated.
    Again, we have in the  action of certain hypnotics
very instructive  experiences  relative  to  the state of
the  brain as regards blood supply.  All those which
produce sleep probably do so by their action in lessen-
ing  the amount of  the intra-cranial arterial  blood.  On 
94          CEREBRAL HYPEREMIA.

the other, hand those substances which increase the
supply are directly provocative of wakefulness.
    From all of which it would appear to be a fact as
well established as any other in  pathology, that  cere-
bral hyperaemia is the immediate cause  of  the symp-
toms mentioned in the course of this monograph.
    And  yet  in his  very  excellent treatise, to which
reference  has already been  made, Krishaber enun-
ciates the opinion decidedly, that it is  to anaemia of
the brain, that the symptoms of the affection are  to be
ascribed.  According to him, cerebral anaemia is the
immediate cause of the cerebral excitement.   It  must
be  admitted,  however,  that  if  a  diminution  in the
amount of blood in the brain causes mental exaltation
and an increase in the intensity of the other cerebral
functions, then is the brain subject to a  different law
than that  which governs the other organs of the body,
and some of the best established  points in cerebral
physiology and  pathology go for nought.   Krisha-
ber's arguments on  the  subject  are, however,  weak
and strained,  and in attempting  to account for the
wakefulness so unvarying an attendant, he is forced
to admit that if his doctrine be true we ought rather
to have somnolence  than  insomnia.  The  disease is
produced  by mental  work and emotional excitement.
It is a fair example  of the  reductio  ad absurdum to
contend that these factors cause the blood in the  brain
to be lessened. 
     MORBID ANA TOMY AND PA THOLOG Y.   95

   In this connection it is interesting to refer to the
remarks  made by that  honored physician,  Dr. Ama-
riah Brigham, * some thirty years ago :
   " The general proposition which I wish to estab-
lish is made evident also from the fact that whatever
excites the mind excites and stimulates the  brain.
   " This we know from experience in a severe head-
ache.   We perceive the pain  to  be increased by in-
tense study or thinking, and that  mental application
determines more blood to the head.   So true is it that
mental excitement produces an increased flow of blood
to the head, that  surgeons are very careful  to  pre-
serve a quiet state of  mind in those whose  heads are
wounded.   Sir Astley Cooper, speaking of such inju-
ries, says that if any mental power  remains all  excite-
ment of the  brain  should be avoided, and relates  the
following case :  ' A young gentleman was brought to
me from the north of England who  had lost a  portion
of his skull just above  the eyebrow.   On examining
the head I distinctly saw the pulsations of  the brain,
which were regular and  slow, but at this time he was
agitated by  some opposition  to  his wishes,  and di-
rectly the pulsations of  the brain were increased, and
became more violent, and  more blood rushed  to  the
brain.   If, therefore, you omit to keep the  mind  free

   * Mental Exertion in  relation to Health.   English  edition,
"txidon: 1864, p. 20.  The American editions, of  which there
were several, have long been out of print. 
96          CEREBRAL HYPEREMIA.

from agitation, your other means will be unavailing in
injuries of the head."
   " The same author mentions another similar case ;
that of a young man who had an opening in his skull
from a wound, and through which  he could see an in-
creased action in the brain whenever anything oc-
curred, even in conversation, to agitate the mind of the
patient."
   As an instance of  the effect of certain kinds of
emotion in causing even more serious disease  than
cerebral hyperaemia—though this is  doubtless  their
starting point—the following case, detailed by Brous-
sais, and also cited by Dr. Brigham, is of interest:
   M. Thavernier, a  captain  in   the  French  army,
forty-two  years  of  age,  moderately stout,  but  well-
formed, received in the middle of the Palais Royal, in
May,  1815, ninety days before his death, a letter  con-
taining  bad news.  Whilst perusing it he  remained
motionless,  as if thunderstruck, and the left  side of
his face became  paralyzed and drawn to  the opposite
side.   He was taken to Val de Grace and attended to.
At this time he had  complete paralysis of the arm,
thigh, and  leg of  the right  side, and  was unable to
speak.  After using various remedies for more than
two months he began  to improve, and became so much
better as to  be able to stand up, and to speak, although
with difficulty.
   In this  state of improvement  M. Thavernier re- 
     MORBID ANA TOMY AND PA THOLOGY.   97

ceived  another letter, said to be from his wife.   He
read it, and instantly there occurred loss of speech,
general immobility, abolition  of sense, and complete
apoplexy.   He died in three days after the attack, and
on examining the head, there was found engorgement
of blood in the sinuses, and several  abscesses were ob-
served in the substance of the brain, and  other marks
of organic diseases.
   M.  Broussais  considered  this  case  to be one of
chronic inflammation of the brain, induced by a moral
cause.
   Every now and then we read accounts of  persons
dropping  dead under the influence of some strong
emotion produced, for instance, in  a court of justice.
" If I am  not speaking the truth  may God  strike  me
dead!" exclaims the witness.  He,falls  to the floor
as if shot,  and a post-mortem  examination  discloses a
cerebral haemorrhage, caused by a sudden overpowering
strain on the blood vessels of the brain.
   Some  emotions doubtless lessen the  amount of
intra-cranial blood just as some cause the countenance
to become pale ; but in such  cases the accompanying
phenomena are very different from those of cerebral
hyperaemia, although to  a superficial observer  there
may seem to be a close resemblance.
                          7 
CHAPTER  VII.
                   TREATMENT.

   Although, as I have said.it is rarely the case that
cerebral  hyperaemia spontaneously disappears, there
are few affections more amenable than it to treatment.
The  measures which it is proper  to adopt  consist of
those which are strictly medical and of others which
may  be regarded as hygienic.   The indications are to
relieve the  hyperaemic co/icition of  the brain by less-
ening the amount of arterial blood circulating through
it; to afford rest to the brain by  cessation or diminu-
tion  of mental work  and  by  diversions  of various
kinds ; and to  prevent a recurrence of- the disorder.
The  medical agents which  I have found most effica-
cious are :
   i st. The internal administration of the bromide of
sodium, calcium, lithium potassium or ammonium, and
even occasionally of zinc.
   The action of any one  of  these bromides is pri-
marily to lessen the amount of blood in the brain, as I
was  the first to announce over  twelve years ago.*  I
then said:
   * On Sleep and Insommia.   New  York Medical  Journal,
June, 1865, p. 202.
       98 
                  TREA TMENT.                99

   " Bromide of potassium can almost always be used
with advantage to diminish the amount of blood in the
brain and to allay any excitement of  the nervous sys-
tem that may be present in the sthenic form of insom-
nia.  That the first named of these effects  follows its
use I have recently ascertained by experiments on
living animals, the details of which will be given here-
after, suffice it now to say, that I have administered it
to dogs whose brains had been  exposed  to view by
trephining the skull, and  that I have  invariably found
it to lessen  the quantity of blood circulating within
the cranium, and to produce a shrinking of the brain
from this cause.  Moreover, we have only to  observe
its  effects upon the  human  subject to be  convinced
that this is one of the most  important  results  of
its  employment.  The  flushed  face,  the  throbbing
of the carotids  and temporals,  the suffusion of  the
eyes, the feeling of  fulness in the head, all disappear
as if by magic under its use."
   Of  the bromides, I  prefer either the sodium  or
calcium  compounds, though there is really not much
choice.   Any one of them may be given  to adults in
doses of  about fifteen grains three times a day.
   2d.  Ergot   is  scarcely less  beneficial  than  the
bromides in lessening  the quantity of blood  in  the
brain.  Both it and these latter appear to  act by the ^
increased tone which they give to  the coats  of the
arteries, and hence the diminution of their diameters. 
IOO
CEREBRAL HYPEREMIA.
A teaspoonful of the fluid extract (U. S. P., which I
have found to be preferable to Squibb's) may be given
with advantage three times a day.   A  better plan is
to give'the bromide dissolved in the fluid-extract.
   3d. Digitalis is generally of great service in giving
strength to  the heart and  arresting  its  disorderly
movements.  Eight or ten drops of the tincture may
be added to each dose of the foregoing mixture.
   4th. In those cases in which there are dyspeptic
symptoms the  administration of saccharated  pepsin
and charcoal  with each meal will be  found of great
service.
   5 th. The  application of  the actual  cautery to the
nape of the neck is a measure of  great value in the
treatment of cases  of cerebral  hyperaemia.   Care
should be taken that the cauterizing instrument, which
should have  a  platinum  tip, be heated to whiteness,
and that the skin be only lightly touched by it. There
are several forms of apparatus by which a very intense
heat can be  obtained.  A French instrument  lately
much in  use in this city soon gets out  of order  and
becomes worthless.
   The actual cautery appears to have a positive  and
in some cases an immediate influence in diminishing
the size of the cerebral arteries.  This it does, doubt-
less, through the sympathetic nerve in the neck.
   6th. Ice applied daily for a few minutes to the nape
of the neck is of decided benefit.   It acts through the 
TREA TMENT.
IOI
same agency as the cautery, and both  are but better
applications of a principle well known to our grand-
mothers—that a cold key placed on  the upper part of
the spine  soon arrests an ordinary nasal haemorrhage.
   7th. The galvanic current of low tension applied
to the nucha and the head, and repeated every day or
every alternate day for five minutes, as the  case  may
require, is  of great  benefit.  One pole should  be
placed at  the very summit of the spine and  the other
some three  or four  inches below it.   I have repeat-
edly seen, as I  stated several years ago * the arteries
of the retina contract while  the  current was passing
in this way—an  indication  that  a like influence was
exerted on the intra-cranial vessels.
   A similar effect is  caused by passing the current
directly through the brain, the poles being  applied to
the  mastoid processes.   A slight feeling of vertigo
is experienced both when  the circuit is closed and
opened.   Care should be taken that  the current is not
too intense.
   Such is  the medical  treatment which I have found
most generally serviceable in the treatment of cerebral
hyperaemia during  what may be  called  its  acute
stage.  But occasionally we meet  with cases in which
the  bromides are not well borne, and again, others in
which  ergot causes gastric  and   intestinal  irritation.
   * Spinal Irritation.—Journal  of Psychological  Medicine.
April, 1870. 
102
CEREBRAL HYPEREMIA.
In such instances arsenic may be substituted with ad-
vantage for either of these remedies.
    Lisle* has very clearly pointed out the benefit to be
derived from the  administration of arsenious acid in
cases of cerebral congestion, and this practice is equally
applicable to the  stage  of hyperaemia.  It appears to
me that the arsenious  acid is preferable to Fowler's
solution, or  any other arsenical preparation.   I usually
begin with the administration of one-fiftieth  of a grain
after each meal, and gradually increase to double this
quantity.  Lisle gives it  in closes of from one fourth to
the third of a grain daily, and there is no doubt, that it
may be given to this extent for several weeks, or even
longer,  without the least danger.
    When the  patient has been under the  foregoing
treatment for a month more  or less,  as  the  case may
be—at the end of which  time he will ordinarily be free
from  cerebral  hyperaemia—there is usually a state of
physical debility present which  ought to  be counter-
acted.   For this purpose  recourse  may be advan-
tageously had  to  strychnia,  phosphorus, iron  and
quinine, given either singly or in  combination.  If
either of the two  latter  be administered, it should al-
ways be in union with hydrobromic acid, prepared ac-
cording to Fothergill's formula.
   Strychnia may be added to the  solution  of  iron,
  * Du  traitement de la congestion cerebrale et de la folie avec
congestion et hallucinations, par l'acide arsenieux.  Paris : 1877. 
                  TREATMENT.                io3

quinine and  hydrobromic  acid,  or may be given as
extract  of  nux  vomica  alone  or  in  combination
with phosphorus.  In the former case I usually em-
ploy the following formula.   1$ strychniae sul., gr. i
quiniae sul., 3i. ferri  bromidi, 3 ss acid.  hyd.  brom.
(Fothergill's), 3iv. glycerinae, 5ij.  M.  ft. sol.  Dose:
a teaspoonful in water three times  a  day after meals.
    Should it seem desirable to administer phosphor-
us, as indicated by the existence  of decided nervous
debility, I usually make use of the  phosphide  of zinc.
The chemical formula of this substance is Zn.  P. and
consequently a grain represents a little  more than one
seventh of a grain of phosphorus.  The proper dose
is therefore about  the tenth of a grain.  A good for-
mula is B Zinci phosphidi gr. iij., nucis vom. ext. gr.
x., m. ft. in pill. no. xxx.  Dose : one three times a day
after meals.
    The hypophosphorus acid in doses of ten  or fif-
teen drops in  water three times a day, is  also an
eligible preparation of phosphorus.
    In two cases of cerebral hyperaemia of sudden de-
velopment and  in  which the symptoms were of great
intensity,  recently under  my care and occurring in
gentlemen whose brains were  kept  at  more  than
their full  measure of  work, I  derived   immediate
benefit from the application  of leeches to  the  inside
of the nostrils.   In no other  way can the blood be so
advantageously drawn  directly from the brain  as by 
104
CEREBRAL HYPER .EMI A.
this  method.   In general,  however, blood-letting in
any form is not required ; on the contrary, it is likely
to prove injurious.
   Thoughout  the  whole course  of  the  disease hy-
gienic means should be persistently carried out.  The
food should be nutritious, digestible and ample, though
not  excessive in quantity.  Alcohol  and  tobacco, if
used habitually by the patient, should be restricted to
moderate limits, and the former should certainly never
be taken in the form of spirits—whiskey, brandy, gin,
or rum.   Light malt beverages and the wines of Ger-
many, Italy or France, when used discreetly, are not in
my experience injurious—on the contrary, I think that
in the latter  stage, when tonics are  so generally ap.
plicable, they are of decided advantage ; used of course
with becoming moderation.  Tobacco I  have never
seen do harm, unless indulged in to excess.   Tea and
coffee may safely be left to  the patient's own inclina-
tions and  experience.   I believe  that more  harm  is
done by suddenly breaking off a habit, even though it
be somewhat injurious, than by tolerating it within due
bounds.  Exercise in  the open air—walking,  horse-
back riding,  or  driving, is  always  beneficial.  The
same cannot be  said of gymnastic contortions, which,
to make them worse, are usually performed in hoi
rooms.
   Baths are always serviceable.   Whether  they are
to be hot, warm or cold may be left to the inclination 
                  TREATMENT.                105,

of the patient, or be determined by experience in each
case.   A hot footbath on going to bed certainly aids
in procuring  sleep by its  derivative effect from the
head.   A cloth wrung out of hot water, and laid over
the pit  of  the stomach, often has a like influence.
The effect of a light supper, taken  just before retiring
for  the night,  is frequently very decided in its action
as a producer of sleep.   The rationale is not difficult
to understand.  For food to be digested, there must be
an  increased flow of blood  to the stomach, and a part
of this  comes from the brain to the  relief of the sur-
charged vessels.
    Massage or " rubbing " is sometimes of service in
cases of cerebral hyperaemia, but is  more frequently,
in my  experience, productive  of nervous irritability.
It cannot take  the place of exercise in  the open air
except  with those who cannot walk.  To see a strong,
robust  man  submitting himself to the manipulations
of the  "rubber" has always  struck me as an absur-
dity, and the  same may  be  said  of  " lift cures."
None of these things are more than  sorry substitutes
for  a brisk walk.
    Amusement whereby the mind is as it were  got
out of the rut  in which it is running, are of great im-
portance.   No people  take amusements  with  more
difficulty than Americans, of whom some one has said
" they  are  never  happy  unless  they are miserable."
The man who  is harassed by daily cares and anxieties- 
I06         CEREBRAL HYPEREMIA.
does not get rid of them by going home  and sitting
down to think.   He requires  a complete change to
turn the current of his thoughts—diversion in the
fullest sense of the word.   Each one must choose for
himself that form  which  is  most agreeable; but  I
think it may safely be  said that, in general, theatrical
performances of some kind, should enter largely into
the systematic scheme of amusements for the subjects
of cerebral hyperaemia.
    And perhaps, as a permanent means of taking the
mind from its laborious employment, nothing equals
a " hobby "—something to which we  can turn  after
work is over with the certainty of  finding the diver-
sion which the brain so  imperatively demands. As to
the kind of subject to be taken  up, the  taste  and
means of the patient must determine.   If the patient
is unable to take an interest in anything but his  busi-
ness, the case is indeed  a bad one, and the possibility
strong, that some more serious affection than cerebral
hyperaemia will assuredly make its  appearance.   Cer-
tainly while the disease exists, the patient, if he ex-
pects to be cured, must consent to use his brain in  a
rational manner.  To  take medical  treatment  and
then to  continue the mental exertion which has been
the prime cause of  the  disorder, is so absurd that it
is  surprising that otherwise sensible  people will not
see its folly—and yet, as a rule, they do not, and  then
are dissatisfied that they do not get well as rapidly as 
                  TREA TMENT.                l0y

they think they should or that they suffer from relapses.
It would be just as sensible for a person to put a heal-
ing salve on a burnt hand and then immediately stick
the hand in the fire; and the cause that induced the
disease in the first instance will  just as  certainly in-
duce it again if the opportunity be given.
    " But," as I have said in another place,* "it is not
always the case that the most positive advice on this
point is  followed.  Men who  would  readily see the
impropriety of walking three or four miles while  suf-
fering from an inflamed knee-joint, do not hesitate to
exert a disordered brain to the extreme limit  of its
power.  It is impossible  that the action of a brain
thus  affected  can be  such  as to  evoke sound  and
healthy thoughts.  It  is not to be wondered at, there-
fore, that the subjects  of cerebral congestion, who in-
sist upon  attending  to .ueu avocations and on con-
cocting schemes  for obtaining wealth or fame,  should
perpetrate acts which  result in the loss of fortune,
and the acquisition of  a reputation far different from
that sought."
    The first requirement  in the treatment of  a dis-
eased organ is almost always rest.  Work is  neces-
sarily the result  of an  increased blood  supply.  If,
therefore, the patient  already  suffering from the ef-
fects of too great a flow of blood to his brain, persists
   * A Treatise on  the Diseases of the  Nervous  System. 6th
edition, New York: 1876,  Art. Cerebral Conjestion, p. 55. 
108         CEREBRAL HYPERAEMIA.
in those actions which directly augment the already
excessive current, the result will inevitably be an ag-
gravation of the symptoms, and in all probability, the
development of  some hopelessly incurable malady to
which cerebral hyperaemia is as nothing.
FV!>. 
CHAPTER VIII.
ANIMAL THERAPEUTICS IN THE TREATMENT OP CERE-
                BRAL HYPEREMIA.

  It is well known that many of the most powerful
medicines of the pharmacopoeia are obtained from vege-
tables.  It is also a familiar fact that the mineral king-
dom supplies many of the most active remedies of the
materia medica.
  In the first category we have opium and the various
substances, morphia,  codeine, narcotine, and  a large
number of others contained in it; strychnine from nux
vomica, atropine from belladonna, aconitine from the
aconitum napellus  (a  plant  so  similar in its  general
characteristics to our  common horse-radish that cases
of poisoning from mistaking one for the  other are
numerous), hyosciamine from henbane, and hundreds
of others of greater or less power.
  Among the minerals are mercury and its preparations,
chief among which are calomel and corrosive sublimate;
arsenic, which is used in medicine chiefly as Fowler's
solution; iron and  its score or more of compounds, such
as the sulphate, the phosphate, the citrate; bromine and
its combinations with sodium, potassium, calcium, and
ammonium as bromides; iodine, chiefly used as iodide
     109 
no        CEREBRAL  HYPERAEMIA.
oi potassium;  all the alkalies, as soda, potash,  lime,
ammonia, and magnesia.  There is scarcely a single
elementary substance in the whole alphabetical range
from arsenic to zinc that is not used in medicine.
  Now, how is it with the animal kingdom ?
  During the Middle Ages various parts of the lower
animals, and even of man himself, were used as reme-
dies.   This, however, was not so much from  any reason
based on a knowledge of their chemical constitution as
from the idea that they  were possessed of  an occult
influence, due to some peculiar circumstances connected
with them.  Thus the fingers of  a man who had been
hanged were considered to be of special efficacy in the
treatment of certain diseases; the flesh and internal
organs of lizards, snakes, cockroaches, and other repul-
sive animals were thought to be of great value, and so
on with even more disgusting agents.
  Until recently all  these ideas were looked  upon by
modern physicians as relics of a superstitious and semi-
barbarous age, for they saw in the fact  of the employ-
ment of these substances nothing beyond the horror of
the associations connected with them; but recent investi-
gations lead us to a very different conclusion.   It is well
known  that some  of the  most active  poisons known
to science are formed during the decomposition of ani-
mal bodies.   Certain bacteria  make their appearance
in  these organisms  and  produce compounds  called
'' ptomaines,"  which cannot be distinguished by the 
ANIMAL  THERAPEUTICS.         Ill
most rigid chemical analysis from  certain other sub-
stances derived from vegetables.
  Thus there is one resembling digitaline, another mor-
phine, another atropine, another aconitine, and so on;
and this not only chemically, but also in their effects on
the human system.   It will be  called to mind by our
readers that in the case of the late Carlyle Harris it was
disputed  by the chemical experts who testified at the
trial  whether or not the  reactions obtained  by  the
analysis of his murdered wife's  body were due to mor-
phine or  to a substance produced during decomposition
and acting  to tests  exactly in  the  same way  as mor-
phine.   Selmi, an Italian  chemist,  has saved several
suspected murderers from punishment by proving that
the substances found in the bodies of the dead persons
were not strychnine or morphine or delphinine,  but pto-
maines scarcely, if  at all,  distinguishable from these
alkalies.   How do we know, therefore, that there is. not
some remedial power in a hanged man's fingers ?  Not,
of course, because he has died by hangirig, but because
they are animal substances in a state of incipient putre-
faction.
   Medical science has not yet, however, taken hold of
the ptomaines to any considerable extent,  though doubt-
less the time will come in the near  future when these
powerful substances will be brought into subjection and
employed with safety and effect in the treatment of dis-
ease.  Already there are indications of such an advance. 
112        CEREBRAL HYPEREMIA.
The prevention of small-pox by vaccine matter; hydro-
phobia by the diluted virus passed through the bodies
of animals and then introduced into the human system;
the treatment of tetanus, or lockjaw, by an anti-toxine,
of tuberculosis by another, and diphtheria, the cholera,
and the  plague  by others,  are  all steps toward  the
yjtematic U32 of ptomaines.
   But the animal kingdom has not been altogether neg-
lected by modern medicine, for several agents of no small
efficacy belonging to this domain are used in the treat-
ment of disease.   Thus  we  have spider's web  for
malarial fevers, musk for certain spasmodic affections,
cantharides  (Spanish flies)  for  making blisters,  the
potato' fly for a like purpose,  ox-gall as a purgative,
pepsin from the pig's stomach for dyspepsia, and a few
■others not so frequently employed as those mentioned.
   But three or four years ago an impetus was given to
animal therapeutics by that eminent physician, the late
Dr. Brown-Sequard, which has been so markedly reen-
forced through the researches of several observers, my-
self and others, that practical medicine, and through it
humanity, will probably be more greatly benefited than
by any discovery that has been made since the notable
one of Jenner, and this latter was a step in the direction
of isopathy, to which  subject we shall presently more
fully advert.
   Dr. Brown-Sequard's observations referred to but one
organ of the body,  and  were not made in accordance 
            ANIMAL  THERAPEUTICS.        113

with a systematic theory such as that under which my
researches were conducted.  This theory may be ex-
pressed  in  a concrete form by the single word '' Iso-
pathy."
  Two distinct but analogous doctrines are embraced
under this term.   One is that diseases may be cured by
the products of similar diseases; as, for instance, small-
pox by the matter of small-pox and hydrophobia by the
peculiar virus of that disease.   This theory has recently
become  thoroughly well established through  the re-
searches of  Pasteur, Koch,  Kitisato, and others.   It
also embraces a theory that a diseased organ of the body
may be cured by the introduction into the system of the
corresponding organ of the healthy animal.   As show-
ing the rapidity with which science advances in these
days and the danger of dogmatic assertions by people
who do not know what they are talking about,  we may
state that the gentleman who defined isopathy for the
Century Dictionary—which, we believe, was published
only three years ago—rather superfluously adds the
statement that " both theories are absurd."   Probably
he will change his opinion before the next edition  of
the dictionary is issued.
  Relative to the researches I have made on the subject
of extracts  from  animal tissues  and the  theory upon
which I conceive their efiicacy rests, I can do no better
than submit an extract from the lecture on the subject
as it  was delivered before the class of the New York 
114        CEREBRAL HYPEREMIA.
 Post-graduate Medical School and Hospital January 16,
 1893,  aua*- subsequently published in the New York
 Medical Journal January 28, 1893, an(i i11 many other
 medical journals in this country and abroad:
   '' Organic beings possess the power of assimilating
 from the  nutritious matters they absorb the peculiar
 pabulum which each organ of the body demands for its
 development and sustenance.  The brain, for instance,
 selects that part which it requires;  the heart, the mate-
 rial necessary for its growth and preservation, and so on
 with the liver, the lungs, the muscles, and the various
 other organs of the body.  No mistake is  ever com-
 mitted; the brain never takes liver nutriment, nor the
 liver brain nutriment, but each selects that which it re-
 quires.  There are, however, diseased conditions of the
 various organs in which this power is lost or impaired,
 and as a consequence disturbance of  function, or even
 death itself, is the result.
   " Now, if we can obtain the peculiar matter that an
 organ of the body requires and inject  it directly into the
 blood,  we do away with the performance of many vital
 processes which are accomplished only by the expendi-
 ture of a large amount  of vital force.
   '' Iyet us suppose a person suffering from an exhausted
 brain, the result of excessive brain-work.  Three hearty
 meals are eaten every  day; but no  matter how judi-
ciously the food  may be arranged, the condition con-
tinues.  Now, if we inject into  that person's blood a 
            ANIMAL THERAPEUTICS.         115

concentrated extract of the brain of a healthy animal
we  suppty at  once the  pabulum which the organ re-
quires.   Then if, under  this treatment,  the morbid
symptoms disappear, we are justified in concluding that
we have successfully aided nature in doing that which
unassisted she could not accomplish.
  "All this is  applicable, not onl}' to the brain, but cer-
tainly to  the heart, the  generative  system, the spinal
cord, and, I believe, other organs of the body.  I have
repeatedly seen a feeble heart rendered strong, the blood
corpuscles increased in  number, and the color of  the
blood deepened by the  use of ' Cardine,'  and I have
many times seen an exhausted sexual system  restored
to its normal  power by the use of  ' Testine,' l Cere-
brine,' and 'Medulline.' "

  After giving in detail  the process for making  the
extract from the brain, " Cerebrine " (and the other
extracts are made with the same menstruum, with slight
variations in the proportions), the  effects of '' Cere-
brine '' upon  the healthy system are stated  to be as
follows:
  '' The most  notable effects on the human system of a
single dose are as follows, though  in very strong, robust,
and large persons a somewhat larger dose is required,
never, however, exceeding ten minims:
  " 1.  The pulse is increased in the  course of from five
to ten  minutes, or even less in  some cases, by about 
116         CEREBRAL  HYPEREMIA.

twenty beats in a minute, and is rendered stronger and
fuller.  At the same time there is a feeling of distention
in the head, the perspiration is largeh* increased, the
face is slightly flushed, and occasionally there is a mild
frontal,  vertical, or occipital headache, or all combined,
lasting,  however, only a few minutes.
   " 2. A feeling of exhilaration is experienced, which
endures for several hours.   During this  period the
mind  is more than usually active and more capable of
effort.  This condition is so well marked that if a dose
be taken about bedtime wakefulness is the result.
   "3. The quantity of  urine  excreted is increased,
when other things are  equal, by from eight to twelve
ounces in twenty-four hours.
   '' 4. The expulsive force of the bladder and the peri-
staltic action of the intestines are notably augmented,
so much so that in elderly persons, in wdiom the bladder
does not readily empty itself without considerable ab-
dominal effort, this action is no longer required, the
bladder discharging itself fully  and  strongly, and any
existing tendency to constipation disappears,  and this
is to such an extent that fluid operations are often pro-
duced from the rapid emptying of the  small intestine.
   "5. A decided increase in the muscular strength and
endurance is noticed at once. Thus I found in my own
case that I could ' put up ' a dumb-bell weighing forty-
five pounds fifteen times with the right arm  and thir-
teen times with the  left arm, while after a  single dose 
ANIMAL  THERAPEUTICS.         117
of extract I could lift the weight forty-five times with
the right arm and thirty-seven times with the left arm.
   "6. In some cases in elderly persons an increase in
the power of vision is  produced,  and the presbyopic
condition disappears for a time.
   "7. An increase in the appetite and digestive power.
Thus a person suffering from  anorexia  and  nervous
dyspepsia is relieved of these symptoms, temporarily at
least, after a single dose t^podermically administered.
   '' These effects are generally observed after one hypo-
dermic injection, and they continue for varying periods,
some of them lasting for several days.  In order that
they may be more enduring, two doses a day should be
given every day or every alternate day, as may seem
necessary, one in the morning and one in the afternoon,
and kept up as long as the case under treatment seems
to require."

   An agent capable of exhibiting such a striking influ-
ence over the brain and nervous  system generally as
'' Cerebrine '' has been proven to exercise could scarcely
fail to be of great  use in cerebral  hyperaemia and its
consequent phenomena  characteristic  of the  so-called
'' nervous prostration," " nervous exhaustion,'' or neu-
rasthenia.  That it is in reality a remedy of extraordi-
nary power has  been abundantly shown,  not only in
my own practice in my private hospital, where patients
are constantly under observation, but in the experience 
n8        CEREBRAL HYPEREMIA.
of other physicians of  undoubted skill  as  clinicians.
Used either alone or, as the case may require, in con-
junction with "Cardine,"  "Medulline,"  "Cerebrine,"
or " Testine," I know of nothing in the  way of thera-
peutics  at all equally capable of giving  favorable re-
sults.
  The very best results are obtained from the employ-
ment of the animal extracts in conjunction with the free
use of the Buffalo  lithia  water.  Many years ago  I
stated my opinion of this water in cases of cerebral hy-
peraemia, and time has only served to confirm the favor-
able views then expressed.
  The average dose of any one of the Animal Extracts
made according to my published formulas is five drops
two or three times a day.  Of course there are so-called
animal extracts manufactured  by unprincipled persons
and  largely advertised  in  the public press which have
none of  the properties of those to which I refer in this
treatise and which do not produce the effects mentioned
on pages 115 and 116.   These are, therefore, not to be
confounded with the genuine extracts, being absolutely
devoid of all physiological and therapeutic influence. 
    DR. WILLIAM A. HAMMOND'S
          PRIVATE HOSPITAL
                 FOR
DISEASES OF  THE NERVOUS SYSTEM
AND FOR THOSE DISEASES GENERALLY IN WHICH
     THE HAMMOND ANIMAL EXTRACTS
        ARE ESPECIALLY USEFUL.
FOURTEENTH STREET AND SHERIDAN AVENUE,

            WASHINGTON, D. C.

        WM. A. HAMMOND, M. D.f
           Ph ysician=in=Chief. 
 
 
 
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