-% r— r> ps p, f ■^r" 1 \/ F1 **"" T"'V ,? ■*" ° * A « r\C.DKAL | * Y p - :; V i / 1 ^ .»„ f«t r l/ 0 L S i i"»™ T * S ± w i LJi. i • L/ U u rS I c\/ *.->*PT;-iV.*i NATIONAL LIBRARY OF MEDICINE NLfl 005ST7LdLd D SURGEON GENERAL'S OFFICE LIBRARY Section.............................................. Form 113c No. W.D.,S.G.O. QCi |- ,\ U. S. GOVERNMENT PRINTING OFFICE; 1928 NLM005597660 Cerebral Hyperemia; DOES IT EXIST? A CONSIDERATION OF SOME VIEWS OF DR. WILLIAM A. HAMMOND, C. F. BUCKLEY, B.A., M.D., FORMERLY Superintendent of Haydock Lodge Asylum, England. y r '•A, NEW YORK G. P. PUTNAM'S SONS 27 and 29 West 2 3D Street 1882 VJ F. Trne^ "D C Copyright, 1882, By G. P. PUTNAM'S SONS. %%vtf - <%> ■UPLI6#TE Cerebral Hyperemia. DOES IT EXIST? Possibly among the developments of that most civilizing and beneficent of inventions—the printing press—there is none more curious, and certainly none more detrimental to public morals, than the ever-increasing plague of medical literature, so to speak, with which we are everywhere environed. But apart altogether from those infamies that are laid at our door-steps, or obtruded into our hands at the street corners, the medical practitioner has a grievance of his own of another* order. "To keep up with the times" he must perforce wade daily through no end of meaningless magazine literature, and must necessarily pour over seriatim those ephem- eral "works " which in nine cases out often appear to be published for no other purpose than to herald abroad the " genius " of some particular individual. There seems to be no conceivable form of extrava- gance that has not got its specious advocate; and 2 CEREBRAL HYPEREMIA. every advocate, to express his peculiar views, must forsooth write a pretentious volume or two, which had better be expressed in as many pages. The more general vice, however, is the garbling and dis- torting of ideas long since well expressed and pub- lished, or the attenuating and re-echoing fallacies long exploded. The result of all this is that the conscientious and diligent student of medicine has to undergo an insufferable amount of valueless labor in order to glean a few grains from the superabun- dant chaff. It really reminds one of the complaint of Horace, " Scribimus indocti, doctique po'emata passim.''1 More than once recently professional friends, whose natural endowments and matured ex- perience would entitle them to a foremost profes- sional rank anywhere, have expressed the opinion that the most cultivated observers in medicine seem to write the least at the present time, and that the little they do write is frequently pushed aside or obscured for a season by the more noisy efforts of those meretricious laborers whose sole aim in life seems to be a plunge into notoriety and lucre through the compilation of a ponderous volume. This idea has frequently been impressed on myself, but never so much as recently when trying to gather some information from several of the latest works on the " Nervous System," more particularly from the writings of Dr. W. A. Hammond, of New York. DOES IT EXIST? 3 His is probably the most prominent name in the medical literature of this country at the present time; and I doubt if there be another which carries so much weight in the public mind, whether the engaging question be a " forty days' fast " or the arraignment of some unhappy creature for his life in our courts of law. In this latter class of cases it has been my un- pleasant duty on more than one occasion to differ materially from the distinguished writer, and while I have done so on all occasions with the greatest deference, yet am I constrained to admit that the more consideration I have given to the study of his works the less diffident have I become in express- ing dissentient opinions. At best it is a very irk- some and unpleasant duty for any physician, in public court of all other places, to have to express views opposed to one who is looked, up" to almost as the leader of thought in this particular direction; and hence on more than one occasion I have been desirous of publicly showing some cause for my transgressions against the canons of Dr. Hammond. Some recent events, however, have tended to hasten my hitherto immatured decision. Several persons of excellent parts, whose minds had been highly and judiciously cultivated, whose physiques had never been deteriorated by ease or excess, whose family histories were unexceptional, and whose A CEREBRAL HYPEREMIA. habits and occupations were all of the most health- giving character, have called to consult me at various times. They recounted the sad, dreary his- tory of the multifarious ills that only hypochondri- acs and their physicians are familiar with. I found some few had read Dr. Hammond's last brochure on " Cerebral Hyperaemia," and others again who had not seen it were familiar with much of its con- tents from near relatives or friends who had been presented with the aesthetic monograph, and who had carefully conned its interesting pages. The consequence was that while some had " too much blood in the brain," others had " too little," and all were little removed from the condition of the pit- iable youth who had devoted more time than intel- ligence to the prurient pages of " Curtis on Man- hood," and kindred efforts. Thus this fastidious monograph on " Cerebral Hyperaemia" interested me intensely; and while banishing from my mind all unworthy considerations on the part of the writer, from my individual observation, as hinted above, I cannot withhold the opinion that the effect of the work is misleading, if not pernicious, not alone to the non-professional reader who may happen to consult its pages, but even to the professional reader, who may be disposed to follow blindly in the glamor of a great name. With this belief, I shall freely express my views DOES IT EXIST? 5 for what they may be worth, trusting that whatever defects or errors shall have a place in these pages may not be overlooked by abler pens, but dealt with in the same spirit—the spirit of truth-seeking— which has been the only incentive to their utterance here. In this way only has real progress been made in science generally, as well as in medicine : and it is my individual opinion that if a stricter censorship of medical works could be more generally adopted, we should all be saved much valuable time now de- voted to re-reading over and over the attenuated repetitions of our standard authors, or the sorry verbiage of semi-educated novices. " Non ego ventoscs plebis suffragia venor Impensis ccenarum et tritce munere vestis." CHAPTER I. INTRODUCTORY. To the careful reader of this Monograph on " Cerebral Hyperaemia," one of the earliest im- pressions, it seems to me, must be the strange med- ley of positive contradictions contained within its own one hundred and odd pages ; and whether he contrasts one chapter with another, or even com- pares different portions of the same chapter, the result will remain the same. Though desirous above all things to endeavor to do justice to the work as a whole, and avoid all semblance of partial or hyper-criticism, it can hardly be out of place to call attention, at the outset, to such glaring inconsistencies as those wherein the author at one moment announces to us the novel doctrine that chlorosis is the result of " cerebral hy- peraemia," and immediately after informs us that this same " cerebral hyperaemia" has, for its lead- ing symptom, " the redness of the face and throbbing of the cephalic arteries, indicating an increased sup- ply of blood to the brain:' 6 IN TROD UCTOR Y. y Again, as proof positive—nothing less—of the existence of the malady, the deleterious effects of "strychnia and quinine among other things which we know to increase the amount of blood in the brain," are pointed out in no doubtful language, and, very few pages later, we find recommended : " Strychnia Sulph. gr. i: Quin. Sulph. 3 i: Ferri Bromid. 3 ss : Acid Hydrobrom. § x: Glycerini § ii. Dose, a teaspoonful in water three times a day after meals." Another very remarkable peculiarity of the work is that while it claims to deal with a hitherto unrec- ognized undiscovered condition demanding a dis- tinctive name in our nosology, there is not a single pathological fact recorded in its pages to uphold the position assumed: and it is not too much to say that the chapter devoted to " Morbid Anatomy " is one of the boldest paradoxes in medical literature, inasmuch as all the " cases " of the new disease re- corded in the monograph—all recovered7 Hitherto in medical literature the rule has been that, in order to establish the identity of a previously unrecog- nized disease, which was to be henceforth desig- nated by a distinctive nomenclature, some new phase of morbid activity has been first demonstrated. But Dr. Hammond reverses this rule, gives us a chapter on " Morbid Anatomy" without a line on morbid anatomy in the chapter, but instead relates 8 CEREBRAL HYPEREMIA. a number of " cases " which may safely be referred to other and more generally recognized causes, and which " cases " are of necessity bereft of all " mor- bid anatomical" interest for the simple plain reason that not one of them was ever subjected to post- mortem examination. Not unlike statistics in the hands of the adroit politician, " cases " in the hands of the medical advocate are brought forward to sus- tain every conceivable theory. By way of illustrating this remark, I may be per- mitted to digress briefly from the subject imme- diately under notice, and take a " case " from the larger work of Dr. Hammond, " Diseases of the Nervous System." It is the first case in the chapter on " Cerebral Softening," p. 161, and though incur- ring the risk of becoming tedious it is necessary to quote the author's remarks at length in order that the reader may judge for himself. " Mr. R., a gentleman twenty-four years of age, awoke one morning, about the middle of March, 1870, with a sensation of numbness extending through the whole of the left arm and leg, and with a feeling of vertigo which was insupportable when he arose from the bed. He sat down in a chair, and while in this position was conscious of a buzzing sound in the right ear. In the course of half an hour the vertigo passed off, but the numbness and sound in the ear remained, and he occasionally saw INTRODUCTORY. g double. In a few days afterward he noticed a slight difficulty of articulation, owing to apparent thick- ness of the tongue, and about the same time ob- served that in the morning the pillow was wet with the saliva which had run from his mouth dur- ing sleep. His uncle, a wealthy gentleman of this city, sent him off traveling, but he returned in a few weeks with loss of power in the left arm and leg* which had begun to be manifested to a slight extent before his departure. * He came under my charge May 15th, 1870. " At this time the paralysis of both motion and sen- sation was well marked on the left side, as shown by the aesthesiometer and dynamometer. The line made by the dynamograph with the right hand was perfectly straight, while that made by the left was at an angle of forty-five degrees with the other. In his conversation he clipped his words, and he some- times left out the smaller ones. His memory he stated was materially impaired. There was almost constant headache over the whole frontal re- gion, and attacks of vertigo were frequent. There was no marked paralysis of the face, though the muscles of both sides were paretic, and he frequently had double vision. The right pupil * I would draw early attention to the completeness of the hemi- plegia in the case, 10 CEREBRAL HYPEREMIA. was largely dilated and insensible to light. Oph- thalmoscopic examination showed the left eye to be perfectly normal, but the retinal vessels of the right were smaller and straight, and the choroid was paler than natural. Upon inquiry I ascertained that he had given extraordinary attention to his business for a period of several months before the attack of numbness, frequently being up making cal- culations till three o'clock in the morning, and thus depriving himself of the necessary amount of sleep. " My opinion was that he was suffering from in- cipient softening of the brain due to disease of the capillaries, which in its turn resulted from cerebral congestion and exhaustion. I was further of the opinion that the lesion involved the right hemi- sphere and motor tract. I prescribed the phos- phide of zinc in the dose of the tenth of a grain, with half a grain of nux vomica in pill three times a day, with the constant galvanic current three times a week—the latter to be derived from fifteen of Smee's cells, and to be passed from forehead to oc- ciput for three or four minutes at a time. At the end of ten days he had lost his diploplia ; the pupil of the right eye had regained its natural diameter and irritability, and the vertigo and headache had notably diminished. The treatment was continued, and at the end of a month he had recovered the sen- sibility and power on the paralyzed side to such an IN TROD UCTOR Y. II extent, and had improved so much in other respects, that I advised him to take a short journey. He was absent two weeks, during which period he con- tinued to take the pills as before, and on his return was to all appearance well. He has since remained in excellent health." This case is of uncommon importance from more than one standpoint, and the reader can only do it justice by a careful consideration of every line. First of all, if the diagnosis be correct, it illus- trates the marvellous, we might indeed say magical effects of phosphide of zinc, nux vomica, and the constant galvanic current in curing diseases com- monly considered hopeless as regards complete and •permanent recovery ; and all this, too, in the brief short span of TEN DAYS. Secondly, it is no doubt intended as the type of this condition under consideration, viz., Ramollisse- ment or Brain-Softening ; and so given the place of honor in the record of cases : although its pathol- ogy is rather vague, inasmuch as we are told that the softening was due " to disease of the capillaries, which in its turn resulted from cerebral congestion and exhaustion "—whatever this may mean. And lastly, it is important, because if the evidence of brain-softening herein is defective; nay, if the weight of opinion be entirely opposed to any such assumption, it follows that the observations of the 12 CEREBRAL HYPEREMIA. writer are not always entitled to the credit com- monly accorded them hitherto, but, on the contrary, are to be received with judicious caution. Taking the report as it stands, and especially those portions of it relating to the complete hemiplegia and the quick and complete recovery, it does seem, to say the least of it, a very unique case of cerebral softening; and this view of its singularity is con- firmed by Dr. Hammond himself, in his treatise on Cerebral Hyperaemia, as will be seen later on. But in order to form a correct judgment on the matter it is necessary to consult the best opinions among our standard authorities, always bearing in mind that the writer himself in this case attributes the cerebral softening to u disease of the capillaries." Let us first refer to Hughes Bennett, whose pains- taking clinical labors are surpassed by few, if any, of the writers of this century. Under the heading " Cerebral Softening," p. 354, American edition 1870, he says:— " From a careful analysis of numerous cases of cerebral softenings I have arrived at the conclusion that they may originate in six ways: 1st, from ex- udation which is infiltrated among the elementary nervous structures ; 2d, from a mechanical break- ing up of these structures by hemorrhagic extrava- sations, whether in large masses, or infiltrated in small isolated points ; 3d, from fatty degeneration of INTRODUCTORY. j* the nerve cells independent of exudation ; 4th, from the mere inhibition of serum, which loosens the connection between nerve tubes and cells; 5th, from mechanical violence in exposing the nerve centres ; and 6th, from putrefaction." Further on, at page 3 5 5, in treating of hemorrhagic softening, he remarks : " There are none of the gran- ule cells so characteristic of an inflammatory soften- ing, although they may appear later as the result of exudation from the cerebrum surrounding the clot." This is worthy of note as showing that he desires not to confound hemorrhagicwith inflammatorysoftening —a fact which the text more fully elucidates. De- siring not to cumber the memory with extended quo- tations, I beg to refer the reader now to p. 357. Herein the author remarks : " From a careful analysis of 32 cases of softening of the nervous centres, which I published in 1842-43, it was shown that different symptoms were connected with exudative or inflam- matory, from those which occurred in non-inflam- matory softening. % In 24 of these cases in which cerebral softening was observed, granular corpus- cles were present in 18, whilst in 6 no trace of these bodies could be found. On analyzing the symptoms of the 24 cases a marked difference was found be- tween tho#e resulting from the two lesions. Thus in the cases where only inflammatory softening was present, well marked symptoms invariably existed, I4 CEREBRAL HYPEREMIA. such as loss of consciousness, preceded ox followed by dulness of intellect, contraction and rigidity of the extremities, or paralysis. On the other hand, in the six cases of non-inflammatory softening there was no paralysis ox contraction, and no dulness ox dis- turbance of the intellect. Again, in the four cases where both lesions were present, symptoms were always observed in the side of the body opposite to the seat of the inflammatory softening, but none ex- isted in the opposite side in the #ale, il lui semblait qu'il allait s'evanouir ; pour ne pas tomber il etait force de s'appuyer sur ce qui se trouvait a sa porte. Jamais cependant il ne perdit connaissance." To this he adds : " A lady at a certain time of life comes from Paris to Bordeaux, to consult me about brain symptoms which have troubled her for several months, and SYMPTOMS. ,y which consist mainly of forms of vertigo that scarcely give her any repose. On the most trifling occasions they manifest themselves, and go so far as to produce a state of syncope that enforces the re- cumbent position. Motion on the street, the sight of persons passing by, of a carriage moving a little quickly, brought on a return of the attack, so that in a short time the lady was unable to leave her bed- room. She believed herself threatened with apo- plexy, and her fears were increased by her unhappy surroundings that in a measure tended to foster this idea. To avoid the congestion that she dreaded ac- cording to the theory advanced she pursued a sys- tem of rigid dietary—limiting herself to gruel and soup—through fear of increasing her blood. Her appetite diminished, but her digestion in general re- mained tolerably regular. " Some medication and a sustaining and nourish- ing dietary at the end of eight days brought about a notable change in the situation. The attacks of vertigo were much less frequent, and in a short time the patient was entirely rid of them. Six weeks later her natural rotundity and health re- turned." If the interested reader can detect any intrinsic difference between the train of " symptoms" that (as Dr. Hammond asserts) characterize " cerebral hyperaemia," and those described by Trousseau as 48 CEREBRAL HYPERAEMIA. accompanying ordinary stomach disturbance (in some people), I shall heartily accord him a capacity for discernment that has not been given to me. * Compare the first case under the heading " symp- toms," by which Dr. Hammond illustrates the pres- ence of " cerebral hyperaemia" with the first case quoted above from Trousseau. Translate the one into French and the other into English, and as far as the essentials of illustration are concerned, and as far as relates merely to " symptoms," either may serve the purpose of one writer or the other. " F. H., a gentleman engaged in a manufacturing business which required all his attention to make it profitable, was informed one morning by his super- intendent that a large lot of material had been spoiled. He at once experienced an intense sensa- tion of vertigo, a sharp pain in the head, palpitation of the heart, and would have fallen had he not been supported by the bystanders. There was also a roar- ing sound in the ears and flashes of light before the eyes. On attempting to stand, the vertigo and pal- pitation were increased. There was at no time loss of consciousness, though the ideas were confused and the speech thick. In the course of a few hours the severity of these symptoms diminished, but that night he was unable to sleep, and in the morning the morbid phenomena reappeared, but with dimin- ished violence. For several months afterwards he SYMPTOMS. 49 was troubled with wakefulness, a sense of fulness and tightness in the head, occasional weakness of the limbs, a slight numbness, and a total inability to exert his mind in his business affairs without an in- crease in all the symptoms. Under appropriate treat- ment he entirely recovered." This case of F. H. is so essentially like that of Trousseau's hospital patient, that if clad, as I have said, in the same garb of language, it would be diffi- cult to tell them apart. The question then natur- ally arises, among such diametrically opposed views, which is the correct one ? Dr. Hammond refers this form of trouble to brain hyperaemia; Trous- seau would refer the same to a disordered stomach, with probably a leaning to the view that the sympa- thetic system is more or less implicated—and which guide are we to follow ? The practical physician, who is not a specialist, will have observed numbers of cases of this nature, and will formulate his own views accordingly. To myself the answer is simple enough, believing as I do, without further proof, in the impossibility of existence of such a condition as the " cerebral hyperaemia" of Dr. Hammond. To those, however, who may be inclined to adopt the brain theory (so to speak) in this connection, I would suggest to observe the effect of shock in its various manifestations on different constitu- tions. By it one's breathing is suddenly arrested; 3 50 CEREBRAL HYPEREMIA. another falls down in syncope; a third vomits; a fourth becomes a lunatic ; a fifth has jaundice ; each, according to some constitutional peculiarity, has a distinct and separate disturbance from what may be to others again a source of no evil whatever. I would further remind them of the fact that Trous- seau very plainly tells us how he restored his patient's health—by tonics and substantial fare; while Dr. Hammond forgets to inform us of any- thing more definite than " appropriate treatment," by which, indeed, if we follow the later instruction of the author, we may reach the very opposite poles of the pharmacopeia.* To follow the author into details is as difficult as unprofitable, and the more care devoted to the pur- suit the more manifest this assertion becomes. For example, after having recited two more cases like that of F. H., he deliberately tells us " These cases are cited not as exhibiting perfect representations of cerebral hyperaemia, but merely for the purpose of illustrating the suddenness with which the con- dition may be induced." * When we have recommended such diametrically opposed plans of treatment as that of bromide of potassium on the one hand, and phosphorus, nux vomica, etc., on the other, it is high time to ask which has been adopted in any given case, or at least our current notions of the therapeutic action of those drugs should be corrected by careful and unimpeachable experiments. SYMPTOMS. 5I It would appear then that in this disease, which, later on, we are gravely informed is merely a prelude to more serious mischief, there are various stages, and yet to the less instructed than Dr. Hammond it would seem that a mere prelude to other diseases, like the one in question, and that, too, in a matter of plain, tangible anatomy, which has lasted over twelve months, like some of the cases recited, ought to be pretty perfect of its kind—pretty well devel- oped, as far as such development is possible. This is merely pointed out as perhaps the culpa- ble carelessness of expression, which the author, in justice to himself, and the profession he would in- struct, should make an effort to correct in future editions—if such be demanded—of this most novel work. As far as warrantable, now, I shall endeavor to avoid minutiae and endeavor to present the writer's views in full. We are told that the symptoms of this new disease are broadly : Wakefulness, Illusions, Hallucinations, or Delusions, Mental introspection, Vertigo, Heat, pain, and a' sense of fulness in the head. On carefully comparing those symptoms either separately or collectively, it does seem a little odd that any author should base on them the fabric of a new disease, seeing that they are not at all un- common in diseases with which we are more or 52 CEREBRAL HYPEREMIA. less familiar. What there is " characteristic " about those symptoms seems, to say the least, a little ob- scure. What febrile condition do we know of that in its inception is not commonly accompanied by this same train and chain of symptoms? Take an acute case of hepatitis or gastritis, or even nephritis for example, and has it not in many subjects all the so- called "characteristic" symptoms of "cerebral hy- peraemia?" In the commonest disease of our climate of California, which for want of a better name we call catarrhal fever—a general febrile disturbance aris- ing from cold—what do we more commonly observe than "wakefulness, illusions, vertigo, pain and heat," etc., and are not these the exact indications of its presence, without any further positive evidence? But it will be urged that the complete combination of the symptoms mentioned is the characteristic feature of the disease under consideration. In an- swer to this I would simply ask the reader to glance over the illustrative cases in Dr. Hammond's own work. Again it may be alleged that the diseases I refer to produce cerebral hyperaemia. This I readily concede, and also recognize this form of cerebral hyperaemia. But what would be the result if in either of those diseases our treatment were solely or even primarily directed to the cerebral disturb- ance? Suppose in a common bilious attack, as the popular expression goes—and the nomenclature is SYMPTOMS. 53 far from misleading in the sense that more grandil- oquent ones are—which has all the "characteristic" symptoms above quoted, we commenced by pouring in bromide of potassium as the chief instrument in reducing blood-pressure to the brain, what would be the result? Only intense aggravation of the malady, as far as we can judge from the common action of the drug. And thus we may go on recounting and culling from various authors diseases of the most divergent origin and course to which all those symptoms are common. Not only will they be found in Dr. Beard's work on Neurasthenia—the counterpart of Dr. Hammond's cerebral hyperaemia—but they fre- quently appear in monographs on uterine diseases, and indeed among the works on the male genital organs also they familiarly obtrude themselves on our notice. I must not be understood, however, as implying that under those varied circumstances they exist merely in the imagination of the writers. On the contrary, I am convinced that this series of symptoms will be found in any form of malady pro- ducing grave constitutional disturbance no matter from what cause arising. But while it is one thing for an author to point them out as existing in rela- tion to the special subject of which he treats, it is quite another proceeding when a prominent writer asserts that they are "characteristic" of an entirely 54 CEREBRAL HYPEREMIA. new order of things, which on this basis alone he moulds into a new and distinctive name. To enter now on a little more detail: " Wakeful- ness," we are informed, " is generally the first symp- tom 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 com- plete 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." After this we are treated to various illustrations of the direful effects, that follow, on the emotions, memory and judgment. For my own part I have little doubt that wake- fulness unduly protracted leads at length to very deplorable results, although I have known hysteri- cal ladies, otherwise healthy, whose maximum of sleep has not exceeded an average of more than two hours in twenty-four for years in succession, and I am acquainted with professional gentlemen whose capacity* for mental toil is unsurpassed, who assure me that three or four hours is as much as they can sleep any night for weeks, and even months at. a * One of the ablest lawyers in the United States, who, recently in a noted criminal trial, displayed his pre-eminent ability, assured me that for one hundred and fifty nights prior to this trial, he never re- tired to bed before 3 A.M., and breakfasted between 8 and 9 a.m. SYMPTOMS. 55 time, and this without the slightest impairement of their intellectual vigor. But the question here, is, whether " wakefulness " be due to cerebral hyperae- mia or not. Now on this question there is much in- formation to be derived from the views of alienist physicians, and among them there is a rare concur- rence of opinion that this symptom of insomnia is one of the first and most frequent indications of ap- proaching insanity, but none claim that insanity is due to cerebral hyperaemia. On the contrary, there is a tolerable unanimity of opinion among this class of observers, and statistics tend to prove it, that the hydra-headed malady of this name is com- monly the offspring of brain fatigue and malnutri- tion ; of destitution and want; of irregular habits and exhausting toil, combined with the strain that a precarious mode of living, naturally produces on an enfeebled nervous system. Nor is insanity by any means the only malady of which wakefulness is the precursor. Who has not observed it in typhoid fever before the disease had fairly set in ? who has not noticed it in that painful scourge, acute phthisis, even when no other indication existed, save perhaps an occasional night-sweat? But it is unnecessary to multiply examples of this nature, and I shall therefore pass on to a very curious illustration of the strange pranks to which " hyperaemia " can sub- ject the human judgment. 56 CEREBRAL HYPEREMIA. " I have known," Dr. Hammond tell us, " a patient suffering from the disorder in question, take several thousand dollars every day 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." This gentleman's case may, indeed, be a very cu- rious study, but wherein the certainty of his condi- tion depending on "cerebral hyperaemia" lies, I am at a loss to understand. Under the light of recent brain physiology, however, it is quite intelligible that while at home, i.e., before leaving his house, some surrounding circumstance may invariably pro- duce a hyperaemia of that portion of his brain that presides over the passion of avarice, and when on Wall street, the wrecks strewn around or other no- ticeable objects, may produce an ebb in the avarice tract and a flood in the direction of the caution re- gion. Possibly this same theory of hyperaemia may explain how an esteemed professional friend missed a fortune! In discussing the question of " free will," on one occasion to sustain his negative view, he re- marked, " Now I held such and so many shares of mining stock, for a long time, and paid assessments faithfully for years. One morning something dis- agreed with me at breakfast, which gave me a mis- SYMPTOMS. 57 erable attack of nausea, and a horrid fit of " the blues " in consequence. In my unpleasant frame of mind, I went to my brokers and ordered all my stocks sold that morning. That same day stocks began to advance, and in a month from then I should have been a millionaire if it were not for that accursed breakfast." Applying this course of reasoning generally, how readily it may be argued that stomach-hyperaemia has as much to do with the emotions and judgment as cerebral hyperaemia has ; nor is the assumption inconceivable considering our very limited knowl- edge of the great sympathetic nervous system. However, to enter even briefly on a discussion of the effects of external conditions on the mind is no part of my object at present, no matter how allur- ing this subject may be. My task is simply to en- deavor to establish the fact that gentlemen in our pro- fession, even of the most colossal reputation, are not to be followed blindly without scrutiny of the ideas they advance; and, I make bold to say that in the brochure before us, the reader, who is at all inter- ested, will admit that the author is far from advanc- ing professional knowledge. I think it is no exaggeration to say that the chapter on symptoms, by no means the worst of its contents, would alone entitle this work on "cere- bral hyperaemia" to a prominent place among 58 CEREBRAL HYPEREMIA. the " curiosities of medical literature." Take the following: " 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 annoyance, and the little every day troubles of life appear of vast importance. The disposi- tion accordingly becomes suspicious, peevish, fret- ful. 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 even' kind, in the vain expecta- tion of being able by such means to overcome the disease; and, again, others strive by a constant change of one physician for another, or substitu- tion of one quack medicine for another equally quackish, to get relief from their mental and phys- ical distress. In some there are very few decided symptoms present, except the inability to sleep and the incapability of concentrating the mind on any object of study or labor, without inducing pain or discomfort of some kind in the head. In all, how- ever, there is the same mental introspection. If this be not an excellent description of our old familiar enemy, hypochondria, pure and simple, SYMPTOMS. 5g without even a change of dress, English phraseol- ogy can bear more widely divergent interpretation than I am familiar with*; and if Dr. Hammond can demonstrate that this most intractable malady is due to " cerebral hyperaemia," mankind and the profes- sion for the centuries to come would bless his mem- ory. But alas ! th;s theory has been tried and found sadly, woefully defective ; and the physician at the present time who would strive to subdue hypochon- driasis by those mighty subduers of " cerebral hy- peraemia"—the bromides—had better have a care that their patients cannot at all times lay hands on dangerous weapons. Although the question as to whether hypochondria—and even Dr. Hammond cannot refuse the name to the symptoms described —depends on " cerebral hyperaemia" or not, scarcely admits of serious discussion, yet it may be proper to see how other authorities view this obscure malady. Sir William Gull and Dr. Anstie, whose laborious efforts and general ability few will dispute, in de- scribing its etiology, make use of the following lan- guage: "The 'causes of hypochondriasis' is an expression even more singularly unhappy than the * In order to avoid further quotations than strict necessity de- mands, I would refer the reader to the article on hypochondriasis in Reynolds' " System of Medicine," where he will find this same de- scription applied to the diseases discussed therein, 6o CEREBRAL HYPEREMIA. average instances of a phraseology of causation ap- plied to those circumstances which preceded the outward and invisible development of functional disorders. Again it is commonly said that reading or con- versation on medical topics often frightens laymen, and more rarely even doctors into a nervous and hypochondriacal frame of mind. There is, doubtless, something to be attributed to such influences, but the most thoughtless person could not fail to be struck on reflection with the surprising infrequency of hypochon- driasis in comparison with the ubiquitous operation of such influences as grief, fatigue, the sense of shame- ful failure, the habit of miserable and heart-weary- ing idleness, and the practice by the laity of reading medical treatises." Again, concerning the pathology, they say: " The pathology of hypochondriasis in the strict sense of the word does not exist, for there are no anatomical or physiological facts upon which it can be based. Morbid anatomy has revealed absolutely nothing which in the slightest degree explains the occurrence of the disease; and the physiology of the symptoms is to the last degree obscure and un- certain in its interpretation. " It is neither impossible nor unlikely that the improved modern methods of examining the ner- vous centres, if they could be applied to the central SYMPTOMS. 61 ganglia of certain visceral nerves (and especially to the nucleus of the vagus) might detect appreciable changes even in the early stages of the disease." Bearing in mind that the symptoms above quoted from Dr. Hammond's work coincide almost verbally with those detailed in Gull and Anstie's articles re- ferred to, the reader is called upon to adopt the pathology suggested by the former, or accept the " unvarnished tale" of the latter gentlemen. To my mind the undiscovered and impossible pathol- ogy of Dr. Hammond only proves to what extrava- gance " hobbies" can lead the individual in any calling, who is pampered by an unmerited popular reclame. If the reader for a moment imagines that I am the advocate of any special theory, or have other motive than a common sense of justice in this matter, I would beg of him to read this monograph on " cere- bral hyperaemia," from pages 27 to 32. I doubt if in the English language there be a more succinct description of all the symptoms of hypochondria, and yet we are blandly informed that they are the "characteristic symptoms" of the "new" disease. Again: " 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 See prior quotations from Trousseau. 62 CEREBRAL HYPEREMIA. 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 within reach, to sit down on the nearest door-step, or even the curb-stone, till the violence of the attack had in a measure abated." Thus we are carried along in the loose category of "characteristic symptoms," without even a pause being made to enquire as to the possibility of their arising from totally different causes or not. An un- reasonable theory is upheld by a profusion of mean- ingless verbiage that mystifies the reader at every step, and the unfortunate practitioner who unfalter- ingly follows the dicta laid down in this singular monograph, will too late discover to what absurdi- ties he is so unhesitatingly led. Vertigo, the most prominent symptom of " cere- bral hyperaemia," of what exhausting disease or con- dition is it not a symptom ? Is it not one of the foremost symptoms of uterine diseases as well as that under discussion? When we pass an instru- ment to relieve a stricture of the urethra, and the individual topples over, half conscious on the floor, must we at once conclude that this direful cerebral hyperaemia has set in? When an individual with disease of the uritral valves tells us that he felt so faint as to be obliged to lean against a door or lamp SYMPTOMS. 63 post, else he would have fallen on the streets from vertigo, are we to recognize at once enlargement of the brain arteries, and deplete them accordingly? When we open a felon in the hand of a poor, ema- ciated domestic, and vertigo ensues, must the bro- mides be immediately called into requisition, and her digestion deranged in addition to her already existing discomfort ? This " characteristic symp- tom," in short, I find so commonly existing among diseases of all characters and kinds, that I am totally at a loss to understand how it can be claimed in a modern work on medicine as peculiar to any one disease. Not only is it a common characteristic of diseased conditions, however, but it is also quite compatible with an excellent degree of health. What surgeon, leaning for a long time over some tedious operation ; what student, sitting at his desk for several hours devoted seriously to some common mental labor, has not occasionally experienced more or less vertigo on assuming the erect position ? And in this connec- tion, bearing in mind ordinary hydraulic laws, I would ask the physiologist whether cerebral anaemia, under such circumstances, be not a more probable cause of vertigo, i. e., if the vertigo be at all govern- ed by the condition of the circulation. Considering my previous remarks about " cases," it is not quite consistent to introduce any of my own, but I trust 64 CEREBRAL HYPERaEMIA. two very marked cases of vertigo, which have come under my notice, will not be here out of place, the more especially as I feel assured they accord with the experience of every intelligent practitioner whose attention is at all turned to the strange phases of nervous diseases. One is that of an eminent member of the bar of this State, who for several years had been the slave of alcohol, but otherwise of an uncommonly robust constitution, physical and mental. Through the efforts of a powerful will and some slight aid on my part, he abandoned his besetting vice several years ago, but for some two years after he frequently report- ed himself as afraid of falling on various occasions ; sometimes in court, at other times on walking along the street. During an absence on my part of some six months in Europe he consulted an intelligent gentleman unacquainted with his previous history, and the very first advice he received was to indulge in "a moderate quantity of wine and stimulants." He did so, and immediately his "vertigo" disap- peared, but feeling that this course was injudicious he again abandoned stimulants, and again his ver- tigo returned. As on the former occasion, again all alcohol was withheld on my return, and the patient was put on a free use of valerian, nux vomica, ammo- nia and calisaya bark—all of which as far as we know their therapeutic value—tend to produce cere- SYMPTOMS. 65 bral hyperaemia, and yet this gentleman now, after a lapse of six years, not only survives in the flesh, free from the dreadful consequences Dr. Hammond so eloquently depicts, but stands forth as an ornament of his profession, alike remarkable for his assiduity and talent. Another case is that of a gentleman about fifty years old, whose ample fortune suddenly disappear- ed in one of the financial collapses to which we are so periodically subjected. He is known to all his acquaintances as a man of the most imperturbable character, having been more than once sorely tried in most trying situations. He is probably the nearest approach to the " man of iron nerve," it has ever been my fortune to meet, and yet on more than one occasion of late he has fallen unconscious on the street. On the last occasion the attack lasted such a length of time, that he found himself in the receiving hospital of the police department, without knowing anything as to how or wherefore he arrived there. On his consulting me after this, I concluded that his malady was some of the ob- scure forms of epilepsy, for the reason that all his organs appeared to be in the most excellent condi- tion. Other illness in the family, however, shortly after led me to visit the house, and from the revela- tions then made, I readily changed my opinion. I found that the proud man had been for some time 5 66 CEREBRAL HYPERaEMIA. living in a condition to which he had all his life-time been a stranger—that meagre and even scanty fare had taken the place of generous and sumptuous liv- ing. A worthy friend by suitable occupation re- lieved the " res angusti domi," and now for eight- een months there has been no collapse on the street; no vertigo. Was this, I ask, a case for depleting the cerebral arteries; for these all-powerful bromides that nauseate the stomach; or for abundant and nutritious diet? So much for " vertigo the most prominent of all the symptoms." Let us now glance at the subject of illusions where we find— " The special senses could scarcely be expected to escape giving evidence of derangement, and hence among the chief manifestations of the intra-cranial disorders 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 firearms. A gentleman recently under my care suddenly heard a report as if a pistol had been shot off within a foot of his head. 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. After this there was scarcely a day that the sound was not heard. It was entirely subjective, as per- SYMPTOMS. 67 sons in close proximity to him at the time heard nothing." If a novice in medical literature had published this sort of twaddle, the probabilities are that all the journals of the country would so load him with ridicule that his name would be never heard again. In the name of common sense, so frequently out- raged in this precious monograph, why not first prove that illusions in general are dependent on hyperaemia, and then proceed to illustrate it by cases ? But what medical observer at the present time doubts that cerebral anaemia is not a more frequent cause of illusions and hallucinations than cerebral hyperaemia. Witness the mental condition of our patients in any exhaustive disease, and above all follow closely the asylum records of confirmed insanity of one kind or other, and it will be found that physical exhaustion and hardship, and malnu- trition, are the great factors in filling up the homes for the insane throughout the world. Apropos of this subject of illusions, how does the writer explain their constant presence in delirium tremens, and their complete abolition by such hypnotics as opiates and chloral hydrate, which we know—if we can rely on anything as definite in therapeutics—produce the utmost afflux of blood to the brain. This form of inconsistence, however, is so fre- quent and marked that it would be ludicrous were 68 CEREBRAL HYPERaEMIA. it not for the gravity of the subject. For example, in the page next to the quotation above given, we find: " In another case, the onset of the disease in a gentleman who had for many years overworked his brain, was extremely sudden and was attended with facial paralysis. I treated him for this latter con- dition with electricity, with but little benefit; but one day he struck his head violently against a gas burner hanging over his desk, and shortly after- ward 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." This is exquisitely droll, and the writer must have, at least, a fine vein of humor in his composition, for the advices implied herein are—that electricity, which he so constantly recommends in cerebral anaemia, can also be turned to relieve cerebral hy- peraemia ; and, 2d, failing in this, we are to try the efficacy of a first-class bludgeon on the obdurate head of the patient, for a good hickory may, with- out doubt, be said to lay claim to as much virtue in this direction as a mere commonplace gas burner. After this we are naively informed that " such cases are inexplicable," although the while they are all given as illustrations of " cerebral hyperaemia," and the reader must then form his own conclusions SYMPTOMS. fig as to how a writer, who thus so abruptly contradicts himself, has ever achieved any higher position than a mere butt for ridicule. There surely must be some " brain bankruptcy" in the immediate neighborhood of an effusion that in one breath claims that a certain condition is the result of " enlargement of the cerebral arteries," and immediately after claims that the condition is " inexplicable." I shall not attempt to follow the writer through the various mazes of his aural and ophthalmoscopic investigation, but it is not too much to claim that all the conditions detailed by him as existing in those organs are found abundantly in the diseases peculiar to these parts without any brain disease whatever, and are as frequently missing in the cere- bral diseases most closely allied to this alleged new one. Among the symptoms, after those above referred to, are given : " Disturbance of the sense of smell and taste; sensation and the power of motion ; the appe- tite ; constipation and the urinary secretion." Why not add club foot or hernia? In view of the paragraphs already taken from Trousseau and Foster, however, the remarks on ap- petite and urinary disturbance are quite interesting in their way. " The appetite is capricious, and the stomach acts 70 CEREBRAL IIYPERaEMIA. imperfectly and sluggishly. The gastric juice is not secreted in sufficient quantity for the purposes of digestion, and, the peristaltic action of the stomach being weakened, the food remains within it a long time undigested and undergoing fermentation. Re- gurgitations both of the solid contents and the gases are common, and the patient tastes his meals sev- eral hours after they have been swallowed. Gases accumulate 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 to the error of regarding them as of primary importance, instead of considering them as they are merely con- sequent on the head trouble." Now given the conditions here detailed in a pa- tient under notice, I ask the reader not carried away by any wild theory of an alleged new dis- covery, whether he would direct his primary treat- ment. I ask Dr. Hammond himself whether he would treat a person thus suffering with nauseating bromides to dispel presumed brain trouble, or treat the positive manifest disturbance of the stomach with tonics and light nutritious diet? Every reader will recall many cases of this nature in which the " stomacho Iceso" theory advanced by Trousseau has left nothing to desire, and in which, if the brain SYMPTOMS. j T were the point of attack so to speak, failure would undoubtedly result. " The urine is in some patients scanty and high- colored ; in others it is prof use and almost as pale as ivater. Oxalate of lime is often present, and an excess 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 ner- vous 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 emo- tional strain." After what has been already said against this theory, that the amount of phosphates or salts in the urine bear any proportion whatever to the amount of brain labor, a further discussion of the subject would be out of place here. It is, however, interesting to observe that what was positive asser- tion on a foreign occasion {vide introduction) is here thrown out with a judicious modicum of hesi- tation by the writer. Tedious and profitless as it may be, I would ask the reader to give some consideration to the follow- ing, also among the " characteristic symptoms" : " But one of the chief categories of symptoms re- mains to be considered—chief at least so far as the more obvious appearances go, though like the other 12 CEREBRAL HYPERaEMIA. 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 publication 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 twenty to thirty or even forty beats to the minute. Besides this, there are frequent and violent palpitations, either spontaneous, or provoked by the most insignificant causes, mental or physical. " Emotional excitement is, however, the most prolific cause of cardiac disturbance in patients affected with cerebral hyperemia, and at times leads to serious results." The least that can be said of this meaningless method of dealing, with a subject of extreme profes- sional importance, is that it is reprehensible beyond measure. What human heart is not disturbed by "emotional excitement " in a greater or less degree, and are not all the human family sufferers accord- ingly from " cerebral hyperaemia " according to Dr. Hammond ? But the little real consideration given SYMPTOMS. 73 to this whole subject by the writer, is probably herein more apparent than in any paragraph of similar length in the work. Surely a gentleman who i parades before the nation as an authority on ner- vous diseases, cannot be ignorant of the fact that the sympathetic nervous system—not the brain—is universally regarded as the motor power of the heart, i.e., as far as experimental physiology can elucidate the subject, and consequently the assump- tion that hyperaemia of the brain can be the cause of cardiac disturbance, is entirely without founda- tion ; while, on the other hand, it can be easily un- derstood how readily cardiac disturbance can give rise to such form of cerebral hyperaemia as is pos- sible. It is unnecessary to remind the reader that the sequence would naturally be—1st, emotional disturbance ; 2d, cardiac excitement; and 3d, cere- bral hyperaemia—always denying that this condition described by Dr. Hammond has existence other than in his imagination. I presume another " characteristic symptom" is intended by the following: " If the disease be not arrested, it is quite certain to develop into one or another of the forms of cerebral congestion, apoplec- tic, paralytic, epileptic, soporific, maniacal or aphasic, to which in another place I have given full consid- eration. I do not dwell on them here for the reason that this essay is concerned only with a series of 74 CEREBRAL HYPERaEMIA. phenomena which I conceive to be due to cerebral hyperaemia, constituting the first, or prodromatic, stage of congestion of the brain." This final paragraph on " symptoms," though by no means unique in the work, baffles all criticism, for its ring and clamor is only worthy of the street vender of patent medicines. I would not worry the reader by contrasting the various epithets above applied to different forms of cerebral hyperaemia. In face of all authentic facts to the contrary, estab- lished on a basis as secure as anything in the posi- tive sciences, he jumbles together a string of words, and would have us believe that such widely differ- ent diseases as apoplexy and epilepsy, aphasia and mania, have a common origin, and then, with a boldness that is positively unrivalled in the legiti- mate ranks of the profession, wheels round and in- forms us that this new disease—which on a former occasion he informs us lasted in some cases over twelve months—is merely " the prodromatic stage of cerebral congestion." This, undoubtedly, it must be, whenever it has any existence, and, as a prodro- matic stage, cannot last longer than two or three beats of the heart at most. CHAPTER III. "DIFFERENTIAL DIAGNOSIS." The opening of this chapter, not unlike much that precedes it, must be curious reading to the thoughtful practitioner of medicine, and while in the main feature of inconsistency it is not materially different from the others, yet, if anything, there seems to be more abandon displayed throughout as the writer progresses. Thus: "Although the main features 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, chlorosis, malarial disease, and even under the very opposite condition to that to which I assign them, ' cerebral ancemia.'" In this category it is a little surprising that " hy- pochondria," the description of which so closely conforms to that of the new disease, has no place or mention, and that the vivid portraiture by Trous- seau of " vertigo a stomacho Iceso" which is not a j6 CEREBRAL HYPERaEMIA. dyspepsia pure and simple, and which in the main so closely resembles " cerebral hyperaemia," has also been completely ignored, though this form of mal- ady is probably one of the most frequent with which practical men have to deal. Nor is it less surprising that "chlorosis" and malarial disease should have a place herein, considering how distinct their features are, compared with the symptoms already given of the " new disease." But more of this anon. To continue the quotation: " The name by which we designate a disease is of no consequence so long as it does not lead us into erro- neous 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 affection under notice. It is important, therefore, to have ex- act conceptions of the character of the symptoms and the general course of the disease before we venture to give it a name."* The truth of this statement throughout no ra- tional physician will dispute, but how closely Dr. Hammond adheres to the fundamental idea, the reader must be the judge, both from what precedes and follows. What " exact conception" of " cere- bral hyperaemia" can be obtained from the series of * It may also be essential to have some faint idea of the pathology of the disease. "DIFFERENTIAL DIAGNOSIS." 77 platitudes contained in this disjointed and diffused chapter on " characteristic symptoms " ? It is no exaggeration to say that there is nothing character- istic in it, that all the symptoms detailed therein are common to many diseases, two especially: hy- pochondriasis, and " vertigo a stomacho Iceso." That injury has been done, and will continue to be done, by this unique monograph, and especially in consequence of the author's prominence, needs no proof whatever on my part; but if such be needed, it is necessary only to bear in mind what the writer dwells on with most force throughout, though not expressing it in so many words, viz. : that nearly, if not quite, all the obscure diseases to which flesh is heir (see chapter on symptoms) arise from " cere- bral hyperaemia," and that the remedy, par excel- lence, for this condition is one or other of the bro- mides. It is true, however, that in detailed instruc- tions these two leading principles are constantly departed from, and so somewhat foiled in their viciousness. To further show that I do not exaggerate in stating that the author ascribes to " hyperaemia " such multitudinous diversities of neurotic troubles, let us take the first case in this chapter on "differ- ential diagnosis ": " Many of the so-called menstrual neuroses are, in reality, cases of cerebral hyperaemia, the result 78 CEREBRAL HYPERaEMIA. of inordinate 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 the head of hyperaesthesia, is clearly an al- most typical case of ' cerebral hyperaemia,' and is as follows: 'Jeanne Thillois, aged 51 years, was of strong constitution and had never been ill till at about her thirty-sixth year a violent mental emo- tion caused a suppression of the menses, and this was followed by heaviness of the head, wandering rheumatic pains, then by weakness in the arms, legs, shoulders and scalp, and by attacks of vertigo of so intense a character 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 blisters to the skin. With time there was a gradual amelioration of the pains, but the weakness of the limbs, troubles of speech and the difficulty of deglutition persisted' (Berthier). Many cases similar to the foregoing might be readily collected from Berthier, and nothing is more com- mon than for just such mistakes to be made in regard to cause and effect as in the instance cited." This case is recorded no doubt to show mistaken diagnosis and improper treatment. But the proof of both ! what doth it consist of? Merely the dic- tum, the unsupported assumption of a writer who "DIFFERENTIAL DIAGNOSIS." publishes a work on an unrecognized disease in medi- cine without a solitary fact to sustain his position in this regard ; indeed, it might be said, publishes a work which is a paradox in itself. This method of dealing with the subject—of annihilating dissentient opinions, is not, however, new to the reader, and the only inference left for him in the above is that, if the infallible bromides had been poured into this unfortunate, her speech and deglutition and other faculties would be peremptorily restored—perhaps in ten days ! Considering his method of reasoning —and it would be only a natural sequence of the past—it would not be at all surprising to hear of Dr. Hammond next expounding a new system of inductive philosophy, for assuredly he bids a per- sistent defiance to all our received notions on this subject; and Aristotle and Bacon must pale before the new " lux major." In reference to the subject of chlorosis, the tone of the work is progressively displayed, without stint, and possibly introduces one new feature in the author's method of displaying his singular facility for falling into his own trap. It will be remembered that chlorosis in this chapter on " Differential Diagnosis" is one of the maladies to be carefully distinguished from " cerebral hyperaemia," but, like dyspepsia^ id genus omne, it now falls into line, and becomes a part and parcel of the great progenitor of all human 8b CEREBRAL HYPERaEMIA. ills—that fons et origo malorum—" cerebral hyper- aemia." " The affection known as chlorosis occasionally presents features similar in some respects to cerebral hyperaemia, and indeed there is reason to believe that the former is not only a disease of the nervous system, as I pointed out several years ago, but is in no essential respect different from the latter. A case occurring in my own experience, and reported in the essay referred to (Chlorosis a Disease of the Nervous System.—Quarterly Journal of Psychologi- cal Medicine, July, 1868, p. 417), is so apposite in the present connection that I quote it in full." (Case referred to later.) One portion of this paragraph contains a claim to originality so unmistakable that it had better be disposed of at once. In July, 1868, Dr. Hammond " points out that chlorosis is a disease of the nervous system," but long years before he had a name the Great Laennec advanced the same view, and Trous- seau, at least twenty years in advance of Dr. Ham- mond, insisted on Laennec's idea in no very equivo- cal terms. Can Dr. Hammond claim ignorance of the opinions of so eminent and widely-known a lecturer on medicine as Trousseau, the third edition of whose classic lectures was published in 1868 ? Strange admission, indeed ! but stranger still, if, ac- quainted with them, he should publish the foregoing to the world! "DIFFERENTIAL DIAGNOSIS." 81 The very heading of Trousseau's lecture on chlo- rosis, which indeed is highly instructive and signifi- cant also in relation to this case of Dr. Hammond's, speaks for itself. It is " On false chlorosis or tuber- culous anaemia—Preparations of iron should not be prescribed in this false chlorosis—Tuberculous chlo- rosis should be treated by bitters and arsenic—On false chlorosis or syphilitic anaemia—Action of the vaso-motor nerves in producing the vascular mur- mur— True chlorosis is a nervous disease ; the altera- tion of the blood is secondary." Thus an author, known throughout the civilized world as one of the few great lecturers on practical medicine, has been lecturing and publishing for a quarter of a century or more the opinion that true chlorosis is a disease of the nervous system—not " cerebral hyperaemia," however—and then Dr. Ham- mond blandly informs us that he pointed out this same fact, after the third edition of Trousseau's lectures was given to the world. Here is an instance of gross ignorance of current medical literature on the part of the author, or an assumption of such existing among his readers. To return to the " case "— " A. G., a young lady aged eighteen, 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 6 82 CEREBRAL HYPERaEMIA. aside, and escape injury. She gets home, and after taking a glass or two of wine recovers her usual good health and equanimity. Her previous health was unexceptional, but soon after the occurrence of the event referred to, her friends noticed the begin- ning of a gradual change in this respect, but espe- cially in her susceptibility to nervous impressions. From having been cheerful and buoyant in mind, she became melancholy and depressed, etc. At the same time her temper grew irritable and peevish. The slightest sudden noise caused her to start; a bright light disturbed her ; a slight touch was mag- nified into a severe blow. Unpleasant odors were perceived and taste perverted. Her appetite was capricious and irregular, and dyspepsia with consti- pation supervened. The heart palpitated violently on slight exertion, and the cervical and dorsal regions of the spine were tender on pressure. All these changes were effected within a month after the occurrence of the shock to her nervous system al- ready mentioned. During this period I repeatedly examined the blood microscopically, and always found the normal proportion of red corpuscles to be present. Finding no change in the blood, and detecting no bel- lows murmur at the base of the heart or along the course of the great vessels, I did ?iot suppose the affection to be chlorosis, for I had been taught to regard this disease as due to anaemia, and as always being as- "DIFFERENTIAL DIAGNOSIS." 83 sociated with the signs and symptoms of that con- dition. From the history of the case, and the prom- inent 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, there- fore, treated it for the first two or three weeks with antispasmodics and tonics, the latter consist- ing of quinine and iron, and recommended good nourishing diet and moderate physical exercise. Had the existing condition been one of anosmia these measures would have been clearly indicated, and would doubtless have proved beneficial." We are then entertained with further details of the treatment, together with a complete analysis of the blood (which is perfectly normal); the un- pardonable bungling of another practitioner, and finally we are informed that strychnia and arsenic are the source of her salvation. " 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 reason that the disease appeared to me one in which de- rangement of the nervous system formed the most prominent feature, and because 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 de- 84 CEREBRAL HYPERaEMIA. rangements of the viscera due to disturbed nervous action." I do not wish to detain the reader further with quotations from this remarkable case, but if the author does not stultify himself by the record of it, then tolerably plain English is not intelligible to me. First of all, it is given to us as an illus- trative case of chlorosis. Chlorosis without the only two features that distinguish it from other anaemias! ! No change in the blood and no bellows murmur! Wherein then is the evidence of true chlorosis ? Again we are informed, of course, that it is all the result of " cerebral hyperaemia," and be- hold, it is cured by arsenic and strychnia, which the author himself has found to give tone to exhausted nervous centres! Here, surely, is another instance of " bankruptcy" of the perceptive faculties, for we find in pages 83 and 84—in the chap- ter on " Morbid Anatomy " by the way—that the indications of the existence of this direful new disease are : 1st, the redness of the face, and the throbbing of the cephalic arteries indicate an in- creased determination of blood toward the head .... 7th, the effect of quinine, strychnia, alcoholic liquors and other agents, which we know increase the amount of blood in the brain in aggravating the symptoms of the disease ! The young lady, it will be observed, had all three " DIFFERENTIAL DIAGNOSIS." 85 agents denounced in "canon " 7. It may then be unhesitatingly asserted that the author himself establishes beyond a reasonable doubt: 1st, that his illustrative case of chlorosis as the result of "cere- bral hyperaemia " is not true chlorosis at all; and 2d, that it could have had no connection whatever with his " impossible " disease, because it lacks the two distinctive features of true chlorosis, and is cured by the very means which he himself plainly tells us " only" tend to aggravate the symptoms of " cerebral hyperaemia." It is scarcely necessary to pursue this matter further; but lest the claims of the author, that he was the first to point out that true chlorosis is a nervous disease—and, further, lest his assertion that it is a consequence of "cerebral hyperaemia" should in any degree be accepted through the amount of mere verbosity brought to bear on the question, let us compare a few extracts from the lecture of Trousseau on this subject. After having given an illustration of syphilitic anaemia unaffected by iron preparations, but restored by mercury and iodide of potassium, he proceeds : " I have persisted in bringing these facts under your notice,* in order that you may thoroughly un- derstand what a multitude of causes can change the composition of the blood so as to resemble chloro- • * This hasty translation has a claim to nothing more than a true rep- resentation of the author's views. 86 CEREBRAL HYPERaEMIA. sis, and I have done so, above all, to put you on your guard against the evil effects of iron prepara- tion, insufficient in the majority of cases, useless in some, and frequently dangerous in others." Discussing the causation of the " bruit de souffle " he says— "There is then no doubt that in true chlorosis the vaso-motor nervous system is changed in some special manner, and that this change is to a certain extent independc7it of the composition of the blood. It does not correspond with the increase or diminution of the red globules, since those suffering from anaemia rarely have the double vascular murmur, and again the sufferers from chlorosis continue to present this symptom even long after the composition of the blood is restored. " What I have just said, gentlemen, is sufficient to give you to understand that, in my opinion, chlorosis must be ranked in the category of nervous diseases. Laying aside for a while the constituent elements of the blood, let us observe by what phenomena, other than the pallor of the tissues, this disease is manifested. These symptoms have almost exclusive reference to the nervous system. The intellect, sen- sation, and the motor power of the muscular system, both voluntary and involuntary, are profoundly affected. It is rare that .a young chlorotic girl does not suffer from those perversions of the understand- "DIFFERENTIAL DIAGNOSIS:1 87 ing of which so many examples have come under our notice. She becomes irritable and frivolous; and the affection of the mind sometimes progresses to insanity. If we examine the sensation power of the skin with caution, we shall find anaesthesia in a large number of points, and again we find hy- peraesthesia over a smaller number. Whenever in your presence I have examined chlorotic women I have invariably questioned them as to any neural- gic pains that afflicted them, and you have been able to see for yourselves how uncommon it is to find one who has not suffered from neuralgia more or less violent. " Spasmodic affections of the voluntary muscular system are quite frequent, and you know how com- mon hysterical convulsions are among chlorotic women. But palpitation of the heart, and spasms of the stomach of the intestines, and of the uterus, nearly all those afflicted with chlorosis suffer from. " This disturbance of the nervous system does, however, bring about a radical change in the differ- ent secretions of the economy. The gastric juices are changed in their chemical composition, and hence the water brash, and eructations, flatulence, etc. The secretions of the liver and kidneys at one time suppressed, at another greatly increased, bear sufficient testimony to the nervous disturbance on which I have frequently dwelt; and the great secre- 88 CEREBRAL HYPERaEMIA. tion of the ovary, which performs one of the most important functions, is quite frequently suppressed, together with the menstruation, which is its conse- quence. " It is unnecessary to remind you of the many re- cent experiments conducted by the ablest physiolo- gists, which go to prove what powerful influences nerve disturbances exercise over both the secretions and the component parts of the blood. We can readily understand that, when the function of a blood-making organ like the lung, liver or spleen, is radically changed, the components of the blood it- self must be vastly altered. "This influence of the nervous system will betimes man- ifest itself with singular rapidity. You remember a young woman who had already twice entered our hos- pital service to undergo treatment for chorea. She had excellent health until badly frightened one night. From the following day her health commenced to fail, and four days after she came to our ward with all the symptoms of a confirmed chlorosis. And in No. 3 of the same ward, we have a young woman of eighteen years old, who, in like manner, after some violent emotion, became chlorotic in a few days. This indicates to you how little importance we must primarily attach to the condition of the blood, and how very necessary it is, on the contrary, to give anos- mia a mere secondary place." "DIFFERENTIAL DIAGNOSIS." 89 What more intelligible or forcible language could any writer use to insist on the proposition, that chlorosis is primarily a nervous disease, and that the condition of the blood is a mere sequence, than is herein expressed ? And yet Dr. Hammond, with char- acteristic modesty, informs us that he " first pointed out this fact to the profession in 1868." What fur- ther proof need be adduced of his utter unreli- ability as a medical authority; for, assuredly, if the old logical aphorism—Falsum in uno, falsum in omnibus—has any force in ordinary life, it must apply with much more vigor to the ordinary practice of medicine wherein so much deference is paid to prominent authorship? The unveracity of the medical writer is not unfortunately limited to his own sphere or generation. Chlorosis, then, being accepted as a disease of the nervous system, the next question arises, Is it the result of a disturbed vaso-motor system, as Trous- seau claims, or is it dependent on " brain hyperaemia," as Dr. Hammond asserts? If we first had any proof of the existence of " cerebral hyperaemia," and after this some connection traced between this hyperae- mia and true chlorosis, the subject may admit of some discussion, but, none such existing, it is scarcely a matter to waste the reader's time over. On the other hand, Trousseau, with customary lucidity, goes directly to the base of the subject when he says— 90 CEREBRAL HYPERaEMIA. " I need not here remind you of those recent ex- periments prosecuted by the most expert physiolo- gists which demonstrate the influence that the va- rious disturbances of the nerve functions exercise at the same time over the formation and composition of the blood. We can readily understand that when the special functions of the blood-producing organs —such as the lungs, liver and spleen, etc.—are al- tered, the composition of the blood itself must also undergo considerable change. This is at once a philosophic and readily comprehen- sible view of the cause of true chlorosis, but to trace it to hyperaemia certainly requires some proof further than the mere assertion of one whom we find so constantly adopting views, or advancing them, which, almost in the same page, he again, wittingly or un- wittingly, condemns. The following, taken from this chapter on " dif- ferential diagnosis," is by no means a solitary in- stance of what I have just said—" Dr. Hadfield Jones has, under the name of ' hyperaemia of the brain,' described a condition bearing but slight resemblance to that under consideration, but rather in its main features assimilating with congestion ; but the dis- order which he designates 'cerebral excitement' is so very like what I would term hyperaemia, that I am quite sure we refer to the same pathological entity. Indeed, he expresses the opinion that the arterial "DIFFERENTIAL DIAGNOSIS." 91 vessels of the brain are in a state of repletion, but he regards this condition as secondary to another which he believes to be an excitation of the tissue. The cases cited by Dr. Jones all present more or less affinity with ' cerebral hyperaemia,' as I have de- scribed it in the present essay. I quote one which was under his own care." (Dr. Hammond.) " H. T., aged fifty-two, was admitted November 25, 1866. A very strong-made, large, hardy-looking man, who has achieved well-deserved repute by his able and successful 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 when he was out with the life-boat, from a man being washed overboard. He felt ' his in- side run round' and he became 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. At present he is quite un- nerved ; gets 110 sleep at night* being troubled with dreaming and fancies ; in fact has a degree of delir- ium—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 and legs, or else he is busy electioneering or cutting arms and legs, or singing, etc. The tip of his tongue gets very * This deserves special notice in view of the treatment adopted and Dr. Hammond's notions relative to sleep and anuimia. 92 CEREBRAL HYPERaEMIA. sore, too, at night. Every morning for years since he has been ailing, he has vomiting and purging on getting up ; 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 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 ancsmic. Manner quiet; has always been temperate. Appetite bad ; tongue natural. Is worse than he was a year ago. At the time of admission he was rather better than he was a month before, since he had kept quite still and done no work. His urine was of sp. gr. 1020, of full red color ; not albuminous. He was ordered strychnia, nitric acid, valerian, morphia, hyoscyamus ; and for diet, cocoa, one pint of ale and four ounces of brandy. The dose of strychnia was increased, the valerian was replaced by quinine, and this again by 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 resuming his former arduous exertions." (Hadfield Jones.) * One of Dr. Hammond's modest assumptions that he has a mono- poly of the mode of ascertaining temperature. "DIFFERENTIAL DIAGNOSIS." 93 Such is Dr. Jones' case, and Dr. Hammond imme- diately adds—" I should certainly call this a case of ' cerebral hyperaemia ' as I understand it." In the name of all common sense, on what grounds? Does the gentleman already forget the celebrated Canon No. 7, in his marvellous chapter on " mor- bid anatomy" which I take the liberty of repeating —" The effect of quinine, strychnia, alcoholic liquors and other agents which we know to increase the amount of blood in the brain in aggravating the symptoms of the disease " ? Thus an eminent observer describes a condition that he is unable to find any definite pathology to explain, and calls it very properly "cerebral excite- ment," which it will be remembered Dr. Hammond is quite sure corresponds exactly with what he calls "cerebral hyperaemia." Further the "cere- bral excitement" is treated successfully with the remedial agents that Dr. Hammond assures us can only tend to aggravate "cerebral hyperaemia" ; and yet in face, of these facts we have the strangely painful spectacle of Dr. Hammond disagreeing with Hadfield Jones, and insisting on claiming that this condition is nothing more or less than " cerebral hyperaemia." Unreason can scarcely reach more absurd limits, and it is certainly a deplorable condition of public 94 CEREBRAL HYPERaEMIA. and medical education that a mind which has evinced only this capacity throughout, should be regarded as anything above the merest irresponsibility. To regard one as an authority on the very highest branch of medical science whose efforts have no- where shown a higher range than that pointed out here, is a'sad commentary on what might be called the medico-social condition of our profession throughout the country, because, if a proper esprit de corps existed, the folly of such aspirations would readily be exposed. At every page the same reck- less disregard of consistency confronts us, and it seems almost incredible that such utter oblivious- ness of what one paragraph contains, should be im- plied by the contents of another immediately suc- ceeding. For example, we are cautioned against confounding anaemia with hyperaemia, as the conse- quences may be disastrous, and then informed that "the condition often induced by shock presents some features of resemblance to cerebral hyperemia." 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. " In a somewhat less severe form of cerebral ancemia there may be illusions and hallucinations and "DIFFERENTIAL DIAGNOSIS." 95 some confusion of ideas. A low form of delirium may be also present. But again there are the dilated pu- pil,* the feeble heart, the pallid face, the cold skin, so characteristic of deficient blood-supply to the brain." In this manner the writer seeks to distinguish be- tween shock and hypercemia—a matter that should be judiciously attended to. But will the reader kindly turn to his case—his novel case of chloro- sis already quoted, where he will observe that "hy- peraemia cerebral" and chlorosis are only different names for the same condition. In that case he will surely find pallor of the face and illusions and hallu- cinations, and, moreover, he will also learn from the author himself that the whole disturbance arose from shock—shock, and nothing more ! In unmistakable language the case of chlorosis recorded is stated to be the result of " cerebral hyperaemia," which in turn is directly attributed to shock. And now we are strenu- ously cautioned against confounding hypercemia with shock as the result would be lamentable ! Another instance of brain bankruptcy, no doubt. Amid the gloom, however, it is pleasant to remember that all * That " dilated pupil " should be regarded by Dr. Hammond as indicative of cerebral anamia, requires some explanation, considering that in his view sleep is the result of cerebral an&mia, and in this con- dition the most casual observation would have shown him the pupil to be in a state of contraction. 96 CEREBRAL HYPERaEMIA. the treatment in the case of " chlorosis " was any- thing but of a nature to subdue " cerebral hy- peraemia," and hence that the patient—whilst her* disease may have been the theme of an untenable nomenclature—has at the same time the benefit of a sound and rational medication. In this " differential diagnosis " chapter we now come to one of the most important—if not the most important, and at the same time most vicious, portion —of all Dr. Hammond's labors—the one which he claims most especially his own, and regarding which there is a stout claim to originality* pervading each of his numerous publications. It is this : " That sleep is due to diminished blood-supply to the brain." " 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 wake- ful, the patient is, on the contrary, almost constantly drowsy. No diagnostic mark is of so great impor- tance as this latter, and I regard it as of itself suffi- cient 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 * The claim to originality herein will be found to be as defective as that of having been the first to " point out that chlorosis is a nerve affection." "DIFFERENTIAL DIAGNOSIS." 97 brain is to an inordinate extent deprived of its circu- lating pabulum drowsiness is the consequence; wake- fulness, on the contrary, is produced by an excessive amount of arterial blood in the brain, and hence it becomes a prominent feature of cerebral hy- peraemia. It is true that in the advanced stage, when instead of hyperaemia there is rather conges- tion, stupor may ensue, but stupor is by no means sleep." This invaluable passage may be said to contain four important announcements—1st, that stupor is by no means sleep; 2d, that cerebral anaemia is al- most always accompanied by drowsiness; 3d, that this fact of itself is sufficient, in the author's estima- tion, to distinguish anaemia from hyperaemia, which is invariably attended with wakefulness ; 4th, that sleep is the result of diminished blood supply to the brain. I am forbidden by the proposed limits of this essay to enter on as complete a discussion of these propositions as their nature may demand, but I trust that a mere hint will enable the interested reader to follow up the subject for himself, and I feel assured that the more diligently he pursues the investigation, the more baseless will appear the latter three propositions in this category, and the more injurious in treatment if carried to their logical results. 7 98 CEREBRAL HYPERaEMIA. With regard to the first proposition, there can be little question if we confine ourselves to the stupor or coma incidental to apoplexy, uraemia or typhoid fever as distinguished from healthy natural sleep, but then the stupor of opium or alcohol (which un- questionably increase* the blood supply in the brain) is rather difficult to distinguish from the sleep of the bromides, which the author himself assures us is the direct result of a diminished blood supply. When the same apparent result (to our untutored observation) is produced by agents claimed to have such diverse physiological action, why it should be called stupor on the one hand and sleep on the other, requires some satisfactory reason, but as in so many other things in this also we receive none. The fallacy of announcements two and three can readily be inferred, if it be shown that the fourth is without foundation. To prove this, it is only necessary to refer to the author himself. We find in the case previously quoted from Hadfield Jones, and passed to the credit of cerebral hyperaemia by Dr. Ham- mond, that such a list of circulation stimulants, as, morphia, ale, brandy, strychnia and valerian produced total recovery of a patient who "gets no sleep at night" until placed under this plan of * See standard authorities in therapeutics passim as well as writers on medical jurisprudence. See author himself, Canon 7. in " Mor- bid Anatomy." "DIFFERENTIAL DIAGNOSIS." 99 treatment. In one of his introductory remarks also the author tells us a very well recognized fact, that intellectual labor produces cerebral hyperaemia, and is it not a natural converse of this proposition, and quite in accord with what is elsewhere observed in the economy, that intellectual or brain repose ox sleep should produce more or less anaemia? But despite this proposition, one part of which he recognizes, he persistently asserts that it is the anaemia produces sleep. That his view must be incorrect is further proven by the effects of most narcotics, such as chloroform, opiates, chloral and alcohol as stated above—substances which all therapeutists claim to increase the quantity of blood in the brain—but which we have to call into constant requisition for the purpose of producing sleep. Dr. Hammond, it is true, claims to have shown by practical experiment that the bromides produce sleep, by lowering the brain circulation. From a comparison of the action of many substances that are constantly used to induce sleep, it is not too much to claim that his conclusions must be erro- neous; but on the contrary that the bromides giving rise to sleep—not in the manner claimed—the sleep then in turn—no matter how induced—tends to lower pro tanto the brain circulation. Epilepsy is conced- ed by pathologists, to be a disease accompanied by brain anaemia, i.e., prior to the spasm, and the treat- 100 CEREBRAL HYPERaEMIA. ment recommended by the best authorities is of a nature to improve the blood in quality and quantity generally—yet we know that no one drug has such a powerful influence in its subjugation as one or other of the bromides—an additional proof that their tendency cannot be (as Dr. Hammond concludes) to produce directly brain anaemia, else assuredly epi- lepsy, far from being benefited, would necessarily be aggravated by them. But, lest our common observations and the au- thor's own inconsistency be insufficient to refute this great claim of his, let us again glance at the most recent and able compendium of physiology (Foster, pp. 717). After having shown that all portions of the body participate in sleep as much as the cerebral hemi- spheres he proceeds : " We are not in a position at present to trace out the events which culminate in this inactivity of the cerebral structures. It has been urged that during sleep the brain is anaemic*; but even if this anosmia is a constant accompaniment of sleep, it must, like the vascular condition of a gland or any other organ, be regarded as an effect, or at least as a subsidiary event, rather than as a primary cause. The explanation of the condition is rather to be * Durham Guy's Hospital Reports, vol. iv., 1869—(which, it is well to remember, was several years prior to Dr. Hammond's original experiments made by " Mr. Durham and myself.") "DIFFERENTIAL DIAGNOSIS. IOI sought in purely molecular changes, and the analogy between the systole and diastole of the heart, and the waking and sleeping brain, may be profitably pushed to a very considerable extent. The sleeping brain in many respects resembles a quiescent but still living ventricle. Both are, as far as outward mani- festations are concerned, at rest, but both may be awakened to activity by an adequately powerful stimulus. Both, though quiescent are irritable ; in both the quiescence will ultimately give place to activity, and in both an appropriate stimulus, ap- plied at the right time, will determine the change from rest to action. Just as a single prick will, under certain circumstances, awake a ventricle, which for some seconds, has been motionless, into a rhythmic activity of many beats, so a loud noise will start a man from sleep into a long day's wake- fulness. And just as in the heart the cardiac irri- tability is lowest at the beginning of the diastole, and increases onwards till a beat bursts out, so is sleep deepest at its commencement after the day's labor ; thence onward slighter and slighter stimuli are needed to wake the sleeper. We cannot at present make any definite statement concerning the nature of the molecular changes which determine this rhythmic rise and fall of cerebral irritability. Preyer's leaning toward this view, that the accumulation of the products of protoplasmic 102 CEREBRAL HYPERaEMIA. activity may become in the end an obstruction to that activity, has been led to think that the pres- ence of lactic acid, one of the products certainly of muscular, and probably nervous metabol- ism tends, to produce sleep; but this is doubtful. The suggestion of Pflugen that the diminution of irritability, and consequent suspension of auto- matism, is dependent on the exhaustion of the store of intra-molecular oxygen (p. 364) is more worthy of attention. The phenomena of sleep show very clearly to how large an extent an apparent automatism is the ulti- mate outcome of the effects of antecedent stimula- tion. When we wish to go to sleep, we withdraw our automatic brain as much as possible from the influence of all extrinsic stimuli ; and an interesting case is recorded of a lad, whose connection with the external world was, from a complicated anaes- thesia,* limited to that afforded by a single eye and a single ear, and who could be sent to sleep at will* by closing the eye and stopping the ear. The force of these remarks needs no comment; all therapeutical and clinical observations corrobo- rate them, and until we are educated by a series of new experimental facts, we must continue to accept * Possibly Dr. Hammond may explain how this closure of the eye or stoppage of the ear produced the amount of brain anaemia neces- sary for sleep in his calculations. "DIFFERENTIAL DIAGNOSIS." 103 this view of sleep though in complete antagonism to the assertions repeated by Dr. Hammond through- out his numerous writings, and as constantly refuted by his more rational methods of treatment. Not far from this paragraph regarding sleep and its mode of induction is another no less strange, if less important. It is an effort at general instruction to distinguish between hyperaemia and " ramoUis- sement cerebri," and runs : " In fact, the two have scarcely any but the most superficial resemblance. In softening, the intellect is seriously and perma- nently impaired, and the morbid process advances sometimes slowly, but almost always certainly to a fatal termination." With the correctness of this view relative to cerebral softening few will feel in- clined to differ, but it will be found rather startling in its confliction with the statements elsewhere made by the writer, and especially in his article on " cerebral softening " (in his larger work on nervous diseases), where so many cases are reported as " per- manently cured " and " now quite well,"—some in- deed completely restored after ten days' treatment.* It would evidently be a loss of time to follow the writer in his distinction between this new malady and Bright's or Meniere's disease. Each one of these * See author's work on " Diseases of the Nervous System," art. " Cerebral Softening," or case recorded in the introductory chapter to this essay IO4 CEREBRAL HYPERaEMIA. latter has of course its distinctive features which the merest tyro in medicine cannot fail to recognize when the attention is so directed. And consider- ing accordingly how little enlightenment there is in this chapter on " differential diagnosis," what a total absence there is in it of anything really indicating the existence of" cerebral hyperaemia," it is not very astonishing to find this termination to it: " Indeed, there are few diseases so distinctly marked by their symptoms and clinical history as that which forms the subject of this essay." The ridiculous nonchalance of this finale is beyond explanation, unless the writer seeks to defy all pro- fessional opinion ; or has lost the most commonplace capacity for rational inference. CHAPTER IV. GENERAL CONCLUSIONS. THE chapter on Etiology or causation (of an im- possible disease), though containing much of a gen- eral nature that is true, but nothing original, is by no means free from the more pronounced defects of its predecessors, as will at once be apparent in the opening paragraph. " 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 affec- tion instantaneously ; but still more common are those instances in which some powerful emotion, act- ing, day by day, and even night by night, slowly perhaps but with terrible certainty, leads to the more or less permanent increase of the intra-cra- nial arterial blood with all the inseparable phe- nomena." It would be quite a work of supererogation to ad- 5* 105 I06 CEREBRAL HYPERaEMIA. duce further arguments against the assertion that any cause can produce increase of the intra-cranial arterial blood, without a corresponding increase of the intra-cranial venous blood, which reduces the mat- ter at once to one form or other of congestion which we all recognize. This matter has been sufficiently gone over elsewhere, and it is scarcely necessary to repeat the conclusion, that even from ordinary hy- draulic principles the theory must be untenable. But it is not a little odd to see our old friend "shock" coming here into such bold relief again. At one time it was the direct cause, according to our author, of chlorosis or " cerebral hyperaemia " (for we were assured they meant the same thing) ; at an- other place we were stoutly cautioned not to con- found shock with " cerebral hyperaemia," as the con- sequences may be appalling; and now again we are blandly informed that a " sudden shock may induce this affection instantaneously." This repeated self- refutation will of course be apparent throughout the monograph; but it may be asked, What useful pur- pose can a further exposition of it serve here ? This: that if left unchallenged some practitioner may be inclined to credit the theory, that shock led to hy- peraemia (cerebral); that, indeed, the brain is the organ exclusively suffering in this condition, and consequently the only one to be treated, which could not lead to other than disastrous conse- GENERAL CONCLUSIONS. i0j quences. Now, it is needless for me to observe that shock, i. e., moral shock as indicated here, and as we recognize it, leads to a chain of troubles very dif- ferent from any form of cerebral hyperaemia—that, in fact, the vaso-motor system receives the brunt of the attack, and whatever brain hyperaemia or anae- mia supervenes differs in no essential particular, as regards its causation, from the faintness, nausea, diar- rhoea ox jaundice that so frequently results from this same cause. There is another idea of paramount importance pervading this chapter on " causation," which, though advanced with some caution, nevertheless becomes apparent throughout, viz., that intellectual labor predisposes to brain disease. The writer, it is true, recognizing general physiological laws, tells us that the brain of man, far from being injured, is really strengthened by full mental labor as surely as the muscles are invigorated by physical exercise. But then he readily loses sight of this general principle, and diverges off into details of the small amount of mental toil endurable, and adds, that few can safely indulge even in his moderate limit, that the conse- quence of effort in this direction would be brain- destruction to the many, because, forsooth, " 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," 108 CEREBRAL HYPERaEMIA. There can be little doubt of the general correctness of the analogy touching the effects of their appro- priate exercise on muscular and nervous tissues ; but we now learn for the first time that brain exer- cise produces weakness of the intra-cranial vessels, while we know that muscular exercise—judicious, of course—will produce strength and vigor of the vessels pervading muscular tissue. If we are to rely on the author's assertions, however, it is among the class who might be most capable of physical exer- cise that this weakness of the intra-cranial vessels is most likely to occur; and as this opinion is so di- rectly opposed to all analogy elsewhere, to all the recognized laws of physiology, it would be only simple justice to inform us how the intra-cranial vessels are affected so differently from the other vessels of the system, by the same causes. But all forms of demonstration are completely ignored in this unique work on Cerebral Hyperaemia, and it cannot be other than unfortunate that asser- tions so novel and startling should thus proceed, without regard to fact, from so prominent an au- thority, as doubtless many readers, incapable of judging for themselves, may in consequence be de- terred from beneficial and vitalizing mental effort. There is now no question of the fact, that judicious physical exertion will strengthen the muscles and blood-vessels generally, and that what we recognize GENERAL CONCLUSIONS. 109 as fatigue is the one indication for a discontinu- ance of exercise: that this indication of fatigue is further and further deferred as the parts, by effort, acquire increased vigor.* Nor does it require any but the most commonplace observation of every individual to discover that exactly the same rule holds good in the case of mental exercise; that the untrained brain readily tires of intellectual toil, that this fatigue demands rest, and that the sense of fa- tigue is further and further deferred, as well in purely mental labor as in the complex labor of the musician's hand, as progress is made in intellectual strength by judicious mental toil. Dr. Hammond evidently would have his readers confine their brain labors to very narrow limits, which, if followed im- plicitly, should have deprived us of many a great and noble work of the past, and may deprive us of still greater achievements in the future. The fact is well recognized that perseverance, persistent effort by comparatively dull brains, i. e., those at first easily fatigued, has done more for the world ten- fold than the spasmodic efforts of the bright and gifted, to whom mental effort was never fatiguing, and if the former had been taught to dread a giving way of their intra-cranial vessels, how few of the achievements that mankind are proudest of would * It is very questionable if the nervous system does not play a leading role, even in what is regarded as solely muscular exercise. no CEREBRAL HYPERaEMIA. be transmitted to us ! If his doctrine had any force at all, one of the first results should naturally be, that a larger percentage of mental alienation, brain bankruptcy, or whatever he may choose to name it, would be found among the members of the learned professions and literary men than among any other class. Statistics on this subject, if ever published, are not at hand, but I feel confident that such would be very far from aiding his theory. The unfortunate habits of the American public, whose brains (we are assured) are so much more strained than those of other nations—a hackneyed field for meaningless platitudes—should, according to our author, lead to a very much higher percentage of insanity among them than is to be found among other nations. Such is not the fact, however; but on the contrary, as far as ascertained, the proportion of insane to population is a little less in these States than in the civilized nations of Europe. There can be scarcely a question among physiolo- gists and practical physicians at the present time, that not only the mind—or brain, its organ—as a whole can be educated by effort, by labor, but that also the different faculties of the mind—different portions of the brain no doubt representing them— (and this subject is worthy the attention of those small philosophers who scoff at moral training) can be cultivated beyond limits previously unthought GENERAL CONCLUSIONS. Ill of, just as the muscular system of individuals— pedestrians, for example—has acquired a capacity for endurance heretofore considered impossible. There can be little doubt that Reason, Memory, Imagination, and even the Will itself, can in almost any individual be brought to a higher standard by effort than he may himself at first regard as possi- ble, and in this way, as we so often observe, the moral discipline is acquired by which one is able to abandon the vice which has swayed him for years. All this form of training might be frequently avoided if the individual should accept the theory that by any or all forms of mental effort the walls of his intra-cranial vessels would be likely to suc- cumb, and no doubt much of the hypochondriasis among intelligent persons, who come before us so often, arises either directly or indirectly from the promulgation of doctrines of this quality. The fact is that mental toil—not the enfeebling pursuit of shadows—is as necessary for the brain's continuance in a healthy condition as proper muscular exercise is for the preservation of physical vigor, and there is quite as little danger to the intra-cranial vessels from the one, as there is to vessels that pervade the muscular structure in the other. From what has just been said, however, it must not be inferred that I regard it as anything like impossible to injure the human brain by over-study. On the contrary, as 112 CEREBRAL HYPERaEMIA. fully as Dr. Hammond, I recognize that injury may result, but not from the same amount of cause, or in the same manner. For in'stanee, the child's mus- cular system is easily over-strained and injured, and in like manner the child whose brain is over-taxed may be perpetually injured. Furthermore, the child who is forced into an uncongenial groove, whose mind is perpetually crammed with subjects for which there is no receptivity, as it were, is very apt to have faculties of a more powerful, more useful nature, dwarfed into insignificance by the very effort to force another, and thus a mind that may become conspicuous in some useful sphere is stunted in all by the injudicious effort of parent or teacher, in striving to force it into a beaten track.* Again the imposition of too much study on the youth—study even of the most congenial nature—is a source of danger, for the exhausting brain-labor, as well as the sedentary habits necessary therefor, will lead to general constitutional debility, phthisis, etc., in which, of course, the brain itself soon participates. These views are common to the ablest physiolo- gists and physicians throughout the world, and few modern thinkers in this sphere will agree with the formulated rules of Dr. Hammond relative to eight or ten hours' study in general, and that " mathe- * This, of course, would also apply to older persons in a minor de- gree, from the necessity of making a suitable livelihood, &c. GENERAL CONCLUSIONS. jr? matics are specially injurious to ladies." This sub- ject admits of no rules, and the old adage, "Chaque un a son gout" should be under proper early train- ing the guide in all cases no less in the female sex than in the male. The general principle that is sought to be established, and one with which few observant men will differ, is this: that the hours of study of any healthy, congenial nature can be in- creased to very extended limits, by effort and train- ing, without injury to the nervous system, just as muscular exercise can be vastly increased by the same means, and that the mental toil which at first readily expresses itself by fatigue, just as in the case of the physical system, will gradually become less and less tiresome, as the mind becomes more inured to the form of labor to be undergone. There can be no necessity of prolonging this dis- cussion on the causation of this factitious malady, but the general recklessness of treatment is well shown by Dr. Hammond when he produces an array of "causes" for the support of his position, which Dr. Richardson has already adduced as giving rise to totally different consequences, and then makes lengthened quotations from Dr. Richardson's work on " Physical Diseases from Mental Strain," while this writer nowhere recognizes a disease arising from " Enlargement of the intra-cranial capillary arteries." The following also among the "causes" cannot 8 114 CEREBRAL HYPERaEMIA. fail to prove interesting: " There are many sub- stances which, when taken into the stomach or in- haled 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, sulphuric ether, chloroform, nitrate of amyl, &c. A like power is also exerted by tea and coffee, and probably in some cases by tobacco."* When we are told that these substances produce merely an increase of arterial blood, as our standard authorities inform us that general blood stasis arises from their use, in consequence of their capacity to prevent natural metabolism, it would plainly be the duty of the writer to inform us as to how he has arrived at his conclusion. The one expression in this paragraph, of " opium in small doses " is, how- ever, a slight diplomatic concession to our precon- ceived and pretty well established views relative to the action of this drug, inasmuch as the only doses —poisonous ones of which we can form an absolute definite opinion—act in a somewhat different man- * In view of what has been uttered in previous chapters, there is nothing very singular in what we notice here. A disease of the cerebral arteries, lasting over a year, is ascribed to drugs so transient in their action as alcoholic liquors, morphia, chloroform, sulphuric ether, &c. While we observe elsewhere that these same drugs are commonly prescribed to cure the disease of which they are here regarded as the cause. GENERAL CONCLUSIONS. H5 ner. According to all observers, therapeutists, and medical jurists, poisonous doses of opium produce immense enlargement of the intra-cranial venous system, or cerebral congestion. But how it can in smaller ones produce enlargement of intra-cranial arteries merely, is a problem that awaits some new therapeutical and physiological enunciations which, from the monograph before us, is not at all beyond the reach of our author's astounding capacity. The chapter devoted to " Prognosis " has one de- cided merit—brevity—and is futher consoling in the fact that the writer has never "seen a patient die of simple cerebral hypercemia " (a fact which the reader may have already inferred from the impossibility of its existence). The reader, however, who can fathom the meaning of the following has a capacity for dis- cernment greatly to be envied: "The tendency of the affection, if it be not arrested, is to pass into one or other of the fully developed forms of cerebral congestion already mentioned, and then the liability to secondary lesions such as softening cerebritis, cere- bral hemorrhage, aneurism, general paralysis, &c, must be taken into account. The apoplectic form of cerebral congestion is that to which there appears to be the greatest predisposition, and the epileptic and paralytic come next in order. The soporific, the maniacal and aphasic, are more rare, but are occa- sionally met with." n6 CERE BR A L II YPERaEMIA . This jumble of mere grandiose verbiage is suffi- cient to " stop the breath" of the thoughtless or mayhap uneducated reader, but to the professional mind it has no meaning whatever. WThat is the difference, for instance, between softening ccrebritis and general paralysis ? None whatever. Synony- mous terms merely ; and that hyperaemia, even as recognized, has aught to do with the causation of cerebral softening is a doctrine of antique and obso- lete pathology. The same is true of apoplexy ; and the additional information that there is an apoplectic and epileptic form of cerebral hyperemia requires something like proof, while the distinction between the paralytic and apoplectic needs nothing less than genius to demonstrate, inasmuch as every apprecia- ble form of apoplexy produces more or less physical or mental paralysis. The soporific, maniacal and apha- sic varieties are truly overwhelming! According to its etymology, soporific has undoubtedly something to do with sleep-producing, and yet we have been told over and over again that cerebral hyperaemia is essentially a condition of wakefidness, while now we are introduced to the soporific variety of it. "Dormitat magnus Homerus," verily! With regard to the aphasic variety of cerebral hy- peraemia, it is not too much to say that, taking the sentence just quoted as an exposition of his views, he must be sadly ignorant of what aphasia means, GENERAL CONCLUSIONS. 117 and the discovery of Broca must be to him a veri- table " terra incognita." We now come to what must necessarily be the crowning absurdity of this whole monograph, viz.: the chapter on " Morbid Anatomy and Pathology," an effusion of several pages without a trace of" mor- bid anatomy" to enliven it (which could not be well otherwise, seeing that the author—or any one else, for that matter—had never known a death to occur from this imaginary disease). Instead of " morbid anatomy," however, we are treated to the following extraordinary series of " cannons " as an assurance of its presence : " 1st. The redness of the face and the throbbing of the cephalic arteries* indicate an increased de- termination of blood toward the head. "2d. The sensation of fulness of the head almost invariably present. * Discussing cerebral hemorrhage, Niemeyer makes some remarks that Dr. Hammond in this case may well take to heart: "In all large hemorrhages this anaemia may not only be recognized with cer- tainty after death, but even during life it shows itself by a very im- portant symptom, which is usually falsely interpreted ; that is, by a remarkable pulsation of the carotids. This symptom is very gener- ally regarded as a sign of ' increased pressure of blood to the head,' although it really indicates that the flow of blood into the skull is obstructed ; we may at any moment induce the same phenomenon in the artery of the finger by tying a string tightly around the end of the finger. I:8 CEREBRAL HYPERaEMIA. " 3d. The increased heat of the head, not only subjectively, but as indicated by the thermometer, or the thermo-electric calorimeter. "4th. The persistent insomnia always present—a condition now known to be due to cerebral hypere- mia.* " 5th. The aggravation of all the symptoms of in- tellectual exertion or emotional disturbance. " 6th. The results of ophthalmic and aural exam- inations. " 7th. The effect of quinine, strychnine, nitrite of amy I, alcoholic liquors, and other agents which we know increase the amount of blood in the brain, in aggravating the symptoms of the disease. " 8th. The speedy disappearance of the phenom- ena under the influence of mental quietude, and of those therapeutic agents which lessen the amount of intra-cranial blood." The ordinary student of medicine could only place those " cannons " in the category of Symptoms, if anywhere, for assuredly between them and what is commonly regarded as " morbid anatomy" there is no resemblance whatever, and the difficulty of fol- lowing our author for ten lines consecutively be- comes more evident in consequence. I shall not, therefore, ask the reader to follow any detailed re- * What of the soporific variety of " cerebral hyperemia " ? GENERAL CONCLUSIONS. IIOy marks on the assertions contained in them, for their reputation is sealed, not only by the common obser- vation of practical physicians, but by the author himself,* in diverse portions of his work. The task I have undertaken is not to follow all the peculiari- ties of the writer; it is rather to ascertain how far he is to be relied upon as a guide in general, and hence the two prominent features of all his works, and without those they would have few points of distinction, are the ones that I endeavor to draw special attention to throughout. They are, 1st, that sleep is due to cerebral anemia; 2d, that the bro- mides produce sleep by reducing the blood supply to the brain. I have elsewhere quoted from Foster what is the intelligible and received view among physiologists regarding sleep at the present time, and which, weighed side by side with the therapeutical effects of the many sleep-producing drugs, has about it a basis of irrefutable argument against which the idle repetitions of Dr. Hammond are unworthy a mo- ment's consideration. To show how frequently these two leading ideas occur in the author's labors it is only necessary to refer even to the chapter on " Morbid Anatomy," where the reader who has been interested by the previous remarks, will find the fol- * See case of Hadfield Jones commented on ; also chapter on Treat- ment. 120 CEREBRAL HYPERaEMIA. lowing not unwonted platitude : " The principal sub- jective symptoms of cerebral hyperaemia, when it is of such a degree of intensity as to constitute dis- ease, are wakefulness, pain increased by mental exertion; and mental aberration of some kind. Of these the first is the most important* not only on account of the suffering and injury it is to the patient, but because it is the necessary accom- paniment, the pathognomonic symptom of the affection in question. Without wakefulness there is no f cerebral hyperemia, with cerebral hy- peremia there is always wakefulness." This is a bold reiteration of a theory which never had a shadow of reason to sustain it, and which is as man- ifestly incorrect as the most absurd of the dreams of the humoral pathologists. It has been so proven long before the publication of this monograph by Dr. Hammond, and hence there is no excuse for its constant recurrence in this work. Furthermore by one who has ever taken the slightest pains to study the physiological action of such substances as chlo- roform, alcohol and opium—all sleep-producers of the most unmistakable character—this worthless * Ordinary minds would conclude that mental aberration or in- sanity is at least as important as mere wakefulness. f This, it will be observed, is the manner in which "morbid anatomy " is served up throughout the chapter. GENERAL CONCLUSIONS. 121 repetition of a mischievous, misleading doctrine could never be so persistently reproduced. We are told that " the experiment of Mr. Durham and myself proved this matter beyond a question," though it is unnecessary to remind the reader that the experiments of Mr. Durham were made five years prior to any publication by Dr. Hammond on this subject, and that as regards their value in connec- tion with this subject they have no weight whatever. All that the experiments demonstrated was simply this: When the animal " went to sleep," the brain showed a lessened quantity of blood flowing through, and when the animal awakened the quantity in- creased. Now do we not observe this same result constantly in the case of the babe whose anterior fontanel is yet unclosed ? Even when the child sleeps, as it commonly does, after its natural repast, and when, as we know, the general activity of the circulation, and consequently that through the brain, is decidedly increased, the fontanel will be- come more or less depressed, a fact which also con- forms with our accepted ideas of physiological laws. For it is now indisputable that, ceteris paribus, the amount of blood directed to any organ of the body will be in direct proportion to the activity of the organ at the time, so that the quiet of the brain, the repose which the condition known as sleep mani- festly produces, is the cause of the lessened blood 6 122 CEREBRAL HYPERaEMIA. supply of the brain, and not the consequence of it, as more clearly elsewhere enunciated by Foster. Nor, indeed, could anything well be more corroborative of the falsity of his position in this regard than the very cases quoted by himself to sustain it. Take the following for example: " Dendy states that there was in 1821 at Montpellier a woman who had lost part of her skull, and the brain and itsmembranes lay bare; when she was in a deep sleep the brain remains motionless beneath the crest of the cranial bones ; when she was dreaming it became somewhat elevated, and when she was awake it was protrud- ing through the fissure of the skull." The question now arises: What produces the hy- peraemia in this and similar conditions, if the dreams be the result of hyperaemia ? Sleep is no doubt a continued, unchanged condition as long as it lasts notwithstanding the presence of dreams, and as long as the individual remains undisturbed by any external influence in the same bodily position, there could, in a case like this, have been no external agency pro- ducing first hyperaemia and consequent dreams, while on the contrary recognizing the opposite view, that the action of dreaming produces the hyperae- mia, we at once arrive at a perfectfy satisfactory and philosophic explanation. We know that dreams arise in relation to thoughts that have crossed the mind with more or less impress, on prior occasions, GENERAL CONCLUSIONS. 123 that while more urgent matter, as it were, presses them aside in our wakeful moments, they again and again recur in the somnolent brain and assert them- selves like the thoughts we sometimes cannot banish whilst awake. Now, one of these passing thoughts asserting itself in this condition of sleep, will, of course, give rise, according to its importance, to a greater or less degree of mental or brain activity, which activity in turn produces, in conformity with all analogy elsewhere in the body, the observed hyperaemia. Strangely, but consistently enough, the action of hypnotic drugs is also introduced to add proof to his doctrines in this regard, and we are told that: " All those which produce sleep probably do so by their action in lessening the amount of intra-cranial arterial blood." This subject has been discussed sufficiently else- where to show that, so far is this from being the case, that the most powerful stimulant of the cir- culation, as alcohol, is also a powerful hypnotic, and it is not now too much to add that since the discov- ery of the circulation by Harvey, no medical teacher, worthy the name, has propounded so crude and me- chanical a notion of the action of drugs. As it stands, it implies this, if anything: that a drug which is absorbed into the general circulation has the power of lessening this same circulation in one direction and increasing it in another, that, in 124 CEREBRAL HYPERaEMIA. fact, it has placed in position a series of stop-cocks at certain portions of the system, and can mechani- cally reduce or increase the flow of blood in certain directions. Possibly at no distant day this philo- sophic writer will point us out the drugs that in- crease the circulation of the right arm, and reduce it in the left, and vice versa. Clearly the physiology of the vaso-motor nervous system, and its regulat- ing power over the circulation of the different tracts of the body, has not received all the atten- tion needed from the author of " Cerebral Hyper- aemia." Again, in the chapter on " Treatment," we find this same mechanical idea of therapeutics empha- sized with the customary vigor. We are told that the " 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 system that may be present in the sthenic form of insomnia." Throughout the paragraph, as in the work gener- ally, this same extraordinary strain prevails, with- out the slightest apparent regard for fact or previous assertions. If the writer had for a moment consid- ered the action of such drugs as aconite, veratrum viride, and tartar emetic, what conclusion might not have been arrived at relative to their sphere of usefulness ? These are substances which, it is fair GENERAL CONCLUSIONS. 125 to presume he will concede, have the direct effect of lowering the general circulation, and consequent- ly that of the brain. Hence, according to his theory, they should be very powerful hypnotics, unless they are defective in stop-cock action ; but it is reserved for future investigators to demonstrate that they have the slightest effect in sleep-producing, for, so far, it has not been asserted by any reputa- ble authority, and from our daily clinical observa- tion of their effects, there is anything but evidence of their power to control excitement of the nervous system. 'some forty years ago Wilks, of Guy's Hospital, London, discovered that bromide of potassium had a powerful influence in allaying many forms of ner- vous excitement, and since that time it has been very extensively adopted by the profession for such purposes; yet Dr. Hammond, with customary mod- esty, claims that he was " the first to announce this fact to the profession twelve years ago." By this time the reader must be somewhat accus- tomed to this species of assertion, but considering the ex cathedra dogma so frequently propounded, to the effect that wakefulness constantly depends on " cerebral hyperaemia," he will be scarcely pre- pared for the admission above implied, that there is an asthenic as well as a sthenic form of insomnia, for we are carefully reminded that " the bromide of 126 CEREBRAL HYPERaEMIA. potassium, by limiting the amount of blood 'in the brain, will allay any form of nervous excitement de- pendent on the sthenic form of insomnia." Again, the same happy indifference to consistency as well as to therapeutic discoveries greets us in the next page on treatment, when we are recommended to use, in this incomprehensible malady, the most powerful heart-tonic in the Pharmacopoeia, viz., digi- talis, for the reason, as we are informed, that " it is of great service in giving strength to the heart." Thus this medical philosopher, who delights in surprises, will instruct the engineer in hydraulics: " Your elastic tubes in this region (and the brain arteries are to some extent closely corresponding), are over- distended ; I am very much afraid they will give way ; your only proper plan of reducing the strain is to add more force to your pumps " !! ! The foregoing is not, however, the only recom- mendation in the chapter on " Treatment " worthy of note, not for any information it contains, but as a mere matter of curiosity. The very next para- graph to the above informs us that if dyspeptic symptoms are present we are to use pepsine and charcoal with our meals. Elsewhere in this mono- graph we were carefully cautioned to guard against the fact that dyspepsia was one of the diseases liable to be confounded with cerebral hyperaemia—a con- fusion that must be healthily provided against. GENERAL CONCLUSIONS. i2y Thus Trousseau's idea concerning " vertigo, a stomacho laeso," which so closely conforms to our daily observation in practice, herein receives the positive indorsement of Dr. Hammond, viz., that the stomach is primarily the peccant organ in some forms of" cerebral hyperaemia," but unhappily this indorsement is accompanied by a feeble and futile effort at treating the multifarious malady known as dyspepsia. The application of the actual cautery to the nape of the neck is also recommended in treating this factitious disease, but why we cannot understand, unless for a reason corresponding to that given above relative to the use of digitalis, or an unenlightened belief in the old derivative notion of counter-irritants. But disputable points of this character need not detain us, for we will find in the list recommended for treatment such powerful heart tonics and nerve tonics as arsenic, strychnia, iron, phosphorus and quinine—all of which it will be re- membered were in that terrible " Cannon No. 7 " in Morbid Anatomy; and the deleterious effects of which were given as the proofs—indeed, almost the only proof—of the existence of the malady. We find whiskey, brandy, gin and rum strictly forbidden, whilst the light malt beverages, i. e., ales* and beers, * No doubt these substances are commended for the abolition of "cerebral hypercemia" because the appearance of brewery men is so characteristic of cerebral anaemia !! 128 CEREBRAL HYPERaEMIA. and the lighter wines of France, Germany and Italy strongly recommended, though, as regards the cere- bral circulation, what the difference may be be- tween good brandy reduced down to the alcoholic strength of light wine and the light wine itself is a problem that may be worth more to the author to solve than all his contributions to medical litera- ture. Again, tea and coffee may be " left to our own discretion." Coffee! the most powerful stimulant of the circulation in common use! If the reader doubts this let him count his radial pulse immedi- ately before and after having taken a small cup of black coffee. But then, possibly, coffee has the stop-cock action already alluded to, i. e., it may perhaps increase the vigor and frequency of the radial pulse and diminish both in the external ca- rotid artery and so cut off supplies to the brain!! A light supper before retiring is also commended, and the rationale of its effects are explained: " For food to be digested there must be an increased flow of blood in the stomach, and a part of this comes from the brain to the relief of the surcharged vessels." This is really profound, and the stop-cock action in physiology is not confined to the action of drugs alone. All physiologists tell us that after eating the general circulation is more active and vigorous, and every individual can find this out for himself GENERAL CONCLUSIONS. i2g by an examination of the pulse immediately before and after any repast. It was reserved for Dr. Ham- mond, however, to inform the world that while the circulation in general may be more active; that while the radial artery, for instance, may have a quicker and fuller flow of blood through it, the ca- rotids supplying the brain will tell a totally different tale!! If extravagant unreason in medicine can go any further I am unaware of the fact and incapable of comprehending it. And if from such evidence as is here adduced—while I believe strict justice has been done the monograph—the reader can convince him- self that such a disease as " cerebral hyperaemia" in the sense here referred to has any existence out- side Dr. Hammond's imagination, his discernment and reasoning faculties are of an order to which I am a stranger. 4 V f >" NLM005597660