CEREBRAL HYPERJEM IA 
THE RESULT OF 
MENTAL STRAIN OR EMOTIONAL DISTURBANCE 
\ 
BY 
WILLIAM A. HAMMOND, M.D. 
Late Surgeon-General, IL S. Army : Professor of Diseases of the Mind and Nervous System in 
the Medical Department of the University of the City of New York, and in the Medical 
Department of the University of Vermont; Fellow of the College of Physicians 
of Philadelphia, and of the Academy of Arts and Sciences, Boston ; 
Member of the Academy of the Natural Sciences of Philadel- 
phia ; of the American Philosophical Society ; of the 
New York Neurological Society ; of the American 
Neurological Association ; Corresponding 
Member erf the British Medical Asso- 
ciation ; Member of the Med- 
ico-Ch irurgical Society 
of Edinburgh, 
etc., etc. 
Read before the New York Neurological Society {in outline}, Nov. $th, 1877. 
NEW YORK 
G. P. PUTNAM'S SONS 
182 Fifth Avenue 
1878. Copyright, 
1878, 
By G. P. Putnam's Sons. PREFACE. 
The disease which is considered in the ensuing 
pages is more common, according to my experience, 
than any other affection of the nervous system. It 
is especially an outgrowth of our civilization, and of 
that restless spirit of enterprise and struggle for 
wealth so characteristic of the American people. It 
is an easily preventible disorder, not for this purpose 
requiring extensive hygienic operations, but simply 
the acts of the individual in using his or her brain 
with the same regard for its well-being as is ordinarily 
extended by the humane carter to the muscular system 
of his horse. The brain of man is strong : it will en- 
dure a terrible amount of ill usage ; but there are limits 
to the abuse which may be inflicted upon it with im- 
punity, and few there be who do not pass them. 
It is, perhaps, too much to expect the emotions to 
be entirely under the control of the individual, nor is 
it desirable that we should be reduced to the condition 6 
PREFACE. 
of intellectual automata, moved always by reason and 
judgment and never by feeling. But it is entirely 
within the power of every one, by that self-discipline 
so seemly in all, to obtain such a degree of mastery 
over unworthy or excessive passions, as will prevent 
them dominating over the whole mind and body to 
the detriment of both. 
Ill-regulated emotions are even more prolific of 
brain disorders than severe mental labor, and many a 
person considered to be suffering from what is called 
nervous prostration or exhaustion, is simply the sub- 
ject of emotional disturbance and a consequent con- 
dition of cerebral hyperaemia. 
The last few years have witnessed the death of 
many distinguished persons from the direct results of 
excessive brain-work, or the passional excitement so 
commonly produced in men and women by the mul- 
titude of causes in operation upon them. In the 
hope, that what I have written may tend to the pre- 
vention or alleviation of suffering, I send out this little 
monograph. 
WILLIAM A. HAMMOND. 
43 West Fifty-Fourth St., 
New York, January i, 1878. CONTENTS. 
CHAPTER I. 
Page. 
Introduction 9 
CHAPTER II. 
Cerebral Hypertemia-Symptoms 17 
CHAPTER III. 
Differential Diagnosis 52 
CHAPTER IV. 
Causes 69 
CHAPTER V. 
Prognosis 81 
CHAPTER VI. 
Morbid Anatomy and Pathology 83 
CHAPTER VII. 
T RE ATMENT 98 CEREBRAL HYPERtEMIA. 
CHAPTER I. 
INTRODUCTION. 
The condition in which the brain is left after very 
intense or protracted mental application, or as a con- 
sequence of powerful emotional disturbance, is one 
of very great importance, both as regards the imme- 
diate results to the individual, and as predisposing to 
subsequent disease. Up to the time of the publication 
of a monograph of mine on Wakefulness,* nearly 
twelve years ago, the subject had scarcely attracted 
any attention ; and even since then, the very few ob- 
servations that have been made by others have been 
from wrong stand-points, and hence devoid of satis- 
factory therapeutical results. In subsequent writ- 
* On Wakefulness, with an Introductory Chapter on the 
Physiology of Sleep. Philadelphia: 1865. 10 
CEREBRAL HYPERsEMIA. 
ings * I have insisted upon and amplified the views 
then enunciated, and in the present monograph I pro- 
pose to reconsider at length the whole subject, em- 
bodying in the discussion the main points of a greatly 
enlarged personal experience as well as the results of 
some interesting observations recently made abroad. 
That an increased amount of blood flows through 
the cerebral vessels during mental activity, that these 
vessels may become permanently over-distended, and 
that profound interstitial changes may thereby be 
eventually produced in the brain-substance, are facts 
in regard to which I have no question. The first 
two are capable of actual demonstration ; the last 
is a matter of inference, but of inference so very 
decided in its character as scarcely to allow of the 
existence of a doubt. What these changes are, 
and what relation they bear to the kind and degree 
of cerebral action, we are far from being able to 
determine. 
Helmholtz,! several years ago, ascertained for 
* Sleep and its Derangements. Philadelphia: 1869. On 
the Effects of Excessive Intellectual Exertion. Bellevue and 
Charity Hospitals Reports. New York: 1870. A Treatise on 
Diseases of the Nervous System. New York: 1871, and sub- 
sequent editions. 
f Muller's Archiv., 1843, p. 72. Also Die Chemie der Ge- 
vebe, von Julius Eugen Schlossberger, Erster Band. Leipzig 
& Heidelberg, 1856, p. 186. INTRODUCTION. 
11 
muscles what we cannot with equal certainty deter- 
mine for the brain. He amputated the legs of a frog, 
and, leaving one of them in a state of rest, excited 
the other to contractions by means of galvanism, con- 
tinuing the current so long as the muscles retained 
their irritability. The flesh of the two limbs was 
then submitted to chemical examination with the re- 
sult of ascertaining that the water-extractive was 
from twenty to twenty-five per cent less in the exer- 
cised limb than in the other, while the alcohol-extrac- 
tive was correspondingly increased. I have repeat- 
edly performed Helmholtz's experiment with similar 
results. 
Such experiments show how profoundly the exer- 
cise of an organ modifies its structure. 
Gulliver's observations lead to no important con- 
clusion except that muscular rigidity ensues at a com- 
paratively early period in animals hunted to death. 
The effects of emotion over the solids and fluids 
of the body has long been known, and in some of its 
phases is a matter of every-day observation. Thus 
we see the vessels of the face and chest become sur- 
charged with blood under the influence of anger or 
shame ; the saliva of man may be changed from a 
bland fluid to a powerful poison through the effect of 
rage, and fear or horror converts the sustenant milk 
of the mother into a potion of deadly qualities. In 
fact, scarcely an organ of the body resists this influ- 12 
CEREBRAL HYPEREEMIA. 
ence altogether, and some exhibit it in a very marked 
degree. Even the muscles are subject to it, and 
may be profoundly changed in chemical constitution 
through emotional disturbance or physical suffering. 
Doubtless the primary effect is in all such cases pro- 
duced upon the blood, but this does not lessen the 
value of the examples as analogical to what we have 
ample assurance, takes place in the structure of the 
brain from similar causes. 
The influence of bodily suffering in rendering 
the blood poisonous, is very strikingly shown in the 
following account: 
" In order to procure a roast for Easter," says Dr. 
Rbser, " C. in R. desired his family to set a snare for 
a roebuck. Accordingly one of these poor animals 
was caught in the snare, which, as its head and breast 
had passed through, held it by the hinder parts of the 
body, the abdomen and pelvis being enclosed in the 
cord, so that it must have succumbed after a most 
agonizing struggle. It was found dead the next day. 
The master and mistress of the family ate on Easter 
day the best part of this dainty ; the servants had 
little; the remainder was laid in vinegar but not 
eaten. 
" On the same day all of the family who had eaten 
of the venison observed a striking dryness of the 
mouth, oppression of the stomach and nausea ; all 
complained of oppression of the head, giddiness, and INTRODUCTION. 
13 
great weariness of the limbs. The master lost his 
sight for several days, and in short, there now began 
a series of remarkable symptoms requiring in many 
ways the assistance of Dr. Rbser. The husband was 
only restored to health in July, but the wife never re- 
covered. She lingered more than two years, and at 
last died after severe sufferings. The daughter, the 
man-servant, and the maid who had eaten little of the 
tortured animal, were soon cured. The symptoms in 
many respects resembled those of the effects of the 
bite of rabid animals (and of the sausage poison of 
Wiirtemburg ?) " 
Dr. Roser concludes his communication in these 
words : 
" Many an animal (for example in hunting) is 
tortured to death in the most barbarous manner like 
the roebuck in the snare. Ought not the medical po- 
lice to be led by cases like this to adopt the strictest 
regulations to prevent the use as food of animals which 
have in any way been tortured to death, and to insure 
that the animals intended for food are not tortured 
before being slaughtered ? " * 
Every one, too, has noticed the feeling of fatigue 
experienced after severe physical exertion. This is 
* Dr. C. G. Carus in Der Menschenfreund in seiner Bezie- 
hungen ziir belebten Welt., quoted by Liebig in his Familiar 
Letters on Chemistry, etc. Third edition, London, 1851. Ap- 
pendix, No. 4, p. 531. 14 
CEREBRAL HYPEREEMIA. 
of course due to structural changes in the muscles as 
well as to nervous exhaustion. It is also well known 
that the flesh of animals hunted to death is stringy, 
unsavory, and that microscopical examination shows 
the fibrillae of the muscles to be ruptured and separ- 
ated from each other by minute extravasations of 
blood. In addition to these evidences of muscular 
change we have that afforded by the products of the 
waste of the muscular tissue-the debris, as it were, 
which appear in the urine, and enable us to measure 
with considerable accuracy the extent of the decom- 
position. 
Now, in regard to the brain, somewhat similar re 
suits ensue from intellectual exertion and emotional 
excitement; and, although, as I have said, we cannot 
determine with any great degree of exactness, the na- 
ture or extent of the change produced, we are not al- 
together without important data which tend to give us 
some conception of what is going on. By means of 
various physical apparatus we are able to obtain ap- 
proximately correct notions in regard to the quantita- 
tive state of the cerebral circulation, and a careful 
study of the symptoms aids us still further in arriving 
at exact ideas on the subject. We can also, after the 
manner of the chemist-who weighing the ashes left 
in the grate will tell us how much coal has been con- 
sumed-measure the waste of the nervous tissues and 
thus determine with an approximation to accuracy how INTROD UCTION. 
15 
much brain has been decomposed in a given period. 
The two conditions are apparently inseparably con- 
nected. Whenever there is an increased amount of 
blood circulating in the cerebral vessels, there is at the 
same time an augmented waste of the cerebral sub- 
stance. 
Thus, several years ago desiring to ascertain the 
effects of excessive mental labor upon the brain as in- 
dicated by the excretion of urine, I performed a series 
of experiments upon myself by which it was clearly 
ascertained that the solid matter eliminated by the 
kidneys was notably increased in direct relation with 
the extent to which the brain was worked. All this 
was, for the time being at least, within the limits of 
health. But by persevering with the experiments and 
carrying the mental exertion to a still higher point, a 
stage would have been reached at which the decom- 
position of brain substance would have been greater 
than the formative processes, and then disease would 
have existed. I would have been living, as it were, 
on my brain capital instead of the income, and brain 
bankruptcy would have been only a question of time, 
just as it is in financial matters. This is exactly what 
people do with their brains continually. Overwork 
causes them to use up their brains faster than they 
make them, and as a consequence, that organ which 
of all others it is essential to keep in a healthy con- 
dition, becomes the seat of serious disease. To the 16 
CEREBRAL HYPEREMIA. 
consideration of some of the consequences of inordi- 
nate brain action, I propose to devote the following 
pages. CHAPTER II. 
CEREBRAL HYPER2EMIA SYMPTOMS. 
That one of the primary effects of intellectual ex 
ertion or emotional disturbance is an increase in the 
amount of blood circulating through the brain, does 
not admit of a doubt, except from those who, still re- 
fusing to learn, contend that the cerebral circulation 
is not subject to variation under any circumstances. 
Experimental physiology has, however, determined 
this point so positively in the affirmative that it is 
scarcely necessary to adduce the evidence in its sup- 
port. It will be sufficient to recall the numerousfacts 
observed by others and myself with reference to the 
immediate cause of sleep, by which it is shown that 
during the condition of wakefulness the quantity of 
blood in the brain is much greater than it is during 
sleep; the first being a state of intellectual activity, 
the latter one of almost complete cerebral rest. * 
* Those who desire further information on this and analo- 
gous points are referred to the writer's monograph entitled, 
Sleep and its Derangements, and to his Treatise on Dis- 
eases of the Nervous System, chap, i., on Cerebral Congestion. CEREBRAL HYPERAEMIA. 
18 
Excessive mental exercise inordinately augments 
the activity of the cerebral circulation. The blood- 
vessels become over-distended, and if the brain be 
kept long in a condition of extraordinary action, they 
maybe rendered incapable of returning spontaneously 
to their normal dimensions. Like a bladder filled to 
repletion with urine, they become in a manner paral- 
yzed and unable to contract upon their contents. 
They lose, to a certain extent, their elasticity, and like 
the India-rubber band, kept too long around a large 
bundle of papers, they do not regain their natural size 
even when the distension is removed. A state of 
cerebral hyperaemia is thus induced which gives rise 
to a set of perfectly characteristic symptoms and 
which is fraught with peril to those in whom it oc- 
curs. 
In a monograph published some four years ago, 
Dr. M. Krishaber * described a disorder of the brain 
and heart which is probably identical with the one 
under consideration, and to which, under the name of 
cerebral hyperaemia, or the prodromatic stage of cere- 
bral hyperaemia, I called attention in the first edition 
of my Treatise on Diseases of the Nervous System, 
published in 1871. Krishaber's studies have very 
considerably advanced our knowledge of the subject, 
and as my own more recent investigations and enlarged 
experience have tended still further to the elucidation 
* De la " cerebro-cardiaque." Paris : 1873. SYMPTOMS. 
19 
of a very interesting and important condition of the 
nervous system, I have thought it would not be out of 
place to bring some of the more notable results of our 
labors to the notice of the Neurological Society. It 
may be as well, however, to state here at the outset, that 
I differ with Krishaber entirely relative to the pathol- 
ogy of the disorder we have both described, and that 
I am of the opinion that the cardiac symptoms upon 
which he lays great stress are really of quite second- 
ary importance. In other respects there is no essential 
point of difference between us in the representations 
of an affection studied, independently of each other, 
and from altogether different stand-points. 
The disease is sometimes developed with great 
suddenness, but ordinarily it advances little by little 
to completeness. When the former is the case the 
patient experiences, under the influence of great men- 
tal excitement, pain in the head, vertigo, an inability 
to speak, or at least imperfection of articulation. 
There are noises in the ears, flashes of light before 
the eyes, and occasionally for a short time double 
vision. The heart beats with increased force and 
rapidity and is more or less irregular in its action ; the 
face is flushed, and a feeling of suffocation is ex- 
perienced. If he attempts to walk, his gait is uncer- 
tain or staggering, not only in consequence of the 
vertigo present, but from actual loss of power in the 
limbs. Numbness is commonly felt in some part of 20 
CEREBRAL HYPEREMIA. 
the body, and clonic spasms of the muscles, notably 
of those of the face, are generally present. 
With all these physical symptoms there are others 
indicating mental disturbance. Chief among these 
are hallucinations, or illusions of the senses, particu- 
larly of sight and hearing. Insomnia is an almost 
invariable attendant, and what little sleep the patient 
obtains is interrupted by unpleasant or even frightful 
dreams. Gradually, the disorder becomes established, 
and then other functions, especially those connected 
with digestion, are deranged. From the first the 
urine is loaded with urates and phosphates. 
As instances of the suddenness with which the 
disease may make its onset, I cite the following cases 
from my note-book : 
F. H., a gentleman engaged in a manufacturing 
business which required all his attention to make it 
profitable, was informed one morning by his superin- 
tendent that a large lot of material had been spoiled. 
He at once experienced an intense sensation of ver- 
tigo, a sharp pain in the head, palpitation of the heart, 
and would have fallen had he not been supported by 
the bystanders. There were also a roaring sound in 
the ears and flashes of light before the eyes. On at- 
tempting to stand, the vertigo and palpitations were 
increased. There was at no time loss of conscious- 
ness, though the ideas were confused and the speech 
thick. In the course of a few hours the severity of SYMPTOMS. 
21 
these symptoms diminished, but that night he was 
unable to sleep, and in the morning the morbid phe- 
nomena re-appeared, though with diminished violence. 
For several months afterward, he was troubled with 
wakefulness, a sense of fulness and tightness in the 
head, occasional weakness of the limbs, slight numb- 
ness and a total inability to exert his mind in his busi 
ness affairs without an increase in all the symptoms. 
Under appropriate treatment he entirely recovered. 
S. L., a book-keeper, after a day of unusually ar- 
duous work, left his place of business to go home. 
He had hardly taken half a dozen steps when he was 
seized with vertigo and fell unconscious on the side- 
walk. He almost immediately regained his senses, 
but on trying to stand found that he was paralyzed 
in both legs, and that the least motion of the 
body brought on a return of the vertigo, which was 
now attended with pain in the head, mostly in the 
frontal region, noises in the ears and indistinctness of 
vision. On attempting to speak, his articulation was 
so imperfect that he could scarcely be understood. 
There was an uneasy feeling at the pit of the stomach, 
but neither nausea nor palpitation of the heart, 
though the action of this organ was irregular. He 
was taken home in a carriage, and after a sleepless 
night found himself very little better except in the 
fact that though his legs were still weak there was no 
absolute paralysis. Gradually he got somewhat bet- CEREBRAL HYPERPEMIA. 
22 
ter, though walking always produced vertigo, and his 
gait was similar to that of a partially-drunken man, as 
he found it impossible to avoid a zigzag course, or a 
decided tendency to sidle over to the edge of the 
pavement. Sleep was almost every night imperfect, 
being disturbed by dreams of difficulties from which 
he could not extricate himself, such as the house be- 
ing on fire, and on his springing from bed discover- 
ing his door to be locked on the outside ; falling into 
the water and being on the point of drowning from 
inability to divest himself of heavy boots, and so on. 
Mental application was impossible without leading to 
an aggravation of all his symptoms, and the least 
emotional excitement was sufficient to augment them 
to a high degree. He suffered in this manner for 
nearly a year, before relief was obtained, being in 
that time treated with remedies directed to the re- 
moval of cerebral anaemia, when in fact the intra- 
cranial condition was directly the opposite. 
M. S., a young lady, aged 19, and without notable 
predisposition to neurotic disturbances, was deeply 
chagrined at not being invited to a ball at which she 
had confidently anticipated being present. While 
talking the matter over with some friends she sud- 
denly experienced a severe pain in the head, vertigo, 
noises in the ears, flashes of light alternating with 
darkness, and violent palpitation of the heart. At the 
same time a peculiar thrilling sensation was felt SYMPTOMS. 
23 
throughout the body, especially on the left side. These 
symptoms continued with great intensity all that day, 
notwithstanding that stimulants and antispasmodics 
were administered in large quantities by the physi- 
cians called to attend her. During the night, every 
attempt to turn over in bed was attended with ver- 
tigo and palpitation of the heart. For over a year 
there was very little improvement, and the course of 
the disease was not essentially different from the other 
cases cited. The most distressing symptom in her case 
was the persistence of the insomnia, it rarely happen- 
ing that she obtained over an hour or two of unre- 
freshing slumber. When she came under my care 
some thirteen months after the inception of the dis- 
ease, I found that the affection, though mitigated in 
the violence of the attendant phenomena, was still 
sufficiently distressing to impair her capacity for en- 
joyment and her usefulness to others. Recognizing 
the existence of congestion of the brain rather than 
anaemia, for which she had uniformly been treated, I 
acted accordingly, and had the satisfaction of seeing 
her gradually improve till, at the end of less than six 
weeks, she was as well as she ever had been in her 
life. 
These cases arc cited not as exhibiting perfect 
representations of cerebral hyperaemia, but merely for 
the purpose of illustrating the suddenness with which 
the condition may be induced. They are selected at CEREBRAL HYPEREMIA. 
24 
random from many others occurring in my hospital 
and private practice, and detailed in my note-book. 
Eventually, no matter how brusque may be the de- 
velopment of the symptoms, the course of the disease 
is not materially different from that of the more grad- 
ually established form next to be described. Indeed 
there are no differences except as regards the order of 
sequence in which the symptoms ensue and in the 
fact that in the present form, there is, in the begin- 
ning, a greater degree of intensity in the abnormal 
manifestations. 
In the majority of cases, therefore, the affection is 
evolved more slowly and the order of appearances of 
the phenomena somewhat different. 
Wakefulness is generally the first symptom indica- 
tive of cerebral disturbance, and this may be of all 
degrees from the loss of an hour or two of sleep to the 
passing of night after night in a state of complete 
insomnia. Even if sleep be obtained in some cases, 
it is disturbed by nightmare and frightful dreams, and 
the patient accordingly rises feverish, unrefreshed and 
entirely unfit for mental or physical exertion. 
Upon endeavoring to apply himself to mental 
labor, he finds it difficult to fix the attention, and the 
effort to do so, or to obtain correct ideas of even 
simple matters, almost invariably increases the pain 
or uneasiness felt in the head. I think these phenom- 
ena are especially observable in those who have to SYMPTOMS. 
25 
deal with arithmetical questions. The most accurate 
accountant is unable to add up a column of figures 
without making errors, of which in health he would 
be incapable. Repeated attempts in this direction 
render the task more and more difficult, and aggravate 
the mental confusion and physical discomfort. Indeed, 
so great is the disturbance thus induced that at 
times, utter despair takes possession of the mind. 
In a case of the disease under notice, occurring in a 
gentleman holding a prominent position in a bank of 
this city, an attempt at suicide was made, solely be- 
cause of the chagrin induced by the inability to obtain 
a correct result in the addition of a number of 
figures. 
The progress of the affection is indicated by ad- 
ditional evidences of mental derangement. The 
memory in regard to recent occurrences and the names 
of persons and places is notably weakened, and oc- 
casionally there are other aphasoid symptoms, such 
as substituting one word for another of similar sound, 
or imperfectly pronouncing words consisting of two or 
more syllables. Thus, a patient spoke of his slippers 
as " flippers," another, well educated, alluded to sexual 
intercourse as " sectional " intercourse, and a third, 
who was at the time suffering also from haemorrhoids, 
repeatedly spoke of his fundament as his "condiment." 
The judgment is weak and vacillating, the most 
strongly expressed determination is changed appar- 26 
CEREBRAL HYPERAEMIA. 
ently without reason, and again, there is an impossibility 
of arriving at a decision, in cases where ordinarily, but 
little reflection would be necessary. I have known a 
patient suffering from the disorder in question, take 
several thousand dollars every dav for a month or 
more, to Wall Street, fully resolved, when he left his 
house, how to invest his money, but always returning 
with his purpose unfulfilled-a prey to doubts for 
which he could give no sufficient cause even to himself. 
Illusions, hallucinations or delusions, may be pres- 
ent, but are not usually fixed; and the patient will 
often laugh at the absurd images he has seen, voices 
he has heard or ideas he has entertained not five 
minutes before. Persons thus affected will often 
reason clearly in regard to apparitions or voices of 
the unreality of which, they are fully sensible. 
A condition very often present is a morbid appre- 
hension of impending evil, for which there is no 
assignable cause, and the nature of which the patient 
can rarely define. He is sure something will happen 
to him, but what, he does not know ; or if he does 
designate the form of trouble to ensue, he changes 
from one kind to another without any more reason 
than he had for the erroneous idea in the first place. 
Again, he is afraid that he may do some injurious act 
either against himself or others, and is hence fearful 
of being left alone. One patient was afraid to cross 
the ferry from Brooklyn lest he might be tempted to SYMPTOMS. 
27 
throw himself off of the boat; another kept away from 
railway tracks, fearing that he might be led by the 
sight of a passing train to put himself in the way of 
the engine ; another begged his wife to lock up his 
razors ; and another would not take a warm bath under 
the apprehension that he might neglect to turn off 
the hot water in time. It would be easy to enumerate 
very many more like instances. They remind us of 
"morbid impulse," but the subjects unlike those of 
this last-named condition, never yield to the excitation. 
In fact it is not an impulse but the fear of an impulse 
by which they are influenced. 
The emotional system participates in the general 
mental disturbance, and indeed is often the part of 
the mind most prominently deranged. The passions 
are easily roused into activity by slight exciting 
causes ; trifling circumstances produce great annoy- 
ance, and the little every-day troubles of life appear 
of vast importance. The disposition accordingly be 
comes suspicious, peevish and fretful. Persons thus 
affected are very far, ordinarily, from being pleasant 
companions. Many of them avoid social intercourse, 
and shut themselves up in their rooms to brood over 
their real and imaginary disorders. Others, again, 
plunge into dissipation and excesses of every kind, in 
the vain expectation of being able by such means to 
overcome the disease ; and again, others strive, by a 
constant change of one physician for another, or the 28 
CEREBRAL HYPEREMIA. 
substitution of one quack medicine for another equally 
quackish, to get relief from their mental and physical 
distress. In some, there are very few decided symp- 
toms present, except the inability to sleep, and the 
incapability of concentrating the mind upon an object 
of study or labor, without inducing pain or discomfort 
of some kind in the head. 
In all, however, there is the same mental intro- 
spection. Every symptom is exaggerated ; and if one 
with which the patient has suffered should happen to 
be absent, he is dissatisfied till it makes its appearance 
again, or till he has, by concentration of his mind on 
the subject, brought it back, and with it an aggrava- 
tion of all the other phenomena. " Doctor," said a 
gentleman to me a few days since, " I am afraid I am 
getting worse, for last night I slept several hours, and 
if stupor should set in, I suppose it would be bad." 
Another, who had for several months suffered from 
an almost perpetual pain in the head, was quite sure 
sensibility was being destroyed when he found him- 
self a whole day without it. 
This fixing of the attention upon the body, is of 
course apt to develope symptoms which would other- 
wise, doubtless, never make their appearance; and 
scarcely a day passes that instances in point do not 
come under my observation. The experiments of 
Mr. Braid in this direction are very instructive, and 
will bear quotation in the present connection. He symptoms. 
29 
requested four gentlemen, whose ages varied from 40 
to 56 years, and who were in good health, to lay their 
hands, palms upwards, on a table, and to look at them 
fixedly for a few minutes. They were not to speak, 
but were, as far as possible, to concentrate the atten- 
tion on the upturned palms, and to await the result. 
In about five minutes one of these gentlemen, a mem- 
ber of the Royal Academy, said that he felt a sensa- 
tion of great cold in the hand ; another, an author of 
distinction, said that at first he thought nothing was 
going to happen, but at last he felt a darting, prick- 
ing sensation, as if electric sparks were being drawn 
from the hand ; the third, late mayor of a large city, 
reported that he felt a very uncomfortable sensation 
of heat come over the hand ; and the fourth, secre- 
tary to an important association, had become rigidly 
cataleptic, the arm being firmly fixed on the table.* 
Speaking of this subject, Sir Henry Holland f 
says : 
" One limb, for instance, or even a single finger, 
or a portion of the sentient surface of the body, may 
be taken for observation, and the results tested and 
checked by means wholly independent of the subject 
* For many illustrations of the power of the attention over 
the body, the reader is referred to the author's "Spiritualism, 
and Allied Causes and Conditions of Nervous Derangement. 
New York: 1876. 
t Chapters on Mental Physiology, p. 24. London: 1852. 30 
CEREBRAL HYPERAEMIA. 
of experiment, a point often very important to the 
truth of the result. 
" We have here, as in other parts of the inquiry, 
to look to the respective cases of attention directed 
by express volition, or suggested by some outward 
cause acting on the mind. In the former and more 
simple case, if a limb be taken for experiment, a pecu- 
liar sense of weight, with a vibratory tingling, or sen- 
sations approaching to cramp, are produced by the 
consciousness concentrated upon it. It is difficult to 
describe by words, feelings of this nature, evanescent 
or changing at each moment, and different doubtless 
in different persons ; but probably the closest resem- 
blance is to those produced in ordinary cases by mus- 
cular fatigue or stagnant circulation through the 
limb. There is reason, indeed, to suppose, that the 
muscular structure is actually affected in these cases, 
and frequently even by particular conditions of move- 
ment, though not volitional in kind." 
Medical men are said, and doubtless with truth- 
as many cases will occur to the mind of the profes- 
sional reader-to be particularly liable to be affected 
with the diseases to which they have given special 
attention ; and every winter, during my course of 
lectures on the nervous system, I am consulted by 
medical students, who imagine themselves to be the 
subjects of the diseases I have brought to their notice ; 
and in some cases with reason. Under another divi- SYMPTOMS. 
31 
sion of the subject, I shall have occasion to return to 
this matter for further consideration. 
It follows from what has been said, that if well 
persons are liable to contract diseases through mental 
concentration, the subjects of cerebral hyperaemia 
must be peculiarly prone to the extension of their 
morbid symptoms through a like influence, and in fact 
this is exactly what occurs. A slight accidental sen- 
sation in some part of the body engages the attention, 
and becomes a fixture in the clinical history of the 
patient. Neuralgic pains, numbness, spasm, and even 
paralysis, may be thus induced, to say nothing of 
functional disturbances of the several organs. 
Under this latter head there is none more fre- 
quently met with than what for a want of a better 
name may be called false impotence. To the produc- 
tion of this condition the erroneous ideas which pre- 
vail relative to spermatorrhoea and the fears excited by 
the advertisements and books of unprincipled quacks 
largely contribute. Indeed, it is rarely the case, that a 
male patient affected with cerebral hyperaemia does 
not at some time or other of its course imagine that 
he is impotent, and the only grounds he has for this 
notion are the facts that he has an occasional noctur- 
nal emission, or the exudation of a little urethral mu- 
cus under the influence of sexual excitement. Still 
the fact is not to be overlooked that the predominence 
of this idea is extremely prejudicial to the patient's 32 
CEREBRAL HYPEREMIA. 
well-being, and it is therefore important that the phy- 
sician should, by obtaining his confidence and enlight- 
ening his ignorance, dispel the delusion at the earliest 
possible moment. 
In addition, there are certain physical symptoms 
of disordered cerebral action which by their promi- 
nence force themselves into notice. Thus there are 
p.ain, heat, a feeling of fulness or of distension in the 
head, the sensation as if a tight band encircled it 
or the impression of a dragging or clawing character 
at the vertex. Vertigo is, however, the most prominent 
of all this category of phenomena in the majority of 
cases, and may be so severe as to prevent the patient 
moving about. In one case recently under my 
charge, the subject, a gentleman of about forty years 
of age, was often seized with intense vertigo while 
walking in the street, and was obliged at such times 
to seize hold of a lamp-post, or, if this was not within 
reach, to sit down on the nearest door-step, or even 
the curbstone, till the violence of the attack had in a 
measure abated. 
Again, the least movement of the body, the 
slightest attempt at mental exertion, or the most tri- 
fling emotional disturbance is sufficient to excite it. 
At times it is clearly aggravated by indiscretions in 
diet or the injestion of even a small quantity of any 
stimulating liquor, and at others is present during the 
whole period of being awake. There are two kinds SYMPTOMS. 
33 
of this vertigo. In one the patient seems to be in 
motion ; in the other the objects about him appear to 
be tumbling topsy-turvey around him. In the latter 
the ground in front appears to rise up to meet him, 
and hence he walks as if ascending a hill. In some 
cases the two conditions co-exist or may alternate. 
Probably no symptom is more distressing than this. 
It almost invariably excites more fear of serious con- 
sequences than in reality should attend it, and it pre- 
vents the patient taking that bodily exercise so con- 
ducive to his restoration to health. In some cases, 
however, it is entirely absent, though such are, I 
think, rarely met with, and, no matter how intense it 
may be, is scarcely ever accompanied by nausea. 
In other cases headache constitutes the chief phys- 
ical feature of the disease, and even when not pre- 
dominant is a more or less constant attendant on the 
morbid condition. It may be very severe, unfitting 
the sufferer for the slightest mental or physical exer- 
tion, or may consist of a dull, aching pain, very wear- 
ing but yet bearable. It is aggravated by any effort 
to use the mind or body, and especially by any cause, 
such as a dependent position of the head, the use of 
stimulating ingesta, a constriction about the abdomen, 
chest or neck-likely to increase the amount of the 
intra-cranial blood. 
In some cases there is no actual pain except as 
the immediate consequence of some one or other of 34 
CEREBRAL HYPERAEMIA. 
the existing causes mentioned; but the patient is 
always conscious of an uncomfortable sensation in 
the head, which if not a pain, is capable of being 
readily converted into one. This is, as I have said, 
sometimes a mere feeling of fulness or tightness, or 
as if the brain-so a patient described it-" were 
being gathered together into a heap," or, as another 
said, were " being scratched with a claw." Again 
there is the impression that the head is exactly bal- 
anced on a very sharp point, and that some effort is 
required to keep it from falling off. 
Usually the painful sensations in the head disap- 
pear towards night, or on the attempt to sleep, but 
resume their violence as soon as the patient awakes 
in the morning. 
The special senses could scarcely be expected, to 
escape giving evidences of derangement, and hence 
among the chief manifestations of the intra-cranial 
disorder are those connected with the perceptive 
organs. 
Thus there are noises in the ears such as roaring, 
rumbling or singing, and occasionally loud reports 
such as might be produced by the discharge of fire-arms. 
A gentleman recently under my care for the affection in 
question, informed me that when he first experienced 
the sensation mentioned he was sitting in his library, 
quietly reading, when he suddenly heard a report as 
if a pistol had been shot off within a foot of his head. SYMPTOMS. 
35 
He jumped to his feet, expecting to see an assailant 
behind him, but to his surprise there was no one to 
be seen, and it was very evident that no explosion had 
taken place. He was greatly astonished at this, but 
attributed the whole matter to an exaggeration, excited 
by his irritable nervous system, of some street noise. 
He had no further experience of the kind till the fol- 
lowing morning, when on rising from bed after a 
wretched night of sleeplessness, he again heard the 
sound, and this time it was as nearly as possible like 
the noise produced by striking two stoutly bound 
books together close to his ears. After this there 
was scarcely a day that the sound was not heard. It 
was entirely subjective, as persons in close proximity 
to him at the time, heard nothing. 
Several such cases have come under my observa- 
tion. It is not in all that the sound appears to be in 
the ears. In some it has seemed to be located in dif- 
ferent parts of the head, generally, however, in the 
posterior region. 
In some cases patients have experienced the sen- 
sation as if something snapped or gave way within the 
head, and this has, in a few rare instances, been at- 
tended with the sudden disappearance of some of the 
more striking symptoms. Thus, a young lady, in con- 
sequence of an intense emotion, was seized with sud- 
den vertigo and pain in the head, and fell to the floor 
unconscious. Recovering her senses in a few minutes 36 
CEREBRAL HYPEREMIA. 
she found herself unable to speak a word, though she 
uttered in an excited way inarticulate sounds having 
no resemblance to speech. This condition continued 
for several hours, when she suddenly felt " something 
snap " in the head, and she instantly recovered the 
power of talking. The vertigo, pain in the head and 
other symptoms, persisted for two or three months 
afterwards. 
In another case the onset of the disease in a gen- 
tleman who had for many years overworked his brain 
was extremely sudden, and was attended with facial 
paralysis. I treated him for this latter condition with 
electricity, with but little benefit ; but one day he 
struck his head violently against a gas-burner hanging 
over his desk, and shortly afterwards felt something 
give way within his head with a sharp snapping sound, 
and the paralysis instantly disappeared, after having 
lasted some five or six days. 
Such cases are in the present state of our knowl- 
edge inexplicable. 
The ear becomes hyperaesthetic, and loud noises 
are therefore disagreeable. At times the sense of 
hearing is morbidly acute, while at others it is 
markedly impaired. Sounds are misinterpreted with 
some persons and illusions result. This is espe- 
cially the case at night, when the patient is lying 
awake, the mind stretched to its utmost tension. A 
gentleman informed me that a circumstance with SVAfFTOMS. 
which most persons are familiar-the conversion of 
the sound of the ticking of a clock into some phrase 
or other-was to him a matter of agonizing weariness. 
Night after night as he lay in bed, the ticking of a 
large clock in the hall seemed to be the constant 
repetition of the word " farewell." Not wishing to 
reveal the matter to others, he endured for many 
nights the consequent suffering, till finally he made 
an excuse for leaving the city. But still the wheels 
of the railway cars seemed to be uttering the word 
" farewell," and it was only after a fatiguing journey 
to Baltimore and repose in a quiet room that he 
escaped the infliction. 
In addition to illusions, hallucinations of hearing 
are not uncommon and are usually in the form of 
whispered words which the patient hears with as much 
vividness as though they were real utterances. Like 
the misinterpretations of real sensorial impressions, 
these are usually experienced at night, and may be 
excited by any circumstance, mental or physical, 
which tends to increase the amount of blood circula- 
ting in the intra-cranial vessels. Thus, a powerful 
emotion, an unusually severe mental task, a strong 
muscular effort, or a dependent position of the head 
may induce them. In one case, that of a gentleman 
of rather obese development, a whisper of some kind 
or other was always heard when he stooped to button 
his gaiter-boots. In another, straining in the water- 
37 38 
CEREBRAL HYPERAEMIA. 
closet frequently caused a like symptom. In one very 
interesting instance the sounds were like those of 
musical instruments, and were arranged into familiar 
tunes, to the no small satisfaction of the subject; and 
in another they assumed the similitude of the bark of 
a dog. Occasionally they are in the form of com- 
mands to perpetrate some act of violence, such as 
suicide. A patient who came from Brooklyn to con- 
sult me heard a voice whispering in his ear and order- 
ing him to throw himself into the river. " What is 
the use of your going to see a physician ? " it said. 
" The best thing you can do is to kill yourself. You 
are of no service to yourself or any one else. Jump 
overboard and end the matter at once." Though 
these hallucinations never imposed upon the reason 
of the patient, they were nevertheless sufficiently dis- 
tressing, giving rise as they did, to the fear that he 
might, some day or other, be influenced by them to 
commit an act which he abhorred. 
The aural speculum is almost, if not quite, as valu- 
able as the ophthalmoscope in affording important in- 
formation relative to the affection under notice ; and I 
have been in the habit for the last five years of em- 
ploying it in every case presenting the more obvious 
features of the disease. I do not mean to be under- 
stood as intimating that positively affirmative results 
are to be obtained in all instances, but neither are they 
of any other single symptom. That the tympanum SYMPTOMS. 
39 
does afford an indication of the state of the intra- 
cranial circulation, is sufficiently evident from a con- 
sideration of the experiments performed by my friend 
Prof. Roosa and myself * relative to the influence 
of the sulphate of quinine, the results of which have 
been amply confirmed by the subsequent investiga- 
tions of Prof. Roosa, as well as by those of other ob- 
servers. 
In the cerebral disorder under notice evident con- 
gestion will almost always be observed of the vessels 
over the handle of the malleus, and the tympanum 
will be seen to be of a light pinkish color. In some 
cases we are prevented making the usual examination 
owing to the accumulation of cerumen. This must be 
removed by forceps or by washing, and the inspection 
deferred till next day. 
I may add that physicians wishing to observe the 
connection between cerebral hyperaemia and tympanic 
congestion have a ready method of satisfying them- 
selves on this point by examining the tympanum be- 
fore and after the subject has inhaled a few drops of 
the nitrite of amyl. This was first done, so far as 
I am aware, by Mr. Galton, f and detailed in his paper 
*The Influence of the Disulphate of Quinine over the Intra- 
Cranial Circulation. Psychological and Medico Legal Journal, 
October, 1874, p. 230. 
t West Riding Lunatic Asylum Medical Reports, vol. iii., 
1873, p. 258. 40 
CEREBRAL HYPERAEMIA. 
entitled, "Notes on the Condition of the Tympanic 
Membrane in the Insane." 
The facility of vision is almost invariably more or 
less disturbed. Sometimes there are bright flashes of 
light from over excitation of the retina, and these, like 
the other symptoms, are rendered more intense upon 
mental or physical exertion. At other times dark 
spots, muscce volitantes, render the vision indistinct; 
and again there is the appearance of an undulatory 
vapor, such as is seen around a hot stove, or on a 
plain heated by the sun. 
The conjunctivae are suffused. The pupils con- 
tracted. There is intolerance of light, and motion of 
the eye-balls is painful, and the ophthalmic symptoms 
are aggravated by the effort to use the eyes. The 
ocular muscles easily become fatigued, and hence pain 
is excited by any attempt to read or to adjust the 
visual foci for near objects. 
Ophthalmoscopic examination shows the arteries of 
the retina to be increased in size and tortuosity, and 
vessels which in health are not visible are now clearly 
perceived. The optic disk is often more or less con- 
gested, exhibiting the appearance to which Allbutt 
has applied the name " Congestion Papilla," but which 
is perhaps more generally known as " choked disk." 
The tint of the choroid is deeper than it is when in a 
normal condition. 
The effect of cerebral congestion in giving rise to SYMPTOMS. 
41 
visual hallucinations has long been known, though it 
often happens that in practice the value of the fact as 
an indication of the state of the intra-cranial circula- 
tion, is in a great measure disregarded. In another 
work* I have considered the subject of hallucinations 
of sight at some length, and as showing the influence 
of undoubted cerebral congestion, in producing them, 
I quote the following case which occurred in my own 
experience : 
" A gentleman under the professional charge of 
the writer can always cause the appearance of images 
by tying a handkerchief moderately tight around his 
neck, and there is one form which is always the first 
to come and the last to disappear. It consists of a 
male figure clothed in the costume worn in England 
three hundred years ago, and bearing a striking re- 
semblance to the portraits of Sir Walter Raleigh. 
This figure not only imposes on the sight but also on 
the hearing; for questions put to it are answered 
promptly." 
" A similar instance is related in Nicholson's Jour- 
nal. f ' I know a gentleman,' he states, 'in the vigor 
of life, who, in my opinion, is not exceeded by any one 
in acquired knowledge and originality of deep re- 
search ; and who for nine months in succession was 
* Spiritualism and Allied Causes and Conditions of Nervous 
Derangement. New York, 1876, p. 8. 
f Vol. vi., p. 166. CEREBRAL HYPERYEMIA. 
42 
always visited by a figure of the same man, threatening 
to destroy him, at the time of his going to rest. It ap- 
peared upon his lying down and instantly disappeared 
when he resumed the erect position.' " 
A case somewhat like the first of the two fore- 
going is referred to by De Boismont,* in which 
an individual was able to obtain hallucinations of 
sight by inclining his head a little forward. By this 
movement the return of blood from the interior of the 
cranium was prevented, and hence a state of repletion 
favorable to the production of hallucinations was in- 
duced. 
Now, in the state of cerebral hyperasmia which re- 
sults from excessive brain-work or intense emotional 
disturbance, a condition exists not essentially differ- 
ent from that present in the case referred to, except in 
the circumstance that the excess of blood is mainly 
arterial instead of venous, and that hence the conges- 
tion is more active than passive. But it must be 
borne in mind that it requires a very great degree of 
hyperaemia to cause the production of visual hallucin- 
ations, and therefore that we are not to expect them 
to occur in all patients who are its subjects. So far 
as my own experience extends, only about one in five 
exhibits the symptom with any degree of distinct- 
ness. 
* History of Dreams, Visions, Apparitions, etc. American 
edition. Philadelphia: 1835. SYMPTOMS. 
43 
Double vision is occasionally a phenomenon of the 
disease in question, though it is generally transient, 
and as Krishaber remarks, ordinarily only manifested 
in regard to bright objects. 
This author also speaks of a peculiarity of sight 
which has not come under my notice. " A patient," 
be says, "looks at himself in a glass with astonish- 
ment, as if he had forgotten his appearance. Another 
is horrified at his image, which represents a being 
altogether of different traits from those which he con- 
ceived himself to possess. But he is not alarmed, for 
he knows that it is only his perception which is 
changed. This aberration exists not only as regards 
his own person, but other objects as well. The 
patient finds men and things changed; he is aston- 
ished, always astonished, and it seems to him that he 
is a being transported to another planet." * 
The sense of smell is very often lost, perverted, or 
intensely exalted. Perhaps the second named of these 
changes is the one most frequently met with. I have 
a patient now under my care, a gentleman, who from 
over-mental work is suffering from cerebral hyper- 
aemia, and who constantly while awake smells the 
odor of illuminating gas. So strong is this, that he is 
at times unable to resist the impression that gas is 
escaping somewhere, and he goes from burner to 
burner of his residence and office seeking for the im- 
* Op. Cit., p. 168. 44 
CEREBRAL HYPERAEMIA. 
aginary leak. Another is constantly sensible of the 
smell of turpentine or new paint, and another has the 
odor of mint constantly present in his nostrils. 
The taste is also occasionally affected in like man- 
ner, usually, so far as my experience goes, in the way 
of perversion. " Things don't taste as they used to," 
is a common complaint, and the saliva and buccal 
mucus often give the gustatory impression of other 
substances. It is not at all unlikely, however, that 
" the bad taste in the mouth," so often mentioned by 
patients, is due to a real change in the properties of 
the saliva or mucus. I have observed several cases 
in which any mental or emotional strain was sufficient 
to cause a bitter or other, unpleasant taste in the 
mouth, and the same phenomenon is quite common as 
a consequence of gastric disturbance. Krishaber 
cites two cases in which both smell and taste were 
entirely abolished. 
Sensation and the power of motion are usually 
affected, and generally, though not always, on one 
side of the body only. Thus, the arm or the leg feels 
heavy, and a feeling as of ants crawling over it, pins 
and needles sticking in it, or, as if the limb were 
"asleep," is experienced. Sometimes these sensations 
are confined to the face, the muscles of which feel 
drawn or tight and the skin of which has the various 
indications of anasthesia, mentioned. Most frequent- 
ly, however, they are, I think, experienced on the SYMPTOMS. 
45 
scalp, giving rise to the several sensations already 
mentioned. 
Again, there is an exaltation of the sensibility of 
the skin and of the sensory nerves generally, and thus 
neuralgic pains are felt in various parts of the body ; 
or the cutaneous surface is extremely sensitive to the 
impression made upon it, whether of heat, cold or 
slight pressure. 
Slight convulsive actions or twitchings of individ- 
ual muscles or groups of muscles are generally pres- 
ent. Sometimes a few fibres only are affected. The 
face, and especially the eye-lids and angles of the 
mouth, are particularly liable to be thus involved. The 
muscular strength is usually weakened. The patient 
tires after slight physical exertion, and occasionally 
certain muscles, such as the deltoid and tibialis anti- 
cus, become distinctly paretic, so that there is an im- 
pairment of the ability to raise the arm from the side 
or to elevate the foot sufficiently high in walking, to 
clear ordinary inequalities in the pavement. The 
dynamometer shows the grasp of the hand of one or 
other side, or of both, to be weakened, and the line 
made by the dynamograph is zig-zag or uniformly 
depressed. 
The appetite is capricious, and the stomach acts 
imperfectly and sluggishly. The gastric juice is not 
secreted in sufficient quantity for the purposes of 
digestion, and the peristaltic action of the stomach 46 
CEREBRAL HYPERAEMIA. 
being weakened, the food remains within it a long 
time undigested, and undergoing fermentation. Re- 
gurgitations, both of the solid contents and of gases, 
are common, and the patient tastes his meals several 
hours after they have been swallowed. Gases accu- 
mulate in the stomach and give rise to the sense of 
fulness experienced even after a very slight repast has 
been taken. Such symptoms are usually classed under 
the name of " nervous dyspepsia," a not improper 
designation, if it does not lead us into the error of re- 
garding them as of primary importance instead of 
considering them as they are, merely consequent on 
the head trouble. 
The bozvcls are ordinarily costive, though at times 
this condition alternates with diarrhoea. 
The urine is in some patients scanty and high 
colored, in others it is profuse and almost as pale as 
water. Oxalate of lime is often present, and an ex- 
cess of phosphates an invariable condition, so far as 
my experience extends. I have already spoken of 
this circumstance. Whether or not, the phosphates 
in the urine are to be regarded as the ashes of the 
nervous system and hence a measure of the amount 
of nerve tissue decomposed, there is no doubt that 
they are inordinately increased after intense mental 
or emotional strain. 
I have spoken of the heat of the head of which 
the patient generally complains. That there is a real SYMPTOMS. 
47 
increase of temperature can often be perceived by the 
hand or by the use of an ordinary thermometer. But 
in some cases the actual rise of temperature is so 
slight notwithstanding the feeling of heat which the 
patient experiences that we cannot detect it by either 
of these means. In such cases resort should be had 
to the thermo-electric differential calorimeter of Lom- 
bard, by which very minute changes of temperature 
can be detected, and the part of the brain in which 
the temperature is highest be readily ascertained. 
The experiments of Lombard, performed several years 
ago, show very beautifully the influence of cerebral 
action in augmenting the external heat of the head, 
and it may be remembered, that over two years ago I 
detailed to the Neurological Society the results of 
some experiments of my own in the same direction. 
For several years past I have never examined a pa- 
tient presenting the more obvious features of cerebral 
hyperaemia without carefully determining the surface 
temperature of various parts of the scalp. At times 
and in some regions the elevation reaches two degrees 
of centigrade above the normal standard.* 
* Since the above was written I have become acquainted 
with some recent experiments of Prof. Broca, of Paris, in the 
same direction. As he does not refer to either Lombard's or 
my own experiments, though the former {Experiments on the 
Relation of Heat to Mental Work} were published in the New 
York Medical Journal, January, 1867, p. 198, and a synopsis 48 
CEREBRAL HYPEREMIA. 
But one of the chief categories of symptoms remains 
to be considered-chief- at least, so far as the more ob- 
vious appearances go, though like the other visceral 
derangements, I must regard these as being due to the 
brain disorder-and that is the group of phenomena 
connected with the heart. To Krishaber, in the work 
already cited, belongs the credit of being the first to 
call attention to this remarkable series, for in the pub- 
lication of my own to which I have referred, it was in 
a great measure overlooked. As Krishaber remarks, 
the troubles of the circulation consist especially in 
an irritability of the vascular system, so that the least 
movement, such as rising erect from the sitting 
posture, or to the sitting from the recumbent, leads to 
an acceleration of the pulse of from 20 to 30 or even 
40 beats a minute. Besides this, there are frequent 
and violent palpitations either spontaneous, or pro- 
voked by the most insignificant causes, either mental 
or physical. 
Emotional excitement is, however, the most pro- 
of my own in the Journal of Nervous and Mental Disease, 
January, 1876, I presume he is unacquainted with either. Prof. 
Broca ascertained by means of thermometers, applied to differ- 
ent parts of the scalp, that the external temperature was affected 
by different internal morbid, and physiological conditions, and 
hence confirmed the previous observations of Lombard and 
myself. His experiments would have yielded much more 
delicate and accurate results if he had employed Lombard's in- 
strument. SYMPTOMS. 
49 
lific cause of cardiac disturbance in patients affected 
with cerebral hyperaemia, and at. times leads to serious 
results. The pulsations of the heart may be so irreg- 
ular and the action of the organ so strong as to in- 
duce grave interference with the respiratory apparatus. 
Upon one occasion a lady, while in my consulting 
room, was seized with a paroxysm of the kind in ques- 
tion, of so severe a character that for a moment or 
two I thought she was about to die. For several 
months she had been wakeful, had suffered from ver- 
tigo and slight pain in the head, and while relating to 
me her symptoms, a blast near by, where a cellar was 
being excavated, exploded and produced so violent and 
sudden a shock as to bring on the excessive cardiac 
action mentioned. The heart throbbed with so. great 
a degree of violence that its pulsations could be 
readily seen through her dress and heard at the dis- 
tance of two or three feet; her face and neck became 
livid, and gasping for breadth, she fell to the floor in- 
sensible. In a very short time, however, the inordi- 
nate movements ceased and she recovered conscious- 
ness. 
Physical examination of the heart fails in these 
cases to reveal the existence of any organic lesion. 
In the intervals between the paroxyms of inordi- 
nate cardiac action, the pulse is small, often slow, soft, 
compressible, but by no means regular, either in force 
or frequency. Intermissions of the beats are com- CEREBRAL HYPEREMIA. 
50 
mon phenomena, and give rise to anxiety and morbid 
apprehensions in the patient. 
Krishaber states that at the very beginning of the 
disorder there is sometimes present a series of pheno- 
mena simulating fever, such as a chill, followed by a 
distinct period of febrile excitement. During this last 
stage the temperature of the body is elevated almost 
half a degree centigrade, or nearly a whole degree of 
our scale, and may even be double this. This acces- 
sion may be repeated with some degree of periodicity, 
but it soon ceases, and does not reappear after the full 
development of the disease. 
I have observed this condition in about one-third 
of the cases that have come under my observation, 
though usually, close questioning is necessary to elu- 
cidate the fact of its existence, so little impression 
does it make upon the mind of the patient. Some- 
times, however, the paroxyms are of such severity as 
to excite the belief that they are of malarious origin, 
and being treated with quinine they and the other 
symptoms attendant on the disease are greatly aggra- 
vated. 
During the most intense period of the disease there 
are occasionally paroxyms characterized by entire in- 
ability to move a muscle of the body, the conscious- 
ness, respiration, and circulation not being materially 
disturbed. I have never had a case which exhibited 
these symptoms, though Krishaber appears to regard SYMPTOMS. 
51 
them as not uncommon. On the other hand, syncope 
with complete loss of consciousness, which he speaks 
of as rare, is, according to my experience, by no means 
uncommon. With both of these conditions there is 
an almost continuous praecordial pain, sometimes 
severe enough to excite the idea of the existence of 
angina pectoris, and causing the gravest apprehen- 
sions on the part of the patient and his friends. 
If the disease be not arrested it is quite certain to 
develop into one or another of the forms of cerebral 
congestion, apoplectic, epileptic, paralytic, soporific, 
maniacal or aphasic, to which in another place* I have 
given full consideration. I do not dwell upon them 
here for the reason that this essay is concerned only 
with a series of phenomena which I conceive to be 
due to cerebral hyperaemia, constituting the first or 
prodromatic stage of congestion of the brain. 
* A Treatise on the Diseases of the Nervous System, 6th 
edition. New York : 1876, chap, i., Cerebral Congestion. CHAPTER III. 
DIFFERENTIAL DIAGNOSIS. 
Although the symptoms of cerebral hyperaemia, 
such as I have described them, have been to some 
extent known, they have heretofore been ascribed to 
very different pathological conditions. Thus, they 
have been classed under the heads of nervousness, 
dyspepsia, chlorosis, malaiial disease, and even under 
the very opposite condition to that to which I assign 
them-cerebral ancemia. 
The name by which we designate a disease is of 
no great consequence so long as it does not lead us 
into erroneous ideas of treatment. But it is rarely 
the case that this can be avoided, and I am very sure 
injury has been done in the nomenclature of the af- 
fection under notice. It is important, therefore, to 
have exact conceptions of the character of the symp- 
toms and the general course of the disease before we 
venture to give it a name. 
Under the name of nervosisme or " nervousness" 
Bouchut,* several years ago, described an affection 
* De 1'etat nerveux aigue et chronique ou nervosisme, etc. 
Paris : i85o. 
52 DIFFERENTIAL DIAGNOSIS. 
53 
which, so far as I can determine, does not essentially 
differ from that to which from the pathological condi- 
tion I call cerebral hyperaemia. Among the symp- 
toms are fever, general hyperaesthesia, headache, ver- 
tigo, hallucinations of sight and hearing, insom- 
nia, palpitations of the heart, dyspepsia, paralysis, 
constipation, etc. Bouchut, however, almost entirely 
ignored the fact of the occurrence of these symptoms 
in men, and though recognizing the circumstance 
that they are often the result of emotional disturb- 
ance, is more disposed to attribute them to certain 
conditions of female life-pregnancy, disorders of 
menstruation, lactation, change of life, uterine affec- 
tions, etc. Moreover, he made no observations with 
the ophthalmoscope or auroscope and no determina- 
tions of the temperature of the head, and hence fails 
altogether to identify the symptoms as being due to 
an increase in the amount of blood circulating within 
the cranium. Consequently the treatment recom- 
mended is not such as appears to be proper. 
Many of the so-called menstrual neuroses are, in 
reality, cases of cerebral hyperaemia, fhe result of in- 
ordinate emotional strain. To establish this point it 
is only necessary to consult the collection of cases 
made by Berthier.* Thus, for instance, case 34 under 
* Des nevroses menstruelles; ou la menstruation dans ses 
rapports avec les maladies nerveuses et mentales. Paris: 1874.  CEREBRAL HYPERAEMIA. 
54 
the head of hyperaesthesia, is clearly an almost typical 
case of cerebral hyperaemia, and is as follows (p. 49) : 
"Jeanne Thillois, aged 51 years, was of strong 
constitution and had never been ill, till at about her 
thirty-sixth year a violent mental emotion caused a 
suppression of the menses, and this was followed by 
heaviness of the head, wandering rheumatic pains, 
then by numbness in the arms, legs, shoulders, and 
scalp and by attacks of vertigo of so intense a char- 
acter as to cause her to fall to the ground. A year 
later there were headache, delirium, weakness of the 
limbs, and pain along the whole length of the spinal 
column. She was treated with the cautery, and with 
blisters to the skin. With time there was a gradual 
amelioration of the pains, but the weakness of the 
limbs, troubles of speech and difficulty of deglutition 
persisted." 
Many other cases similar to the foregoing might 
be readily collected from Berthier, and nothing is 
more common than for just such mistakes to be made 
in regard to cause and effect, as in the instance cited. 
The affection known as chlorosis, occasionally pre- 
sents features similar in some respects to those of 
cerebral hyperaemia, and indeed there is reason to be- 
lieve that the former is not only a disease of the nerv- 
ous system, as I pointed out several years ago,* but 
* Chlorosis, a Disease of the Nervous System. Quarterly 
fozirnal of Psychological Medicine. July, 1868, p. 417. DIFFERENTIA L DI A GNOSIS. 
is in no essential respect different from the latter. A 
case occurring in my own experience and reported in 
the essay referred to, is so apposite in the present 
connection that I quote it in full : 
" A. G., a young lady aged 18, and in good health, 
was frightened by a runaway horse which, dashing 
furiously down the road along which she was walking, 
scarcely allowed her time to spring aside and escape 
injury. She managed to get home, notwithstanding 
the great mental and physical prostration which im- 
mediately succeeded her terror, and after drinking a 
glass of wine, to all appearance recovered her usual 
good health and equanimity of mind. 
" Previous to her fright she had never been what 
is called " nervous." Menstruation had begun at 
fourteen and had always been regular in every re- 
spect. Her appetite also had constantly been excel- 
lent, and she was strong and well developed for her 
age. Her complexion was ruddy, her pulse full 
and strong, her mind of good quality and of sound 
and healthy tone, her temper cheerful and equable and 
her character remarkable for its strength and for the 
conscientious devotion to duty, which was apparent in 
all her acts. 
" But soon after the occurrence of the event refer- 
red to, her friends noticed the beginning of a gradual 
change in these respects, but especially in her sus- 
ceptibility to nervous impressions. From having 
55 56 
CEREBRAL HYPERAEMIA. 
been cheerful and buoyant in mind she became mei- 
ancholy and depressed ; and instead of being open- 
hearted and free from deceit, she began to show evi- 
dences of hypocrisy and even of want of truthfulness. 
At the same time her temper grew irritable and 
peevish. The slightest sudden noise caused her to 
start; a bright light disturbed her; the least touch was 
magnified into a severe blow ; she constantly smelt bad 
odors and complained that nothing tasted as it did 
formerly. Her appetite became irregular and capri- 
cious. Things which she once liked she could not 
now eat at all, and others which she had never fancied 
became the chief articles of her diet. Sometimes she 
ate voraciously, while at others she would go for 
several days scarcely eating enough to sustain life. 
Severe dyspepsia, attended with pain, heartburn and 
eructations set in. The bowels were generally con- 
stipated, the liver was inactive, the heart palpitated 
violently on the least exertion, the skin was dry and 
harsh, her hair began to fall out, her spine became 
tender in the cervical and dorsal regions, and her 
complexion assumed the greenish color so character- 
istic of chlorosis. 
" All these changes were effected within a month 
after the occurrence of the shock to her nervous sys- 
tem already mentioned. During this period I repeat- 
edly examined the blood microscopically and always 
found the normal proportion of red corpuscles to be DIFFERENTIAL DIAGNOSIS. 
57 
present. The menstrual period came on during the 
third week. The flow was as good as usual, and was 
neither of diminished nor increased quantity. 
" Finding no change in the blood and detecting no 
bellows murmur at the base of the heart or along the 
course of the great arteries, I did not suppose the af- 
fection to be chlorosis, for I had been taught to regard 
this disease as being due to anaemia and as always 
being associated with the signs and symptoms of that 
condition. From the history of the case and the 
prominent phenomena of its course, I was disposed at 
first to regard it as one of those hysterical affections 
so frequently met with in young women, and which 
in some respects it actually resembled. I therefore 
treated it for the first two or three weeks with anti- 
spasmodics and tonics, the latter consisting of quinine 
and iron, and recommended good, nourishing food and 
moderate physical exercise. Had the existing condi- 
tion been one of anaemia, these measures would have 
been clearly indicated and would doubtless have 
proved beneficial. As it was, the patient showed no 
signs of amendment; on the contrary, she grew grad- 
ually worse, and a month subsequent to the beginning 
of her disease was in a condition from which I was 
fearful it would be difficult to rescue her. I now 
abandoned the use of antispasmodics, of which I had 
tried a large number, and though I could, upon re- 
peated examination, find no diminution of the red CEREBRAL HYPERAEMIA. 
58 
corpuscles, I was certain the disease was chlorosis. I 
therefore continued to administer iron and quinine, 
and in addition prescribed a bottle of ale every day. 
"About this time, being necessarily absent on one 
occasion when I was sent for to see her, another phy- 
sician was called in for the emergency. He, conceiv- 
ing the case to be one of congestion of the liver, bled 
her to the extent of eight ounces and gave her a pow- 
erful dose of some cathartic medicine, of which calo- 
mel formed the staple ingredient. I returned soon 
after he had taken his leave, and while the blood still 
stood in a basin on the table. Coagulation had taken 
place, and the fluid was altogether of perfectly normal 
characteristics. As to the patient, she was very 
materially weakened. I took the whole quantity of 
blood with me for the purpose of analyzing it. The 
following table exhibits the result, Scherer's method 
of analysis being employed. I omit that part of the 
table showing the composition of the serum, as having 
no direct bearing on the main points concerned: 
" iooo parts of blood 
Water 791.27 
Solids 208.73 
Fibrin 2.18 
Blood corpuscles 131.11 
Albumen 65.09 
Extraction 3.98 
Soluble salts 20.41 
Total 212.77 
Difference 4.04 DIFFERENTIAL DIAGNOSIS. 
59 
" I had never made an analysis of the young lady's 
blood before the accession of her ill health, and there- 
fore I am unable to present a comparison of the com- 
position of this fluid in both conditions. It will, how- 
ever, be seen that there is no abnormal deviation from 
the ordinary healthy standard, and that the quantity 
of red corpuscles is fully up to the average of full 
health. 
" After the bleeding and severe purgation the 
patient was greatly reduced in strength, so much so 
as to make me anxious for her life. I had given iron 
and quinine faithfully, and had endeavored to maintain 
her strength by nourishing food and the employment 
of sound hygienic means ; all, however, had been with- 
out avail, and I found my preconceived ideas relative to 
the pathology of the disease under which she labored 
entirely confounded by the repeatedly ascertained 
facts, that there was no bellows murmur at the base of 
the heart or along the course of the great vessels, no 
diminution in the quantity of red corpuscles present 
in the blood, and no derangement of the menstrual 
functions. Under these circumstances I carefully 
re-studied the case, and although I could not avoid 
seeing that, while all the symptoms of the affection 
under which she labored were those of chlorosis, it 
was very evident that the signs indicating anaemia 
were absent. While, therefore, I continued the use 
of a strong nourishing diet and enjoined moderate 60 
CEREBRAL HYPEREMIA. 
physical exercise and mental relaxation, I substituted 
arsenic and strychnia for the other medicines. I gave 
her ten drops of Fowler's solution and the thirtieth of 
a grain of strychnia, three times a day. I decided on 
this treatment for the reasons that the disease ap- 
peared to be one in which derangement of the nervous 
system formed the most prominent feature, and be- 
cause I had previously, in other affections, satisfied 
myself of the efficacy of arsenic and strychnia in 
giving tone to the exhausted nervous centres and in 
relieving those functional derangements of the viscera 
due to disturbed nervous action. 
" She had not taken these remedies longer than 
four or five days before a change was perceptible in 
her condition. She said she felt more like herself 
than at any time since her fright; her eyes became 
brighter ; she began to take interest in events which 
were passing around her ; her appetite increased and 
was natural in its tendencies ; from having been ex- 
ceedingly wakeful at night, she now slept well ; the 
tenderness along the spine disappeared ; she was no 
longer startled at slight sudden noises ; she became 
able to concentrate her mind upon subjects ; and her 
abnormalities of character and disposition became less 
and less strongly shown. Gradually all these changes 
and others necessary to her restoration to health went 
on, and after taking the arsenic and strychnia for 
about six weeks her recovery was complete, so far as DIFFERENTIA L DIA GNOSIS. 
61 
I could see, in every respect. About a year subse- 
quently she married. She has now five healthy chil- 
dren and is herself the type, mentally, morally and 
physically of what American women ought to be." ; 
And it gives me pleasure to add, that she is now, 
twenty years after her restoration to health and the 
mother of eleven children, more able to endure men- 
tal or physical strain than nine-tenths of the women of 
half her age. 
Dr. Handfield Jones* has, under the name of " Hy- 
peraemia of the Brain," described a condition bearing 
but slight resemblance to that under consideration, but 
rather in its main features assimilating with conges- 
tion ; but the disorder which he designates " Cerebral 
Excitement " is so very much like what I would term 
cerebral hyperasmia, that I am quite sure we refer to 
the same pathological entity. Indeed, he expresses 
the opinion that the arterial vessels of the brain are 
in a state of repletion, but he regards this state as 
secondary to another which he believes to be an 
" excitation of the tissue." 
The cases cited by Dr. Handfield Jones all present 
more or less affinity with cerebral hyperaemia, as I 
have described it in the present essay. I quote one 
which was under his own care : 
" H. T., aged 52, admitted November 25th, 1866. 
* Studies on Functional Nervous Disorders. London: 1870. 62 
CEREBRAL HYPEREMIA. 
A very strong-made, large, hardy-looking man, who 
has achieved well-deserved repute by his able and suc- 
cessful management of a well-known life-boat. I saw 
him first October 29th, when I made the following 
notes :-About six years ago he got a fright while he 
was out with the life-boat, from a man being washed 
overboard. He felt his inside run round and he be- 
came giddy, but did not lose consciousness, and went 
on with his work. He never got quite right after that 
night: his head has been affected ever since. Before 
this happened, on one occasion he was pitched out of 
the life-boat into a vessel and hurt his shoulder. His 
left knee has been injured also in the same way, but 
he does not seem to have hurt his head at any time. 
At present he is quite unnerved, gets no sleep at night, 
being troubled with dreaming and fancies. In fact, 
has a degree of delirium-does not know what he is 
about. Has much sweating at night, and is either "all 
on a work," as his wife describes it, with his arms or 
legs, or else he is busy electioneering or cutting arms 
and legs off, or singing, etc. The tip of his tongue 
gets very sore, too, at night. Every morning for years 
since he has been ailing, he has vomiting and purging 
when he gets up in the morning; it does not occur 
during the day if he keeps quiet. Is so irritable, if he 
worries himself at all he gets all in a tremble. Is 
often obliged to come home and go to bed two or three 
times a day. His limbs are full of aches and pains in DIFFERENTIAL DIAGNOSIS. 
63 
blowy weather. His memory fails very much ; no 
paralysis ; pupils normal; no strabismus. Head not 
unduly warm [probably Lombard's instrument would 
have told a different story]; is not anaemic. Manner 
quiet. Has always been temperate. Appetite bad ; 
tongue natural. Is worse than he was a year ago. At 
the time of his admission he was rather better than he 
was a month before, since he had kept quite still and 
done no work. An intelligent observer who took great 
interest in his case described him as a wreck. His 
urine was of sp. gr. 1020, of full red color, not albu- 
minous. He was ordered strychnia, gr. -|- acid nitric 
Mij. tr. valerian, 3 i. -j- infus. valerian, §i. ter die 
morph, muriat. gr. ext. hyosciami, gr. iv. 0 n, and 
for diet ordinary cocoa, ale Oj., brandy §iv. During 
the earlier part of this stage in the hospital he com- 
plained of trembling, numbness, and tingling of arms 
and legs, coming on intermittently, of bad head- 
ache followed by black spots before his eyes, itch- 
ing of head and back of neck, and forgetfulness. 
The dose of strychnia was raised to gr. [?] and the 
valerian was replaced by quin, disulph.gr. iij., and this 
again by gr. viij. of citrate of iron and quinine. By 
January 30th he had recovered so far that he had lost 
almost all trace of nervous disorder and returned home 
well and hearty, though by no means capable of re- 
suming his former arduous exertions." 
I should certainly call this a case of cerebral hy- 64 
CEREBRAL HYPERAEMIA. 
peraemia, as I understand it. It is of course marked 
by " cerebral excitement; " but then this latter is only 
a symptom, while the former is a disease. 
It is often the case that cerebral hyperaemia is con- 
founded with another entirely different affection- 
cerebral anaemia, or a deficient circulation of blood 
within the cranium. As the two affections are the 
very opposite of each other, and as a mistake in the 
diagnosis would lead to serious errors in treatment, it 
is proper to consider the differential points at some 
length. 
The condition often induced by some powerful 
emotion, and known as shock, presents some features 
of resemblance to cerebral hyperaemia. Thus, there 
may be loss of consciousness, irregular action of the 
heart, and pain in the head. But the pallor of the 
face, the dilatation of the pupils, the coldness of 
the skin and the feeble respiration and pulse, are 
sufficient for the ready recognition of the real char- 
acter of the state in question, and the subsequent 
clinical history only serves to make the diagnosis 
more decided. 
In a somewhat less severe form of cerebral anaemia 
there may be illusions and hallucinations, and some 
confusion of ideas. A low form of delirium may also 
be present. But there is again, the dilated pupil, the 
feeble heart, the pallid face, the cold skin, so charac- 
teristic of a deficient blood supply to the brain. DIFFERENTIAL DIAGNOSIS. 
65 
And in chronic cerebral anaemia, no matter what 
may be the other symptoms-and frequently they pre- 
sent great resemblances to those of cerebral hyperae- 
mia,-the distinction can be clearly drawn by attention 
being given to the foregoing points. 
When, however, we come, in addition, in all forms 
in which anaemia of the brain may present itself, 
to bring to our aid the calorimetor of Lombard- 
or in its absence sufficiently delicate thermometers 
applied to the scalp-the ophthalmoscope, and the 
aural speculum, errors in diagnosis can scarcely 
occur. 
And to supplement all this, we have to recollect 
that in cerebral anaemia, vertigo is scarcely ever a 
prominent feature, and that so far from being wakeful, 
the patient is, on the contrary, almost constantly 
drowsy. No diagnostic mark is of so great import- 
ance as this latter, and I regard it as of itself sufficient 
to determine the question. Sleep is the result of a 
diminished amount of blood in the cerebral vessels, 
and when this diminution does not pass a certain nor- 
mal limit, natural sleep results. If, however, the brain 
is to an inordinate extent deprived of its circulating 
pabulum, drowsiness is the consequence. Wakeful- 
ness, on the contrary, is produced by an excessive 
amount of arterial blood in the brain, and hence it be- 
comes a prominent feature of cerebral hyperaemia 
It is true that in the advanced stage when, instead of 66 
CEREBRAL HYPERAEMIA. 
hyperaemia there is rather congestion, stupor may 
ensue, but stupor is by no means sleep.* 
Cerebral hyperaemia may be confounded with soft- 
ening of the brain, and it is not unfrequently the case 
that patients come to me to be treated for the latter 
disease, when they are in fact suffering from the 
former. I generally tell such that when they get to 
be affected with cerebral softening they will not of 
their own accords consult a physician, but will be 
brought to him by their friends. In fact, the two 
conditions have scarcely any but the most superficial 
resemblance. In softening, the intellect is seriously 
and permanently impaired, and the morbid process 
advances sometimes slowly, almost always certainly, 
to a fatal termination. In those cases due to embol- 
ism there are often loss of consciousness and persist- 
ent hemiplegia coming on suddenly and followed by 
death in a few days ; or there is an equally sudden 
aphasia, accompanied by loss of the power of motion, 
generally on the right side, and unattended by any de- 
rangement of the mental faculties, beyond, perhaps, 
emotional weakness ; or there is delirium without 
* For a fuller description of cerebral anaemia the reader is 
referred to the sixth edition of the author's Treatise on Dis- 
eases of the Nervous System, and for a still more complete 
account, to Dr. J. Milner Fothergill's essay on Cerebral Anae- 
mia, in the West Riding Lunatic Asylum Medical Reports, 
vol. iv., 1874, p. 94. DIFFERENTIAL DIAGNOSIS. 
67 
paralysis or convulsions, but with a great degree of 
mental and physical prostration. In these cases, care- 
ful inquiry will generally reveal the pre-existence of 
articular rheumatism or the presence of organic dis- 
ease of the heart. 
Some of the head symptoms of Bright's disease 
are similar to those of cerebral hyperaemia, but atten- 
tion to the clinical history of the case will prevent any 
mistake in the diagnosis of the affections. Thus, the 
existence of kidney-disease, as revealed by a chemical 
and microscopical examination of the urine, the ana- 
sarca of the face or limbs, and the repeated attacks of 
convulsions and coma, will be sufficient to deter- 
mine the presence of the former affection and not 
the latter. 
In the vertigo which occasionally results from gas- 
tric derangement, the fact that it is only present 
while the stomach is digesting its contents, and that 
other symptoms of dyspepsia are evident and unac- 
companied by the mental and physical disturbances 
characteristic of cerebral hyperaemia, will prevent in 
the majority of cases any errors of diagnosis being 
committed. When to these we add the results 
obtained by ophthalmoscopical and calorimetrical 
examination, the liability to mistakes is greatly les- 
sened. 
In auditory vertigo or Meniere's disease, as it is 
sometimes called, there are auditory troubles. The 68 
CEREBRAL HYPERsEMIA. 
face is pale, and there is almost invariably vomiting, 
or at least intense nausea. 
Indeed there are few diseases so distinctly marked 
by their symptoms and clinical history, as that which 
forms the subject of this essay. CHAPTER IV. 
CAUSES. 
In the introductory chapter I have considered, to 
some extent, the most prolific causes of cerebral 
hyperaemia-those of a mental or emotional char- 
acter-and of this category the emotional are by far 
the more frequent. A sudden shock of this description 
may, as we have seen, induce the affection instan- 
taneously ; but still more common are those instances 
in which some powerful emotion, acting day by day, 
and even night by night, slowly, perhaps, but with ter- 
rible certainty, leads to the more or less permanent in- 
crease of the intra-cranial arterial blood with all the 
inseparable phenomena. 
But, though unduly severe or prolonged intellectual 
effort is exceedingly liable to cause the disorder under 
consideration, I by no means wish to be understood as 
intimating that regular and full mental labor is at all 
a common factor in the production of cerebral hyperae- 
mia. The brain of man is constructed for just that 
kind of work, and so far from the organ being injured 
thereby, it is developed and strengthened as certainly 
69 70 
CEREBRAL HYPEREMIA. 
as are the muscles by physical exercise. Eight or 
even ten hours of the twenty-four may, in the average 
individual, safely and advantageously be occupied with 
brain-work of as intense a character as may be neces- 
sary. But occasionally we meet with persons who are 
no more capable of such exertion than others are of 
running a half mile in two minutes, and who cannot 
be brought to the ability by any amount of training. 
For them to persevere in a contest for great mental 
superiority, or for accomplishing a task beyond their 
powers, is destruction of their cerebral organization. 
The walls of their intra-cranial vessels are weak, and 
hence when once they have become distended, they do 
not readily return to their normal size. 
The same effect is produced by inordinate mental 
exercise in those to whom eight or ten hours labor of 
the kind in question is no more than they can health- 
fully perform. Deprivation of amusement, insufficient 
physical exercise, by which the blood is not sufficient- 
ly diverted from the brain, and above all, using their 
brains during the hours that should be given to sleep, 
will speedily result in cerebral hyperaemia, and prob- 
ably, even, in some more serious disease. The indi- 
vidual who shortens his normal period for sleep, in 
order that he may increase his hours of intellectual 
labor is, by depriving his brain of the necessary 
amount of repose, in the position of one who is " burn- 
ing his candle at both ends." He is literally consum- CA USES. 
71 
ing his brain-tissue faster than he makes it, and per- 
severance in that course will certainly lead to brain- 
bankruptcy. Few organs in the body can endure as 
much hard usage as the brain ; but there is a limit to 
its power of resistance and recuperation, in every one, 
which cannot be passed with impunity. 
Cases of cerebral hyperaemia from excessive intel- 
lectual exertion are frequently met with in the young, 
whose mental powers are overtasked before their brains 
are sufficiently developed. A growing brain needs to 
husband its powers for the normal formative processes 
of the cerebral organization. The blood which cir- 
culates in its substance is charged with no more pab- 
ulum than is sufficient for this growth, and for such 
mental labor as will aid in strengthening the various 
faculties of the mind, and if it be consumed in the 
production of force beyond these requirements, disease 
is the necessary consequence. Cases of the kind in 
young men and women who are striving to cram their 
minds with numerous studies are of almost daily ob- 
servation. Certainly, my experience goes to establish 
the fact that the study of mathematics is bad for the 
average young woman's mind. I have repeatedly had 
instances of cerebral hyperaemia under my charge oc- 
curing in young ladies of from fifteen to seventeen 
yee.rs of age, in whom it was directly induced by the 
study of calculus, spherical trigonometry, and civil en- 
gineering. I have now the care of a young lady, six- 72 
CEREBRAL HYPEREMIA. 
teen years of age, in whom the disease came on 
rapidly, in consequence of long-continued and close 
application to the solution of a mathematical problem. 
But so long as there are ambitious women who want 
their sex to study all the subjects men do, I suppose 
civil engineering will be responsible for many hyperae- 
mic brains in young girls. 
Dr. Richardson * says in regard to the subject of 
mental work for the young : 
"The extent to which over-mental strain is injuri- 
ous to the young varies according to the kind and 
character of work. The endeavors to fill the minds 
of children with artificial information leads to one of 
two results. Not unfrequently in the very young it 
gives rise to direct disease of the brain itself, to de- 
posit of tubercles if there be predisposition to that 
disease, to convulsive attacks or even to epilepsy. In 
less extreme cases it causes simple weakness and ex- 
haustion of the mental organs with irregularity of 
power. The child may grow up with a memory taxed 
with technicals and impressed so forcibly that it is 
hard to make way for other knowledge; and added to 
these mischiefs there may be and often is the further 
evil that the brain, owing to the labor put on it, be- 
comes too fully and easily developed, too firm and too 
soon mature, so that it remains throughout manhood 
* Discourses on Practical Physic. London: 1871, p. 15. CA USES. 
73 
always a large child's brain, very wonderful in a child, 
and equally ridiculous in a man or woman. The de- 
velopment in an excessive degree of one particular 
faculty is also a common cause of feebleness." 
From another work * I quote the following appo- 
site case : " A youth of fifteen was brought to me by 
his father, on the 16th of August, to be treated for 
obstinate wakefulness, the consequence of severe 
mental exertion at school several weeks previously. 
He had not attended school since the last of June, 
but had scarcely slept more than an hour or two each 
night since that time, according to his own and his 
father's statement. He was a healthy, well-grown lad, 
with a good appetite, and nothing unusual in his ap- 
pearance beyond a slight look of weariness and anxi- 
ety in his face. During the day there were no hallu- 
cinations of any kind, and towards evening he inva- 
riably felt overpowered with sleep. As soon, however, 
as he lay down, he heard voices repeating extracts 
from the lessons he had recently been reading, and 
his mind became occupied with imaginary scenes in 
which the gods and goddesses of mythology, and the 
heroes and poets of antiquity, played prominent parts, 
and the whole power of his attention was thus kept 
engaged with these and other scenes, which were 
formed with astonishing rapidity. Towards morning 
* Sleep and its Derangements. Philadelphia: 1869, p. 256. 74 
CEREBRAL HYPERYEMIA. 
he fell into an uneasy slumber, and awoke feeling 
more weary even than when he had gone to bed. 
" Medicines, among which opium was the chief, 
had been employed without success. On the con- 
trary, his condition was manifestly rendered worse 
through their influence. Laudanum, of which he had 
taken large quantities, always caused headache with- 
out producing the least amelioration in his symptoms. 
Notwithstanding the palpable connection which exist- 
ed between the wakefulness and his former intense 
mental application, he had been allowed to continue 
his studies, and when he came to me had a Latin 
grammar in his hand which he had been diligently 
studying in a street railway car. 
" After some plain conversation with the father 
relative to the great danger to which he was subject- 
ing his son, by thus inordinately taxing his mind, I 
directed the entire cessation of all studies for the 
present, and a complete change of associations, by a 
visit to the sea-shore and free indulgence in bathing, 
fishing, and other recreations. I likewise advised the 
use for a few nights of small doses of the bromide of 
potassium. My advice was implicitly followed, and a 
few days since I received a visit from the boy's father, 
and was told by him that his son's health had been 
completely restored. I recommended that the visit 
to the sea-side should be prolonged a week or two, 
that the return to study should be gradual, and that CA USES. 
75 
the boy's eagerness to learn should be somewhat re- 
strained by occupations and amusements requiring 
but little mental occupation." 
There are certain occupations which, owing to the 
harassing emotions to which they give rise, are di- 
rectly productive of a tendency to cerebral hyperae- 
mia, and in many cases to the disease itself. And 
here I am again tempted to quote from Dr. Richard- 
son's suggestive address " On Physical Disease from 
Mental Strain'' merely premising that his remarks 
are equally applicable to the affection now under no- 
tice. 
" First, there is the mere copyist, the man who 
sits all day at his desk and transfers copies of writing 
or of a speech to a piece of paper. The clerk, the 
compositor, the reporter, and the second and third 
rate author are of this class. 
" Secondly, there is the thinker and writer who 
copies also, but not directly from other writings nor 
from thoughts expressed by other minds, but who 
goes to the great manuscripts of the Supreme Author 
-to the hills and plains and oceans, to the living 
kingdoms of all animals and of all times, and trans- 
lates the histories of them in written words, bringing 
the vastness of the Universe, as seen by his superior 
sense, into moderate compass and legible form so 
that lesser minds may read through him the truths he 
sees and unfolds. 76 
CEREBRAL HYPEREEMIA. 
"Thirdly, there is the speculative man, usually 
very selfish and locked up in himself ; who, from day 
to day, and night to night, and hour to hour, schemes ; 
who walks with his head down, his eyes on the earth, 
and thinks; thinks how he shall meet this obstacle, 
waylay that plan, shrewdly anticipate such and such 
events ; a truly business man in the world's common 
acceptation. 
" Fourthly, there is the man who carries on his 
shoulders other people's anxieties, who thinks for 
others rather than for himself, and must never be 
tired of the effort; the professional man is here rep- 
resented, the politician, the minister of religion, the 
physician and surgeon, and the accountant. 
" Fifthly, there is the artist who labors towards 
perfection in producing some given form, ideal or 
real, who, absorbed in his work, forgets the noisy 
crowd around him, and day after day toils on, living 
with his own creations, one in the world but not of 
the world. 
" Lastly, there is the student; the child or youth 
whose will is hardly his own, who works when he is 
bidden, and plays when he is permitted, who is fed 
too often with flattery or blows, and between or by 
one and the other, is at length turned out in life pre- 
pared, as it is thought, by education and training, to 
fight the great and unceasing battle of life." 
And it may be added as specially applicable to CA USES. 
77 
this country that here all these avocations are pursued 
with an intensity unknown in the old world, and that 
as the nervous system of the average American is far 
more impressionable than that of the average Euro- 
pean, the abnormal effects are more certain and far 
more decided. The man who goes down to Wall 
street day after day, after a sleepless night, not know- 
ing exactly where he is to get the money to meet his 
obligations by three o'clock, or even that he will get 
it at all, is the prey of just that kind of emotional 
disturbance-anxiety-which is most powerful in 
producing cerebral hyperaemia, and this condition, 
sooner or later, is almost certain to be the result. 
There is an occupation followed quite extensively 
in this country, though almost unknown as a distinct 
business in Europe, and that is, inventing machines 
and devices of various kinds, for which patents are 
obtained. The inventor who is assiduous in the prac- 
tice of his profession, is probably more subject to 
mental strain than the followers of any other occupa- 
tion. His mind is constantly engaged in making new 
combinations, in seeking to counteract obstacles, and 
in endeavoring, often, to come as near as possible to 
some one else's machine without infringing the pa- 
tent right. All this requires very intense mental ex- 
ertion and strain, and at the same time various con- 
flicting emotions are brought into operation to increase 
the cerebral disturbance. It is not, therefore, a sub- 78 
CEREBRAL HYPEREEMIA. 
ject for surprise that such people break down, are af 
fected with wakefulness, pain in the head, mental 
confusion, and the other symptoms indicative of the 
existence of cerebral hyperaemia. Sometimes, the 
mind becomes manifestly weakened, and sharp, shrewd 
men overlook some important point, to the detriment 
or entire ruin of their schemes for acquiring wealth. 
Thus, a man came to me not long since complain- 
ing of most of the symptoms I have mentioned in the 
present connection, and who, for several years, had 
been intensely engaged in the invention of an appa- 
ratus for rolling bandages. The instrument was ex- 
ceedingly complicated and expensive, but was capable 
of rolling several thousand bandages a day. It was 
certainly very beautiful, but his time and money had 
been entirely thrown away, for there was not the least 
demand for anything of the kind. I do not suppose 
he ever sold a single one. 
Individuals who are not accustomed to the use of 
their minds in a regular and thorough manner, or 
who are so circumstanced as not to be hardened, to 
some extent, to the effects of emotional disturbance, 
break down under strains that would be nothing in 
others, who, living in large cities and mixing with the 
world, become in a manner used to hard mental work 
and temporary excitement or depression, as the case 
may be. These things are relative. The farmer, for 
instance, gets a hyperaemic brain from calculating how CA USES. 
79 
much he is going to receive from his few tons of hay 
and bushels of corn, while the bank clerk or the 
Wall street operator will add up hundreds of columns 
of figures, and determine the results of all kinds of 
abstruse financial problems without the least brain 
derangement. Again, a person whose whole life has 
been passed amid tranquillity, succumbs to an emo- 
tion that the care-hardened man of the world resists 
with ease. Some of the worst cases of cerebral hy- 
peraemia I have ever seen, have occurred in country 
people as the results of mental exertion or emotional 
disturbance, which the city-bred individual would re- 
gard with entire indifference. 
But it is not to be forgotten, that the mass of cases 
of cerebral hyperaemia rests largely with those in- 
dividuals, who are apparently inured, by repeated ex- 
periences, to all kinds of mental strain and emotional 
excitement. With them as with grosser forms of 
matter excessive use causes excessive decay- 
" Gutta cavat lapidem, consumitur annulus usu, 
Et teritur pressa vomer adhuncus humo." 
There are other causes of cerebral hyperaemia be- 
sides those to which attention has been drawn. Thus, 
very hot weather may induce it by the general irrita- 
tion of mind to which it gives rise. Cold weather may 
cause it by its constringing influence on the cutaneous 
vessels, and the consequent accumulation of blood in 
the brain as well as in other internal organs. 80 
CEREBRAL HYPERCEM1A. 
The direct rays of the sun falling upon the ex- 
posed scalp give rise to many cases of cerebral hy- 
peraemia, especially in large cities ; and artisans 
whose occupations require them to expose their heads 
to direct artificial heat often suffer in like manner. I 
have known two cases in which it was apparently 
caused by the use of hot shower-baths, in which the 
water was allowed to fall from a height on the naked 
scalp. 
There are many substances which, when taken into 
the stomach or inhaled into the lungs, increase the 
amount of intra-cranial arterial blood. Among these 
are the various alcoholic liquors, camphor, opium in 
small doses, belladonna, Indian hemp, quinine, sul- 
phuric ether, chloroform, the nitrite of amyl, etc. A 
like power is also exerted by tea and coffee, and 
probably in some cases by tobacco. 
Of the causes inherent in the individual, sex and 
hereditary influence are especially to be noticed. 
The disease is certainly more common in males than 
in females, and there appears in many cases to be a 
decided tendency to hereditary transmission. 
Venereal excess is an efficient cause in both sexes, 
but especially in males. It is difficult in general to 
arrive at the truth in regard to this point, but the re- 
sults of my experience are such as to establish the 
fact of its influence beyond a doubt. CHAPTER V. 
PROGNOSIS. 
The probability of recovery in cases of cerebral 
hyperaemia depends on the submission of the patient 
to proper treatment, medical and hygienic, and the re- 
moval of the cause. If these means can be carried 
out, a favorable result can almost always be antici- 
pated. A spontaneous recovery is, however, a rare 
circumstance, and it becomes impossible if the patient 
continues to do those very things which have caused 
the disease. The tendency of the affection is, if it be 
not arrested, to pass into one or the other of the fully 
developed forms of cerebral congestion already men- 
tioned, and then the liability to secondary lesions, 
such as softening, cerebritis, cerebral haemorrhage, 
aneurisms, general paralysis, etc., must be taken into 
account. 
The apoplectic form of cerebral congestion is that 
to which there appears to be the greatest predisposi- 
tion, and the epileptic and paralytic come next in 
order. The soporific, the maniacal and aphasic, are 
more rare, but are occasionally met with. 
I have never known a patient to die of uncom- 
81 82 
CEREBRAL HYPERAEMIA. 
plicated cerebral hyperaemia. But instances of a 
fatal result from some one or more of the ulterior 
conditions into which it tends to develop, are not very 
uncommon. CHAPTER VI. 
MORBID ANATOMY AND PATHOLOGY. 
The morbid anatomy and pathology of the disease 
exhibiting the phenomena to which the foregoing re- 
marks have been applied, must remain to some extent 
a subject for speculation till post-mortem examinations 
enlighten us as to its real nature. Nevertheless I 
am quite sure, for the reasons already stated and 
others presently to be adduced, that the affection con- 
sists primarily of an increase in the quantity of blood 
circulating in the cerebral arterial vessels ; or of what 
I have designated cerebral hyperaemia. 
Briefly these are as follows : 
1. The redness of the face, and throbbing of the 
cephalic arteries, indicate an increased determination 
of blood towards the head. 
2. The sensation of fulness of the head almost 
invariably present. 
3. The increased heat of the head, not only sub- 
jectively, but as indicated by the thermometer or 
the thermo-electric calorimeter. 
4. The persistent insomnia always present-a con- 
dition now known to be due to cerebral hyperaemia. 
83 CEREBRAL HYPERAEMIA. 
84 
5. The aggravation of all the symptoms by intel- 
lectual exertion or emotional disturbance. 
6. The results of ophthalmoscopic and aural exam- 
ination. 
7. The effect of the sulphate of quinine, strychnia, 
nitrite of amyl, alcoholic liquors, and other agents 
which we know increase the amount of blood in the 
brain, in aggravating the symptoms of the disease. 
8. The speedy disappearance of the phenomena 
under the influence of mental quietude, and of those 
therapeutical agents which lessen the amount of the 
intra-cranial blood. 
But it is still the habit of some individuals in the 
medical profession to declare that the quantity of the 
intra-cranial blood is unalterable. I may, therefore, 
perhaps, be excused for quoting from another work * 
the following remarks on this subject :- 
" In the cases of infants, in whom the anterior 
frontanelle is still open, the scalp is seen to be elevated 
above the level of the skull, when the head is depend- 
ent, and depressed when the head is elevated. 
" The same fact is observed in persons who have 
suffered injury of the skull involving the loss of a 
portion of its substance. During strong emotional 
excitement, or the action of any cause capable of in- 
creasing the force of the circulation, the scalp is 
* A Treatise on the Diseases of the Nervous System. New 
York* 1876, p. 49. MORBID ANA TOMY AND PA THOLOGY. 
85 
elevated ; from the action of opposite causes, it is 
depressed. Both in infants and in persons who have 
received injuries such as those cited, the scalp is seen 
to be depressed during sleep, and to rise as soon as 
the individual awakes. 
" A dependent position of the head causes a sen- 
sation of fulness or even pain ; and blood may pour 
from the nostrils. The eyes are observed to be blood- 
shot, and the countenance indicates congestion. A 
tumor, a ligature, or any other cause capable of ex- 
citing pressure on the jugular veins, will produce like 
effects. Ophthalmoscopic examination under such cir- 
cumstances shows the veins of the retina to be en- 
larged, indicating that an obstruction exists to the 
return of blood through the sinuses and veins within 
the cranium. Post-mortem examination of persons 
dying who, during life, have suffered interruption to 
the perfect return of blood from the head, reveals the 
existence of intra-cranial congestion. Animals sub- 
jected to experiments calculated to act in the manner 
stated, are after death found to have congested brains. 
" In animals bled to death, the brain is found 
anaemic in an extreme degree. 
" Direct experiment still more positively estab- 
lishes the fact under consideration. If a portion of 
the skull of an animal be removed, and the aperture 
be then securely closed with a watch-glass, the ves- 
sels will be seen to enlarge and contract, according 86 
CEREBRAL HYPERZEMIA. 
to the cause brought into action, and the brain will be 
correspondingly elevated or depressed. 
" By means of an instrument devised, independently 
of each other, by Dr. S. Weir Mitchell and myself, 
the degree of pressure within the cranium can be 
accurately measured. It is thus seen that the quan- 
tity of blood circulating in the brain undergoes ma- 
terial variation.* 
" The anatomical arrangement of the blood-vessels 
of the cerebral tissue, is such as to admit of an enlarge- 
ment of their calibre, without necessarily subjecting 
the perivascular substance to pressure. Kobin f dis- 
covered the existence of sheaths around these vessels, 
and his observations were subsequently confirmed by 
His, | who ascertained that the same arrangement 
exists in the spinal cord. According to His, ' Fine 
transverse sections of a hardened brain, having its 
vessels injected or otherwise, show that all the blood- 
vessels, arteries, veins, and even capillaries, are sur- 
* ££ For a more complete argument on the subject, and for a 
statement in detail of the experiments of Mr. Durham and my- 
self, the reader is referred to the author's monograph, Sleep 
and its Derangements, Philadelphia: J. B. Lippincott & Co., 
1870. The cephalo haemometer here referred to in the text is 
described in that work (Appendix), and also in the Introduction 
to this treatise." 
f Journal de la Physiologic de I'homme et des Animaux: 
1859, p. 527. 
J Zeitschrift fiir Wifsenschaftliche Zoologie: 1865, B. & V, MORBID ANA TO MY AND PA THOLOG Y. 
87 
rounded by a clear space, prominent in the case of the 
largest vessels, but in all cases quite sharply defined 
externally. In transverse sections the vessels are seen 
to be surrounded by ring-like spaces ; and in parallel 
sections the space is seen on each side of the trunk 
of the vessel, and follows its ramifications. 
" These perivascular canals are lined by a hyaline 
membrane, and are capable of being injected, and in 
case of chronic congestion may become permanently 
enlarged, so as to cause the appearance referred to 
under the heading of " Morbid Anatomy." 
Admitting that there is such a condition as cere- 
bral hyperaemia, the next question to be considered 
is-Does the fact of the amount of arterial blood in 
the brain being increased, account for the symptoms 
observed in the disease under notice ? In other 
words, what are the effects of cerebral hyperaemia ? 
These questions have already been considered to 
some extent, but a few more remarks on the subject 
will probably not be considered out of place. 
Every action of the brain, whether it be a percep- 
tion, an emotion, an intellection, or a volition, is the 
immediate result of an increase in the amount of the 
intra-cranial blood. With each manifestation of men- 
tal force in any one of the ways mentioned, there 
is a necessary decomposition of a certain quantity of 
cerebral tissue. Within certain limits, these are 
healthy processes. The brain is so constituted, that 88 
CEREBRAL HYPERAEMIA. 
it can become hyperasmic ; and it is a normal act for 
its tissue to be consumed, in order that brain-force- 
mind,-may be evolved. A slight exaggeration in the 
ordinary, habitual, every-day flow of blood to the 
brain, leads to acuteness of perception, brilliancy of 
thought, excitement of the emotions, and strength of 
the will. 
Some persons are dull in all their intellectual pro- 
cesses till they become excited,-warmed up to their 
work as it were-that is, till the circulation in their 
brains is rendered more active, and then their thoughts 
come thick and fast, and are of good quality. Others 
can never compose prose, poetry, or music, till they 
have excited the action of the heart, and, as a conse- 
quence, increased the amount of arterial blood in the 
brain, by stimulating ingesta, such as opium, alcoholic 
liquors, tea or coffee; others require to make use of 
physical means to augment the vividness of their per- 
ceptions, their thoughts or emotions. It is said that 
the tints of the landscape are brighter if we reverse 
the position of the head. A " tumbler " in a circus told 
me not long since that everything around him ap- 
peared more brilliant, and that his thoughts were cer- 
tainly more intense when he stood on his head. 
Tissot * cites an instance in which position was 
taken advantage of to solve a problem in mathematics. 
* Avis aux gens de lettres et aux personnes sddentaires sur 
leur sante. Paris: 176S. MORBID ANA TO MY AND PA THOL OGY. 
89 
A gentleman, remarkable for his accuracy in calcula- 
tion, for a wager, lay dozvn in bed, and wrought by 
mere strength of memory a question in geometrical 
progression while another person in another apart- 
ment performed the same operation with pen and ink. 
When both had finished, the one who had worked 
mentally, repeated his product, which amounted to six- 
leen figures, and insisting that the other gentleman 
was wrong, desired him to read over his different pro- 
ducts. On this being done he pointed out the place 
where the first mistake lay, and which had run through 
the whole. He paid very dearly, however, for gaining 
his wager, as for a considerable time he had a swim- 
ming in his head, pains in his eyes, and severe head- 
a.hcs upon attempting any mathematical labor. 
The engineer Brindley used to retire to bed for an 
hour or two when he was reflecting on a great or sci- 
entific project. 
A gentleman informs me that so assured is he of 
the greater activity of his mind when he lies down, 
that he has had constructed a special apparatus by 
which he is enabled to write while in the recumbent 
position. 
Cases such as these are on the border-line of dis- 
ease, and sooner or later pass over to the other side. 
The same may be said of most instances in which re- 
course is had to stimulating ingesta to render the brain 
more active. 90 
CEREBRAL HYPERAEMIA. 
The principal subjective symptoms of cerebral hy- 
peraemia, when it is of such a degree of intensity as 
to constitute disease, are wakefulness, pain increased 
by mental exertion; and mental aberration of some 
kind or other. Of these the first is the most import- 
ant, not only on account of the suffering and injury 
it is to the patient, but because it is the necessary 
accompaniment, the pathogonomic symptom of the 
affection in question. Without wakefulness there is 
no cerebral hyperaemia, with cerebral hyperaemia there 
is always wakefulness. To establish the connection 
between the phenomena and the pathological condition 
is a matter of great moment, and that point I propose 
therefore to consider at some length. 
It has been definitely established by the experi- 
ments of Mr. Durham and myself that during sleep 
the quantity of the intra-cranial blood is lessened. 
Durham made circular perforations in the skulls of 
animals so as to expose the brain, and then covering 
the openings with watch-glasses hermetically sealed 
around the edges, observed the state of the circulation 
below. Whenever the animal went to sleep the sur- 
face of the brain became pale, and the whole organ 
was reduced in size, as shown by the fact that it no 
longer rose into the hole in the skull. As soon as the 
animal awoke the vessels became full, and the brain 
enlarging in consequence, protruded through the per- 
foration in the cranium. My own experiments, per- MORBID ANATOMY AND PATHOLOGY. 
91 
formed independently of Mr. Durham's, though a short 
time afterward, were to the same effect, and by means 
of an instrument to which reference has already been 
made, the amount of expansion with wakefulness and 
collapse with sleep were very accurately measured. 
Since then, additional experiments, with like results, 
have been performed. 
But we are not obliged to rely on experimental 
evidence, at least not on such testimony of our own 
devising. Thus, it is stated by Blumenbach * that a 
young man, eighteen years of age, fell from an em- 
inence and fractured the frontal bone on the right side 
of the coronal suture. After recovery took place, a 
hiatus remained covered only by the integument. 
While the young man was asleep, this chasm was quite 
superficial, but as soon as sleep ensued, it became very 
deep. The change was due to the fact, that during 
sleep the brain was in a collapsed condition owing to 
the diminished quantity of blood, while as soon as 
wakefulness began, the brain, being possessed of an 
increased amount of blood, was larger. 
Dendy f states that there was in 1821, at Mont- 
pellier, in France, a woman who had lost part of her 
skull, and the brain and its membranes lay bare ; when 
she was in deep sleep the brain remained motionless 
* Elements of Physiology, translated by John Elliotson, M, 
D., etc., 4th edition, London: 1828, p. 191. 
t Philosophy of Mystery, London: 1841, p. 283. 92 
CEREBRAL HYPEREMIA. 
beneath the crest of the cranial bones ; when she was 
dreaming it became somewhat elevated ; and when she 
was awake it was protruded through the fissure of the 
skull. 
In 1854, a man came under my observation who 
had, through a frightful railway accident, lost about 
eighteen square inches of his skull. There was thus 
a fissure of his cranium three inches wide and six 
inches long, the brain being only covered by its mem- 
branes and the scalp. The lost portion consisted of a 
great part of the left parietal, and part of the frontal 
occipital and right parietal bones. The man, who was 
employed as a wood-chopper, was subject to severe 
and frequent epileptic fits. In the course of my treat- 
ment of him I soon became acquainted with the fact, 
that at the beginning of the comatose condition which 
succeeded the fits, and during which, the brain was 
gorged with blood, there was invariably an elevation of 
that portion of the scalp covering the deficiency of the 
cranium. As the stupor passed away and natural sleep 
ensued, the scalp gradually became depressed. When 
the man was awake, the region of scalp in question 
was almost always on a level with the upper surface 
of the cranial bones. I also noticed on several occa- 
sions, that during natural sleep, the fissure was deeper, 
and that on the instant of awaking, the scalp covering 
it rose to a much higher level. 
Recently, I had occasion in the performance of an MORBID A NA TOM Y AND PA THOL OG Y. 
93 
operation on the cranium of a boy about twelve years 
of age, to remove, with the trephine, saw and pliers, 
about six square inches of the skull, the centre of the 
removed part consisting of the posterior superior an- 
gles of both parietal bones, and the posterior angle of 
the occipital bone. Owing to the fact, that the dura- 
mater remained intact, the surface of the brain was not 
visible, but as the edges of the scalp were not brought 
together for several hours on account of a little oozing 
of blood which existed, I had the opportunity of ob- 
serving that when the boy slept, the brain sank away 
from the fissure, while as soon as he awoke it arose far 
up into the hole, so that at the centre it was higher 
than the outer surface of the skull. As the superior 
longitudinal sinus occupied this situation, I was en- 
abled to perceive, that there was no apparent increase 
in its size during wakefulness, and that therefore the 
augmentation in the size of the brain was due to an 
increased afflux of arterial blood. 
If the scalp covering the anterior frontanelle of 
very young infants be observed while they are asleep, 
it will be noticed that it is depressed, and that when 
they are awake it is elevated. 
Again, we have in the action of certain hypnotics 
very instructive experiences relative to the state of 
the brain as regards blood supply. All those which 
produce sleep probably do so by their action in lessen- 
ing the amount of the intra-cranial arterial blood. On CEREBRAL HYPER.EMIA. 
94 
the other, hand those substances which increase the 
supply are directly provocative of wakefulness. 
From all of which it would appear to be a fact as 
well established as any other in pathology, that cere- 
bral hyperaemia is the immediate cause of the symp- 
toms mentioned in the course of this monograph. 
And yet in his very excellent treatise, to which 
reference has already been made, Krishaber enun- 
ciates the opinion decidedly, that it is to anaemia of 
the brain, that the symptoms of the affection are to be 
ascribed. According to him, cerebral anaemia is the 
immediate cause of the cerebral excitement. It must 
be admitted, however, that if a diminution in the 
amount of blood in the brain causes mental exaltation 
and an increase in the intensity of the other cerebral 
functions, then is the brain subject to a different law 
than that which governs the other organs of the body, 
and some of the best established points in cerebral 
physiology and pathology go for nought. Krisha- 
ber's arguments on the subject are, however, weak 
and strained, and in attempting to account for the 
wakefulness so unvarying an attendant, he is forced 
to admit that if his doctrine be true we ought rather 
to have somnolence than insomnia. The disease is 
produced by mental work and emotional excitement 
It is a fair example of the reductio ad absurduin to 
contend that these factors cause the blood in the brain 
to be lessened. MORBID ANA TOMY AND PA THOL OG Y. 
95 
In this connection it is interesting to refer to the 
remarks macle by that honored physician, Dr. Ama- 
riah Brigham, * some thirty years ago : 
" The general proposition which I wish to estab- 
lish is made evident also from the fact that whatever 
excites the mind excites and stimulates the brain. 
" This we know from experience in a severe head- 
ache. We perceive the pain to be increased by in- 
tense study or thinking, and that mental application 
determines more blood to the head. So true is it that 
mental excitement produces an increased flow of blood 
to the head, that surgeons are very careful to pre- 
serve a quiet state of mind in those whose heads are 
wounded. Sir Astley Cooper, speaking of such inju- 
ries, says that if any mental power remains all excite- 
ment of the brain should be avoided, and relates the 
following case : ' A young gentleman was brought to 
me from the north of England who had lost a portion 
of his skull just above the eyebrow. On examining 
the head I distinctly saw the pulsations of the brain, 
which were regular and slow, but at this time he was 
agitated by some opposition to his wishes, and di- 
rectly the pulsations of the brain were increased, and 
became more violent, and more blood rushed to the 
brain. If, therefore, you omit to keep the mind free 
* Mental Exertion in relation to Health. English edition, 
London: 1864, p. 20. The American editions, of which there 
were several, have long been out of print. 96 
CEREBRAL HYPERBEMIA. 
from agitation, your other means will be unavailing in 
injuries of the head." 
" The same author mentions another similar case ; 
that of a young man who had an opening in his skull 
from a wound, and through which he could see an in- 
creased action in the brain whenever anything oc- 
curred, even in conversation, to agitate the mind of the 
patient." 
As an instance of the effect of certain kinds of 
emotion in causing even more serious disease than 
cerebral hypermmia-though this is doubtless their 
starting point-the following case, detailed by Brous- 
sais, and also cited by Dr. Brigham, is of interest: 
M. Thavernier, a captain in the French army, 
forty-two years of age, moderately stout, but well- 
formed, received in the middle of the Palais Royal, in 
May, 1815, ninety days before his death, a letter con- 
taining bad news. Whilst perusing it he remained 
motionless, as if thunderstruck, and the left side of 
his face became paralyzed and drawn to the opposite 
side. He was taken to Vai de Grace and attended to. 
At this time he had complete paralysis of the arm, 
thigh, and leg of the right side, and was unable to 
speak. After using various remedies for more than 
two months he began to improve, and became so much 
better as to be able to stand up, and to speak, although 
with difficulty. 
In this state of improvement M. Thavernier re- MORBID ANA TO MY AND PA THOL OGY. 
97 
ceived another letter, said to be from his wife. He 
read it, and instantly there occurred loss of speech, 
general immobility, abolition of sense, and complete 
apoplexy. He died in three days after the attack, and 
on examining the head, there was found engorgement 
of blood in the sinuses, and several abscesses were ob- 
served in the substance of the brain, and other marks 
of organic diseases. 
M. Broussais considered this case to be one of 
chronic inflammation of the brain, induced by a moral 
cause. 
Every now and then we read accounts of persons 
dropping dead under the influence of some strong 
emotion produced, for instance, in a court of justice. 
" If I am not speaking the truth may God strike me 
dead!" exclaims the witness. He falls to the floor 
as if shot, and a post-mortem examination discloses a 
cerebral haemorrhage, caused by a sudden overpowering 
strain on the blood vessels of the brain. 
Some emotions doubtless lessen the amount of 
intra-cranial blood just as some cause the countenance 
to become pale ; but in such cases the accompanying 
phenomena are very different from those of cerebral 
hyperaemia, although to a superficial observer there 
may seem to be a close resemblance. CHAPTER VII. 
TREATMENT. 
Although, as I have said, it is rarely the case that 
cerebral hyperaemia spontaneously disappears, there 
are few affections more amenable than it to treatment. 
The measures which it is proper to adopt consist of 
those which are strictly medical and of others which 
may be regarded as hygienic. The indications are to 
relieve the hyperaemic condition of the brain by less- 
ening the amount of arterial blood circulating through 
it; to afford rest to the brain by cessation or diminu- 
tion of mental work and by diversions of various 
kinds ; and to prevent a recurrence of the disorder. 
The medical agents which I have found most effica- 
cious are : 
1st. The internal administration of the bromide of 
sodium, calcium, lithium potassium or ammonium, and 
even occasionally of zinc. 
The action of any one of these bromides is pri- 
marily to lessen the amount of blood in the brain, as I 
was the first to announce over twelve years ago.* I 
then said: 
* On Sleep and Insommia. New York Medical Journal, 
June, 1865, p. 202. 
98 TREA TMENT. 
99 
" Bromide of potassium can almost always be used 
with advantage to diminish the amount'of blood in the 
brain and to allay any excitement of the nervous sys- 
tem that may be present in the sthenic form of insom- 
nia. That the first named of these effects follows its 
use I have recently ascertained by experiments on 
living animals, the details of which will be given here- 
after, suffice it now to say, that I have administered it 
to dogs whose brains had been exposed to view by 
trephining the skull, and that I have invariably found 
it to lessen the quantity of blood circulating within 
the cranium, and to produce a shrinking of the brain 
from this cause. Moreover, we have only to observe 
its effects upon the human subject to be convinced 
that this is one of the most important results of 
its employment. The flushed face, the throbbing 
of the carotids and temporals, the suffusion of the 
eyes, the feeling of fulness in the head, all disappear 
as if by magic under its use." 
Of the bromides, I prefer either the sodium or 
calcium compounds, though there is really not much 
choice. Any one of them may be given to adults in 
doses of about fifteen grains three times a day. 
2d. Ergot is scarcely less beneficial than the 
bromides in lessening the quantity of blood in the 
brain. Both it and these latter appear to act by the 
increased tone which they give to the coats of the 
arteries, and hence the diminution of their diameters. 100 
CEREBRAL HYPERAEMIA. 
A teaspoonful of the fluid extract (U. S. P., which I 
have found to be preferable to Squibb's) may be given 
with advantage three times a day. A better plan is 
to give'the bromide dissolved in the fluid-extract. 
3d. Digitalis is generally of great service in giving 
strength to the heart and arresting its disorderly 
movements. Eight or ten drops of the tincture may 
be added to each dose of the foregoing mixture. 
4th. In those cases in which there are dyspeptic 
symptoms the administration of saccharated pepsin 
and charcoal with each meal will be found of great 
service. 
5 th. The application of the actual cautery to the 
nape of the neck is a measure of great value in the 
treatment of cases of cerebral hyperaemia. Care 
should be taken that the cauterizing instrument, which 
should have a platinum tip, be heated to whiteness, 
and that the skin be only lightly touched by it. There 
are several forms of apparatus by which a very intense 
heat can be obtained. A French instrument lately 
much in use in this city soon gets out of order and 
becomes worthless. 
The actual cautery appears to have a positive and 
in some cases an immediate influence in diminishing 
the size of the cerebral arteries. This it does, doubt- 
less, through the sympathetic nerve in the neck. 
6th. Ice applied daily for a few minutes to the nape 
of the neck is of decided benefit. It acts through the TREATMENT. 
101 
same agency as the cautery, and both are but better 
applications of a principle well known to our grand- 
mothers-that a cold key placed on the upper part of 
the spine soon arrests an ordinary nasal haemorrhage. 
/th. The galvanic current of low tension applied 
to the nucha and the head, and repeated every day or 
every alternate day for five minutes, as the case may 
require, is of great benefit. One pole should be 
placed at the very summit of the spine and the other 
some three or four inches below it. I have repeat- 
edly seen, as I stated several years ago * the arteries 
of the retina contract while the current was passing 
in this way-an indication that a like influence was 
exerted on the intra-cranial vessels. 
A similar effect is caused by passing the current 
directly through the brain, the poles being applied to 
the mastoid processes. A slight feeling of vertigo 
is experienced both when the circuit is closed and 
opened. Care should be taken that the current is not 
too intense. 
Such is the medical treatment which I have found 
most generally serviceable in the treatment of cerebral 
hyperaemia during what may be called its acute 
stage. But occasionally we meet with cases in which 
the bromides are not well borne, and again, others in 
which ergot causes gastric and intestinal irritation. 
* Spinal Irritation.-Journal of Psychological Medicine. 
April, 1870. 102 
CEREBRAL HYPEREEMIA. 
In such instances arsenic may be substituted with ad- 
vantage for either of these remedies. 
Lisle* has very clearly pointed out the benefit to be 
derived from the administration of arsenious acid in 
cases of cerebral congestion, and this practice is equally 
applicable to the stage of hyperaemia. It appears to 
me that the arsenious acid is preferable to Fowler's 
solution, or any other arsenical preparation. I usually 
begin with the administration of one-fiftieth of a grain 
after each meal, and gradually increase to double this 
quantity. Lisle gives it in doses of from one fourth to 
the third of a grain daily, and there is no doubt, that it 
may be given to this extent for several weeks, or even 
longer, without the least danger. 
When the patient has been under the foregoing 
treatment for a month more or less, as the case may 
be-at the end of which time he will ordinarily be free 
from cerebral hyperaemia-there is usually a state of 
physical debility present which ought to be counter- 
acted. For this purpose recourse may be advan- 
tageously had to strychnia, phosphorus, iron and 
quinine, given either singly or in combination. If 
either of the two latter be administered, it should al- 
ways be in union with hydrobromic acid, prepared ac- 
cording to Fothergill's formula. 
Strychnia may be added to the solution of iron, 
* Du traitement de la congestion cerebrale et de la folie avec 
congestion et hallucinations, par 1'acide arsenieux. Paris : 1877. TREATMENT. 
103 
quinine and hydrobromic acid, or may be given as 
extract of nux vomica alone or in combination 
with phosphorus. In the former case I usually em- 
ploy the following formula. B strychniae sul., gr. i 
quiniae sul., 3 i. ferri bromidi, 3 ss acid. hyd. brom. 
(Fothergill's), 5 iv. glycerinae, 5 ij. M. ft. sol. Dose: 
a teaspoonful in water three times a day after meals. 
Should it seem desirable to administer phosphor- 
us, as indicated by the existence of decided nervous 
debility, I usually make use of the phosphide of zinc. 
The chemical formula of this substance is Zn. P. and 
consequently a grain represents a little more than one 
seventh of a grain of phosphorus. The proper dose 
is therefore about the tenth of a grain. A good for- 
mula is B Zinci phosphidi gr. iij., nucis vom. ext. gr. 
x., m. ft. in pill. no. xxx. Dose : one three times a day 
after meals. 
The hypophosphorus acid in doses of ten or fif- 
teen drops in water three times a day, is also an 
eligible preparation of phosphorus. 
In two cases of cerebral hyperaemia of sudden de- 
velopment and in which the symptoms were of great 
intensity, recently under my care and occurring in 
gentlemen whose brains were kept at more than 
their full measure of work, I derived immediate 
benefit from the application of leeches to the inside 
of the nostrils. In no other way can the blood be so 
advantageously drawn directly from the brain as by 104 
CEREBRAL HYPERPEMIA. 
this method. In general, however, blood-letting in 
any form is not required ; on the contrary, it is likely 
to prove injurious. 
Thoughout the whole course of the disease hy- 
gienic means should be persistently carried out. The 
food should be nutritious, digestible and ample, though 
not excessive in quantity. Alcohol and tobacco, if 
used habitually by the patient, should be restricted to 
moderate limits, and the former should certainly never 
be taken in the form of spirits-whiskey, brandy, gin, 
or rum. Light malt beverages and the wines of Ger- 
many, Italy or France, when used discreetly, are not in 
my experience injurious-on the contrary, I think that 
in the latter stage, when tonics are so generally ap- 
plicable, they are of decided advantage; used of course 
with becoming moderation. Tobacco I have never 
seen do harm, unless indulged in to excess. Tea and 
coffee may safely be left to the patient's own inclina- 
tions and experience. I believe that more harm is 
done by suddenly breaking off a habit, even though it 
be somewhat injurious, than by tolerating it within due 
bounds. Exercise in the open air-walking, horse- 
back riding, or driving, is always beneficial. The 
same cannot be said of gymnastic contortions, which, 
to make them worse, are usually performed in hof 
rooms. 
Baths are -always serviceable. Whether they are 
to be hot, warm or cold may be left to the inclination TREATMENT. 
105 
of the patient, or be determined by experience in each 
case. A hot foot-bath on going to bed certainly aids 
in procuring sleep by its derivative effect from the 
head. A cloth wrung out of hot water, and laid over 
the pit of the stomach, often has a like influence. 
The effect of a light supper, taken just before retiring 
for the night, is frequently very decided in its action 
as a producer of sleep. The rationale is not difficult 
to understand. For food to be digested, there must be 
an increased flow of blood to the stomach, and a part 
of this comes from the brain to the relief of the sur- 
charged vessels. 
Massage or "rubbing " is sometimes of service in 
cases of cerebral hyperaemia, but is more frequently, 
in my experience, productive of nervous irritability. 
It cannot take the place of exercise in the open air 
except with those who cannot walk. To see a strong, 
robust man submitting himself to the manipulations 
of the "rubber" has always struck me as an absur- 
dity, and the same may be said of " lift cures." 
None of these things are more than sorry substitutes 
for a brisk walk. 
Amusement whereby the mind is as it were got 
out of the rut in which it is running, are of great im- 
portance. No people take amusements with more 
difficulty than Americans, of whom some one has said 
" they are never happy unless they are miserable." 
The man who is harassed by daily cares and anxieties 106 
CEREBRAL HYPERAEMIA. 
does not get rid of them by going home and sitting 
down to think. He requires a complete change to 
turn the current of his thoughts-diversion in the 
fullest sense of the word. Each one must choose for 
himself that form which is most agreeable; but I 
think it may safely be said that, in general, theatrical 
performances of some kind, should enter largely into 
the systematic scheme of amusements for the subjects 
of cerebral hyperaemia. 
And perhaps, as a permanent means of taking the 
mind from its laborious employment, nothing equals 
a " hobby "-something to which we can turn after 
work is over with the certainty of finding the diver- 
sion which the brain so imperatively demands. As to 
the kind of subject to be taken up, the taste and 
means of the patient must determine. If the patient 
is unable to take an interest in anything but his busi- 
ness, the case is indeed a bad one, and the possibility 
strong, that some more serious affection than cerebral 
hyperaemia will assuredly make its appearance. Cer- 
tainly while the disease exists, the patient, if he ex- 
pects to be cured, must consent to use his brain in a 
rational manner. To take medical treatment and 
then to continue the mental exertion which has been 
the prime cause of the disorder, is so absurd that it 
is surprising that otherwise sensible people will not 
see its folly-and yet, as a rule, they do not, and then 
are dissatisfied that they do not get well as rapidly as TREATMENT. 
107 
they think they should or that they suffer from relapses. 
It would be just as sensible for a person to put a heal- 
ing salve on a burnt hand and then immediately stick 
the hand in the fire; and the cause that induced the 
disease in the first instance will just as certainly in~ 
duce it again if the opportunity be given. 
" But," as I have said in another place,* " it is not 
always the case that the most positive advice on this 
point is followed. Men who would readily see the 
impropriety of walking three or four miles while suf- 
fering from an inflamed knee-joint, do not hesitate to 
exert a disordered brain to the extreme limit of its 
power. It is impossible that the action of a brain 
thus affected can be such as to evoke sound and 
healthy thoughts. It is not to be wondered at, there- 
fore, that the subjects of cerebral congestion, who in- 
sist upon attending to their avocations and on con- 
cocting schemes for obtaining wealth or fame, should 
perpetrate acts which result in the loss of fortune, 
and the acquisition of a reputation far different from 
that sought." 
The first requirement in the treatment of a dis- 
eased organ is almost always rest. Work is neces- 
sarily the result of an increased blood supply. If, 
therefore, the patient already suffering from the ef- 
fects of too great a flow of blood to his brain, persists 
* A Treatise on the Diseases of the Nervous System. 6th 
edition, New York: 1876, Art. Cerebral Conjestion, p. 55. CEREBRAL HYPERYEMIA. 
108 
in those actions which directly augment the already 
excessive current, the result will inevitably be an ag- 
gravation of the symptoms, and in all probability, the 
development of some hopelessly incurable malady to 
which cerebral hyperaemia is as nothing. 
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PART II