Carotid compression and brain rest

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r

CAROTID COMPRESSION

AND

BRAIN REST.

~t J ^

• "

w ■> w •

BY

J. LEONARD CORNING, M.D.,

MEMBER OF THE NEW YORK NEUROLOGICAL SOCIETY, ETC.

NEW YORK:
ANSON D. F. RANDOLPH & COMPANY,

900 BROADWAY, COR. 20th ST.

1

• •

»•• •
• ••
• • • •

• • • • •

.• • •• •
» • • •

•

COPYRIGHT, 1882, BY
J. LEONARD CORNING, M.D.

NOTE.

This Memoir represents substantially the amplifica-
tion of certain experimental researches^ which were
summarized in a paper published in the ^^ Medical Rec-
ord'' of February iSthj 1882.

The kindly interest unremittingly displayed by a large
number of gentlemen who are advancing the cause of
scientific medicine^ has led me to hope that this brief
essay may find a charitable reception. The vast and
unexplored nature of the problem is apparent^ and this
fact may be urged as a reason for the present publica-
tion*

No. 365 Lexington Avenue,
New York,
March 39M, 1882.

DIGITAL
COMPRESSION OF THE CAROTIDS.

HISTORICAL.

There exists but little doubt that the more
ancient writers on medicine were familiar with
the fact that digital compression of the carotids
may produce a state of unconsciousness analo-
gous to physiological sleep. Dr. Pilz* refers
to the knowledge which Rufus of Ephesus
(Morgagni, de sedibus et caus. Morb. epist. 19),
possessed on this subject. The following quo-
tation from the latter is derived from Dr. Pilz's
admirable paper: "Arterias percollum subentes
carotides, id est somniferas, antiquos nominesse,
quoniam compressae hominem sopore grava-
bant."

Around all these early attempts at compres-

* **Zur Ligatur der Arteria Carotis communis," von Dr.
C. Pilz, contained in Langenbeck's "Archives for Clinical
Surgery," vol. ix., p. 406. 1868,

(5)

^

6 Digital Compression of the Carotids.

sion, however, there hangs a veil of uncertainty,
which is but in ill accord with the logical exi-
gencies of modem medical science. For a very
considerable period of time, the procedure was
entirely forgotten. In 1792, however, the at-
tention of the profession was again directed to
the subject by Parry, of Bath, who resolutely
defended digital compression as a most useful
measure for the alleviation of convulsive dis-
orders.

In 1819 Dr. M. Bland published some inter-
esting cases, illustrative of the efficacy of digi-
tal compression of the carotids in brain. dis-
orders characterized by cerebral engorgement.

An interesting paper, by J. B. Stroehlin,* en-
titled, " De la compression de la carotide, employ^
comme moyen therapeutique dans les maladies
convulsivesy' contains many points of value:
After presenting several cases treated by digi-
tal compression of the carotids, the author of
this article proceeds to state that he shares the
opinion of Dr. Trousseau, that the device of
digital compression of the carotids is useful in

♦Contained in the youmal Medico-Chirurgical oit^ovcta-
ber, 1840.

Digital Compression of the Carotids. 7

cases of " congestive convulsions," in which a
" fluctuation '* of blood toward the brain is re-
cognizable as a causative factor. This author
furthermore states in the same article, that he
had frequently heard Dr. Trousseau remark,
that if he or his children should become afflicted
with epilepsy, he (Trousseau) would have no
hesitation in demanding the ligation of the ca-
rotid on the side opposite to that on which the
convulsions appeared.

In a brief, but most suggestive article, pub-
lished in the J/<?rf/^^/jE;ir^/«/«^r of April, 1841, Dr.
Trudeau calls attention to the great efficacy of
digital compression of the carotids in convulsive
disorders. The author also cites a case of
" acute meningitis," in which he essayed digital
compression of the carotid arteries with good
results. Dr. Trudeau refers in the same paper
to the discussion respecting the priority of dis-
covery of digital compression, which ensued
on the publication of MM. Trousseau's, Bade-
locque's, and Malapert's papers. Reference is
also made to the published criticism of Dr. De-
zeimeris, which also appeared in connection with
the discussion of priority. By this arbiter the

8 Digital Compression of the Carotids,

honor of the discovery of the therapeutic effi-
cacy of digital compression of the carotids is
awarded to Parry, of Bath. In concluding his
interesting paper. Dr. Trudeau says : " From my
own experience, I do not hesitate to say that it
(carotid compression) ought to take its place
among the most powerful means which we pos-
sess of combating these (convulsive) diseases.
The subject is but little known ; a vast field is
open ! "

In 1848 Waller* published an essay on the
uses of digital compression, in which he speaks
favorably of its employment in headache, epi-
lepsy, hysteria, etc. He also cites cases in
which he has had recourse to this form of treat-
ment, and speaks well of its results. This author
speaks of the difficulty often experienced in
the application of digital compression to the
carotids during very violent epileptic attacks,
owing to the excessive convulsions of the cer-
vical muscles. It was this fact, also observed
by myself, which induced me to construct a

* "On Compression of the Carotids — Its effects on Head-
ache, Epilepsy, Hysteria, etc." By Augustus Waller, M.D.
Journal of Psychological Med, London, 1848.

Digital Compression of the Carotids. g

special instrument for the performance of tem-
porary instrumental compression of the carot-
ids. I shall have occasion to refer to this in-
strument hereafter.

T. W. McArthur,* in a paper published in
1855, expresses his conviction that compression
of the carotids is beneficial " in at least some
convulsive diseases.'*

" De la Ligature et de la Compression des
Artftres Carotides/* is the title of a comprehen-
sive article by Dr. Guibert,t published in 1865.
The author gives expression to his views, touch-
ing the merits of digital compression as a thera-
peutic agent, and notes with regret the fact that
a procedure of such manifest value should have
been so long ignored by the profession. The
effects of ligation of the carotids, more especial-
ly as exhibited in animals, are referred to by
this author at considerable length.

For comprehensive and felicitous elucidation
of the various questions involved in the con-
sideration of sleep. Dr. Hammond's classical
work on " Sleep and its Derangements ** certainly

* Medical Counselor for September, 1855.

f Appeared in the Union Medicate of January, 1865.

t

lO Digital Compression of the Carotids.

belongs in the front rank of scientific research.
More particularly to be commended are Dr.
Hammond's profound experimental researches
on the condition of the brain during sleep and
wakefulness.

DIGITAL COMPRESSION OF THE CAROTIDS IN

EPILEPSY.

About one year ago, considerations of an ana-
tomical and physiological character induced me
to begin a series of experimental investigations,
with the object of elucidating certain phenom-
ena, observable in epileptics, which point to a
deranged condition of the cerebral circulation.

The extraordinary venous hyperaemia, as well
as the violent pulsations of the carotids, which
these patients exhibit during the attacks,
awakened in me the suspicion that there is some
co-sequence between the sanguineous engorge-
ment and the persistent continuance of the
" attack."

It did not occur to me, however, to perceive
in this engorgement the inceptive motive of the
attack ; indeed the striking pallor which epilep-
tics exhibit immediately prior to the seizure.

Digital Compression of the Carotids, 1 1

would appear to afford sufficient proof that the
attack is primarily owing to the irritative influ-
ences of excessive anaemia. But admitting all
this to be true, it would nevertheless seem nec-
essary, after the cessation of the anaemia, to
look elsewhere for those causes most intimately
concerned in the further continuance of the
seizure. As above intimated, the most striking
phenomena which present themselves, after sub-
sidence of the first condition of anaemia, are the
excessive venous hyperaemia and the throbbing
of the carotids. I therefore determined, before
perceiving in more occult forces a reason for the
continuance of the attack, to allay artificially
the condition of cerebral engorgement and to
await the result. With this end in view, I com-
pressed digitally both common carotid arteries
of an epileptic who had just entered upon a
series of violent paroxysms ; the usual duration
of the status epilepticus, in this case, being from
thirty to forty-five minutes. In about five min-
utes, the convulsions were completely checked,
and the patient remained in a perfect state of
consciousness. The rapidity with which fulness
developed in the radial pulse on compression

12 Digital Compression of the Carotids.

of the carotids was most striking. Noteworthy
also was the concomitant return of conscious-
ness and cessation of convulsions with the in-
crease in strength of the radial pulse. At this
time I was totally unaware of the achievements
of Parry, in 1792, with digital compression, and
my experiments were undertaken as the result
of deductive reasoning from purely anatomical
and physiological premises.

author's instrument for temporary com-
pression OF THE CAROTIDS.

INSTRUMENTAL
COMPRESSION OF THE CAROTIDS.

TEMPORARY INSTRUMENTAL COMPRESSION OF

THE CAROTIDS.

After having essayed digital compression on
several subsequent occasions, and having re-
peatedly convinced myself of its efficacy as a
means of aborting epileptic attacks, I became
unhappily aware that in certain very violent
paroxysms it is impossible to exert the neces-
sary pressure upon the arteries with the fingers,
owing to the excessive spasm of the cervical
muscles. I must confess that for some time I
was in considerable doubt as to how this ob-
stacle was to be overcome ; but finally, as good
fortune would have it, I hit upon the expedient
of constructing an instrument which enables the
operator to exert his strength to the best pos-
sible advantage {^id, plate No. i), while admitting
of a far more accurate adjustment than can possi-

14 Instrumental Compression of the Carotids.

bly be obtained by the use of simple digital
compression. The chief features of this instru-
ment are two curved metallic armatures, to each
of whose extremities is attached a pad, which
by means of a screw, provided with a detach-
able key, can be placed at any desired angle.
The object of this latter device is to permit of
so arranging the pads that the artery is com-
pressed away from the jugular vein, and in the
direction of the spinal column. The other ex-
tremities of the curved armatures are attached
to a handle by means of an Archimedian screw,
which transfixes the latter in its entire length.
By rotating the button which is attached to the
disengaged end of the screw, the curved arma-
tures can be extended or approximated at will.

MODE OF EXECUTING TEMPORARY INSTRU-
MENTAL COMPRESSION.

Digital compression of the carotids has beei
found of the greatest utility in a very largv.
variety of convulsions. It has been essayed
during the convulsions peculiar to epilepsy,
hysteria, and acute meningitis, but I am not
aware that its effects on the spasmodic condi-

Instrumental Compression of the Carotids, 1 5

tions peculiar to hydrophobia have ever been
ascertained. My own experience with compres-
sion is confined more particularly to epilepsy,
maniacal excitement, and congestive headache.
Those authors, however, who have resorted to
it in various other convulsive disorders, speak of
its efficacy in the highest terms ; and certainly,
statistics on this subject would be most valuable.
The method of employing the instrument,
devised for temporary compression, is quite
simple, and I have found it vastly superior to
the primitive procedure of digital compression.
Having placed the patient upon a bed, In a
horizontal and semi-dorsal position, the head
and shoulders being supported with properly
adjusted cushions, the operator takes his posi-
tion by the bedside, in such a manner that his
left side is turned toward the bed, and his view
directed toward the face of the person requir-
ing assistance. Then, having with the index
finger of the right hand ascertained, by careful
exploration, the exact position of the arteries,
the operator proceeds, accurately adjusting the
armatures of the instrument, in such wise that
the pads, which have previously been turned

A

1 6 Instrumental Compression of the Carotids.

somewhat inward, and fixed by means of the
key, will, when brought into position over the
arteries, press the latter away from the pneu-
mogastric nerve and jugular vein in theMirection
of the spinal column.

In exerting compression, the instrument
should be held in the right hand, the handle
of the same forming a perpendicular to the
arteries. With the left hand pressed firmly
against the superior portion of the neck, the
operator exerts the necessary counter-pressure,
and at the same time contributes to the support
of the head in the desired position. To be
effectual, such pressure must be considerable —
very much more so than in prolonged compres-
sion. Compression should, however, never be
carried to such an extent as to cause entire
closure of the lumina of both arteries ; such a
procedure may cause convulsions, should the
anastomotic facilities in the Circle of Willis be
inadequate to meet the unwonted physiological
exigencies. This contingency, however, is not
liable to occur, as the degree of pulsation in the
temporal arteries affords reliable information as
to the extent of the circulatory obstruction.

Instrumental Compression of the Carotids. 1 7

Very severe instrumental compression should
not usually, I believe, be continued for more
than ten or twelve minutes.

That portion of the continuity of the com-
mon carotid artery, which I have found best
suited to the application of instrumental com-
pression, is situated opposite a point which is
located slightly above the juncture of the
thyroid with the cricoid cartilage. Although
much can be obtained by instruments, the final
success attending their use will depend greatly
on the dexterity of the operator himself.

PROLONGED INSTRUMENTAL COMPRESSION OF

THE CAROTIDS.

Having repeatedly convinced myself that it is
usually possible to arrest the paroxysms, pe-
culiar to epilepsy, by means of temporary com-
pression of the carotids, I began to soliloquize
as to the nature of epilepsy itself. On referring
to histories of numerous autopsies, I was bewil-
dered by a mass of pathological findings, dis-
tributed throughout the various organs, no par-
ticular group of which could I by any logical
necromancy identify as pre-eminently charac-

1 8 Instrumental Compression of the Carotids.

teristic of the disorder in question. There was
one species of lesion, however, of tolerably fre-
quent occurrence, namely, an affection of the
cortex, usually involving, to a greater or less
degree, the integrity of the adjacent membranes.
When I considered the prominent part which the
branches of the internal carotid play in the
blood-supply of the hemispheres, I could not
help asking myself the question : Is there not
some connection between these lesions and the
extraordinary anomalies in the cerebral circu-
lation, which prevail during the attack? And
granting this to be a logical supposition, is not,
I asked myself, the fact that the convulsions
cease on diminishing the amount of blood in
the carotid circulation, sufficient to arouse
strong suspicions that the tonic and clonic
spasms are caused by cortical discharge due to
the irritative effects of the engorged cerebral
vessels ?

As a matter of course, this argument pre-
supposes the direct or indirect primary inva-
lidity of the vaso-motor mechanism. It was a
natural thought that perhaps the effects of this
central decrepitude might possibly be indemni-

\

No. II.

AUTHOR*S CAROTID TRUSS.

Instrumental Compression of the Carotids. 19

fied by resort to some means of artificial limi-
tation, applied to the trunks of those great ar-
teries most intimately concerned in the cortical
blood supply. These and kindred reflections
induced me to essay prolonged compression,
soon after having noted the possibility of
checking an epileptic seizure by pressure upon
the carotids. To this end, I made experiments
with various mechanical devices, which I de-
signed for the purpose of protracted compression
of the carotids. Some of these appliances were
formidable and complicated, but as inefficient
as they were formidable. It was only after re-
peated and discouraging trials, that I finally
succeeded in devising a species of truss, which,
while being simple and inexpensive in construe-
tion, seems to fulfill both the theoretic and
practical demands of the problem in every re-
spect (;vid, plate No. 2). This carotid truss con-
sists of two semicircular springs, one of which
is provided with a longitudinal slot. Through
this slot passes a screw, that is securely imbed-
ded in the periphery of the second spring which
lies directly below and in perfect apposition
with the first. By sliding one over the other.

t

20 Instrumental Compression of the Carotids,

the radius formed by the two springs may be
increased or diminished at will ; while by tight-
ening a nut, with which the screw is provided,
they may be held in any desired position. To
each of the free extremities of the springs is
attached, by means of a ball and socket-joint, a
delicate pad. The ball of this joint is attached
to a screw which can be lengthened or short-
ened at will. The pads can be moved to and
fro by means of a short longitudinal slot, and
secured in position with a screw.

MANNER OF APPLYING PROLONGED COM-
PRESSION.

The mode of applying this instrument is as
follows : Having first, by means of the radial
screw, which provides a coarse adjustment,
adapted the radius of the truss to the circum-
ference of the neck of the patient whose arte-
ries are to be compressed, the operator next
proceeds to adapt the pads to the arteries, by
means of the smaller anterior slots and screws,
which afford a fine adjustment. The region of
the artery to be selected for permanent com-
pression is precisely the same as that to be

Instrumental Compression of tJie Carotids. 21

chosen in temporary compression. The pads
should be so arranged, namely, that their supe-
rior margin is situated about opposite the junc-
ture of the thyroid with the cricoid cartilage.
Connection may be established between the
extremities of the truss by means of an elastic
band, secured at each extremity by detachable
clamps. This elastic band is provided with a
buckle. By lengthening or shortening the
band, pressure can be increased or decreased at
will. Protracted pressure should never be so
great as to cause serious inconvenience or giddK
ness. On the other hand it must be sufficient
to sensibly diminish the lumen of the artery,
otherwise no good will be likely to result from
the procedure. More difficulty is experienced
in the adjustment of instrumients to the necks
of fleshy persons than to those of less full
habit. Prolonged compression is furthermore
not usually so well borne by these fleshy pa-
tients, as in order to act upon the lumen of
the artery through the superincumbent adi-
pose tissue, considerable pressure must be em-
ployed, and this they find it hard to reconcile
themselves to for very considerable periods of

22 Instrumental Compression of the Carotids.

time. In most cases, however, with the em-
ployment of proper dexterity and tact, patients
are very glad to wear apparatus of this kind
for very long periods of time. This is all the
more readily accomplished when they become
aware that a high loose collar effectually con-
ceals the truss from the gaze of the inquisitive.
With this and similar instruments I have com-
pressed for more or less protracted periods the
carotid arteries of a number of epileptics. Al-
though some of these patients were subject to
as many as three or four attacks every twenty-

■

four hours at the time I began treatment by
protracted compression, I was enabled to arrest
the convulsions entirely for the space of many
days — indeed in some instances for several
weeks. Nor did these good effects disappear
directly on cessation of compression ; on the
contrary, the attacks were less frequent for a
considerable time after removal of the instru-
ment. Remarkable was the effect of compres-
sion on the peripheral circulation. In some of
the cases in which I essayed compression, the
disordered state of the vaso-motor mechanism

ly displayed in the cold and

Instrumental Compression of the Carotids. 23

cyanotic condition of the extremities. After
applying compression for a certain length of
time in these cases, the venous stasis was re-
placed by a healthy glow, and the condition of
frigidity was replaced by one of actual warmth.
These facts are certainly significant, for I can
only attribute the above effects to the direct
or indirect beneficial influence of compression
on the vaso-motor centres.

Certainly the amount of blood excluded from
the brain by compression, and consequently
directed to other corporeal regions, would of
itself hardly account for the peripheral effects.
We must rather, I believe, ascribe these bene-
ficial results to the benignant action of com-
pression on the cerebral centres themselves.

COMPRESSION AS A SOMNIFEROUS AGENT IN
MANIACAL EXCITEMENT.

Having noted the efficacy of compression in
epilepsy, it became a question with me whether
the procedure might not prove of value as a som-
niferous agent in maniacal excitement, where,
as is well known, there is often a considerable
degree of cerebral hyperaemia. Accordingly I

24 Instrumental Compression of the Carotids.

compressed the carotids of a patient who was
suffering from a protracted and most violent
attack of mania. He had slept but little for
weeks, although taking large doses of hyosci-
amus and chloral. This patient was violent
and destructive, tearing and breaking everything
within his reach. To adjust apparatus to this
man's neck, I was obliged to have him restrained
by a number of attendants; his mental and
motor excitement were something frightful to
contemplate. His face was much distorted and
flushed, and both conjunctivae much injected.
I applied compression to his arteries while he
remained in a sitting posture. After the Japse
of a few moments, his cries and struggles
ceased, his eyelids drooped, and he began to
oscillate to and fro upon his chair. In this con-
dition he suffered himself to be led to his bed.
There he remained quietly upon his back,
evincing all the symptoms of drowsiness. In a
shorter time than it takes to relate it, he was
wrapt in slumber. This repose had all the
characteristics of physiological sleep. Respira-
tion was deep and perfectly regular. There was
not the slightest cardiac irregularity or disturb-

Instrumental Compression of the Carotids. 25

ance whatever. Patient continued to sleep for
several hours, and when at last he awoke, ap-
peared much refreshed. I have since employed
compression many times with the object of
placing the brain in a condition favorable to
sleep, and with an eye to limiting the amount
of ganglionic activity.

I can only say that I am astounded that a
method which, for theoretic reasons, must com-
mend itself to every thoughtful understanding,
should, for so long a time, have eluded the
progressive inquest of the profession.

EFFECTS OF PROGRESSIVELY INCREASED COM-
PRESSION OF THE CAROTIDS.

The phenomena observable on augmenting
more or less rapidly pressure upon the carotids
are substantially as follows :

{a). Facial pallor.

{b). Drooping of the eyelid.

{c). Decrease in rapidity of respiration.

(rf). Dizziness and frequently well-marked
soporific tendency.

{e). In very anaemic persons frequently syn-
cope ; and if compression be very severe, so j

26 Instrumental Compression of t)ie Carotids.

that the lumina of the arteries are almost en-
tirely closed, general convulsions may be in-
duced.

I do not attempt to offer on this occasion any
explanation for the well-known, but apparently
paradoxical physiological fact, that the two op-
posite conditions of excessive cerebral anaemia
and excessive cerebral engorgement frequently
result in irritative phenomena, which may cul-
minate in clonic and tonic convulsions. The
fact is certainly most significant and well cal-
culated to arouse an interesting train of re-
flections.

The symptoms above referred to are usually
preceded by transitional appearances of conges-
tion, which, however, usually disappear rapidly
as soon as the vis h tergo has been effectually
re-established. The phenomena produced by
compression also exhibit considerable variation
in their appearance, and it is not always possible
to demonstrate them all in the same individual.
In the course, however, of a large number of
experiments, I have had occasion to observe
most of these effects many times. What meas-
ure of inconstancy actually does exist, particu-

Instrumental Compression of the Carotids, 27

larly in the latter symptoms of the above group
of phenomena, is adequately accounted for, I
believe, by the well-known variability in the
anastomotic connections between the vertebral
and carotid systems at the Circle of Willis.

CEREBRAL ACTIVITY DEPENDENT ON THE

BLOOD-SUPPLY.

Dr. Weir Mitchell, in his admirable mono-
graph on "Wear and Tear," proceeds, after
discussing the effects of over-taxation of the
nervous centres, as follows : " When in active
use, the thinking organs become full of blood,
and, as Dr. Lombard has shown, rise in temper-
ature, while the feet and hands become cold.**
" Nature meant that, for their work, they
should be, in the first place, supplied
with food, next that they should have
certain intervals of rest to rid themselves
of the excess of blood accumulated during
their periods of activity ; and this is to be done
by sleep, and also by bringing into play the
physical machinery of the body, such as the
muscles — that is to say, by exercise which
flushes the parts engaged in it, and so depletes

28 Instrumental Compression of the Carotids.

the brain." What far-reaching truths are con-
tained in these few sentences, so pregnant with
physiological significance ! Employ what argu-
mentative sophistry we may, it is none the less
evident that the amount of cerebral activity is
in direct ratio to the magnitude of the blood-
supply.

CURTAILMENT OF CEREBRAL . ENERGY BY
LIMITING THE BLOOD -SUPPLY TO THE
GANGLIA.

If, then, it be admitted that the ganglia
are directly or ultimately dependent for their
functional activity pn the good offices of
the blood-stream, it becomes perfectly evident
that limitation of blood-supply means curtailment
of ganglionic function. When it \s furthermore
considered that those reparative processes, with-
in the ganglia themselves, are best performed
while the organ is in a state of comparative
anaemia, I can not repress the conviction that in
carotid compression we possess the true physio-
logical throttle valve of psychical and motor
energy. Upon the great physiological principle
then, that the extensity and intensity of gan-

Instrumental Compression of the Carotids, 29

glionic activity are ultimately dependent upon
the magnitude of the blood-supply, I believe
should be founded every rational system of
Brain Rest. As a matter of course, the avowal
of this conviction does not exclude the employ-
ment of sedatives, more particularly where there
is a state of irritation within the ganglion
cells themselves. I have myself employed
carotid compression, in conjunction with very
moderate doses of the bromides as well as of
hyosciamus and chloral ; and I have seen small
doses of these drugs, which by themselves would
have remained ineffective, produce most excel-
lent sedative effects when employed in conjunc-
tion with carotid compression. And herein lies,
it would seem, the future of compression of the
carotids. It is not, 1 believe, a procedure which
is destined to displace the existing employment
of certain powerful drugs. The beneficial re-
sults to be anticipated from its employment are,
on the contrary, the possibility of curtailing the
use of certain powerful remedies, such as the
bromides, hyosciamus, chloral, etc., etc. As an
anti-phlogistic in the inflammatory invasions,
which attack the meninges and the adjacent

30 Instrumental Compression of the Carotids.

membranes, I believe that arterial compression
has a future. In cerebral hemorrhage it might
prove useful. Whether it would prove useful in
arresting the growth of tumors is of compara-
tively minor importance. In concluding this
paper I can not refrain from a reference
to Dr. William A. Hammond's remarkable
case, which so graphically and conclusively
proves that the brain is in a compara-
tive state of anaemia during sleep. The
case in question is published in Dr. Hammond's
classical work on " Sleep and its Derangements,"
page thirty-seven. " In 1854 a man came under
my observation who had, through a frightful
railroad 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 lost portion consisted of a great
part of the left parietal, and a 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, during which I often attended him. In the
course of my treatment I soon became ac-
quainted with the fact that, at the beginning of

Instrumental Compression of the Carotids. 3 1

the comatose condition which succeeded the
fits, there was invariably an elevation of that
portion of the scalp covering the deficiency in
the cranium. As the stupor passed away, and
sleep, from which he could easily be aroused,
ensued, the scalp gradually became depressed.
When the man was awake, the region of the
scalp in question was nearly on a level with the
upper surface of the cranial bones. I also
noticed, on several occasions, that during nat-
ural sleep the fissure was deeper, and that in
the instant of awaking, the scalp covering it
rose to a much higher level.'*

" After my attention was thus drawn to this
subject, I observed that in young infants the
portion of scalp covering the anterior fontanelle
was always depressed during sleep, and elevated
during wakefulness.**

Dr. Hammond also refers to the published
paper of Dr. Flemming, late professor of medi-
cine, Queen*s College, Cork, in which that able
observer states that he has frequently succeeded
in producing sleep by compression on the
carotids.

32 Instrumental Compression of the Carotids.

For a further elucidation of this and allied
subjects, a perusal of Dr. Hammond's interest-
ing and instructive experiments respecting the
nature of sleep, contained in the monograph
above referred to, will be found most useful.

^

APPENDIX.

APPENDIX.

Since the preceding paper went to press I have
undertaken a series of experiments with Carotid Com-
pression in conjunction with :

(i). An apparatus, constructed on Junot*s princi-
ple, which envelopes the lower half of the body.

(2). With hot bath to the lower extremities.

(3). With ice-bags to head and spine.

CAROTID COMPRESSION IN CONJUNCTION WITH JUNOT'S

APPARATUS.
il^td, Plate No. 3).

Treatment on this plan may be conducted while
the subject assumes a horizontal or erect position.
The effects obtainable in a vertical position are of
course greater than are possible in a horizontal pos-
ture, as the results of gravity are added to those of
compression, and the derivative influences of a greater
or less degree of vacuum. The advantage of com-
bining treatment by derivation with carotid compres-
sion consists in the fact that under these circum-
stances it is not necessary, and, indeed, is not advisa-
ble, to create as great a vacuum as would be required
were the derivative apparatus employed alone and
unaided by arterial compression. I have usually em-

(35)

36 Appendix.

ployed this method with the subject reclining in some
position between the horizontal and vertical, the inferior
half of the body always remaining below the level of
the head. In order, furthermore, to readily place a
patient in any desired attitude, I have designed a spe
cies of couch provided with a ratchet and pinion
attachment. By turning a crank the plane of this
couch can be varied from the horizontal to any de-
sired degree of inclination.

When employing this method of treatment, care
should be taken not to cause too much redness or
distension of the lower extremities. The condition of
the radial pulse should also be carefully watched, and
in very anaemic persons it is not advisable to reduce the
fulness of the latter to a considerable degree, as syn-
cope might be induced by such a procedure. The
degree of vacuum may be measured by an appropri-
ately constructed manometer.

CAROTID COMPRESSION IN CONJUNCTION WITH HOT
BATH TO LOWER EXTREMITIES.

This is a very effective method of treatment in
cases of insomnia and congestive headache. It is
well to have the receptacle sufficiently deep to admit
of plunging the lower extremities into the bath for
some distance above the knees. When the limbs be-
come thoroughly reddened compression may some-
times be dispensed with and the patient allowed to
fall quietly asleep. A chair with a depressable back
is a valuable adjunct in this treatment. Patients will
frequently sleep in a chair when all efforts in this

Appendix. 37

direction prove ineffectual in bed. If the patient be
placed in bed after this treatment it is well to thor-
oughly warm the lower portion of the bed. Wrapping
the reddened extremities in flannel is likewise an ex-
cellent plan. The head should always be supported
on cushions in such wise that, without causing incon-
venience, it is retained in a more elevated position
than the rest of the body. All sensory excitation
should be excluded. The apartment should be care-
fully darkened. All extraneous or discordant noises
are to be carefully excluded. The ticking of a metro-
nome, however, or the monotonous roar of the ocean
waves are sometimes valuable adjuncts in this treat-
ment.

CAROTID COMPRESSION WITH ICE-BAGS TO HEAD AND

SPINE.

I have essayed this method of treatment on one or
two occasions and believe the combination to be a
good one. My experience, however, with this system
of treatment is still too limited to warrant the expres-
sion of a definite opinion as to the merits or demerits
of the procedure. Although I have no experience
bearing on the matter, I should not be astonished, for
theoretical reasons, to find carotid compression prove
more or less efficacious in acute inflammations ot
tissues lying above the seat of compression and largely
dependent upon the carotid for their blood supply.

Also, in the arrest of epistaxis and traumatic hem-
orrhage temporary compression might prove of advan-
tage. A trial of compression in the first stage ot

38 Appendix,

cerebral hemorrhage might develop interesting results.
Statistics as to the value of compression in the inflam-
matory troubles of the cerebral membranes would be
of value. The propriety of employing compression
in those functional troubles, so ably described by Dr.
Beard, in his work on ** Neurasthenia," is self-evident.
Derangement of cerebral circulation is one of the most
common phenomena in these disorders, and Dr. Beard
has called attention to the evidence of this morbid
condition of the vaso-motor centres, where he describes
the extraordinary facial flushings often present in these
cases. Passive congestions of the nerve-centres, es-
pecially transient hyperaemias of the brain, are among
the most frequent results of Neurasthenia, according to
Dr. Beard. When the intimate relationship which con-
gestive phenomena sustain to epilepsy, hysteria, and
other neuroses, is borne in mind, and when we con-
sider the profound circulatory derangements which are
so prominent a feature in these grave diseases, the
necessity of treating all early morbid circulatory de-
rangements, before they result in profound organic
changes, is evident.

As a means of treating derangements in the vascular
districts lying below the seat of compression the method
is most valuable, as I have frequently found in the
peripheral derangements of epilepsy and dementia.
Very recently I have made trial of carotid compression
in conjunction with inhalations of nitrous oxide gas,
chloroform, and ether.

In concluding these remarks I can not refrain from
citing an interesting case of congestive headache from

Appendix, 39

the practice of my friend, Dr. M. Josiah Roberts, of
New York, which he had the courtesy to communicate
to me in the following letter :

** 4 W. 28th St., April i, 1882.

** My dear Doctor : — T have obtained such a bril-
liant result in the use of your instrument for temporary
compression of the carotids that I feel it my duty to
detail it to you, without further delay. You may per-
haps remember that some days since you inadvertently
left one of your earlier instruments for temporary
compression in my office, and it was this which I made
use of. My patient had been suffering severely from
an intense throbbing headache for more than seven
hours. Her face was flushed, conjunctivae injected,
and tears stood in her eyes ; in fact I have never seen
a patient suffering more severely from congestive
headache. At once the use of your instrument sug-
gested itself to my mind. With it I made firm pres-
sure over both carotid arteries for forty-five seconds,
when the patient declared her headache had entirely
disappeared, and I removed the instrument, and have
not since reapplied it.

" One week has now elapsed, and the patient told me
to-day that she has had no recurrence of the trouble.

" Faithfully yours,

**M. JosiAH Roberts."

LANK MRDICAL LIBRARY

To avoid flne, this book should be returned
m or before the date last stamped below.

L582 Corning, J. L, Carotid
GSi.i'coiapresBion and brain
1882 rest. ■ 11819