Can we diagnosticate Ilyper- 
semia or Anaemia of the 
Brain and Cord ? 
BY 
LANDON CARTER OKAY, M. D., 
PRORHOR O¥ NEKVOUH AND MENTAL DIMEAHKB IN THE 
NEW YOKK POLYCLINIC. 
ubpiiinted fbom 
®t)t Neto ¥orfc J&eDfcal Journal 
for May 34, 1890. Reprinted from the New York Medical Journal 
for May 2A, 1890. 
CAN WE DIAGNOSTICATE 
OR ANaEMIA OF THE 
BRAIN AND CORD?* 
By LANDON CARTER GRAY, M. D., 
PROFESSOR OF NERVOUS ANI) MENTAL DISEASES IN THE NEW YORK TOLYCLINIC. 
Hyperemia and anaemia of the brain and cord are terms 
that are very glibly used by the general practitioner to ex- 
plain many symptoms whose pathology is obscure to him, 
although the use of the terms by the specialist has steadily 
decreased within the last ten or fifteen years. Can such 
hypersemia or anaemia be diagnosticated ? is a very impor- 
tant question that we may well ask ourselves in the interests 
of precise medicine. It will be instructive in this regard to 
review the opinions of recent writers of standing. 
Gowers speaks with great skepticism of cerebral conges- 
tion, or the possibility of the recognition of this condi- 
tion. The author only speaks of cerebral anaemia as recog- 
nizable when it is due to general anaemia, cardiac weakness, 
intracranial pressure, and obstruction of some cerebral ar- 
tery. Of anaemia and hyperaemia of the spinal cord he 
says: “ The occurrence of variations in the state of the ves- 
* The presidential inaugural address read before the New York 
Neurological Society, Tuesday, May 6, 1890. 2 
IIYPERASMIA OR AN ASM IA 
sels of the cord, and the effects that such variations may 
produce, are matters of inference from symptoms observed 
during life—symptoms that are in themselves open to vari- 
ous interpretations. Where the ground is barren of facts, 
theory is always luxuriant.” Seeligmuller, in 188V, speak- 
ing of cerebral anaemia and hypenemia, says : “ The differ- 
ential diagnosis between the two, remarkable as it may 
seem, is often accomplished with great difficulty, although 
it is of great importance in a therapeutic sense. A chlo- 
rotic girl may display the same ruddy cheeks, the same 
sensation of pulsation in the brain, the same vertigo, the 
same excitement as a person who is threatened with cere- 
bral haemorrhage. Even other diagnostic signs fail one, 
such as the amelioration of the anaemic headache by putting 
the head in a dependent position, or after a hearty meal. 
If one examines more precisely, however, in most cases of 
cerebral anaemia the pallor of the skin and the visible mu- 
cous membranes, the blowing murmur of the heart and the 
large vessels, the small pulse, etc., can readily be distin- 
guished from the lively injection of the conjunctiva and 
other mucous membranes and the full and heaving pulse of 
cerebral hyperaemia. If, in addition, there should be found 
a hypertrophy of the left ventricle, the diagnosis would be 
so much safer. In general, we can state the signs of differ- 
ential diagnosis to be as follows: 
“Of cerebral hyperamia : Insomnia, myosis, cephalalgia, 
extended headache and vertigo, better in standing; hyperae- 
mia of the retinal vessels; pulse slow and full. 
“Of cerebral anaemia: Drowsiness, mydriasis, headache 
restricted to a small space; headache and vertigo better in 
lying ; anaemia of the retinal vessels; pulse small and rapid ; 
heart and venous sounds.” 
In spinal hyperaemia he would have the symptoms to con- 
sist of certain dull pains and slight sensory derangements in OF TI1E BRAIN AND CORD. 
3 
the lower extremities, spontaneous muscular twitchings and 
tremor, and slight exaggeration of reflexes ; and he quotes 
with approval Hammond’s statement that vesical paresis and 
erections may occur frequently. The main differential diag- 
nosis, in Seeligmiiller’s opinion, is from the pain of gall- 
stones. Spinal anaemia is not mentioned by this author. 
Lieberineister (1886), speaking of cerebral hyperemia, says : 
“As symptoms, which perhaps are deducible with a certain 
probability from simple arterial hypenemia, may be men- 
tioned these: Cephalalgia of pressing or beating typo, ex- 
citability and irritability, intellectual and bodily unrest And 
excitement, with impulse to activity, increased energy of 
the movements, greater vivacity of the association of ideas 
and thought, and insomnia. But we must freely admit of 
these symptoms that they are, to a certain extent, theoretic- 
ally constructed, and that for the most of them the proof 
of their dependence upon simple hypenemia without other 
disturbance has not been made.” Of cerebral anaemia he 
speaks with more certainty, and the causes which he alleges 
are obstruction of cerebral arteries, great loss of blood, gen- 
eral anaemia, cardiac disease, and organic intracranial dis- 
ease. Striimpell (1887), speaking of cerebral hypenemia and 
anaemia, says : “ In many cases in which pronounced cere- 
bral symptoms point to an abnormal condition of the cere- 
brum, but where we can, nevertheless, for many reasons, ex- 
clude a gross anatomical lesion, we can assume the existence 
of circulatory disturbances in the brain without being able 
to adduce a direct reason. So we may attribute to cerebral 
circulatory disturbances certain ca«es of headache, pressure 
in the head, vertigo, general hyperesthesia, and that Pro- 
tean and yet well-characterized symptom-group which is 
known as cerebral neurasthenia. But how far cerebral cir- 
culatory disturbances here play a part, what their nature is, 
and whether purely functional disturbances of the brain may 4 
HYPERAEMIA Oil AN/EMIA 
not arise entirely independent of them, has not yet been 
positively determined.” Writing of the spinal circulatory 
disturbances, he says: “Our knowledge of the occurrence 
and the clinical significance of pure circulatory disturbance 
in the spinal cord is very scanty. All that is stated in this 
regard in the descriptions of spinal pathology largely corre- 
sponds more to theoretic assumptions than to real objective 
facts.” Ross (1882) admits that “ the symptoms of cerebral 
anaemia are not unlike those of hyperaemia of the brain, and 
the delirium from anaemia which arises in the course of 
acute disease may very readily be mistaken for the delirium 
of active congestion. Anaemia and hyperaemia of the brain 
can indeed only be distinguished from one another by care- 
ful attention to the concomitant symptoms. The symptoms 
themselves are not to be relied upon, as the delirium in 
anaemia may be as violent as in congestion, and the color of 
the face is not always a faithful index of the condition of 
the cerebral circulation. The diagnosis must be founded 
upon the general history of the case, the nature of the con- 
comitant symptoms, and the treatment which has been 
adopted prior to the onset of the delirium. As further 
aids to the diagnosis, it may be tried whether the erect or 
horizontal posture has any influence in aggravating or 
diminishing the symptoms, and whether they are increased 
or relieved by alcoholic stimulants. The state of the gen- 
eral circulation must also be carefully examined.” All that 
he says in regard to the diagnosis of spinal anaemia is this : 
“ The diagnosis must rest mainly on the concomitant symp- 
toms, the symptoms of the acute ischaemic form resem- 
bling those due to spinal haemorrhage, and anaemia can only 
be inferred to be the cause when the aorta is known to be 
obstructed or a great loss of blood has recently occurred. 
The chronic forms of spinal anaemia resemble chronic mye- 
litis or chronic meningitis, but when severe general anaemia OF THE BRAIN AND CORD. 
5 
exists it may l>e inferred that the disease is caused hy it. 
The fact that the horizontal position relieves the symptoms 
may afford valuable aid in forming the diagnosis,” which 
latter point he borrows from Dr. Hammond. Of hyper- 
femia of the cord he says: “ The diagnosis of hyperaemia of 
the structures within the spinal canal is based on the slight 
and transitory nature of the sensory and motor symptoms, 
the absence of increase of temperature, the short and favor- 
able course of the symptoms, and the success of treatment 
calculated to relieve congestion.” Of all contemporary 
authors, however, Dr. William A. llammond is the most 
precise, enthusiastic, and comprehensive in his account 
of the symptoms of cerebral anaemia and hyperaemia. 
Writing (1886) of cerebral congestion, he treats of the 
active and the passive forms separately. Of the first he 
recognizes six varieties, which are designated by the chief 
feature characterizing the attack—namely, the apoplectic, 
the paralytic, the convulsive, the soporific, the maniacal, 
and theapbasic; “the latter,” he says, “being a sixth form 
which is now for the first time systematically arranged in 
the present category.” He goes on to say : “ It will doubt- 
less be the case that, as our knowledge of the functions of 
the brain becomes greater, other forms of cerebral conges- 
tion, especially those of a partial character, like the aphasic, 
for instance, will be recognized.” In cerebral anaemia the 
symptoms given by Dr. Hammond are syncope; headache 
limited to a small spot or consisting of a sense of constric- 
tion ; tinnitus aurium ; dilated and sluggish pupils; small 
retinal vessels; pale chorioid; paresis of ocular muscles; 
great facial pallor; nausea and vomiting in extreme cases; 
epileptiform convulsions occasionally, and always when 
there has been great loss of blood ; general muscular weak- 
ness or general or partial paralysis; anaesthesia; mental 
disturbances, varying from complete coma through the 6 
HYPEREMIA OR ANA3MIA 
gradations from low delirium to great mental irritability or 
intellectual lassitude; hallucinations and illusions; drowsi- 
ness ; rapid death ; a melancholic tendency, or even posi- 
tive insanity. The symptoms of spinal congestion, accord- 
ing to Dr. Hammond, are: a dull, aching pain, increased by 
the recumbent posture and by standing, if the lower cord is 
aifected, but not augmented by pressure; an occasional 
sensation of heat in the cord; disturbances of sensibility 
and motility, such as hyperresthesia, shooting pains, girdle 
sensation, formication, etc. ; erections, vesical and rectal 
paralysis, diminution of electro-muscular reaction, and bed- 
sores. Of spinal anaemia Dr. Hammond writes: “A de- 
ficient quantity of blood in the spinal cord, or a deprecia- 
tion of the quality of the blood circulating through its 
tissue, give rise to cognate but, so far as their phenomena go, 
different affections. In one of these, which has heretofore 
been known as spinal irritation, the morbid action is in a 
great measure confined to the posterior columns of the 
cord; in the other, which embraces several differently 
named disorders, characterized by paralysis—such as reflex 
paralysis, inhibitory paralysis, spinal paresis, paralysis from 
peripheral irritation, etc.—the antero-lateral columns are 
mainly affected. In thus specifically locating the lesions in 
these affections, I am aware of the fact that post-mortem ex- 
aminations are wanting to support them. Nevertheless, the 
symptoms characteristic of each are so distinctly marked, 
and are in such intimate physiological relation with the 
regions of the cord specified, that I do not think I am at 
all exceeding the limits of probability.” 
All the authors quoted are writers of the last decade, 
and their views are fairly representative of the views held 
by neurologists in general, except that those of Dr. Ham- 
mond would, I think, be regarded as extreme. Among the 
older writers the expressions in favor of hyperaemia and OF THE BRAIN AND CORD. 
7 
anaemia of the brain and cord are much more marked, but 
it would profit us little to spend any time in learning what 
their opinions were, because they classed under these gen- 
eral names so many diseases that have since been differen- 
tiated. 
It may be said, then, that the symptoms alleged to be 
those of cerebral hyperaemia or anaemia are headache, flush- 
ing or pallor of the face, delirium, vertigo, motor or sensory 
paralysis, retinal changes, slight aural changes, insomnia, 
myosis. If these symptoms are examined one by one, the 
significance of each one will become decidedly problematical 
to any one who has had much acquaintance with the clinical 
aspects of cerebral disease. Headache, for example, is a very 
general symptom, indicating too many disorders to be of 
any service except in conjunction with other signs, and the 
statement that it is apt to be localized and widespread in 
cerebral hyperaemia is a pure assumption, of which no proof 
has ever been adduced. The condition of the capillary 
circulation of the face is by no means a reliable guide to 
the condition of the cerebral capillary circulation. Anv 
hospital surgeon knows that marked meningeal hyperamiia 
is often associated with great facial pallor in fractures of 
the skull and the attendant cerebral hyperaemia, just as 
great pallor may exist with many hyperaeinic intracranial 
conditions, at the same time that precisely the same patho- 
logical states may cause vascular flushing in other individ- 
uals. Delirium, like headache, is a general symptom indic- 
ative of too many conditions to be of any value by itself. 
The same remark is true of vertigo. Of motor and sensory 
paralysis as symptoms of cerebral hyperaemia and anaemia 
it may simply be said that there is not an authentic case on 
record in which a simple anaemia or hyperaemia has caused 
a motor or sensory paralysis. It is almost, if not abso- 
lutely, impossible to distinguish retinal changes consisting 8 
IIYPER.EMIA OR ANAEMIA 
only of slight differences in vascularity from the normal, 
as every ophthalmologist knows, while the more marked 
changes of neuro-retinitis have never yet been shown to 
have been produced by cerebral anaemia or hyperaemia. 
Tinnitus aurium and insomnia, like headache, delirium, and 
vertigo, are symptoms that are absolutely worthless by 
themselves. Myosis is said to be a symptom of cerebral 
hyperaemia. It may be, but nobody has yet made public 
the proof. It will thus be seen that, of all these symptoms, 
headache, delirium, vertigo, tinnitus aurium, and insomnia 
are general symptoms which only derive a diagnostic value 
from their associates, while Hushing or pallor of the face 
are extremely doubtful indications of the intracranial cir- 
culation ; motor and sensory paralysis and retinal changes 
are absolutely worthless as signs, and the diagnostic value 
of myosis is a pure assumption. Anaemia and hyperaemia 
of the cord have, as we have seen, very lack-luster defenders 
among the modern writers, with the exception of Dr. Ham- 
mond. The former ascribe to them certain vague pains, 
which might be due to so many varying general, muscular, 
and neuralgic conditions that the differential diagnosis would 
be practically impossible, even if it were of any practical 
use. But when we come to consider the symptoms which 
Dr. Ilammond alleges to be those of cerebral hyperaemia, 
we are confronted by the picture of an organic cerebral dis- 
ease. If cerebral hyperaemia can produce the symptoms of 
apoplexy, paralysis, convulsions, a soporific condition, mania, 
and aphasia, it certainly is capable of producing serious or- 
ganic symptoms, and we should naturally expect to havelhe 
proof. When we turn to Dr. Hammond’s chapter on the pa- 
thology of this particular form of cerebral disease we find the 
statement that the capillaries and large blood-vessels of the 
brain and pia mater will be found to be increased in size, 
that the white matter of the brain is increased in consistence OF THE BRAIN AND CORD. 
9 
and density, the gray matter is red or even violet in hue, there 
is a large amount of subarachnoid effusion or even an effusion 
into the ventricles, and the chorioid plexuses are often en- 
larged. If there have been repeated attacks of cerebral con- 
gestion, granules of h,Tinatin will be found in contact with 
the blood-vessels, or the latter may be found to be unusually 
tortuous and to have minute aneurysms. Now, I submit 
that this description is not that of a mere hyperaemia, but 
is a condition of actual structural disease of the cerebral tis- 
sue quite as pronounced as can be found in many cases of 
general paresis of the insane, or in the severer cases of 
chorea, or in certain cases of intracranial syphilis; indeed, 
it would seem that a part of this description—that relating 
to the htematin and the tortuosity and aneurysmal swell- 
ings of the arterioles—is acknowledged to be from the work 
of Laborde upon Softening and Congestion of the Brain of 
the Aged, and written in 1866. In addition to this de- 
scription, Dr. Hammond also says that we will find that 
state of the brain described by Calmeil in 1826, and subse- 
quently given the name of Vetat crible by Du rand-Fardel in 
1854, and described respectively in treatises upon the insane 
and the aged. Dr. Hammond’s symptoms of spinal conges- 
tion are those of myelitis, and there is no means of making 
the differential diagnosis, while that spinal anaemia may be 
confined to the posterior columns of the cord, giving rise to 
the symptoms of spinal irritation, or confined to the antero- 
ateral columns of the cord, givin rise to paralytic symp- 
toms, is a theory which he himself acknowledges to be 
wanting in the support of autopsies. 
The truth of the matter is that our knowledge of nerv- 
ous diseases has increased so rapidly within the last quarter 
of a century as to make it a matter of little surprise that 
the older authors should have attempted to satisfy their 
ignorant consciences by dubbing as congestion or hyper®- 10 
HYPEREMIA OR ANvEMIA 
mia the many puzzling symptoms which time has resolved 
into distinct symptom groups. The most difficult of all 
phrases for the average scientist is, “ I do not know.” A 
disease must be labeled at any cost, and, once labeled, it 
takes many years to rub out the brand. Meningitis, gen- 
eral paresis, porencephalitis, cerebral and spinal syphilis, 
disseminated sclerosis, bulbar lesions, poliomyelitis ante- 
rior, central or transverse myelitis, syringomyelitis, pro- 
gressive muscular atrophy, acute ascending or Landry’s pa- 
ralysis, locomotor ataxia, especially in its early stages, many 
forms of neuritis, focal diseases of the brain in the light of 
our modern knowledge of localization, lateral sclerosis, 
many forms of lithaemia and neurasthenia—these are many 
diseases of which we now possess a knowledge at which the 
practitioner of twenty-five years ago might well stand ap- 
palled, and which he may well be pardoned for supposing 
to be due to some vague form of anaemia or hyperaemia. 
Indeed, Leyden, writing in 1875 of essential infantile pa- 
ralysis, thought it to be due to a peculiar congestion of the 
cord, while Cornil and Lepine had demonstrated some two 
years before that the pathological condition was a disap- 
pearance of the great ganglion cells in the anterior horns 
of the spinal cord, the autopsy in their case being followed 
by another one to the same effect by Gombault in the same 
year as Leyden’s article. 
After this necessarily cursory review we may ask our- 
selves again. Can hyperaemia or anaemia of the brain and 
cord be diagnosticated? I, for my part, would answer very 
positively that the diagnosis is not possible by means of 
the nervous symptoms alone ; in other words, the symptoms 
as I have narrated them above are not sufficient by them- 
selves to warrant a diagnosis of anaemia or hyperaemia of 
the brain or cord. It must be remembered that the brain 
is an exquisitely and almost inconceivably complex organ, OF THE BRAIN AND CORD. 
11 
pulsating and vibrating with the most explosively nitrogen- 
ized molecular life, and reacting to a myriad reflex influ- 
ences in the kaleidoscopic way that constitutes the never- 
tiring charms of character, poetry, music, and the varied 
forms of mental activity. To put our finger on a few slight 
changes of temporary nature that occur in an organ like 
this, say that they are really due to hyperaemia or anaemia, 
and exclude all the cellular play, all the reflex influences 
from the other viscera of the body, all the morbific ele- 
ments that may be circulating in the blood, all the factors 
of temporary discomfort that are to be found in the atmos- 
phere, in tli3 food and clothing, and in the circumstances 
of a human being’s environment—even if this is not impos- 
sible, it has certainly not been done. If we have evidences 
of some intracranial disturbance, such as those we have 
already detailed—headache, delirium, vertigo, tinnitus au- 
rium, insomnia, flushing or pallor of the face—and with 
these we have some concomitant conditions that would 
make it reasonable to suppose that there might exist a con- 
gestion or ansemia of the brain or cord, then we should be 
warranted in regarding such a diagnosis as probable. Thus 
certain cardiac conditions, lesions of the great vessels of 
the chest, abdomen, and thorax, certain forms of hepatic 
disease, tumors making pressure upon these great vessels, 
a general anaemia, leucocythaemia, intense mental exertion, 
or exposure to great heat—these conditions, when associated 
with the above-described general symptoms, would make it 
probable that the general symptoms were due to hyperaemia 
or anaemia, as the case might be ; but even then there might 
not be certainty. I can not conceive, however, how we are 
to make the diagnosis of spinal anaemia or hyperaemia, for 
I know of no pathological observations that would warrant 
on the one han4 the diagnosis by means of the vague pains 
that are described by some authors, or, on the other hand, 12 
HYPER/EMIA OR ANAEMIA OF THE BRAIN. 
by means of the symptoms of full-fledged myelitis which 
are described by Dr. Hammond. 
Bibliography. 
Gowers. Diseases of the Nervous System, 1888. 
Hammond. Diseases of the Nervous System, 1886. 
Ross. Diseases of the Nervous System, 1882. 
Seeligmiiller. Lehrbuch der Krankheiten des Riiekenmarks 
und Gehirns, etc., 1887. 
Strumpell. Lehrbuch d. spec. Pathol, u. Therap. d. inueren 
Krankheiten. I. Theil, Krankheiten des Nervensystems, 1887. 
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