anæmia of this form in weakly and aged individuals might terminate in
death. This condition corresponded to the so-called serous apoplexy of
the old writers. With increasing accuracy in our autopsies this
condition is more and more rarely recorded, although the possibility
of its occurrence as a pathological rarity cannot be denied. As a
rule, the chronic form of cerebral anæmia when it terminates fatally,
which is exceptional, is marked by a deepening coma and gradual
extinction of the vital processes, the Cheyne-Stokes phenomenon
preceding this.
Patients suffering from chronic cerebral anæmia are afflicted with
morbid irritability of the optic and auditory nerves. Loud sounds and
bright lights are very annoying to them. Roaring, buzzing, and beating
sounds in the ear are common, and scintillations, muscæ volitantes,
and temporary darkening of the visual field—particularly noticed when
the head is suddenly raised—are complained of in all cases. It is
often found that the tinnitus disappears and the hearing power
improves on assuming the horizontal position.
Headache of greater or less severity is found in the majority of
cases: it is more severe in the rapidly-developed forms, and I have
found it to be complained of in agonizing intensity by women who had
risen from childbed and who had flooded considerably. As a rule, the
headache, whether severe or mild, is symmetrical and verticalar, in
some cases associated with an ache subjectively appearing as if it
extended to the back of the orbit. It is remarkable for its constancy,
and its exacerbations are often complicated with vertigo and nausea,
so that it is not infrequently interpreted as a reflex evidence of
gastric disorder. A stitch-like feeling, located in both temples, is
often associated with it.
Occasionally sufferers from chronic cerebral anæmia experience
seizures, or rather exacerbations, of their disorder which approach in
character, while not equalling in degree, an attack of syncope.
Whether in bed or in a chair, they then feel as if their limbs were of
lead; they deem that they cannot stir hand or foot; the other symptoms
related are {784} aggravated; they yawn and breathe deeply, but hear
all that is said by those near them, and do not lose consciousness.
They express themselves as feeling as if everything around them were
about to pass away. One of my patients would frequently find that if
this condition overtook her while lying on one side, that side would
remain numb for some time and be the seat of a tingling sensation
which disappeared on the parts being rubbed. The same was noticed when
she awoke in the morning in a similar position. To what extent these
features were due to the general anæmia is doubtful. As previously
stated, true syncope occurs in chronic cerebral anæmia, but much less
frequently in those subjects of this disorder who have reached middle
life than in adolescents.
The radial pulse in cerebral anæmia does not necessarily show the
anæmic character; not infrequently the general blood-pressure is
increased at the onset of the acute form, and if long continued this
may be followed by a decrease of the same. The pulse-character may
therefore vary greatly in frequency, resistance, and fulness. In
protracted cases it is soft, easily compressible, and rapid.
It is not uncommon to find indications of a slight unilateral
preponderance of the signs of cerebral anæmia. In one case which
terminated in recovery, and was otherwise pure, vertigo was not
produced on turning from the left to the right, but it was produced to
a distressing degree on turning in the opposite direction; in a
second, equally typical, there was for a long time a subjective
sensation of falling over toward the right side.
There appears to be much less constancy in the relationship of the
deficient blood-supply to the severity of the symptoms than is usually
supposed. Much depends upon the time of life at which the disorder
develops: a brain that has acquired stability through education and
exercise is less vulnerable to the influence of general anæmia than
one that has not. The nerve-centres appear, to some extent at least,
to regulate their own blood-supply; and whether it be through a change
in the blood-current rapidity or some other factor neutralizing the
evil effects of the intrinsically inferior quality of the blood, we
must attribute to the self-regulating nutrition power of the brain the
not uncommon phenomena of an active mind in an anæmic body. And where
the general anæmia reaches so high a degree as to involve the brain,
under such circumstances we find that irritability to sensory
impressions and fretfulness are more prominent than the lethargy and
indifference which characterize the juvenile chlorotic form. Although
this distinction is less marked between these two classes in regard to
acutely-produced anæmia, yet it is observable even there. If in a
youth or girl while undergoing phlebotomy cerebral anæmia were to
reach such a degree as to cause subjective sounds, they would either
approach or fall into a faint; but Leuret, the distinguished cerebral
anatomist, while being subjected to the same procedure, hearing a
hissing sound, did not lose consciousness, but complained that some
one must have upset a bottle of acid on a marble table in the same
room, as he supposed he was hearing the sound of effervescence thus
produced.
Much, too, appears to depend on dynamic and other thus far
undiscovered intrinsic conditions of the brain-tissue itself,
irrespective of the mere amount and rapidity of the blood-current. If
the subject be exposed to wasting diseases, to blood-poisons, or to
vicissitudes of temperature and {785} to physical exhaustion in
addition to the causes producing cerebral malnutrition, deliria of a
cortical nature are more apt to characterize the case than in simple
anæmia. These are known as the deliria of inanition, and present
themselves under two forms. The first has been frequently observed in
sailors, travellers, and others who have undergone starvation in
exposed situations, and is tinctured by the psychical influences
incident to such a condition. Just as the Greeley survivors at Cape
Sabine, when reduced to their miserable rations of seal-skin
boot-leather and shrimps, entertained each other with the enumeration
of imaginary culinary luxuries, so others who have suffered in the
same way declaim about gorgeous banquets in the midst of a howling
wilderness, or, as occurred to a miner who lost his way in Idaho a few
winters ago, experienced hallucinatory visions of houses, kitchen
utensils, and persons with baskets of provisions. In others the terror
of the situation leads to the development of rambling and incoherent
delusions of persecution.
The second form, regarded as a variety of starvation delirium, is
found in the post-febrile periods of typhoid and other exhausting
fevers. In aged persons it may even develop shortly after the onset of
the disease. It is usually unsystematized, of a depressive cast, and
may be associated with a condition resembling melancholia agitata. In
a small proportion of cases insanity of the ordinary types, but more
commonly of the special kinds comprised in the group of post-febrile
insanity, develops from the anæmic fever delirium as its
starting-point.
The spurious hydrocephalus (hydrocephaloid, hydrencephaloid) of
Marshall Hall and Abercrombie, referred to in the section on Etiology,
is an important condition for the diagnostician to recognize. A child
suffering from this disorder presents many symptoms which are
customarily regarded as characteristic of tubercular meningitis or of
chronic hydrocephalus; thus the pupils are narrow—sometimes
unequal;[30] there is strabismus, and there may be even nuchal
opisthotonos, while the somnolent state in which the little patient
usually lies may deepen into a true coma, in which the pupils are
dilated, do not react to light, nor do the eyelids close when the
cornea is touched. Ominous as this state appears, it may be completely
recovered from under stimulating and restorative treatment. On inquiry
it is found that the symptoms above mentioned were preceded by cholera
infantum or some other exhausting complaint, such as a dysentery or
diarrhœa, and that the somnolent condition in which infants are often
found toward the close of such complaints passed gradually into the
more serious condition described.[31] The infants thus affected do
not, however, sleep as healthy children do, but moan and cry, while
apparently unconscious of their surroundings. The surface of the body
is cool and pale; the pulse and respiration are normal, except in the
comatose period, but the former is easily compressible. The chief
points distinguishing hydrocephaloid from true hydrocephalus and other
diseases associated with similar symptoms are the following: 1st,
There is no rise of temperature; 2d, the pupils are equal; 3d, the
fontanelle is sunken in; 4th, the pulse and respiration, with the
exception stated, are natural; 5th, there is an {786} antecedent
history of an exhausting abdominal disorder; 6th, also a facial
appearance characteristic of the latter.
[Footnote 30: This is not admitted by most writers, but does occur
exceptionally.]
[Footnote 31: It should not be forgotten, however, that very similar
symptoms occur after cholera infantum, with a much graver pathological
condition—namely, marantic thrombosis of the sinuses.]
One of the gravest and rarest forms of cerebral anæmia is one which
occurs as a result of extreme general anæmia in very young infants. In
a remarkable case which I have had an opportunity of studying, the
abolition of certain cerebral functions reached such a degree that the
opinion of a number of physicians was in favor of tubercular
meningitis.[32] There was at the time of my examination complete
extremity hemiplegia, and there had been conjugated deviation,
restlessness in sleep, and dulness in the waking hours: all these
symptoms except the hemiplegia disappeared whenever a more assimilable
and nutritious food was used than the one previously employed. On one
occasion there were evidences of disturbed vaso-motor innervation; on
several, convulsive movements. This history, associated with ordinary
evidences of general anæmia, covered a period of eighteen months,
without the slightest abnormality of temperature being noted or
discoverable during that period. The mucous surfaces of this child
were almost colorless, certainly without any indication of the normal
tinge; the mother had nursed it, and her milk had been found to
possess scarcely any nutritive value. The case terminated fatally at
the age of twenty months.
[Footnote 32: It was stated by an experienced practitioner that death
occurred with unmistakable symptoms of tubercular meningitis.
Certainly, the absence of temperature disturbance at the time of the
hemiplegic and other exacerbations, as well as other important
features for a period exceeding a year, shows that whatever favorable
soil the earlier condition may have furnished for the secondary
development of such or other gross structural disease, tubercular
meningitis did not exist at the time; while the absence of pupillary
and optic-nerve symptoms, as well as the rapid changes from day to day
or week to week under dietetic treatment, militate against the
assumption of any other organic affection incident to childhood.]
Partial Cerebral Anæmia.—Most writers on cerebral anæmia discuss a
number of varieties of partial cerebral anæmia as distinguished from
the acute and chronic general forms. Some of the conditions thus
described properly appertain to the angio-spastic form of hemicrania,
others to epilepsy, and the majority to circulatory disturbances
dependent on arterial disease. Aside from the partial cerebral anæmia
resulting from surgical causes, I am acquainted with but one evidence
of limited cerebral anæmia which can be regarded as independent of the
neuroses or of organic disease, and that is the scintillating scotoma.
This symptom, in the only case in which I observed it, occurred in a
medical student, accompanied by pallor and nausea in consequence of
the disgust produced in him by the combined odors of a dissecting-room
and of a neighboring varnish-factory. The totally blind area of the
visual field was strictly hemianopsic in distribution and bounded by a
colored zone scintillating, to use the sufferer's words, like an
aurora borealis. The attack, probably protracted by his great alarm at
being blind in one-half of the visual field, lasted three hours. As
the cause in this case was a psychical impression and accompanied by
the ordinary signs of that fainting which is not an uncommon
occurrence in the dissecting-room; as, furthermore, the individual in
question never had a headache except in connection with febrile
affections, and then in the lightest form, and is neither neurotic
himself nor has a neurotic ancestry or relatives,—I regard it as the
result of a simple arterial spasm intensified in the visual field of
{787} one hemisphere, analogous to the more general spasm of ordinary
syncope.[33]
[Footnote 33: It may be remembered that Wollaston had scintillating
scotomata, and that after his death a small focus of softening was
found in the one visual field. Ordinarily, this disturbance is
associated with hemicrania.]
DIAGNOSIS.—There is so little difficulty in recognizing the nature of
those cases of acute cerebral anæmia which depend on recognizable
anæmia-producing causes that it is unnecessary to point out their
special diagnostic features. With regard to chronic cerebral anæmia,
and its differentiation from other circulatory brain disorders, I
refer to the last article. In this place it will be necessary only to
point to some of the symptoms which, individually considered, are
found in other disorders, and may therefore be misinterpreted. The
chief of these is vertigo, which, as already stated, being associated
with nausea, and even vomiting, is not infrequently confounded with
stomachic vertigo, while the opposite error is also, though less
frequently, fallen into. The chief differential points are—that
stomachic vertigo is relieved by vomiting, and anæmic vertigo is not;
that the former is rather episodical, the latter more continuous; that
in the free intervals of the former, while there may be some dulness,
there is not the lethargy found with anæmia; that the headache with
the former is either over the eyes or occipital, and most intense
after the passage of a vertiginous seizure, while anæmic headache is
verticalar or general, and not subject to marked momentary changes. It
is unnecessary to indicate here the positive evidences of gastric
disorder which are always discoverable in persons suffering from
stomachic vertigo; but it is also to be borne in mind that such
disorder is frequently associated with the conditions underlying
general and cerebral anæmia, particularly in the prodromal period of
some pulmonary troubles.
There are a number of organic affections of the brain which are in
their early periods associated with symptoms which are in a
superficial way like those of cerebral anæmia. As a rule, focal or
other pathognomonic signs are present which render the exclusion of a
purely nutritive disorder easy; but with some tumors, as is generally
admitted, these signs may be absent. It is not difficult to understand
why a tumor not destructive to important brain-centres, nor growing
sufficiently rapid to produce brain-pressure, yet rapidly enough to
compress the blood-channels, may produce symptoms like those of simple
cerebral anæmia. It is claimed that with such a tumor the symptoms are
aggravated on the patient's lying down, while in simple anæmia they
are ameliorated.[34] The latter proposition holds good as a general
rule; as to the former, I have some doubts. Not even the
ophthalmoscope, although of unquestionable value in ascertaining the
nature of so many organic conditions of the brain and its appendages,
can be absolutely relied on in this field. Until quite recently, optic
neuritis, if associated with cerebral symptoms, was regarded as
satisfactory proof that the latter depended on organic disease; but
within the year it has been shown by Juler[35] that it may occur in
simple {788} cerebral anæmia, and both the latter and the associated
condition of the optic nerve be recovered from.
[Footnote 34: The increased flow of blood to the brain in anæmia is
not always momentarily remedial: if, for example, the patient stoop
down, he flushes more easily than a normal person, and suffers more
than the latter. The same is observed with regard to stimulants.]
[Footnote 35: _British Medical Journal_, Jan. 30, 1886. In the case
reported suppression of the catamenia is spoken of, as well as the
fact that treatment was directed to the menstrual disturbance. It is
not evident from the brief report at my disposal whether the
suspension of the menstrual flow was symptomatic of general anæmia or
of a local disturbance. Optic neuritis has been recorded as having
been present in a large number of cases with no other assignable cause
than a uterine disorder. As previously stated, Hirschberg and Litten
found choked disc under like circumstances.]
The claim of Hammond and Vance that ordinary anæmia of the brain may
be recognized through the ophthalmoscope is almost unanimously
disputed by experienced ophthalmoscopists, nor is it unreservedly
endorsed by any authority of weight among neurologists. That there may
be color-differences to indicate anæmia is, however, not impossible;
and the fact that a concentric limitation of the visual field
sometimes occurs should not be forgotten. It is distinguished from
that found with organic diseases by its variability through the day
and in different positions of the body.
TREATMENT.—Chronic as well as acute cerebral anæmia, dependent on
general anæmia, usually requires no other medicinal treatment than
that rendered necessary by the general anæmic state of which it is a
part. This has been discussed at length in the third volume of this
work: it remains to speak of certain special precautions and
procedures rendered necessary by the nervous symptoms predominating in
such cases. As the insufficiently nourished brain is not capable of
exertion, mental as well as physical rest is naturally indicated. And
this not only for the reason that it is necessary to avoid functional
exhaustion, but also because the anæmic brain when overstrained
furnishes a favorable soil for the development of morbid fears,
imperative impulses, and imperative conceptions. This fact does not
seem to have been noticed by most writers. The mind of the anæmic
person is as peculiarly sensitive to psychical influences as the
anæmic visual and auditory centres are to light and sound; and in a
considerable proportion of cases of this kind the origin of the morbid
idea has been traced to the period of convalescence from exhausting
diseases. The prominent position which masturbation occupies among the
causes of cerebral anæmia perhaps explains its frequent etiological
relationship to imperative conceptions and impulsive insanity.
Although the radical and rational treatment of cerebral anæmia is
covered by the treatment of the general anæmia, there are certain
special symptoms which call for palliative measures. Most of these,
such as the vertigo, the optic and aural phenomena, improve, as
stated, on assuming the horizontal position. The headache if very
intense will yield to one of three drugs: nitrite of amyl, cannabis
indica, or morphine. I am not able to furnish other than approximative
indications for the use of remedies differing so widely in their
physiological action. Where the cerebral anæmia and facial pallor are
disproportionately great in relation to the general anæmia, and we
have reason to suppose the existence of irritative spasm of the
cerebral blood-vessels—a condition with which the cephalalgia is often
of great severity—nitrite of amyl acts as wonderfully as it does in
the analogous condition of syncope.[36] Where palpitations are
complained of, and exist to such a degree as to produce or aggravate
existing insomnia, small doses of morphine will act very well, due
{789} precautions being taken to reduce the disturbance of the
visceral functions to a minimum, and to prevent the formation of a
drug habit by keeping the patient in ignorance of the nature of the
remedy. When trance-like conditions and melancholic depression are in
the foreground, cannabis indica with or without morphia will have the
best temporary effect: it is often directly remedial to the
cephalalgia. Chloral and the bromides are positively contraindicated,
and untold harm is done by their routine administration in nervous
headache and insomnia, irrespective of their origin. Nor are
hypnotics, aside from those previously mentioned, to be recommended;
the disadvantages of their administration are not counterbalanced by
the advantages.[37] Frequently, in constitutional syphilis, insomnia
resembling and probably identical with the insomnia of cerebral anæmia
will call for special treatment. In such cases the iodides, if then
being administered, should be suspended, and if the luetic
manifestations urgently require active measures, they should be
restricted to the use of mercury in small and frequent dosage, while
the vegetable alteratives may be administered if the state of the
stomach permit.
[Footnote 36: There are disturbances in the early phases of cerebral
syphilis, whose exact pathological character is not yet ascertained,
which so closely resemble the condition here described that without a
knowledge of the syphilitic history, and misled by the frequently
coexisting general anæmia, it is regarded as simple cerebral anæmia.
Under such circumstances, as also with the cerebral anæmia of old age,
amyl nitrite should not be employed.]
[Footnote 37: Urethran and paraldehyde have failed in my hands with
anæmic persons.]
Among the measures applicable to the treatment of general anæmia there
are three which require special consideration when the cerebral
symptoms are in the foreground: these are alcoholic stimulants, the
cold pack, and massage. It is a remarkable and characteristic feature
of cerebral anæmia that alcoholic stimulants, although indicated, are
not well borne[38]—at least not in such quantities as healthy persons
can and do take without any appreciable effect. I therefore order
them—usually in the shape of Hungarian extract wines,[39] South Side
madeira, or California angelica—to be given at first in such small
quantities as cannot affect the cerebral circulation unpleasantly, and
then gradually have the quantity increased as tolerated. In fact, both
with regard to the solid nourishment and the stimulating or nourishing
fluids and restorative drugs the division-of-labor principle is well
worth following. The cerebral anæmic is not in a position to take much
exercise, his somatic functions are more or less stagnant, and bulky
meals are therefore not well borne. Small quantities of food,
pleasingly varied in character and frequently administered, will
accomplish the purpose of the physician much better.