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ANi^MIA. 
 
 BY 
 
 FREDERICK P. HENRY, M.D., 
 
 PROF. OF CLINICAL MEDICINE IN THE PHILADELPHIA POLY- 
 CLINIC; ONE OF THE PHYSICIANS TO THE EPISCOPAL HOS- 
 PITAL; ONE OF THE PHYSICIANS TO THE PHILADELPHIA 
 HOSPITAL ; CONSULTING PHYSICIAN TO THE HOME FOR 
 CONSUMPTIVES ; CORRESPONDING MEMBER OF THE 
 ROYAL MEDICAL ACADEMY OF ROME, ETC., ETC. 
 
 REPRINTED FROM 
 
 THE POLYCLINIC. 
 
 PHILADELPHIA: 
 P. BLAKISTON, SON & CO., 
 
 No. IOI2 Walnut Street. 
 1887. 
 
Copyright, 1887, by 
 P. BLAKISTON, SON & CO. 
 
DR. S. WEIR MITCHELL, 
 
 THIS WORK IS, BY PERMISSION, RESPECTFULLY 
 DEDICATED. 
 
 " Semper honos, nomenque tuum, laudesque manebunt. 
 Quae me cunque terrae vocant." 
 
PREFACE. 
 
 This, the first systematic treatise on anaemia 
 published in this country, is a reprint of a series 
 of articles published in The Polyclinic dur- 
 ing the past year, and embodies the results 
 of many years' study of the blood and the dis- 
 orders consequent upon its imperfect elabora- 
 tion. The statements which it contains are, 
 for the most part, based upon personal obser- 
 vation, and where this has been wanting, upon 
 accepted facts of physiology and pathology. 
 I have endeavored to supply the want of a 
 trustworthy guide to a wide and growing field 
 of research — a want which I myself have 
 keenly felt. 
 
 7^7 Pine Street, June ist, i88j. 
 
COiNTENTS. 
 
 PAGH 
 
 Introduction, I 
 
 Methods of Examination, lo 
 
 Anaemia in General, 15 
 
 Exciting Causes of Antemia, 20 
 
 Symptoms of Anaemia, 27 
 
 Anatomical Characters of Ameiiiia, 30 
 
 Diagnosis of Anaemia, 31 
 
 Prognosis of Anaemia 34 
 
 Treatment of Anaemia iu General, 35 
 
 Varieties of Anaemia, 43 
 
 Chlorosis, Ancemia of Puberty, 47 
 
 Anaemia Lymphatica, 59 
 
 Leucocythaemia, 75 
 
 Anaemia Splenica, 102 
 
 Pernicious Anaemia, 1 14 
 
 Secondary Anaemia, 129 
 
 Toxan^emia, 130 
 
 Parasitic Anarmia, 132 
 
 Index, 135 
 
 vii 
 
ANAEMIA. 
 
 INTRODUCTION. 
 
 The blood holds in solution certain albumin- 
 ous bodies, of which the principal are serum- 
 albumin, serum-globulin, and fibrinogen, and a 
 number of mineral substances, the chief of 
 which are common salt (sodium chloride) and 
 sodium carbonate. These may be classed as 
 the invisible constituents of the blood, and their 
 investigation belongs to the domain of the 
 physiological chemist. In addition, it holds in 
 suspension certain bodies, the red and white 
 corpuscles, which are open to direct inspection, 
 and may, therefore, be classed as the visible 
 constituents of the blood. The study of these 
 latter, as regards their form, color, size, number 
 and relative proportion, is the province of the 
 histologist, and it is with these properties that 
 we are concerned in this treatise. 
 
 The red corpuscles of man are circular disks, 
 with rounded edges and depressed centres. On 
 account of the difference in thickness between 
 
 A 1 
 
the central and peripheral parts of a red cor- 
 puscle, it is impossible that its entire surface 
 can be accurately focused by the microscope 
 at the same time, and, accordingly, when its 
 centre appears bright its periphery is dark, and 
 vice versa. The diameter of the human red 
 corpuscle is about j|g of a millimetre, or -g^aVo ot 
 an inch. The chemistry of the red corpuscles 
 is quite complex, and, in some respects, still 
 unsettled. The most important ingredient, 
 haemoglobin, is conspicuous by its brilliant op- 
 tical properties, and its amount may be most 
 readily determined by these alone. It is the 
 only proteid of the body that contains iron, and 
 the amount of this mineral in the ash of the 
 blood affords a method of determining the 
 amount of haemoglobin in a given specimen. 
 It is by means of the hsemoglobin in the red 
 corpuscles that the blood conveys oxygen to 
 the tissues. Haemoglobin is characterized by 
 the readiness with which it absorbs and parts 
 with oxygen. It exists in the blood in two. dis- 
 tinct forms : in the arterial blood as oxy-haemo- 
 globin, and in the venous blood as reduced 
 haemoglobin. These two forms are readily 
 distinguished by means of the spectroscope. 
 
Haemoglobin is crystallizable, the crystals being 
 obtained with greater or less ease from the blood 
 of different animals. They may be obtained 
 most readily from the blood of the rat, by simply 
 mixing it with distilled water on a glass slide. 
 Other means employed with the blood of other 
 animals are : alternate freezing and thawing of 
 the blood, the passage through it of electric 
 shocks, of the vapors of ether and chloroform, 
 and the addition of the alkaline salts of the bile. 
 The largest crystals are deposited from blood 
 that is allowed to undergo decomposition. Thus 
 obtained, they are often of enormous size — from 
 three to five centimetres long. This is explained 
 by the supposition that putrefaction destroys 
 substances which are preventive of crystalliza- 
 tion. If there is any single element of the body 
 that deserves to be called "vital," it is undoubt- 
 edly haemoglobin. It is universally present, 
 and conveys to the tissues the element, oxygen, 
 that is most essential to the life of the individual, 
 while its diminution below the normal, even 
 when slight, is manifested by various symptoms 
 of functional disorder, and when extreme and 
 long continued, leads to grave and irreparable 
 organic lesions. Its chemical properties are 
 
extraordinary, and apparently contradictory. 
 It is organic and yet crystallizable ; it has an 
 eager affinity for oxygen, and yet parts with it 
 on the shghtest demand ; it is soluble in water, 
 and circulates in the blood without leaving the 
 red corpuscles ; and, finally, without losing its 
 identity, it exists in the blood in two distinct 
 forms : in the arteries as oxy-hsemoglobin, in 
 the veins as reduced haemoglobin. The ab- 
 sence of this substance from the blood in greater 
 or less degree, is at the root of the various forms 
 of anaemia, about to be considered. 
 
 The white, or colorless corpuscles, are spher- 
 ical masses of granular, nucleated protoplasm, 
 having a diameter of io/-i^ or 23V0 o^ ^-^ inch. 
 They possess the power of spontaneous move- 
 ment, and hence are sometimes called amoeboid 
 cells, from their resemblance, in this respect, to 
 the unicellular rhizopod, called the amoeba. 
 They exist in healthy blood in about the pro- 
 portion of one white to five hundred red cor- 
 puscles. Their specific gravity is less than 
 that of the red corpuscles, and, therefore, if 
 blood be placed in a narrow cylindrical vessel 
 
 * T)ie Greek letter, /i, is used as the sign of the micromilli- 
 metre, or one-thousandth of a milhmetre. ^ 
 
and kept from coagulating by a temperature a 
 little above the freezing point, or by the addi- 
 tion of a saline, such as sodium sulphate, the 
 red corpuscles will collect at the bottom of the 
 vessel, and the white at the top. Owing to 
 their scanty numbers, great difficulty stands in 
 the way of their accurate chemical analysis. 
 Nevertheless, some work has been accom- 
 plished in this direction. Their contractile 
 power is probably dependent upon a substance 
 closely resembling the myosin of voluntary 
 muscle. Their nuclei may be isolated from 
 the surrounding protoplasm by the action of 
 gastric juice, which dissolves the protoplasm 
 and leaves the nucleus intact. The latter is 
 composed of a mucin-like substance, contain- 
 ing phosphorus, called nuclein. The minute 
 granules scattered throughout the substance of 
 the white corpuscles are, some of them, soluble 
 in ether and alcohol, and therefore regarded as 
 fat granules ; the nature of the granules not 
 thus dissolved is unknown. Glycogen is also 
 contained in the white corpuscles, as may be 
 demonstrated by treating them with a solu- 
 tion of one part iodine, and two parts potas- 
 sium iodide, in one hundred parts water. 
 
6 
 
 Besides the red and white corpuscles, other 
 morphological elements exist in the blood, con- 
 cerning the character and function of which 
 there exists considerable confusion. They are 
 the haematoblasts of Hayem, identical with the 
 blood-plates (Blutplattchen) of Bizzozero, the 
 microcytes, and the advanced lymph disk or 
 invisible corpuscle of Norris. When blood is 
 examined under the microscope, there may be 
 occasionally observed, and sometimes in large 
 numbers, certain granular-looking masses of 
 irregular shape, the size of which is variable, 
 but may considerably exceed that of the white 
 corpuscles. They are known as Schultze's 
 granule masses. With strong lenses, it is 
 readily seen that they are not granular or 
 amorphous — like the amorphous urates seen in 
 urine — but are composed of distinct and inde- 
 pendent individual elements,"'^ which latter are 
 the haematoblasts or blood-plates. " They are 
 the elementary corpuscles of Zimmermann, the 
 globulins of Donne, the grai7is sarcodiques of 
 Vulpian, and the granulations litres of Ran- 
 vier. The latter regarded them as particles of 
 fibrin, which serve as centres of coagulation, 
 
 * This was first demonstrated by Osier. 
 
just as a cr}'stal of sodium sulphate dropped 
 into a solution of the same will serve as a 
 centre of crystallization." * 
 
 These bodies are not, as has been supposed, 
 disintegration products of the white corpuscles, 
 for they may be seen circulating in the blood 
 of transparent tissues, such as the mesentery. 
 Their function is intimately concerned with the 
 production of fibrin. 
 
 The microcytes are round or disk-shaped 
 bodies, much smaller than the red corpuscles. 
 They vary considerably in size, their average 
 diameter being 3/-^. They resemble minute red 
 corpuscles, and sometimes contain considerable 
 coloring matter. They are very numerous in 
 idiopathic, so-called pernicious, anaemia, while, 
 on the other hand, the granule masses are but 
 scantily present in that disease. Microcytes 
 are also to be found in perfectly healthy blood. 
 
 The colorless corpuscle of Norris is a red cor- 
 puscle minus its coloring matter. Norris claims 
 that it is a young red disk that has been elabo- 
 rated in the lymph glands, and has entered the 
 blood by the thoracic duct, and that it gradu- 
 
 *The Coagulation of the Blood. F. P. Henry, Archives of 
 Medicine, December, 1884. 
 
8 
 
 ally acquires all the properties of a mature red 
 corpuscle. His opponents contend that it is a 
 red corpuscle deprived of its coloring matter by 
 the veiy manipulations used to demonstrate it. 
 The question is still unsettled. 
 
 The functional power of the blood is depend- 
 ent upon the number and quality of its red 
 corpuscles. When a deficiency exists in either 
 of these respects, the tissues suffer for the want 
 of oxygen — the most important nutritive ele- 
 ment of the body. When the degree of anaemia 
 is slight, it may be manifested by symptoms 
 which are not to be distinguished from neuras- 
 thenia in its various forms, except by an exami- 
 nation of the blood. The latter affection often 
 co-exists with a perfectly normal condition of 
 the blood. When the anaemia is of higher 
 grade, the want of oxygen — equivalent to want 
 of breath — may not be experienced except upon 
 exertion, of which the amount necessary to pro- 
 duce this symptom is in inverse ratio to the 
 degree of anaemia. In extreme cases, simply 
 raising the head from the recumbent position 
 will suffice to induce breathlessness or even 
 syncope. Even in such extreme cases, the 
 symptoms alone will not suffice for diagnosis, 
 
for there are diseases of which the most promi- 
 nent symptoms are due to irregular distribution 
 of the blood, a hyperaemia of one vascular dis- 
 trict necessarily causing a correlative ansemia 
 of another, while the constitution of the blood 
 is normal. The most conspicuous example of 
 this condition is furnished by Addison's disease, 
 in which, owing to vasomotor paralysis, there 
 is great accumulation of blood in the ab- 
 dominal vessels and a correlative anaemia of 
 the brain. Here, also, dyspnoea arises upon 
 slight exertion ; the muscles are weak and 
 easily fatigued, and in extreme cases, during 
 the frequent exacerbations of the disease, simply 
 raising the head from the pillow is sufficient to 
 induce syncope. Until very recent times, these 
 symptoms of Addison's disease were ascribed 
 by the most eminent authorities to a high degree 
 of anemia. It is now established that in such 
 cases the constitution of the blood may be 
 normal, and that the symptoms are due to its 
 irregular distribution. Further instances are 
 unnecessary to prove the diagnostic importance 
 of a proper examination of the blood. The 
 presence of anemia may be guessed at without 
 such examination, and the diagnosis (?) con- 
 
10 
 
 firmed or rejected by the result of the treatment, 
 while the patient, in the meantime, may have 
 been losing what might have been saved by 
 proper methods. Not only the bare presence 
 of ansemia, but its variety and degree, are to be 
 ascertained by examining the blood, as well as 
 its progress under different modes of treatment. 
 In short, no contribution to the clinical history 
 of a case of anaemia deserves to be compared 
 with that derived from an examination of the 
 blood. 
 
 METHODS OF EXAMINATION. 
 
 These consist in the enumeration of the red 
 and white corpuscles, and the determination 
 of the percentage of haemoglobin in the former. 
 The instruments used for counting the corpus- 
 cles are all constructed upon the same principle, 
 the different modifications being such as are 
 designed to facilitate the rapid counting of the 
 cells, and the easy reckoning of their percentage 
 as compared with the standard of health. A 
 known quantity of blood is diluted with a known 
 quantity of fluid, and in a cell of certain depth 
 and superficies — the latter indicated by squares 
 of a certain size ruled upon an ocular micro- 
 meter, or on the bottom of the cell containing the 
 
11 
 
 blood — the number of corpuscles is counted. 
 With these factors — the depth of the cell, its 
 superficies, and the degree of the dilution — the 
 number of corpuscles in a cubic millimetre of 
 blood, for instance, is readily estimated. It 
 is self evident that the more the blood is 
 diluted, the easier is the counting of the 
 corpuscles, and the longer the subsequent 
 calculation. The chief instruments in use 
 for counting the blood corpuscles are the 
 compte-globules of M, Malassez, for a de- 
 scription of which see Coniptes Rendus de 
 L! Academie des Scietices, Dec, 1872, also 
 These de Paris, 1873; the hematim^tre of 
 MM. Hayem and Nachet, described in the 
 Coniptes Rendus de L' Acadeinie des Sciences, 
 26 Avril, 1875 ; ^^i^ the haemacytometer of 
 Dr. Gowers, of London. 
 
 The different instruments for counting the 
 blood corpuscles may be used in combination. 
 Thus, in many of my own observations, I have 
 used Gowers' pipettes with Hayem and Nachet's 
 cell and eye-piece. Thoma and Zeiss {Her- 
 inann's Hand duck der Physiologie, IV, Bd. I), 
 also, have constructed an apparatus composed 
 of the pipette used with Malassez' instrument. 
 
12 
 
 known as the mixer [melangew') of Potain, and 
 a cell similar to that of Gowers. The instru- 
 ments of Gowers and Zeiss are superior to the 
 others mentioned, in that they may be used 
 with any microscope without adjustment for the 
 different objectives employed. The counting is, 
 however, sometimes rendered very difficult with 
 Gowers' instrument, on account of the large 
 size of the squares — ^^ of a millimetre. The 
 squares in the cell of Zeiss' instrument are only 
 2V of a millimetre, rendering the counting a very 
 easy task. Until quite recent times, it was sup- 
 posed that the quality of the blood could be 
 accurately determined by counting its corpus- 
 cles. If these were found below the standard — 
 5,000,000 per cubic millimetre — anaemia was 
 supposed to exist ; while, on the other hand, if 
 above this standard, anaemia was confidently 
 declared to be absent. It was apparently taken 
 for granted that the red blood corpuscle was a 
 constant quantity, a unit, containing invariably 
 the same amount of haemoglobin. It is now 
 thoroughly established that the amount of 
 haemoglobin in two red corpuscles, from differ- 
 ent individuals, may vary as much as 50 per 
 cent., so that the mere number of the corpuscles 
 
13 
 
 does not afford an infallible proof of the pres- 
 ence or absence of anaemia. When the cor- 
 puscles are decidedly below the normal average, 
 anaemia, of course, can be determined by a 
 mere count, but even here its degree can 
 only be accurately estimated by determining 
 the percentage of hsemoglobin, the reduction 
 of which is usually greater than that of the 
 number of the corpuscles. It is, however, in 
 those cases of anaemia in which the number 
 of the corpuscles is normal, or even gi'eater 
 than normal, that the superiority of the haemo- 
 globin test is unmistakably manifested. The 
 writer agrees with Hayem, that, if one had to 
 choose, in cases of this sort, between the two 
 methods, the color test would undoubtedly be 
 preferred.^ 
 
 The principal point to be determined in an 
 examination of the blood is the functional value 
 of the red blood corpuscles, which bears a direct 
 ratio to the amount of haemoglobin in each. 
 
 * " Si dans les cas de ce genre, cas d'ailleurs extremement com- 
 muns, on voulait s'en tenir si I'une des deux methodes d'examen 
 du sang, c'est done sans hesitation au precede chromometrique 
 qu'il faudrait donner la preference." Recherches sur r anat. 
 norm, et path, du sang. Paris, 1878. 
 
14 
 
 As a rule, when the number of blood corpuscles 
 is normal, the amount of haemoglobin is also 
 normal, or nearly so, but, and this fact deter- 
 mines the value of a color test, there are numer- 
 ous exceptions to this rule. Thus, Baxter and 
 Willcocks found 6,600,000 corpuscles per cubic 
 miUimetre, in a case of typhoid fever, but they 
 contained only 45 per cent, of the normal quan- 
 tity of haemoglobin, making their functional 
 value equal to that of 2,970,000 normal corpus- 
 cles ; so that, in spite of the high figures, the 
 degree of anaemia was great. 
 
 Instruments for estimating the percentage of 
 haemoglobin have been devised by Hayem, 
 Malassez and Gowers, of which the most simple 
 is the globinometer of Dr. Gowers. I have used 
 this apparatus with much satisfaction. It is 
 light, compact, and easily manipulated. The 
 words of its inventor are equally applicable to 
 the instruments of Hayem and Malassez. " The 
 instrument is only expected to yield approxi- 
 mate results, accurate within two or three per 
 cent. It has, however, been found of much 
 utility in clinical observations." 
 
 From these introductory^ remarks, the import- 
 ance, for clinical purposes, of a proper exami- 
 
15 
 
 nation of the blood is manifest. It is a signifi- 
 cant fact that those who, in the course of their 
 practice, make frequent examinations of the 
 blood, encounter cases of disease never met 
 with by others, with perhaps much greater op- 
 portunities for observation ; but no more so than 
 that the oculist has become able, by improved 
 clinical methods, to classify cases formerly 
 vaguely known as "amaurosis," into retinitis, 
 choroiditis, atrophy of optic nerve, separation of 
 retina, glaucoma, etc. The wonderful progress 
 of ophthalmology in recent times has been due 
 to the skillful handling of a small mirror, and 
 what we know of blood diseases, is due to the 
 microscope in conjunction with an apparatus 
 which is already regarded as one of its import- 
 ant "accessories." We now proceed to the 
 consideration of our proper subject, Anaemia. 
 
 ANEMIA IN GENERAL. 
 
 The term anaemia, signifying an impoverished 
 state of the blood, is to be preferred, both on 
 the grounds of etymology and euphony, to such 
 terms as spansemia, oligaemia, oligocythaemia, 
 which have been introduced at various times 
 on the plea of greater accuracy. It has, be- 
 sides, the great advantage of possessing its 
 
16 
 
 exact equivalent in the French and German 
 languages — " anemie " and " andmier All the 
 different varieties of anaemia are characterized 
 by a diminution of the number or value of the 
 red blood corpuscles ; that is to say, of the nor- 
 mal amount of haemoglobin. From a clinical 
 point of view, this is the primary and essential 
 morbid condition. It is supposed and argued 
 that this reduction in the amount of haemogrlo- 
 bin is preceded by a reduction in the amount 
 of the plasmatic albuminates ; but this question 
 is quite as obscure as that concerning the pre- 
 albuminuric stage of Bright's disease. Anaemia 
 is not a neurosis or a functional disorder, as one 
 might suppose, from the loose manner in which 
 the term is occasionally employed, but a sys- 
 temic condition dependent upon a lesion which 
 can be demonstrated with the utmost precision. 
 There are certain predispositions to anaemia 
 dependent upon sex, age and constitution. The 
 female sex is more prone to anaemia than the 
 male ; and peculiarly so during the pregnant 
 condition, in which, owing to the great demands 
 upon the blood for the nourishment of the foetus, 
 anaemia is the rule. On the other hand, the 
 female sex is more tolerant of anaemia than the 
 
17 
 
 male, which is partly due to the fact that the life 
 of females is, as a rule, more sedentary. ]\Tany 
 women go through a long life without any par- 
 ticular ailment, but are known to possess what 
 is termed a delicate constitution. Being for- 
 tunately free from any constitutional vice, no 
 organic disorder develops ; nevertheless they are 
 chronic invalids. They are usually treated 
 with excessive consideration by friends and rela- 
 tives of their own sex, and regarded by the 
 average practitioner as lucrative humbugs. The 
 fact is, that such women are suffering — if such a 
 term may be applied to a condition which brings 
 with it so great freedom from responsibility — from 
 a light grade of chronic anaemia. It is astonishing 
 upon what a small amount of food such persons 
 support a long existence ; but it is to be observed 
 that if the income is small the output is still 
 smaller. Many such persons play the role of 
 amiable drones in the hive of busy workers. 
 They do not repine at their lot, preferring to 
 bear those ills they have rather than fly to others 
 (the responsibilities of health) that they know 
 not of. 
 
 The predisposing influence of age is most 
 marked during youth and advanced life. The 
 B 
 
18 
 
 demands of growth during adolescence render 
 the equilibrium of the blood peculiarly unstable. 
 This, also, is more marked in females, in whom 
 the evolution of the sexual system is, as a rule, 
 attended with more systemic perturbation. 
 
 Anaemia should, undoubtedly, be classed 
 among the tissue changes known to the histolo- 
 gist as "senile;" indeed, there is excellent 
 ground for believing that it is at the root of 
 those which are most suddenly disastrous, to 
 wit, the degenerations of the walls of small 
 blood vessels. During the inevitable period 
 known as the " decline of life," the system is 
 especially intolerant of nutritive losses. The 
 recuperative power of the blood is impaired. 
 It is just at this period, also, that the diseases 
 attended with such losses are most prevalent ; 
 among which are to be reckoned chronic 
 catarrhs of mucous surfaces, such as the pul- 
 monary and vesical ; hemorrhoids, ulcers, etc. 
 
 Anaemia may be congenital. In 1883, while 
 examining the blood of several new-born chil- 
 dren -at the Maternity Hospital, I encountered 
 the following case : — 
 
 " Case 3. — Mary C , born 5.20 a.m., 
 
 November 5th, Count made 2.30 p.m., Novem- 
 
19 
 
 ber 6th. Child weighed six and three-fourths 
 pounds at birth ; labor natural. Number of red 
 corpuscles per cubic millimetre, 3,625,000; pro- 
 portion of white cells to red, i to 145. This 
 case was undoubtedly one of congenital anemia. 
 The child's only appearance of malnutrition 
 was a shriveled state of the integuments of the 
 feet, and a less rosy color of the skin than normal. 
 For anew-born child, it was decidedly pale. This 
 shriveled state of the skin emphatically nega- 
 tives the idea of a relative ansemia from excess 
 of fluid. The blood was probably deficient in 
 quantity (oligaemia) as well as defective in 
 quality (oligocythsemia). There was also a 
 decided increase in the number of the white 
 cells. Careful inquiry proved that there had 
 been no hemorrhage from the cord. As pos- 
 sibly bearing upon the congenital imperfection 
 of' this child, I may mention the fact that the 
 parents were themselves immature — the father 
 being seventeen, and the mother eighteen years 
 old."* It is possible, also, that the case may 
 have been one of congenital syphilis. 
 
 * See paper entitled "A Contribution to the Study of Icterus 
 Neonatorum," by Frederick P. Henrj', m.d. Archives of 
 Medicine, October, 1883. 
 
20 
 
 The third cause, above mentioned, as predis- 
 posing to anaemia, is cotistitutio7i. No better 
 proof of the existence of such a tendency can 
 be brought forward than the report of the above 
 case of congenital ansemia. An extended series 
 of examinations would probably show that such 
 congenital deficiencies in the composition of 
 the blood are by no means uncommon. Cer- 
 tainly, the widest differences of external appear- 
 ance are presented by the new-born, from the 
 pale, puny sickling of five or six pounds, to 
 the rosy, vigorous child weighing from ten to 
 twelve. With proper care, the puny child may 
 thrive and grow, perhaps, too rapidly, and pre- 
 sent every appearance of health, but in after 
 life, under circumstances to which its more 
 vigorous contemporary would rise superior, the 
 i?i7iate tendency to anaemia will manifest itself. 
 Precisely similar facts are observed with refer- 
 ence to the other tissues of the body. One in- 
 dividual will not only retain his weight, but grow 
 fat upon a diet which another would regard as 
 but little removed from starvation. 
 
 EXCITING CAUSES OF ANAEMIA. 
 
 It is hard to draw a sharp line between the 
 predisposing and exciting causes of anaemia. 
 
21 
 
 To the writer it seems proper to include among 
 the latter such causes as are equally operative 
 in either sex and at all periods of life ; but in 
 such a division no allowance is made for the 
 wide differences. in individual power of resist- 
 ance. 
 
 A cause will excite anaemia in an individual 
 with an innate tendency to the disease ; while 
 in another, devoid of such tendency, it will not 
 do so, unless long continued or frequently re- 
 peated. In the former the cause deserves to be 
 called exciting ; in the latter its action is more 
 closely allied to that of the causes called predis- 
 posing. Bearing this in mind, the exciting 
 causes of anaemia include hemorrhage and 
 other pathological discharges, sexual excess, in- 
 sufficiency of food, light or air (bad hygiene), 
 the depressing emotions of grief and anxiety, 
 fever, and, finally, whatever interferes with the 
 digestion, absorption and assimilation of food. 
 It is not pretended that this list is complete, for, 
 as Immermann remarks, "Nearly every mor- 
 bid process, when it occurs in a severe form, is 
 sooner or later followed by anemia." It would 
 be tedious to enter at length into even the chief 
 exciting causes of anaemia ; but two, which are 
 
22 
 
 the most frequently encountered in medical 
 practice, deserve more than a passing notice. 
 These are hemorrhage and fever. Experiments 
 of Vierordt upon the lower animals — dog, rabbit, 
 guinea pig — show that death ensues promptly, 
 when, after bleeding, the red corpuscles are re- 
 duced about fifty per cent. Later observations 
 show that these figures are not applicable to 
 human beings, whose powers of resisting hem- 
 orrhage are very much greater. For example, 
 Behier (quoted by Laache) reported the case of 
 a woman whose blood, after a metrorrhagia, 
 contained but 19 per cent, of the normal num- 
 ber of red corpuscles ; having, theretofore, suf- 
 fered a reduction of 81 per cent. The woman 
 recovered after transfusion. Laache examined 
 the blood of five previously healthy women 
 who had suffered from profuse hemorrhage, and 
 found the red corpuscles reduced respectively 
 37, 61, 62, 64 and 68 per cent. In three of the 
 cases there was complete restitutio ad vitegrum , 
 without transfusion ; in one, death occurred from 
 an intercurrent disease, septicaemia ; and in the 
 remaining case, improvement was progressing 
 at the time of the report. It must be borne in 
 mind, however, that the result of a blood ex- 
 
2S 
 
 amination after hemorrhage, depends upon the 
 time at which such examination is made. It is 
 self-evident that, if from a quantity of blood 
 outside the body three-fourths be removed, and 
 a sample of the remaining fourth be examined, 
 its centesimal composition will be the same as 
 that of a sample taken from the whole mass. 
 So, also, if the blood in the living vessels be ex- 
 amined immediately after a profuse hemorrhage, 
 its composition will closely resemble that of the 
 entire volume of blood before the hemorrhage. 
 It will not be identical with it, however, for dur- 
 ing the progress of a hemorrhage, the lymph, 
 the tissue juices, and any ingested fluids, are 
 rapidly taken up by the blood vessels to re- 
 store the blood volume ; so that, as Immermann 
 remarks, the immediate effect of a profuse 
 hemorrhage is a " complex dyscrasia, made up 
 of hypalbuminosis, leucocytosis and oligocy- 
 thaemia." It is no doubt true, in the majority 
 of cases, that even during the progress of a 
 hemorrhage, owing to the diminished vascular 
 tension, the " osmotic current of tissue juices " 
 is strongly directed toward the blood vessels ; 
 but I believe there are cases in which, on ac- 
 count of the shock to the system produced by 
 
24 
 
 the sudden escape of a large amount of blood, 
 this current is extremely feeble, or even, for a 
 time, held in abeyance, and in which, therefore, 
 an examination of the blood, immediately after 
 hemorrhage, will show little or no difference in 
 its cellular composition. The following is a case 
 in point : — 
 
 On June 6th, 1885, 1 examined the blood of a 
 woman, Mary L., set. thirty-two, who, during 
 the preceding four weeks, had suffered from con- 
 stant metrorrhagia, which, on two occasions, 
 had been quite profuse. I only succeeded at 
 last in stopping the hemorrhagia by the intra- 
 uterine application of Monsell's solution. On 
 June 5th there was still some slight oozing, 
 which had entirely ceased by the 6th, the day 
 on which the examination was made. Number 
 of red corpuscles, per cubic millimetre, 4,600,- 
 000. Proportion of white cells to red, i to 
 460. 
 
 " As far as the number of red corpuscles per 
 cubic millimetre is concerned (I quote from my 
 note book), and the proportion of white to red, 
 the blood may be considered absolutely normal, 
 but the woman is greatly prostrated, with 
 blanched skin and mucous membranes. The 
 
25 
 
 volume of her blood is evidently greatly dimin- 
 ished." 
 
 As studies of the centesimal cellular compo- 
 sition of the blood after hemorrhage, Laache's 
 cases are defective, as he himself admits, on 
 account of the time between the hemorrhage 
 and the first examinations. These were made, 
 respectively, in Case I, on the 20th day after the 
 hemorrhage; in Case II, on the 21st; in Case 
 III, on the 6th; and in Cases IV and V, on 
 the 5th. 
 
 The ansemia of fever offers certain peculi- 
 arities, to which I have called attention in an 
 article in The Polyclinic for September 15th, 
 1885, entitled "The Latent Ansemia of Typhoid 
 Fever." These are, in part, dependent upon 
 the loss of water sustained by the system in all 
 febrile affections, and particularly in typhoid, 
 o\\ang to its long duration and intestinal com- 
 plications. In t}'phoid fever, which may be 
 taken as a type, notwithstanding the evidences 
 of an impoverished state of the blood, afforded 
 by the profound adynamia and the muscular 
 tremors, an examination during the height of 
 the disease will show, at least, a normal number 
 of red corpuscles. The blood taken from the 
 
26 
 
 finger is of a dark venous hue, does not flow 
 readily on puncture, and is evidently inspis- 
 sated. The condition is precisely the reverse 
 of that which obtains after hemorrhage, which 
 is a point of some interest, since it has been 
 held, by at least one eminent authorit}% that 
 a moderate hemoiThage during the course of 
 typhoid fever is not to be dreaded as a compli- 
 cation. This clinical fact, if it be one, may be 
 explained by the tendency of the blood, after 
 hemorrhage, to regain its former volume by the 
 imbibition of water. The therapeutical deduc- 
 tion is to supply fever patients abundantly with 
 water, as was so strongly advocated by the late 
 Dr. J. Forsyth Meigs. 
 
 Although the number of red corpuscles in a 
 cubic millimetre of blood may be normal in 
 typhoid fever, their value is decidedly below 
 par. They are deficient in haemoglobin, so 
 much so, that six million corpuscles may have 
 only the functional power of three million. 
 
 In one form of fever, the malarial, recent in- 
 vestigations tend to show that a micro-organism 
 may be directly active in destroying the red 
 corpuscles. These organisms, if such they be, 
 were beautifully demonstrated by Dr. Council- 
 
27 
 
 man, of Baltimore, at the recent meeting of the 
 American Association of Physicians. They oc- 
 cupy the interior of the red corpuscles, and are 
 apparently capable of distinct amoeboid move- 
 ments. That some agency destructive of the 
 red corpuscles is operative in certain cases of 
 malarial fever is proved by the occurrence of 
 haemoglobinuria as a symptom, which latter is 
 but itself the sequence of a preceding hsemoglo- 
 binaemia. The blood corpuscles are destroyed 
 while circulating in the vessels. 
 
 SYMPTOMS OF AX.EMIA. 
 
 It is customary' for medical writers to describe 
 the immediate effects of the sudden escape of 
 blood from the vessels as typical of what they 
 call acute anaemia; but this, in my opinion, is 
 a mistake. As I have elsewhere said: "The 
 symptoms of acute loss of blood, and its fre- 
 quently fatal termination when not more than 
 one-half the normal amount has been lost, are 
 due to sudden ischaemia of the nerve centres." 
 Anaemia undoubtedly exists, but is not the cause 
 of the immediate symptoms of hemorrhage. 
 These are due to a disorder of the circulation, 
 which may be precisely imitated by the appli- 
 
28 
 
 cation of Junod's boot to one of the lower ex- 
 tremities. 
 
 The remote effects of a hemorrhage, that is 
 to say, the condition of the patient when the 
 nervous system has recovered from its shock 
 and the circulation has regained its equilibrium, 
 may be taken as typical of acute anaemia. The 
 chief of these are pallor of skin and mucous 
 membranes, muscular weakness, vertigo or syn- 
 cope, on exertion, or even on assuming the up- 
 right position, and a small, soft, frequent and 
 excitable pulse. In addition, there is thirst, 
 anorexia, or an appetite that is irregular and 
 fanciful. The digestion is feeble and readily 
 disordered. There is a prevailing sense of cold, 
 and yet on slight exertion the skin becomes 
 flushed and perspiration breaks out. The tem- 
 per is apt to be peevish and irritable, and the 
 normal control of the emotions is impaired. 
 While the temperature, upon the whole, is low- 
 ered, irregular pyrexia, to which the term " an- 
 aemic fever" has been applied, is commonly 
 observed in the severest forms of anaemia. The 
 cause of this fever has given rise to much dis- 
 cussion, and the explanation offered by Immer- 
 mann seems to be the most plausible. It is 
 
29 
 
 that, owing to the extreme reduction of the nu- 
 tritive properties of the blood, the tissues suffer 
 to such an extent as actually to undergo a spon- 
 taneous decay or necrobiosis, which is attended 
 with the evolution of heat, as is always the case 
 "when chemical compounds of a more stable 
 kind are generated from such as are less stable," 
 Hsemic, systolic, cardiac murmurs, and a 
 musical murmur (bruit de diable) in the jugular 
 veins, are among the physical signs. In high 
 degrees of anaemia there is great emaciation, 
 which is generally masked by oedema. Hem- 
 orrhages from mucous surfaces, particularly in 
 the form of epistaxis, and into the retina, are 
 of common occurrence, A fatal termination is 
 generally ushered in by a mild form of delirium, 
 which may be for days preceded by a condition 
 of lethargy, from which the patient is readily 
 roused to full consciousness, but relapses into 
 the lethargic state as soon as the effort to attract 
 his attention is abandoned. The last remarks 
 are only applicable to certain fatal forms of 
 ansemia into which there is reason to believe an 
 anaemia simplex may sometimes be converted. 
 If an anaemia of high degree, whether it origi- 
 nate in hemorrhage, fever, or what not, becomes 
 
30 
 
 chronic, all the organs of the body, and among 
 them, of course, those concerned in blood mak- 
 ing, will suffer from malnutrition, so that a con- 
 dition which was at first what is termed func- 
 tional, may eventually become organic ; that is 
 to say, dependent upon lesions to which it has 
 itself given rise. 
 
 ANATOMICAL CHARACTERS. 
 
 The anatomical characters dependent upon 
 a marked and long-continued deficiency of red 
 corpuscles, are dryness and translucency of the 
 tissues and fatty degeneration of the heart, in- 
 tima of the arteries, renal and gastric epithelia, 
 and the hepatic cells. In the heart, the papillary 
 muscles are chiefly affected, especially those of 
 the left ventricle, and the morbid change may 
 be detected by the naked eye in the form of 
 minute, yellowish streaks, which have been 
 called "tabby mottling," or " tabby-cat stria- 
 tion." The retinal hemorrhages are dependent 
 upon degeneration of the vessel walls and, in 
 one form of anaemia, upon this, in connection 
 with a plugging of the vessel affected, with white 
 blood corpuscles. The blood is seen to be less 
 than normal in quantity and of a lighter color 
 
31 
 
 than natural. In well-marked cases, it is of a 
 light pink color, resembling water in which beef 
 has been washed, and the hue which it imparts 
 to linen is sometimes a pale yellowish pink, 
 which would hardly be recognized as a blood 
 stain. Notwithstanding the deficiency of red 
 corpuscles, and the consequent pale tint of the 
 blood, the muscles, even in the highest degrees 
 of anaemia, are often found of a deep red color, 
 and the adipose tissue of a rich yellow. 
 
 DIAGNOSIS. 
 
 The lighter grades of ansemia merge imper- 
 ceptibly into health. In city residents, even of 
 the well-to-do classes, whose occupation is at- 
 tended with considerable mental work and its 
 inevitable anxiety, anaemia is the rule rather 
 than the exception. A number of corpuscles, not 
 below 5,000,000 per cubic millimetre, of which 
 the richness in haemoglobin, as determined by 
 Gowers' haemoglobinometer, does not fall below 
 90 per cent., may be considered normal. This 
 being understood, the lightest grade of anaemia 
 would be expressed by the following formula : — 
 N. (number of red corpuscles per cubic m.) = 100 
 H. (percentage of haemoglobin) . . . =.80 
 V. (value of each corpuscle) • . • . = ^ 
 
32 
 
 An individual whose blood condition would 
 be expressed by these figures, might show little 
 or no departure from health, and be aware of 
 none. I have several times found such figures 
 in young men whose blood I have examined 
 for the purpose of comparing one counting in- 
 strument with another. In the above example, 
 N. is normal, say 5,000,000, but these 5,000,000 
 corpuscles possess only four-fifths the normal 
 percentage of haemoglobin, and are, therefore, 
 functionally equal to 4,000,000 normal corpus- 
 cles. 
 
 Anaemia, as a rule, is not clinically appreciable 
 until the haemoglobin represents between three 
 and four million corpuscles per cubic m. The 
 actual number of red corpucles may be five, or 
 even six, million per cubic m., but their real 
 value is sixty, or even fifty, per cent, of the 
 normal. This degree of anemia is attended by 
 both signs and symptoms, such as pallor, a ten- 
 dency to vertigo, flushing of the face, perhaps 
 tinnitus aurium, muscular fatigue on slight 
 exertion, backache, irregular appetite, and a 
 capricious, captious temper. Such a condition 
 might be merely functional, or secondary to the 
 early stage of some organic affection, such as 
 
33 
 
 Bright's disease, diabetes mellitus, carcinoma, 
 phthisis, etc. 
 
 The next grade of anaemia is that in which 
 the real value of the corpuscles is between two 
 and three millions. In this degree, the percent- 
 age of haemoglobin may be much greater than 
 in the preceding, owing to the fact that now the 
 corpuscles are decidedly reduced in number. 
 It is a familiar fact to all students of blood 
 diseases that, as the number of corpuscles di- 
 minishes, the percentage of haemoglobin in- 
 creases, until in the severest forms of anaemia 
 — those termed pernicious — it may equal or ex- 
 ceed, even double, the percentage of red cor- 
 puscles. A reduction of both number and value 
 of red corpuscles is much graver than a mere 
 diminution of value. A number as low as 
 3,000,000 generally indicates a serious state of 
 affairs, and may depend upon a more advanced 
 stage of one of the diseases above mentioned, 
 or upon one or other of the diseases of the 
 blood-making organs, to be considered later. 
 
 The highest grades of anaemia are those in 
 
 which the real value of the corpuscles varies 
 
 between 500,000 and 2,000,000 per cubic m. 
 
 Such figures are generally the expression of 
 
 c 
 
34 
 
 diseases of the blood-making organs — spleen, 
 lymph glands, bone marrow — or of that form 
 of '' ancematosis'" to which the term pernicious 
 has been justly applied. An apparent paradox 
 is met with in these intense forms of anaemia, 
 namely, that 500,000 corpuscles may contain as 
 much hsemoglobin as is usually found in one 
 million. When this is the case, it is due to the 
 fact that the average diameter of the corpuscles 
 is decidedly above the normal. This increase 
 in size may possibly be a conservative provision 
 on the part of nature, but the fact remains that 
 increased size and altered shape (poikilocytosis) 
 of the red corpuscles must be regarded as of 
 very grave significance. An average diminu- 
 tion in the size of the corpuscles is generally 
 combined with an increase in their number, a 
 set of conditions commonly observed in that 
 form of anemia called chlorosis. 
 
 PROGNOSIS. 
 
 The prognosis of anaemia in general has been 
 sufficiently hinted at in the preceding remarks ; 
 but it may be well to emphasize the fact that 
 an anaemia per se is never grave until distinct 
 anatomical alterations in the red corpuscles — 
 
35 
 
 alterations of size and shape — are manifested. 
 The prognosis of secondary ansemias is involved 
 with that of the primary disease. 
 
 TREATMENT OF ANAEMIA IN GENERAL. 
 
 On account of the general prevalence of 
 Anaemia, its preventive treatment is of the 
 utmost importance. The great majority of in- 
 dividuals who are "run down" in health, or 
 suffering from "nervous exhaustion," which 
 they attribute to overwork, are simply, as before 
 said, more or less anaemic. Overwork is the 
 unfortunate scapegoat whose erratic conduct 
 renders him an easy prey to both physician 
 and patient. Work may be rather regarded as 
 a raw, nutritive material, which is usually pre- 
 pared and served in an underdone condition. 
 There may be exceptional cases in which 
 anaemia is justly attributed to overwork alone, 
 but the writer has never seen one. There is a 
 careless way of regarding this matter which 
 leads to inaccurate statements. For instance, 
 if the hours of work encroach upon those of 
 sleep, it is the want of sleep, as much as the 
 excess of work, that is to blame for the result- 
 ing anaemia. If the irrational worker neither 
 
36 
 
 takes the time to eat or digest his meals, his 
 anaemia is due to inanition or indigestion. If 
 he finds, or imagines, that the steady use of 
 tobacco, coffee and alcohol is helpful in the 
 kind of work he is performing, it is just possible 
 that his habits are alone to blame for his im- 
 paired physical state. 
 
 As this is not a treatise on hygiene, I shall 
 not stop to indicate the amounts of food, air, 
 exercise and sleep essential to preserve the 
 health of the average man, woman or child ; 
 but I cannot refrain from pausing to condemn 
 a prevalent error. There appears to be a wide- 
 spread delusion in the minds of young men that 
 muscular strength and bodily health are synony- 
 mous terms. This is true, indeed, but only to 
 the extent that a certain a7nount of muscular 
 strength coincides with the healthy condition. 
 There is a limit in each individual — a Rubicon 
 — the ver}' attempt to cross which is attended 
 with danger. The story of the man who began 
 by lifting the calf, and continuing to do so each 
 day, ended by lifting the cow, is one of those 
 plausible lies which only serve to enhance the 
 beauty of truth by showing how a germ of the 
 latter may give an air of vraisemblance to a 
 
37 
 
 tissue of falsehood. It is a pitiful sight, relieved 
 only by its absurdity, that of a young, slender 
 stripling exhausting himself in vain efforts to 
 become an "athlete." Out-door sports are 
 excellent for the growing boy, but heavy gym- 
 nastics should be reserved, as a rule, for those 
 who have attained their full growth. The boy 
 will defeat his object of becoming a strong man 
 by practicing them too early. Let him possess 
 his soul in patience. As the fisherman says, 
 in La Fontaine's fable : — 
 
 " Petit poisson deviendra grand, 
 Pour\'u que Dieu lui prete vie." 
 
 The curative treatment of a case of anaemia 
 is, in part, determined by its causes, and includes 
 the control of hemorrhage and other patho- 
 logical discharges ; the removal from an unfav- 
 orable hygienic environment; the administration 
 of a proper amount of nutritious food, and the 
 suppression of causes which interfere with its 
 digestion and assimilation. In many inveterate 
 cases, in which cure is still possible, this result 
 cannot be attained without weeks, perhaps 
 months, of persevering treatment. A complete 
 control of the patient is essential, and to this 
 
38 
 
 end, the seclusion insisted upon by Dr. Weir 
 Mitchell is of great importance, for by it an 
 important obstacle to recovery is at once re- 
 moved, to wit, the demoralizing sympathy of 
 injudicious friends. Excellent results have been 
 accomplished by the means so judiciously em- 
 ployed by Dr. Mitchell, namely, rest, seclusion 
 and passive exercise in combination with the 
 diet and medication adapted to the peculiar 
 exigencies of the case. This method of cure 
 has been elaborately explained by Dr. Mitchell 
 in his well-known work, entitled, " Fat and 
 Blood," and is doubtless familiar to the medical 
 men of this country. I have seen a number of 
 cases of chronic anaemia whose treatment by 
 this method has been attended with the happiest 
 results. I have also seen it fail, as is to be ex- 
 pected where everything fails, namely, in the 
 secondary anaemia of malignant disease, and 
 also in certain advanced cases of pernicious 
 angemia, 4n which there were marked alterations 
 in the size and shape of the red corpuscles, as 
 well as extreme diminution of their number. 
 
 The advantages to be derived from a thorough 
 employment of the so-called rest cure are with- 
 in the reach of few, and in the majority of cases 
 
39 
 
 our main reliance is on drugs. The chief of 
 these are iron, arsenic, the mineral acids and 
 cod-liver oil, Hayem also reports the success- 
 ful employment of ferrocyanide of potassium 
 in cases of decided ansemia. The preparations 
 of iron are so numerous that, supposing them 
 to be of equal value, one might well be at a loss 
 to select from among them. This, however, is 
 by no means the case, and I will, therefore, in- 
 dicate those which I consider the best. In pill 
 form nothing has given me more satisfaction 
 than the formula of Blaud : — 
 
 R . Ferri sulphatis, 
 
 Potassii carbonatis, aa gr. iss. M. 
 
 SiG. — One, or more, after each meal. 
 
 To obtain the best effects of a ferruginous 
 preparation, it is often necessary to give it in 
 large doses, and the above is no exception to 
 this rule. It may be pushed, if well borne, to 
 the extent of three pills thrice daily. The lac- 
 tate, the pyrophosphate, the malate and Oue- 
 venne's powder, are all excellent preparations 
 of iron. Strychnia, quinia and arsenic may be 
 advantageously combined with the iron. The 
 latter preparation is best given in the form of 
 
40 
 
 Fowler's solution. In addition to its specific 
 action upon the skin, arsenic has for a long 
 time been recognized as possessing a general 
 beneficial action in certain states of impaired 
 nutrition, which had caused it to be classed 
 among the agents known as " eutrophic." 
 There is no doubt that much, if not the whole, 
 of this favorable effect is due to the increased 
 amount of haemoglobin in the blood, which 
 results from its administration. Arsenic is spe- 
 cially indicated in anaemias of malarial origin, 
 although its use is by no means limited to these 
 forms. 
 
 The treatment of secondary anaemias is 
 largely influenced by the nature of the primary 
 affection. As a general rule, arsenic will be 
 found of service in those forms of secondary 
 anaemia in which there is a state of congestion 
 or catarrh of the gastro-intestinal mucous mem- 
 brane. Osier reports good results from its use 
 in the anaemia of heart disease, the " cachexie 
 cardiaque'" of French writers. In the causa- 
 tion of this form of anaemia, the obstacle to ab- 
 sorption presented by the engorgement of the 
 gastro-intestinal veins is an important factor. 
 
 In cases with a syphilitic history, the mercuric 
 
41 
 
 chloride may be usefully administered with iron, 
 as in the following formula : — 
 
 R. Hydrarg. chlorid. corrosiv., gr.j 
 Tinct. ferri. chlorid., ^ij 
 
 Glycerin., ^ ss 
 
 Aquae, q.s. ad. ,§iij- M. 
 
 SiG. — One drachm after each meal. The dose 
 may be gradually increased to two drachms thrice 
 daily. 
 
 The ferrocyanide of potassium recommended 
 by Hayem is worthy of trial, on account of its 
 endorsement by so distinguished an authority 
 on the physiology and pathology of the blood. 
 He begins by giving one gramme (about gr. xv) 
 daily, in two powders, and gradually increases 
 the dose until six grammes, in six powders, are 
 given. 
 
 Transfusion is a measure which has been so 
 often adopted as a dernie7' ressort that it has 
 fallen into discredit. If any benefit is to be 
 derived from transfusion, it is certainly not 
 when the patient is moribund. After the sud- 
 den escape of a large amount of blood, the 
 natural process of restoration may be best imi- 
 tated by the injection into a vein of a normal 
 
42 
 
 saline solution (0.6 per cent. NaCl.), the 
 amount of which must be determined by the 
 effects upon the patient ; or the following for- 
 mula of Hayem for intra-venous injection in 
 cholera, may be employed : — 
 
 R . Distilled water, i litre 
 
 Sodium chloride, pure, 5 grammes 
 
 Sodium sulphate, pure, 10 grammes. M. 
 SiG. — Filter and inject slowly at a temperature of 
 38° C. (100.4° F.) 
 
 When the object of transfusion is not so 
 much to overcome the effects of sudden ischae- 
 mia of the nerve centres as to introduce a gradual 
 improvement in the patient's nutrition, defibrin- 
 ated blood should be employed. 
 
 It has been pointed out that when the respira- 
 tion is greatly embarrassed, the injection into 
 the vessels of an additional amount of reduced 
 haemoglobin, such as exists in venous blood, 
 may only make matters worse by adding to this 
 embarrassment, and so accelerate a fatal end- 
 ing. In such cases the blood to be transfused 
 should be taken from an artery. Quite recent- 
 ly the injection of defibrinated blood into the 
 peritoneal cavity and into the subcutaneous 
 
43 
 
 connective tissue has been practiced with ap- 
 parent benefit. The dangers attendant upon 
 the transfusion of heterogeneous blood are well 
 known. It should never be used. Milk has 
 been transfused successfully in a few rare in- 
 stances, but for this purpose is greatly inferior 
 to defibrinated blood. It is apt to occlude the 
 vessels, many of its globules being much larger 
 than the largest white corpuscles. If used, it 
 should be boiled, in order to destroy the bacteria 
 which are almost sure to be present. 
 
 VARIETIES OF AN.EMIA, 
 
 Anaemias are properly classified with refer- 
 ence to their origin. The nutritive fund of the 
 blood is continually drawn upon in the processes 
 of nutrition, and if the demands are inordinate, 
 as in fever and hemorrhage, the resulting anae- 
 mia may be justly ascribed to undue waste. 
 Under this head a large number of anaemic 
 conditions might be grouped. A large propor- 
 tion of the remainder might, with equal pro- 
 priety, be attributed to inadequate supply of 
 nutritive materials, due either to absolute want 
 of proper food, or to its imperfect digestion and 
 absorption. There would still remain a number 
 of cases in which both of these^ausative factors 
 
44 
 
 are so intimately combined that it is impossible 
 to decide which of them deserves the greater 
 etiological importance. A division based upon 
 such physiological data as above pointed out, 
 although desirable, is, with our present knowl- 
 edge, altogether inadequate. Like .so many 
 classifications in other departments of medicine, 
 it is not ample enough to cover our ignorance 
 of the subject. In a previous contribution* to 
 the literature of anaemia, I advocated a division 
 of its different forms into essential and symp- 
 tomatic, and gave the following explanation of 
 my reasons for so doing : — 
 
 "By essential anaemia, I mean those forms 
 of the affection that are associated with disease 
 of the cytogenic organs, or with congenital mal- 
 formations of the vascular system, namely, the 
 lymphatic, splenic and medullary anaemiae, and 
 chlorosis; and by symptomatic anaemia, those 
 forms of the disease associated with affections 
 of non-C}^ogenic organs which interfere with 
 nutrition, such as febrile anaemia, the anaemia 
 of phthisis, cancer, Bright's disease, the anaemia 
 of heart disease — cachexie cardiaque of Andral 
 — the anaemia of lead poisoning and of inani- 
 
 * Carrwright, Essaj^ 1881. 
 
45 
 
 tion. Malarial and syphilitic anaemia occupy 
 the border line between the two classes. When 
 recent and dependent upon an acute attack, 
 they may come under the head of febrile anae- 
 mia, but when chronic, they are frequently 
 essential, the one generally of the splenic, the 
 other of the lymphatic, variety. These afford 
 intei"esting examples of the conversion of a 
 symptomatic into an essential anaemia, and it 
 is held by the writer to be highly probable 
 that they are not the only instances of such 
 conversion." 
 
 The time that has passed since the above 
 paragraph was written has only served to 
 strengthen the opinions it contains, more espe- 
 cially that concerning the conversion of one 
 form of anaemia into another. At present, 
 however, I prefer the terms "primary" and 
 "secondary" to "essential" and "symptom- 
 atic," because they are more widely employed 
 and more in accord with our general medical 
 nomenclature. 
 
 In addition, I am in favor of a third division, 
 to include those forms of ansemia due to the 
 destructive effect of toxic substances upon the 
 blood corpuscles, and would suggest for them 
 the term toxancE7nia. 
 
46 
 
 Anaemias of parasitic origin are so important 
 in certain countries (and perhaps more so in 
 our own than we suspect) as to merit separate 
 classification. 
 
 The following classification is offered, in the 
 belief that it is one under which all the different 
 varieties of anaemia may be appropriately 
 grouped : — 
 
 I. PRIMARY AN.^MIAS. 
 
 Chlorosis. 
 
 Lymphatic anaemia (Hodgkin's disease). 
 
 Splenic " 
 
 Leucocythaemia. 
 
 Pernicious ansemia. 
 
 II. SECONDARY ANEMIAS. 
 
 Anaemia of fever. 
 
 *' hemorrhage. 
 
 " phthisis. 
 
 " heart disease. 
 
 " cancer. 
 
 " syphilis, etc. 
 
 III. TOXANiEMIAS. 
 
 Ansemia of lead poisoning (saturnine anaemia). 
 " arsenic " 
 
 " arseniuretted hydrogen poisoning. 
 
 " phosphorus poisoning. 
 
 " nitric oxide " 
 
47 
 
 lA'. PARASITIC AN.^MIAS. 
 
 Anaemia caused by Anchylostomum duodenale. 
 '' " Bilharzia haematobia. 
 
 " *' Filaria sanguinis. 
 
 " " Plasmodium malarise. 
 
 CHLOROSIS. AN.EMIA OF PUBERTY. 
 
 With the advent of puberty comes the most 
 sudden and imperative demand upon the blood 
 that is encountered during the normal life his- 
 tory of the individual, and this is superadded 
 to the continued demands of growth, which is 
 most active at this period. It is, therefore, not 
 surprising that an anaemic condition is common 
 at this time of life ; the wonder is that it is not 
 the rule. The developmental impulse of pu- 
 berty will rouse from their dormant existence 
 any congenital imperfections of the blood such 
 as were described in an early part of this 
 work. 
 
 A great deal of confusion surrounds the sub- 
 ject of chlorosis, which is partly due to the fact 
 that statements made by well-known authorities 
 in times when the blood was but rarely exam- 
 ined, have been repeated ever since by writers 
 upon the subject. The researches of Johann 
 
48 
 
 Duncan, in 1867,* demonstrated that in chlo- 
 rosis the red corpuscles may be normal in num- 
 ber, while their value — the quantity of haemo- 
 globin they carry — is greatly reduced. In 
 Duncan's cases — three in number — the percent- 
 age of haemoglobin was 0.3. 0.31 and 0.37, the 
 normal standard being i. While there can be 
 no question of the originality and value of 
 Duncan's demonstration that the coloring mat- 
 ter of the red corpuscles may be reduced with- 
 out a corresponding diminution of their number, 
 I am convinced that such a condition is not pe- 
 culiar to chlorosis or any other form of anaemia. 
 In fact, in one of the cases upon which his cele- 
 brated observations were made there is room 
 for doubt as regards the diagnosis, owing to the 
 fact that the patient had a splenic tumor. 
 
 By chemical analysis of the blood, in cases 
 of chlorosis, a condition has been detected 
 which is thought by some to be pathognomonic. 
 Becquerel and Rodier, and Ouinquaud have 
 found a normal proportion of albuminates in 
 the plasma of chlorotic blood, while in the blood 
 of anaemia in general, they are said to be di- 
 
 * Sitzungsbericht der K. Acad, der Wissensch. in Wien. 
 B. Iv, 1867. 
 
49 
 
 minished. Indeed, the first two observers have 
 found a condition of hyperalbuminosis. Im- 
 mermann, in his excellent article in Ziemssen's 
 Cyclopaedia, adopts this as the distinguishing 
 trait of chlorosis, which he regards as an affec- 
 tion sui generis, and deprecates any attempt to 
 " merge it in the great ocean of anaemia. " He 
 holds that the blood in this affection is deficient 
 in haemoglobin alone without any corresponding 
 diminution in the albuminates of the plasma. 
 
 Quincke, in view of the discrepancies between 
 his own examinations of the blood in cases of 
 chlorosis and those of Duncan, concluded that 
 there must be at least two kinds of chlorosis — 
 the one with a normal number of corpuscles 
 deficient in haemoglobin ; the other with a di- 
 minished number of corpuscles, which may be 
 either normal or deficient with regard to their 
 haemoglobin.* Laache has examined the blood 
 of cases presenting the typical picture of chlo- 
 rosis, and found it normal in every respect. He 
 
 * " Es muss daher verschiedene Chlorose geben, die eine mit 
 normaler Zahl aber verringertem Hb-gehalt, die andere mit 
 verminderung der Zahl derselben wobei der Hb-gehalt des 
 einzelnen normal oder ebenfalls vermindert sein kann." — Vir- 
 chow's Arch., 1872, B. liv., p. 537. 
 
 D 
 
50 
 
 proposes for these anomalous cases the term, 
 pseudochlorosis. He contends that they are 
 cases of chlorosis, because their symptoms are 
 identical with that affection, and quotes with 
 approval the following sentence from the thesis 
 of Moriez : "L'hematologiste diagnostiquera 
 I'anemie et ne pourra pas diagnostiquer la 
 chlorose ; ceci est affaire au clinicien." I may 
 say, in passing, that I entirely dissent from this 
 view of the subject. Virchow has endeavored 
 to place chlorosis upon a distinct anatomical 
 basis by demonstrating, in fatal cases, an im- 
 perfect development of the heart and blood 
 vessels. He has found the aorta of a full-grown 
 woman so small as barely to admit the little 
 finger, and its coats, while preserving their elas- 
 ticity, were much thinner than normal. In 
 addition, degenerative changes in the intima 
 were often met with. With this diminished 
 calibre of the arterial system, the heart may be 
 either normal in size, subnormal, or hypertro- 
 phied. When it is recalled that the blood vessels 
 and the red corpuscles are derived from the 
 same embryonic layer — the mesoblast — the 
 bearing upon the pathology of chlorosis of a 
 congenital hypoplasia of this portion of the 
 
51 
 
 skeleton becomes manifest. Virchow's doctrine 
 has not, however, met with general acceptance. 
 One of the most important functions of the ar- 
 terial system is its power of adaptation to varying 
 volumes of blood, and in chlorosis, to employ 
 the words of Coupland, "no proof has been 
 given that the diminution in size of the vessels 
 has not followed upon diminution in the total 
 quantity of blood." With reference to this 
 subject, Fagge remarks : "I believe that such 
 affections are not congenital, but due to endo- 
 carditis occurring in childhood. Thus it seems 
 to me that the hypoplasia of the aorta, instead 
 of being itself a primary defect, is but a second- 
 ary result of the valvular lesion. I am not, 
 therefore, disposed to attach much value to Vir- 
 chow's observations as they stand at present." 
 
 From the above remarks, an idea may be 
 obtained of the obscurity surrounding the sub- 
 ject of chlorosis from an anatomical and chemi- 
 cal standpoint. The same is true with regard 
 to its clinical history. The most various con- 
 ditions of different organs and systems have 
 been described as more or less symptomatic 
 of this affection. The heart has been found 
 abnormally small in some cases, abnormally 
 
52 
 
 large in others. The genital system is some- 
 times imperfectly developed ; at others, its devel- 
 opment exceeds the normal limits. Sometimes 
 amenorrhoea exists, and may either precede or 
 follow the anaemic symptoms. On the other 
 hand, a chlorotic menorrhagia has been spoken 
 of. The number of red corpuscles has been 
 found normal in some cases, increased or dimin- 
 ished in others. Immermann's view that the 
 blood of chlorosis is peculiar in that it is only 
 deficient in haemoglobin, the plasmatic albu- 
 minates being undiminished, is not generally 
 accepted, for "it has not been proved, except 
 in a few cases of pernicious anaemia, that the 
 serum albuminates are diminished in other 
 forms of idiopathic anaemia besides chlorosis."* 
 With regard to Laache's cases of pseudochlo- 
 rosis, there can be no doubt that the symptoms 
 were due to irregular distribution of the blood, 
 especially to the supra-diaphragmatic portion 
 of the trunk. A blood of good quality, if not 
 properly distributed, may give rise to some of 
 the gravest symptoms of anaemia, such as pallor, 
 syncope, cardiac palpitation, feeble pulse, etc. 
 
 * Coupland. Gulstoniau Lectures on Ansemia. Lancet, 
 April i6th, 1881. 
 
53 
 
 This is well seen in certain cases of Addison's 
 disease. 
 
 The confusion in which the subject of chlo- 
 rosis is involved is due to the persistence in 
 regarding it as a disease sui generis, distinct 
 from all other forms of anaemia. The truth of 
 the matter appears to me to be simply this : At 
 the time of puberty there is an urgent physio- 
 logical demand upon the blood, which is com- 
 plied with by vigorous individuals without detri- 
 ment to the organism. The ordeal of puberty 
 is safely passed. In less vigorous, but still 
 sound, healthy organisms, a decided degree of 
 anaemia, one calling for treatment, declares 
 itself at this time. Finally, in those with any 
 congenital tendency to anaemia, whether this 
 may have been due to general malnutrition 
 during intra-uterine life, or to a special hypo- 
 plasia of the vascular system (the mesoblast), 
 the anemia of puberty is intense. The case is 
 a typical one of chlorosis. 
 
 The term chlorosis is too convenient to be 
 readily abandoned, for under it has been, and 
 will be, included many sins of diagnosis. This 
 is a questionable advantage, and the term should 
 only be used to express an anaemia occurring 
 
54 
 
 at the age of puberty and in the great majority 
 of cases, in the female sex. 
 
 DIAGNOSIS. 
 
 The diagnosis of chlorosis is included in that 
 of anaemia in general. There is nothing special 
 with regard to the blood to mark it as a distinct 
 disorder. In mild cases there may be a normal 
 number of blood corpuscles, and a reduction 
 in the amount of haemoglobin which may be 
 but 60, or even 50, per cent, of the normal. In 
 severe cases the number of corpuscles and the 
 percentage of haemoglobin are both reduced. 
 In the well-marked case of a young lady aet. 
 17, whose blood I recently examined, I found 
 the following figures : — 
 
 No. red corpuscles per cubic millimetre, 2,690,000. 
 Color (haemoglobin) 32 per cent. 
 
 The percentage of red corpuscles (haemic 
 unit), as compared with the normal (5,000,000), 
 was 54, so that the value of each corpuscle was 
 only If of the normal, making the 2,690,000 
 corpuscles found equal to 1,594,080 normal 
 corpuscles. 
 
 The corpuscles were smaller than normal and 
 perfectly circular in outline. The white cells 
 
55 
 
 were not increased. With reference to the 
 mere number of the red corpuscles in chlo- 
 rosis, Hayem gives 3,520,000 as the mean of 
 eighteen counts (about 70.4 per cent.), and 
 Coupland about 3,000,000, or 60 per cent, as 
 the mean in seven cases. As concerns the size 
 and shape of the corpuscles, there are different 
 statements. As a rule, they vary considerably 
 in size, but the average is below the normal. 
 This is also the opinion of Hayem and Laache, 
 while Malassez considers the average size of 
 the corpuscles to be increased. This discrep- 
 ancy may be due to the fact that in the more 
 intense forms, those approaching pernicious 
 anaemia in their symptoms, there is a greater 
 number of large-sized corpuscles. In perni- 
 cious anaemia the average size of the corpus- 
 cles is decidedly above the normal, and since 
 this fatal affection is due, in my opinion, rather 
 to the prolonged operation of the ordinary 
 causes of anaemia than to one that is specific, 
 it is evident that those cases of chlorosis which 
 approach the border line will show a greater 
 number of large corpuscles than those further 
 removed from it. Chlorosis is to be distin- 
 guished from Bright' s disease, especially the 
 
66 
 
 insidious form so often associated with con- 
 tracted kidneys, and from tlie early stage of 
 phthisis. The former differential diagnosis is 
 to be made by careful, perhaps repeated, exam- 
 inations of the urine ; the latter by means of 
 the thermometer. According to Peter, the sur- 
 face temperature of the superior intercostal 
 spaces is normal or subnormal in cases of chlo- 
 rosis, and the same on both sides ; whereas, it 
 is elevated on both sides, with a difference be- 
 tween the two, in latent tuberculosis. In chlo- 
 rosis, also, the phosphates of the urine are 
 below the normal figure, while in early phthisis 
 phosphaturia is quite common. The cardiac 
 murmurs in chlorosis should not be too hastily 
 set down as haemic. An interesting case in 
 point is reported by Dr. T. K. Chambers (" Re- 
 newal of Life ") — that of an unmarried servant, 
 aet. 25, with symptoms of anaemia so marked 
 that the attempt to stand upright caused faint- 
 ness. There was pain in the cardiac region and 
 a loud blowing murmur with the first sound. 
 " This blowing murmur was very audible all 
 over the cardiac region and up the large vessels 
 into the neck, but loudest, and of a harsher 
 character than elsewhere, just at the level of 
 
57 
 
 the aortic valves." Under the use of Mist. 
 Ferri Comp. all the anaemic symptoms disap- 
 peared in twenty-one days, although the " car- 
 diac murmur remained as loud, if not louder, 
 and was equally ringing- in its tone at the level 
 of the aortic valves." There had been no his- 
 tory of acute rheumatism, and Chambers con- 
 cluded — and I think most justly — that the car- 
 diac lesion was one of arrest of development. 
 
 PROGNOSIS. 
 
 The prognosis of recent, uncomplicated chlo- 
 rosis is good. If of long duration, the nutrition 
 of the cytogenic organs may have suffered to 
 such an extent that they are incapable of re- 
 suming their normal functional activity. The 
 case is now inveterate, or pernicious, and its 
 progress is, as a rule, from bad to worse. The 
 blood corpuscles now resemble those of the 
 amphibia in their number, their size, their shape 
 and their percentage of haemoglobin, and re- 
 covery is all but hopeless. Intercurrent febrile 
 and inflammatory affections are more than usu- 
 ally dangerous in cases of chlorosis. The com- 
 plications to be dreaded in chlorosis are phthisis, 
 gastric ulcer, endocarditis and chorea. There 
 also seems to be a certain causal relationship 
 
58 
 
 between chlorosis and exophthalmic goitre — 
 Graves' disease. The best test of the ultimate 
 prognosis is the immediate effect of proper 
 treatment, the response to which in chlorosis is 
 remarkably prompt and decided. 
 
 TREATMENT. 
 
 For the treatment of uncomplicated chlorosis, 
 we have a specific in the preparations of iron. 
 To show numerically the effect of this drug, 
 I append the following figures from a case 
 published by me in the Cartwright essay, 
 1881:— 
 
 April 23d, No. red globules per c. mm., 1,870,000 
 April 30th, " " " 2,945,000 
 
 May 7th, " " " 3,905,000 
 
 May 19th, " " " 4,315,000 
 
 June i6th, " " " 4,695,000 
 
 " This case affords a remarkable instance of 
 the effect of iron in the treatment of certain 
 forms of anaemia. It is classified under the 
 head of chlorosis, on account of the menstrual 
 troubles to which the patient has been subject 
 since the period of puberty, the habitual delicacy 
 of her constitution depending, so far as can be 
 ascertained, upon a chronic deficiency in the 
 blood-making function ; and, finally, on account 
 
59 
 
 of the h^mic cardiac murmurs, which gradu- 
 ally disappeared as the quality of the blood 
 improved." The preparations used were, first, 
 the reduced iron, which was afterward changed 
 to the pyrophosphate. Blaud's pill, the proto- 
 chloride of iron in pill form (Rabuteau's pill), 
 the lactate and the malate,may all be employed. 
 There are many cases in which, owing to digest- 
 ive troubles, iron cannot be immediately em- 
 ployed. The best method of preparing such 
 patients for specific treatment with iron is a 
 more or less systematic employment of the rest 
 cure, including massage, passive exercise, and 
 a carefully regulated, nutritious diet. Before 
 administering iron, the physician must be satis- 
 fied that a cardialgia, if present, is not dependent 
 upon a gastric ulcer. To effect a cure, iron must 
 sometimes be given in heroic doses. Valuable 
 therapeutic data may be obtained by frequent 
 examinations of the blood during the treatment 
 of a case. 
 
 ANiEMIA LYMPHATICA. 
 
 This disease is almost as rich in synonyms 
 as in symptoms. In addition to the title at the 
 head of this section, the following terms are 
 commonly applied to it : Adenia, Pseudoleu- 
 
60 
 
 ksemia, Malignant Lymphoma, Lymphaden- 
 oma, Lymphosarcoma, and Hodgkin's Disease. 
 These are far from being equally appropriate ; 
 but something can be urged in favor of each 
 one of these terms, in accordance with the point 
 of view of him who applies it. Thus, the sur- 
 geon, having his attention directed to the ex- 
 ternal manifestations of the disease, will natu- 
 rally employ one of the titles ending in otna, 
 while the countrymen of Hodgkin will con- 
 tinue to make use of the one which associates 
 with the disease the name of the discoverer. I 
 have already written upon this subject, under 
 the title " Hodgkin's Disease," with the explan- 
 ation that "the perplexing nomenclature of this 
 affection has led the writer to adopt the term 
 ' Hodgkin's Disease,' in the belief that it is 
 more generally understood than any of the 
 other terms employed." From the present 
 standpoint, that of anemia, it seems to me that 
 the term Anaemia Lymphatica is to be pre- 
 ferred. I refer those who may be interested in 
 investigating the claims of Hodgkin to the dis- 
 covery of this disease to the Medico- Chirurgical 
 Transactions, Vol. xvii, 1832, where it is first 
 clearly described from a clinical point of view. 
 
61 
 
 From a purely anatomical standpoint, Malpighi 
 deserves the honor of having been the first to 
 call attention to the pathological combination 
 of enlargement of the splenic corpuscles which 
 bear his name with general hypertrophy of the 
 lymphatic glands. This is proved by the fol- 
 lowing quotation, which was brought to the 
 notice of Dr. Hodgkin by Mr. G. O. Heming : 
 " In homine difficilius emergunt (speaking of 
 the granules in the spleen), si tamen ex morbo 
 universum glandularum genus turgeat, mani- 
 festiores redduntur, aucta ipsarum magnitudine, 
 ut in defuncta puella observavi, in qua lien 
 globulis conspicuis racematim dispersis totus 
 scatebat." 
 
 The a?iatomical features of anaemia lym- 
 phatica are hypertrophy, more or less general, 
 of the lymphatic glands ; hypertrophy of the 
 spleen, due to enlargement of its Malpighian 
 bodies ; the development of adenoid tissue in 
 various parts of the body ; a high, although 
 usually not extreme, degree of ansemia ; and 
 the absence of leucocythaemia. It usually be- 
 gins as a local, glandular swelling upon the 
 surface of the body, which may remain lim- 
 ited for weeks or months to one lymphatic 
 
62 
 
 group. We are ignorant of any law governing 
 the extension of the glandular enlargement. 
 At times it follows the course of the lymph 
 stream ; at others, beginning in the neck, axilla 
 or groin, it will next attack glands in either of 
 these situations on the opposite side. The 
 superficial glands are usually chiefly involved, 
 especially those of the neck and axilla, but 
 cases have been observed in which the morbid 
 process has been limited to the deep lymphatics 
 of the trunk. In a case reported by Osier 
 {^Canada Med. and Surg. Journal, Feb., 1881) 
 the retro-peritoneal glands were the only ones 
 affected. The enlargement is not inflamma- 
 tory, neither does it cause inflammation in the 
 surrounding connective tissue. The individual 
 enlarged glands are, therefore, freely movable 
 upon each other, and not united into a dense 
 mass, as in scrofula. Their consistence varies. 
 They may be soft, almost to the point of fluc- 
 tuation, or of nearly cartilaginous hardness, but 
 no division of the disease can be based upon 
 such differences, for hard and soft glands may 
 be present in the same case at the same time. 
 While the change's characteristic of scrofula 
 — chronic inflammation, suppuration and case- 
 
63 
 
 ation — are conspicuous by their absence, there 
 is no positive antagonism between " lymphad- 
 enoma " and scrofula, and, therefore, such 
 changes are now and then encountered. They 
 may be excited by traumatism of the super- 
 ficial tumors. On section, the soft glands are 
 gray or grayish red, and yield an abundant 
 turbid juice, while the hard ones are, on section, 
 of a yellowish white color, and exude a thin, 
 transparent fluid. Ecchymotic spots and apo- 
 plectic extravasations may be present in both 
 forms of tumor. Under the microscope, the 
 difference in consistence of the growths is found 
 to be owing to the degree of thickening of the 
 glandular reticulum and septa. The soft tumors 
 are due solely to numerical increase of the 
 cells, which differ, for the most part, in no 
 respect from normal lymph cells, although, 
 here and there, larger, darkly granular cells, 
 with two or three nuclei, may be met with, 
 and true giant cells, with ten to twenty nuclei. 
 The hard tumors present the same appearances, 
 with more or less thickening of the glandular 
 connective tissue. 
 
 The splenic enlargement, although a char- 
 acteristic feature, is believed to be generally 
 
64 
 
 secondary to that of the glands, for cases have 
 been observed in which, with general involve- 
 ment of the latter and secondary formations of 
 adenoid tissue in other organs, the spleen re- 
 mained normal. The enlargement of the 
 spleen is mainly due to an hypertrophy of those 
 masses of adenoid tissue which so closely resem- 
 ble the lymphatic glands — the Malpighian cor- 
 puscles. The spleen, in this disease, never 
 attains the colossal size it sometimes reaches 
 in leucocythaemia, its long diameter rarely 
 exceeding ten inches. The diameter of the 
 hypertrophied Malpighian corpuscles varies from 
 that of a pin's head to one or two centimetres, 
 and their white or yellowish color, like that of 
 the lymphatic glands, contrasted with the dark 
 red color of the pulp, gives to the cut surface a 
 characteristic variegated appearance. Adhe- 
 sions of the capsule of the spleen to neighbor- 
 ing organs are commonly met with. The en- 
 larged corpuscles may easily be mistaken for 
 tubercular masses, especially as, under the 
 microscope, they are seen to contain the same 
 elements, namely, small round cells, more or 
 less altered in appearance, and giant cells con- 
 tained in a reticular tissue. The arrangement 
 
65 
 
 of these constituents, however, is, according to 
 Langhans, different from that of tubercle. In 
 the tubercular nodule the reticulum is in the 
 centre, or in a zone between the periphery and 
 the centre, while in the lymphadenoid nodule 
 the reticulum occupies the periphery, the cells 
 the centre. 
 
 The infective nature of Ansemia Lymphatica 
 is shown by the development of adenoid tissue 
 in organs and tissues of which it is not a normal 
 constituent, such as the liver, kidneys, lungs, 
 heart, testicles and digestive tract ; less fre- 
 quently the bones, skin and nerve centres. The 
 metastatic nodules spring from the connective 
 tissue of the organ ; in the lungs, from the 
 peribronchial connective tissue ; in the liver, 
 from the capsule of Glisson, etc. The suppo- 
 sition that they may arise from the endothelial 
 cells of the lymph spaces has not. yet been 
 established. The microscopic structure of the 
 nodules has been most carefully studied in the 
 liver, and their origin proved to be in the inter- 
 acinous tissue, by the fact that a bile duct 
 usually occupies their centre. Dr. Burdon- 
 Sanderson, having observed a thickening of 
 the walls of the intra-lobular capillaries and a 
 
 E 
 
66 
 
 vacuolated condition of the liver cells, thinks it 
 probable that the growth may originate in the 
 glandular tissue. Instead of nodules, a diffuse 
 leucocytal infiltration of the inter-acinous tissue, 
 as in incipient cirrhosis, is sometimes observed. 
 In the lungs, the nodular deposits have been 
 often mistaken for tubercle. They invade the 
 organ from behind forward, starting from al- 
 ready enlarged lymphatic glands. In the kid- 
 ney the deposit assumes the form of inter-tubular 
 streaks. On the serous membranes it occurs 
 in the form of flattened patches, which may be 
 half an inch in diameter. Under the influence 
 of this disease the thymus gland may, although 
 almost completely atrophied, resume its original 
 shape and size. The follicles at the base of the 
 tongue, the tonsils and the retro-nasal adenoid 
 tissue (" pharyngeal tonsil "),may be so greatly 
 enlarged as to completely occlude the posterior 
 nares. The thickening of the intestinal walls 
 from new formation of adenoid tissue may be 
 enormous, but it has never been known to cause 
 stricture. In a case reported by Dr. Murchison, 
 the walls of the duodenum were from one to 
 two inches thick, and yet the " intestinal mucous 
 membrane corresponding to the morbid deposit 
 
67 
 
 was not ulcerated, and the calibre of the gut 
 did not appear materially narrowed." Various 
 forms of paralysis may be due to the deposit 
 having its seat in the nerve centres, but such 
 cases are exceedingly rare. The blood is dimin- 
 ished in quantity and of poor quality. Macro- 
 scopically, it is light colored, thin and un- 
 coagulated in the heart chambers, 'or, if coag- 
 ula are present, they are quite small. Careful 
 counts of the blood corpuscles have proved that 
 the diminution in their number is, as a rule, by no 
 means so great as that observed in cases of per- 
 nicious ansemia. In four cases carefully studied 
 by Laache the greatest reduction in the number of 
 the red corpuscles was 1,830,000 per cubic mil- 
 limetre, the count having been made eleven 
 days before the death of the patient. In a case 
 of my own, a boy of five, with enormous en- 
 largement of the right cervical glands, the num- 
 ber of corpuscles per cubic millimetre was 
 5,462,000, while the hemoglobin was only sixty 
 per cent, of the normal ; so that the functional 
 value of the corpuscles was diminished by forty 
 per cent. In a case reported by Dr. Richard 
 Geigel [Deutsches Archiv fur Klinische Medi- 
 cin, Bd. 37, p. 59, 1885), that of a boy twelve 
 
68 
 
 years old, the right side of whose neck was occu- 
 pied by a glandular tumor as large as a child's 
 head, almost daily counts of the blood corpus- 
 cles were made from June 7th to July 23d. The 
 lowest count was 960,000, on July 12th. The 
 percentage of haemoglobin was never estimated. 
 
 Effusion into the pleural and abdominal cavi- 
 ties is oftei! found, and may be due to the irri- 
 tation caused by growths of adenoid tissue upon 
 these membranes, or to the pressure of en- 
 larged glands upon the vena azygos and the 
 vena portae. Hydrops lactea may be caused 
 by the pressure of enlarged glands upon the 
 thoracic duct. The bone marrow is very rarely 
 affected. Birch-Hirschfeld knew of but one 
 case in which this tissue was abnormal. The 
 bones themselves, especially the vertebrae, 
 sternum and ribs, may be eroded by the pres- 
 sure of enlarged glands. 
 
 Nature of the Disease. — This is best under- 
 stood by comparing it with another disease, 
 with which, but for an examination of the 
 blood, it would certainly be confounded, 
 namely, leucocythsemia. Langhans, in view of 
 the fact that the principal distinction between 
 these two diseases is the absence in the former 
 
69 
 
 of an increase in the number of white corpus- 
 cles, has suggested their classification under 
 one head, such as adenia or lymphadenoma, 
 with the division into a leukaemic and a non- 
 leukaemic form. Dr. H. C. Wood is of the 
 opinion that, " clinically, the so-called true and 
 false leukaemia are the same, save only in the 
 matter of the white blood corpuscles." This is 
 also the view of Dr. Wm, Pepper, who in- 
 cludes under the term '' ancBmatosis " the affec- 
 tions which I have grouped under the head of 
 primary anaemia, with the exception of chlo- 
 rosis. The term is apt, convenient and com- 
 prehensive, but has not been widely adopted. 
 While admitting the fundamental relationship 
 between these various forms of anaemia, I think 
 that better scientific work will be accomplished 
 by continuing to treat them as separate affec- 
 tions, by dwelling upon their points of diverg- 
 ence. In fact, the tendency of late has been 
 rather to separate than to unite anaemia lym- 
 phatica and leucocythaemia. Dr. Moxon and 
 others hold that there is no such disease as 
 pure lymphatic leucocythaemia, the grounds for 
 which will be stated in treating of leucocy- 
 thaemia. 
 
70 
 
 The disease may be defined as an infective 
 hyperplasia of the lymphatic tissue of the body, 
 with progressive anaemia. 
 
 Symptoms. — These are due to the pressure of 
 enlarged glands and new formations of adenoid 
 tissue in the most various situations, causing 
 stenosis of ducts, blood vessels, air passages, 
 oesophagus, etc. ; and to the profound disturb- 
 ance of nutrition and resulting anasmia, which 
 set in sooner or later. By the pressure of the 
 enlarged cervical and bronchial glands may be 
 caused cough, dyspnoea and difficult deglutition, 
 which may all be aggravated by the simul- 
 taneous enlargement of the tonsils and retro- 
 nasal adenoid tissue. The cerebral circula- 
 tion may also be disturbed by pressure upon 
 the cervical veins. In the axilla, enlarged 
 glands may cause brachial neuralgia and 
 oedema, and enlarged inguinal glands may 
 give rise to similar disturbances in the lower 
 extremity. Enlarged portal glands may give 
 rise to ascites and jaundice. Sensor)^ and motor 
 paralysis may be caused by growths in the 
 brain and spinal cord. Digestive disturbances 
 may be due to the growth of adenoid tissue in 
 various portions of the alimentary canal. As a 
 
71 
 
 rule, the glandular enlargement does not cause 
 pain and is not tender, or very slightly so, on 
 pressure. The same is true with regard to the 
 spleen, but occasionally the hypertrophy of this 
 organ gives rise to a sense of weight and drag- 
 ging in the left hypochondrium, or even pain 
 that may radiate to the back and opposite side. 
 Pyrexia is frequent during the course of the 
 disease, but presents nothing characteristic, 
 being sometimes continuous, at others remit- 
 tent or irregularly intermittent. Murchison and 
 De Renzi have each observed a case in which 
 the glandular enlargement, instead of gradually 
 increasing, was paroxysmal, coinciding with 
 attacks of pyrexia of several days' duration. 
 After each attack the enlargement subsided, 
 but remained greater than before. On the 
 other hand, Laache has reported a case in which 
 during the febrile attacks the glands diminished 
 in size. He suggests, in explanation, that a 
 pyrogenic material may be absorbed from the 
 glands. In the great majority of cases no 
 change in the dimensions of the enlarged 
 glands is observed during the attacks of fever. 
 The remaining symptoms are those of steadily 
 progressive anaemia, namely, muscular weak- 
 
72 
 
 ness, paleness of skin and visible mucous mem- 
 branes, palpitation of the heart with sometimes 
 a systolic murmur, frequent pulse, epistaxis, 
 oedema, and serous effusion not accounted for 
 by mechanical obstruction. 
 
 Diagnosis. — This presents certain difficulties 
 when the enlargement remains for a long time 
 limited to one glandular group. It is to be 
 distinguished from scrofula, sarcoma and car- 
 cinoma. Strumous glandular enlargement is 
 generally associated with other signs of scrofula, 
 such as affections of the bones, joints, skin and 
 mucous membranes, and especially with the 
 characteristic y««Vj- of the strumous diathesis. 
 The glands, too, are usually adherent to each 
 other and to the skin, and the morbid process 
 slowly advances to an unhealthy suppuration. 
 In sarcoma, also, the glands are adherent, 
 whereas the tumor of anaemia lymphatica is dis- 
 tinguished by the free mobility of the enlarged 
 glands upon each other. This communicates 
 an unmistakable sensation on palpation, which 
 Southey has aptly compared to that experienced 
 in handhng a number of balls enclosed in a 
 net. Carcinoma is almost always secondary, 
 and extends by glandular contiguity, while, as 
 
73 
 
 already remarked, there appears to be no law 
 governing the direction of the progress of 
 lymphadenoma. Leucocythaemia is excluded 
 by a microscopic examination of the blood. 
 
 Prognosis. — The prognosis of this disease is not 
 so hopeless as might be inferred from the term, 
 "malignant lymphoma," applied to it by Bill- 
 roth. In estimating the probable course of a 
 case, and its duration, the most important factor 
 is the stage which the growth has reached. If 
 local, a cure is not only possible, but highly 
 probable, provided the tumor is situated in one 
 of the superficial lymphatic groups ; that is to 
 say, within the province of surgery. If the 
 affection has become general, the prognosis is 
 unfavorable ; but even then, individual cases 
 present wide differences with regard to the 
 rapidity of their downward course, depending 
 chiefly upon the amount of pyrexia and the 
 degree of anaemia. The average duration of the 
 disease is about two years, but is largely influ- 
 enced by the preceding health of the patient, 
 being shortest in those of delicate constitution. It 
 has been observed to run a very rapid course 
 after parturition, especially when this had been 
 accompanied with considerable hemorrhage. 
 
74 
 
 Treatmetit. — An early diagnosis is the most 
 important requisite to a successful treatment. 
 In most of the cases on record the affection has 
 remained limited to one of the superficial 
 lymphatic groups for a varying period, during 
 which the propriety of extirpating the tumor 
 should be considered. By this means the dis- 
 ease may sometimes be cured and its progress 
 often delayed. The enlarged glands must 
 sometimes be removed as a palliative measure, 
 when they threaten to destroy life by impeding 
 respiration or deglutition, or cause intense pain 
 by pressure upon nerves. Friction over the en- 
 larged glands has been said to cause a reduc- 
 tion of their size, and the same result has been 
 attributed to the application of electricity. The 
 general nutrition of the body should be main- 
 tained, as far as possible, by a diet as generous 
 as the digestive system can dispose of. The 
 anaemia should be combated with iron and 
 arsenic, and the latter is believed to exert a 
 specific action when injected into the morbid 
 growths. Warfwinge reports several cases 
 cured by the intra-splenic and intra-glandular 
 injection of Fowler's solution. He injected four 
 drops of the solution thrice daily, and observed 
 
75 
 
 a steady reduction of the size of the tumors and 
 a gradual improvement of the condition of the 
 blood. 
 
 LEUCOCYTH^MIA. 
 
 The consideration of this disease naturally 
 follows that of the one which has so often been 
 mistaken for it. From the point of view that 
 the genuine should always have precedence 
 over the spurious, it might well have come first 
 in order, but the object of this work, as its name 
 implies, is to keep prominently in view the anse- 
 mia common to the various disorders of which 
 it treats. From this standpoint, the anaemia 
 of pseudo-leukaemia, being uncomplicated, de- 
 serves the precedence. 
 
 Nomenclature. — Of the two names of this dis- 
 ease, leucocythsemia (white-cell blood) and leu- 
 kaemia (white blood), the former is certainly the 
 more accurate ; for the latter might be applied, 
 with equal propriety, to the appearance of the 
 blood after a meal containing an abundance of 
 fat, and in many cases the blood presents to the 
 unaided eye no deviation from the normal ap- 
 pearance. Nevertheless, the term leucocythae- 
 mia has been practically rejected by German 
 writers, whose important contributions to our 
 
76 
 
 knowledge of this disease entitle their prefer- 
 ences — or prejudices — to respectful considera- 
 tion. I shall, therefore, employ both terms 
 interchangeably in the course of this article, 
 giving the preference, when an adjective is 
 needed, to that derived from the shorter of the 
 two. 
 
 Anatomical Characters. — This disease is pre- 
 eminently one to which the term organic or 
 structural may be applied ; for it cannot be said 
 to exist until a striking change in the composi- 
 tion of the blood has become manifest. The 
 degree of this change — the increase in the 
 number of the white cells — necessary to con- 
 stitute the disease, is not agreed upon ; and this 
 is not surprising, since, as all are aware, the 
 number of these bodies in healthy blood can 
 only be approximately stated. In health, after 
 meals, the number of leucocytes in the blood is 
 increased, and this increase coincides with a 
 congestion and tumefaction of the spleen, of 
 which the elastic capsule is specially adapted to 
 these periodic changes of volume. This condi- 
 tion of physiological increase in the number of 
 the white cells is known as leiicocytosis, and the 
 same term is applied to the undue proportion of 
 
77 
 
 these bodies sometimes observed in fevers and 
 during pregnancy. A narrow boundary line 
 between leucocytosis and leucocythsemia cannot 
 Be drawn. They are, rather, separated by a 
 broad strip of territory, which either may invade. 
 During the progress of a case of leucocythaemia 
 that may eventually end in death, there may 
 be periods of remission, during which the pro- 
 portion of white cells to red may be but little 
 removed from the normal ; and, on the other 
 hand, a state of the blood at first regarded as a 
 mere leucocytosis may gradually, by its per- 
 sistence and further progress, convince the ob- 
 server that he has to deal with a genuine leuco- 
 cythaemia. The tendency, however, is, rather, 
 to regard leucocytosis as leucocythaemia than 
 the reverse. 
 
 Three forms of leucocythaemia are described 
 — the splenic, lymphatic and medullary, which 
 are secondary to changes in those organs — the 
 spleen, lymph glands and bone marrow, uni- 
 versally accepted as hcBmatopoietic , or blood 
 making. Cases have been supposed to be due 
 to lesions of other organs, such as the thymus 
 and thyroid bodies, the tonsils and intestinal 
 glands, but these were mostly reported before 
 
78 
 
 Neumann had directed attention to the marrow 
 as a fons et origo ?nali, and there is no proof 
 that such cases were not of the medullary or 
 myelogenous form. As the affection is mostly 
 one of adult life — the greatest number of cases 
 occurring between thirty and fifty years of age 
 — the part taken in its production by a foetal 
 organ, such as the thymus, is highly prob- 
 lematical. 
 
 The first stage of the morbid process in the 
 spleen is a hypersemia, which may be so intense 
 in degree and so rapid in development, as to 
 cause great enlargement of the organ and sen- 
 sations of discomfort, weight, and even pain, in 
 the left hypochondrium. The tissue of the gland 
 is soft and its surface irregular, the depressions 
 corresponding to the insertions of the fibrous 
 trabeculae. At this period the condition differs 
 only in its degree and persistence from that 
 which normally exists during digestion. Soon, 
 however, the enlargement acquires a more per- 
 manent — a structural — foundation, from numer- 
 ical hypertrophy of the cells of the splenic 
 pulp. The size of the organ increases, and may 
 become so enormous as to fill the space between 
 the ribs and groin on the left side, and extend 
 
79 
 
 beyond the umbilicus on the right. The results 
 of inflammation of the capsule are commonly 
 apparent in the form of thickenings, opacities 
 and adhesions to neighboring organs. The 
 gross appearance of the cut surface is variable. 
 Sometimes it differs in no respect from that of 
 a normal spleen ; at others, all traces of the 
 Malpighian bodies ha,ve disappeared ; the sec- 
 tion is smooth and firm, closely resembling that 
 of the liver. In the pure splenic form of leu- 
 cocythaemia the Malpighian bodies, while, per- 
 haps, plainly evident, are not enlarged. They 
 become so only in the lymphatic and lieno- 
 lymphatic forms. Hemorrhagic infarctions are 
 often observed. 
 
 The alterations of the lymphatic glands, 
 like those of the spleen, are due to simple 
 hyperplasia, and have been already described 
 in the section on anaemia lymphatica. In 
 leucocythsemia their consistence is usually 
 soft. 
 
 The changes in the bone marrow, to which 
 attention was first called by Neumann, are two- 
 fold. In the first form it is of grayish-yellow or 
 yellowish-green color, and closely resembles a 
 thick, creamy pus ; in the second, more or less of 
 
80 
 
 red is mingled with the gray or yellow, until in the 
 most marked degrees of this variety the medulla 
 may be of the color of raw beef. These variations 
 in color are explained by Ponfick as being due to 
 varying densities in the accumulations of white 
 cells and corresponding variations in the 
 amount of blood in the vessels. The leucocytes 
 are seen, under the microscope, to be embedded 
 in an extremely fine reticular tissue. In this 
 altered marrow there may be apoplectic extrav- 
 asations such as have been described as occurring 
 in the spleen and lymph glands. The bones, 
 of which the medulla most frequently under- 
 goes these changes, are the sternum, ribs and 
 vertebrae. 
 
 In other than lymphatic organs, any alter- 
 ations are due to the altered state of the blood, 
 and consist of the fatty degenerations common 
 to anaemia in general and of infiltrations and 
 nodular deposits of leucocytes. The infiltra- 
 tions are most common in the liver and kid- 
 neys, causing considerable enlargement of these 
 organs. The nodules have been observed both 
 in the substance of organs and on their serous 
 surfaces, as well as on the mucous membranes 
 of the air passages and stomach. The peri- 
 
81 
 
 toneum may be covered with gray, semi-trans- 
 parent nodules varying in size from a pin's 
 head to a pea, and so closely resembling miliary 
 tubercle in their gross and microscopic appear- 
 ances that the absence of the bacillus may be 
 the only differential point. The minute struc- 
 ture of the nodules of this " leukaemic peritonitis" 
 may also resemble that of alveolar sarcoma, as 
 in a case described by Laache. 
 
 Cha7iges in the Retina. — In well-marked 
 cases of leucocythaemia, certain retinal lesions 
 are commonly observed, to which attention was 
 first directed by R. Liebreich in 1861. Being 
 generally situated near the periphery of the 
 fundus oculi, they but seldom cause any visual 
 disturbance, and, therefore, their frequency can 
 only be estimated by an ophthalmoscopic ex- 
 amination of all cases. The eye-ground is of 
 an orange-yellow hue, its veins pale and wider 
 than normal, and traces of hemorrhage are 
 scattered along their course. Other spots are 
 observed, of which the appearance indicates 
 a more compound structure than that of mere 
 hemorrhage. They have a whitish-yellow cen- 
 tre and a reddish border of extravasated blood, 
 and are analogous to the lymphoid deposits 
 F 
 
82 
 
 in other tissues. The cause of these retinal 
 hemorrhages is twofold. They are favored by 
 the malnutrition of the vessels from deficiency 
 of red corpuscles, and excited by the obstructions 
 from excess of the white. 
 
 Changes in the Blood. — The characteristic 
 feature of leucocythaemia is an absolute in- 
 crease in the number of white blood cells, which 
 in extreme degrees of the disease may be 
 even greater than that of the red. This alter- 
 ation in the cellular composition of the blood 
 may alter its macroscopic appearance by 
 causing it to assume a pale-red, grayish-red, 
 or chocolate color ("milchchocolade") ; but it 
 would be exceedingly rash to predict the exist- 
 ence of leucocythaemia from a gross examina- 
 tion of a specimen of blood. Such a caution 
 will not seem unnecessary to those who, like 
 myself, have seen a case reported as leucocy- 
 thaemia in which the blood was never examined 
 at all. The white cells are by no means uni- 
 form in size. In one of Hosier's cases the 
 smallest were one-third smaller than the red ; 
 the largest four times larger than the red. It 
 is doubtful whether, as Virchow supposed, any 
 diagnostic significance can be attached to such 
 
83 
 
 variations ; for in a case of pure splenic leucocy- 
 thsemia the leucocytes have varied in diameter 
 from 5 jj. to 15 a. Virchow holds that in the 
 latter variety the leucocytes in the blood are 
 identical with the cells of the splenic pulp, and 
 that in the lymphatic form they are uninucleated 
 like the cells of the lymphatic glands. Before 
 attempting, however, to make the diagnosis of a 
 disease, it is necessary' to establish its existence, 
 and that of the so-called lymphatic leucocy- 
 th^mia is emphatically called in question. In 
 the medullary form, Neumann has found in the 
 blood, red nucleated cells such as normally in- 
 habit the marrow, and regards them as charac- 
 teristic of this variety. They are not always 
 present, having been searched for in vain by 
 Mosler in a typical case of medullary leu- 
 kaemia {Berl. klin. IVoch., 1876, No. 49). 
 
 The degree of ansmia is rarely extreme, 
 ases may steadily proceed to a fatal termina- 
 tion without a reduction of more than fifty per 
 cent, of the normal number of red corpuscles, 
 although exceptional cases occur in which the 
 number of red corpuscles is exceedingly small ; 
 for example ,0.5 million per cubic millimetre. 
 There are no characteristic changes in the size 
 
84 
 
 and shape of the red corpuscles. The value of 
 the latter (their percentage of haemoglobin) is 
 well maintained, rarely sinking below seventy- 
 five per cent. A point of some importance 
 with reference to the pathogeny of the disease 
 is that the number of white and red cells to- 
 gether is less than that of the normal number of 
 red. Certain pointed octahedral crystals were 
 discovered in leucocythaemic blood by Charcot 
 in 1853, identical with those subsequently ob- 
 served by Leyden, in 1 871, in the sputa of 
 asthmatics. In i860, in a case reported by Dr. 
 Calvin Ellis, Dr. White found " numerous mi- 
 nute crystals. They were colorless, elongated, 
 faintly marked, rhombic octahedra, exhibiting 
 irregularities of form, indicating an organic na- 
 ture." To these crystals he gave the name of 
 " Leiikosi?ty In 1863 Dr. Howard Damon dis- 
 covered, in the leucocythjemic blood of a boy, 
 certain crystals which, he asserts, " differed en- 
 tirely, in form, size, color, degree of resistance 
 at atmospheric influences, refractive and other 
 properties, from all known crystals of the human 
 blood.'' They were composed of " hexagonal 
 and pentagonal plates of unequal sides, of rec- 
 tangular plates in the form of squares and 
 
85 
 
 parallelograms, and also of a few triangular 
 plates. Some of these crystals were twice the 
 size of the red blood corpuscles in the same 
 field of view." The name of '' Leiicocrystallin " 
 was applied to them by Dr. Damon.* Certain 
 normal constituents of the spleen have been 
 found in leucocythaemic blood, such as lactic 
 and formic acids, leucine and hypoxanthine. 
 The specific gravity of the blood is diminished 
 in leucocythsemia ow4ng to the fact that the red 
 corpuscles are replaced by the lighter leuco- 
 cytes ; and, further, because the normal propor- 
 tion of water is retained. The proportion of 
 fibrin is, as a rule, increased. 
 
 Clinical History. — In the insidious nature of 
 its onset, and its gradual progress, leucocy- 
 thasmia resembles many fatal diseases which run 
 a chronic course. The first symptoms com- 
 plained of are those of anaemia in general, such 
 as muscular weakness, lassitude, indisposition 
 to exertion, either physical or mental, anorexia, 
 indigestion, and dyspnoea, on exertion. As the 
 case progresses, other symptoms arise, of which 
 some are to be attributed to leuksemic deposit in 
 
 * See Bolyston Prize Essay on Leucocythsemia, 1864. 
 
86 
 
 the parts affected. Among these are hemor- 
 rhages, either spontaneous or traumatic; the 
 former variety being most commonly met with 
 in the form of epistaxis ; the latter, after the ex- 
 traction of teeth. Diarrhoea is now the rule, 
 and oedema of feet and legs and ascites finally 
 set in. The last-named symptoms are most 
 common when the spleen is greatly enlarged 
 and indurated, and are favored by deposits in 
 the liver and by the leukaemic peritonitis above 
 mentioned. Singular anomalies are sometimes 
 observed in the course of this disease. For ex- 
 ample, although the appetite is generally mark- 
 edly deficient, often to the point of absolute 
 anorexia, it may be voracious, as in a case 
 obser\^ed by Prof. Da Costa (Am. Jour. Med. 
 Sci., Jan. 1875), i^ which, in spite of an inordi- 
 nate consumption of food and the absence of 
 diarrhoea, the loss of flesh was progressive. On 
 the other hand, in a case reported by Mosler, in 
 which the blood was chocolate-colored and the 
 white cells were to the red as two to three, the 
 digestion was unimpaired and the body weight 
 maintained. Dizziness, aggravated by move- 
 ment, may be a marked symptom. In the 
 splenic form, sensations of weight, dragging 
 
87 
 
 and pain are felt in the left hypochondrium ; and 
 in the medullary variety, tenderness of bones, 
 particularly the sternum, may be detected. 
 Visual disturbances may be due to hemorrhage, 
 to leuksemic deposit, or to leukaemic retinitis ; 
 but marked retinal changes may be observed 
 in cases which have presented no symptoms of 
 eye disease. There is no peculiar facies of this 
 disease. The extremepallor of pernicious ane- 
 mia is rarely observed. On the contrary, the 
 cheeks often present a circumscribed flush, 
 even in a late stage of the affection. There is 
 nothing typical in either pulse or respiration, 
 but fever of irregular type is invariably met with 
 at some period of the clinical history. The 
 proportion of white cells to red is dim^inished by 
 the occurrence of suppuration in any part of the 
 body. When the leukaemic cachexia is fairly 
 established, the enlarged spleen may diminish 
 greatly in size without any corresponding im- 
 provement in the symptoms. In a case reported 
 by Laache, the spleen, which had projected to 
 the right, beyond the median line and downward 
 almost to the symphysis pubis^ gradually con- 
 tracted until, just before death, it extended but 
 three centimetres below the left costal border. 
 
88 
 
 Hypoxanthine is found in the urine as well as 
 in the blood, and in the former fluid the pro- 
 portion of uric acid is increased, sometimes to 
 six or eight times the normal. 
 
 A division of the course of the disease into 
 two stages has been suggested : the first con- 
 sisting of the development of the morbid pro- 
 cess in the haematopoietic organ or organs first 
 attacked and in the blood ; the second, of the 
 extension of the process to other non-lymphatic 
 organs. This division, although excellent from an 
 anatomical standpoint, is too objective for clinical 
 purposes. The secondary leukaemic deposits can- 
 not be detected, as a rule, in any organs but the 
 lymph glands, assuming, for the moment, that 
 the enlargement of these organs is secondary. 
 
 Pathogenesis. — To properly appreciate the 
 cause of any deviation from the normal com- 
 position of the blood, it is necessary to under- 
 stand how that composition is produced and 
 maintained. In the problem before us — the 
 nature of leucocythsemia — the first step is to de- 
 cide whether there is any normal relationship 
 between the r^d and white cells. If there be 
 any, it is manifest that the red, on account of 
 their greater functional importance, their size, 
 
89 
 
 shape, color and number, are derived from the 
 white, and not the white from the red. The 
 question, therefore, is one concerning the origin 
 of the red corpuscles ; and those who have 
 studied it will doubtless agree with me that 
 there is scarcely a subject in physiology con- 
 cerning which our notions are so fragmentary 
 and confused. This being the case, it is im- 
 possible to offer more than an hypothesis of the 
 nature of leucocythasmia. 
 
 All authorities are agreed that in adult life 
 the lymphatic system — in which are included 
 the spleen, lymphatic glands, and red marrow 
 — is the sole source of the red blood corpuscles. 
 The cells of the splenic pulp, the smaller uni- 
 nuclear cells of the lymphatic ganglia, and the 
 red, nucleated marrow-cells — first described 
 by Prof. Neumann, of Konigsberg, in 1868, 
 and subsequently called by Malassez, "cellules 
 hemoglobiques ' ' — are by some, perhaps different, 
 means converted into the bi-concave discs of 
 the circulating blood. Time is requisite for this 
 conversion — a time of incubation in the blood- 
 making organs. Any unusual activity of the 
 circulation in these glands may hasten the exit 
 of their cells, and cause them to appear in the 
 
90 
 
 blood in an immature condition. This is demon- 
 strated by the physiological concurrence of 
 leucocytosis with splenic post-prandial conges- 
 tion. In leucocythsemia, there is a persistent 
 hyperaemia of spleen or other blood-making 
 organ, which prevents the leucocytes from at- 
 taining their proper development. They enter 
 the circulation as leucocytes. This view is 
 endorsed by Dr. Richard Norris, of Birming- 
 ham, and held by others, who do not agree 
 with him concerning the stages of the process 
 by which the white cells are normally elaborated 
 into red corpuscles. Norris contends that in 
 health the great majority of the leucocytes in the 
 blood-making organs are, before entering the 
 circulation, converted into a pale, colorless, bi- 
 concave disc, which he terms the " advanced 
 lymph disc." This corpuscle acquires haemo- 
 globin, and with it its full functional perfection. 
 The white blood corpuscles represent those 
 leucocytes which have prematurely entered the 
 circulation, for instance after a meal. These lat- 
 ter, however, may develop into red corpuscles 
 in the circulation. The former mode of ori- 
 gin of red corpuscles Norris calls the " major 
 process " of blood-formation ; the latter, the 
 
91 
 
 "minor process," and, therefore, in accordance 
 with his views, " leuksemia, in a word, is the 
 encroachment of the minor upon the major 
 process of blood-making." 
 
 Several observers have noticed a diminution 
 or absence of amoeboid movement in the white 
 cells of leucocythaemic blood. " The earliest 
 observations on this point were made by Dr. 
 Laking, in 1873, ^^^ remained unpublished. 
 The results were communicated by Dr. Pye- 
 Smyth to the Pathological Society in 1878, and, 
 in the same year, to the Lancet, by Dr. Cafavy. 
 Neumann also, in 1878, found amoeboid move- 
 ments wanting, or very sluggish, in a case of 
 leukaemia, although they were active in the 
 corpuscles of fluid from blisters in the same 
 patient." {Lancet, 1880, ii, 769.) Dr. John 
 Cafavy, who has given special attention to this 
 subject, concludes that " the colorless corpuscles 
 in leukaemia are dead, or dying, and hence 
 incapable of development." This functional 
 incapacity of the white cells may be referred to 
 the shortness of their stay in the lymphatic 
 organs, of which the hyperaemia prevents their 
 reaching the normal term of their gestation. 
 They are to be regarded as abortive products. 
 
92 
 
 Under this section it is appropriate to con- 
 sider the question, which has been raised, as to 
 whether the customary division of this disease 
 into three varieties, the splenic, lymphatic and 
 medullary, is warranted. A primary splenic 
 leucocythaemia being- universally accepted, it 
 remains to consider whether the lymphatic 
 glands and the bone marrow may be the start- 
 ing point of the disease. Some authorities, 
 while not explicitly rejecting the lymphatic and 
 medullary varieties, do so tacitly by describing 
 no other than the splenic. Dr. Moxon is the 
 most outspoken upholder of the doctrine that 
 the spleen is the only starting point of leuco- 
 cythaemia, and emphatically rejects the theory 
 of a lymphatic leuksemia, which he stigma- 
 tizes as a "myth." He holds that the enor- 
 mous accumulations of leucocytes in the lymph 
 glands and bone marrow are secondary de- 
 posits from the blood, and, in support of this 
 view, he has demonstrated that the leucocytes 
 normally present in the lymph spaces — which 
 have been shown by Dr. Klein to be out-wan- 
 dered white blood cells — are greatly increased 
 in number in cases of leucocythaemia. These 
 cells are conducted through the lymphatic 
 
93 
 
 vessels to the glands, and if these are pervious, 
 re-enter the blood ; if not, the glands enlarge 
 by the continual accession of out-wandered 
 blood cells ; " so that," Dr. Moxon concludes, 
 " lymphatic leukaemia is a myth ; and the 
 pathology of leukaemia, now so complex, should 
 be simplified, when it will better conform with 
 the clinical uniformity which characterizes the 
 disease." I am inclined to accept Dr. Moxon's 
 opinion in so far as the lymphatic variety is 
 concerned, for the reason that in anaemia lym- 
 phatica we find a lesion of the glands identical 
 with that which exists in lymphatic leukaemia. 
 The last-named affection, assuming its existence 
 for the sake of the argument, is made up of 
 lymphatic anaemia plus leucocythcemia, I be- 
 lieve, however, that there is substantial proof 
 of the existence of a primary medullary leukae- 
 mia. For example, in a case observed by Vir- 
 chow, fracture of the femur appeared to be the 
 determining cause. In another, reported by 
 Mursick, the disease attacked a soldier five 
 days after amputation for a gunshot wound of 
 the knee-joint, and at the autopsy osteo-myelitis 
 of the femur was found. The patient had been 
 previously healthy. In the remarkable case of a 
 
94 
 
 sea captain, reported by Mosler, in whom the dis- 
 ease followed prolonged exposure to cold during 
 an Arctic winter, pain and tenderness over the 
 entire length of the sternum were among the 
 earliest symptoms, and speedily became so in- 
 tense as to compel the man to desist from any 
 kind of manual work. The list of cases such 
 as those last referred to is so long, and the 
 cases themselves so remarkable, that those 
 who are at all familiar with them feel the ne- 
 cessity of great caution in discussing the ques- 
 tion of a primar}' medullary leukaemia. As 
 above stated, I believe the evidence is in favor 
 of such an affection, and, with the object of 
 obtaining further confirmation, I would suggest 
 to hospital surgeons and their assistants the im- 
 portance of examining the blood after injuries 
 of the bones. 
 
 JEtiology. — The male sex is more predisposed 
 to this disease than the female, the male cases 
 on record standing to the female in the pro- 
 portion of about two to one. The influence of 
 age is not striking, although the disease occurs 
 most frequently during adult life, and between 
 the ages of thirty and fifty. Neither infancy 
 nor old age is exempt. Cases in infants of 
 
95 
 
 fifteen and sixteen months have been reported 
 by Trousseau and Hosier, and one of Vidal's 
 cases was sixty-nine years old. Dr. Goodhart 
 has also reported to the Clinical Society of Lon- 
 don six cases under two years of age. Poverty 
 includes, in one word, a number of predisposing 
 factors, such as an unfavorable hygienic en- 
 vironment, insufficient food, and the depressing 
 emotions of care and anxiety. A few cases 
 have been attributed to traumatism of the spleen, 
 and others, as already stated, to that of the 
 bones. There can, I think, be no doubt that 
 long-continued exposure to severe cold has 
 excited the disease in several instances. 
 
 Diagnosis. — This can be made in no other 
 way than by a microscopic examination of the 
 blood, and to warrant the diagnosis of leucocy- 
 thsemia, the increase in the number of the white 
 cells must be absolute as well as relative. In 
 well-marked cases the microscopic inspection 
 of a drop of blood will suffice for the barest pur- 
 poses of diagnosis, but will give no idea of the 
 grade of the affection. With the latter oljject 
 in view, the number of red and white cor- 
 puscles in a given volume of blood — a cubic 
 millimetre — must be estimated bv means of a 
 
96 
 
 haemacytometer, such as that of Gowers or 
 Zeiss. I have more than once refuted a di- 
 agnosis of leucocythaemia which had been 
 made by the examination of a drop of blood 
 under the microscope. In one of the cases the 
 diagnosis thus made seemed unmistakable, 
 but on carefully counting the red and white 
 cells, I found a great reduction of the former, 
 and a proportion of one to eighty between the 
 white and red, but thetiumber of the white cells 
 per cubic 7nilliineire was within normal limits. In 
 every case of profound anaemia in which the 
 number of white cells is not reduced /(2r//<a;jjr« 
 with the red, the diagnosis (?) of leucocythaemia 
 is liable to be made, unless the most accurate 
 methods of investigation are employed. I have 
 seen as many as from twelve to fifteen white 
 cells in each microscopic field of a specimen of 
 blood of which a more careful examination 
 showed that the increase was merely relative. 
 The liability to error being so great, what is the 
 increase, absolute and relative, which warrants 
 the diagnosis of leucocythaemia ? There is no 
 fixed rule. Each observer is a law unto him- 
 self. For my own part, if the number of leuco- 
 cytes per cubic millimetre is increased (z. e., if 
 
97 
 
 they are more than 10,000), and if the propor- 
 tion of white cells to red is as great as one to 
 fifty, I consider that the limits of leucocytosis 
 have been overstepped. This is confirmed by 
 the co-existence of great tenderness of sternum, 
 ribs or vertebras, and made absolutely certain 
 by the detection of any enlargement of the 
 spleen. As to the question whether the pre- 
 cise variety of the disease may be ascertained 
 by an examination of the blood, there is little 
 to be said. As already mentioned under the 
 head of changes in the blood, the size of the 
 white cells may vary greatly in the purely 
 splenic form. The presence of red nucleated 
 cells in the blood is believed by Neumann to be 
 pathognomonic of the medullary variety, but 
 their absence does not exclude an implication^ 
 of the marrow. The absent or diminished 
 amoeboid movement of the white cells is a point 
 with which diagnosis is not so much concerned 
 as pathogenesis, and, therefore, it has been re- 
 ferred to under the latter head. 
 
 Dr. Richard Geigel {Joe. cit.) has suggested 
 and practiced the following method for making 
 easier the counting of the white cells. To fifty 
 cubic centimetres of a one-half of one per cent. 
 
 G 
 
98 
 
 chloride of sodium solution, are added four 
 drops of a one and one-half per cent, solution 
 of gentian violet, and by using this in the 
 counting of the corpuscles, instead of the ordi- 
 nary diluting fluid, the red corpuscles are un- 
 altered, while the leucocytes are stained blue, 
 so that it is impossible to overlook a single one 
 of them. 
 
 The diagnosis of leucocythaemia having been 
 made with the microscope, its variety is to be 
 determined by the ordinary methods of physi- 
 cal diagnosis. A case in which the spleen 
 is increased in size, while nothing abnormal 
 can be detected in lymph glands or bones, is 
 one of pure splenic leukaemia. Combinations 
 of enlarged spleen and lymph glands are desig- 
 iiated as lieno-lymphatic or lymphatico-splenic, 
 in accordance with the supposed priority of the 
 organ affected. The medullary form may also 
 be complicated with an enlarged spleen or with 
 hypertrophied lymphatic ganglia, and the same 
 remarks are applicable to it. 
 
 Prognosis. — In the earliest stage, that of hy- 
 peraemia of the haematopoietic organ involved, 
 a cure may be effected by a proper course of 
 treatment. The prognosis is more unfavorable 
 
99 
 
 when the enlargement of spleen or other organ 
 is maintained by numerical hypertrophy of 
 its cells, and becomes absolutely so when the 
 leukaemic infection has become general. The 
 latter event — the establishment of the leukaemic 
 cachexia — may sometimes be demonstrated by 
 an inspection of the fundus oculi, in which leu- 
 kaemic deposits are readily seen. A not un- 
 common m^ode of death is apoplexy, to which 
 there is a predisposing cause from malnutrition 
 of vessel walls, and an exciting one from ac- 
 cumulation of leucocytes within their lumina. 
 
 From one to three years is the average dura- 
 tion of the disease. 
 
 Treatment. — The cures reported have been 
 mostly in children, which may be owing to the 
 fact that their impressible systems render easier 
 an early diagnosis. The very fact that their 
 powers of resistance are less than those of adults 
 is thus favorable, from a therapeutic stand- 
 point. Dr. Goodhart has reported to the Chni- 
 cal Society of London six cases of children, 
 under two years of age, which were cured by 
 the administration of either phosphorus, iodide 
 of iron, or cod-liver oil. In all of them the 
 spleen was moderately enlarged and the white 
 
100 
 
 cells increased about tenfold. Mosler also has 
 reported the cure of a boy of ten years, who 
 " took adrachmandahalf of sulphate of quinine 
 in the course of four days, and then ten grains, 
 and afterward six grains daily ; he completely 
 recovered." The case was of the splenic form. 
 Mosler prefers quinine to all internal remedies, 
 but recommends also the employment of oil of 
 eucalyptus and piperin, in accordance with the 
 results of certain experiments by himself and 
 Hans Soenderop, which show that both these 
 substances cause contraction of the spleen in 
 dogs. They may be prescribed in pill, as in the 
 following formula : — 
 
 R . 01. eucalypti, gtt. lOO 
 
 Piperini, 
 
 Cerse albse, aa 3J 
 
 Pulv. altheae, ^ij. 
 
 M. et ft. pil. No. C. 
 
 SiG. — Three to five pills thrice daily. 
 
 Careful counts of the blood corpuscles during 
 the employment of arsenic, have proved that 
 this drug has a favorable influence over the 
 course of leucocythaemia. It should be given in 
 full doses and pushed to the point of toleration. 
 A local treatment of the enlarged spleen by 
 
101 
 
 means of electricity, cold douches, and ice bags, 
 has been practiced, and often wdth the result of 
 materially reducing its size. Once, however, 
 the disease is fairly established, the spleen may 
 fluctuate very greatly in size, without any cor- 
 responding effect upon the patient's condition. 
 In the early stage of the splenic form, local 
 treatment should not be neglected. Botkin re- 
 ports a case of lieno-lymphatic leukemia in 
 which faradization was followed by a consider- 
 able reduction in the long and transverse 
 diameters of the enlarged spleen, which coin- 
 cided with improvement in the general con- 
 dition of the patient. In opposition it must be 
 stated that Mosler has not been able to confirm 
 the statement that the size of the spleen is re- 
 duced by faradization, but has seen its long 
 diameter a^/i are/i //y dimmished by being pushed 
 upward by the contraction of the abdominal 
 muscles. Transfusion of defibrinated blood 
 has been employed with marked temporary 
 benefit, but cannot be regarded as a curative 
 measure. 
 
 Extirpation of the spleen is only mentioned 
 for the purpose of condemning it. 
 
 Postscript. — Although not without an opinion 
 
102 
 
 concerning the rival claims of Bennett and Vir- 
 chowtothe discovery of leucocythaemia, I have, 
 thus far, purposely refrained from expressing it. 
 It appears to me that the credit of having pre- 
 sented the subject of leucocythaemia in such a 
 light as to attract the notice of the whole pro- 
 fession, and to convince Bennett that six weeks 
 before he had discovered a new disease, un- 
 doubtedly belongs to Virchow. I also think that 
 when a labored argument, such as that of Ben- 
 nett, is necessary to make good a claim, it is 
 self-evident that the right of possession can be 
 called in question. 
 
 ANEMIA SPLENICA. 
 
 Definition. — This disease, which is the splenic 
 form of pseudoleiikcEmia, is completely ignored 
 by nearly all the numerous text books, hand 
 books, systems and cyclopeedias of medicine. 
 Even Dr. Adolph Striimpell, who published an 
 elaborate article in the Archiv der Heilkunde, 
 Vol. XVIII, 1877, entitled Ziir Kentniss der 
 Aiiceniia Splenica, devotes but eight lines to 
 this subject in his recent text book of medicine. 
 Although apparently unknown to most of the 
 writers of the works above mentioned, splenic 
 
103 
 
 anaemia has long been recognized as a distinct 
 affection by those who have paid special atten- 
 tion to diseases of the haematopoietic organs. 
 For example, in the course of an article on the 
 " Relations of LeucocythasmiaandPseudoleukse- 
 mia," in the American Journal of the Medical 
 Sciences for October, 1871, Prof. Horatio C. 
 Wood remarks: "I now desire to show that 
 there is still a third form of pseudoleuksemia — a 
 splenic variety. Under the names of tumor of 
 the spleen, splenic cachexia, etc., from time far 
 back, medical records furnish accounts of cases 
 which I believe represent this affection." He 
 then proceeds to report a typical case of anae- 
 mia splenica. 
 
 The best account of this affection that I have 
 been able to find in medical literature is by Dr. 
 Guido Banti {Annali Universali di Medicijia 
 Chirurgia- Parte Rivisia, 1883), and is based 
 upon a critical study of three cases : a woman 
 of 73, a boy of 18, and a girl of 16. To it, as 
 well as to the article by Striimpell above re- 
 ferred to, I am largely indebted for the follow- 
 ing description. 
 
 Anatomical Characters. — The cadaver pre- 
 sents the well-known appearances of extreme 
 
104 
 
 anaemia, and there is usually a certain amount 
 of subcutaneous cEdema and serous effusion. 
 The spleen, while retaining its shape, is en- 
 larged, sometimes to thrice its normal size ; its 
 tissue is more or less indurated, and its in- 
 cisures deeper than normal. The capsule pre- 
 sents patches of thickening and opacity, and is 
 sometimes adherent to neighboring organs. On 
 the surface of a section which is of a reddish- 
 brown color, white or yellow-white spots, usually 
 not exceeding the size of a pea, may often be 
 observed. With the microscope, it is found 
 that the normal adenoid tissue has more or less 
 completely disappeared, its place being more 
 than supplied by a thickening of the reticulum, 
 which, in parts of the organ, may be so great as 
 to form parallel bundles of fibrous tissue, con- 
 taining narrow lacunse, in which are embedded 
 a few lymphatic cells. The change is precisely 
 similar to that of the indurated glands in anae- 
 mia lymphatica, and in order to emphasize the 
 fibrous character of the alteration in both these 
 diseases, Banti proposes for it the name of 
 fibroadenia. In the heart and voluntary mus- 
 cles, fatty changes are the rule. The blood 
 corpuscles are notably diminished. From 
 
105 
 
 5,000,000 per cubic millimetre, they gradually 
 descend to four, three, or even one million. In 
 a case of my own their number was between 
 one and two millions. They present the same 
 alterations in size and shape as are encountered 
 in all pernicious forms of anaemia. Notwith- 
 standing Banti's assertion that red nucleated 
 cells have never been observed in the blood of 
 splenic anemia, they are said, by Striimpell, 
 to have been numerous, in his case, in blood 
 from the veins of the lungs, liver and spleen. 
 They varied greatly in size and shape, and 
 were mostly uninuclear, although some con- 
 tained two nuclei, and a few contained three. 
 With reference to the proportion of white cells, 
 the cases may be divided into two classes. In 
 the first, the normal number of white cells is 
 not surpassed. In the second, the white cells 
 are increased in number, without, however, ex- 
 ceeding the limits of leucocytosis. Their pro- 
 toplasm is granular, and, on the addition of 
 acetic acid, becomes transparent, and shows, 
 as a rule, but one nucleus. They do not contain 
 pigment granules, and, on a warm stage, ex- 
 hibit well-marked amoeboid movements. 
 
 The marrow may present the changes that 
 
106 
 
 have been erroneously supposed to be peculiar 
 to the so-called progressive pernicious anaemia. 
 In Striimpell's case the medulla of sternum, ribs, 
 and tibiae, was of a dark-red color, and of un- 
 usually firm consistence, and presented the fol- 
 lowing minute changes: i. Scarcely any fat 
 cells were present. 2. The colorless marrow 
 cells were of widely different size and shape, 
 mostly uninuclear, though some contained two 
 nuclei and others enclosed red blood corpuscles. 
 3. Besides the ordinary red blood corpuscles, 
 there were numerous round, pale-red, non- 
 nucleated cells of different size, and many red 
 nucleated cells of varying size and shape, some 
 round, others elliptic ; the former sometimes 
 granular, the latter mostly homogeneous. Their 
 nuclei were often double, and of the same pale- 
 red color as the rest of the cell ; sometimes of 
 a more yellowish tinge. Occasionally, the 
 nucleus was enlarged so as to almost fill the 
 entire cell ; often it was placed eccentrically. 
 
 Clinical History. — The disease may be pro- 
 perly divided into three stages, of which the 
 first, the enlargement of the spleen, is often 
 so insidious as to pass for a long time unob- 
 served by both patient and physician. It mani- 
 
107 
 
 fests itself more frequently by a sense of weight 
 in the left hypochondrium, which may be ex- 
 perienced only when in the upright position. 
 Sometimes, however, it gives rise to severe 
 neuralgic paroxysms. The second stage, that 
 of anemia, presents the phenomena of anaemia 
 in general, such as pallor of skin and mu- 
 cous membranes, dyspnoea, cardiac palpitation 
 and fatigue, on slight exertion. These symp- 
 toms increase in severity until the third stage, 
 that of cachexia, is reached. The distinguish- 
 ing features of this stage are hemorrhage and 
 fever. The skin is now the color of yellow wax ; 
 the muscular prostration is extreme ; the men- 
 tal state is one of hebetude, and the oedema and 
 serous effusions increase. The adipose tissue 
 generally disappears to a greater or less extent, 
 but is sometimes preserved. The disease, 
 instead of being continuously progressive, may 
 recur in separate attacks, between each of which 
 there may be intervals of good health, of several 
 months' duration. This intermittent character 
 of the affection was particularly well marked in 
 the case reported by Striimpell, that of a young 
 man, set. 25, who, in the course of eighteen 
 months, was the subject of four attacks of pro- 
 
108 
 
 found anaemia, each of which coincided with 
 enlargement of the spleen. Twice he recovered 
 from an apparently hopeless condition. A third 
 attack ensued after several months of good 
 health, and he was again improving when he 
 fell into a state of melancholia, during which 
 the fourth attack occurred and was fatal. 
 
 Careful examinations of the urine were made 
 by Striimpell in the case referred to. It was 
 always acid, never contained albumin and, 
 notwithstanding the icteric hue of the skin, 
 never responded to the tests for bile pigment. 
 Repeated examinations showed that the greatest 
 destruction of albumin in the body, inferred 
 from the amount of nitrogen excreted, coincided 
 with the worst periods of the anaemic attacks. 
 This fact is in perfect analogy with certain 
 physiological experiments of Bauer and Frankel. 
 The former found, after bleeding animals, that 
 the destruction of albumin in their bodies was 
 augmented. The same was true in cases of 
 phosphorus poisoning, in which there is de- 
 struction of red cells. Frankel demonstrated 
 an increased excretion of urea after any obstacle 
 to respiration had been placed in the large air 
 passages. A similar increase had been demon- 
 
109 
 
 strated in cases of carbonic oxide poisoning. 
 As is well known, in cases of CO poisoning the 
 functional power of the red corpuscles is para- 
 lyzed ; they cannot carry O until the CO is dis- 
 placed. In a word, experiments show that any 
 cause which interferes with the conduction of 
 oxygen to the tissues may produce secondarily 
 an increased destruction of albumin in the body ; 
 and this is found also in states of profound 
 anaemia in which the diminished consumption 
 of O is inferred with almost absolute certainty 
 from the fact of an enormous destruction of O 
 carriers, and is confirmed by the presence of 
 fatty degeneration of heart, blood vessels, etc. 
 
 Nature of the Disease. — Although ansemia 
 splenica has been generally confounded with 
 other forms of pernicious ansemia, there can be 
 no question that it constitutes a distinct patho- 
 logical entity. The enlargement of the spleen 
 is primary, the ansemia secondary ; as to the 
 relation between them, there are two hypotheses 
 — to wit : Either the altered spleen directly de- 
 stroys the red corpuscles, or in it are formed 
 materials which enter the circulation and inter- 
 fere with the functions of hgematopoiesis. Of 
 these views, Banti espouses the latter. With 
 
110 
 
 regard to the primary enlargement of the spleen, 
 nothing is known. That the disease is the splenic 
 form of pseudoleukaemia, is, according to the 
 author just cited, proved by the following facts. 
 In pseudoleuksemia [i.e., anemia lymphatica, 
 or Hodgkin's disease), the lymphatic glands are 
 rarely the only organs affected ; generally the 
 spleen is enlarged at the same time. In some 
 cases, the enlargement of the spleen is in much 
 greater proportion than that of the glands, and, 
 finally, there are cases (and these belong to the 
 category of anaemia splenica) in which the spleen 
 is alone involved. 
 
 The view that this disease is the splenic form 
 of pseudoleukaemia may be opposed on the 
 ground that the morbid changes in the spleen in 
 anaemia splenica are not identical with those of 
 the same organ when affected in anaemia lym- 
 phatica. In the latter disease, the malpighian 
 bodies of the spleen, when that organ is second- 
 arily affected, are hypertrophied to such an 
 extent that, as I have said under the head of 
 "Anaemia Lymphatica," "their white or yellow- 
 ish color, like that of the lymphatic glands, con- 
 trasted with the dark-red color of the pulp, gives 
 to the cut surface a characteristic variegated 
 
Ill 
 
 appearance." This change is beautifully shown 
 in a plate illustrating an article on Lymphade- 
 noma by Dr. Murchison, in the London Path. 
 Sac. Trans., vol. XXI. In marked contrast to 
 this description, the spleen, in the case reported 
 by Prof. H. C. Wood, was much enlarged and 
 indurated, but the " vialpighian corpuscles were 
 not at all evident.''' In summing up the ana- 
 tomical characters of the disease, Banti says, 
 with reference to this point: "The histological 
 alterations of the spleen consist of an atrophy 
 and sclerosis of the itialpighian corpuscles" etc. 
 
 These apparent discrepancies may be ex- 
 plained in this manner : The spleen is not a 
 lymphatic gland, but contains within its pulp 
 numerous bodies — the malpighian corpuscles — 
 analogous to the lymph glands. As the latter 
 may, or may not, be enlarged in cases of pseu- 
 doleuksemia — using this term in its broadest 
 sense — so their analogues in the spleen may, or 
 7nay not, be enlarged. 
 
 Course and Prognosis. — The duration of 
 splenic anaemia is from five or six months to 
 three years. These figures are certainly within 
 the mark, for in all the cases, owing to the 
 insidious nature of the onset, more or less of 
 
112 
 
 the first stage passes unobserved. The disease 
 sometimes occurs in separate attacks, from all 
 of which, except the last, there may be complete 
 restoration to health ; and, on account of this 
 peculiarity in its course, there is great danger of 
 prematurely reporting cases as cured. According 
 to Striimpell, permanent cures are unknown ; 
 but this opinion must be modified in favor of a 
 few cases in which splenectomy has been prac- 
 ticed successfully. 
 
 Diagnosis. — The tumor being recognized as 
 an enlarged spleen, by its situation, shape and 
 mobility during respiration, the question arises 
 as to the character of the enlargement. There 
 is no difficulty in distinguishing the tumor in 
 anemia splenica from other tumors of the spleen 
 which alter its normal shape, such as carcinoma, 
 and echinococci, but the tumors of amyloid 
 disease, paludal cachexia and leukaemia are to 
 be carefully differentiated. Amyloid disease is 
 secondary to suppuration, especially in or about 
 the bones ; to syphilis, or to phthisis, and is not 
 confined to the spleen. It may be demonstrated 
 at the same time in the liver, and perhaps also 
 in the kidney, by an examination of the urine. 
 LeukcCmia splenica is excluded by a careful 
 
113 
 
 count of the white and red cells ; and paludal 
 cachexia by the histoiy of the case and the 
 presence in the blood of the plasmodium ma- 
 lariae, 
 
 A case of ansemia of high grade associated 
 with a uniform splenic enlargement, not mala- 
 rial, leuksemic, or amyloid, can be no other than 
 one of anaemia splenica. 
 
 Treatment. — The medical means ofrelief arethe 
 same as those employed in other pernicious forms 
 of anaemia, and have been, thus far, attended 
 with but little success. Among them are the 
 salts of quinia, piperin, oil of eucalyptus, and 
 arsenic. The latter may be given by the mouth, 
 or may be injected into the splenic pulp, as has 
 been done with marked success by Warfwinge, 
 in cases of ansemia lymphatica. 
 
 Faradization should be given a thorough trial; 
 for, even admitting that it has no direct effect 
 upon the spleen, there is reason to believe that 
 a salutary influence is exercised upon that 
 organ by the contraction of the abdominal 
 muscles. 
 
 Pain, vomiting, diarrhoea, ascites and epistaxis 
 are to be treated in the same manner as in other 
 diseases attended with these symptoms. Banti 
 
 H 
 
114 
 
 has tabulated the cases of splenectomy per- 
 formed for non-traumatic lesions. They number 
 twenty-one, of which four were undoubted 
 cases of anaemia splenica. Of these four, three 
 recovered. 
 
 PERNICIOUS ANiEMIA. 
 
 No7nenclature. — The term idiopathic was first 
 applied by Addison to certain cases of profound 
 anaemia of unknown origin, w^hich were in all 
 respects identical with those subsequently 
 described by Biermer, in 1872, under the title 
 of " progressive pernicious anaemia." In the 
 latter term the adjective " progressive " appears 
 to me not only unnecessary but, to a certain 
 extent, absurd ; for all diseases are progressive 
 in one or other direction. In using the term 
 "idiopathic," Addison was, no doubt, impressed 
 with the idea that when the anatomical basis of 
 a disease is unknown, it is best to apply to it a 
 title acknowledging that ignorance. This I re- 
 gard as an error. It is one thing to acknowl- 
 edge ignorance and another to parade it. A 
 terminology based upon etiology is doubtless the 
 most scientific, but one based upon symptoma- 
 tology is not unscientific. I fully agree with 
 the late Dr. Fagge that the " phenomena 
 
115 
 
 which are commonly spoken of as symptoms 
 are part of the disease to which they belong, no 
 less than the lesion or the specific cause or 
 whatever is taken as its main characteristic." 
 To those who may think these remarks unnec- 
 essary, it is a sufficient reply that our knowl- 
 edge of the causes of several forms of miscalled 
 idiopathic ansemia dates from the time when 
 Biermer substituted a significant symptomatic 
 term for one that had nothing but vagueness to 
 recommend it. 
 
 Nature of Pernicious Ancemia. — In placing 
 pernicious anaemia in the category of primary 
 anaemias, although I do not regard it as an 
 independent disease, I have not been incon- 
 sistent. An anaemia becomes pernicious when 
 the blood corpuscles undergo a series of 
 changes which cause them to resemble, in 
 more than one respect, the corpuscles of th-e 
 amphibia. Pernicious anaemia is the final 
 stage of several forms of symptomatic anaemia 
 and of chlorosis. The prognosis of anaemia 
 per se is good until the changes in the blood 
 corpuscles above referred to are manifest. 
 
 I cannot better explain my views with refer- 
 ence to this afi'ection than by quoting from an 
 
116 
 
 article that I contributed to the Philadelphia 
 Medical Times for April 3d, 1886. " The most 
 interesting fact in connection with the exami- 
 nation of the blood of pernicious ansemia, and 
 one to which, so far as I know, attention has 
 never been particularly directed, is that it 
 demonstrates a reversion to the type of blood 
 found in the lower animals. This might be 
 justly regarded as a fanciful idea if it were based 
 upon a resemblance of the blood of pernicious 
 anaemia to that of the lower animals — birds, 
 fishes, reptiles — in any one particular ; but I 
 propose to show that the red corpuscles in this 
 disease approach those of the lower animals in 
 many, if not in all, of their chief characteristics ; 
 namely, in their number, their size, their shape, 
 and the amount of haemoglobin they carry." 
 After giving some details concerning the 
 blood corpuscles of the lower vertebrate ani- 
 mals and their percentage of haemoglobin, I 
 continued as follows: "Turning from these 
 interesting facts of comparative physiology to 
 their bearing upon the subject of this paper, 
 we observe in well-marked cases of pernicious 
 anaemia: i. A reduction in the number of the 
 red corpuscles to a degree that is normal in the 
 
117 
 
 cold-blooded animals. It is not at all uncommon 
 to find in this disease less than 1,000,000 corpus- 
 cles per cubic millimetre. My lowest counts 
 have^ been 525,000 five days before death ; 
 560,000 in a case in which recovery took place ; 
 and 315,000 a few hours before death. In the 
 celebrated case of Quincke there were but 
 143,000 per cubic millimetre, and yet the 
 patient recovered. Figures like these are, as 
 has just been said, normal in the cold-blooded 
 animals. 2. In pernicious anaemia the propor- 
 tion of haemoglobin is often much greater than 
 normal. It has been observed by Laache and 
 others to be double the normal amount. This, 
 in the opinion of the writer, is the most remark- 
 able feature of this disease, distinguishing it 
 from all other forms of anemia, and is due to 
 the fact that — 3, many, sometimes the majority, 
 of the corpuscles are greatly increased in size. 
 This is well seen in the accompanying cuts, 
 from photo-micrographs of diseased and normal 
 blood, made for me by Mr. W. H. Walmsley, 
 of this city. The photographs of the two speci- 
 mens were made under precisely similar opti- 
 cal conditions. The patient furnishing the 
 diseased specimen of blood is a typical case of 
 
119 
 
 pernicious anaemia, and is still under my obser- 
 vation.* 
 
 " By applying the points of a pair of compasses 
 to the enlarged corpuscles, it will be proved that 
 many of them are at least double the normal 
 size. 4. The corpuscles are not only increased 
 in diameter, but altered in shape, and have a 
 decided tendency to assume an oval outline. 
 So much so that, in measuring them in the 
 manner indicated, we have to take into con- 
 sideration the direction in which the measure- 
 ment is made. They have a long a?id a short 
 diameter y 
 
 The specimen from which the above cut 
 was taken was not selected with the view of 
 upholding this theory of reversion, but may be 
 regarded as typical of the corpuscles of per- 
 nicious anaemia. The enormous size of the cor- 
 puscles (megalocytes) and their altered shape 
 are still better shown in a cut in the work of 
 Laache {^Die Anceinie), who had no theory of 
 reversion to maintain. 
 
 From the standpoint of the blood changes 
 and of the clinical history, I contend that per- 
 nicious ansemia is a condition that may result 
 
 * He has since died. 
 
120 
 
 from a number of causes. Prominent amono: 
 these is atrophy of the stomach. In the Ameri- 
 can Jour 7ial of Medical Sciences, April, 1886, I 
 reported, in conjunction with Prof. Wm. Osier, 
 a typical case of pernicious anaemia in which 
 the only special lesion was atrophy of the mu- 
 cous membrane of the stomach. " This was 
 evident to the naked eye in the thin, cuticular 
 appearance, and was abundantly confirmed by 
 the microscopical examination, which showed 
 that the peptic glands had been destroyed over 
 the greater portion of the organ." About the 
 same time I had under observation another case, 
 a lady, whose symptoms and blood changes 
 were identical with those of the above mentioned 
 case. After an illness of more than a year she 
 died, and at the autopsy, at which I was present, 
 no lesion was found to explain the profound 
 alteration of the blood. According to most 
 authorities, the first of these cases in which a 
 lesion was found, to which the symptoms might 
 be reasonably attributed is, for that very reason, 
 not a case of pernicious anaemia. The second 
 case, on the other hand, is a case of pernicious, 
 or " idiopathic," anaemia because a lesion, to 
 which the symptoms might be attributed, was 
 
121 
 
 not found. This appears to me to be a very- 
 unscientific mode of considering this subject. 
 Little by little, causes have been discovered suffi- 
 cient to account for all the symptoms of many- 
 cases of idiopathic anaemia. One of the latest 
 contributions of this sort has been that of Dr. Gus- 
 tav Reyher {Detdsches Archiv fur Klin. Med., 
 Bd. xxxix), who reports thirteen cases of profound 
 ansemia caused by an intestinal parasite, the 
 bothriocephalus latus. In all their features, 
 these cases deserve the name of pernicious, and 
 had they been fewer in number and treated 
 in a different manner, the anaemia might have 
 been considered "idiopathic," the presence of 
 a tapeworm in the intestine being regarded, in 
 a country where this parasite is not uncommon, 
 as a mere coincidence. The proof that the 
 anaemia was secondary and parasitic was fur- 
 nished by the fact that, in every instance, a 
 wonderfully rapid recovery from an apparently 
 hopeless condition followed the expulsion of 
 the worm. From such facts as these it is reason - 
 able to conclude that our ignorance concerning 
 the cause of the most obscure forms of perni- 
 cious anaemia, and our expression of that igno- 
 rance by the term "idiopathic," will gradually 
 disappear. 
 
122 
 
 Having stated above that I do not regard 
 pernicious ansemia as an independent disease, 
 some explanation is needed of my reasons for 
 classifying it under the head of primary anae- 
 mias. I have none better than the one already 
 given by me in the course of an article in the 
 Medical News for July 3d, 1886 : — 
 
 " Opinions are divided as to whether per- 
 nicious anemia is due to the operation of a 
 cause (unknown) sui generis, or to the pro- 
 longed operation of the ordinary causes of anae- 
 mia. The writer is of the opinion that the 
 varied clinical history of the different cases on 
 record furnishes most decided evidence in favor 
 of the latter view. Anaemia, once established, 
 tends to perpetuate itself in that species of 
 vicious circle of which so many examples are 
 furnished by pathology. Thus, to take an ex- 
 treme example, the epileptiform convulsions 
 which immediately precede death from hemor- 
 rhage are due to cerebral ischaemia, and this 
 very ischaemia is increased by the convulsions, 
 for experiments have shown that the voluntary 
 muscles contain a much greater amount of 
 blood during contraction than while at rest. It 
 is quite as essential to the blood-making organs 
 
123 
 
 as it is to the nerve centres that they be properly 
 supplied with blood, in order that they may act 
 their important part toward maintaining the 
 bodily health. Doubtless there are reserve 
 powers and compensatory activities in each and 
 all of the blood-making organs, which may 
 suffice to furnish a fair quality of blood under 
 the most adverse circumstances. These powers, 
 however, have their limit, and, once exhausted, 
 the anaemia, instead of continuing 'simple,' 
 ' functional,' or ' symptomatic,' becomes ' essen- 
 tial,' ' oiganic,' or ' pernicious.' " 
 
 In short, I consider some forms of pernicious 
 anaemia to be due to malnutrition of the cyto- 
 genetic organs. 
 
 Symptoms. — In the words of Coupland, "the 
 symptoms of pernicious anaemia are those of 
 simple anaemia aggravated and intensified." 
 In well-marked cases the appearance of the 
 patient is, to a certain extent, diagnostic. The 
 lips and palpebral conjunctiva are of a milky 
 white color and the skin of a lemon tint. This 
 hue of the skin is characteristic, and at once 
 gives rise to the suspicion of pernicious anaemia 
 to those who have seen one or more cases of 
 the disease. It is unnecessary to enter at length 
 
124 
 
 into the symptoms of this affection which are, 
 for the most part, dependent upon want of 
 oxygen. The chief of them are extreme muscu- 
 lar prostration, breathlessness and syncope on 
 slight exertion, or even in raising the head from 
 the pillow ; and digestive disturbances, such as 
 anorexia, nausea and vomiting, and constipa- 
 tion alternating with diarrhoea. Insomnia is 
 more frequent than drowsiness until toward the 
 end, when somnolence gradually deepens into 
 lethargy and coma. Physical examination, in 
 typical cases, reveals nothing but anaemic mur- 
 murs over the heart, most distinct at the base 
 and the bruit de diable in the veins of the neck. 
 The pulse is usually rapid, from loo to 120. 
 The bones, particularly the sternum, are often 
 tender on percussion. Retinal hemorrhages are 
 found in the majority of cases. The blood is 
 not only of the poorest quality, but is so small 
 in quantity that often a drop is squeezed with 
 great difficulty from a deep puncture in the 
 finger pulp. It resenlbles serum more than 
 blood, and is aptly compared to water in which 
 beef has been washed. On examination with 
 the microscope, the corpuscles present great 
 diversities in size and shape. The majority are 
 
125 
 
 often much larger than normal, and, compared 
 with normal corpuscles, are worthy of the name 
 of Jiiegalocytes. Others are much below the 
 normal size, and are called microcytes ; while 
 others are greatly distorted, being pear-shaped 
 for the most part, but sometimes biscuit-shaped, 
 hammer-shaped, or anvil-shaped. These last 
 are known 2^'=, poikilocytes. The percentage of 
 haemoglobin, owing to the increased size of the 
 corpuscles, is often as great as, or greater than, 
 normal, sometimes attaining twice the normal 
 proportion. This abnormal proportion of hae- 
 moglobin is not always due to the increased 
 size of the corpuscles alone ; for, in some cases, 
 the blood contains a large number of minute, 
 highly-colored globules, which Eichhorst re- 
 garded as pathognomonic. They are so minute 
 as to look like " small, red-tinged, fat globules." 
 These bodies are, of course, not counted in esti- 
 mating the number of the red corpuscles, and 
 yet their coloring matter contributes to the esti- 
 mate of the percentage of haemoglobin. The 
 corpuscles are, therefore, sometimes credited 
 with more coloring matter than they possess. 
 These minute colored bodies are not always 
 present. I have met with them in but one case. 
 
126 
 
 and Dr. Grainger Stewart was unable to find 
 them in two well-marked and ultimately fatal 
 cases which occurred in his practice. Fever 
 of irregular type is certain to occur in late 
 stages of pernicious anaemia. It has already 
 been spoken of among the symptoms of anaemia 
 in general. An increased excretion of nitrogen 
 by the kidneys has been demonstrated in this 
 affection by Striimpell, and is due to the inade- 
 quate supply of oxygen to the tissues. This 
 fact is of interest in connection with the exten- 
 sive fatty degeneration, which is sometimes the 
 only lesion detected in this disease. " The fat 
 represents the non-nitrogenized remnants of the 
 decomposed albuminoids." 
 
 Anatomical Characters. — These are the 
 changes in the blood itself and the consecutive 
 lesions in other tissues. The former have been 
 already described and figured in the course of 
 this section Of the latter, the fatty degenera- 
 tions of heart, intima of blood vessels, gastric 
 tubules, etc., are mentioned under the head of 
 anatomical characters of anaemia in general. 
 In 1875, Prof. William Pepper suggested the 
 marrow as the source of the blood lesions of 
 pernicious anaemia, and " described definite 
 
127 
 
 changes, chiefly of small, granular cells, in the 
 marrow of the radius and sternum in one case." 
 The marrow in this case, the first in which a 
 careful examination of this tissue was made, is 
 described as "decidedly paler than in health." 
 This is not the appearance of the hyperplasia 
 of the marrow, which is regarded by some as 
 the fundamental lesion of this affection. The 
 marrow is of a reddish purple color ; its consist- 
 ence is increased ; its fat cells have disap- 
 peared, and the specific cellular elements of the 
 medulla have increased in amount. Frequently, 
 also, large numbers of nucleated red corpuscles 
 are found. These changes, interesting and sug- 
 gestive though they be, are by no means pecu- 
 liar to pernicious anaemia and, when present, 
 are not primary. They maybe entirely absent, 
 as in a thoroughly studied case reported by Dr. 
 J. H. Musser, of Philadelphia. They may also 
 be present in other diseases. They were found 
 by Litten in four cases of uterine carcinoma, 
 and by Oi?th in a case of carcinoma recti, and 
 in another of carcinoma mammae. {^Berlin 
 Klin. Wochensch., xiv, 748.) 
 
 Diagnosis. — In accordance with the views 
 here presented, an anaemia has entered upon 
 
128 
 
 the pernicious stage when the blood corpuscles 
 are greatly diminished in number — below 
 2,000,000 per cubic millimetre — and have under- 
 gone the alterations in size and shape already 
 described and figured. In addition, the per- 
 centage of haemoglobin may be normal or 
 above normal ; certainly but little below it in 
 any case. A blood containing megalocytes, 
 poikilocytes and microcytes, is the blood of 
 pernicious anaemia. This condition may be 
 secondary, i. e., the cause is known ; or primary, 
 z. <?., the cause is, as yet, unknown. 
 
 Prognosis. — The prognosis of pernicious anae- 
 mia is unfavorable, but there are brilliant excep- 
 tions to this rule ; for example, those furnished 
 by Reyher's cases. These were, doubtless, 
 from an etiological standpoint, cases of parasitic 
 anaemia, but clinically they presented every 
 feature of pernicious anaemia. In general terms, 
 when the cause is known and removable, the 
 prognosis is good ; when known and not re- 
 movable, it is hopeless ; when unknown, it is 
 doubtful. 
 
 Treatment. — Confining what is to be said 
 about treatment to those cases in which the 
 cause is unknown, the best results have been 
 
129 
 
 attained by the use of arsenic, iron, and quinine. 
 Numerous undoubted cures have followed the 
 use of the first of these drugs, which may be 
 given in pill or in Fowler's solution. Trans- 
 fusion has been attended with little or no suc- 
 cess, but Dr. Oscar Silbermann reports two 
 cases of profound ansemia which recovered 
 after subcutaneous injections of defibrinated 
 blood. The blood was injected under strict 
 antiseptic precautions, and the quantity of each 
 dose varied from twenty to forty grammes. In- 
 halations of oxygen and the subcutaneous in- 
 jection of quinine are recommended by Dr. 
 Henrot of Rheims. Of equal importance with 
 drugs, is a nutritious diet, of which the digestion 
 may be assisted by malt and pancreatic extract 
 or the food may be peptonized before its inges- 
 tion. 
 
 SECONDARY AX.CMIA. 
 
 As already remarked on a previous page, 
 " Nearly every morbid process, when it occurs 
 in a severe form, is sooner or later followed by 
 anaemia." It is therefore impossible, within the 
 limits of this work, to consider every form of 
 secondary anaemia. It is also unnecessary, for 
 I 
 
130 
 
 the differences between the various forms are 
 those of degree, not of kind. 
 
 The anaemias of fever and hemorrhage have 
 already been considered. That of syphilis has 
 been studied by Wilbouchewitch ; by Keyes, of 
 New York, and by Laache, of Christiania, and 
 it has been demonstrated that the improvement 
 which follows the administration of mercurials 
 is accompanied with an increase in the number 
 and value of the red corpuscles. In the ad- 
 vanced stages of phthisis, cancer, Bright's dis- 
 ease, and cirrhosis of the liver, the blood 
 corpuscles are greatly reduced in number — be- 
 tween 2,000,000 and 3,000,000 — and may assume 
 the characters — increased size and altered shape 
 — of pernicious anaemia. 
 
 TOXANiEMIA. 
 
 A poison may produce anaemia either directly 
 or indirectly. The ingestion of arsenic and 
 phosphorus, and the inhalation of arseniureted 
 hydrogen are directly followed by the destruc- 
 tion of red corpuscles in such quantities that 
 haemoglobin appears in the urine, and even 
 jaundice (haematogenous) may ensue. In 
 certain susceptible individuals the same symp- 
 
131 
 
 toms are caused by prolonged exposure to cold. 
 Other substances, such as potassium chlorate 
 and certain edible fungi, morchella andhelvella, 
 esculenta, produce the same effects. For details 
 concerning these and other agents destructive 
 to the red corpuscles, the reader is referred to 
 my article on " Hsemoglobinuria," in " Wood's 
 Reference Handbook of Medicine." The action 
 of lead upon the blood corpuscles is probably 
 altogether indirect, through the marked disturb- 
 ances of digestion to which it gives rise. A 
 decided degree of ansemia in a case of chronic 
 lead poisoning should lead to a careful examina- 
 tion of the urine ; for, as is well known, the long- 
 continued ingestion of lead is one of the causes 
 of cirrhotic kidney. 
 
 The anaemia, if such it can be called, pro- 
 duced by carbonic oxide poisoning, differs from 
 all other forms of toxanaemia. This gas, when 
 inhaled, "displaces the oxygen of the blood- 
 coloring matter, and takes its place, molecule for 
 molecule. The combination thus formed is re- 
 markable for its stability, although, contrary to 
 what was formerly supposed, it can be displaced 
 by an indifferent gas or in a vacuum. Its crys- 
 tals are isomorphous with those of oxy-haemo- 
 
132 
 
 globin, but have a slight bluish tinge. Its 
 spectrum is almost identical with that of O-hse- 
 moglobin, but the two absorption bands are 
 moved very slightly nearer the violet end."''^ 
 The effect of this gas is to pm-alyze the red cor- 
 puscles which, until it is displaced, are incapable 
 of performing their functions. The symptoms 
 of this form of toxanasmia are coma, with ster- 
 torous respiration, pallor and coolness of the 
 skin, while the mucous membranes are bright 
 red; rigidit}^ of muscles, dilated pupils and 
 usually a slow, easily-compressible pulse. The 
 symptoms are, however, not uniform ; for cases 
 are reported in which there was no stertor, the 
 pulse was small and quick and the pupils con- 
 tracted. Convalesence is apt to be very slow. 
 In a case reported by Dr. John Graham in 
 the "Transactions of the College of Physicians 
 of Philadelphia," series iii, vol. viii, the patient, 
 a woman, aet. 74, was not able to sit up until 
 seventy-three days after the accident. 
 
 PARASITIC ANEMIA. 
 
 The parasites which have been thus farrecog- 
 
 *Articleon Blood, in " Wood's Reference Handbook," by 
 F. P. Henry. 
 
133 
 
 nized as causative of anasmia are the anchy- 
 lostomum duodenale, the bilharzia hsematobia, 
 the filaria sanguinis, the bothriocephalus latus, 
 and perhaps, also, the plasmodium malarise. 
 
 The anchylostomum duodenale was first 
 recognized by Griesinger, in 1854, as the cause 
 of a profound endemic anasmia, known as 
 Egyptian chlorosis. Since then it has attacked 
 the Italian laborers employed in the construction 
 of the St. Gothard tunnel, and has also prevailed 
 among brickmakers in Germany. The bilharzia, 
 first discovered by Bilharz in Egypt, in 185 1, 
 gives rise to anasmia by the hsematuria caused 
 by its presence in the body. The adult animals 
 lie in dilated blood vessels in the neighborhood 
 of the bladder or other urinary outlet, and the 
 symptoms are due to the interference with the 
 circulation and the irritation caused by the ova 
 on their way to the urinary passages. The 
 filaria sanguinis causes ansemia by interfering 
 with the lymphatic circulation. The obstruction 
 to the lymph vessels may be so great as to lead 
 to their rupture, in which event the lymph 
 escapes from the body, usually with the urine 
 (chyluria) ; sometimes, however, directly from 
 the integument, as in cases of lymph-scrotum. 
 
134 
 
 This parasite is quite common in certain tropical 
 and subtropical countries, especially in China, 
 and has recently acquired a new interest from 
 the discovery, by Dr. John Guiteras, of 
 Charleston, S. C, that it is indigenous to the 
 United States.* 
 
 The Plasmodium malarise is the hasmatozoon 
 discovered by Laveran in Algiers. It exists 
 within the red corpuscles and free in the blood, 
 and is probably operative in the causation of 
 malarial anaemia. This organism has been 
 studied by several careful observers ; in this 
 country particularly by Councilman,! of Balti- 
 more, and Osler,J of Philadelphia, although, to 
 quote the latter, " Laveran's original descrip- 
 tion is well nigh complete, and subsequent 
 workers have done little else than confirm his 
 results, though to Marchiafava and Celli is due 
 the credit of insisting upon the amcEboid char- 
 acter of the intra-cellular form." 
 
 * Medical News, April loth, 1886. 
 
 f " Transactions of the Association of American Physi- 
 cians," vol. i. 
 X British Medical Journal , March 12th, 1887. 
 
INDEX. 
 
 PAGES 
 
 Ansematosis, ?4, 69 
 
 Ansemia, predispositions to, 16, 17 
 
 senile, 18 
 
 congenital, 18 
 
 from hemorrhage, 22 
 
 latent, 25 
 
 lightest grade of, 31 
 
 highest grades of, 33 
 
 classification of, 46 
 
 lymphatica, synonyms of, 59 
 
 infective nature of, ' 65 
 
 nature of, 69 
 
 symptoms of, 70 
 
 diagnosis of, 72 
 
 prognosis of 73 
 
 treatment of, 74 
 
 splenica, 102 
 
 anatomical characters of, 103 
 
 clinical history of, 106 
 
 nature of, 109 
 
 course and prognosis of, iii 
 
 diagnosis of, 112 
 
 treatment of, 113 
 
 Blood-plates, 6 
 
 Chlorosis, 47 
 
 confused ideas concerning, 51 
 
 diagnosis of, 54 
 
 prognosis of, 57 
 
 treatment of, 58 
 
 Compte-globules of Malassez, 11 
 
 Corpuscles, red, i, 2 
 
 white, 4 
 
 Fibroadenia, 104 
 
 Globinometer, 14 
 
 135 
 
136 INDEX. 
 
 PAGES 
 
 Hsemacytometer, ii, 12 
 
 Hsematoblasts, 6 
 
 Hsemic unit, 54 
 
 Haemoglobin, 2 
 
 Hayem's formula for intra-venous injection, 42 
 
 Hematimetre, 11 
 
 Leucocrystallin, 85 
 
 Leucocythsemia, 75 
 
 nomenclature of, 75 
 
 anatomical characters of, 76 
 
 retinal changes in, 81 
 
 blood changes in, 82 
 
 clinical history of, 85 
 
 pathogenesis of, 88 
 
 lymphatic, a " myth^" 92 
 
 aetiology of, 94 
 
 diagnosis of, 95 
 
 prognosis of, 98 
 
 treatment of, 99 
 
 Leucocj'tosis, 76 
 
 Leukosin, 84 
 
 Microcytes, 7 
 
 Parasitic anaemia, 132 
 
 Pernicious anaemia, 114 
 
 nature of, 115 
 
 symptoms of, 123 
 
 anatomical characters of, 126 
 
 diagnosis of, 127 
 
 prognosis of, 128 
 
 treatment of, 128 
 
 Poikilocytosis, 34 
 
 Pseudochlorosis, 50 
 
 Schultze's granule masses, 6 
 
 Secondary anaemia, 129 
 
 Toxansemia, 130 
 
 Transfusion, 41 
 
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