diseases which are caused and characterized by numerical loss or waste in the actual or normal numbers of the red corpuscles. (Instead of existing in the proportion of 130 per 1,000 parts of the blood as in health, they are reduced to a
80, 60,
or even
less.)
Individually the red corpuscles, although numerically weak, may be enlarged but there is no diminution of the quantity of hemoglobin
NOTES ON ANEMIA, ITS PATHOLOGY AND TREATMENT. By Surgeon ALES. S.
FAULKNER, Bombay Army.
i
M.S.,
Although the following lines may seem to be recapitulation of more or less known facts, yet I think the importance of the subject warrants their reproduction. Of all the most striking symptoms one notices amongst Europeans resident in the tropics and even amongst Natives themselves, none perhaps is more universally apparent than anaemia. Amongst the numerous terms by which different diseases are known to us, none is more inappropriately applied and generally misleading than the word anaemia, as, pathologically, the diseases iucluded under this term differ markedly from each other. Indeed, as a broad statement, I may say that the term anaemia iu its usual adaptation is used more to describe a symptom thau an actual disease. Auy derangement of the blood causing loss of colour and giving the face or conjunctiva} a blanched appearance are all alike, incorrectly, included under this term. Pathology?Anaemia being essentially an affection of the blood, I will refer to the latter as a circulating tissue, the most importaut constituents of its protoplasmic bases being the corpuscles, of these the red corpuscles and the haemoglobin contained in them, individually and collectively, are especially concerned in the pathological anaaffection. tomy of this In other words, the causation of two distinct varieties or classes of anaemia is traceable, of the red pathologically, to the condition of the blood. corpuscles aud the haemoglobinare included those In the first class or variety a
characterized anatomically diseases which contained a diminution of the haemoglobin by in the red corpuscles with no consequent diminution in the normal number of the corpuscles themselves. Under tlie second class or variety are those are
contained in each, and, on the contrary, if any are thus enlarged, the enlargement is due to an increased absorption of hemoglobin. The above anatomical facts in these diseases can fairly be demonstrated by Dr. Gower's "Hemacytometer" for ascertaining the numerical strength of the blood corpuscles and by his " Hemoglobinometer" for the clinical estimation of hemoglobin. With reference to these two classes it must be noted that the anatomical differences enumerated above refer only to marked and characteristic diseases of each variety. Undoubtedly there are intermediate types of anemia which are constantly met with, and which pathologically combine the two, and hence in these cases a combination in treatment would be necessary. Excluding those it will be seen we have two distinct varieties of disease to all of which a single term is applied, viz., anemia. Consequently this term is misleading, and its mere existence tends to originate errors in treatment which I fear are not uncommon, especially if the pathology of these affections is not referred to as the bases, or at any rate as an aid to their treatment. The characteristic diseases under the first class in which hemoglobin-formation is depressed include chlorosis or chloremia, anemia due to renal, febrile and other acute diseases. Of, all these chlorosis is the most characteristic as it is the most common disease of this group. Coming to the second class in which the essential feature is depressed, corpuscle-reproduction, are included those diseases which most concern us working in the tropics, the most characteristic being pernicious anemia, mala^
spleen anemia, lymphatic anemia, &c., in fact, most diseases, with anemia, as a prominent symptom and more or less of a rial and
chronic nature first variety.
as
compared
to those under
the
I will now briefly refer to some more recent and important hypotheses on the further pathology of these affections. Chlorosis.?Sir Andrew Clark in his paper entitled " Observations on the Anemia and Chloro sis in Girls,"1 brought to the notice of the profession that chlorosis and anemia in young o-ir]a 0jnervous temperament and imperfectly developed sexual organs was probably due to the -
absorp-
1
Medical Society of
London, November
1887.
THE INDIAN MEDICAL GAZETTE.
9R4
[Sept.
1890.
is indeed the tiou in the system of poisonous materials ela- mia iu the tropics, states that it and of digescause of fever, of disease, spleen borated in faecal matter which has been abnortive disorders quite as often as the consequence," mally retained in the viscera. I cannot say " that blood-degeneration is initiathow far experience has confirmed this theory, and further in ed of the European from the very the system but it is one, which, in my humble opinion, commencement of tropical residence." I can would be the cause of a good many diseases quite appreciate that anaemia might be the reother than the chlorosis of young girls. sult of continued residence in a tropical climate Mr. Lawson Tait disputes the relation bein one whose constitution is foreign to such a tween chlorosis and menstruation, and refers climate, but I cannot conceive that " blood-deto the occurrence of pregnancy iu such cases. be initiated in sucli Dr. Stephenson in his analyses of over 200 generation" can possibly a system from the commencement of tropi" 1 very found that cases of chlorosis the chlorotic cal residence. diatheses accelerated the appearance of the With reference to the blood changes in anosmenses, and that it is not a cause of retarded Sir W. Moore believes that anaemia must mia, appearauce of the catamenia." Whilst discussascribed be to a deteriorated condition of albuing this subject a paper by Dr. Holies2 is minoid In and of red particles. compounds of He worthy perusal. appropriately substi- what are deteriorated former manner the precise tutes the term chloromia "for chlorosis, and " may defines the disease as a blood disorder, either cannot even be safely conjectured, but it of surmised be formathat the corpuscle power or with associated other ailments, idiopathic tion is more or less abolished, and that corpusconsisting essentially of a greatly diminished cles formed have little power to absorb haemopercentage of haemoglobin and of a variable globin, aud consequently do not reach their full decrease in that of the red corpuscles." Pernicious ancemia.?Returning to those di- development." On this same subject Dr. Maclean1 is seases under the second variety of which perni- more explicit. He " states the number of red cious anaemia is characteristic, there is very little doubt that so far as our present knowledge of this globules diminishes sometimes to the extent of lose much of their red colour affection is concerned, very little is known as to 75 per cent., they and their spherical shape are slow to gather into in these its causation. cases there Undoubtedly and their edges become serrated." is an abnormal destruction of red corpuscles, but rouleaux now to the treatment Treatment.?Proceeding how this condition is caused has not yet been time from immemorial been it has of anaemia, defined. Dr. W. Hunter 3 isolated a ptomaine custom to vaguely prescribe iron in its the which closely corresponded to putrescine from forms in all cases where anaemia was the urine in a case of pernicious anaemia, and different uu objective symptom; in fact, a white, colourthe loss or waste of the red corpuscles he conseless, face or n blanched appearance of the quently assigned to the presence of this specific mucous linings at once seemed to be an indicaorganism iu the system, but how far in theory tion for the administration of iron. alone can this information be accepted as appliFrom the anatomical distinctions of the two cable to all such cases ? of anaemia, it is obvious, that varieties although affection this states Dr. Motfc in referring to blanched appearance, which we have a general that an examination of the blood shows the is due to the want of the normal numbers of corpuscles greatly diminished in numbers, the red corpuscles, that iron, in these cases not is diminution of colouring matter proportional In one case the only is non-indicated, but its administration to the falling off in number. be harmful. In other words, the blood corpuscles were one-sixth of the normal and may contains a sufficient amount of haemoalready to one-sixth. the hajmoglobin also reduced and does not call for an excess of iron Malarial and splenic ancumia. With refer- globin, but what is actually deficient the in system, ence to malarial and splenic anaemia or "cachexia" How often, however, ia are the red corpuscles. Sir as this condition is familiarly known, Joseph this drug alone indiscriminately prescribed iu the "On his Malarial in chapter Fay re r states cases ? these Splenic Cachexia"4 that the "blood is rendered The true value of this drug, on the contrary, unfitted for the purposes of perfect nutrition, its seen in its administration iu those diseases is most important defects, perhaps, being those of mentioned under 'the first class, and the relation, quantity and quality of the cor- chlorosis or chloremia as the type, theretaking is no " puscles be that iu iron doubt this disease may regarded Sir William Moore5 in referring to anaeas a specific. The system suffers from the want ^ Transactions of the Obstetrical Society for 1889. of haemoglobin iu its red corpuscles, and to Q Chloreinia and its Treatment." B. M. J. May 31st 1 o 3\). artificially supply this want, the administration 3 Case of Pernicious Anosmia." Medical Society of London, March 31, 1890. 1 Lectures on Diseases of Tropical Climates. By W, C. Tropical Diseases by Sir Joseph Fayrer. K.C.S.l. 5 i Maclean, m.d.. c.b. Diseases of India. By W. J. Moore, c.l.E. "
"
"
'
.
Sept.
Du. MOORHEAD ON CEREBROSPINAL FEVER,
1890.]
265
iibsorb hemoglobin and are already overof irou is indicated. Sir William Moore rewith iron. Phosphorous has been tried charged ferring to this disease states: "It lnu3t and be found wanting. Probably the best tonics understood that chlorosis is dependant as much are quinine and arsenic." on scanty absorption of iron into the system asNo doubt this advice, based on true patholoon a deficient supply of iron; hence unless gical grounds, is correct so far as medicinal combined with well regulated sanitary condiadjuncts are concerned in the treatment of tions and hygiene, iron will do little
80, 60,
or even
less.)
Individually the red corpuscles, although numerically weak, may be enlarged but there is no diminution of the quantity of hemoglobin
NOTES ON ANEMIA, ITS PATHOLOGY AND TREATMENT. By Surgeon ALES. S.
FAULKNER, Bombay Army.
i
M.S.,
Although the following lines may seem to be recapitulation of more or less known facts, yet I think the importance of the subject warrants their reproduction. Of all the most striking symptoms one notices amongst Europeans resident in the tropics and even amongst Natives themselves, none perhaps is more universally apparent than anaemia. Amongst the numerous terms by which different diseases are known to us, none is more inappropriately applied and generally misleading than the word anaemia, as, pathologically, the diseases iucluded under this term differ markedly from each other. Indeed, as a broad statement, I may say that the term anaemia iu its usual adaptation is used more to describe a symptom thau an actual disease. Auy derangement of the blood causing loss of colour and giving the face or conjunctiva} a blanched appearance are all alike, incorrectly, included under this term. Pathology?Anaemia being essentially an affection of the blood, I will refer to the latter as a circulating tissue, the most importaut constituents of its protoplasmic bases being the corpuscles, of these the red corpuscles and the haemoglobin contained in them, individually and collectively, are especially concerned in the pathological anaaffection. tomy of this In other words, the causation of two distinct varieties or classes of anaemia is traceable, of the red pathologically, to the condition of the blood. corpuscles aud the haemoglobinare included those In the first class or variety a
characterized anatomically diseases which contained a diminution of the haemoglobin by in the red corpuscles with no consequent diminution in the normal number of the corpuscles themselves. Under tlie second class or variety are those are
contained in each, and, on the contrary, if any are thus enlarged, the enlargement is due to an increased absorption of hemoglobin. The above anatomical facts in these diseases can fairly be demonstrated by Dr. Gower's "Hemacytometer" for ascertaining the numerical strength of the blood corpuscles and by his " Hemoglobinometer" for the clinical estimation of hemoglobin. With reference to these two classes it must be noted that the anatomical differences enumerated above refer only to marked and characteristic diseases of each variety. Undoubtedly there are intermediate types of anemia which are constantly met with, and which pathologically combine the two, and hence in these cases a combination in treatment would be necessary. Excluding those it will be seen we have two distinct varieties of disease to all of which a single term is applied, viz., anemia. Consequently this term is misleading, and its mere existence tends to originate errors in treatment which I fear are not uncommon, especially if the pathology of these affections is not referred to as the bases, or at any rate as an aid to their treatment. The characteristic diseases under the first class in which hemoglobin-formation is depressed include chlorosis or chloremia, anemia due to renal, febrile and other acute diseases. Of, all these chlorosis is the most characteristic as it is the most common disease of this group. Coming to the second class in which the essential feature is depressed, corpuscle-reproduction, are included those diseases which most concern us working in the tropics, the most characteristic being pernicious anemia, mala^
spleen anemia, lymphatic anemia, &c., in fact, most diseases, with anemia, as a prominent symptom and more or less of a rial and
chronic nature first variety.
as
compared
to those under
the
I will now briefly refer to some more recent and important hypotheses on the further pathology of these affections. Chlorosis.?Sir Andrew Clark in his paper entitled " Observations on the Anemia and Chloro sis in Girls,"1 brought to the notice of the profession that chlorosis and anemia in young o-ir]a 0jnervous temperament and imperfectly developed sexual organs was probably due to the -
absorp-
1
Medical Society of
London, November
1887.
THE INDIAN MEDICAL GAZETTE.
9R4
[Sept.
1890.
is indeed the tiou in the system of poisonous materials ela- mia iu the tropics, states that it and of digescause of fever, of disease, spleen borated in faecal matter which has been abnortive disorders quite as often as the consequence," mally retained in the viscera. I cannot say " that blood-degeneration is initiathow far experience has confirmed this theory, and further in ed of the European from the very the system but it is one, which, in my humble opinion, commencement of tropical residence." I can would be the cause of a good many diseases quite appreciate that anaemia might be the reother than the chlorosis of young girls. sult of continued residence in a tropical climate Mr. Lawson Tait disputes the relation bein one whose constitution is foreign to such a tween chlorosis and menstruation, and refers climate, but I cannot conceive that " blood-deto the occurrence of pregnancy iu such cases. be initiated in sucli Dr. Stephenson in his analyses of over 200 generation" can possibly a system from the commencement of tropi" 1 very found that cases of chlorosis the chlorotic cal residence. diatheses accelerated the appearance of the With reference to the blood changes in anosmenses, and that it is not a cause of retarded Sir W. Moore believes that anaemia must mia, appearauce of the catamenia." Whilst discussascribed be to a deteriorated condition of albuing this subject a paper by Dr. Holies2 is minoid In and of red particles. compounds of He worthy perusal. appropriately substi- what are deteriorated former manner the precise tutes the term chloromia "for chlorosis, and " may defines the disease as a blood disorder, either cannot even be safely conjectured, but it of surmised be formathat the corpuscle power or with associated other ailments, idiopathic tion is more or less abolished, and that corpusconsisting essentially of a greatly diminished cles formed have little power to absorb haemopercentage of haemoglobin and of a variable globin, aud consequently do not reach their full decrease in that of the red corpuscles." Pernicious ancemia.?Returning to those di- development." On this same subject Dr. Maclean1 is seases under the second variety of which perni- more explicit. He " states the number of red cious anaemia is characteristic, there is very little doubt that so far as our present knowledge of this globules diminishes sometimes to the extent of lose much of their red colour affection is concerned, very little is known as to 75 per cent., they and their spherical shape are slow to gather into in these its causation. cases there Undoubtedly and their edges become serrated." is an abnormal destruction of red corpuscles, but rouleaux now to the treatment Treatment.?Proceeding how this condition is caused has not yet been time from immemorial been it has of anaemia, defined. Dr. W. Hunter 3 isolated a ptomaine custom to vaguely prescribe iron in its the which closely corresponded to putrescine from forms in all cases where anaemia was the urine in a case of pernicious anaemia, and different uu objective symptom; in fact, a white, colourthe loss or waste of the red corpuscles he conseless, face or n blanched appearance of the quently assigned to the presence of this specific mucous linings at once seemed to be an indicaorganism iu the system, but how far in theory tion for the administration of iron. alone can this information be accepted as appliFrom the anatomical distinctions of the two cable to all such cases ? of anaemia, it is obvious, that varieties although affection this states Dr. Motfc in referring to blanched appearance, which we have a general that an examination of the blood shows the is due to the want of the normal numbers of corpuscles greatly diminished in numbers, the red corpuscles, that iron, in these cases not is diminution of colouring matter proportional In one case the only is non-indicated, but its administration to the falling off in number. be harmful. In other words, the blood corpuscles were one-sixth of the normal and may contains a sufficient amount of haemoalready to one-sixth. the hajmoglobin also reduced and does not call for an excess of iron Malarial and splenic ancumia. With refer- globin, but what is actually deficient the in system, ence to malarial and splenic anaemia or "cachexia" How often, however, ia are the red corpuscles. Sir as this condition is familiarly known, Joseph this drug alone indiscriminately prescribed iu the "On his Malarial in chapter Fay re r states cases ? these Splenic Cachexia"4 that the "blood is rendered The true value of this drug, on the contrary, unfitted for the purposes of perfect nutrition, its seen in its administration iu those diseases is most important defects, perhaps, being those of mentioned under 'the first class, and the relation, quantity and quality of the cor- chlorosis or chloremia as the type, theretaking is no " puscles be that iu iron doubt this disease may regarded Sir William Moore5 in referring to anaeas a specific. The system suffers from the want ^ Transactions of the Obstetrical Society for 1889. of haemoglobin iu its red corpuscles, and to Q Chloreinia and its Treatment." B. M. J. May 31st 1 o 3\). artificially supply this want, the administration 3 Case of Pernicious Anosmia." Medical Society of London, March 31, 1890. 1 Lectures on Diseases of Tropical Climates. By W, C. Tropical Diseases by Sir Joseph Fayrer. K.C.S.l. 5 i Maclean, m.d.. c.b. Diseases of India. By W. J. Moore, c.l.E. "
"
"
'
.
Sept.
Du. MOORHEAD ON CEREBROSPINAL FEVER,
1890.]
265
iibsorb hemoglobin and are already overof irou is indicated. Sir William Moore rewith iron. Phosphorous has been tried charged ferring to this disease states: "It lnu3t and be found wanting. Probably the best tonics understood that chlorosis is dependant as much are quinine and arsenic." on scanty absorption of iron into the system asNo doubt this advice, based on true patholoon a deficient supply of iron; hence unless gical grounds, is correct so far as medicinal combined with well regulated sanitary condiadjuncts are concerned in the treatment of tions and hygiene, iron will do little
