Blood-pigment deposits which are demonstrable in all primary blood destruction, were absent.
The symptoms depend upon the gravity of the anemia. In milder cases there are no particular complaints except a gradually increasing pallor and the child, which does not thrive and is usually rachitic, may he quite vivacious. In severer eases the pallor increases and assumes a yellowish tint; the child becomes weak, ill at ease, peevish, lies down listlessly, and answers every attempt to change its position with pitiful crying. This is to a large extent occasioned by severe rachitic changes, and besides there are often intestinal disturbances, and a large percen tage suffer from bronchopneumonic affections following an exceedingly chronic course. In cases of this kind there are also febrile manifesta tions. Frequently there are slight luemorrhages in the skin and mucous membranes, less frequently on the surface, especially epistaxis. Retinal hemor rhages are hardly ever ob served even in severe cases.
Among the objective signs in severe cases there is always an enlarged spleen, but under certain circumstances only so slightly enlarged that it does not reach beyond the costal arch by more than 1 to finger's breadth, in other eases the spleen may reach down to the iliac crest and extend by sev eral fingers' breadth be yond the median line, so that its outlines are dis tinctly visible through the flabby abdominal wall when the child lies on its back. On palpation the organ feels strikingly hard and the incisure of the up per margin may often be felt distinctly. As a mat ter of course these enlarge ments distend the abdomen considerably, widen the inferior thoracic aperture and disturb the movements of the t hor a ci c organs. The liver is seldom much enlarged, hut if it does ex tend by two fingers' width beyond the costal arch, it generally feels soft. Muel'i :welling of the lymphati• glands is seldom present, but nodes the size of a pea or bean are often felt in the neck, axilla‘ and in the flexures at the elbow and groin.
The blood findings (see Plate S, Figs. 1 and 2) vary according to the degree of the anemia and show in various cases every gradation to the severest lesions. In mild cases there is hardly more alteration than a diminution of the hremoglobin, which may be followed later by a more or less important diminution of the red blood corpuscles. The hremo
globin quotient of the red blood corpuscles is diminished. As the an remia progresses, considerable differences in the size of the red blood corpuscles arc noticeable, forms but slightly indented, also here and there nucleated cells of normal size (normoblasts). The white blood cor puscles in mild cases without complications are but slightly increased beyond the normal number for the infantile period (10,000 to 20,000); the percentage of the lymphocytes corresponds about to the normal proportion for the first year of life. In the severest cases which are also classed as splenic or pseudoleukremic anremia, as explained before, the hremoglobin may sink to 30 per cent. of the normal and lower still, the number of red corpuscles to below a million. The amount of hremoglobin contained in the separate red blood corpuscles may vary considerably. The specific gravity may be materially reduced and the tendency to nummular formation may be absent. The red blood cor puscles exhibit considerable differences in size from dwarf to giant proportions, sometimes there is a pronounced poikilocytosis, polychro matophilia and in isolated cases granular degeneration. Nuclear forms are sometimes met with in such large quantities as hardly in any other blood affection, up to 20,000 in a c.mm. (Lehndorff), figures of many thousands are not rare, and as many as 25 per cent. may be megalo blasts. There is a considerable increase in the colorless blood cells up to 50,000, in fact, cases have been reported with initial leucocyte counts of 114,510 (Jaksch) and 122,222 (Baginsky) which have been cured. The increase concerns rather the mononuclear form, so that the per centage of polynuclear neutrophile cells (30-40 per cent.) may well appear diminished against the normal infantile figure; the proportion, however, is subject to changes. Besides, very frequently sonic neutro phile and eosinophile myelocytes are met with in cases which are like wise susceptible to improvement. "Mastzellen" exist only in small quantities. Often there arc strikingly large cells with round, stainable nuclei and abundant, coarse. weakly basophile or homogeneous proto plasm which is also stainable by eosin.