shows : enormous pallor of all internal or gans, hemorrhages, especially in the serous membranes, fatty degenera tion, especially pronounced in the cardiac muscle, siderosis of the liver (ha‘mosiderosis), in some cases atrophy (anadenia) of the gastric and intestinal mucous membranes which however may not be regarded as specific manifestation of the affection, transformation of the yellow mar row of the long tubular bones into red marrow, which may also occur in other amemias (E. Neumann), whereas, on the other hand, yellow mar row may be, found in pernicious anemia (aplastic marrow, Ehrlich), in which case there should be no nuclear cells in the blood. The red marrow of pernicious anemia is, according to Ehrlich, megaloblastic.
The course of the disease may be subacute or decidedly chronic, frequently there are also relapses following improvements. Death ensues in coma owing to progressive weakness.
The prognosis depends partly upon the cause. Can the latter be removed, as in the ease of intestinal parasites, the affection is amenable to treatment. But also in the cases of obscure origin the prognosis is not absolutely unfavorable under appropriate therapy, a point again and again emphasized by Grawitz.
The diagnosis of pernicious anteinia, is made by the haemorrhages in the retina., possibly by a demonstration of urobilinuria, and finally by the blood examination. In children over four years old'and in adults the demonstration of megaloblasts is important, but not in younger children. Against a diagnosis of pseudoleukremic anaemia speak a dim inution of the white blood cells, excessive diminution of the red, and perhaps a considerable poikilocytosis; on the other hand nuclear red cells exist in large numbers in pseudoleukcemic anemia.
The therapy should pay particular attention to etiological condi tions: the first thought should be of intestinal parasites; Lazarus' ad vice to administer an antiparasitic medicine (extract of male fern) even where no eggs can be detected, seems well worthy of consideration; the second thought is of syphilis (osteosclerosis), although the therapy (iodine and mercury) does not seem to hold out many chances in these cases; in the third place stand occult haemorrhages especially in the gastro-intestinal canal—there arc very exact methods of examination now to detect blood in the gastric contents and in the feces; in the fourth place should be mentioned the possibility of chronic effects of carbon monoxide and lead; in the fifth place, the gastro-intestinal canal should be treated by irrigation of the stomach and intestine, administration of hydrochloric acid, salol, calotnel, or better by bitters, etc. The diet should be easily digestible, very nutritious (albuminoid
with vegetables preponderating in the beginning). The appetite should be stimulated and care taken to provide rest, light and air. There is only one medicine which is sometimes attended with excellent results, and that is arsenic in drops or pills. Children of S-15 years receive up to .1-1- of the maximum adult close; or it may be injected subcutaneously. According to Ziemssen's method 1 Gm. (15 grains) arsenic is dissolved in 5 c.c. (1 dr., trt 15) boiling normal soda solution, then distilled water is added to make 100 c.c. (3 oz., 2 dr.), and filtered; in adults a sterile injection is made of 0.001 c.c. (II up to 0.01-0.02 c c. (nt or sterilized subcutaneous injections may be made of sodium cacodylicum Merck in doses of 0.05-0.1 c.c. (rit 1-11) in adults. It is always neces sary to commence with very small doses, increasing or diminishing the same slowly, this being the method to avoid intoxicating phenomena. Among the latter, pigmentation of the skin is without. importance, while susceptibility of the buccal mucous membrane, gastric pains, (edema of the eyelids, herpes zoster, would demand at least a temporary inhibition of the medication, although it is perfectly possible that these symptoms may partly be occasioned by the Finally the injection of small quantities of defibrinated blood in very grave cases should be considered. Surprising, although unfortu nately only transitory results (Quincke, Ewald) have been attained by the introduction of small quantities (40 c.c.), the cause of which is prob ably to be found in the extreme reaction of the organism to its intro duction (Bier), as shown by severe manifestations, high fever, etc.