69

Mar.20

hypoplasia of the blood-vessels an important part in the pathology of the disease. The view that chlorosis is an autogenetic disease, due to the absorption of poisonous substances in the intestines, has been referred to by several writers. Schücking investigated the relation of the disease to menstrual disorders, and found, in 700 cases, irregularity of menstruation in 652, of which 124 had been regular before; temporary amenorrhoea in 200; total amenorrhoea in 43; menorrhagia in 85, alternating with scanty menstruation in 10 cases, and in 246 of the cases menstruation was never well developed.

88

69

Limbeck opposes the old view, recently revived by Graeber, that the blood of chlorosis shows oligochromamia without oligocythæmia, basing his objection on the study of 16 cases, in which there was oligocythæmia as well as diminution of hæmoglobin. In his study of 84 cases, Schücking found the number of corpuscles reduced little below 4,000,000 in 58, considerably below this in 26, and once as low as 2,200,000, the latter group of cases being in older persons. This oligocythæmia, he holds, is secondary to the diminution in coloring matter.

6

27

Mar.26

Richardson, has contributed an interesting paper on the bruit de diable and venous hums in chlorosis. The former occurred in 51.4 per cent. of his cases,―a proportion which is low, inasmuch as he used the hæmoglobinometer, which detects the disease in the absence of pallor and other visible signs. As to venous hums, he found, in 180 cases, none in 49.4 per cent.; on the right side only in 33.3; on the left side in 6.1, and on both sides in 11.1 per cent. Of 27 cases in which relapses occurred, 66 per cent. had venous hums,—a fact which may prove of some use in prognosis. The bruits usually disappeared when the hæmoglobin showed some increase, which Richardson looks upon as a proof that they are the result of anæmia. Barr found, in 205 cases, 115 with cardiac bruits. Of these, 56 were audible at the base, 13 at the apex, 24 at base and apex, and 22 at base, apex, and back. The last group were always accompanied by distinct dilatation of the ventricle and strong impulse; they were the first to disappear under treatment, a fact which shows that they are present in the more advanced cases. In 2 of the 22 cases, the murmur persisted after seven and nine months, respectively, and Barr thinks that these will remain as permanent mitral regurgita

5 Oot.

17

Dec. 9,90

3

tions. Schubert, found the venous hums to disappear after bleeding cases of chlorosis, and concludes from this fact that the cause of these is a plethora, due to hypoplastic blood-vessels. Potain 17 Dec 23,30,90; Dec.13, regards many of the bruits supposed to be intracardiac as really due to the action of the heart against the lungs. Fever may occur in the course of chlorosis, and is the feature of a variety of the disease first described by Mollière. Paul Chéron makes three classes: cases with (1) continuous, (2) intermittent, and (3) inverted fever. The continuous form is perhaps commonest; the intermittent-of which a remarkable case, with wasting, cough, and other suspicious symptoms, occurred in the practice of Jaccoud-is least so. Hayem regards cases of pure "febrile chlorosis" as very rare, the cases usually so regarded being due to fatigue or other complications. Potain saw one case, and thinks most of them are due to constipation and absorption of poisons from the bowels.

3

Nov.A

17

Dec. 23,30,*90

Dec. 30, '90

Dyspepsia in chlorosis has received no small degree of attention, especially as it interferes with treatment. Labat 100 points out that there may be a dyspepsia medicamentosa in addition to the dyspepsia chlorotica. Hayem investigated 72 cases of chlorosis, and found excess of pepsin in 36, decrease in 28; excess of hydrochloric acid in 6, and normal gastric juice in 2. He remarks that, in boys and girls at the age of adolescence, there is commonly some dyspepsia from "hyperpepsia," and that the advent of chlorosis makes this prominent. Liégeois, 184 Labat, De Chéron, De, and others believe the dyspepsia of chlorosis to be due, as Hayem first pointed out, to lack of hydrochloric acid. Ketcher investigated the urine of chlorotics, and found the quantity discharged about normal, specific gravity decreased, as also the amount of urea, uric acid, phosphates, chlorides, and sulphates. The quantity of extractives was increased. Diminution of urea and uric acid was in about equal proportion.

100

30,90

586

No.46,90

17

Dec.23,30,90

17

9,90

Sept.15

Potain, pee in a clinical lecture, warns against hasty diagnosis of chlorosis from mere inspection, pointing out various deceptive features, including certain anesthesias and analgesias, comparable to those of hysteria, but not to be confounded with such. he regards as a common symptom. The disease has been growing more infrequent, owing to the better hygienic conditions of our

Asthma

100

100

Jan.16

Treatment.-Iron is the generally acknowledged remedy for this disease. The French writers especially have been busied in seeking forms of ferruginous preparations which might be active and, at the same time, acceptable to the stomach. Maistre recommends the "peptonate of iron of Robin," which, he says, is assimilable, dialyzable, non-irritating, and may be given in wine, lozenges, or drops. It is of especial value where the stomach is irritable. Labat, in calling attention to the absence of hydrochloric acid as a factor in chlorotic dyspepsia, suggests the combination of this acid with iron in the treatment, and recommends two preparations. The first, "phospho-fer," a chlorhydrophosphate of iron, contains 0.10 gramme (13 grains) of phosphate of iron in the tablespoonful; the second, "phospho-fer-calcique," has 0.05 gramme (grain) of phosphate of iron and 0.25 gramme (3 grains) of phosphate of calcium in the tablespoonful. Both are limpid, stable, tasteless fluids, the latter especially being useful in children.

Nos. 42,43,90

3

Nov.4

Kahane insists on rest, together with clysters for the bowels, iron, and arsenic. Liégeois remarks that treatment must vary, according as the case is simple or complicated with gastric, intestinal, vascular, nervous, or ovarian troubles. In dyspeptic cases he advises hydrochloric acid after each meal, and uses reduced iron, or the malate, tartrate, or citrate, if necessary. When these cause disturbances, he tries the albuminate or peptonate of iron, and, finally, in the most obstinate cases, ferruginous waters or hypodermatic administration. Hayem points out how the dyspeptic disorders so often met with may become a serious obstacle to active treatment, and advises that such cases be looked upon and treated as simple dyspepsias, until the stomach be brought into condition for the treatment of the chlorosis itself. Allbutt regards the alkali in the much-used Blaud's pill as unnecessary, and, further, ascribes many failures to cure chlorosis to the insufficiency of iron given. He advises the sulphate of iron, -at first, 1 grain (0.065 gramme), three times daily, for a week; then 2 grains (0.13 gramme) for ten days; and, finally, increased to 9, 10, or 12 grains (0.58, 0.65, or 0.78 gramme) daily. The pills should be freshly made, without admixture of gum; and, in case of constipation, should contain extract of aloes. When pills cannot be taken, the saccharated carbonate may be used. Mac

2

Feb.14

He

kenzieq also thinks the alkali in. Blaud's pill excessive. advises a pill containing 2 grains (0.13 gramme) of the dried sulphate of iron, 1 (0.07 gramme) of carbonate of potash, and enough glycerite of tragacanth to make the pill. Treatment must be prolonged, as the hæmoglobin increases less promptly than the corpuscles, and relapses may occur.

The hypodermatic administration is advised by various writers in obstinate cases. Bongiovanni, reports a case of very marked chlorosis in a girl of 13, who had taken iron for three months without avail, and who subsequently made a rapid and complete recovery under treatment with subcutaneous injections of iron. The preparation used was a solution of ammoniated citrate of iron, 1.20 grammes (183 grains) in distilled water and laurel-water, of each, 5 grammes (1 drachms). Injections were made with the Pravaz syringe, 0.02 gramme (grain) of the salt being first injected, and, finally, as much as 0.12 gramme (1 grains) at a time. Subcutaneous injections are painful and irritating, but those deep into the muscles, followed by vigorous massage, never caused unpleasant results. Morgagni records his experience with 10 cases of chlorosis treated by subdermal injections of iron. He used the pyrophosphate and citrate and the citro-ammonium pyrophosphate of iron, in 5-per-cent. solution, and in dose of 3 grammes (46 grains). The injections were made with a long needle, so that the solution might be deposited some distance from the point of puncture. Speedy cure was obtained in every case. Liégeois 35,112 reports 30 cases treated with the acetophosphate of copper. Two pills, each containing grain (0.011 gramme) of neutral acetate of copper, were given daily before meals, mint-water with hydrochloric acid after meals, and tincture of nux vomica in the intervals. Patients took this from one to three months without trouble, taking in all 60 to 100 pills.

Jan.24

Apr.30

Jan.7; June

The almost paradoxical treatment instituted by Dyes, viz., repeated bleedings, has been freely lauded and condemned. Scholz, of Bremen, in a work on "Chlorosis," in which the blood condition is treated of as secondary to contraction of blood-vessels, regards chlorosis as, in fact, a plethora. He, therefore, reasons that depletion would answer the therapeutic indication, and records his results in 30 cases treated by hot baths and venesection. The improvement was marked in every case, and urgent symptoms disap

May 2

peared almost at once. Schubert 84, coincides in his views with Scholz, and, like him, found the treatment of great practical usefulness. He advises bleeding in bed, 0.5 to 1 gramme (74 to 15 grains) of blood for every pound of weight being removed, and that the patient subsequently be kept in bed twenty-four to fortyeight hours. After venesection, sweating, care in diet, and stay at the sea-shore are useful adjuncts to the treatment. Wilhelmi, in opposing the views of Schücking, who regards bleeding as theoretically and practically unwise, remarks that, in 56 cases, he had found the treatment of great service, and uniformly prompt to effect improvement. Schücking, however, saw cases in which great depression was caused by the treatment, and regards success as due to diminution in uterine or ovarian congestion rather than to removal of plethora.

2

et seq.

69 Mar.26

ANEMIA.

69

Mar.26

The most important contributions to the literature of anæmia during the last year are the Lettsomian Lectures delivered by Stephen Mackenzie. Jan.1. After a consideration of some of the problems of blood formation and destruction, to which reference has been made above, the lecturer proceeds to the study of the anæmias, which he would classify as (a) those due to excessive hæmolysis and (b) those due to defective hæmogenesis. He makes four degrees of anæmia, according to the corpuscular richness, but admits that this is not as scientific a classification as that of Hayem, in which the individual corpuscular richness in hæmoglobin is taken as a standard. The number of red corpuscles may, he says, be extremely reduced, and he refers to the case of a child in which the number fell to 290,000 shortly before death. Decreased amount of hæmoglobin, while more or less characteristic of chlorosis, is likewise met with in some cases of cancer and purpura. The hæmorrhages of anæmia are due to the degree and not the kind of anæmia. When the number of red corpuscles falls below 50 per cent. hæmorrhages are likely to occur, and he points out that this time may be roughly estimated by noting that the pink color under the finger-nail has entirely disappeared. The remedial drugs he would divide into two groups: (a) those which increase blood formation and (b) those which lessen destruction,-the antihæmolytics. Of the former, we have iron, potash, manganese, phosphorus, arsenic (?), hydrochloric acid (indirectly), and oxygen.