312 THE ANEMIAS 



cells of normal size or smaller; the smallest forms, the microcytes, are fre- 

 quently observed. 



All other peculiarities of simple anemia are to be found in progressive 

 pernicious anemia: Poihilocytosis, polychromatophilic degeneration, and 

 " stippled " erythrocytes; contrary to the rule in simple anemia stippled eryth- 

 rocytes are found with great regularity in progressive pernicious anemia. 



The red corpuscles are always noticeably reduced, often to the low figure 

 of 30 per cent, to 10 per cent, of the normal. 



The leukocytes are often absolutely reduced, but not always; moreover, a 

 neutrophilic hypoleukocytosis is often found. [Especially in the remissions 

 of the disease when the number of red cells is rapidly increasing and the mar- 

 row is very active. — Ed.] 



The other blood values differ little from those of severe cases of simple 

 anemia. The hemoglobin percentage, the specific gravity, the amount of sol- 

 ids, and the amount of albumin show a diminution of their values correspond- 

 ing with the grade of the disease. [Why the authors do not mention at this 

 point the high color-index, i. e., the relatively increased hemoglobin which is 

 so characteristic (though not invariable) in the disease, I do not under- 

 stand. — Ed.] 



According to this, of all the changes in the blood, only the changes in the 

 size of the erythrocytes, and the formation of the nuclei of the erythroblasts 

 denote the variety of anemia. The appearance of megalocytes and megalo- 

 blasts is characteristic of progressive pernicious anemia, while their permanent 

 absence is indicative of the simple form. For megaloblasts and megalocytes 

 appear in the blood only when some region of the bone-marrow shows a megalo- 

 blastic degeneration. The simultaneous occurrence of normoblasts, normo- 

 cytes, and smaller forms, as well as a temporary predominance of one or the 

 other of these forms, is not at all surprising when we consider that the trans- 

 formation of the bone-marrow is always only partial, and is often limited to 

 very small areas, while in the other regions of the bone-marrow the blood ele- 

 ments are produced physiologically. 



The other properties of the blood can only be looked upon as denoting the 

 DEGREE of the disease, as in simple anemia. We must expressly state that 

 in undoubted cases of progressive pernicious anemia moderate values of the 

 hemoglobin, a moderate number of red blood-corpuscles, a moderate specific 

 gravity, etc., may be found; Avhile, on the other hand, minimal values are met 

 with in positive cases of simple anemia. It follows that the degree of anemia 

 is, to a certain extent, independent of its type. 



In the CLINICAL picture of progressive pernicious anemia marked charac- 

 teristics are a peculiar pallor and a slight puffiness of the skin, which may 

 enable the physician to guess the diagnosis at the first glance. No word will 

 exactly describe the color of the skin ; the designation " faded-yellow " perhaps 

 best portrays the real condition, but no description can take the place of per- 

 sonal observation. 



Moderate jaundice is frequently present, and slight edema may be almost 

 always noticed in the face, in the abdomen, and in the legs. 



The contrast between the severity of the constitutional symptoms and the 



