1. B. The best example of anemia which depends upon diminution of the hemoglobin content of the red cells is that known as chlorosis. In this there are few recognizable signs of destruction of corpuscles, even under chemical microscopic examination; consequently the blood picture is very simple. The color index is very low, yet similar conditions may also be seen in syphilis, tuberculosis, and cancer. The underlying feature of all of these cases is malnutrition.
Within a few years a peculiar form of intense anemia has been described by Banti and others, and is often spoken of as splenic anemia or Banti’s disease. It is characterized by three stages: first, of splenic enlargement and anemia; second, a transitional stage; third, a stage of ascites which increases up to death. It is quite closely allied to Hanot’s hypertrophic cirrhosis of the liver. It is quite generally regarded as an example of an infection by some as yet unknown organism. It is of interest to the surgeon because if the spleen is removed early there are fair prospects of recovery.
2. A. Anemias with marked leukocytosis include especially those first spoken of by Virchow as leukemia. Originally he applied the term to a particular alteration of the blood, but it is now made to cover a group of diseases, all of which are characterized by peculiar and more or less similar increase of white corpuscles. Sometimes these are increased to such an extent as to make the blood grossly resemble a mixture of blood and pus. This resemblance led some of the earlier observers to speak of the condition as “suppuration of the blood.” The number of leukocytes is sometimes enormously increased; 1 to 10 of the red cells is quite common and 1 to 5 not exceedingly rare. Cases have been known in which the white cells outnumbered the red. In well-marked cases of leukemia, the red cells will be somewhat diminished, while the white will number from 100,000 to 500,000 per cubic millimeter. Accompanying this change in the blood there are alterations in the spleen, the lymph nodes, and the bone-marrow, sometimes one predominating, sometimes another. It has been customary in fact to speak of splenic, lymphatic, and medullary leukemia, but these forms are not sharply differentiated and a pure type of either form is rare. In this country we speak mainly of lymphatic and splenomedullary forms, the latter being much more common. The latter is accompanied by enlargement of the spleen, while in the lymphatic form the lymph nodes are involved and may become as large as walnuts. In the lymphatic form over 90 per cent. belong to C and D; in the splenomedullary or splenomyelogenous form the increase of F and G is most marked, while A will be reduced to 50 per cent. and D to about 10 per cent. The red corpuscles are decreased in number, but not necessarily in an inverse ratio; their number may be reduced even to 2,000,000 in extreme cases.
In these cases, besides the change in number and form of the leukocytes already described, there are frequently found in the blood very minute crystals first described by Charcot. These are small, often adherent to the leukocytes, and most frequently found when eosinophile cells predominate; their exact significance is not known. The pathology of leukemia is too remote from the purpose of this work to receive consideration here. Without asserting its germ character one may say that it is under suspicion, and that various observers have described appearances supposed to indicate a specific cause, probably a protozoön.
2. B. Pseudoleukemia.—This has, in time past, gone under many different names, of which the most common is [Hodgkin’s disease] (q. v.). Many speak of it as malignant lymphoma. This is doubtless a disease with a specific cause, as yet unrecognized, which produces very significant changes in the blood, especially in the white corpuscles. The spleen and lymph nodes are both involved, mainly the latter. The general blood changes are quite variable and one may find many types. As a rule, these comprise not so much an increase in the number of leukocytes as a decrease in the number of red cells by which an apparent leukocytosis is brought about; hence the expression pseudoleukemia. Many cases, however, will present a certain degree of actual leukocytosis, the proportion of the whites to the reds being about 40 to 50.
What interpretation in general is to be given to leukocytosis? A condition deserving this name is, first of all, essentially temporary. In acute infectious diseases it shows itself during the febrile stage and the principal increase is in the finely granular oxyphile cells. In such diseases as erysipelas, as well as pneumonia, it lasts but a short time after the crisis has been reached and the temperature has fallen. In diseases like acute appendicitis and acute peritonitis from any cause a marked leukocytosis may be regarded as indicating the presence of pus; it should be emphasized, however, that pus may be present without this indication, and it has been previously stated that such a fact is to be interpreted either as an example of a mild degree of infection or an exceedingly reduced vitality.
Differential Leukocyte Count.
—It seems to be now quite clearly demonstrated that the mere establishment of a certain degree of leukocytosis does not furnish the surgeon a reliable guide for determining the presence of pus, it being an index of reaction rather than of actual severity of any particular kind of infection. A much more reliable guide is found in the proportion of polynuclear cells to the total number of leukocytes counted, i. e., by what may be called a differential count. In order to make this reliable, the normal ratio should first be determined. This is put at a point between 68 and 80 per cent. by various writers. As Gibson (Annals of Surgery, April, 1906) says, 75 per cent. may be considered the best working average. This average should be maintained as the total number of leukocytes increases, or else there is a disproportion which becomes significant. With a moderate leukocytosis there is a notable increase in polynuclear cells, and it may be estimated that there is either a severe form of lesion or less resistance to absorption, or both.
PLATE I
Fig. I.