482 
Hinsdale, Pernicious Anaemia. 
[ April 
Article XIV. 
A Case of Pernicious Anaemia; Recovery. By Guy Hinsdale, M.D., 
of Philadelphia. 
The following case, which was under treatment at the Episcopal Hos- 
pital, Philadelphia, is of such an interesting character, and terminated so 
successfully, that it is deemed worthy of being placed on record. 
Theo. J., aet. 22, a bartender, was admitted to the wards of that insti- 
tution September 20, 1882, under the care of Dr. Morris J. Lewis. For 
the past three or four years he had been in the habit of drinking wine, 
gin, and whiskey freely, and of using tobacco. He had been taking from 
1 These positions have been eompared with supposed similar ones for taction. This 
could have been done with the other senses. 1885.] 
Hinsdale, Pernicious Anaemia. 
483 
fifteen to twenty-five drinks a day, and he said that the whiskey he drank 
might be reckoned at half a pint daily. He denied having had any vene- 
real disease or its symptoms, although he had frequently been exposed to 
contagion. His parents had died in his infancy. 
The patient's previous health had been good, and he stated that he had 
never had four days' illness in his life. He never worked in phosphorus, 
metals, or paints. He was of good color until his present attack, which 
commenced two weeks previous to admission. He was not thin ; a fair 
amount of subcutaneous fat was present. Having been costive for some 
time past, he began to have a dull, continuous pain in the back of the head, 
which was augmented by exertion. For seven or eight days his conjunc- 
tiva had been yellow ; a little later his skin was tinged with yellow, but 
upon admission had more of a waxy-white color. Three days previous to 
admission he had anorexia, followed by a chill at night with vomiting. 
His tongue was pale and covered with a white coat. No symptoms of 
dyspepsia ; bowels never loose. Mucous membranes pale. 
The patient's spleen was slightly enlarged in the vertical line. Its area 
of dulness measured 4x4 inches. The area of liver dulness began 
anteriorly at the sixth rib, and extended to the margin of the ribs, but not 
below. The superficial veins of the arms were small and of a slightly 
pink color. There was no lymphatic enlargement perceptible, and no pain 
on pressure over the bones. Fluid was noticed in the abdominal cavity a 
few days after admission. 
The heart was rapid (120) ; pulse small, but regular. The apex beat 
was at the fifth interspace, 1.5 inches within the nipple line, and was quite 
forcible. There was a soft, long, systolic murmur over the pulmonary 
artery, and a loud venous hum in the neck on sitting up. There was no 
oedema ; neither had there been any hemorrhages, nor were there any 
petechias. 
The blood was examined by Dr. F. P. Henry, one of the attending phy- 
sicians of the hospital, who reported, October 1st, 985,000, and November 
1st, 1882, 890,000 red corpuscles to the cu. mm., one-fifth of the normal 
number. White cells numbered one to two hundred red, absolutely but 
not relatively diminished. 
The urine was slightly acid; sp. gr. 1.015. No albumen was found 
after several examinations. Five days after admission, tests showed the 
presence of bile. 
The following is a record of the temperature:- 
M. 
E. 
M. 
E. 
M. 
E. 
Sept. 20 . 
101 
Oct. 8 ... 
.. 100 
100.4 
Oct. 17 ... 
.. 99 
100 
30 . 
.... 102.4 
100 
9 ... 
.. 99 
100.8 
18 ... 
.. 99.5 
100 
Oct. 1 . 
.... 99 
99.4 
10 ... 
... 100 
100 
19 ... 
.. 99.5 
99.5 
9 
.... 98.2 
99.2 
11 ... 
... 100 
100.4 
20 ... 
.. 99 
99.5 
3 . 
.... 99 
100.1 
12 ... 
... 98.8 
100 
21 . . 
... 99 
99 
4 . 
.... 98.5 
100 
13 ... 
.. 98.8 
98.9 
22 ... 
... 99 
98.5 
R 
.... 98 
100.5 
14 .. 
... 98.5 
100 
23 ... 
... 98.5 
98.5 
6 . 
.... 99.6 
100.5 
15 ... 
... 100 
100.5 
24 ... 
... 98 
7 . 
.... 98.5 
101 
16 ... 
... 99 
100 
The pulse at first remained rather high-110 to 130. 
The journal shows that, after the first few days, excepting his pain in 
the back of the head, he complained of no bad feeling, and only occasion- 
ally felt weak and liable to faint. By the end of the first month the color 
of his face and lips improved. His veins filled up, and the blood became 
richer and the man stronger. After seven weeks of treatment he was dis- 
charged. 484 
Hinsdale, Pernicious Ana?mia. 
[April 
The treatment from the start was arsenic, in Fowler's solution, and 
afterwards arsenious acid in pill, with iron. Cod-liver oil was added 
after the first week, and quinia and tincture of iron after the second. 
The patient's diet was liberal, and consisted of milk, mutton, chicken, 
eggs, etc. 
Dr. Albert G. Heyl, one of the ophthalmic surgeons of the hospital, has 
furnished the following notes :- 
" Oct. 8, 1882. R. E. Media cloudy. Margin of the disk obscured 
below. Retinal arteries, if of abnormal calibre, somewhat increased as 
regards diameter. The retinal veins were tortuous, apparently flattened, 
and about double the normal calibre. A number of circular hemorrhages 
with white centres were observed ; most of them were contiguous to large 
vessels, probably lying underneath them in the deeper layers of the retina. 
L. E. The condition was much less marked than in the R. E. 
" 18tA The principal change observed was in the hemorrhages. In 
some the red coloring matter had been completely absorbed, leaving be- 
hind oval or circular white spots. In others the absorption was not com- 
plete, and then the patches were speckled with red points. This seems to 
show that, in certain abnormal states of the blood, retinal hemorrhages 
may lose the red coloring matter before the remainder of the clot is ab- 
sorbed. 
"A few days later the case was examined by reflecting sunlight into the 
eyes. Some fresh hemorrhages were observed. Also the optic disk and 
fundus were of a yellow hue, due, perhaps, to the haematin which had 
escaped into the tissues. The conjunctiva was also noted as being yellow. 
" The patient then passed from observation until July 30, 1884. The 
result of the examination at this date was as follows: R. E. V = 
Probably with cylindrical correction the vision would have been greater, 
as the refraction was astigmatic. 
"L. E. V= |§. 
" In the R. E. the margin of the optic disk was distinct. All over the 
fundus the fine arterioles and venules were visible, due to the abnormal 
injection. In the upper half of the fundus the main veins were enlarged. 
In the lower half the following observations were made. 
" (a) The main artery seemed to alter its calibre-sometimes to become 
thinner, then of normal calibre. (&) If the observer's eye be directed so 
that the line of sight falls in the vertical plane passing through the vessel, 
it appears well defined; if it be viewed in a slanting direction, it is very 
dim, and with difficulty differentiated from the retinal tissue. This may, 
in a measure, be due to the direction given to the ophthalmoscope, but 
principally is caused by some abnormality in the blood current, (c) One 
or two pulsatile movements were noticed in the vessel on the retina; they 
could not be compared with the radial pulse, (c?) From the main artery 
a branch was given off, of an apparent calibre of 1 mm. ; it rapidly 
diminished to a point, and for the remainder of its course appeared as a 
fine thread-like vessel; following its course was a vein of similar thread- 
like calibre. Just before its junction with a large vein the current lost its 
continuity, appearing as red points separated by white interspaces. There 
was a general haziness over the fundus, probably due to retinal clouding. 
In the L. E. the veins were generally hyperaemic. An arterial branch 
with a conical beginning and thread-like continuation leading to a spot 
characterized by pigmentary changes was likewise observed. 1885.] 
Hinsdale, Pernicious Anaemia. 
485 
" These late changes are unknown, I believe, in connection with per- 
nicious anmmia, and point probably to a defective state of the intima of 
the vessels, dating back to the acute stage of the dyscrasia." 
I have taken the trouble to hunt up this man, and now, over two years 
from the date of his discharge from the hospital, I find him fully restored 
to health. He weighs over one hundred and sixty pounds-a gain of 
twenty-five pounds since leaving the ward. Dr. Henry kindly examined 
the blood again, and reported, July 31, 1884, " 4,500,000 red corpuscles to 
the cubic mm. No white corpuscles in the specimen examined. The 
blood may therefore be considered of the normal standard. The blood 
flowed freely on moderate puncture of the finger, affording a marked 
contrast to that obtained two years ago, when more than one deep punc- 
ture had to be made before a drop could be obtained." 
The ophthalmoscopic examination has been given in Dr. Heyl's report. 
The man is in full bodily vigor. On listening to his heart, the murmur 
present during his illness is not heard, but the first sound may be said to 
be muffled. The second sound is distinct. The lungs are clear. The 
liver and spleen are both enlarged. The man still drinks beer, but con- 
siders himself temperate. 
The descriptions by Drs. Sidney Coupland,1 Stephen Mackenzie,2 Pye- 
Smith,3 Pepper,4 Lepine,5 and Gardner and Osler6 should certainly be 
read by any one interested in the study of this disease. Pye-Smith says 
that the diagnosis can never be considered absolutely certain during the 
patient's life; but he believes that occasionally recovery has taken place 
beyond reasonable doubt, and mentions, in a list of 122 cases of the 
disease, 20 cases of recovery, which he believes to be well substantiated. 
He describes one case which was under observation, however, for only one 
year after apparent recovery, but in which no blood count was made; also 
another case, forming the subject of his article, which, after being dis- 
charged from Guy's Hospital, improved, was re-admitted, and died four- 
teen months from the commencement of treatment; another, in which the 
count fell to 1,100,000, then to 425,000, recovered, the final numeration 
being nearly five million corpuscles in the cubic mm. 
A case of pernicious anaemia,7 which was under the care of Drs. J. H. 
Hutchinson and Morris J. Lewis, in the Pennsylvania Hospital, was 
discharged apparently well (no blood count was made), and he was able 
to return to his work as a coal-miner ; ten months later he was re-admitted 
to the hospital with the same symptoms, and, I am informed, died of the 
disease. Dr. Hutchinson has also seen a second case of fatal remission in 
1 Coupland. Gulstonian Lectures. Lon. Lancet, 1881, vol. i. 
2 Mackenzie. Lon. Lancet, 1878, vol. ii. 
3 Pye-Smith. Guy's Hospital Reports, 1883. 
4 Pepper. Amer. Jour. Med. Sciences, Oct. 1875. 
5 Lepine. Rev. Mens, de Med. et Chirurg. 1877, p. 63. 
6 Gardner and Osler. Canada Med. and Surg. Jour. 1877, p. 385. 
7 Medical News. Philadelphia, February, 1879. 486 
Sattler, One-sided Transitory Exophthalmos. 
[April 
pernicious anaemia. Such occurrences have been recorded by Habershon,1 
Wilks,2 and Lepine.3 
As for retinal hemorrhages, Coupland states that they do not imply a 
fatal termination ; and, on the other hand, their absence does not neces- 
sitate a favorable prognosis. Quincke found no retinal hemorrhages in 
9 out of 39 cases. 
Pernicious anosmia is therefore not necessarily a progressive disease. 
The fact that these patients sometimes temporarily regain their health 
has doubtless tempted some to believe that a cure has been effected, while, 
on the other hand, the absolutely hopeless view of the affection entertained 
by most writers has doubtless led others to doubt the accuracy of their 
diagnosis had they called it progressive pernicious anaemia. 
The records of the case which I have furnished, extending over more 
than two years, and terminating in a normal blood count, and full bodily 
vigor, add one more to the list of cases which justify us in having a slightly 
more hopeful view even of so dangerous a malady as pernicious anaemia. 
4004 Chestnut St., Philadelphia. 
1 Habershon. Lon. Lancet, 1863, p. 518. 
2 Wilks. Guy's Hospital Reports, 1857. 
3 Loe. cit., p. 63.