Cases of Idiopathic Anaemia. 
Read before the Medical Society of the District of Columbia, 
February 8, 1888. 
Large Celled Sarcoma of the 
Lumbar Vertebrae. 
Read before the Medical Society of the District of Columbia, 
January 23, 1888. 
BY r 
ROBERT T. EDES/M.D., 
OF WASHINGTON, D. C. 
Reprinted from the Journal of the American Medical 
Association, April 28 and May 26, 1888. 
CHICAGO: 
Printed at the Office of the Association. 
1888. CASES OF IDIOPATHIC ANEMIA. 
I do not intend here to give a systematic history 
of this interesting class of cases, but only to call at- 
tention to some of the prominent points illustrated 
by some which have fallen under my own observa- 
tion. A very complete and lucid account of the 
general subject is to be found in the article by Dr. 
Osler in "Pepper's System," vol. iii. It is neces- 
sary, however, for the sake of clearness, to mention 
the more characteristic and diagnostic points which 
justify us in giving to a case of anaemia the designa- 
tion of idiopathic, essential, or progressive perni- 
cious. The latter adjectives are only applicable to 
a part of the cases which are properly classed to- 
gether by every characteristic except a fatal termi- 
nation, and it is not justifiable, certainly until the 
nature of a disease is better known than that of the 
one under consideration, to incorporate in its name 
a prognosis which is not an invariable one. 
The first of these points is the intensity of the 
anaemia; often, and, indeed, frequently, without ema- 
ciation, or at any rate with a degree of emaciation 
which does not correspond in degree to the anaemia. 
The color of the skin in cases of this kind, owing to 
the fat which is still retained under it, is yellow and 
waxy rather than white, as it is more likely to be in 
the forms of anaemia depending on malnutrition, and 
might sometimes suggest jaundice, but does not, of 
course, extend to the conjunctiva. 
The count of the blood corpuscles is low, lower 
even than the amount of coloring matter would in- 2 
dicate, presenting in this respect a marked contrast 
to the anaemia of chlorosis. It not infrequently, 
even in cases which recover, falls below 1,000,000 
to the cubic millimetre, the normal being in the 
neighborhood of 5,000,000 for men and 4,500,000 for 
women. 
The proportionate color of the blood (haemoglo- 
bin) may be a little greater, so that the individual 
corpuscle is even a little richer in haemoglobin than 
normal. In chlorosis, on the other hand, the haemo- 
globin contents of the blood are much more dimin- 
ished in proportion, and the individual corpuscle is 
much less colored than it should be. 
A few weeks ago I counted the corpuscles of a 
chlorotic young woman and found but little diminu- 
tion of the count below normal, while the color test 
(which has been several times repeated with the same 
result) gave only about one-third of the normal. 
The shape of the corpuscles is irregular. They 
become swollen, more nearly spheres than discs, and 
sometimes look like a foot-ball partly blown up, or 
they are elongated and assume the shape of a pear, 
a battledore, or a snow-shoe, or they have tails. This 
is more obvious in a fresh than in the dried specimen. 
In size also they vary within wider limits than the 
normal, and there are found very large and very 
small individuals (megalocytes and microcytes). 
The specimens I show here were kindly photo- 
graped for me from a dried specimen of the blood of 
the last case I shall report, by Dr. Gray, of the Army 
Medical Museum. I show a photograph of normal 
blood by way of comparison. Some other less im- 
portant and less constant changes are sometimes 
observed. The proportion of white corpuscles is 
not materially changed. 
While the irregularity of shape would of itself, in 
a case of which nothing else was known, be sufficient 
to raise a suspicion of idiopathic anaemia, yet it is 
not quite certain that severe anaemia of other forms 3 
may not produce them. I have myself seen in other 
cases alteration in the shape of the corpuscles, not 
equalling in degree, but resembling, that of the form 
now under consideration. 
So much for the form of anaemia. The next point 
is that there js no discoverable adequate cause for 
the condition; and here, of course, comes the oppor- 
tunity for many difficulties and errors in diagnosis. 
It is obvious that many obscure diseases attended 
by a secondary loss of corpuscles and color may, 
before their true nature is discovered, be considered 
idiopathic anaemia. Abdominal cancer, not yet evi- 
dent to the touch or not giving rise to distinct local 
symptoms, is one of the conditions likely to be sus- 
pected among the first. Anaemia from haemorrhage 
which the patient does not think of sufficient conse- 
quence to mention, chlorosis, the various obscure dis- 
eases connected with changes in the spleen, lymphatic 
glands or suprarenal capsules, may counterfeit it 
more or less closely. A case in which idiopathic 
anaemia was among the conditions suspected, but 
which was found at the autopsy to be one of chronic 
pancreatitis, was reported in The Journal of the 
American Medical Association for December 24, 
1887. 
The difficulty is not lessened when, as not infre- 
quently happens, there are slight symptoms pointing 
in some other direction, as will be seen in two of the 
following cases, where it would have been difficult, in 
the absence of a microscopic examination of the 
blood, to say that the anaemic appearance of the pa- 
tients was not due in one case to an interstitial neph- 
ritis, and in the other to a chronic diarrhoea. 
If we adopt the most alarming nomenclature and 
the prognostic views associated with it, the recovery 
of the patient may be a fortunate but confusing ele- 
ment in the diagnosis. 
The details of symptomatology I do not propose 
to describe. I will only mention, as of especial im- 4 
portance, digestive disturbances, great weakness, 
dyspnoea on exertion, and various haemorrhages, in- 
cluding cerebral and retinal, the latter of which may 
have considerable diagnostic significance. 
The most noteworthy recent contribution to our 
knowledge of this affection has been the.observation, 
now many times repeated, that in a certain number 
of cases marked atrophy of the stomach tubules co- 
exists with the anaemia. The temptation is naturally 
strong to attribute the anaemia to lack of nutrition. 
It is, however, not yet certain that the atrophy is not 
simply a part of a general degeneration, and depend- 
ent on, rather than causing, the diminished nutritive 
power of the blood. 
The gastric symptoms, though present in these 
cases, are not so marked as we should expect to find 
in a case which is to end in so excessive a degree of 
anaemia. They are not by any means so severe as 
we may meet with in cancer or ulcer of the stomach, 
and yet the failure in the nutrition of the blood is 
much greater. 
If it can be shown that, in a certain proportion of 
cases, gastric atrophy distinctly precedes the devel- 
opment of an extreme anaemia having the features 
of the form we are describing, it seems to me we can 
no longer call it "idiopathic or essential, " for the cause 
is an adequate one, and we can only say that certain 
kinds of gastric (and perhaps further investigation 
may show, intestinal) atrophy, give rise to a set of 
symptoms closely resembling those which occur in 
other cases in which no such lesion can be found. It 
is to these cases that the adjectives "progressive per- 
nicious" most strictly apply. 
In another set, intestinal parasites, especially taeniae, 
have been found, but not frequently enough to estab- 
lish a rule, or to do more than make it desirable, in 
forming a diagnosis, to exclude this possible condi- 
tion ; which, however, has not, so far as I am aware, 
been noticed in this country. Neither arc we afflicted 5 
with the anchylostoma duodenale which, among the 
workmen in some of the tunnels under the Alps, have 
been found to be the cause of a severe form of anaemia. 
As regards etiology I can only say that in none of 
the cases I have to report has either of the most 
common causes been present. These are the puer- 
peral condition or severe mental shock. 
CASES. 
I. An old soldier of characteristic appearance, with 
a blood count below i,ooo,ooo, but 40 per cent, of 
haemoglobin, had a slightly enlarged spleen for a 
time; but it soon disappeared from touch. This 
might have been considered a case of leucocythaemia 
had the blood not been examined and found not to 
contain any excess of white corpuscles in proportion 
to the red. His appetite was good and his digestion 
fair. He was soon lost sight of, but I have little 
doubt that his life was not long. 
II. A young man, who had previously considered 
himself healthy and strong, noticed a loss of color in 
his face and soon began to have headache, dizziness, 
and noises in his ears. When seen he appeared mus- 
cular, not emaciated, but his skin was almost yellow 
and his mucous membrane nearly white. He ex- 
pressed himself as feeling strong, and was not sure 
that he could not lift a barrel of sugar out of a wagon 
as he had been in the habit of doing; although, half 
an hour previously, he had nearly fainted on walking 
from the ward to the lecture-room. 
There were a good many purpuric spots on his 
body, and also retinal haemorrhages. 
A blood count gave less than 670,000 red corpus- 
cles to the cubic millimetre, but there was not so 
much change in shape and size as sometimes seen. 
The further progress of the case was unfortunately 
simple and uninfluenced by treatment. He steadily 
and rapidly lost strength, becoming so weak that he 
could hardly move in bed without danger of fainting. 6 
Delirium, diarrhoea, great dyspnoea on exertion pre- 
ceded the fatal termination, which took place about 
seven weeks after he first felt himself sick. The au- 
topsy revealed extreme anaemia without great emaci- 
ation; there were ecchymoses in various organs. 
There was granulo-fatty degeneration of the heart 
and kidneys, and there were opaque yellow patches 
in the stomach which may have been fatty, but of 
which there is no record of a microscopic examina- 
tion. There certainly was not any well-marked atro- 
phy of the mucous membrane. The aorta was of 
somewhat smaller calibre than usual, and its walls 
thin. The marrow of the femur was in places red 
and jelly-like, and contained, in addition to the usual 
constituents, a few nucleated red corpuscles. The 
marrow of the sternum was of a reddish-yellow color, 
but was not examined microscopically. 
This was as typical a case of the " progressive perni- 
cious" form as one often sees, and yet both symptoms 
and lesions remove it clearly from the class of those 
dependent (if any are) upon gastric atrophy; al- 
though it is by no means improbable that, had the 
patient lived some weeks longer, such an atrophy, 
consequent upon fatty deneneration of the glandular 
elements, might have followed. 
III. A middle-aged woman was seen in consulta- 
tion, presenting the characteristic external appear- 
ances. The blood was pale, but the corpuscles were 
not counted; as, not knowing the sort of case I was 
going to see, I had not provided myself with the 
necessary apparatus. They were, however, irregular 
in shape and size. Nothing else could be found by 
physical examination. She died in about ten days. 
In this case there had been no pregnancy for some 
years and no mental shock. 
IV. The next case, more chronic in its course, was 
that of a college professor 57 years of age. There 
had been a good deal of trouble in his family in the 7 
way of sickness and sudden death, but hardly any- 
thing that could be called a shock. 
His general appearance was sallow; his face and 
hands brown, partly at least from exposure, his legs 
yellow. His wife had noticed the dark color. He 
complained chiefly of weakness, so that going up a 
slight elevation distressed him, and of oppression or 
sinking Across the chest and in the epigastrium. 
Pulse 100 to 108. His mind was clear. There was 
only slight and occasional digestive disturbance. 
Nothing was to be found by the usual physical exam- 
ination except a soft systolic souffle along the left 
edge of the sternum. 
The blood was not examined, partly because I had 
not prepared myself with the apparatus, but chiefly 
because my mind was occupied by a diagnosis which 
turned out to be erroneous. This was Addison's dis- 
ease. The diagnosis of his attending physician, a man 
of wide experience and learning, rather inclined to 
abdominal cancer. 
After some weeks, during which I did not see him 
again, he died, and there were found fatty changes 
in various organs and red marrow in the bones. 
There were no changes of the suprarenal capsules. 
V. A man, set. about 55, had been sick three years 
with anaemia without known cause, had recovered 
under the use of arsenic, again had the same trouble 
and again partial recovery. 
When seen, in June, he had been failing since De- 
cember or January. He was very pale, his face a 
little bloated. Nothing was to be got by physical 
examination except a tender spot at the epigastrium 
and one lower down. There was no jaundice, no 
hsematemesis and no polyuria. It was supposed that 
there had been some fat in the stools. The blood 
corpuscles were irregular in size and shape. The 
diagnosis was idiopathic anaemia with a possibility of 
cancer about the head of the pancreas. 
The autopsy, at which I was not present, showed 8 
the muscles to be dark-red, but the other tissues 
blanched. The stomach was thin and pale; the py- 
lorus and duodenum contracted to about one third 
the ordinary size; small intestine pale but healthy. 
Pancreas normal; mesenteric glands somewhat en- 
larged. There may have been some increase in the 
connective tissue of the kidneys. Unfortunately, 
there was no microscopic examination of the stom- 
ach or of the marrow of the bones. 
An examination of the gastric tubules would have 
been highly satisfactory, but there seems good reason 
to suppose, from the gross appearances, that this was 
one of the cases of atrophy of which several have 
been minutely described. 
VI. A ship carpenter aet. 41, a man of large 
frame, not fat but by no means emaciated, had not 
been well for two years. Complexion pale and yel- 
lowish. He complains of weakness, headache, and 
dyspnoea on exertion, and loss of appetite. His sight 
is dim and he is somewhat deaf. Slight cough with- 
out expectoration, pain in the lumbar region. He 
has had a little oedema of the feet and ankles. The 
urine shows some traces of nephritis, which disap- 
peared in a few days. The improvement in this 
respect, it should be noted, took place before his 
general condition was much better. 
The diagnosis might easily have been made of a 
moderate nephritis in the way of recovery, had not 
the condition of the blood, both as indicated by his 
complexion and the count, been entirely out of 
proportion to the amount of nephritis. The charac- 
ter of the corpuscles was of the usual kind, they 
varying both in size and shape, while the successive 
counts were as follows: 
May 20, 780,000; May* 27, 735,000; May 31, 
955,000; June 7, 1,290,000; June 14, 2,036,000; 
June 24, 2,695,000. 
This is one of the cases where uncertainty in diag- 
nosis arises from recovery. Soon after this last count 9 
the patient eloped from the hospital and continued 
well enough to elude my search as, although I got 
distant tidings of him as being pretty well, he evi- 
dently thought I wanted him for some legal rather 
than scientific purpose. At an early period of his 
sickness, after about a fortnight of very careful feed- 
ing, rendered necessary by his deficient nutrition, 
being, in fact, partly by the rectum, he made an un- 
authorized meal of ham and eggs without harm, which 
seems a valuable piece of negative evidence as re- 
gards any atrophy of the stomach. The treatment, 
in addition to the diet, consisted in arsenic in the 
form of Fowler's solution. 
VII. D. C. P., a young man, with chronic diar- 
rhoea, anaemic, very weak, pale and listless. The 
diarrhoea improved and disappeared under the use of 
large mildly astringent enemata. 
Examinations of his blood were as follows: 
Oct. 14, 763,000. No excess of white. A good 
many of small diameter. A good many pointed and 
tailed. Oct. 21, 1,019,000. Oct. 31, 1,877,000. Nov. 
5, 1,665,000. Nov. 10, 2,178,000. Nov. 15,2,438,- 
000. Dec. 10, coloring matter about 50 per cent, of 
the normal. Dec. 13. Discharged, gaining in flesh, 
strength and blood. Went to Florida. 
VIII. A man set. 71, of active habits, had not 
been well for two years except during a visit to Cali- 
fornia the previous winter. He was seen on January 
13, 1887. Last September he noticed shortness of 
breath on exertion, his feet and legs felt cold. Six 
weeks ago, on going out into the street, felt a sudden 
weakness of the legs and was obliged to return, 
which he did with much difficulty, being hardly able 
to get up the doorsteps. When I saw him he was in 
bed, though he was able to stand up for a part of the 
examination. He complained chiefly of coldness 
and stiffness of the legs, as well as of weakness but 
of no pain there. There was considerable pain 
about the rectum which turned out to be largely due 10 
to his over anxiety on the subject of his bowels and 
consequent over treatment. It soon ceased to give 
him further trouble. A sensation of constriction or 
pressure across the lower part of the bowels was a 
constant accompaniment of the case and seemed to 
have little or nothing to do with any condition of 
constipation or otherwise. 
With the history of his sudden attack and the pe- 
culiar sensations and weakness in his legs my atten- 
tion, like that of his family and his former attendants, 
was naturally directed toward any evidence of spinal 
disease. The limbs could be moved freely in any 
desired direction as he lay in bed. The muscles 
were flabby and small but not decidedly atrophied 
and reacted well to the faradic current. Sensation 
was everywhere present, and both superficial and 
deep reflexes were of nearly normal intensity. He 
could stand with his eyes shut. 
Examination of the urine, rectum, and the fundus 
of the eye gave negative results. 
There was a systolic murmur at the base of the 
heart transmitted toward the right, and some prolon- 
gation of respiration over the whole chest, but no 
distinct rales. I should have said that their was con- 
siderable expectoration of thick mucus. A count of 
the blood a week after my first visit gave 1,575,000 
to the cubic millimeter with many of the corpuscles 
irregular and small. My diagnosis excluded any dis- 
tinct organic spinal disease, as haemorrhage, soften- 
ing, or inflammation, or the systematized scleroses, and 
attributed the abnormal sensations and the pseudo- 
paralysis to anaemia of the cord as a part of a gen- 
eral condition. I was not able for some time to rid 
myself of the suspicion of malignant disease of the 
vertebrae, or of some abdominal organs, but repeated 
physical examinations with negative results, and the 
absence of any new symptoms pointing to such 
growth, together with the positive results of an in- 
spection of the blood, left no alternative open but 11 
idiopathic anaemia. Whether the feeling of tightness 
across the lower part of the abdomen was simply an 
abnormal sensation like the rest I could not be sure, 
but it certainly was not due to any distension or 
growth. 
The dependence of a well-marked paraparesis 
upon a general anaemia is a phenomenon of sufficient 
interest to justify a digression. Anaemia and hyper- 
aemia of the spinal cord, from the very nature of the 
case, and in fact much like the corresponding condi- 
tions in the brain, have been the subject of many 
more suppositions (most of them reasonable it is true) 
than of direct observation. 
Localized anaemias of the spinal cord may be pro- 
duced by obstruction of the aorta or by embolism of 
the spinal arteries. A theory has also been held that 
in some of the so-called reflex paralyses a spasm of 
the vessels cuts off the blood supply from more or 
less limited areas of the cord. With these, however, 
we are not at present dealing. 
The existence of a paraplegia dependent, not upon 
a local anaemia, but upon a general one is, however, 
admitted, though certainly not at all common in a 
well marked form. Cases of paraplegia after severe 
puerperal haemorrhage, such as have been a large 
proportion of those reported, cannot be regarded as 
quite so conclusive in this way, since other puerperal 
processes like septicaemia and thrombosis may com- 
plicate the matter, but undoubtedly a part of them 
are of this character. There have been, however, 
others where large haemorrhages from the bowels 
have been followed by a temporary paraplegia, and 
one where such a paraplegia consequent upon uterine 
haemorrhage and in process of recovery, underwent 
two exacerbations on renewal of the haemorrhage. 
Another case occurred after profuse epistaxis. 
Last winter I saw with my friend Dr. Bates, of the 
Navy, a case of this kind, a young man under the 
care of your Secretary, Dr. Adams, who intends to 12 
report in full. He had suddenly lost the power in 
his legs. His history at first would have led one to 
suppose that the sudden paralysis was the beginning 
of his illness, and naturally enough to think of haemor- 
rhage into the cord or its membranes or a very rapid 
myelitis, but it appeared on further inquiry that he 
had been having frequent and profuse haemorrhages 
from the rectum for a long time previous, but had 
kept^.bout his usual work until this attack. When I 
saw him there were no disorders of sensation, his 
reflexes were normal, and voluntary motion of every 
kind was present though not very strong. The haemor- 
rhage, which came from a small vessel an inch or two 
above the anus, was being treated by Dr. Adams with 
the result of a complete restoration of the functions 
of the spinal cord. 
It is not difficult to explain why deficient supply 
of nutriment should affect the spinal cord sufficiently 
to cause a loss of function, but it is not so clear why 
the cessation of function should come on so suddenly 
when the condition that causes it must be gradual in 
its development; nor why it should be confined to 
the lower segment of the cord when the anaemia is 
general. 
We can find analogies, if not an explanation, for 
the first difficulty, as for instance, in fatty degenera- 
tion of the heart which certainly must be developed 
very slowly but which kills very rapidly. The ner- 
vous centres of the heart pushed to the full extent of 
their failing powers break down under a sudden in- 
creased demand. The last straw breaks the camel's 
back. As to the second, there may be some condi- 
tions of the circulation which render the effects of a 
general anaemia more perceptible in the lower part of 
the cord, or, what is more probable, that the lumbar 
enlargement is sooner exhausted because more 
usually called upon for a constant expenditure of en- 
ergy than that portion which supplies the arms. It 
is often noticed in animals coming under the influ- 13 
ence of a paralyzing poison that they continue to 
drag themselves around by the fore paws when the 
hind legs no longer support them. 
Hilton Fagge says he knows of no case where 
anaemic paraplegia.has been reported in connection 
with pernicious anaemia, but the fact of his making 
the remark shows that this sagacious observer recog- 
nized the possibility of such a connection. 
The further progress of the case is briefly told. 
Careful feeding and the use of tonics, especially ar- 
senic and strychnine, improved the nutrition. The 
patient gained a little flesh and a little strength. His 
blood counts went from the original count, on Jan. 
21,1,575,000; Jan. 28,1,425,000; Feb. 26, 1,620,000; 
March 27, 1,850,500; April 19, 2,060,000; May 23, 
2,250,000; June 13, 2,540000; coloring matter 70 
per cent. By this time he had gained considerable 
flesh and some strength, was eating, enjoying and di- 
gesting, a very good variety of solid food. It was 
noticed soon after this that the patella reflex was 
wanting, but there were no other symptoms of in- 
creasing paralysis. There was a good deal of stiff- 
ness and some pain about the hips and the hands, 
and one episode of constipation and irritative diar- 
rhoea relieved by a dose or two of castor oil. The 
question of his going away to avoid the hot weather 
was discussed, but he preferred not to give up the 
comforts of home until he felt stronger, and during the 
extremely hot weather of last July he contracted an 
enteritis from which he rapidly sank. 
The only notable point in the treatment, not al- 
ready mentioned, was the use of inhalations of oxygen 
for some weeks, but so far as the patient or I could 
see, it did no good. LARGE CELLED SARCOMA OF THE LUMBAR 
VERTEBRA. 
Attacks of supposed sciatica for some years. Par- 
aplegia dolorosa. Extreme pain on movement. 
Curvature at level of last dorsal and first lumbar 
vertebrae. Tumor in the back. Vomiting. Death. 
Dilatation of the stomach. Destruction of the bodies 
of the second and third lumbar vertebrae by a giant- 
celled sarcoma which also formed a large tumor on 
each side of the vertebral column. 
A married woman, 35 years old, had a difficult 
labor with her only child, now 7 years old. Soon 
after she had a tender spot in her back. Four or 
five years ago she had some attacks of sciatica, last- 
ing a few days, which early in 1886 began to be more 
severe and continuous. In May she went to New 
York to consult a physician, but when she arrived 
the pain disappeared, so that she went shopping and 
to the theatre instead. The pain soon returned, how- 
ever, attended with numbness and uncertainty of gait. 
In September, 1886, she entered the Homcepathic 
Hospital in Boston. Late in that year her husband 
was informed of a curvature of the spine, which, how- 
ever, the physicians said they had been aware of 
since September, but as it was not painful and was 
only slight, it was supposed to be congenital or due 
to an old caries. A fulness in the side was noted at 
the same time. 
During a part of the time she was in the hospital 
she was able to walk about and ride out, but in No 
vember she had to get up very carefully. On De- 
cember 9 she was moved from one bed to another 
and then became almost completely paralyzed, and 16 
soon after completely so in the lower limbs. There 
was, however, soon some improvement in the move- 
ments of the limbs. From this time she had her 
alternations of improvement and the reverse, but with 
the balance on the wrong side. In June last the 
swelling in the left back below the rib was punctured, 
but only a few drops of pus obtained. Attempts 
were made to fix the spine by apparatus, but it 
could not be borne. 
When first seen by me, in October, she had been 
in bed nearly a year. She was greatly emaciated, 
but no more anaemic than would be expected from 
her condition, and there was nothing to indicate the 
so-called cancerous cachexia. Her lower limbs lay 
almost motionless, supported and protected with the 
greatest care. There was a little movement of the 
toes and feet possible. There was great pain about 
the hips and running down the legs, which was 
greatly aggravated by the slightest movement and 
often by the slightest pressure, or even contact. The 
sciatic, and sometimes the anterior crural nerve on 
the right side, were painful on pressure, and at times 
the whole surface seemed hypersesthetic, Move- 
ments of the arms perfect but often painful. There 
was a bed sore over the sacrum, and to dress this 
and change the bedding she was several times ether- 
ized and raised, this procedure being followed by ex- 
treme pain lasting for hours. 
The functions of the bladder and rectum were 
sluggish, but there was no loss of control. Appetite 
and digestion fair, but considerable trouble from con- 
stipation and flatulence. 
The urine at times contained a large amount of 
phosphate and carbonate of lime, with mucus and no 
pus. Once an excess of indican was noted. There 
was at no time any fever. 
For several weeks she improved considerably and 
got a very good appetite, with less constant pain 
down the legs and less tenderness. She used a little 17 
morphine, on one or two nights none at all, and some 
codeia. 
On the night of December 20 she took antipyrin 
for the relief of pain, which gave her a good night 
and no nausea. During the forenoon of the next 
day she began to vomit a greenish and feownish 
fluid, which after more than twenty-four hours be- 
came stercoraceous in smell. I found the bacteria 
of putrefaction therein. The abdomen became tense 
and tympanitic at the upper part, the vomiting was 
relieved by nothing but morphine, and she died while 
partly under its influence. 
The autopsy showed the stomach to be greatly di- 
lated, sagging down nearly to the pubis, half-filled 
with a brownish fluid and much gas. 
There was nothing remarkable about the appearance 
of the liver, spleen or intestines. The ureters passed 
over the surface of the tumors soon to be described, 
but they were nowhere either strictured or dilated. 
In the right kidney was a little turbid fluid, one stone 
as large as a small chestnut and a good many smaller 
ones; otherwise both were healthy. 
The specimen before us consists of the last dorsal 
and what remains of the three upper lumbar vertebrae, 
sawn longitudinally. The left side is preserved 
whole, with the exception of a little dissection to 
show the extent of damage done to the bone. The 
right side has been macerated and cleaned. 
On both sides we have the last dorsal vertebra 
intact. 
The first lumbar is little affected on the right side 
except two little spots of erosion of the body. On 
the left the transverse and articulating processes have 
disappeared and are replaced by this soft reddish 
mass. The second lumbar has almost entirely dis- 
appeared, nothing remaining but a thin, gritty lam- 
ella between two fibro-cartilages which are displaced 
but not destroyed, and a little piece of the end of the 18 
spinous process connected with the supra-spinons 
ligament. 
The third lumbar is represented as to its body by 
this reddish pulp between two fibro-cartilages, and by 
the whole spinous process and some fragments of the 
articulating processes on each side. 
In the macerated specimen the two vertebrae are 
the first and fourth, the other two being represented 
only by a few fragments. 
A new growth occupies the angles formed by the 
sliding back of the first vertebrae, and similar growths 
between and eroding the arches encroach on the 
spinal canal. The narrowest point is just below 
the termination of the spinal cord, so that it was not 
pressed upon, and there was enough room left to per- 
mit the passage of the cauda equina, which appeared 
to the naked eye normal. On each side and closely 
connected with the bone is a large rounded tumor, as 
large as one fist on the right side, and two fists on 
the left. It is this latter which pressed through be- 
low the rib and was felt during life. Upon its pos- 
terior surface is a mass of inspissated blood; in its 
outer margin are calcified patches. The central por- 
tion of the growth seems to be situated beneath the 
periosteum. 
There were no secondary growths found and no 
enlargement of the glands. By inadvertence the 
liver was not incised. 
The structure of the new growth is that of a giant- 
celled sarcoma. 
In the Boston Med. and Surg. Journal, June 17, 
1886, I published several cases of malignant disease 
of the vertebrae with painful paraplegia, of which I 
will here refer to only one, which was that of a man 
of 55 with many symptoms like those in the case 
just described: great pain on turning in bed, pain in 
the legs, inability to walk, with no distinct paraplegia, 
but general loss of strength in the lower limbs. 
The growth was here also connected with the body 19 
of the second lumbar vertebra, implicating to some 
extent the first and third, though the tumors outside 
were much smaller than in the case before us. It 
was a round-celled sarcoma with giant cells. 
In the other case the disease was more extensive. 
After malignant disease has invaded the vertebrae, 
usually the lumbar, the symptoms are about the same 
whether it be a sarcoma or a carcinoma, and the 
cases just described may be considered fairly typical. 
In another point, however, they differ; in that the 
sarcoma is primarily a bone disease, while the carci- 
noma is usually and, so far as I know, always, second- 
ary to a similar growth elsewhere. In a large number 
of reported cases the starting-point has been the 
mammary gland. A case which seems to be an ex- 
ception to the first part of this rule was reported by 
Dr. Kempe, where a lady had had a cancer of the 
breast removed by a member of this Society (Dr. 
Garnett), and afterward died after symptoms similar 
to those already described. The secondary growth 
in this case was pronounced alveolar sarcoma. 
The diagnosis of this affection is likely to be ob- 
scure, especially in its early stages. When a cancer 
is known to be present elsewhere, the existence of 
severe and persistent pain in the nerves of the lumbar 
or sacral flexures, or both, is a very suspicious cir- 
cumstance. 
When there is no primary cancer, the diagnosis 
between this disease and caries may be for a long 
time in doubt, and the existence of curvature, and 
even of a tumor, does not at once clear it up. A 
large flattened tumor without tendency to pointing 
would, as in this case, be in favor of a neoplasm. 
Setting aside these, which may almost be called acci- 
dental aids in the diagnosis, I think that the extreme 
and continued pain on turning over or sitting up in 
bed, while at the same time no fever is present, is 
somewhat characteristic, as distinguishing it on the 
one hand from caries, and on the other from any sim- 20 
ulated spinal disease. In some cases it may be pos- 
sible to investigate more closely the condition of 
motion, reflexes, and so on, or to palpate more deeply 
the abdomen, which in this case would have undoubt- 
edly disclosed the presence of the tumors in the 
cavity. 
The explanation of the sciatic and crural pains in 
the pressure exercised on the nerves, both within and 
without the spinal canal, is too obvious to need more 
than mention, but it should not be forgotten that an 
actual myelitis may result from the pressure, as in 
one of the cases reported by me. This is not, how- 
ever, one of the most usual results, probably for the 
reason that, as the lumbar vertebrae are the place of 
election of the new growths, the narrowing takes 
place below the cord. In other cases, even when the 
bones of the dorsal vertebrae are extensively dis- 
eased, the softening proceeds with comparatively lit- 
tle encroachment on the calibre of the spinal canal.