PULMONARY ATELECTASIS 
AS A 
Cause of Anemia 
By ALBERT ABRAMS, M. D., San Francisco 
Reprint from the transactions of " The Medical Society of 
the State of California," April, 1892 
In this paper I will discuss anemia not as a substantive, but 
as a symptomatic affection. I have referred elsewhere* to 
cases of anemia occurring in individuals, the examination of 
whose lungs showed insufficient distension (atelectasis). 
Since then, my observations have been supplemented by 
accurate blood measurements, which enable me to assert posi- 
tively, that atelectasis of the lungs is a frequent factor in the 
etiology of anemia. Atelectasis, or collapse of the lung, is 
often encountered as a physiological condition, and I have 
adverted to it in my "Manual of Clinical Diagnosis"! as follows: 
" Remembering that the tidal or breathing volume of the 
air amounts to only 33 cubic inches, and the complemental 
air, which is the air taken into the lungs by forced breathing, 
in addition to the tidal volume, amounts to 100 cubic inches, 
and knowing that the average respiratory capacity of an adult 
is about 225 cubic inches, the conclusion is evident, that even 
in a state of health, the lungs are imperfectly aerated and in 
a condition of physiological atelectasis. 
11 My invariable custom before conducting an examination 
of the lungs is to have the patient make repeated forced 
inspirations. In this way I avoid many errors in auscultation 
and percussion." 
t Manual of Clinical Diagnosis, Abrams, 1891. 
♦Report of 163 cases treated bv the Pneumatic Cabinet, Pacific Medical Journal, September, 
1891. 2 
I have particularized this matter for the reason, that I have 
failed to find similar detailed reference to physiological atelec- 
tasis in our text-books on diagnosis. I can recall a number of 
cases where an examination of the lungs revealed dullness in 
one or both apices and where an unfavorable prognosis was 
given in accordance with the physical examination. I can 
also testify with chagrin that these very cases which I con- 
sidered so unfavorable continued well despite my inauspicious 
prognostications. These errors in diagnosis are examples of 
similar errors made by other physicians, and will continue to 
be made until pulmonary atelectasis is recognized as a physi- 
ological condition. I have repeatedly demonstrated patients 
to my classes in physical diagnosis who showed not only cir- 
cumscribed dullness of the apices or borders of the lungs, but 
even, in fact, of an entire lung ; and it was shown in these 
cases how, after repeated forced inspirations, dullness was 
supplanted by resonance. These cases were not recruited 
from bed-ridden individuals, in whom such a condition might 
be expected, but from ambulatory patients. There is no indi- 
vidual, however resonant his lungs on percussion, who cannot 
render them more resonant after repeated deep inspirations. 
If atelectasis is found as a physiological condition in robust 
individuals, how much more frequent is itin those individuals 
with incomplete thoracic development who forego all hygienic 
influences which tend to promote proper respiratory activity? 
The occurrence of anemia with its concomitant symptoms in 
pulmonary atelectasis is not accidental, but almost constant. 
The blood is a definite living tissue whose chemical composi- 
tion is almost constant. By means of the blood the constituent 
elements of the body are furnished with the nutrient sub- 
stances and the oxygen they require ; both are derived from 
without, the former from the alimentary tract, the latter, 
through the lungs. The entrance of oxygen into the blood is 
necessarily influenced by the vascular area exposed to the air, 
which in pulmonary atelectasis is of course diminished. The 
excretion of carbonic acid from the blood must for the 
same reason be impaired. Then again, the excretion of 
organic matter during expiration is interfered with, the accu- 
mulation of which in the blood conduces to auto-intoxication. 
The symptomatic complex, of individuals with collapse of the 
lung, based on an analysis of 25 cases, is as follows: haemoglobin 
(estimated with Fleischl's haemometer) is reduced to 50 per 
cent or lower; the red blood corpuscles are diminished in 
number. The reduction of haemoglobin and in the number 3 
of red blood corpuscles is proportional to the area of lung 
collapsed. 
Fatigue on exertion, shortness of breath, palpitation of the 
heart, loss of appetite, and constipation are the usual subjective 
symptoms. 
On inspection diminished movements of the thorax are 
noted. Percussion of the lungs shows diminished resonance 
throughout; the apices may show dullness on percussion and 
circumscribed areas of dullness are ofton found in the inter- 
scapular regions, particularly on the right side. The upper 
lobe of the left lung adjacent to the manubrium sterni is a 
frequent seat of dullness. 
Auscultation shows on quiet respiration an absence of respi- 
ratory sounds over the dull areas, while over the entire lung 
the respiratory murmur is diminished. When the patient is 
instructed to take deep inspirations, atelectatic crepitation is 
heard. The diagnosis is usually easy ; repeated forced inspi- 
rations cause a disappearance of the dullness and a reappear- 
ance of respiratory sounds. All my cases showed almost 
immediate improvement after the inhalation of relatively 
compressed air by means of the pneumatic cabinet. The 
improvement in pulmonary atelectasis was phenomenally 
rapid and occurred in some of the cases after three or four 
sittings. 
The color of the patients improved, the haemoglobin and red 
corpuscles increased, and the subjective symptoms of anemia 
disappeared. 
If relapses occurred, which were not infrequent, they were 
attributed in the main to neglect of lung gymnastics and a 
return to former modes of life. In a few cases nasal obstruc- 
tion led to relapses. In this connection reference must be 
made to the investigations of Holbrook Curtis,* who demon- 
strated, that all patients with nasal stenosis were anemic, and 
after removal of the obstruction the cases were cured. 
In cases where nasal obstruction cannot be removed the 
simple expedient of having the patient breathe through the 
mouth may be adopted. 
Although I have used the pneumatic cabinet for the treat- 
ment of pulmonary atelectasis, I am thoroughly convinced 
that no special apparatus is required if the patient is properly 
taught to make repeated voluntary forced inspirations. 
In anemia of pulmonary origin the therapeutic action of 
^Journal of the American Medical Association, Aug. 3,1890. 4 
chalybeates may be hastened by inhalations of oxygen. Oxy- 
gen is as essential an element of haemoglobin as iron. 
Sufficient oxygen for all practical purposes may be taken 
into the lungs provided no atelectasis is present, and forced 
inhalations will prove of great value in the treatment of 
anemia, although not of pulmonary origin. 
Oxygen is now commonly used as a therapeutic agent in 
many diseases. The oxygen of the blood is chemically united 
to the iron, and is not subject to the law of absorption, and in 
consequence the exchange of gases between the gases of the 
blood and those of the air vesicles occurs almost exclusively 
through the agency of chemical processes, and therefore inde- 
pendently of the diffusion of gases. 
When pure oxygen is respired, the blood does not take up 
more oxygen than when atmospheric air is respired. Inhala- 
tions of oxygen, nevertheless, do good, and this good is effected 
to my mind, not because pure oxygen is inhaled, but in conse- 
quence of repeated forced inspirations opening up normally 
collapsed lung areas and thus exposing a greater quantity of 
blood to the inhaled oxygen. The cachexia of individuals 
who suffer from cardiac valvular lesions is due largely to 
stasis in the lungs, the turgid vessels compressing the air 
vesicles. It can be shown that the blood of these individuals 
contains less luemoglobin than normal, and that the haemo- 
globin increases when the collapsed lung is opened by volun- 
tary forced inspirations. 
I know of no more simple means of relieving the dyspnoea 
of non-compen sated valvular lesions under certain circum- 
stances than by the inhalation of compressed air, the object 
being to dilate the collapsed areas of lung. 
The following conclusions may be formulated : 
1st.-Physiological atelectasis of the lung is a frequent 
condition. 
2d.-It may be readily diagnosed by the presence of circum- 
scribed areas of lung dullness, which disappear after repeated 
forced inspirations. 
3d.-Physiological atelectasis of the lung is frequently asso- 
ciated with anemia. 
4th.-In all cases of anemia of obscure origin, examination 
for physiological atelectasis of the lung should be made. 
5th.-Anemia, due to physiological atelectasis, may be cured 
after inflation of the lungs. 
6th.-Forced voluntary inspirations are an excellent substi- 
tute for inhalations of pure oxygen, and are of great value in 
anemia from whatever cause.