When she wrote this account, the old lady was seventy years of age. She was in excellent health, and had been ever since her return from Paris in 1843, i.e., for thirty-seven years. I did not know her personally, but one of her sons was a medical friend of mine, and two of her daughters have been my patients. It was not until she was seventy-eight that she began to suffer from any of the infirmities of age. She died from peritonitis at the age of eighty.

I have, of course, no absolute proof that the disease was cancer, but I think it may be taken as practically certain that it was. I know nothing else that behaves as this did. Anyway, it was something that recurred again and again with malignant persistence, and who can doubt that but for the patient's marvellous determination and perseverance she would have succumbed to it?

I have quoted the case because I regard it as a remarkable illustration of what can be accomplished by attacking such growths again and again, and by making up one's mind not to be beaten as long as there is one spark of reasonable hope.

THE DIAGNOSIS OF PERNICIOUS

ΑΝΑΜΙΑ.

By T. Law WEBB, M.D., Ch.B., Honorary Pathologist to the Salop Infirmary, and the Eye, Ear, and Throat Hospital, Shrewsbury.

THERE is a somewhat widespread belief among practitioners that in many cases it is impossible to differentiate anæmias of the progressive pernicious anæmia type from the very grave forms of secondary anæmia due to hæmorrhage, syphilis, cancer, or other exhausting diseases. And this opinion receives some confirmation from the writings of observers who insist that in not a few cases of severe secondary anæmia due to intestinal parasites, cancer, or hæmorrhage, the same typical appearances are found which characterise the blood in true pernicious anæmia.

Ehrlich has forcibly laid down what these appearances are, and has stated that the presence of megaloblasts in the blood, together with a high "colour index," is pathognomonic of pernicious anæmia.

Can we still rely upon this statement of Ehrlich? Or is it true that in certain cases of severe secondary anæmia the same characteristics may be present? be present? It is desirable to be clear in our ideas upon this subject, because severe anæmia without obvious cause is by no means uncommon, and the diagnosis and prognosis in any individual case depends upon the type of blood-change which is found to be present.

For practical diagnostic purposes, the severe anæmias may be classed as follows:

I.-Anæmia of the chlorotic type, in which there is a great loss

of hæmoglobin, but no great diminution of the number of red corpuscles; and in which the colour index is therefore very low.

2. Secondary anæmia of moderate degree, in which, together with a low colour index, there is also some reduction in the number of red cells.

3. Very severe secondary anæmia, in which there is a low colour index, considerable reduction in the number of red cells, poikilocytosis, and sometimes (though very rarely) the blood contains megaloblasts.

4-Anæmia of the pernicious anæmia type, in which the count of red cells is reduced enormously, so that, although there is also a considerable loss of hæmoglobin, the colour index is high. Poikilocytosis is present, with megalocytes and megaloblasts.

It is necessary in any severe anæmia to ascertain by examination of the blood what changes it has undergone, so that we may know definitely which type of anæmia we have to deal with. Such examination must include:

1. A count of the red cells.

2. An estimation of the percentage of hæmoglobin.

3. A careful search over several stained films for megaloblasts.

Where the technique of the blood examination is good, the result is absolutely reliable as to the presence, or otherwise, of megaloblasts. So that if a careful estimate of the amount of hæmoglobin is also made, together with a count of the red cells, there should be no doubt whatever as to the type of anæmia existing in any individual case.

At the present time observers are generally agreed that Ehrlich is correct in saying that in pernicious anæmia the blood is megaloblastic and has a high colour index. The latter is perhaps the most reliable and easily verifiable characteristic of the two. And it has been established by many and repeated observations that in the severe secondary anæmias of syphilis, pregnancy, or hæmorrhage, and in the vast majority of anæmias caused by malignant disease or worm-infections, megaloblasts are not present, nor is there a high colour index. The truth is that exceptions to this rule are exceedingly rare. Indeed, any doubt or confusion which may have arisen in our minds in connection with this subject

is probably due partly to a lack of a sufficiently extended clinical experience, which allows an exaggerated importance to be attached to these exceptional cases, and partly to uncertainty resulting from careless examination or the use of a defective technique.

It will be useful to consider where the technique may be faulty, and afterwards to notice some of those very rare cases of secondary anæmia which form exceptions to the rule that megaloblasts and a high colour index are found only in true pernicious anæmia.

The actual count of the red cells with the Thoma-Zeiss apparatus is troublesome, but cannot be evaded. I find that the blood may be obtained and its dilution much facilitated by the use of Durham's automatic pipette instead of the mouth suction pipette usually supplied with the counting apparatus.

Durham's pipette may be described as a short piece of capillary tube (B Fig. 1) of a definite capacity (such as ten cubic millimetres), fixed in a wider tube (C), having its end closed by a rubber cap (A), the whole arrangement much resembling the ordinary "medicine dropper." The cap, however, has a perforation on one side (G). The tip of the capillary tube, being applied to a drop of issuing blood, fills automatically, and can then be made to empty itself into a previously measured amount of a diluting fluid by compressing the rubber cap, whilst the perforation therein is closed by the thumb.

Much gentleness and skill are required in using this handy little instrument in its ordinary form. One is apt to compress the cap too vigorously, with the result that when the pressure is released blood or fluid from the pipette is carried back by the inrushing air into the wider tube. On no account must this be permitted. To avoid the possibility of this mishap, and to make the pipette easier to use by those who are unskilled in manipulation, I have modified its construction in a manner which will be easily understood by a glance at Fig. 2. Instead of the perforated rubber cap A in Fig. 1, I use a short piece of soft rubber tube (D, Fig. 2), fitting

tightly over the last inch or so of the glass tube (F) carrying the pipette,and projecting the one-twentieth of an inch beyond its extremity. The pipette E, when filled with blood by capillary attraction, can be emptied by holding the tube F between the thumb and second finger, whilst the tip of the forefinger closes the open end of the rubber tube D, and slightly compresses it. The amount of compression possible with this arrangement can be graduated, and is so small that on removing the finger tip there is no backward rush of fluid into the wider tube, although it is sufficient to drive out completely the contents of the pipette. The use of this pipette has several advantages:

I. The diluent can be carefully measured beforehand, and any error corrected without taking more blood.

2. The automatic measurement of the blood.

3. The ease with which the pipette can be cleaned by removing it from its holder and drawing through it a fine needle threaded with darning cotton.

For actual use at the bedside in cases of anæmia, I recommend the following simple procedure. Provide a small box containing a triangular pointed needle, some slips of cigarette paper, and half a dozen clean slides wrapped in tissue paper. Also one capillary pipette of a capacity of ten cubic millimetres, with detachable handle (Dr. Oliver's pipette, the grip of its metal handle having been somewhat loosened, does very well), one Von Fleischl's pipette, one narrow corked tube containing 990. c.m.m. of Pacini's diluting fluid, one wider tube containing 100 cm.m. of distilled water. Having pricked the skin, allow the 10 c.m.m. pipette to fill itself with blood. Then take it out of its handle and drop it bodily into the tube of Pacini's fluid, which must at once be corked and shaken gently to and fro until the blood is diffused throughout the fluid. Next fill the Von Fleischl's pipette with blood, and, dipping it into the wider tube containing the water, move it quickly from side to side so as to mix its contents with the surrounding liquid. The tube must then be corked securely. Finally, a few dried films are to be