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List of Contributors

TO VOLUME XXIV.

DR. ALBERT H. ANDREWS. DR. ROBERT H. BABCOCK. DR. CHARLES S. BACON. DR. CHARLES H. BEARD. DR. W. T. Belfield. DR. ARTHUR DEAN BEVAN. DR. FRANK BILLINGS. DR. WALLACE BLANCHARD. DR. GEORGE V. L. BROWN. DR. JAMES MOREAU BROWN. DR. SANGER BROWN. DR. A. C. COTTON. DR. WILLIAM CUTHBERTSON. DR. JOSEPH B. DELEE. DR. ROBERT L. DICKINSON. DR. ARTHUR R. EDWARDS. DR. WILLIAM A. EVANS. DR. WALTER M. FITCH.

DR. J. HOLINGER.

DR. RUDOLPH W. HOLMES.
DR. F. C. HOTZ.

DR. FRANK S. JOHNSON.
DR. ELLIS KIRK KERR.
DR. ARNOLD C. KLEBS.
DR. F. KREISSL.

DR. W. A. KUFLEWSKI.
DR. G. FRANK LYDSTON.
DR. L. HARRISON METTLER.
DR. JOSEPH L. MILLER.
DR. CHARLES LOUIS MIX.
DR. EDWARD R. MORAS.
DR. JOHN B. MURPHY,
DR. A. J. OCHSNER.

DR. J. RAWSON PENNINGTON.
DR. JOHN S. PEREKHAN.

DR. CHARLES B. REED.

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THE

CHICAGO MEDICAL

RECORDER

JANUARY, 1903.

Original Articles.

THE CHANGES IN THE SPINAL CORD AND MEDULLA

IN PERNICIOUS ANEMIA.

(Modified from the Shattuck Lecture of 1902.)

BY FRANK BILLINGS, M. D., CHICAGO.

PROFESSOR OF MEDICINE AND DEAN OF RUSH MEDICAL COLLEGE, PRESIDENT OF THE AMERICAN MEDICAL ASSOCIATION.

Lichtheim was given the credit for recognizing, for the first time, the spinal cord changes which may occur in pernicious anemia. His report was based upon two cases, and was confined entirely to the changes of the cord in pernicious anemia. Soon after this. his student, Walter Minnich, reported one case in an inaugural dissertation.

The next important contribution was made by James J. Putnam, of Boston, who, in 1891, reported "A Group of Cases of Sclerosis. of the Spinal Cord, Associated with Diffuse Collateral Degeneration Occurring in Enfeebled Persons Past Middle Life, and Especially in Women; Studied with Particular Reference to Etiology." In this paper Putnam mentions Lichtheim's observations of cord changes. in pernicious anemia, and notes the similarity of the cord changes as compared with those observed in his patients. He also mentions the fact that Lichtheim ascribed the cord changes to some blood circulating toxin. Putnam apparently accepted the toxic theory as the chief etiologic factor in his cases, but he emphasized the fact that the age, the sex, the neuropathic inheritance, poor physical development, nutritional disorders, diarrhea, etc., were important contribuChicago Medical and Chicago Neurological Societies, Dec., 1902.

tory causes.

Putnam's paper did not receive the attention which it merited in Europe. The title was perhaps misleading, in that no mention was made of pernicious anemia.

Since 1891 many contributions upon the subject of the spinal cord changes of pernicious anemia have been made abroad and in this country. Nonne; Minnich; Bastianelli; Burr; Russell, Batten, and Collier; Lloyd; Taylor; von Voss; von Noorden, and many others have reported cases and have described the clinical phenomena, the gross and histologic changes which have been found in conditions usually associated with pernicious anemia, and also in conditions in which the blood condition was not like that of pernicious. anemia. Similar cord changes have also been noted and reported by some of the above named authors, and by others in leukemia, lathyrism, pellagra, diabetes mellitus, diphtheria, and associated with the degenerations incident to poisoning by phosphorus, lead and arsenic.

In 1892, Putnam made, with the collaboration of E. W. Taylor, a second report upon "Diffuse Degeneration of the Spinal Cord," in which a review and comparison of the views of many writers were noted. In this article Dr. Taylor made a most admirable report upon the pathologic anatomy of the nervous apparatus.

My observations have been directed to the diffuse degenerations of the spinal cord of pernicious anemia. The similarity of the cord lesions of pernicious anemia and of the conditions enumerated by Putnam, by Russell, Batten and Collier, and also by other reporters, is so striking that it must impress anyone who reviews the extensive literature of the subject. The similarity of the contributory etiologic factors of pernicious anemia and of other conditions in which diffuse degeneration of the spinal cord occurs, as reported by Putnam especially, is notable. It is my object to present cases of pernicious anemia, with the now recognized characteristic changes in the spinal cord, and to discuss somewhat the similarity of the cord changes in pernicious anemia and in the other conditions above mentioned.

It is possible that some of the earlier reported cases of diffuse degeneration of the spinal cord were not ascribed to an existing, but unrecognized pernicious anemia. It is just as likely, however, that some of the cases reported as pernicious anemia, with cord changes, were not typical cases of that disease. This statement is based upon the fact that in some of the earlier cases reported the blood state is not noted sufficiently to enable one to recognize the

case as one of a pernicious type of anemia; and, furthermore, at the time when the first reports were made, the means of recognition and differentiation of the anemias were not as clear as now. In earlier times pernicious anemia was diagnosed upon the basis of a profund progressive anemia, associated with a tendency to subcutaneous, submucous and retinal hemorrhages. When to these symptoms was added the post mortem finding of a characteristic, pale, anemic fatty state of the organs, and especially of the heart,. with an increase of iron in the liver, as was noted by Quincke, and the presence of degenerated bone marrow, the diagnosis was certain. We now have a better knowledge of the morphology of the blood. We are able to separate the primary from the secondary anemias, and the blood of the pernicious type is characteristic and easily recognized. When we find a marked oligocythemia, with the presence of many poikilocytes, microcytes, and macrocytes, with polychromatophilia, and a relatively high percentage of hemoglobin, with a normal or a higher than normal color index, it affords a type of blood which is found in no other anemic state. If to this we add the presence of nucleated red cells, and especially of megaloblasts, the fetal type of red cell and of a few myelocytes which together indicate degeneration of bone marrow, the diagnosis is reasonably certain without a postmortem examination.

CAUSE.

Our knowledge of the cause of pernicious anemia is not satisfactory. We recognize certain contributory factors and infer a condition of toxemia which has not been proved. We know that the disease may occur in certain conditions; that these conditions are so frequently present in individuals who do not develop the disease, that we must look upon them as accidental.

Pregnancy, associated with constant vomiting and malnutrition, has been followed by pernicious anemia. After repeated or severe hemorrhages, and in individuals who are poorly nourished, especially when the poor nutritional condition is associated with some error of physical development, a grave anemia may follow. It is associated with, or follows most frequently, disease of the digestive apparatus. It has been known to follow syphilis and malaria, and in a few instances typhoid fever and la grippe seemed to be associated causes. In one of my cases the patient suffered from scarlet fever, was not well thereafter, and two years later developed the typical disease. The disease so infrequently follows the infections, like

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