Classification of Anemias.pdf

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174 PORTO RICO JOURNAL OF P UBLIC H EAIJTH AND TROP. MEDICINE known error in technique, 'but in a badly dehydrated patient it is apt to completely ruin a correct estimation. This error is fre quently made by those whose tim e is limited. It is difficult to explain some of these abnormally high eryth r ocyte counts. My personal attention was given to the investigation as I had no intention of being deceived by poor technique, realizing as I did that a short cut means accuracy if reliable results arc to be expected. F irst of all, it is !believed that th e normal five million erythrocytes is too low in the tropics. The reasonabl e hypothesis in t he caSe of small doses of poison, whether of mycotic, bacterial or of a chemical nature , (the latter the result of imperfect elimination of waste products) , is that these, like all poisons, stimulate before th ey depress. That in the early and mild anemias of sprue a toxic stimulus to the hemopoietic organs works in this manner , seems worthy of consideration. Another observation which can be made is that th e hemoglobin , is, at least, only very indirectly affected by liver extract. This can be seen notably in case 15. H ere persistent use of liver extract seemed only to increase the erythrocytes, A more poignant question is: Wh at constitutes hematologically, a pernicious type 'of anemi a ' Certainly not color index alone (see cases 15, 38, 39, and others) . iNor cell diameters (see cases 24, 25, 26, 27) . The truth is that the best criterion is the Price-Jones curve. A high mean , a discordant medi an, and wide dispersion, after all, are the best hematologic evidenc e. The ti me-honored high color index is not to be despised, but a reference to case 25 alone, with its vigorous reticulocytosls after liver extract, will shake our hitherto blind faith in high color indices as a sine qua non of' pernicious anemia. The real diagnosis will be made from the sum total of accurate data, clinical and lab o r atory, after skillfully weighing all evidence , and this requires clinical and laboratory knowledge. Even with some facts considered t o be pathognomonic in the hematology of pernicious anemia: clinical experience is indispensable for interpretation. In looking over the ta bulatio n of cases of "secondary anemia" in this paper, it is inevitable that we should inquire : May not many of these be merely a. remission in the course of a pernicious typ e of anemia The writer himself feels confident th at such is the ease, not for any considerable number, but certainly for some. The avarage cell diameter in the few in which such diam eters were taken bespeaks a secondary anemia, but there are elsewhere low values which may indeed be merely pernicious anemia. remissions. There are two very striking differences between the pernleious
SUGGESTIONS FOR A RAPID CLASSIFICATION OF THE ANEMIAS, ETC. 176 anemia of Addison, seen in the temperate zone, and the pernicious anemia of sprue: (1) In only three of th e forty-two cases were normoblasts or megaloblasts seen, and then only extrem ely few. (2 ) The reticulocytosis following the administration of liver extract. is usually feeble (4 to 10 per cent ) compared to the vigorous rise of the curve -ap parently the rule in North ern countries, where, by the way, very few hypoplastic forms seem to exist. A final observation of much importance is the development of pernieions types of anemia in the case of the seemingly strict nutritional unbalance of P orto Rico. The lamented Elders of Amsterdam insisted that pernicious anemia was the result of a nutritional unbalance. 'While, of course, it cannot be supposed that even the majority of cases have such a pathogenesis, without entering into any discussion it should be admitted that in three cases, undoubtedly bearing every evidence of being samples of the pure nutritional syndrome discussed in other papers, a true pernicious anemia developed. In closing, the writer has one statement to make concerning the diagnosis of sprue appear ing in these protocols. This diagnosis has only been mad e in a full ninety per cent of the cases on a clinical picture which I cannot conceive th at any well-informed physician could confuse with anything but the sprue of P atrick Manson, a raw tongue, a gaseous belly, a white frothy dia rrhea, a small liver, and a rapid emaciation. I have been so circumspect in this diagnosis that I have undoubtedly left among the cases diagnosed "digestive incompetence" many a case of incomplete or incipient sprue. But it is for those who read this paper to say whether th e suggestions offered can be made help ful to our patients and to ourselves who, as a class, value above all things our reputation for accuracy and for judicious treatment.
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