PERNICIOUS ANEMIA Nature, name of Pernicious designates an affection in which there is progressive diminution and degeneration of the red blood corpuscles, usually associated with fatty degeneration of internal organs.
Lebert (1S52) and Addison (1S55) had already described the patho logical picture of severe aniemic conditions as a special kind of and Biermer (1864) established its clinical lines of demarcation. The pathological anatomy of the bone marrow was described in detail by Cohnheim in 1S7S, while Ehrlich at a later period gave an exact descrip tion of the blood changes.
Formerly a distinction was made between pernicious anamia with a known cause and a cryptogenie pernicious amemia, but more recently some authors (Grawitz, Lazarus) are inclined to look upon the entire group as secondary disturbances, although there may be a difference in the congenital capacity of the blood-forming organs. The following causes have been observed: Chronic poisoning (carbon monoxide, Laache), tumors, especially of the bone marrow, infectious diseases (sepsis, syphilis, malaria), bodily and mental injuries, disturbances of the digestive tract (autointoxications) and perhaps repeated small hemor rhages. During pregnancy the affection is comparatively frequent. The best investigated kind is parasitic anaemia caused by bothriocephalus latus (Schaumann and Tallquist), anchylostoma duodenale (Zinn and Jacobi), also by ascarides lumbricoides (Demme). There is always a destruction of blood in this affection, as is evident from the large amount of iron contained in the internal organs, especially the liver, urobilinuria, manifestations of (nuclear) degeneration of the red blood corpuscles (Grawitz), but the bone marrow suffers secondarily an obstinate and perhaps permanent change of function. Ehrlich regards the change of the blood-forming function as anatomically characterized by the devel opment of megaloblasts (especially large nucleated red blood corpus cles) in both bone marrow and blood; others do not consider this as specific, but only as an expression of the gravity of the anemia.
Cases occurring in children have been described, but the affection is very rare in children. Many factors which are regarded as causative in the adult, enter rarely or not at all into consideration with children (pregnancy, psychic depression, tumors); it is also possible that the bone marrow of the child reacts differently.
Lazarus found among 240 reported cases 1 in the first decade (S young girls by H. Miller) and 22 in the second decade. Then follow 11 cases compiled by Monti and Berggrin, 6 by Escherieh, 2 by Grawitz (children of 12 and S years respectively), 3 by Koren, 1 by Theodor, 1 by Mott (a 9-months-old girl), 3 caused by anchylostoma by Baravallo, Villa, Cima. These few cases have not even been described with accuracy, some can hardly be accepted as true pernicious anaemia (Baginsky, 1 case by Retslag), others are doubtful (Senator). However
that may be, a few certain cases have been observed even in the first year of life.
Symptoms.—The subjective complaints of children are: lassitude, weakness, headache, fainting spells, nausea, gastric pains, anorexia. Pains in the bones such as occur with adults in the tibia and sternum have not been mentioned in the case of children. Objective symptoms are the following: sallow complexion, fat cushion sometimes well pre served, frequently oedema of the legs, hemorrhages in the skin of various extent, haemorrhages in the mouth, also retinal luemorrhages at an early stage; intestinal luemorrhages have been observed comparatively frequently in children. The body temperature may be normal, in some cases however it is considerably raised, pulse frequent, respiration dys pnaic. The heart shows, aside from visible palpitation and pulsation of the carotids, sometimes enlargement to the left and right, and especially murmurs which may be diastolic and cause the distinct impression of cardiac insufficiency. Venous murmurs may be present. Diarrhoea occurs frequently. Severe disturbances of consciousness also occur in children, but paralysis (from poisoning or anatomic changes) has not been observed. The spleen, usually enlarged in adults, is often swollen in children, but this may be the consequence of a complication. The urine in the adult is usually dark and often contains much indican (increased decomposition of albumin, Grawitz), also u•obilin as a con sequence of blood destruction. The oxygen consumption and the nitrogen metabolism, and also absorption, are frequently entirely undis turbed, provided there is light diet; Rosenquist in a bothriocephalus anxinia observed in the disease periods of increased decomposition of albumin alternating with normal conditions. The blood (Plate S) is watery, of low specific gravity and considerably diminished coagula bility. Hemoglobin and red blood corpuscles arc reduced to a minimum, and yet the coloring power of the individual corpuscle may at the same time be normal or even increased. This manifestation, however, can hardly be looked upon as specific. The white blood cells are relatively and absolutely reduced in numbers (although in one case of Grawitz 50,000 were counted in a child), the proportion to the red blood cor puscles in the adult is reduced to 1:1200 to 1600, and according to the majority of observations the lymphocytes have the highest percentage (up to (10 per cent.). The red blood cells do not exhibit any nummular formation, there is a strongly developed poikilocytosis, exceedingly small (dwarf corpuscles) and sometimes very large forms (megalocytes), further polychromatic and nuclear degeneration, associated with mani festations of regeneration (nuclear normoblasts and megaloblasts).