Classification of Anemias.pdf

SUGGESTIONS FOR A RAPID CLASSIFICATION OF THE ANE­
l\oIIAS OF SPRUE AND NUTRITIONAL UNBALANCE IN
THE TROPICS..
H ,\ILl:Y K. A S IU'OJ(D
From the Schoo l of 'I'ropicul Medil·ine of th e Uuivursity of Port-o Rico, under
th e auspices of Columbia l: niversity. "
In the year 1928, a scientific study of the anemias of sprue and
of the limitations of liver extract in their treatment was presented
b)' the writer at the Internati onal Congress of Tropica l Medicine
and Hygiene, held at Cai ro, Egypt.
The conclusion reached was that pernicious anem ia was not It
disease limited to the original cilnieal picture drawn by Addison,
but a pat hologic state wh ich could accompany a number of diseases
with widely different cau ses and man ifestations, and t hat one of
these diseases is tropical sprue. It was also show n that in sprue
two varieties of pernicious anemia could be distinctly separated by
a study of the blood during the administration of liver ext ract ; one.
a dysplastic form, in which the megaloblasts in the bone marrow
could be stimulated to produce a shower of reti euloeytes , the oth er,
a hypoplast ic form, not responding to this hormone.
I n order to arrive at these conclusions, twenty-fou r eases received
almost exclusive attention for a period of ten months, during which,
in many ins tances, daily and time-consuming lab oratory data was
elicited. This comprised a daily count of one thousand erythrocytes
to estimate the varying number of retieuloeytes, weekly measurements
of one hundred erythrocytes to plot a Price-Jones curve, and
,fr equent counts of red and white cells, differential counts of leucoeytes
and an esti mation of hemogl obin percentage.
I Only those who have plodded through this sor t of work l'calize
that such scientific exactness must be used to establish doctrin e find
that the busy life of a modern pr-actitioner does not permit of this.
Yet these facts must be applied to the practice of medicine, 01' t he
scientific study of disease will have no practical bearing on th e saving
of health.
This paper is written for the purpose of suggesting a brief method
of arriving at a fairly reliable diagnosis and treatment of the an emias
accompanying a frequent nutritional unbalance of th e tropics and
its aU too common sequela, sprue. 1t. has been written in the dem­
• P aper r ead by litl . al the lnal meetinjt of lh e
nal dr-l ~ ort •. by in vit nt io n. in Octub{-T 1929 .
oc iedn d Ar jteDtiDa de Pntolor f.. Rejtlo·
107

168 PORTO RICO JOURNAL OF PUBI,IC HEALTH A..~D TROP. MEDICINE
oeratie spirit which should inspire one who attempts to suggest to
his colleagues a plan of action which must be feas ible, and which
should at the same time satisfy their scientific scr uples. That is
to say, it opens the door to all over-wor ked physicians to say how
much or how little clinical laboratory work must needs be performed
before it is possible to arrive at ;.a fairly reliable diagnosis and
treatment" of these anemias.
The method employed by the writer, with exceptions imposed by
an unusual pressure of work, has been as follows:
( - 1. All persons suffering from clinical sprue or its preceding nutritional
unbalance have their hemoglobin percentage estimated by the
Dare instrument (two minutes).
2. All cases with a hemoglobin of less than seventy per cent receive
a red cell and often a white cell count (ten to twelve minutes).
3. All cases coming under thc latter category with a color index
of plus 1. or over and with a hemoglobin below fifty per cent, r eceive
in addition a differential count of Jeucoeytes and a careful measurement
of ten erythrocytes in a field enabling one to take these ten
cells as they come, one after the other in the same traverse, without
selecting cells that are interestingly large or small (a dangerous
pitfall for an honest average). 'I'hese measurements should be made
with the best filar eye-piece micrometer obtainable ; that is to say, one
which will distinguish one-tenth of a micron. In addition, this must
always be supplemented by a count of reticulocytes. Both procedures
can be accomplished on the same slide by Jetting a drop of a 0.3%
solution of cresyl blue in absolute alcohol, fall on the end of II glass
slide and when it dries, working the drop of blood, caught on the edge
of the end of another slide, back and forth until it incorporates the
stain before making the smea~. It is now stained by Wright's or
Leishman's method and is ready for cell measurement, reticulocyte
count, and (although the cresyl blue changes some differential characteristics
of the leucocyte) a differential count. This should not reo
quire over twenty minutes, and less, if the following technique is
followed:
Let into the eye-piece of th e microscope a glass disk enclosing
about 250 cells in a well spread smear. If the cells are unusually
large or small, one circle-full can be counted as a standard fOI" the
other three. The reticulocytes are now counted in four of such
circles considering each circle to contain 250 cells, or more or less
circles if a standard count demands it_ One is sure to make a ten
per cent, and possibly a twenty-five per cent error, but this will
not prevent the possibility of deducing that there has, or there has

SUGGESTIONS FOR .... RAPID CLASSIFICATION OF T IlE ANEML\.S, ETC. 169
not been a real efficient reticulocytosis in response to liver extract.
This, after all, is the information desired.
4. All cases presenting a pernicious type of anemia should have
reticulocyte counts made four, seven, and ten days after the first
administration of liver extract in order to catch, at least, the up
or down curve of the reticulocyte peak. Such eases can be safely
diagnosed dysplastic anemia, and the maintenance dose of liver extract
should be insisted upon.
Those cases which do not respond to liver extract after two weeks
of administration may' at least be suspected of being hypoplastic and
the continuance of this expensive remedy would seem to be an unnecessary
drain upon the patient's pocket-book.
There are many reasons why this examination should be conducted
in the presence of the patient, not the least of which are his
vizualization of the scientific methods employed to arrive at a correct
diagnosis, and the decision which can be reached while the clinical
supposition is fresh in the physician's mind. If this work can be
confided to a well-trained laboratory assistant while the clinical examination
is going on, the result will be still more satisfactory.
There are many little flourishes that may be employed to make the
diagnosis and course of the disease more vivid. For example, it is extremely
nice, and, at the same time, useful, not to be satisfied with one
Price-Jones curve, but make not less than one Price-Jones curve a week.
The reduction in anisocytosis is thus more sharply defined and the
return to a normal mean and a more closely approximated median
gives a more convincing proof of approaching recovery. Of course,
under such circumstances it would be necessary to measure one hundred
cells each time. A very satisfying evidence of improvement
may be brought out by weekly differential counts in' a substantial
eosinophilia and a reduction in relative lymphocytosis. .A pains-taking
count of platelets reveals that their increase is an emergence from
the shadow of a pernicious anemia.
But all these latter procedures, and perhaps many more can by
no means be of sufficient importance to warrant the neglect of waiting
patients and the expenditure of the valuable time of an overworked
and underpaid practical doctor of medicine. All of these
things can, and should be done in a hospital, but in the eager search
for the essentials in an out-patient clinic or in the private consulting
room, the time they require is generally prohibitory.
No one knows better than the writer that the suggested plan for
the rapid determination of the anemias of the tropics must at, times

170 PORTO RICO JOURNAL OF PUBLIC HEALTH AND TROP. ){EDICINE
bring errors, that it cannot be perfect, but is it not better than the
method used by the average practitioner today Y Does it not, after
all, hold its place satisfactorily among all of the usual methods and
processes of thought upon which most of us depend for a "clinical
diagnosis" 7 Our clinical sense, aided by a hint from the laboratory
will generally bring us to a more elaborate examination of blood in the
given case.
Probably most of us will agree that to withhold liver or an extract
thereof in the presence of a true pernicious anemia, and load iron
into a liver already choked with it is reprehensible. Yet, few realize
the frequent hypoplastic forms of pernicious anemia in the
tropics to be a true exhaustion process, in which a continuance of
liver extract will only serve to drain the purse of the poor who need
the money to restore the blood-making organs by proper food. If
after intelligent diet these organs can have their vital elements built
in again by nature, a second trial with liver extract may succeed,
especially if we take into account that back of all, there is an already
impotent liver which needs protection against dietary abuse, and
nourishing food for its own tissues. In a long series of chemical
analyses of the blood in cases of sprue and its anemia of pernicious
type, there is to be seen quite regularly, a very low cholesterol content
and a high icteric index. But time forbids the tabulation of
this data in this paper.
If what may be a pardonable error in insisting upon liver in
hypoplastic anemia can be condoned, what shall we say of the practice
of administering liver extract by routine in secondary anemia
and worst of all, in hemoglobinemia Y Such conditions usually mean
a dissolution of hemoglobin and erythrocytes in circulation, not a
a failure of the hemopoietic organs.
The writer believes that he has never seen a more precise and
more narrowly limited therapeutic agent than liver extract, judging
from the evidence so far produced. Liver extract will practically always
bring about a shower of reticuloeytes and at least an apparent
cure in von Biermer's dysplastic pernicious anemia. In the experience
of most of us, however, it will not bring about this shower
in secondary anemia. It may do so in a blood, temporarily possessing
a low color index, but in one which measurement of erythrocytes
and a wide dispersion i(anisocytosis) show to be essentially a megoblastic
affair. It may have the same effect in a pernicious anemia
blood with a temporary low color index and a microcytosis, but the

SUGGESTIONS FOR A RAPID CLA~SIFICATION OF THE AN E)!lAS, ETC. 171
Price-Jones curve, properly made will easily disclose the nature of
such " secondary" anemias, A t rue aplasia of the bone marrow was
found at autopsy in One of my cases of pernicious anemia due to
sprue and not responding to l!ver extract by Professor R. A. Lambert
of this School two years ago, and section of bone marrow by biopsy
in a series of such eases now being made by others will demonstrate,
I believe, that aplasia and hypoplasia is the rule in these clinical
types.
It i hoped that liver extract may be an efficient reducer of
high blood pressure but that thi s is a scientific fact is not yet sufficiently
demonst rated to bring about a doctrinal acceptance. It is
not denied that the present belief in a potent hormone on the part
of th e lay pu blic, who attrib ute to it a dominant power to overcome
all anemias, as well as many strange influences on other organs and
their f unctions, may not some day prove to be in some indirect
measure justified, but the practicable, un questiona ble fact confronting
us now is that no sufficient evidence has been produced to show
that such effects are due to liver. F acts in Medicine are not commonly
proven alone hy one man ' 8 flzures but by those of many
r eputable investigators.
Working on th e clinical plan set forth, the 209 cases in which the
condition of blood in sprue an d digestive incompetence was investigated
yield thc following r esults :
CASES L'(
wmcn ON LY THE HEMOGLOB IN WAS INVESTIGATED
Normal H emoglobin (90-100 plus per cent).
Total nutnber of cascs ' 14
Avera ge Hemoglobin perccntage 98.3
Cases of sp rue (3 severe, 4 moderate)_ ______________________________ 7
Average hemoglobin perc entage 102.3
Digest ive incompet ence (t he syndrome of th e prevalent nut ritional unbalan
ce of t his Islan d) 7
Aver ag e hemoglobin 94. 4
Calle. wit h a hcmoglob in perc cntage
Total nu mber of such cascs
Aver ag o hemoglobin perc ent age
Cases of spruc
belOID 90.
74.8
Average hemoglobi n 74. 8
Digestive incompet cnee.,, __ __ ___ ____ __ 50
Average hemoglobin ~ H .8
Loss of weight in the above cases:
Average of 29 cases of spru e
26. 5 pounda
Aver age of 38 cases of digcstive incompetence 17.5 "
84
34

172 PORTO RICO JOUR1'UL OF PUBLIC HEALTH AND TROP. :a.lEDICI\E
CA8l:& IN WHICH BEllOGLOBIN PERCENTAGE WAS TAKEN AND ImVTHItOCYTltB
COUN TED
Hemoglobinemia and Secondary Anemia (non-megalobla.1tio anemia)
Total nuxnber of such cases 9
Casel of spruc 34
Average hemoglobin percentage 63.4
Cases with 5,000,000 cells per cmm. or over 15
Cases with 6,000,000 cells per cmm, or over___ _________________ ______ ~
Cales with 7,000,000 cells per cmm. or over 11
Average erythrocyte count per cmm, 4,876,470
Cases of Digestive incompetence 85
A'I"erage hemoglobin percentage 61.1
Cues with 5,000,000 cells per cmm. or over 17
Cases with 6,000,000 cells per cmm. or over .:_____ 8
Cases with 7,000,000 cells per cmm . or o\'e£- _________________________ 5
Average erythrocyte count per cmm. 5,314,485
(One ease had 8,440,000 and another 10,232,00D-the latter a child
of two years.)
LOiS of weight in above casea :
Average of 24 cases of sprue
28. 1 pounds
Average of 23 eas es of digestive incoxnpetence___ 17 pounds
Average hemoglobin for all 69 cas es 65,7
Average eryt hr ocyte count for all 69 cases 5,098,550 per cmm,
Pernicious types of Anemia (Megaloblastic Anem ia.}
Total num ber of such cases 42
Cases of Sprue 38
Average hemoglobin percentage 49. 6
Cases with from 4,000,00D-5,000,000 cells per c=.__________ ______ __ °
Caaea with 5,000, 000 or more cells p er cmm. 1
Cases with 3,OOO,00D-4,000,000 cella p er emxn.________________________ 6
Cases with 2,000,00D-3,000,000 " " ,, 16
Casea with 1,000,00D-2,000,000 " " " 15
Average erythrocyte count per emrn, 2,371,447.
Cases of Digestive Incompetence____________________________________ ~
Average hemoglobin percentage 47
CMea with 8,000,000 to 4,000,000 or more cella per enun.____________ ___ 1
Cases with 2,000,000 to 3,000,000 or more cella per emm. _______________ I
Cases with 1,000,000 to 2,000,000 or mor e cella per emm. _____________ __ 1
Cases of unknown etiology___________________ _______________________ 1
Av erage hemoglobin perccntage 32
Average erythrocyte coun t per cmm. 2,272,000
Len of weig ht in above eases :
Average of 38 cas as of sprue
Average of 3 cases of digestive incomp cte nce
37.1 pounds
31.6 pounds
In eleven of these forty-two cases the eolor index was less than 1,
hut there were other reasons for considering them cases of pernicious

SUGGESTIONS FOR A RAPID CI,A8SIFlCATION OF THE ANEMIAS, ETC. 173
anemia which, in the writer's mind, outweigh' this apparent discrepancy,
notably, the greatly increased mean and median diameters.
The average diameter of red cells, superior to 8 microns, in
twenty-nine cases was 9.51 microns. The average diameter of red
cells, inferior to 7.7 microns, in three cases was 6.22.
Of the total forty-two cases, eighteen were demonstrated by their
prompt response to liver extract to be dysplastic; eight by their
failure to respond to this substance seemed to be hypoplastic. In
the remaining sixteen cases either the time .element ,f or correct
observation has been too short or they have failed to return for
treatment and no classification is possible.
Divided according to age periods, 206 of these cases are as follows:
Syndrome
Five·year age period s Nutritional
Unbalance
8pru~ Total
--- ---
1- • . . . •. •. • •. . . . . . . . I 3 4,
ll-- 9. . ..... . . . .. .. . . .. .. . I I 2
IG-I4 , . 1 3 (
1ll--19 _ . 2 5 7
20-24 . Jl 7 18
25-211 . 12 11 23
30-31 .. 10 12 22
35-39. . •. . .•. •. . . . . ... .. . . . . . . •... . . .. 18 13 31
4G-44 , . 7 14 21
.5-

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.

l-'
TABLE I.-CASES OF PERNICIOUS ANEMIA -:J
C'l
~
. ~ o ... c Q
.c .. '"
~ o
:0.." . '., ~ 'tl
-e
.~ ~ ~~ 0" SE =
5"
"c ".- Cause Variety .. ~ Erytbro- .9 - .. Days alter
",E
.. illg 2~ cytes !; ~~~
. ~ t
~"'::'
gp.. '0 ~aa alp.. o
'"
~ ...: ",,- ::l '" '' D:l 0 -< ;::;
"' .. IIver estrsct §
- --- --- Q
Ind igestion 12 years. Severe sprue one and a hair yevs. Eltremely III Bnd o
I. . 64 20 .... Sprue Dyspl... 37 1,560,000 1.2 8.72 0 .1 ..............
4.1 7 despondent. ColToo plnnter ruined by tbo cyclone. Now appu8Dtly well to,
8 ................ 33 701,000 2.3 and energetic. AU symptolIl.9 have disappeared.
g
15 ................ 55 2,3 20,000 1.2
:ll
2.. Sll months severe sprue . Now no symptoms.
56 45 .... Sprue Hypo.. . ss 2,9~, 000 I. 8 .75 O. ..·.. ..·····7· Z
o.i ll­
t'
7 ................ os 3,376,000 1.01
21 ................ 67 3.664 ,000 0.92 o
I>j
S.. 67 .... .... Sprue . . . .. . . . . 38 2, 472, 000 0 .77 10.17 0.5 Normoblasts 'r ypical severe sprue.
All th e symptoms 01sp rue ssve sore tongue. 00
4.. «
l\

11..1 g i g I ' Spru o DYS PI
" 1 4 ~ 1 1' 620' 000 1 1.4 1
0.6 , ..
7 10.3 7
21 77 3.200, 000 1.2 8.8
30 80 3. 248, 000 I.2
51 80 7,072,000 0.56
1
12..1 75 I 37 D .1. Dys pl. . . 35 1,690, 000 I 1. 03 2.7 .... ...... ... .
7 . 5 .2 7
12 40 . " ii:il8'
13.. 1 &3 31 I... . Spru e Hypo. 57 2,5 00, 000 1.14 0 .6 ..............
7 alt er Dy sp l., . 4.1 7
8 43 3, 120, 000 0 .70
22 43 1, 814, 000 I. 2
39 .. .. 65 2, OSO, 000 1. 6
45 50 1.872,000 1.3 5
54 50 ............ ...... 9.77
fl.I 50 I, 584, 000 I.6
85 40 2,084 , 000 0.97
92 70 2. 2M, 000
99 •.. • .• ..... .• .• • 71 3, soo, 000 1.01
100 47
lIO 67 3. 240. 000 I. 03
\4..1 &0 I 42 1 . ~ ~r.l ~ ~ .~ .~~~ ~ ' : : 1 21 60 r.ose.eoo 0 .74
" 7 '1 ~ 1. 302, 000 1.6clnlly an lmprovement
In her menta l cond iti on 8S she ls today enthu..iastlc and hope lui and ~
willing to accep t evecy suggest ion mode lor her betterment.
i~
~ o
!
Two Yt"ars 1lI with severe sprue, HI'S n marked pelll\4OrolU ras b On lorearms
an~ neck.
LIV~~~t1~~~ toL~~~~ '[~B~t':ntrr~:8t~~rn~to~e:~(~ :~~I~ ~~'fn'f:r ~~ t~~nna~
re pu tation !IS all educat or. In 1snu l\ry 01 1928 developed t ypical Z
sprue. Went Irom had to worse until he had lost seventy-five pounds
In weight (Irom ISOto 105 pou nds). Developed a pernlclo us type 01anemia
an d was placed on a fru it diet . On th is regime he becam e almost well ~
of his diarrhea but was so much worsc rrom tbo pern icious an emia an d
cachell.. which de veloped tI",t ho embar ked lor Porto Ri co. On the wsy
down he 610 Ireely 01 evcr y t h
l n~ and contlnued to eat lor tw o weeks alter a
rea ching this island . He thus gained welght, reaching 147 poun ds. One
day , att er a hcavy cereal In take be ha ll an acute relapse 11 11 ,1 lost twonty
pounds In three da ys. I th on placed him on IDs y die t for spru e lind In
sIlty-t wo days he had gained filt}··lour pounds. He now weighs, at ti me
j
01 dl.chllrge 191 pounds. bu t up t o ooly a mon th ago steadily relused
to gain IIIblood val ues, remain ing around 50 per eenj hemoglobin In spite of
a rise In erythrocytes. For the first three weeks I used liver extrn ct hut
resolved to stop It In absence 01bene fit un tllI shou ld nourish him sut llclent ­
Iy to bring about a replacement 01megaloblaats nnd a heel thy reaction to
the horm one. 'Phls o~ hl en tl y is what occurred lor on bo~inlllni again tba
!lver ertrac t a polyoythemla ensued and a slow rise III bem oglobtn . The
9
patient Is at pr68ent 10apparent robust heal th .
~
~
~
~
~

,;
Z
5
0
-
Ill. .
~
~
-<
-
114
..
C .5 ..
~
"
", "C -;] Caus e Vari ety
.. 8 -a~
o~
" 0
"
l» "C
~;:.. 0 > ~ a
Q ~ -< I:::
'rABLE L-CJASE8 OF PERNIOIOUS AlmMIA-Continued
~ '""
"'0 ~ ~
." l»
~- . ' S "' ~
Erythro­ .!! ] ] 0 o l:l i

I... . 8prue Oy s pl. . 48 20 ..... ..... ...... 34 ............ I, 496. 000 1.13 .0~0 13 ,
ao ...... .. ...... .. 81 3. 36ll, OOO 1.21
:17 ................ 74 3.256, OOU 1.14
26.. 1 3,\ 1 46 I.. .. Sprue OYSIlI.. 33 s.rs 0 ,2 ..............
7 ........ ,....... 47 ..2:7&i;000' 0 .85 26 ,6 7
In ,............... 53 2, 9H. 000 0 .9 0
26.. 124 1 35 I.... Sprue Drspl. . :II 1, 4-18, 000 1.00 9 .67 0 .6 ..............
14 ....... . ...... 31 1, 600. 000 0 .97 6 .79 3 ,6 One my eelocytte
retlc,
20 m .
27. . 1 36 1 30 1. .. · Sprue Dy spl . . 32 1. 3fJ8, OOU l. IM 6 .1» l. ..............
7 ................ 37 ............ 1l.4 21. 9 7
28..1 65 I 40 I· .. . Spru e Ilypo.. . 80 2, 776, 000 1. 5 ........ 0 . 1 ..............
7 ................ 52 .......... .. 1.4
20.. 1 66 141 1... · Sprue .. .... Ii:! 2, 680, 000 Ull .... .... ..... ..............
aO .. 1 72 175 ,. .. . Sprne . ...... 41l I, C$5, OOO l A ,'j ........ ...... ..............
:H .......... . .... 62 2,1l00.mO 1.1 0
il .... .......... M 3. i OO, Call 0 ,86
lOS 86 r., 42., 000 0 .67
al..I TI I HI.... Sprue . . .. . .. 4l! 2. ooo, 000 0 ,92 ........ .... . ..............
Il ................ G:J 2. 81H. QO{) 1. 1
21 .......... .... fl2 3, l\Il2,000 086
48 ............... M4
12..1 56 1 10 I... . 0 . 1.. . .. . . .. . 52 2, 072, OOU 1. 26 ........ ...... ..............
It .......... ...... 67 2. IlM. 000 1.17
7 .. ........ ... '"
............ .. .. . ........ 1. 6
33..1 37 I 45 I.. .. Spru e H ypo.. . :.6 1, 650, 000 I 72 ........ 0 , ..............
aLI 42 I 2'J I.... Sprue Orsp l. . 43 I. [.2S,000 1. 4.1 ........ 0.4 ...............
14 .............. . 42 1,528,000 U O ........ 6 . 14
2!1 ............ .. rs 2. 392, 000 1.66
59 ................ 71 3, (\~f\ I OOO 0 .97
8Y .............. . 70 3, lr.!O, OOO O,W
IS .. I 62 1 66 I... . Spru e D ysp l. . 73 2,1 :Jfl, OOO 1.7 10 . 0 .2 ..............
10 ................ .... ............ .... . ........ 2.2 10
14 ............... 63 2. '196,000 1.21\
21 ................ 74 I, 8~ S. 000 2.
36 ................ 8i 1, 2:12, 000 1. I I I I
DYRP1.-D~·splastlc
. Uypo.-nypoplnstle. D . f.-Diagnosti c Inecmpeeenee,
B e g~n
lIS acute w rl1e with vom iting and dlarrhes. Hapldl:r reou:hel1 a RtAte
of eachexla. is return to apparent henlth hILS been ilK r~pld and he seem .
now In good health, D2
§
Acute snvera sprue 01only three months' standing. Mlerocytosis Is the feature l::l
of t his oase. tol
tn
>i
2)
Hel A ~s e of Case XVI of Cniro sertes d ue to return to the hahlts of eating
w Ich originally brought abou t ber dlsease. Her t:rpe of cell has always Z
en
been a microcyte .
:8
Only seen once. A case ofsevere spru e. :a
:.­
Bas ha rl tw enty-tw o cblldren nnd th e hnrd lire of a peasa nt woman wlt b trnproper
lood. Severe case of sprue . ~
":l
Ver y severe case of sprue with exaggerated case of pyorrhea. Apparentl:r S
ceased but tbls Is Arelapse after three yeRrs du e to lack of meal and veglla
tables, r"
;s­
An ext remely severe case of sp rue In" dar k mulatto. Econ om ic status good
hydrates au d rats , very low in anima l proteins.
... ~
a
~
Severe sprue Immediately lollowing chihlblrth. Clime on "culely.
~
Z
hu t hab its 01eating are the traditio nal ones of Porto IUco-hlgh In carbo- m
0
:0:01 a picture of s ~ rne but 8 pernlclous t ype 01unarnln In tha course of a IIf.. ":l
time rood unba ance as per case 30. ":1
Vpr}' severe sprue and tnctplent tuberculosls, m
ScvArA

TABLE I.-oASES OF PERNICIOUS AlmMIA-Continued
~
.OJ
z "0 " -e ;..,
" :a.-= -

SUGGESTIONS FOR A RAPID CLASSIFICATION OF THE ANEMlAS, ETC. 181
---- - -
TABLE n .-8ECONDARY ANEMIA
.5
,»­ .... '"
0 0
Loss Day!! ;:t c h­
.. 0
Case Aile weight aft.r Dlsgn",,1s i~ Red8 >Stl l~~
No. pounds admission
e'" gPo.

182 PORTO RICO JOURNAL OF PUBLIC HEALTH .A.ND TROP. MEDICINE
1'ABLE n.-8ECONDARY ANEMIA-Continued
Loss Day s
Age weight alte r Reds
poun ds adm ission
- - - -. -------I------I~--f_-----·I--- --
e4. •. . . . 2J 9 Sprue .. . .. . .. .. .. . 35 6, 0.0. 000
M . 10 6 Sprue . . .. .. . .. . . .. 7i 6, 920, 000
6&. . •• •• 30 11 D. I.. .. .. .. .. .. .. . 56 4.384,000
61 . 40 63 Sprue.. .. .. .. .. .. . 70
39 65 7, 320, 000
68 . M .... .. .... D . I, Pyeloneph . . 74 0, 290, 000
6 ~ . 62 11 D. 1.. . .. . .. . . .. .. . gs
21 .. 6, 286,000
150 ..
09
66 78 Sprue. . .. . .. . .. .. .
80
43
7, 816,000 7 .33
125 62 3.150,000
01. . 71 45 Sprue .. .. .. .. .. ... 84
365 85 '" 692, 000
02 . 33 27 0 .1.. .. . .. 86
33 86 4,313, 000
03 . 24 32 .. .. Sprue. . . . . . . . . . . . . 62
72 76 5, MO,000
99 66 5, 480,000
M . 3 o Sprue .. . .. . .. .. .. . 39 5,272, 000
OS . 66 66 Sprue .. ........ .. 02 3, 810,000
34 Sprue: ::::: :':::::
34 14 4, 344, 000
OL . 63 78 4, :m, 000
01 .. 25 ......... . Sp rue .. 85 5, 384, 000
08 .. 40 22 Sprue .. U . , 900, 000 No
7 .. 46 4, 130, 000
69.. 1 25 0 . 1.. .. 72 a,au,000

SUGGESTIONS FOR A RAPID CLASSIFICATION OF THE ANEMIAS, ETC. 183
TABLE m.-HEMOGLOBIN ONLY
L oss
Hemo­
Number Age in pounds Diagnosis globin
Percent
I. ... . .. . .. . 38 16 D . r.. 87
2 . 43 D. r.. 65
3 . 23 17 D . 1. 88
........................... 22 7 D . I 88
5 . 59 7 D . R . Arteri oso.. .. .. .. 70
G .. 29 12 D.!.. .. . . . . . 62
7 . . .•. . . •• •. .. . . .. . .•.. ... 29 ·.... ....i5· D . I..
72
8 . 39 D. I
72
9 . 50 19 D . r.. 75
10 . 35 21 D. I 80
11.. .. .. ..
.. . 13
4 Sprue
82
12
.. 45 18 D . I
73
13
. 59 14 D.!..
78
14
.. 45
27 D .I..
45
I~ . ..
.. 42
16
.
.... ......3· D. !..
68
42
D . I
77
17..
.. . 21 14 D.l... . .. .. . .. .. .. .. .. .. . .. .. .. 58
18 .. 17 2 D . 1.. 76
19.. .
.. . . U
18 D . I.
57
:ill
. 33 10 Sprue
83
21. . . .
. 63
50 D .1.
81
22
. 30 30 Sprue. .. .. .. 76
23
. 20
7 D . l. . .. .. . ..
81
2 . 29 8 D. I. . .. .. 72
25
.. 30
63 Sp ru o
60
26
.. 40 30 Sprue
85
27
. 45
7 D .!.. .. .. ..
77
28 .. 30 14 D .l 65
29
. 75
7 Sp rue
77
30
.. 31 30
31.
.. 5 .
Sprue . . . . .. . . . . . . . . . . . . . . . . . . . . 65
D . I.. .. .. ..
73
32 . 45 31 D .!.. 65
33 .. 50 ! D . 1.. 87
3
, 27 21 D .!..
79
36
. 43 129 Sp ru e
83
M
. 29 24 Sp ru e
76
31
.. 20 17 D .!..
__ 83
38
.. 39 18 D .!..
85
39
.. 28
3 Sprue
82
. 0.. .. .. .. .. .. .. 29 10 D. I.
75
. 1.
. 30 17 Sprue
84
. 2
. 40
Spru e .. .. . . .. .. .. .. .. .. .. .. .. .. 78
43
. 27 17 D . I
83
44 .. 21 27 D . !.. 64
45
. 65 21 Sp r ue. . .. ..
79
46
. 19
2Q Sprue
__ 79
47
. 40
2Q Spru e
86
48
. 48 13 D . I. .. .. . .. . .
85
. 9
. 28 17 D. I
S9
60
. 52 16 Sprue
76
M
.. 31
52
.. 42 •
Sprue
66
63
.
...... ·..if D .l.
76
18
Sprue
85
64
.. 68 ......
65
. 68 " iii'
Sprue
60
D . I
62
56
. 37
9 D . I
70
67
.. 33 28 Sprue
74
58 ,
. 24
5 D. I.
M
59
.. 49
5 M yalgiR" nd D. 1. . . 70
60
.. 57
3li Sprue
8~
G1. .. .. .. . 21 18 D. I.
62
62
.. 55 13 Sprue
75
63
.. 58
11 Sprue s nd hypertensIon .. . •. ... 87
64. .. .. 37
D . !.
80
65
.. 29
8 Sprue
89
66
. 35 35 Sprue
72
67
. 24 ......... D . I
Il-5
118
. 24 31 Sp ru e
75
e9
.. 77
22 Can cer stomach and D . 1.. 82
70
. 35 10 Sprue
74
71.
.. 37 16 D .!.. .
73
72
. 3t 2t Sprue
86
73
. 12 .......... D . !.. .. . .. .. . .. .. .. . .. .. . .. . .. 88
74 .. 37 ... D. I. .. .. . .. .. .. .. .. .. .. .. 72
16
76
77
.
.
.
39
45
40
45
20
28
D . I
Spru e
D. I
79
71
110

184 PORTO RICO JOURNAL OF PUBLIC HEALTH AND TROP. MEDICINE
TABLE IIL-KBMOGLOBIN ONLY-Continued
Loss
Remo-
Number A.ge in poundo DIaanOllbl globin
Percent
78.. . .. . . . .. . . ... . .. ... . . .. . 17 211 8prue. .. .. ... . . .. .. . . . . .. .. . .. . . es
111......... . . . .......... . . . 14 .... ~
SO•••• •••••• • •••• •••••••. •• 19 43 ~~~~: : :: : : : : :: : : : : : : : : : : :: : : :: :: 05
1l1.. . ........... .. . . .. . . .. . 34 12 D.I.. .. .. .. .. .... . .. .. .. ... .. ... 84
82.. . . .. . . ... ............ . . 36 30 Bprue . . . . ...... ... ... ......... .. 6J Se..en
13..... . . .. . ..... . . . .. . . .. .. 55 U D . I .. .. ... ..................... H
N .................... .. .... 22 ... .... ... Sprue. . . . . . . . . .............. ... 65 ,(oduate
TABLE IV.-NORMAL HEMOGLOBIN
Lolls
HlIDoilobin
Number in poullde Dlngllosis Per~nt
1 .. 22 ~ D .l.. .. In
2 .. 38 31 Sprue .. 110
a 3-1 9 Sprue . 100
, . M 14 Bprue . 111
6 30 10 D . l. .. 100
e . 21 11 Bprue and tubereulosls . n&
1.. . . . 02 34 D. 1. and endocard .. liS
8 . 63 II 0 .1. .. 111
II . ss 100
10 . 23 ~~ ~g~::: : : :: : : : : : : : : : : : : : : :: : : : : : : IN
11 . 58 0.1 .. V2
13. . . .. . . . .. •. •••. ••.. •. . . . . 25 39 Sprue . 100
1 .. 15 15 D. I . IN
1' . ee 39 D .1. .. n