368 ASCORBIC ACID 



from the gums or from some local lesion like a duodenal ulcer or tissue 

 hematoma. Should this be the predominant etiologic factor, the anemia 

 will be similar morphologically to the anemias of acute and chronic blood 

 loss, that is, normocytic or microcytic hypochromic, and the bone marrow 

 will be hyperplastic and normoblastic. General malnutrition or some other 

 chronic disease such as ulcerative colitis or rheumatoid arthritis associated 

 with scurvy may lead to normocytic normochromic anemia and a normally 

 cellular or mildly fatty hypocellular marrow. None of these types of anemia 

 will respond specifically to administration of ascorbic acid except in so far 

 as this vitamin heals scorbutic lesions and stops bleeding. Anemia does not 

 occur in pure ascorbic acid deficiency of mild degree such as has been ob- 

 served in human subjects who have submitted themselves to five months 

 or more of ascorbic acid-free diets which are adequate in all other kno"wn 

 essential nutrients.^^- ^^ Even the loss of 6000 ml. or more of blood during 

 this period is insufficient stress to induce anemia. Patients with mild scurvy 

 seldom have anemia. However, patients with severe scurvy may have one 

 of several types of anemia related directly to the deleterious effect of as- 

 corbic acid deficiency on bone marrow function. 



The anemia may be moderate or severe, depending upon the severity 

 of the scurvy. Erythrocyte counts as low as 1.75 million per cubic milli- 

 meter have been observed. These cells may be normochromic and normo- 

 cytic or sometimes slightly macrocytic. White blood cell counts tend to 

 be low, usually under 6000 per cubic millimeter. Differential white blood 

 cell counts are normal, and platelets may be somewhat reduced in numbers. 

 Initial reticulocyte counts are elevated, sometimes as high as 10 to 12 %. 



In the usual case the bone marrow obtained by sternal aspiration may 

 vary from slight hypercellularity to moderate hypocellularity. Some of the 

 marrow specimens are excessively fatty. There is a relative increase in 

 erythrocyte progenitors, with the majority of these cells at the normoblast 

 and late erythroblast stages of development. Occasionally megaloblasts 

 and bizarre metamyelocytes typical of erythrocyte maturation factor 

 deficiency may be found.^^- ^^ This finding is usually the only evidence that 

 one is dealing with a second type of scorbutic anemia. 



The severity of the anemia correlates well with the severity of the 

 scurvy, with the elevation of the indirect reacting bilirubin in the blood, 

 and with the reticulocytosis. There is no correlation with the amount of 

 blood loss externally or into the tissues, and serum iron levels are usually 

 normal. 



Bed rest alone may be sufficient to induce a remission in the anemia, 

 even though the patient is kept on a diet grossly deficient in ascorbic 

 acid and the vitamins of the B complex. Should no remission occur under 



" G. H. Jennings and A. J. Glazebrook, Brit. Med. J. II, 784 (1938). 



