318 THE ANEMIAS 



If the patient is under observation for a longer time, the appearance of a 

 remission is a remarkable aid to the diagnosis. Even in such characteristic 

 cases, besides the clinical examination, we must not omit an examination of 

 the blood as a control test ; if the general clinical picture of the disease is not 

 perfectly developed, blood examination is even more essential. 



If we find in the blood undoubted megaloblasts besides genuine megalocytes, 

 the diagnosis of progressive pernicious anemia is established beyond doubt. 

 [This statement is certainly too strong. Undoubted megaloblasts with a 

 majority of normoblasts occur in some perfectly curable post-malarial anemias. 

 It is the predominance, not the presence, of megaloblasts and megalocytes 

 that is most significant. — Ed.J If we do not find them it is more difficult 

 to reach a conclusion. Whoever is careful to bear in mind the above-mentioned 

 changes in the bone-marrow will exclude pernicious anemia in doubtful cases 

 only after repeated examinations of the blood have shown it to be entirely 

 free from these characteristic elements. 



We must always remember that the megaloblasts usually pass only in small 

 numbers from the bone-marrow into the blood. Hence we must examine 

 thoroughly several technically perfect preparations before we can positively 

 say that this variety of cell is absent. If the blood is of a pronounced megalo- 

 cytic character, then the diagnosis of progressive pernicious anemia may be 

 made even though megaloblasts are absent, because the appearance in the blood 

 of large numbers of megalocytes cannot occur without a previous megaloblastic 

 transformation of the bone-marrow. 



Another diagnostic difficulty is the fact that there are undoubtedly cell 

 forms which morphologically represent a transitional stage between normo- 

 blasts and megaloblasts. If these are sparse, they may be left entirely out of 

 consideration; if they appear in great numbers, they are indicative of pro- 

 gressive pernicious anemia. 



To determine the cause of progressive pernicious anemia, an examination 

 of the feces for tape- worm ova is necessarily important; the presence of the 

 bothriocephalus ova or links will aid materially in the prognosis and treat- 

 ment. [Uncinaria eggs should also be looked for, though the type of anemia 

 produced by uncinariasis is usually somewhat different from that described 

 here. — Ed.] 



From the standpoint of differential diagnosis we must bear in mind endo- 

 carditis, carcinoma of the gastro-intestinal tract, tabes dorsalis, and Addi- 

 son's disease, and, during the comatose terminal stages of the malady, other 

 affections in the course of which severe disturbances of consciousness occur. 

 In these cases, the verdict depends mainly upon the blood examination. 



THERAPY 



Treatment offers hope of success only in the bothriocephalus anemia. 

 After the anthelmintic (extr. filix mas) has produced its effect, if the anemia 

 is not too far advanced a definite cure will shortly follow. These results 

 encourage us to try the filix mas even in cases in which the bothriocephalus 

 has not been found. 



