The hæmopoietic response to therapy in non-tropical anæmias

533 TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE. Vol. XXVII. No. 6. M a y , 1934.

THE H/EMOPOIETIC RESPONSE TO THERAPY IN NON-TROPICAL ANZEMIAS.* BY

JANET M. VAUGHAN, D.M. (OxFoRD), M.R.C.P. (LoND.).* Belt Memorial Fellow.

The Bernhard Baron Institute of Pathology, The London Hospital.

INTRODUCTION. Blood regeneration is dependent upon the presence of all essential ha~mopoietic factors in adequate quantity and upon the absence of all inhibitory factors. Regeneration both in anaemias due to h~emorrhage and in deficiency dysh~mopoietic anaemias obeys certain principles which are unaffected by the cause of the anemia. Knowledge of these fundamental principles is the best guide to the efficacy of treatment. I propose to analyse the response to therapy in anaemias met with in non-tropical countries. The anaemias occurring in the tropics are discussed by Dr. HAMILTON FAIRLEYin the next paper. The underlying principles are, as far as is known, the same in both groups; any division is merely one of convenience. Blood regeneration is heralded by an output of immature cells from the marrow which is followed by increase in haemoglobin and in mature red cells. All types of immature cells are thrown into the peripheral blood stream as a result of stimulation of the marrow. A careful estimation of the reticulocyte output from day to day forms the most practical criterion of the effectiveness of treatment. The magnitude of the reticulocyte response is conveniently expressed in terms of the maximum percentage of reticulocytes observed during their outflow into the peripheral blood. If adequate amounts of the missing factor are available the output of reticulocytes will form a definite pattern. If submaximal amounts only are present or if there are complicating inhibitory factors the reticulocyte output will be modified. If the amount of available ha~mopoietic material is then increased or if inhibitory factors are removed, a second reticulocyte rise will occur. *I am grateful to Dr. THEODORETHOMPSONand to Dr. DONALDHUNTERfor permission to investigate patients under their care, and to make use of their clinical notes.

534

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Regeneration in Megalocytic Hyperchromic Ancemias. The majority of the megalocytic hyperchromic anaemias, as far as is known at present, are due to lack of the factor present in whole liver and effective in Addisonian pernicious anaemia, which may be called, for the sake of brevity, the P.A. factor. The nature of this factor and its relation to the effective principle in stomach and in marmite cannot be discussed here. The character of the response to effective treatment is similar in all megalocytic hyperchromic anaemias. MINOT and his colleagues (MINOr, MURPHY and STETSON, 1928 ; MINOr, COHN, MURPHY and LAWSON, 1928) first established the principle that in uncomplicated cases of Addisonian pernicious anemia treated with adequate amounts of the P.A. factor, the height of the reticulocyte response is inversely proportional to the level of the red blood cell count before treatment. If the dosage is adequate the reticulocytes rise rapidly to a given level and return to normal with a sharp fall. If the dosage is inadequate or if interfering factors are present the curve is inclined to be prolonged and irregular and not to reach the maximum level. Further treatment with an adequate dose will then give a second reticulocyte response. If the maximal amount of potent material is given in the first instance, increasing the dose will not produce a second reticulocyte response. Above an initial level of 3,000,000 per c.mm. no appreciable reticulocyte rise occurs. The estimated figures, first worked out by MINOT and his colleagues, for the reticulocyte peak in relation to the red cell count were arrived at from a study of the response to oral therapy. (MINOr,COHN,MURPHY and LAWSON, 1928; MINOr, MURPHY and STETSON,1928). It is probable that a more detailed study of the exact relationship of the reticulocytes to the initial red cell count in patients given parenteral therapy will show that higher reticulocyte levels may occur. Higher figures have recently been published in the case of extracts administered intravenously (BETHELand GOLDHAMER,1933). In two patients treated with a liver extract given by intramuscular injection the reticulocyte count was also definitely higher than the figures given by MINor and his colleagues. The first patient was a woman aged 63 who had typical Addisonian pernicious anmmia. Her initial red cell count was 2,300,000 per c.mm. which should give a calculated reticulocyte count at the peak of the rise of 10.4 per cent. The observed figure was 25.6 per cent. after 10 c.c. of a preparation derived from 100 grammes of liver (Fig. 1). The second patient was a man aged 60 who had typical Addisonian pernicious anaemia. He was treated with the same extract. The observed reticulocyte response was 14"3 per cent. after 12 c.c. of extract derived from 120 grammes of liver, while the theoretical response was 8.4 per cent. (Fig. 2). This apparent discrepancy in the response to maximum amounts of the P.A. factor given by mouth or by intramuscular or intravenous injection has not

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yet been explained. It is possibly associated with some failure of utilization in all patients taking the P.A. factor by mouth, i.e., the presence of an inhibitory factor which will be discussed later. It would appear, however, that parenteral preparations are likely to prove more efficient than those given by mouth. For the present, figures for the reticulocyte response to oral therapy offer a satisfactory practical standard as long as they are regarded as minimum rather than maximum values. If liver is given by mouth, in the form either of 300 grammes of whole liver or of extract made from 500 grammes of liver daily, the concentration of red cells usually increases according to MINOT (1932) by about 2,500,000 per c.mm. in 30 days, when the initial concentration is less than 2,000,000 per c.mm. MURPHY (1933) found that the response was slightly more rapid to parenteral therapy. As far as it is possible to calculate, from the figures he gives for dosage, the total dose administered during the whole period of observation amounted to extract made from 800 grammes of liver. There was an average gain of 2,700,000 per c.mm. in 28 days. Individual figures were in some cases higher. A higher red cell level is, therefore, apparently more rapidly reached and more readily maintained in patients receiving parenteral therapy. Megalocytic hyperchromic anaemia associated with idiopathic steatorrhcea gives a response which is indistinguishable from that just described in Addisonian pernicious anaemia. In two patients who were under careful observation the level reached by the reticulocytes in response to treatment with marmite was that calculated for liver from the initial red cell count (VAuGHANand HUNTER, 1932).

Regeneration in Hypochromic Ancemias due to Iron Deficiency. In the case of hypochromic anaemias responding to iron the maximum reticulocyte percentage is more directly related to the initial h~emoglobin level than to the initial red cell level. The reticulocyte count rises higher in patients with a low colour index than in those with a high eolour index though the initial red cell count is approximately equal (MINOT and HEATH, 1932). Considerable rises in reticulocytes occur in response to iron in hypochromic anmmias when the red blood cell level is much above a figure at which in Addisonian pernicious anaemia an insignificant reticulocyte response would occur. To some extent, however, even in hypochromic anaemias the initial red cell count affects the reticulocyte rise. For a given red blood cell level the reticulocyte response to maximal doses of iron will be greater the lower the haemoglobin, and the increase of reticulocytes will be greater, for a given h~emoglobin level, the lower the red blood cell count (MINoT and HEATH, 1931). Patients may have the same colour index with the reticulocytes rising to very different figures depending upon the initial red cell and h~emoglobin levels. For practical purposes in order to assess the reticulocyte response that should be expected in any particular patient it is essential to know both the initial red cell level and the initial hzemoglobin level. The average then of the maximum reticulocyte response for the initial red cell

538

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level and for that of the initial haemoglobin level will give an approximate figure for the reticulocyte response that should occur in the particular patient under consideration (HEATH, 1933). There are then certain differences in the response of the reticulocytes to the P.A. factor and to iron. The height of the reticulocyte response to iron will be greater the lower both haemoglobin and red cells, the height of the reticulocyte response to the P.A. factor will be greater the lower the red cells and the higher the haemoglobin (MINoT and HEATH, 1932). The shape of the reticulocyte curve is also somewhat different (MINOT and HEATH, 1932). There is a tendency for the response to develop sooner and for the curve to be more prolonged in the case of anaemias responding to iron, than in those of anaemias responding to the P.A. factor. The exact significance of these differences has not yet been determined. The differences are probably due in part to the fact that in megalocytic hyperchromic anaemias the need is primarily for cell production while in hypochromic anaemias it is primarily for haemoglobin production. The average rate of haemoglobin increase following iron therapy is a rise of 1 per cent. of haemoglobin daily (HEATH, 1933) when the initial haemoglobin level is below 50 per cent. Higher rates of increase may occur. Regeneration in Ancemia due to lack of Vitamin C. Blood regeneration in the anaemias of scurvy responding to vitamin C has the same general characteristics as regeneration in other deficiency anaemias. There is a rise in the reticulocytes followed by a rise in red ceils and haemoglobin. This response is entirely specific--it occurs in response to vitamin C but not in response to iron or liver (METTIER, MINOT and TOWNSEND, 1931). It has recently been possible to study the effect of pure ascorbic acid upon blood regeneration. * The patient was a man of 71. He was an old-age pensioner living alone on 10s. a week, 8s. of which he paid in rent. His diet was, therefore, extremely deficient. He was admitted to hospital with bleeding gums, large subcutaneous hmmatomata and widespread p u r p u r a . His blood pressure unlike similar cases described by METTIER, MINOr and TOWNSEND (1931) was not raised. The systolic pressure was 120 and the diastolic 60, but X-ray examination for other purposes showed excessive calcification of the arteries. No subperiosteal hmmorrhages were apparent. His red cell count on admission was 3,500,000 per c.mm. and his h~emoglobin was 56 per cent. The mean corpuscular volume was 86.4 cubic /~ and the mean diameter 7.051/~. During a control period of 12 days he was kept on a scorbutic diet and both his red cells and hmmoglobin fell. The reticulocyte count was uneven, presumably due to the stimulating effect of repeated subcutaneous hmmorrhages. In view of the rapid deterioration in the patient's • The ascorbic acid used was prepared by British Drug Houses, by extraction from Capsicum annuum, the Hungarian paprica.

JANET M. VAUGHAN.

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condition it was considered unjustifiable to withhold specific treatment. While still on the same diet he was given 50 mg. of ascorbic acid daily. The result was striking. No further haemorrhages occurred and those present were rapidly absorbed. There was an immediate rise in both red cells and h~emoglobin (Fig. 3). No such effect was obtained when a similar dose of aseorbic acid was given to a patient with typical Addisonian pernicious anaemia. (Fig. 1, p. 535). Trials with ascorbic acid are now being made on hypochromie anaemias other than those due to scurvy.

Regeneration in Anaemias associated with Thyroid Deficiency. The anaemia associated with myxoedema may be of a hypochromic or of a megalocytic hyperchromic type. It is not yet known whether the hypochromic anaemia will respond to iron therapy alone or to thyroid alone, since no well controlled observations are available (LERMANand MEANS,1932). The megalocytic hyperchromic type of anaemia is discussed later.

Regeneration in Anaemia due to Acute Haemorrhage. The healthy body should have an adequate store of h~emopoietic factors. In response to a sudden loss of blood these stores are called upon and there is immediate regeneration which follows the principles already described as occurring when the missing factor is supplied in the deficiency dysh~emopoietic anaemias. There is a rise in the reticulocytes followed by an increase in red cells and h~emoglobin (HEATH, 1933). In some cases the body stores have been depleted before the h~emorrhage occurs either by previous blood loss or by a deficient diet. In such cases there is delayed or absent regeneration following an acute h~emorrhage (HEATH, 1933). This is commonly the case in patients with gastric or duodenal ulcers. The bland diet of the gastric case is only too often deficient in h~emopoietic factors--repeated h~emorrhage has depleted what scanty stores there are. Unless, therefore, h~emopoietic factors are provided the delay in recovery may be prolonged (VAUGHAN, 1932). INHIBITORY FACTORS.

The regenerative phenomena already described as occurring in anaemias, are those found in uncomplicated cases where none of the known inhibitory influences are present and the deficiency is of one essential factor only. The character of the response is, however, only too often modified by the presence of one or more inhibitory factors. Such recognised factors are (1) the presence of multiple deficiencies ; (2) achlorhydria ; (3) " failure of intestinal absorption " ; (4) sepsis ; (5) " arteriosclerosis." There are probably other inhibitory influences which have not yet been recognised. (1) Multiple deficiencies. It is frequently found for instance that a megalocytic hyperchromic anaemia responds well to liver treatment for a few weeks and then either does not improve at all or improves very slowly. The administration of iron may lead to rapid recovery (BEEBEand LEwis, 1931). MURPHY

JANET M. VAUGHAN.

541

(1933) has recently suggested that probably the majority of patients with Addisonian pernicious anaemia suffer from such a dual deficiency. Improvement in h~emoglobin during the first 3 to 4 weeks of treatment occurs at essentially the same rate whether or not iron is given but the use of iron after that period gives an increased rate of h~emoglobin and red cell formation (MURPHY,1933). MURPHY is of the opinion that iron should always be used in the treatment of Addisonian pernicious anaemia as well as the P.A. factor. It should certainly be given a trial in patients who show an incomplete response to the P.A. factor alone. The reverse holds true. There are certain cases that present themselves as hypochromic or iron deficiency anaemias who have also a deficiency of the P.A factor. This is particularly true of the hypochromic amemias following partial gastrectomy (VAUGHAN,1932). A patient who has been under h~ematological observation for 2 years was admitted with a typical microcytic hypochromic anaemia following a partial gastrectomy 10 years previously. The anmmia at first responded well to iron but the red cells became megalocytic within 36 days. She was, therefore, given liver extract. The anaemia improved but it has been impossible to maintain a satisfactory red cell and h~emoglobin count unless both iron and the P.A. factor are supplied (Fig. 4, p. 542). Lack of the P.A. factor may also be associated with lack of thyroid. MEANS, LERMAN and CASTLE(1931), have described a group of cases in which a diagnosis of Addisonian pernicious anaemia was made. Improvement of the red cells and h~emoglobin after adequate liver therapy was not entirely satisfactory. Further examination of the patients showed a definite thyroid deficiency as evidenced by a lowered basal metabolic rate. When thyroid was also given there was an immediate improvement in red cells and in haemoglobin although a smaller dose of liver extract was taken. (2) Achlorhydria. The exact part played by lack of acid in inhibiting h~emopoiesis is not yet determined. METTIER and MINOT (1931) showed originally that iron was apparently more readily utilized from an acid than an alkaline medium, since blood regeneration occurred more readily when iron was given in an acid than when it was given in an alkaline medium. Further, MINOT and HEATH (1932) found that both the magnitude of the reticulocyte response and the rate of the increase of red cell and h~emoglobin appeared to be less in patients with hypochromic amemia associated with achlorhydria than in those in whom acid secretion was normal. They suggested, therefore, that acidity of the gastric contents favours intestinal absorption. There is, however, no proof that absorption is the factor affected by variations in gastric acidity. It is only possible to say that utilization of iron is greater when free acid is present in the gastric juice than when it is absent. (3) " Failure of intestinal absorption." The mechanism of utilization of h~emopoietic factors is little understood. It is apparent, however, that powers of utilization are extraordinarily variable. It is often assumed, without perhaps adequate evidence, that this variability is dependent upon a failure of intestinal

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543

JANET M. VAUGHAN.

Hospital. On examination, he had a definite megalocytic hyperchromic anaemia. The red cell count was 1,600,000 per c.mm., the h~emoglobin was 30 per cent., the colour index 0.93, the total white count 2,200 per c.mm. The mean diameter of the red cells was 8.0285/, and the mean corpuscular volume 96.75 cubic/~. The direct Van den Bergh reaction was delayed, the indirect reaction gave 2 mg. bilirubin per cent. Five months previously partial gastrectomy had been performed. Microscopic examination of the portion of stomach removed showed pyloric hypertrophy and chronic inflammatory infiltration of all coats especially the mucosa. There was no evidence of carcinoma. The blood counts before operation were ambiguous. It is not possible, therefore, to determine whether the anaemia was antecedent to the operative interference with the stomach or followed upon such interference. The exact relationship is not relevant to the present discussion. Treatment for 38 days with large doses of marmite, though it caused some increase in reticulocytes, was unaccompanied by any definite imorovement in red cells or h~emoglobin (Fig. 5). Oral administration of liver Fza. 5. TREATHENT

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extract made from ½ lb. of liver a day caused no further rise in the reticulocytes though some improvement in the red cells and hmmoglobin. The administration of liver extract by intramuscular injection was accompanied by a prompt reticulocyte response which was equal to the calculated rise for the initial red cell level, and by a corresponding improvement in red cells and hremoglobin. This observation shows only that the patient was unable to make full use of potent material given by mouth. There is no direct evidence to suggest that this was due to some failure of intestinal absorption, though this is a possible explanation. (4) Sepsis. Sepsis has a definite inhibitory effect upon both the utilization of iron and of the P.A. factor. The reason for this is not understood. In the presence of sepsis there may be no response to adequate dosage, or far larger doses than normal are required to produce a submaximal response. (5) " Arteriosclerosis." The presence of a raised blood pressure and palpably thickened arteries will also inhibit the action of hremopoietic factors. In patients with such signs the response to therapy is only too often submaximal (BEEBE and LEWIS, 1931). An explanation for this inhibitory action is lacking. Clearly, though much is now known of the factors necessary for normal h~emopoiesis and of the principles governing normal blood regeneration, the part played by inhibitory influences is still little understood.

REFERENCES. BETHEL, F. H. & GOLDHAMER,S• M. (1933). Amer. J. Med. Sci., clxxxvi, 480. CASTLE,W.B. &TAYLOR,F . H . L . (1931). J. Amer. Med. Ass.,xcvi, 1198. HEATH,C. W• (1933). Arch. Int. Med., li, 459.

LERMAN, J. & MEANS, S . H . (1932). Endocrinology,xvi, 533. MEANS,J. H., LERMAN, J. & CASTLE,W.B. (1931). New Eng. J. ]Pied., cciv, 243.

METTIER, S. R., MINOT, G. R. & TOWNSEND,W.C. (1930). J. Amer. Med. Ass., xcv, 1089. METTIER,S.R. & MINOT, G.R. (1931). Amer.J. Med. Sci., clxxxi, 25. MINOT, G. R., COHN, E. J•, MURPHY,W• P. & LAWSON,H.A. (1928). Ibid., clxxv, 599. MINOT, G. R., MURPHY,W. P. & STETSON,R.P. (1928). Ibid., clxxv, 581. MINOT, G. R. & HEATH,C.W. (1931)• Trans. Ass. Amer. Phys., xlvi, 290. &- (1932). Amer.J. Med. Sci., clxxxiii, 110. MINOT, G.R. (1932). ft. Amer. Med. Ass., xcix, 1906. MURPHY,W.P. (1933). Arch. Int. Med., lii, 829. VAUGHAN,J . M . (1932). Lancet, i, 122. • (1932). Ibid.,ii, 1264• VAUCHAN,J. M. & HUNTER, D. (1932). Ibid., 829.