Four cases of liver-refractory macrocytic anemia are described. Three were treated with folic acid perorally and reacted well.
The first was an instance of nontropical sprue with atrophy of the spleen that was diagnosed clinically and confirmed at postmortem examination. The megaloblastic anemia also became completely refractory to crude liver extracts and liver digested with gastric juice.
The second case was successfully treated with liver extracts for twelve years. After that time she suddenly became refractory with severe leucopenia. Folic acid in large doses had an excellent effect and the patient has kept relatively normal blood values for about a year without further treatment of importance. It should be noted that the morbid condition of the tongue could not be influenced by folic acid.
The third case should probably be classified as idiopathic steatorrhea. Folic acid gave a full remission of the macrocytic anemia.
The fourth case resembled typical pernicious anemia more closely, as a histamine-fast achlorhydria was present. This patient had been refractory to liver treatment but reacted well to folic acid in ordinary doses.
The fifth case was a typical instance of idiopathic stcatorrhea with probable atrophy of the spleen. She had a moderate anemia that was refractory to liver extracts. Folic acid perorally and intramuscularly neither influenced the anemia nor the fecal fat.
In a series of cases of uncomplicated pernicious anemia, the immediate response to folic acid in doses of 20 to 30 mg. daily was good. Full remissions as regards hemoglobin and erythrocytes could be expected with a total dosage of 400 to 600 mg.
Certain cases of pernicious anemia refractory to liver extract may respond to folic acid. This indicates that the two substances probably have different mechanisms of action.