Gerald came into the small hospital in Maine where I managed the laboratory. He was in for pre-operative laboratory testing prior to scheduled removal of his gallbladder.

He had been having chronic pain because of the gallstones which had shown up on x-ray.

Gerald’s laboratory work-up, however, raised questions about the causes for his gallstones. Gerald was anemic. His hemoglobin was low and that is not a usual finding in an active 46 year-old male.

His blood serum was more yellow than it should have been and when we measured it, his blood bilirubin was elevated.

The elevated bilirubin could have been explained by gallstone blockage of the bile ducts. But the anemia remained unexplained.

When the technologist examined Gerald’s blood smear, she saw that many of his red blood cells were smaller than normal.

Further, those smaller red blood cells did not have the usual central pale spot, but rather, had high density of color in the middle. She reported her finding as “many microspherocytes.”

To make sense of all this, we need to know that normal red blood cells are shaped like donuts with a thin membrane covering the area where the center hole would be on the donut.

Further, we need to know that an elevation of yellow pigment in the blood may result not only from blockage of the ducts but can instead result from an increase in the rate of destruction of red blood cells.

The body’s spleen is like a policeman. One of its duties is to remove from the blood those red blood cells which are abnormal.

When the bone marrow is making a lot of abnormally-shaped red blood cells, then that spleen is overworked and may become enlarged. Gerald’s small spherical red blood cells are abnormal in shape and his spleen was larger than normal.

Normal red blood cells remain in circulation, doing their normal functions for about 100 to 120 days.

The spleen only allows sphere-shaped red blood cells to stay in circulation for 12 to 14 days.

When Gerald’s four children were brought in for testing, each of them was also found to be anemic; have sphere-shaped red blood cells; and elevated levels of bilirubin in the blood.

Gerald and his children were diagnosed as having hereditary microspherocytosis.

If the “policeman” is taken out of the picture, then the abnormally-shaped spherical red blood cells can remain in circulation much longer and the person may not then be any longer anemic; will have more energy and less fatigue.

So, Gerald and his four children all left their small-town Maine environment and took a trip together to Boston.

Each of the five underwent surgical removal of the spleen and came back home to complete convalescence.

Gallstones may be one of the resultant complications of an increased destruction of red blood cells.

I had known Gerald from the days when we were both teenagers. I had lived for nine months in the home of the woman Gerald would later marry.

Gerald’s father-in-law had agreed to give me room and board and pay my private school tuition in exchange for my milking his cows and feeding his flock of chickens when I was a 16-year-old.

It was a strange twist of Providence that I should, after completing college and professional training, relocate many years later near Gerald’s home town and be one of the medical professionals who would participate in his health care and that of his family.