1069MEDICAL SOCIETY OF LONDON.

llr. FAIRBANK, Mr. ELMSLIE. Mr. PUGH, and othersagreed that the transplant should be undone.Mr. ELMSLIE showed two cases of

Congenital Deformity of the Upper Limbs.The first case was that of a boy, aged 15, who had

formerly been under the care of Mr. Openshaw forcongenital deformities of the arms and bilateral

congenital talipes equino-varus. He had been treated

by manipulation of the feet and division of the

plantar fascia at the age of 3 years, and four yearslater the wrists were manipulated and plaster applied.In 1916 the right elbow was fixed in plaster at a rightangle. In 1922 the patient came under the care ofMr. Elmslie. He then had bilateral talipes equinuswith much wasting of the legs. The hands were heldfully pronated, with the elbows extended and wristsflexed. There was marked wasting of the shoulders,arms, and forearms, but there was some power in theflexor and extensor muscles of the forearm and hands.)Ir. Elmslie had treated the left foot (which was moreseverely affected) by osteotomy of the fibula and ofthe neck of the astragalus, followed by wrenchingand plaster. The hands were manipulated andextended by splinting. An arthroplasty was per-formed on the right elbow. The second case was oneof congenital deformity of the upper limbs in a littlegirl, The deformity strongly resembled that seen inErb’s paralysis, but was symmetrically bilateral, sothat he regarded it rather as a congenital deformitythan a birth palsy.

lfr. BRISTOW congratulated Mr. Elmslie on theimprovement already obtained in the first case. Hehad a similar case now under his care which hadpreviously been treated by unnecessarily severe andprolonged splintage, and had developed a certaindegree of ischaemia in consequence. He thereforethought that in such cases periods of splintage shouldalternate with periods of physical treatment.Mr. BujNDELL BLANKART remarked that the first

case had good scapular movement which might bemade use of by arthrodising the shoulder. The littlegirl, he thought, would benefit by a similar operationto that performed for Erb’s paralysis.In reply Mr. ELMSLIE said he still had the question

of performing an arthrodesis of the shoulder underconsideration, but up to the present was concentratinghis efforts upon attempting to get the patient’s handsinto such a position that lie would be able to feedhimself.Mr. ROTH showed a case of

? Injury to Epiphysis of Left Acromion Process.The patient, a girl aged 16, complained of pain in

the left shoulder which had lasted intermittently forfour months and was relieved by resting the arm. Onexamination at hospital the tip of the acromion was acutely tender, there was marked limitation ofabduction, and all movements of the shoulder pro- duced pain. X ray examination showed partial (fusion of the left acromial epiphysis with displace- ]ment upwards, whereas on the right side the epiphysis remained distinct. The patient improved with restto the arm in a sling, but pain recurred on using the arm contrary to advice. tMr. BLANKART suggested a diagnosis of neuritis s

since there was no history of injury, and he thought che could feel a tender nerve running down over the c

spine of the scapula.Tendon Transplantation for Talipes.

llr. LAMING EvANS showed a girl, aged 9, in whom c

he had performed a tendon transplantation for para- v

lytic talipes equino-varus. Treatment by rnanipula- J.tions and instruments having failed, he had trans- e

planted the tibialis anticus tendon to the base of the nJifth metatarsal, thus converting it into a pronator, awith a satisfactory functional result. pMr. BRISTOW, while complimenting Mr. Evans upon b

the excellent result obtained, could not agree that the btibialis anticus had now been converted into a pronator. He would rather say that by putting the atibialis anticus into its new insertion the muscular nbalance of the foot was restored. b

MEDICAL SOCIETY OF LONDON.

PERNICIOUS ANEMIA.

A MEETING of this Society was held on Nov. 13th,with Lord DAWSON OF PENN, the President, in thechair.

Dr. P. N. PANTON introduced the discussion onPernicious Anaemia. He said that this condition wasuncommon, and was almost invariably fatal. Duringa period of 11 years 117 cases had been collected atthe London Hospital. In this disorder we did notknow whether we were dealing with a single clinicalentity derived from a single underlying factor, or agroup of associated conditions with differing factors.Pernicious anaemia was a condition of very severeanaemia which could not be accounted for by thepatient’s history nor by cl inical examination. It wasevidently the result of a slow and continuous internalhaemolysis, not of a sudden one as in paroxysmal haemo-globinuria or in poisoning by arsenuretted hydrogen(AsH3) gas. This clinical picture was associated witha constant and well-defined blood picture-a low redcell count, with a high colour-index, and the presenceof abnormal red cells (more particularly megaloblasts)in the peripheral circulation. This association ofclinical state and blood picture defined the disorderand made diagnosis comparatively simple. Theclinical state alone might occur in a very differentpathological process, as aplastic anaemia, or the bloodstate alone might occur in poisoning from AsH3 gas.Achylia, glossitis, fever, and intestinal disturbanceswere features . fairly constantly associated withpernicious anaemia, but associated conditions were rare,with the exception of subacute combined degenera-tion of the cord. Fatty degeneration of the heart,free iron pigment in the internal viscera, and hyper-plasia of the red marrow were found post mortem-Dr. Panton proposed dealing with the following facts.emerging from study of the 117 cases admitted to theLondon Hospital between 1909-1920 inclusive : oral;sepsis, achylia, pyrexia, treatment.

Oral Sepsis.In 13 of the cases studied there was no record of

the state of the mouth, and among the other 104patients in only 21, or in about 20 per cent., was thereno past or present dental sepsis. Taking into accountthe average age (46 years) and the class of patient.the speaker did not consider that the evidence thatoral sepsis had any bearing on the aetiology of per-nicious anaemia was very striking. It could not bedenied that secondary anaemia might result fromseptic absorption in the mouth, and in this case dentaltreatment was indicated. If cases with oral sepsisand secondary anaemia with perhaps some poikilo-cytosis of the red cells were diagnosed as perniciousanaemia, and their oral sepsis were cured, they wouldrecover. In this connexion it should be emphasisedthat the haematological diagnosis ot perniciousanaemia from a blood film alone was unjustifiable.Many of the patients in the series considered receivedthe most thorough dental treatment, but Dr. Pantonsaid he had never been convinced that a single caseof true pernicious anaemia had been cured as a resultof this treatment.

Achylia.This condition was almost invariably present in

cases of pernicious anaemia, and associated with itwas an atrophy of the gastric mucous membrane.. ..Achylia was present in 33 of the 35 cases of the seriesexamined for this condition. The achylia of carcinomanight rarely produce a blood picture similar to,alhough never absolutely identical with, that ofpernicious anaemia. The artificial achylia produced)y gastrectomy had been stated to have been followed)y pernicious anaemia. The speaker had never seenuch a case. Pernicious anaemia might occur withoutachylia; achylia frequently occurred without per-Licious anæmia; secondary anaemia might be followed’y achylia, and this when once set up, might persist

1070 MEDICAL SOCIETY OF LONDON.

for life even if the anaemia were cured. Achyliamight be regarded as part of a vicious circle. Itmight result from a haemolytic anaemia alone, and,further, the gastric atrophy might conceivably beinduced in pernicious anaemia by the same toxinwhich acts upon the blood and on occasion upon thespinal cord. Having been so set up, or having beenpresent beforehand, it might favour the entry of thetoxin-producing agent into the system. Thus per-nicious anaemia might produce achylia, and con-

ceivably achylia might be an important predisposingfactor in pernicious anaemia.

Pyrexia.Pyrexia (average range 99°-100° F.) was noted in

90 cases. Improvement in the general condition ofthe patient was synchronous with the return of thetemperature to normal. The more acute the case,the more constant was the presence of the fever.This pyrexia associated with pernicious anaemiamight suggest an infective origin ; but it must beallowed that internal haemolysis alone would accountfor the fever.

S’ome Points in Treatment.

Oral Sepsis.-This condition should be treated, butwholesale extraction of the teeth was deplorable.Dr. Panton thought that vaccine treatment had novalue in these cases.Achylia.-He thought that the administration of

an artificial gastric juice should be adopted in allcases with achylia.

Splenectomy.-This had been practised extensivelyduring the last ten years. It was claimed that thisoperation prolonged life, but the after-results of aseries of splenectomies published in America showedthat the length of life was comparable with that seenin the London Hospital series of cases, where theoperation had only been performed once.

Blood Transfusion was only advisable where it wasdesired specially to prolong life. When the transfusedblood was used up, more had to be given ; Dr. Pantonhad been unable to detect any real recovery of thepatient’s blood-forming tissues after transfusions.

Arsenic.-Either organic or inorganic had a well-established reputation in the treatment of perniciousanaemia, for it was common experience that patientsdesperately ill improved in the most remarkablemanner under the influence of arsenic. A peculiarityof the action of the drug was that when patients weregoing downhill while taking an inorganic preparationthey would rally when injections of arsacetin or sal-varsan were substituted. The converse also occurred.This peculiarity was responsible for the stream of newremedies. Patients were very frequently first seenwith a red cell count of about 1,000,000 per c.mm.,and even if seen and treated early the blood countwas apt to fall to this figure before any improvementtook place. Some cases, indeed, appeared to find acertain level and maintain it untreated for years.It would therefore appear that the morbid processcould strike a certain balance, which, if depressed,tended to swing up again. Arsenic had no effectduring the balance period, but if given during adepression might be unduly credited for the upwardswing. In support of this Dr. Panton quoted a

case treated on the first occasion with arsenic withgreat improvement. Readmitted on a later occasionthe patient made an equally great improvementwithout any drug treatment at all.

Certain Allied Conditions.

The underlying pathological process in perniciousanaemia was generally accepted to be internalhaemolysis, although Ashby and Whipple had producedsome evidence against this view. The blood .picturecould be simply explained, for if blood were destroyedinternally, the haemoglobin was retained and a primaryanaemia with a high colour-index followed. Dr.Panton passed on to consider other clinical statesassociated with internal haemolysis and primaryanaemia. Bothriocephalus anaemia was stated to

produce an identical blood picture, but according to

Pappenheim the characteristic glossitis of perniciousanaemia was absent. Occasionally a very acuteanaemia developed late in pregnancy or during thepuerperium, independently of sepsis or of severe

haemorrhage. The blood picture of these casesresembled that of pernicious anaemia, but the clinicalfeatures differed in the acuteness of onset, and thecompleteness and permanence of the recovery. Itwould appear as if the same toxic state, which mightlead to eclampsia and renal and hepatic damage,might also produce hæmolytic anaemia. Chemicalagents, such as ricin, also produced a similar bloodpicture. AsH3 poisoning, which occurred in sub-marines during the war, produced the blood picture ofpernicious anaemia, with deep jaundice and hæmo-globinuria. If the patient survived a few dayscomplete recovery usually took place. Paroxysmalhaemoglobinuria resulted from a series of differentconditions in which internal haemolysis occurred, butin which the haemoglobin was shed and a secondaryanaemia resulted. Haemoglobinuria occurred fromsuch variable causes as blackwater fever, the injectionof a hæmolytic serum or an incompatible bloodtransfusion, and the inhalation of arsenurettedhydrogen gas. There were three types of obscurehaemolytio anæmias-an acute form occurring inyoung people and ending fatally in a few monthsusually considered to be cases of acute perniciousanaemia ; a second type resembling the acute state ofAsH3 poisoning and providing the link betweenparoxysmal haemoglobinuria and pernicious anaemia,showing the blood picture of the latter combined withattacks of jaundice and haemoglobinuria. Thesecases ran a very chronic course. A third and very raretype was that in which the heamolysis appeared tooccur in the skin. One such case presented the skinpigmentation of a negro, combined with the bloodpicture of pernicious anaemia. Later the skin becamelighter in colour, but the blood picture has persistentlyshown a severe anaemia with nucleated red cells, but onthe whole a low colour-index. A consideration of theassociated conditions led to the view that perniciousanaemia was only one of numerous conditions in whichhaemolysis occurred, and that there were probablyseveral conditions of differing aetiology included underthe title.

R61e of Achlorhydria in Pernicious Anæmia.Dr. A. F. HURST said he was becoming more and

more convinced that constitutional peculiarities or

diatheses played an important part in the productionof disease, and that pernicious anaemia was an excellentexample of disease dependent upon diathesis.Achlorhydria (which was an inborn error of function)was, he thought, almost invariably the predisposingcause of pernicious anaemia, for the recently introducedfractional test-meal showed that in perniciousanaemia free HC1 was absent from the gastric secretionthroughout digestion. It had been suggested that theachlorhydria was secondary to the anaemia, but hehad now collected 12 cases in which the achlorhydriahad preceded the anaemia by periods varying from1 to 12 years. Moreover, the achlorhydria was foundin the early stages of the disease and remainedcomplete during remissions or apparent recovery.Finally, there was no constant change in the gastricsecretion in other forms of anaemia. It was theabsence of free acid that was, in all probability, thepredisposing factor. In many cases the achlorhydriawas due to constitutional achylia gastrica, which, asT. I. Bennett and J. A. Ryle had shown, was presentin 4 per cent. of normal young men ; but this was notinvariably so, for he had ssen a case of perniciousanæmia associated with achlorhydria due to alcoholicgastritis, and he also knew of six cases where thecomplete achylia due to total gastrectomy for cancerwas followed by pernicious anaemia. According toFaber, pernicious anaemia occurs in 10 per cent. ofindividuals with achlorhydria. Dr. Hurst believedthat this 10 per cent. were the victims of oral sepsis,with possibly some additional factor such as vulnera-bility of the blood or bone marrow; streptococicwere swallowed which were not destroyed as in the

1071CARDIFF MEDICAL SOCIETY.

normal individual by the acid gastric secretion. Theyhad found Streptococcus longus in the duodenum ofeach of 12 cases of pernicious anaemia and subacutecombined degeneration of the cord. Achlorhydriafavoured infection of the intestine and also bydelaying the digestion of protein allowed an undueproportion of protein to remain in the lower ileum, inwhich it could undergo bacterial decomposition withthe possible production of toxins. One of thesetoxins might be hæmolytic, and another, the neuro-toxin, repsonsible for subacute combined degenera-tion of the cord. Constitutional achylia gastrica wasnow, owing to the frequent performance of fractionaltest-meals, being discovered often. All patientsexhibiting this condition should be regarded as

potential cases of pernicious anaemia, and shouldtherefore take sufficient hydrochloric acid with everymeal to produce the normal gastric acidity (in mostcases 1½ to 2 drachms of dilute hydrochloric acid wererequired), and should pay special attention to theteeth. When pernicious anaemia was already present,the administration of hydrochloric acid and radicaltreatment of oral sepsis should be combined withthe use of a vaccine prepared from the organism inthe patient’s own duodenum. In severe cases hewas inclined to recommend transfusion, and possibly splenectomy.

Dr. ARTHUR MAITLAND-JONES gave some figurescollected from the 117 cases already referred to byDr. Panton. The records were incomplete, butshowed that the average number of remissions inthe disease was two, although rarely there were asmany as five or six, and the average duration of eachremission was six months. During a remission theblood count rose from 1 million up to 2 or veryrarely 3½ millions. It was remarkable that withonly a slight improvement in the blood count thepatient would profess himself greatly relieved. This,it had been suggested, was due to the increase inblood volume rather than in cells. Eight of the caseswere still alive, one at 17, one at 14, and one at 8years after the commencement of the disease. Thefirst had been exhibited to the society as an apparentcure. He now presented no symptoms, and had ared cell count of 5,200,000. When in the LondonHospital, 13 years ago, his blood count was only1,500,000, and he had complete achylia.Dr. CECIL PRICE-JONES showed diagrams indicating

the great variation in the size of the red cells inpernicious anaemia, whereas normal red cells showedcomparatively little variation. The essential elementin the blood picture of pernicious anaemia was theproduction of a large red cell which was easilyhaemolysed, and when this haemolysis occurred therewas a reaction which resulted in the production ofsmall red cells.Dr. J. J. CONYBEARE, who had with Dr. J. M. H.

Campbell collected the records of all the cases at

Guy’s Hospital during the period 1909-22, said thatthe figures showed that the disease was becomingrelatively more frequent. It was difficult to be surethat the gastro-intestinal symptoms of perniciousanaemia were not due to the administration of arsenic,but in this series such symptoms arose in 35 per cent.of cases before any arsenic had been given. Achlor-hydria had been observed in all the cases in whicha test-meal had been performed with one exception-acase which appeared to have recovered. Pigmentationoccurred in the skin in 12 per cent. and in the mouthin 5 per cent. of cases, and was apt at times to makethe diagnosis from Addison’s disease difficult.

Dr. L. TIDY referred to a unique case recentlyseen at St. Thomas’s Hospital. On admission theblood picture was that of aplastic anaemia, whichchanged after treatment with arsenic to that ofpernicious anaemia. Post mortem the bone-marrowof the femur showed the macroscopic and microscopicappearances in one-half of aplastic and in the otherhalf of pernicious anaemia, with a sharp line of demar-cation. He could not agree with Dr. Hurst as to theimportance of achlorhydria as an aetiological factor, isince it occurred together with a blood picture’

similar to that of pernicious anaemia in two diseases, which were curable-bothriocephalus anaemia and

sprue.Dr. F. J. POYNTON pointed out that the anaemia

gravis of childhood, which many thought to be, aplastic, presented many resemblances to pernicious

anaemia in its mode of onset, and the reduction ofred blood cells, although the colour-index was always

; low. That such cases were not true aplastic anaemiawas shown by the fact that under treatment the redcell count would often increase by 3 millions in afew weeks. This disease also showed the remissionsso characteristic of pernicious anaemia, and reactedsimilarly to treatment only during the upward swing.

Sir P. BASSETT-SMiTH said that sprue differed frompernicious anaemia in having a low colour-index.

Dr. G. RIDDOCH discussed the associated spinalcord lesions. In 84 per cent. of these cases degenera-tive changes were found in the postero-lateral columnsextending often from the cervical to the lumbarregion. The changes were most marked in theregions supplied by the pial arteries. Subacutecombined degeneration of the cord might occur

without the blood picture of pernicious anaemia.Similar changes in the cord occurred in ergot poisoningand pellagra, both diseases in which the toxin wasprobably blood borne.

Reply.In reply Dr. PANTON said he could not agree in

toto with Dr. Hurst as to the r6le of achlorhydria, forhe had seen cases of secondary anaemia with achlor-hydria and also knew of three cases of true perniciousanaemia with free HCI in the test-meal. He could notavoid thinking that the cases of pernicious anaemiastated by Dr. Hurst to have occurred after gastrec-tomy for cancer were examples of mistaken diagnosis-he had made a similar mistake himself upon at leastone occasion. As regards anaemia gravis of childrenhe thought that the low colour-index constitutedsufficient evidence that it was not true perniciousanaemia.At the beginning of the meeting cases were shown

by Dr. MAITLAND-JONES and microscopic preparationsby Dr. PANTON and others.

CARDIFF MEDICAL SOCIETY.

PUERPERAL INFECTION MORTALITY IN WALES.

A MEETING of this Society was held on Nov. 7th,when Prof. E. J. MACLEAN, who presided, delivered hispresidential address with this title. He traced thehistorical basis upon which our present knowledge ofpuerperal infection rests, and discussed the questionsof definition and classification. He proceeded todiscuss the frequency and distribution of puerperalinfection. In 1910 attention was drawn to the factthat in the British Isles during the previous 40 yearsthe mortality from puerperal infection had butslightly diminished, notwithstanding the revolutionwhich had occurred in surgical practice. The lying-inhospitals only participated in the betterment so faras midwifery was concerned, and in these institutionsthe mortality had been reduced to a minimum.Taking a quinquennial period of 70 years ago, thepuerperal death-rate from all causes was 4-9 per1000 births, as compared with 4-2 for a similar periodof 16 years ago, and deaths from puerperal infectionaccount for 50 per cent. of these rates. The Registrar-General’s report for 1920 makes reference to the taleand toll of the intervening years. In 1920 thenumber of deaths assigned to pregnancy or child-birth corresponded to a rate of 4-12 per 1000 births,as against an average rate of 3-78 in the 10 yearsimmediately preceding, and 4-12 for 1919. Prof.Maclean pointed out that the lowest level reachedwas 3-55 in 1918, so that the increase to 4-12 in 1919and 1920 was sudden as well as considerable. Whendistinction was made between deaths ascribed toseptic and to other causes it emerged that the increasewas almost entirely due to sepsis, the rate for which