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PERNICIOUS ANÆMIA UNIT: ST. MARY, ISLINGTON, HOSPITAL.
Report for the year ending 31st December, 1934.
By B. Barling, M.D., B.S., M.R.C.P., M.R.C.S., Senior Assistant Medical Officer,
St. Mary, Islington, Hospital.
In January, 1934, a unit was established at St. Mary, Islington, hospital, under
the auspices of the Medical Research Council, for the therapeutic testing of parenteral
injections of liver extracts. During the period under review, forty-two cases were
examined for this investigation, ten male and thirty-two female.
The scheme used followed that laid down by the Medical Research Council,
which was an adaptation of the method in use in the Department of Clinical Investigation
and Research at the University and the Royal Infirmary, Manchester.
In all cases the diagnosis was confirmed by a full blood count and the presence
of achylia gastrica. Van den Bergh and Wassermann reactions were performed also,
and in addition, in some cases, an X-ray examination of the stomach was made.
Cases with a blood count of under two million red cells were considered the most
suitable.
As far as possible patients who had had no previous treatment, or those to
whom no anti-anaemia treatment had been administered at so recent a date as to
allow it to be effective, were chosen for the investigation.
In all cases there was a control period of a minimum of seven days, during which
time the red blood cell count and hæmoglobin percentage were examined. Only
those patients whose blood count remained stationary or diminished and in whom
the reticulocyte count remained at a low level during this period were considered
suitable.
In each case the intramuscular injection was given for three days and a satisfactory
reticulocyte response expected by the tenth day, together with a steady rise
in red cells and haemoglobin.
The investigation was of great interest, not only because it revealed how
impotent or relatively impotent a preparation might be, but also because it gave an
opportunity of examining in detail cases that had clinically simulated pernicious
anaemia. Furthermore, it was possible to make observations on the general treatment
of the disease, and more especially the effect of treatment on sub-acute
combined degeneration.
Among the cases clinically simulating pernicious anaemia were two of idiopathic
steatorrhœa (Gee's disease) with hyperchromic achlorhydric anaemia, which are
being recorded elsewhere, one case of syphilitic anaemia and one of microcytic
achlorhydric anaemia with multiple telangiectasia.
In treating the cases one fact was clearly established that the manufacturer's
note that the 2 c.c. of liver preparation was extracted from 20 grammes of liver or
100 grammes of liver meant nothing to the therapeutist. For, in some cases,
contrary to what might be expected, the 2 c.c. extracted from 20 grammes was more
potent than that extracted from 100 grammes.
Furthermore, there is no definite dose of liver extract, neither for treatment nor
for the maintenance of a normal blood count. The quantity necessary depends
entirely on the patient under review. In one of the cases 10 c.c. of a potent extract
were administered when the red blood count was only 600,000, and in six weeks
with no other treatment the red count was over five million. In others, it has been
found that with 2 c.c. given daily for the same period the blood count has remained
stationary between three to four million red cells, and it has been necessary to double
the dose before adequate progress has been made.
Theoretically, liver is the treatment for the macrocytic anaemias, i.e., pernicious
anaemia, and iron for the microcytic types, but it was found in practice that in some
cases of pernicious anaemia, whereas the red cells rapidly and steadily increase in
number, the haemoglobin fails to keep pace or having reached a definite percentage,
say 60 per cent. cannot be increased by liver alone. Iron administered as a
scale preparation or as Blaud's pill in adequate dosage rapidly increases the
percentage of haemoglobin.
(83)