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MEGALOBLASTIC ANÆMIA OF PREGNANCY
491 find it increasingly embarrassing to have to visitors and colleagues that I meet that I am in no immediate danger of forgetting how to do a thoraeoplasty or an adhesion division. A general surgeon would accused of being " cholecystectomy-minded on his professional this as a reflection take rightly The suggestion of being " anything-minded " implies that prejudice or obsession has taken the place of scientific judgment. May I please put it on record that this is not the case in Liverpool. LESLIE J. TEMPLE. Liverpool. I
to
myself
explain
"
judgment.
MEGALOBLASTIC ANÆMIA OF PREGNANCY SIR,—In your issue of Aug. 2 Dr. Israels and Dr. Da Cunha emphasise the importance of early diagnosis in megaloblastic anaemia of pregnancy, as this disease is not at all rare and can be adequately treated. They state that folic acid remains the treatment of choice, because vitamin B12 has been found ineffective against this condition in temperate climates. We have previously described1 a case of megaloblastic anaemia in the puerperium reacting to vitamin B12. In this case analysis of the gastric juice showed the presence of free HC1. This excluded the possibility of addisonian pernicious anaemia. Determination of the fat content of the faeces (total fat 50% of the dry weight) pointed to non-tropical- sprue. We came to the conclusion that megaloblastic anaemia in pregnancy in the temperate zone may be classified as : (1) addisonian pernicious anaemia, (2) non-tropical sprue, and (3) true megaloblastic anaemia of pregnancy or puerperium. Since then we have seen a patient of 23, primigravida. She was examined in November, 1950. Her haemoglobin was then 12-5 g. per 100 ml. In April, 1951, she was admitted to hospital because of severe anaemia, which progressed while she was treated with iron. The
She complained of was 8 months pregnant. exertion, headache, and oedema. She suffered
patient
dyspnoea from vomiting, on
which had improved during the last 2 or 3 weeks. Examination showed a systolic murmur. Liver and spleen were not palpable. The tongue was normal. No signs of polyneuritis or involvement of the central nervous system. Investigations.—Hb 5.4 g. per 100 ml. ; red blood-cells 1,200,000 per c.mm. ; white blood-cells 10,000 per c.mm. ; smear of peripheral blood showed 14 nucleated red cells (including some megaloblasts) per 100 white cells. Bonemarrow :
hyperplastic, megaloblastic.
Fractional gastric analysis (free and total acidity in ml. of 01 N HCl per 100 ml. }: (1) 0/27, (2) 0/5, (3) 0/7, (4) 0/12 ; after histamine (5) 6/6, (6) 14/30, (7) 28/45, (8) 34/48. Serum-iron 370 ;j(.g. per 100 ml. ; blood-bilirubin 0-6 mg. per100 ml. Faeces over a 3-day period on a Schmidt’s diet: total weight 110 g.; dry weight 30.5% of total weight; total fat 29% of the dry weight. Glucose-tolerance curve : fasting, 79 mg. per 100 ml., 30 min. 174 mg., 60 min. 149 mg., 90 min. 73 mg., 120 min. 65 mg., 150 min. 74 mg. Treatment.—She was given 400 ml. of blood, which raised her Hb to 6.2 g. per 100 ml., her red-cell count to 1,500,000 per Treatment c.znm., and the haematocrit volume to 22-1%. with vitamin B12 was started on April 18 ; 15 l;r.g. daily was Riven by injection for three days. On the third day she felt better, and the subjective improvement continued. It was 8ceompanied by a reticulocyte crisis of 17.3% on the ninth day. On May2 her Hb was 907 g. per ml., red cells 2,180,000, and hæmatocrit volume 30%. Vitamin B12 was agam given (15 gg. every other day) until May 13, when she was delivered of a healthy child. Blood examination on Jan. 18, 1952, showed Hb 12-8 g. per 100 ml., and red cells 4,710,000 per e.mrn. In this case the normal fat content of the faeces and
100
the normal glucose-tolerance curve excluded the possibility of non-tropical sprue, while the presence of free HC1 after histamine is strongly against the diagnosis of addisonian pernicious anaemia. 1.
H. O., van Buchem, F. S. P., Stenfert Kroese, W. F. Acta med. scand. 1952, 142, 45.
Nieweg,
At the University of Utrecht medical clinic Verloop observed the effectiveness of vitamin B12 in similar patients. In the Netherlands at least, there are two groups of megaloblastic ansemia of pregnancy: the first is caused by a deficiency of vitamin B12;and the second by a lack of folic acid. This differentiation is, of course, of practical importance because of the danger of neurological lesions in patients with vitamin-B deficiency who are given folic acid. University of Groningen,
H. O. NIEWEG.
Holland.
ACHALASIA
v.
CARDIOSPASM
Sir,-Hurst is dead : otherwise he would have replied to your peripatetic correspondent’s attack (Aug. 16). Hurst gave up many of the concepts and therapies " The absent acidmentioned long before his death. barrier in pernicious anaemia " was forgotten in 1928, although I well remember in 1930 Castle, who attended one of Hurst’s combined rounds, saying with obvious sincerity that if Hurst had not emphasised the absence of acid and published his supposedly cured case of Addisonian ansemia, he (Castle) would never have thought of doing his experiment of predigesting a steak in a healthy stomach and transferring it to a patient with Addisonian ansemia. Though Hurst gave up his views about catarrhal jaundice, somewhat obstinately, he never gave up the concept of achalasia. When I do a rectal examination in a patient, if he has a fistula, a fissure, or a thrombosed pile, the sphincter sometimes goes into spasm and this I call anal spasm. In people with a healthy lower gut, the finger usually slips in easily-i.e., there is complete " chalasia." Hurst constantly pointed out that when the mercury tube (I cannot remember his miscalling it a bougie ") passed into the stomach as the sphincter relaxed, the tube was not gripped as it would be in cardiospasm. It was this observation which made him ask Sir Cooper Perry " for a single word to egpressabsence of relaxation.’ "
"
This observation I confirmed this morning when I visited who in the past twenty years has passed her tube over 3000 times. This woman of 53 kindly passed her tube while I waited in the next room, and I was able forthwith to show that there was no gripping, or, as she said : When the tube passes the obstruction, which is rather difficult, there is no difficulty in withdrawing it." She, however, usually keeps it down for five minutes, and she has discovered that this suffices for two to three days of easy swallowing. She has also discovered that it helps to have had a light meal. a
patient
"
Your peripatetic correspondent says that Douthwaite the inept congratulates Avery Jones on excluding word from his new book." But Avery Jones has not "
done
so.
Two of his authors, both surgeons, write thus :
Ronald Belsey (p. 156) says in the differential diagnosis of hiatus hernia from " Achalasia of the cardia. Dilatation of the oesophagus is rare in hiatus hernia, even with stenosis and usual in achalasia. The symptoms are different and the response to octyl nitrite is diagnostic of achalasia " ; and Geoffrey Wooller (pp. 179-199) gives achalasia as a synonym for cardiospasm but uses the word cardiospasm " in the belief that spasm of the cardia exists in the majority of patients," although he admits : "’The cause of cardiospasm is unknown. Psychogenic trauma is an important factor in initiating its
onset."
I am grateful to your peripatetic correspondent for making me do a little research, and rather than try to decry Hurst’s work and his disciples as he does I would like to suggest that we get more information on two unsettled points. Firstly, several people doubt Geoffrey Rake’s work,3 confirmed by E. A. Gallinaro.4 that achalasia is caused by degeneration of Auerbaeh’s plexus and think this is the effect rather than the cause. Surely it is possible to examine Auerbach’s plexus in patients dying from other 2. Verloop, M. C. Personal communication. 3. Guy’s Hosp. Rep. 1926, 76, 145 ; Ibid, 1927, 4. Rass. Neurol. veg. 1947, 4, 464.
77,
141.
to
myself
explain
"
judgment.
MEGALOBLASTIC ANÆMIA OF PREGNANCY SIR,—In your issue of Aug. 2 Dr. Israels and Dr. Da Cunha emphasise the importance of early diagnosis in megaloblastic anaemia of pregnancy, as this disease is not at all rare and can be adequately treated. They state that folic acid remains the treatment of choice, because vitamin B12 has been found ineffective against this condition in temperate climates. We have previously described1 a case of megaloblastic anaemia in the puerperium reacting to vitamin B12. In this case analysis of the gastric juice showed the presence of free HC1. This excluded the possibility of addisonian pernicious anaemia. Determination of the fat content of the faeces (total fat 50% of the dry weight) pointed to non-tropical- sprue. We came to the conclusion that megaloblastic anaemia in pregnancy in the temperate zone may be classified as : (1) addisonian pernicious anaemia, (2) non-tropical sprue, and (3) true megaloblastic anaemia of pregnancy or puerperium. Since then we have seen a patient of 23, primigravida. She was examined in November, 1950. Her haemoglobin was then 12-5 g. per 100 ml. In April, 1951, she was admitted to hospital because of severe anaemia, which progressed while she was treated with iron. The
She complained of was 8 months pregnant. exertion, headache, and oedema. She suffered
patient
dyspnoea from vomiting, on
which had improved during the last 2 or 3 weeks. Examination showed a systolic murmur. Liver and spleen were not palpable. The tongue was normal. No signs of polyneuritis or involvement of the central nervous system. Investigations.—Hb 5.4 g. per 100 ml. ; red blood-cells 1,200,000 per c.mm. ; white blood-cells 10,000 per c.mm. ; smear of peripheral blood showed 14 nucleated red cells (including some megaloblasts) per 100 white cells. Bonemarrow :
hyperplastic, megaloblastic.
Fractional gastric analysis (free and total acidity in ml. of 01 N HCl per 100 ml. }: (1) 0/27, (2) 0/5, (3) 0/7, (4) 0/12 ; after histamine (5) 6/6, (6) 14/30, (7) 28/45, (8) 34/48. Serum-iron 370 ;j(.g. per 100 ml. ; blood-bilirubin 0-6 mg. per100 ml. Faeces over a 3-day period on a Schmidt’s diet: total weight 110 g.; dry weight 30.5% of total weight; total fat 29% of the dry weight. Glucose-tolerance curve : fasting, 79 mg. per 100 ml., 30 min. 174 mg., 60 min. 149 mg., 90 min. 73 mg., 120 min. 65 mg., 150 min. 74 mg. Treatment.—She was given 400 ml. of blood, which raised her Hb to 6.2 g. per 100 ml., her red-cell count to 1,500,000 per Treatment c.znm., and the haematocrit volume to 22-1%. with vitamin B12 was started on April 18 ; 15 l;r.g. daily was Riven by injection for three days. On the third day she felt better, and the subjective improvement continued. It was 8ceompanied by a reticulocyte crisis of 17.3% on the ninth day. On May2 her Hb was 907 g. per ml., red cells 2,180,000, and hæmatocrit volume 30%. Vitamin B12 was agam given (15 gg. every other day) until May 13, when she was delivered of a healthy child. Blood examination on Jan. 18, 1952, showed Hb 12-8 g. per 100 ml., and red cells 4,710,000 per e.mrn. In this case the normal fat content of the faeces and
100
the normal glucose-tolerance curve excluded the possibility of non-tropical sprue, while the presence of free HC1 after histamine is strongly against the diagnosis of addisonian pernicious anaemia. 1.
H. O., van Buchem, F. S. P., Stenfert Kroese, W. F. Acta med. scand. 1952, 142, 45.
Nieweg,
At the University of Utrecht medical clinic Verloop observed the effectiveness of vitamin B12 in similar patients. In the Netherlands at least, there are two groups of megaloblastic ansemia of pregnancy: the first is caused by a deficiency of vitamin B12;and the second by a lack of folic acid. This differentiation is, of course, of practical importance because of the danger of neurological lesions in patients with vitamin-B deficiency who are given folic acid. University of Groningen,
H. O. NIEWEG.
Holland.
ACHALASIA
v.
CARDIOSPASM
Sir,-Hurst is dead : otherwise he would have replied to your peripatetic correspondent’s attack (Aug. 16). Hurst gave up many of the concepts and therapies " The absent acidmentioned long before his death. barrier in pernicious anaemia " was forgotten in 1928, although I well remember in 1930 Castle, who attended one of Hurst’s combined rounds, saying with obvious sincerity that if Hurst had not emphasised the absence of acid and published his supposedly cured case of Addisonian ansemia, he (Castle) would never have thought of doing his experiment of predigesting a steak in a healthy stomach and transferring it to a patient with Addisonian ansemia. Though Hurst gave up his views about catarrhal jaundice, somewhat obstinately, he never gave up the concept of achalasia. When I do a rectal examination in a patient, if he has a fistula, a fissure, or a thrombosed pile, the sphincter sometimes goes into spasm and this I call anal spasm. In people with a healthy lower gut, the finger usually slips in easily-i.e., there is complete " chalasia." Hurst constantly pointed out that when the mercury tube (I cannot remember his miscalling it a bougie ") passed into the stomach as the sphincter relaxed, the tube was not gripped as it would be in cardiospasm. It was this observation which made him ask Sir Cooper Perry " for a single word to egpressabsence of relaxation.’ "
"
This observation I confirmed this morning when I visited who in the past twenty years has passed her tube over 3000 times. This woman of 53 kindly passed her tube while I waited in the next room, and I was able forthwith to show that there was no gripping, or, as she said : When the tube passes the obstruction, which is rather difficult, there is no difficulty in withdrawing it." She, however, usually keeps it down for five minutes, and she has discovered that this suffices for two to three days of easy swallowing. She has also discovered that it helps to have had a light meal. a
patient
"
Your peripatetic correspondent says that Douthwaite the inept congratulates Avery Jones on excluding word from his new book." But Avery Jones has not "
done
so.
Two of his authors, both surgeons, write thus :
Ronald Belsey (p. 156) says in the differential diagnosis of hiatus hernia from " Achalasia of the cardia. Dilatation of the oesophagus is rare in hiatus hernia, even with stenosis and usual in achalasia. The symptoms are different and the response to octyl nitrite is diagnostic of achalasia " ; and Geoffrey Wooller (pp. 179-199) gives achalasia as a synonym for cardiospasm but uses the word cardiospasm " in the belief that spasm of the cardia exists in the majority of patients," although he admits : "’The cause of cardiospasm is unknown. Psychogenic trauma is an important factor in initiating its
onset."
I am grateful to your peripatetic correspondent for making me do a little research, and rather than try to decry Hurst’s work and his disciples as he does I would like to suggest that we get more information on two unsettled points. Firstly, several people doubt Geoffrey Rake’s work,3 confirmed by E. A. Gallinaro.4 that achalasia is caused by degeneration of Auerbaeh’s plexus and think this is the effect rather than the cause. Surely it is possible to examine Auerbach’s plexus in patients dying from other 2. Verloop, M. C. Personal communication. 3. Guy’s Hosp. Rep. 1926, 76, 145 ; Ibid, 1927, 4. Rass. Neurol. veg. 1947, 4, 464.
77,
141.