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bed-making.-Dr. H. TRAYER had found that felsolpowder gave relief in dyspnoea. For failing appetite,half a pint of hot water sipped half an hour beforedinner was helpful. Brandy, sherry, or port couldsometimes be allowed with advantage.
LONDON ASSOCIATION OF THE MEDICAL
WOMEN’S FEDERATION
A MEETING of this association was held at B.M.A.House on May 22nd, when Dr. Lucy WiLLS spoke on
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Tropical Macrocytic AnaemiaDr. Wills gave an account of her work on this subjectduring the last five years. In 1928 this conditionwas described in pregnant women under the title"
pernicious anaemia of pregnancy " and was a serious
cause of maternal and fcetal mortality in the largecities of India. The blood picture resembled that oftrue pernicious ansemia, but the condition could bedistinguished from idiopathic pernicious anaemia
by the following characteristics: (1) earlier age-incidence and the association with pregnancy; (2)absence of natural remissions except after delivery ;(3) the presence of free hydrochloric acid in normalamounts in the gastric content of the majority ofcases ; (4) the absence of a raised indirect van denBergh reaction or an increase in urinary urobilin ;(5) absence of nervous involvement; (6) slightdifferences in the blood picture-e.g., less poikilo-cytosis and polychromasia, higher white cell counts.The cases were frequently febrile but no evidencecould be obtained of an infective or toxic origin.The general course of the disease and the response toadequate doses of liver or liver extracts suggesteda nutritional origin. Further study showed that anidentical form of anaemia also occurred among menand non-pregnant women, which also supported theview that the disease was a deficiency state, the higherincidence and the greater severity in pregnant womenbeing due to the added demands on the organismduring pregnancy. A dietetic survey among thehospital classes in Bombay revealed a deplorablestate of multiple deficiencies, with no significantdifference in the diet of sufferers from this anaemia.All the diets were particularly low in vitamins A and C.Experiments with rats fed on diets based on those incommon use among sufferers from this anaemiaresulted in the production of a macrocytic anaemia,which, however, was associated with the multiplica-tion of Bartonella organisms in the blood stream.A search for similar organisms in the patients gavenegative results and large doses of vitamins A’and Chad no curative effect. Similar experiments withmonkeys (Bartonella free) again led to the productionof a macrocytic anaemia, but both in the controlanimals, who were receiving additional rationsof vitamins A and C, and in the experimental animals.When the ration of the vitamin-B complex wasincreased by the addition of Marmite to the diet theanaemia disappeared rapidly. The trial of marmite inhuman cases was equally successful, 15-30 g. ofmarmite daily resulting in a maximal response anda rapid rise in the red cell count in both pregnant andnon-pregnant cases. At this time Castle and hisco-workers were publishing their work on the factors,intrinsic and extrinsic, necessary for the formationof the hsemopoietic factor in liver. As the tropicalcases had apparently normal gastric secretion it wasassumed that the intrinsic factor was present, butthat the missing dietetic factor was Castle’s extrinsicfactor. After the publication by Dr. Wills of the
results with marmite, the Boston workers tried a
similar autolysed yeast extract and found that thoughinactive alone, when incubated with normal gastricjuice it was highly active in the cure of idiopathicpernicious anaemia. These workers postulatedvitamin B2 or some factor closely associated withit as the extrinsic factor in pernicious ansemia.At the same time Dr. Wills said further work with
standardised vitamins and yeast preparation in relationto tropical macrocytic ansemia had already beenstarted by her with the help of Miss H. Chick, D.Sc.For the test of these preparations uncomplicated casesunder controlled conditions were used, and the activityof a preparation was judged by the height of thereticulocyte peak and the subsequent rate of bloodregeneration. Vitamins B1, B2, and B4 were inactivecuratively when given in the purest available form—i.e., as acid clay and extract of egg white, or inwatery yeast extract of known vitamin potency;further, preparations of marmite free from thesevitamins were still active curatively. The vitamin-B complex was, therefore, excluded as the hsemo-
poietic factor in marmite curative in tropical macro-cytic anaemia and also presumably as the extrinsicfactor in pernicious ansemia. Further experimentsshowed that the hsemopoietic factor in marmite washeat stable and was neither precipitated nor inacti.vated by 80 per cent. alcohol. Whole yeast wasinactive, but Dr. Wills suggested that this might bedue to the fact that yeast cells are resistant to gastricdigestion, rather than to the absence of the .haemo-poietic factor.
She summed up the present position as follows:Tropical macrocytic ansemia is a deficiency, dyshsemo-poietic anaemia due to the lack of the hsomopoieticfactor in the liver known as the pernicious anaemiafactor. The disease is distinct from idiopathicpernicious anaemia and is not necessarily associatedwith diarrhoea, defective gastric secretion, or
pregnancy, other causes of macrocytic ansemia. The
deficiency is, in her opinion, due to a dietetic lack insome substance present in marmite, which is not oneof the known B-vitamins, but which is probablyidentical with the extrinsic factor described byCastle for idiopathic pernicious anaemia. The tropicalansemia is cured by the administration of the missingfactor as marmite or of the pernicious ansemia factorpresent in liver.
Dr. HELEN MACKAY asked if there was any explana-tion of the absence of nervous symptoms and naturalremissions and of the fact that there was no recordof the disease in children, who were normally moresusceptible to deficiency diseases than adults.
Dr. WILLS, in reply, said that possibly as regardsnerve changes there was not time enough for theseto develop in the young patients, but it seemed morelikely, in view of the age of some of the non-pregnantpatients, that the nerve lesions of true perniciousanaemia were associated with the gastric lesion ratherthan with the absence of the haemopoietic factor,which would explain the absence of nerve lesions inthe tropical form. She thought that further studymight show that remission did occur in exceptionalcases, but had no explanation of the absence ofrecorded cases in children.
ST. JOHN’S HOSPITAL DERMATOLOGICAL SOCIETY.-The Prosser White oration of this society will be deliveredby Dr. William Allen Pusey, of Chicago, on Wednesday,June 27th, at 5 P.M., at the house of the Royal Society ofMedicine, 1, Wimpole-street, W. The title of Dr. Pusey’slecture will be "Disease, gadfly of the mind, especiallythe stimulus of disease in the development of the mind."
