Confined 30th "November 1923; child 3 lbs., alive. Died 10th December 1923. CsjtfC'"No. 9.?G., Hindu, 23 years, 2nd gravida; ad- .m'ftted 18th December 1923. Haemoglobin 30 per cent.; R.B.C.'s 1,000,000: confined 19th December 1923; child 2 lbs., still-born. Died 19th December 1923. Case No. 10.?K. P. B., Hindu, 18 years, 1st gravida; admitted 23rd December 1923. Haemoglobin 15 per cent.; R.B.C.'s confined 24th December THE ANiEMIA 1,000,000: 1923; child oFr ??rvAC4SES.C. 5 lbs., still-born. Died 28th December 1923. A STUDY OF FORTY-THREE Case No. 11.?R., Hindu, 35 years, 1st gravida; ad- mitted 10th January 1924. Haemoglobin 30 per f.r.c.s.i., cent.; B-v s. A. McSWINEY, b.a., m.b., B.ch, R.B.C.'s 1,750,000: confined 10th January 1924; child Died 13th 1924. MAJOR, I.M.S., 41 lbs., alive. January Case No. 12.?Mrs. D.'C., Anglo-Indian, 22 years, 2nd j ^ Resident Eden Hospital for Diseases of u/c Surgeon, Resident admitted 24th January 1924. Haemoglobin 30 '"cn and Calcutta: late Second gravida; Children, cent.; R.B.C.'s 1,000,000: Wassermann reaction nega- General Hospital, Calcutta. per u>geon, Presidency tive; confined 25th January 1924; baby 6 lbs., alive. Left against advice 8th February 1924. he; is a condition anaemia of pregnancy Case No. 13.?Mrs. O., Anglo-Indian, 24 years, 6th en- vv^lch so little is known that I am gravida; admitted 11th February 1924. Haemoglobin co R.B.C.'s confined 20th uraged to publish my investigations into forty- 30 per cent.; 2,000,000: February foetus 1 lb. 14 ozs., died soon after birth. Dis- lree cases which came under notice during 1924; my 3rd May 1924. e two I was Resident charged and a half years when Case No. 14.?Mrs. B., Anglo-Indian, 23 years, 6th u?geon in the Eden Hospital, Calcutta. gravida; admitted 19th July 1924. Haemoglobin 40 per extbooks of obstetrics scarcely mention it; cent.; R.B.C.'s 3,000,000: confined 19th July 1924; child jn 4 7 ozs., alive. Discharged 26th August 1924. e literature I can find only two references* lbs., ar Case No. 15.?C. D., Hindu, 19 years, 3rd gravida; se are not available in unfortunately admitted 27th 1924. Haemoglobin 35 per cent.; In 1' them July -!a- * propose, however, to study R.B.C.'s 1,500,000: confined 30th July 1924; foetus 1 lb. vv| fresh 1924. am on ^eave 111 Europe and if any 4 ozs., dead. Died 30th July licrj1 ^OUnc^ have been thrown on the sub- Case No. 16.?N., Hindu, 22 years, 3rd gravida; ad- ie c byi'S these I hope to publish mitted 4th August 1924. Haemoglobin 12 per cent.; investigators R.B.C.'s 500,000: confined 24th August 1924; child 4 lbs. "Copses as a continuation of this article, 6i ozs., dead. Died 25th August 1924. ^ f'le I mean a con- anaemia ?f pregnancy Case No. 17.?S., Hindu, 40 years, 8th gravida; ad- dif can anaem'a f?r which no obvious cause mitted 17th September 1924. Haemoglobin 30 per cent.; be kala- confined 17th 1(fnound?such as haemorrhage, malaria, R.B.C.'s 1,500,000: September 1924; foetus ^ still-born. Left advice leukaemias, etc.; any case 3j lbs., hospital against 29th ^kylostomiasis, September 1924. siio-1' of these conditions was excluded *>gestiye Case No. 18.?T., Hindu, 25 years, 1st gravida; ad- 0111 *his of cases. group mitted 23rd September 1924. Haemoglobin 15 per cent.; Wassermann reaction ?^rs- Jewess, 4th gravida; aged 25; R.B.C.'s 500,000. strongly posi- admfff E., Died 26th 1924?not confined. ^ June 1923. Haemoglobin 30 per cent.; tive. September Red ti Case No. 21 years, 2nd ad- : confined 20th June 1923; child 19.?H., Hindu, gravida; r 10th October 1924. 50 health '^s. 4 ozs. YVassermann reaction negative. mitted Haemoglobin per cent.; Wassermann reaction 30th June 1923. R.B.C.'s 1,050,000. negative. 24th October child 4 lbs. 13 alive. ^harged 2-?K- Hindu, aged 15, 1st gravida; ad- Confined 1924; ozs., 1st November 1924. 1923. Haemoglobin 35 per cent.; R.B.C.'s Discharged 2 Snn nrv! 20.?Mrs. 26 6th 0 ? child 2 lbs. 2 ozs., Case No. E., Anglo-Indian, years, (jjpj confined 29th July 1923; soon after birth. Died 8th August 1923. gravida; admitted 23rd October 1924. Haemoglobin 40 8th R.B.C.'s confined 24th October ^0" J- Mahomedan, 30 years, per cent.; 2,750,000: Rrav'ff admitted 1923. 25 per 1924; foetus 3 lbs. 81 ozs., died after a few hours. Left cent 24th July Hasmoglobin '?r>' 25th 1923; child hospital against advice 3rd November 1924. 5 1,500,000: confined July jl"R-B.C.'s? 1923. ? 12 ozs., healthy. Discharged 4th August Case No. 21.?A., Hindu, 30 years, 5th gravida; ad- 5th f-?Mrs. S., Anglo-Indian, 25 years, mitted 1st November 1924. Haemoglobin 20 per cent.; gravid admitted 9th 1923. Hsemoglobin 20 per R.B.C.'s 1,000,000: confined before admission, still-born. cent ? aA August -?-C.'s confined before admission? 18th November 1924. still V! 1,250,000: Discharged orn. Died 13th August 1923. Case No. 22.?Mrs. B. Indian Christian, 30 years, ad- S., ?S., Hindu, 20 years, 2nd gravida; 4th gravida; admitted 3rd November 1924. Haemoglobin thituff cent. ; September 1923. Hsemoglobin 25 per 50 per cent.; R.B.C.'s Wassermann reaction RRn> twins. 3,000,000. .'s 1j500,000: confined 7th September 1923; negative. Confined 18th November 1924; child 4 lbs. Vp" Discharged lQft,vvi,ns :?3 lbs., alive, and 5 lbs., still-born. 54 ozs., alive. Discharged 28th December 1924. September 1923. 7? 7th Case No. 23.?Mrs. P. S., Anglo-Indian, 24 years, 2nd ^T?- ?Mrs. 28 years, ?ra,a-!f R., Anglo-Indian, 24 gravida; admitted 3rd November 1924. Haemoglobin ' admitted 21st October 1923. Hemoglobin nPt. 40 per cent.; R.B.C.'s 2,750,000: confined 3rd November R-B-C.'s confined 23rd October 1923; chiMCe4U;: 840,000: Died 1924; foetus 5 lbs. 14 ozs., alive. Left hospital against ?' alive died 28th October 1923). 31 st rf (but advice 7th November 1924. October 1923. ^ 4th Case No. Hindu, 20 years, 4th gravida; ad- ^?- ^??Mrs. G., Anglo-Indian, 22 years, 24.?S., mitted 4th November 1924. Haemoglobin 25 per gra^vf admitted 1st December 1923. Haemoglobin cent.; 3o R.B.C.'s Wassermann reaction nlda! R-B.C.'s confined 1st December 1,300,000. strongly posi- ,c-ent-; 1,750,000: November foetus 2 l9P?er' 1923. tive. Confined 4th 1924; lbs. 12f child 4 lbs., still-born. Died 12th December ozs., admitted still-born. Discharged 29th December 1924. 8.?S., Hindu, 20 years, 1st gravida; 30ti1(7j?\-/y<;- 32 ^ovember 1923. Haemoglobin 25 per cent.; Case No. 25?K., Hindu, years, 3rd gravida; ad- g p s negative. mitted 22nd November 1924. 18 ^ 1,500,000: Wassermann reaction Haemoglobin percent.; R.li.C.'s 1,000,000. Wassermann reaction negative. ?* Confined 25th November foetus. ..13 ozs. Dis- Mens, d'obsl. ct dc 1918, 1924; V?i ^a^erson.?Arch. Gyn., 20th December 1924'" <>* %\ vn. 1?21. charged c.sch. Zentralbi.' f.' Gyn., 1921,- 341^345. 488 THE INDIAN MEDICAL GAZETTE. [Sept., 1927.
Case No. 26.?N., Hindu, 22 years, 1st gravida; ad- Case No. 42.?R., Hindu, 22 years, 2nd gravida; ad- mitted 28th November 1924. Haemoglobin 35 per cent.; mitted 10th September 1925. Hremoglobin 55 per cent.; R.B.C.'s 1,750,000: confined 28th November 1924; foetus R.B.C.'s 2,500,000. Wassermann reaction doubtful. 2 lbs., macerated. Died 6th December 1924. Confined 15th October 1925; foetus 3 lbs. 14 ozs., alive. Case No. 27.?Mrs. E., Jewess, 25 years, 3rd gravida; Discharged at own request 2nd November 1925. admitted 1st December 1924. Haemoglobin 30 per cent.; Case No. 43.?Mrs. C., Anglo-Indian, 20 years, 1st R.B.C.'s 1,500,000: confined 25th December 1924; foetus gravida; admitted 30th September 1925. Haemoglobin 4 lbs. 82 ozs., alive. Discharged 7th January 1925. 35 per cent.; R.B.C.'s 2,000,000: confined 30th September Case No. 28.?K., Hindu, 19 years, 2nd gravida; ad- 1925; foetus 3i lbs., alive. Discharged 20th October 1925. mitted 3rd December 1924. Haemoglobin 35 per cent.; R.B.C.'s 1,750,000. Wassermann reaction negative. Incidence. Confined 3rd December foetus 3 lbs. 31 ozs. 1924; (died These cases occurred between the 1st in 7 days). Left hospital against advice 12th January June 1925. 1923 and 30th September 1925. During that time Case No. 29.?Mrs. A. P., Indian Christian, 23 years, 2,544 maternity cases were admitted, so that 3rd gravida; admitted 9th December 1924. Haemoglobin the incidence works out at 1-69 per cent. 30 R.B.C.'s Confined 11th Decem- per cent.; 1,750,000. Without actual for the pur- ber 1924; foetus 3 lbs., still-born. Died 16th December having figures 1924. pose of comparison it is not safe to dogmatise, Case No. 30.?T. B. D., Hindu, 17 years, 3rd gravida; but one's own impression is that the disease is admitted 18th December 1924. Haemoglobin 25 per cent.; much commoner in Calcutta than in England. R.B.C.'s Wassermann reaction 1,250,000. negative. yonr will inform us as Confined 19th December 1924; foetus li lbs., still-born. Perhaps correspondents to its in other of India. Discharged 3rd January 1925. prevalence parts Case No. 31.?M. B., Mahomedan, 25 years, 1st In addition to the 43 cases which form the gravida; admitted 27th December 1924. Haemoglobin 30 subject of this article, there were two* others per cent.; R.B.C.'s 1,350,000. Wassermann reaction who died within 24 hours of admission and negative. Confined 13th January 1925; foetus 2 lbs. before a blood examination was made: the notes 10 ozs., still-born. Discharged 14th March 1925. " in each case. Case No. 32.?K., Hindu, 25 years, 2nd gravida; ad- mention profound amentia" mitted 12th January 1925. Haemoglobin 30 per cent.; One admitted 11th November, 1923, had a dead R.B.C.'s 1,500,000. Wassermann reaction moderately foetus of 51 lbs., and the other admitted 11th positive. Confined 15th January 1925; foetus 3 lbs. November, of 4 lbs. 6 ozs. 11 ozs., alive. Discharged 8th March 1925. 1924, Case No. 33.?S., Hindu, 18 years, 1st gravida; ad- mitted 22nd February 1925. Haemoglobin 50 per cent.; Race: R.B.C.'s confined 22nd foetus 2,000,000: February 1925; Of the 43 cases, 5 lbs. 8 ozs., alive. Discharged 23rd March 1925. were 11 or 25-58 cent. Case No. 34.?L., Hindu, 24 years, 1st gravida; ad- Anglo-Indians per mitted 12th March 1925. Haemoglobin 35 per cent.; Jews were 2 or 4-65 per. cent. R.B.C.'s 2,250,000. Wassermann reaction moderately Hindus were 26 ior 60-46 per cent. Confined 13th March foetus 4 lbs. 10 positive. 1925; ozs., Mahomedans were 2 or 4-65 per cent. alive. Discharged 3rd April 1925. Indian Christians were 2 or 4-65 per cent. Case No. 35.?Mrs. McN., Anglo-Indian, 39 years, 4th gravida; admitted 18th June 1925. Haemoglobin 45 per cent.; R.B.C.'s 2,000,000. Wassermann reaction Mortality: negative. Confined 24th June 1925: twins, 5 lbs. 15 ozs., Maternal . . 15 or 34-88 per cent. 4 lbs. 8 alive. 17th alive; ozs., Discharged August Foetal . . 24 or 55-81 per cent. 1925. Cnse No. 36.?D., Hindu, 26 years, 1st gravida; ad- This foetal mortality includes H sets of twins mitted 29th June 1925. Haemoglobin 30 per cent.; and all the foetuses, whether viable or not, which R.B.C.'s confined 30th 1925. Twins 2,000,000: June were either still-born or died before leaving the 1 lb. 5 ozs., still-born; 1 lb. 2 ozs., still-born. Dis- charged 20th July 1925. hospital. Case No. 37.?C., Hindu, 23 years, 1st gravida; ad- Parity: mitted 29th June 1925. Haemoglobin 35 per cent.; R.B.C.'s 1,700,000. Wassermann reaction strongly posi- Priniipane were 13 or 30-23 per cent. or tive. Confined 2nd July 1925; foetus 2 lbs. 9a ozs., alive. 2nd parse ? 10 23-25 per cent. 14th 1925. or Discharged August 3rd pane ? 6 13-95 per cent. 2nd Case No. 38.?S., Hindu, 18 years, gravida; or 4th parse ,, 5 11-63 per cent. admitted 14th July 1925. Haemoglobin 30 per cent.; 5th ? 2 or 4-65 cent. R.B.C.'s 2,000,000. Wassermann reaction strongly parse per or cent. positive- Left against advice unconfined 8th August 1925. 6th parse ? 3 6-97 per or cent. Case No. 39.? (This is Case No. 14 in her next 7th parse ? 2 4-65 per Mrs. 24 7th or pregnancy). B., Anglo-Indian, years, 8th parse ? 2 4-65 per cent. gravida; admitted 3rd August 1925. Haemoglobin 35 per cent.; R.B.C.'s 2,000,000. Wassermann reaction doubtful. These figures show that the condition is much foetus 4 lbs. 10 Confined 4th August 1925; ozs., healthy. commoner in the early pregnancies than in the Died 9th August 1925. later ones; the figures for age confirm this. Case ATo. 40.?K., Hindu, 25 years, 2nd gravida; ad- mitted 4th September 1925. Haemoglobin 45 per cent.; R.B.C.'s 2,500,000. Was&ermann reaction moderately Age: positive. Confined 4th September 1925; foetus 2 lbs. Under 30 years . . 36 or 83-72 per cent. 6 still-born. Left against advice 13th ozs., hospital 30 years and over 7 or 16-28 per cent. September 1925. Under 25 years . . 26 or 60-46 Case No. Hindu, 18 years, 1st gravida; ad- 41.?K., and over 17 or 39-54 mitted 8th September 1925. Haemoglobin 35 per cent.; 25 years reaction R.B.C.'s 1,750,000. Wassermann moderately The condition is therefore five times more positive. Confined 9th September 1925; foetus 3 lbs. common under the of 30 than over it, and 40 ozs., alive. Died 18th September 1925. age ANAEMIA OF PREGNANCY: McSWINEY. 489 Sept., 1927.] THE
under the patients were compelled by the gravity of the one and a half times more common disease to seek admission. As none of these age of 25 over 25. than cases attended the ante-natal clinic before their it is not pregnancy: admission, possible to state the period Multiple at twins or of pregnancy which the condition became Three out of the 43 cases were five times noticeable. Per cent, of the total, i.e., more than y The conclusion may, therefore, be drawn the usual of twins. Multiple preg that, incidence while there is no to abortion ls the pret isp? & tendency (perhaps therefore amongst possible because the anaemia is not causes.C311 sufficiently advanced), there is a very marked tendency to miscarriage Spleen:o and premature labour. cent. Could not he felt in 33 cases or /6-74 per cent. Post-partum Hccmorrhagc. Was palpable in 7 cases or 16-28 per cent. to what be Greatly enlarged in 3 cases or 6-98 per Contrary might expected, there is 110 tendency to this: in fact the patients seemed Liver: to have particularly bloodless labours. There is cent. no of the of con- Could not be felt in 38 cases or 88-37 per obviously weakening powers cent. traction and retraction of the uterus. In Was palpable in 5 cases or 11-62 per only one case (No. 13) is there a note of post-partum The Blood. haemorrhage and this was due to a partially in extreme cases adherent . The profundity of the anaemia placenta. ls the haemoglobin shown by Case-16, in which Investigation. vas 12 cent, and the R. B. C.'s 500,000, per occur to a were 15 The common causes of anaemia readily Case in which the per 18, figures both malaria, and As be expected, one, e.g., kala-azar, ankylostomiasis, c<:nt. might none 0 500,000. cancer, etc. In of the above these died. tuberculosis, patients 43 cases was there any evidence of these diseases. red normoblasts, Abnormal cells?poikilocytes, to draw attention to another well-known in the graver cases I wish megaloblasts?occurred cause which be overlooked in this con- a may easily rule, but Case 41 did not show any. Ap show any nection, i.e., syphilis. The protean nature of the 1 he total white cell count did not the formal- manifestations of this disease should not be for- variation. It was used with S, j
II. Plenty of nourishing food, fresh air and I recommend termination of the pregnancy be- sunshine are indicated. cause there is a natural tendency to recovery III. Whole blood transfusion or intramuscular after delivery. Most of the cases are marked " " " " injections of whole blood. improved or much improved on discharge, and some of the results were (a) Whole blood transfusion. I think I am extremely gratify- ing; for example:? correct in stating that this may be a very danger- ous weapon in grave anaemia. Within the last Case 25 24-11-24. H'bin 18%. R.B.Cs. 1,000,000. year I assisted a colleague to transfuse an ad- Confined 25-11-2-4. W.R. negative. vanced case of pernicious anaemia. The most On 19-12-24. H'bin 50%. R.B.Cs. 3,000,000 elaborate care had been taken to secure a suitable Case 31On 29-12-24. H'bin 30?/. R.B.Cs. 1,350,000. donor. The only result was instant and dramatic Confined 13-1-25. W.R. negative. was not carried out disaster. Blood transfusion On 12-3-25. H'bin 60%. R.B.Cs. 3,000,000. in any of the cases recorded above. blood (b) Intramuscular injections of whole (Both these cases were treated with intramus- in doses of 15 to 20 c.c. weekly were given in cular injections of whole blood.) 3 cases with results. It would very encouraging VI. The possible effects of a succeeding preg- be to the effect of this treatment interesting try nancy remain to be considered. I saw only one at an of the disease and see whether early stage case in successive pregnancies. This was Case 14 the anaemia could be combated dur- successfully when she had a live baby of 4 lbs. 7 ozs., haemo- the remainder of the pregnancy. ing globin 40 per cent, and R. B. Cs. 3,000,000 and. IV. Specific treatment for cases with a posi- was discharged improved. She returned just one tive Wassermann reaction. year later (Case 39) : haemoglobin 35 per cent.; The results of these cases were extremely grati- R. B. Cs. 2,000,000; had a live baby of 4 lbs. fying: the routine treatment was Mist. Hydrarg. 10 ozs. and died five days later. Biniodide and intramuscular injections of Sulfar- One case is not enough from which to draw senol. conclusions, but I believe the best advice would be to warn the another Examples are:? patient against pregnancy. Period Case. W. R. On admis- After of Discussion. sion. Treatment. treatment It is scarcely necessary to remind the reader 24 H'bin H'bin 5 weeks, Strongly 25% 50% that there is no direct communication between the positive R.B.C. R.B.C. maternal and foetal circulations. One of the 1,300,000. 2,750,000 most striking things in these cases is to see a pale 32 Moder- H'bin 30% H'bin 60% 8 weeks, anaemic mother giving birth to a child of excellent ately R.B C. R.B.C. colour with an apparently normal haemoglobin its positive 1,500,000 2,700,000 index and red cell count. The foetus makes own to do so it a rich of 37 Strongly H'bin 35% H'bin 59% 6 weeks, blood: requires supply iron for the manufacture of its As positive R.B.C. R.B.C. haemoglobin. no iron is in the mother's it is 1,700,000 2,200,000 present plasma, believed that the chorionic villi break down the mother's red cells and and that the It was not possible to follow up these patients. haemoglobin of the latter are ab- They were all poor and ignorant folk who became products of the destruction restless after some weeks of improvement, bitter- sorbed and rebuilt for the red blood cells of the ly resented the innumerable injections and foetus. demanded their discharge at the earliest moment. This leads us to theories as to the cause of V. Termination of the pregnancy. anaemia of pregnancy. This should be carefully considered before the 1. It has been suggested that the mother's has too otherwise disaster disease progressed far; restorative power necessary to counterbalance the to mother or foetus or both will have to be faced. normal destruction of her red cells is inadequate. In 7 cases the mother died within one week of 2. I suggest that some cases may be due to five of the seven had either still-born admission; the destructive action of the chorionic villi on the babies or miscarriages. The maternal mortality mother's red cells, running riot as it were, com- of 34*88 when no interference was car- per cent., to the destructive action of the ried could be parable syncytium out, obviously very greatly improv- running riot in chorion carcinoma. ed. My belief now, after considering these Either accounts for the natural cases, is that we might possibly have saved one theory tendency to after removal the foetus. or two cases?late as they were?if we had ter- recovery of minated the pregnancy at once. 3. A very large number are due to concealed As to the method of terminating the pregnancy, syphilis. slow and gentle methods of induction would be In conclusion, I have to thank Lieutenant- the choice of adoption, as anything in the nature Colonel V. B. Green-Armytage, i.'m.s., First of rapid evacuation would, in my opinion, lead Professor of Midwifery, Medical College, to disaster. Calcutta; for permission to publish these cases.