4
110 BJEGER STRANDELL. This case with well-marked intestinal affection and free HC1 in the gastric juice reminds us in a way of bothriocephalus ane- mia or sprue-anemia where some intestinal affection of course is present and in addition very often free HC1 in the gastric juice. In summary, then, it may be said that not infrequently intes- tinal ulcers are met with in cases of pernicious anemia, ulcers, which, if widespread, may conceivably be of some etiological importance for the anemia. If in a case where the blood has the appearance of pernicious anemia free HC1 is found in the gastric juice, one should bear in mind the possibility of both- riocephalus anemia or sprue’ or some other intestinal affection. XII. Lues and pernicious anemia. In 2 of the 117 cases there was a history of lues. Both patients died at the clinic. Case 16. Record 370/1915. Chief mate, born 1885. Diagnosis. - Pernicious anemia. Myelitis funicularis. Cervical pachymeningitis. Admitted April 29, discharged May 12, 1915, Dead. Acquired lues five years ago. Been treated with salvarsan and a number of Hg-cures. In November 1913 under treatment in Algier for typhus, afebrile after 40 days. Never quite well ever since, has been pale. Returned to work in July 1914. In Pebruary 1915 progres- sive symptoms of anemia. He was admitted markedly anemic with Hb = 32 yo, red blood-corpuscles 0.750 mill., white cells 5,400 per cmm. Wassermann’s reaction in the blood was negative. He was treated with arsenic and neosalvarsan and tentatively with fresh pig’s blood per 0s but died already on the 14th day after admission. Autopsy. Pachymeningitis cervicalis hypertrophicans; Hypertro- phia et dilatatio cordis; Degeneratio parenchymatosa myocardii; Pleuritis chronica adhesiva; Hyperplasia lienis; Degeneratio paren- chymatosa hepatis et renum; Medulla osseum rubra; Anemia gravis organorum. Case 22. Record 704/1916. Agent, born 1876. Diagnosis. - Per- nicious anemia, lues. Admitted Aug. 4, discharged Nov. 29, 1916, dead. Contracted gonorrhoea at the age of 20. In 1912 and 1914 under treatment in hospital for leg-ulcers. *He had no anemia but on blood- test syphilis bacteria were found in the blood.* He was treated locally and with pot. iod. and Hg-injections. Recovery followed. -4nemic A case of so-called sprne from this clinic wa9 described in detail by Eiigel in 1930 wherefore it has not been taken up for discnssion here.

XII. Lues and pernicious anemia

  • View
    220

  • Download
    3

Embed Size (px)

Citation preview

Page 1: XII. Lues and pernicious anemia

110 BJEGER STRANDELL.

This case with well-marked intestinal affection and free HC1 in the gastric juice reminds us in a way of bothriocephalus ane- mia or sprue-anemia where some intestinal affection of course is present and in addition very often free HC1 in the gastric juice.

In summary, then, it may be said tha t not infrequently intes- tinal ulcers are met with in cases of pernicious anemia, ulcers, which, if widespread, may conceivably be of some etiological importance for the anemia. If in a case where the blood has the appearance of pernicious anemia free HC1 is found in the gastric juice, one should bear in mind the possibility of both- riocephalus anemia or sprue’ or some other intestinal affection.

XII. Lues and pernicious anemia.

In 2 of the 117 cases there was a history of lues. Both patients died at the clinic.

Case 16. Record 370/1915. Chief mate, born 1885. Diagnosis. - Pernicious anemia. Myelitis funicularis. Cervical pachymeningitis. Admitted April 29, discharged May 12, 1915, Dead.

Acquired lues five years ago. Been treated with salvarsan and a number of Hg-cures. In November 1913 under treatment in Algier for typhus, afebrile after 40 days. Never quite well ever since, has been pale. Returned to work in July 1914. In Pebruary 1915 progres- sive symptoms of anemia. He was admitted markedly anemic with Hb = 32 yo, red blood-corpuscles 0 . 7 5 0 mill., white cells 5,400 per cmm. Wassermann’s reaction in the blood was negative. He was treated with arsenic and neosalvarsan and tentatively with fresh pig’s blood per 0s but died already on the 14th day after admission.

Autopsy. Pachymeningitis cervicalis hypertrophicans; Hypertro- phia et dilatatio cordis; Degeneratio parenchymatosa myocardii; Pleuritis chronica adhesiva; Hyperplasia lienis; Degeneratio paren- chymatosa hepatis et renum; Medulla osseum rubra; Anemia gravis organorum.

Case 22. Record 704/1916. Agent, born 1876. Diagnosis. - Per- nicious anemia, lues. Admitted Aug. 4, discharged Nov. 29, 1916, dead.

Contracted gonorrhoea at the age of 20. In 1912 and 1914 under treatment in hospital for leg-ulcers. *He had no anemia but on blood- test syphilis bacteria were found in the blood.* He was treated locally and with pot. iod. and Hg-injections. Recovery followed. -4nemic

A case of so-called sprne from this clinic wa9 described in detail by Eiigel in 1930 wherefore it has not been taken up for discnssion here.

Page 2: XII. Lues and pernicious anemia

PERNICIOUS ANEMIA. 111

symptoms since January 1916. Was admitted markedly anemic with Hb = 45 %, red bl.corp. 1.1 mill., and white cells 3,000 per cmm. Wassermann’s reaction in blood was negative. He was treated with arsenic and hydrochloric acid to the food, showed a reticulocytic reac- tion with maximum 10 yo and improved temporarily after which he again became worse. He died of progressive anemia. He had no anti- luetic treatment a t the clinic until shortly before death.

Autopsy. Hypertrophia et dilatatio cordis. Degeneratio lipomatosa myocardii. Pneumonia chronica indurativa bilateralis (Ilues). Hy- perplasia subacuta lienis. Haematochromatosis hepatis. Induratio renum (?chronic nephritis). Hypertrophia prostata. Ulcer. et cicatr. syphilit. cutis. Osteoperiostit. syphilitic. anticrur. dxt.

Summary. Two cases of pernicious anemia and lues. There is no definite evidence in these cases in support of the assump- tion that the anemia would be caused by the luetic infection.

I n two other cases of the material under review lues may pos- sibly have been present. I n both these cases the history was negative. In one of them Wassermann’s reaction was negative, Kahn’s reaction, on the other hand, positive a t first (+ + +) but later negative after anti-luetic treatment. In the other case Wassermann’s reaction was positive but autopsy gave a nega- tive evidence of lues.

This latter case is the only one of the material with positive Wassermann’s reaction. I n all the other 92 cases where this test was carried out i t came out negative. Nor have there been any other indications of lues in these cases.

The rate of lues in the material of pernicious anemia studied here (117 cases) will thus be 1.7 %, calculated on the two certain cases of lues and 3.4 % if including also the two cases where lues was possible or probable but not certain. The rate of lues among all the patients (18,500) treated a t the same time a t the clinic is 3 . 3 %. It will thus be found that the rate of lues in the material of pernicious anemia is not higher than in all the other material of the clinic. Nor has in any of the luetic cases of the pernicious anemia patients a definite relation been found between the lue- tic affection and the anemia. T h e material under investigation thzls gives no evidenck in support of the assumption of some causal relation ezistiny between lues and pernicious anemia.

With regard to the question of lues as an etiological factor of pernicious anemia I thus arrive a t the same result as other authors have done in their study of cases from other places, such as Le- vine and Ladd (1921, Boston, Mass.), Poucar and Stokes (1921), the Mayo Clinic and Narbeshuber (1928), Vienna.

Page 3: XII. Lues and pernicious anemia

112 BLRGER STRANDELL.

According to Naegeli (1931) such a connection between lues and pernicious anemia has been disputed in the literature for the last few years. ))Die Schwierigkeit besteht in der Losung der Frage, ist die Lues nicht Kombination zu einer kryptogeneti- schen Perniciosa.))

According t o his own opinion however Naegeli has got a i d l y reliable case. HIch sah 1898199 einen jungen Mann mit dem kli- nischen und hamatologischen Bilde der Perniciosa, bei gleich- zeitiger schwerer tertiarer Syphilis. Unter Anen und Quecksilber ist dieser Patient von seiner enorm hochgradigen Anamie ge- heilt under dauernd (20 Jahre Kontrolle) reaidivfrei geblieben.)) Everybody will probably agree that one can scarcely but assume here that the anemia had a luetic basis. The question then is whether such a causal connection can be considered definitely proved! I cannot see that such is the case! That the improve- ment in the case in question came in connection with the anti- luetic treatment might possibly tempt one to draw a parallel with other uncertain luetic cases in which after a successful result of anti-luetic treatment the diagnosis is made ex juvanti- bus. The position, however, is quite a different one when i t is a question of, e. g., a tumour suspected of being a gumma and when we are dealing with pernicious anemia with its capricious course where sometimes the remission appears quite indepen- dently of every form of treatment. Nobody can regard i t as proved here that the disease had a luetic basis because remis- sion was obtained in connection with anti-luetic treatment, nor does the duration of the remission convey anything definitely. As far as I can see I have got quite a ))pure)) cryptogenic case of pernicious anemia (case 14, page 62) where the present remis- sion has now lasted for close upon 16 years.

Prolonged remissions thus occur also in the cryptogenic form of pernicious anemia !

In cases of lues running concurrently with pernicious anemia in which a prolonged remission has been obtained in connection with anti-luetic treatment this fact, therefore, is no absolute proof of the anemia having a luetic basis! I cannot see there- fore, that in Naegeli’s above mentioned case lues has been abso- lutely proved to be the cause of the anemia, although the as- sumption of this possibility is dangerously close a t hand. Olav Hanssen and Odd Stub related a case of pernicious anemia in 1927 in which lues was supposed to be the causative factor. The

Page 4: XII. Lues and pernicious anemia

PERNICIOUS ANENIA. 113

case seems about similar t o that of Naegeli except that it died of cancer of t he stomach after a remission having lasted for 11 years.

According t o Schauman and Saltzman (1925), Olav Harissen a n d Odd S tub (1927) a n d Naegeli (1931) t h e two cases above mentioned are t h e only two where it is supposed t o be absolutely proved that pernicious anemia has had a luetic etiology. As neither these cases, according t o t h e above reason, make up any absolute proof, I m u s t thus conclude t h a t so far no absolute evi- dence has on the whole been forthcoming to prove lues to be a n etio- logical factor of pernicious anemia. It seems to m e that such a possibility is quite likely b u t absolute proofs still remain t o be produced.

XIII. Tuberculosis and pernicious anemia. Case 21. This is a fatal case of pernicious anemia at the post-mor-

tem examination of which one found extensive chronic tuberculous changes of the intestinal tract with well-marked strictures and in addi- tion an old tuberculous affection of one of the lung apices. This case has been described more closely under the heading ))stricture anemia)) (see p. 97.)

Case 49. Book binder, female, born 1865. Record 39811922. Ad mitted April 4. Discharged June 17, 1922. Diagnosis. Pernicious anemia. Readmitted August 8, discharged November 25, 1922, Dead. Diagnosis. Pernicious anemia. Bilateral exudative pleurisy. Right- sided pulmonary tuberculosis.

History. Father died of consumption. A daughter has had pleurisy. As for herself patient has had a cough every spring since the age of 24. At about 1905 she noticed three black spots in her right visual field; according to ophthalmological opinion the cause of this was ane- mia. I n the spring of 1911 coughing was particularly severe; hemo- ptysis of about a table-spoonful. At the medical out-patient depart- ment of Serafimer Lasarettet one found tuberculosis of the right apex, for which the patient was admitted later in the year a t the Soderby Sanatorium of the city of Stockholm. Tubercle bacilli were found in the sputum.

In 1914 and 1919 there was again hemoptysis of a table-spoonful. Patient has always been pale for which she has since adolescence

periodically been taking iron. For about six months Rhe has been feel- ing breathless on walking uphill. I n January 1922 she had influenza with coryza, cough and pyrexia. Since then been fepling weak and tired. For the last week her legs have been swollen.

Condition. Complexion pale with a tinge of yellow. No cyanosis. Yo oedema. Mild dyspnea.

8-312829