Seventy patients with pernicious anemia have been observed for periods of not less than ten years. The clinical course in these cases has been analyzed with particular reference to changes in the neurologic status.
Most of the patients, whether treated with oral preparations of stomach or liver, or parenteral crude or refined liver extracts, showed significant improvement of their neurologic manifestations. The period of improvement was limited, essentially, to the first year of therapy.
Thirty-six members of the series received treatment regularly and were maintained consistently in complete hematologic remission. Fifteen of the patients did not adhere to an optimal therapeutic regimen, and their blood values were frequently abnormal, although definite relapses did not occur. In the former group there were no instances of development or progression of neural lesions. In the latter such adverse changes as did occur were transient and reversible on resumption of adequate therapy. Nineteen patients in the series suffered clinical and hematologic relapses after their initial response to intensive therapy. The end results in this group were not so favorable, but nevertheless serious progression of spinal cord involvement was rarely observed. The apparent infrequent occurrence of pronounced changes is attributed to the short duration of the relapses and to the relatively mild degree of nervous system involvement present when the diagnosis of pernicious anemia was made. It may be assumed that patients with more extensive neural disease who suffered relapses, progressed to a fatal termination.
The observations reported in no way justify the conclusion that irregular or sub-optimal therapy is without serious risk. They are presented in order to indicate what the long-term clinical results may be in the case of patients with pernicious anemia, who frequently fail to adhere to an ideal therapeutic regimen.
The early results of treatment with synthetic folic acid, as observed in a series of 15 patients, indicate that both the hematologic and neurologic response to this form of therapy is much less predictable than is the case with stomach or liver preparations. It is suggested that disturbance of folic acid metabolism is not the sole cause of either the hematologic or the neurologic manifestations of pernicious anemia, but that inability to utilize folic acid effectively may play a part in the development of both myeloid and neural abnormalities.
STURGIS, WEARN, TOMPKINS'. ATROl'IN IN EFFORT SYNDROME discrete and in one instance confluent miliary nodules in the paren¬ chyma, lesions that can be correctly estimated as of recent develop¬ ment, while, on the other hand, the lesions present in Case III (Figs. 2 and 3) are evidently very old, as evidenced by the extensive coagulation necrosis and the reactive fibrotic condition in the immediate neighborhood. Summary'. We have given clinical and pathological proof of the occurrence of cases of ascending renal tuberculosis, ascending at least in the sense that the renal and ureteral lesions are secondary to the bladder involvement; rve have shown that minimal tuber¬ culous renal lesions, when associated with extensive vesical and ureteral changes, are doubtless, in some cases, later involvements of the urinary tract, be they produced in the true ascending, canalic¬ ular sense of propagation by contiguity or in a more circuitous fashion by late embolic invasion of the kidney ; and, by the results of the removal of the kidney in two of the cases, have given ample testimony of the value of nephrectomy even in this type of urinary tuberculosis. Although the renal parenchyma is practically unin-Y'olved in some of these cases the retention of tuberculous urine in the pelvis of the kidney and the constant contamination of the bladder with tuberculous products elaborated in the ureter are sufficiently active factors in interfering with recovery.
of the skin. Five per cent, sterile boric acid ointment is a good dressing covered by sterile gauze pad and bandage, or 10 per cent, sodium bicarbonate ointment.The eyes are washed with solution of boric acid and covered, and the lids protected for some time with bland yellow mercuric oxid ointment and fear of further injury dispelled. Later dusting powder of bismuth and zinc oxid, or of zinc stearate will prove satisfactory for abraded skin areas.Dugouts and holes where a person is likely to sit are to be suspected and carefully evacuated by an attendant wearing oil canvas protection. Then chlorinated lime is scattered in places suspected. Articles of salvage and waste should always be held under suspicion of being contaminated. The clothing is soaked in several changes of water at 70 C. Instead of . strong alkaline remedies, potassium permanganate, 0.05 per cent, solution, is recommended, or a 0.1 per cent, zinc chlorid, and between the fingers or folds of the , scrotum, a weak silver nitrate solution. In advanced respiratory cases, oxygen inhalations are used.Owing to the censorship, the photographic reproduction of many interesting cases is not permissible. These cases should be given careful attention, and after treatment one need not necessarily excuse patients with mild skin burns from duty.
This investigation was suggested by and started under the direction of Major Francis W. Peabody, M. C., U. S. Army, and completed under the direction of Capt. Bertnard Smith, M. C., U.
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