An Investigation into the Type, Incidence, and Prophylaxis of Gestational Anaemia in an Industrial Population, Based on a Study of Aetiological Factors and Normal Blood Values in Pregnancy

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AN INVESTIGATION INTO THE TYPE, INCIDENCE, AND PROPHYLAXIS OP GESTATIONAL ANAEMIA IN AN INDUSTRIAL POPULATION, BASED ON A STUDY OP AETIOLOGICAL PACTORS AND NORMAL BLOOD VALUES IN PREGNANCY.

BY

T . 0 . P.D.LAWSON, M B.Ch.B. D .O B st. R .C .O .G . D .P .H . MEDICAL OPPICER OP HEALTH AND SCHOOL MEDICAL OPPICER, COUNTY BOROUGH OP DUDLEY. LATE ASSISTANT MEDICAL OPPICER OP HEALTH, STAPPORDSHIRE COUNTY COUNCIL.

ProQuest Number: 13870152

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uest ProQuest 13870152 Published by ProQuest LLC(2019). C opyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C o d e M icroform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 4 8 1 0 6 - 1346

C h a p te r I .

In tro d u c tio n .

C h a p te r I I .

C l a s s i f i c a t i o n an d A e t i o l o g y o f A naem ia o f P r e g n a n c y .

C h a p te r I I I .

P e r n i c i o u s A naem ia o f P r e g n a n c y .

C h a p te r IV .

N orm al H a e m a to l o g i c a l V a lu e s i n N o n - P re g n a n t an d P r e g n a n t Women, a n d C r i t e r i a o f A naem ia o f P r e g n a n c y .

C h a p te r V.

P re se n t In v e s tig a tio n .

C h a p te r V I.

R e s u lts .

C h a p te r V I I .

D is c u s s io n .

C h a p te r V I I I .

Summary.

CHAPTER

I.

In tro d u c tio n : A naem ia a s s o c i a t e d w i t h t h e p r e g n a n t s t a t e

i s now

g e n e r a lly a c c e p te d a s a c l i n i c a l _ e n t i t y , and a lth o u g h its

in c id e n c e h a s b een v a r io u s ly s t a t e d ,

it

is

u n d o u b te d ly a common c o n d i t i o n w h ic h h a s b e e n w id e ly r e c o g n i s e d f o r many y e a r s .

N a s s e i n 1836 w as t h e f i r s t

t o o b s e r v e t h a t t h e n u m b er o f r e d b lo o d c o r p u s c l e s w as r e d u c e d i n t h e p r e g n a n t woman, b u t n e a r l y a c e n t u r y was to p a s s b e fo re th e s u b je c t re c e iv e d th e i n t e r e s t i t d e serv e d .

In d e e d , u n t i l th e tu r n o f th e c e n tu r y , l i t t l e

i n t e r e s t i n t h e c o n d i t i o n w as a r o u s e d , a n d e v e n a s r e c e n t l y a s 1929 G a llo w a y ( a ) c o u ld f i n d o n ly n i n e t y r e f e r e n c e s r e l a t i v e to th e s u b j e c t , and a l l b u t t e n o f t h e s e , d e a l t w i t h th e p e r n i c i o u s v a r i e t y .

H e n d e rs o n (1 9 0 2 )

s t a t e d t h a t t h e a n a e m ia o f p r e g n a n c y was a s u b j e c t w h ic h u p t i l l t h a t tim e h a d r e c e i v e d l i t t l e

a t t e n t i o n , and

o b s e r v e d t h a t t h e l i t e r a t u r e was v e r y s c a n t y , c o n tin e n ta l,

a n d o f a re m o te d a t e .

c h ie fly

We a r e , h o w e v e r,

i n d e b t e d t o him f o r a sum m ary o f t h e c h i e f c o n t r i b u t i o n s p r i o r t o th e b e g in n in g o f t h i s c e n tu r y . O a se au x (1 8 5 0 ) c o n s i d e r e d t h a t t h e p r e g n a n t s t a t e w as o n e e s s e n t i a l l y a n a lo g o u s t o c h l o r o s i s , a n d b e l i e v e d it

s h o u ld b e t r e a t e d a s s u c h , b u t W il l c o c k s (1 8 8 1 )

d is a g r e e d w ith t h i s th e o r y .

He show ed t h a t t h e b lo o d

p i c t u r e i n p r e g n a n c y d i f f e r e d fro m t h a t o f c h l o r o s i s i n t h a t , w h ile t h e h a e m o g lo b in was r e d u c e d i n b o t h c o n d i t i o n s , t h e r e d b lo o d c e l l s w e re d i m i n i s h e d i n num ber o n ly a n d w ere n o t im p o v e r is h e d a s i n c h l o r o s i s .

He

r e f e r r e d a ls o to th e in c r e a s e in t h e w a te r c o n te n t o f t h e p la s m a .

S p ie g e lb e rg and G s c h e id lin (1 8 7 2 ),

in an

e x a m in a t io n o f p r e g n e n t d o g s r e p o r t e d a s i m i l a r i n c r e a s e i n t h e w a t e r c o n t e n t o f t h e b lo o d a n d a l s o a d i m i n u t i o n o f t h e r e d b lo o d c o r p u s c l e s , a n d B e c q u e r e l a n d R o d i e r (188^.) i n a s t u d y o f n i n e c a s e s ,

c o n fir m e d t h e s e f i n d i n g s .

L u sk (1 8 8 2 ) d e s c r i b e d t h e a n a e m ia o f p r e g n a n c y a s a c o n d itio n o f " s e ro u s p l e t h o r a " , w ith a d im in u tio n o f re d b lo o d c o r p u s c l e s a n d a n i n c r e a s e i n t h e w a t e r c o n t e n t o f th e b lo o d .

He a t t r i b u t e d t h e s e c h a n g e s t o t h e dem and

o f t h e f o e t u s on t h e m a t e r n a l s y s te m .

P l a y f a i r (1 8 9 3 ),

r e f e r r i n g t o t h e d e d u c t i o n s d raw n by C a s e a u x , c o n c lu d e d t h a t " t h e g e n e r a l b lo o d s t a t e a n a e m ia ?

i s te n d in g to p o v e rty and

C h arm in g f i r s t d re w a t t e n t i o n t o t h e c o n d i t i o n

i n A m e ric a i n 181^2 a n d o t h e r c o n t r i b u t i o n s w ere r e c o r d e d b y K is w is c h ( I 8 I4.8 ) ,

S c a n z o n i ( 1 8 6 7 ) , L e b e r t (1 8 7 6 ) a n d

C abot (1 9 0 0 ). W ith t h e t u r n o f t h e c e n t u r y , t h e a n a e m ia o f p r e g n a n c y b e g a n t o r e c e i v e w id e r r e c o g n i t i o n an d m ore fre q u e n t re fe re n c e to th e c o n d itio n began to a p p ea r in th e l i t e r a t u r e .

I n o n e s u c h r e f e r e n c e , G iv e n (1 9 0 6 )

s t a t e d t h a t s o f a r a s h e c o u ld d i s c o v e r , no E n g l i s h

o b s e r v e r up t i l l t h a t tim e , h ad i n v e s t i g a t e d th e h a e m a to lo g y o f p r e g n a n c y a n d t h e p u e r p e r iu m . t h i s may b e t r u e o f t h e E n g l i s h l i t e r a t u r e ,

W h ile i t c e rta in ly

d i d n o t a p p ly t o S c o t l a n d , w h e re H e n d e rs o n (1 9 0 2 ) h a d a l r e a d y p u b l i s h e d h i s " o b s e r v a t i o n s on t h e M a t e r n a l B lo o d a t Terra a n d d u r i n g t h e P u e r p e r i u m ," fro m t h e G lasg o w R o y a l M a t e r n i t y H o s p i t a l ,

He d e m o n s tr a te d a

f a l l i n h a e m o g lo b in , r e d b lo o d c o r p u s c l e s a n d a lo w e re d c o l o u r in d e x d u r i n g p r e g n a n c y .

I n A m e ric a , Thomson (190^-)

p u b l i s h e d t h e r e s u l t s o f a s i m i l a r s t u d y , a n d B lu m e n th a l i n Germ any (1 9 0 7 ) r e c o r d e d h i s o b s e r v a t i o n s on a s e r i e s of cases.

Gram (1 9 2 0 ) p o i n t e d o u t t h a t i t w as p r o b a b l y

n o t g e n e r a l l y known t h a t t h e b lo o d o f p r e g n a n t women h a d a lo w e r c o n t e n t o f h a e m o g lo b in t h a n t h a t o f o t h e r n o rm a l women, b u t h e s t a t e d t h a t t h i s o b s e r v a t i o n h a d a l r e a d y b e e n made b y A n d r a l i n 1814-5.

A ld e r i n 1 92 I4. com m ented

t h a t t h e a n a e m ia o f p r e g n a n c y was so common t h a t i t w as s u r p r i s i n g how l i t t l e

w as known a b o u t i t .

In t h i s

c o u n t r y , h o w e v e r, r e a l i n t e r e s t i n t h e s u b j e c t was s t i m u l a t e d b y t h e p u b l i c a t i o n i n 1919 o f a p a p e r e n t i t l e d "T he S e v e re A naem ia o f P re g n a n c y and t h e P o s t - P a r t u m S t a t e " b y O s i e r , who i s c r e d i t e d w i t h t h e f i r s t c o n tr ib u tio n to th e E n g lis h l i t e r a t u r e . th is

re a l

In s p ite o f

i n c r e a s i n g i n t e r e s t i n t h e s u b j e c t , no l a r g e s c a l e

i n v e s t i g a t i o n s h a d a s y e t b e e n c a r r i e d o u t , a n d no r e c o r d s w ere a v a i l a b l e o f s t a t i s t i c a l s t u d i e s o f a l a r g e s e rie s of cases.

The r e a s o n , h o w e v e r, f o r t h i s a p p a r e n t

l a c k o f i n t e r e s t i n a common m a la d y was p r o b a b l y t h e m il d n e s s o f t h e sym ptom s p r o d u c e d , a n d t h e c o m p a r a tiv e ra rity

o f s e r io u s c o m p lic a tio n s .

o b se rv ed ,

" a n a e m ia o f i t s e l f ,

a la r m i n g sym ptom , i s

As W h itb y (1 9 3 2 )

s e v e r e e n o u g h t o b e an

in t h i s c o u n try ,

so r a r e a

c o m p lic a tio n o f p re g n a n c y , t h a t th e s u b je c t h a s b e en little

s t u d i e d ."

A f t e r t h e e n d o f t h e f i r s t w o rld w a r, a n a e m ia o f p reg n a n cy b eg an to occupy a p o s i t i o n o f e v e r in c r e a s in g p ro m in e n c e i n t h e l i t e r a t u r e ,

b o t h i n t h i s a n d i n many

o t h e r c o u n t r i e s , u n t i l a t t h e p r e s e n t tim e a v a s t a n d v a r i e d l i t e r a t u r e h a s a c c u m u la te d , d e m o n s t r a t i n g t h e w id e p r e v a l e n c e o f t h e c o n d i t i o n . fro m w e ll-k n o w n a u t h o r i t i e s , f i e l d , have a p p e a re d .

Many c o n t r i b u t i o n s

and o t h e r w o r k e r s ,

in t h is

T h ese w i l l be r e f e r r e d t o l a t e r .

T h a t a w id e i n t e r e s t i n t h e s u b j e c t becam e e v i d e n t a t t h i s tim e was p r o b a b l y due t o t h e 1 9 1 14. - 1918 War w i t h its

a f t e r m a t h o f p o v e r t y , m a l n u t r i t i o n a n d lo w e re d

s ta n d a rd s o f l iv i n g .

L a rg e -s c a le in v e s tig a tio n s o f th e

h e a l t h s t a n d a r d s o f t h e p o p u l a t i o n w e re c a r r i e d o u t , a n d i t w as n a t u r a l t h a t t h e s e i n v e s t i g a t i o n s s h o u ld

in c lu d e

t h e h e a l t h o f t h e e x p e c t a n t m o th e r on whom m u st d e p e n d th e h e a lth o f th e f u tu r e g e n e r a tio n . p re g n a n c y , t h e r e f o r e ,

A naem ia o f

came t o b e w id e ly s t u d i e d a n d

much v a l u a b l e i n f o r m a t i o n h a s b e e n o b t a i n e d r e g a r d i n g th e a e tio lo g y ,

i n c i d e n c e an d s e v e r i t y o f t h e c o n d i t i o n ,

n o t o n ly a t t h i s p e r i o d , b u t a l s o d u r i n g t h e r e c e n t

w o r ld w ar w h ic h o f f e r e d a v a l u a b l e o p p o r t u n i t y f o r c o m p a r is o n w i t h p r e - w a r i n v e s t i g a t i o n s . m e n tio n e s p e c i a l l y ,

i n t h i s c o n n e c tio n , a p u b l ic a t i o n

o f t h e M e d ic a l R e s e a r c h C o u n c il , G re at B r i ta i n in S u r v e y s ."

One w o u ld

"H a e m o g lo b in L e v e ls i n

b y t h e C o m m ittee on H a e m o g lo b in

19k3

T h is p u b l i c a t i o n e m p h a s iz e d t h e n e e d f o r a

c o n tin u a l check o f th e n a tio n * s h e a l t h , p o in tin g o u t, in p a rtic u la r,

t h a t t h e r e w e re s t i l l t o o many women

w i t h h a e m o g lo b in v a l u e s b e lo w t h e n o rm a l l e v e l .

I t w ill

be th e o b je c t o f th e p r e s e n t i n v e s t i g a t i o n to a tte m p t a p o s t - w a r s t u d y o f t h e h y p o c h ro m ic o r i r o n - d e f i c i e n c y a n a e m ia o f p re g n a n c y a n d t o d raw a c o m p a ris o n w i t h r e s u l t s p u b l i s h e d i n t h i s c o u n t r y b o t h b e f o r e and d u r i n g t h e r e c e n t w a r. A lth o u g h t h i s i n c r e a s e d i n t e r e s t i n t h e s u b j e c t , and th e p u b l ic a t i o n o f d e t a i l e d r e s u l t s have g r e a t l y i n c r e a s e d o u r k n o w le d g e o f t h e c o n d i t i o n , many f a c t o r s c o n c e r n i n g t h e a n a e m ia o f p r e g n a n c y a r e s t i l l o b s c u r e an d c o n t r o v e r s i a l .

A ld e r, a s a lr e a d y q u o te d ,

on o u r l a c k o f k n o w le d g e , a n d I r v i n g i n A m e ric a s t a t e d t h a t e x a m in a t io n o f t h e l i t e r a t u r e

com m ented (1 9 3 5 )

re v e a le d a

d i v e r g e n c e an d c o n f u s i o n o f o p i n i o n r e g a r d i n g c l a s s i f i c a ­ tio n ,

c a u s e an d t r e a t m e n t .

T h is s t a t e m e n t i s am ply

b o r n e o u t w hen on e a t t e m p t s t o co m p are r e s u l t s p u b lis h e d by v a r io u s w o rk e rs in t h i s and o th e r c o u n t r i e s . Among o t h e r t h i n g s ,

th is s ta te

of a ffa irs

i s u n d o u b te d ly

d u e t o t h e many d i f f e r e n t s t a n d a r d s a n d c r i t e r i a o f

a n a e m ia em p lo y ed i n c l i n i c a l i n v e s t i g a t i o n s .

F u rth e r

r e f e r e n c e w i l l b e made t o t h i s a s p e c t o f t h e s u b j e c t l a t e r . A t t h e moment i t may b e s a i d t h a t u n t i l a n i n t e r n a t i o n a l s ta n d a rd of

h a e m o g lo b in o m e try h a s b e e n e s t a b l i s h e d an d

d e f i n i t e h a e m a t o l o g i c a l c r i t e r i a f o r t h e a n a e m ia o f p r e g n a n c y a c c e p t e d , no c o m p a ris o n o f r e s u l t s c a n b e a t t e m p t e d W ith a r e l i a b l e d e g r e e o f a c c u r a c y . of th is ,

h o w e v e r, a s t u d y o f t h e l i t e r a t u r e ,

In s p ite l e a v e s no

d o u b t a s t o t h e p r e v a l e n c e a n d f r e q u e n c y o f t h e a n a e m ia o f p re g n a n c y .

It

i s g e n e r a lly a g re e d a ls o by a l l

a u t h o r i t i e s on t h e s u b j e c t ,

t h a t t h e p r e d o m in a n t a n a e m ia

o f p re g n a n c y i s t h e s e c o n d a r y o r h y p o c h ro m ic t y p e w h ic h w i l l fo rm t h e s u b j e c t o f t h e p r e s e n t s t u d y . I t w i l l b e s e e n fro m t h e f o r e g o i n g , t h a t a n a e m ia a s s o c i a t e d w i t h p r e g n a n c y i s b y no m eans a r e c e n t d is c o v e r y , a lth o u g h i t s

r e c o g n i t i o n h a s o n ly b e e n a c c la im e d

in c o m p a ra tiv e ly r e c e n t y e a r s .

I n d e e d , B r i n d e a u an d

T h eo d o iid es (1 9 3 5 ) q u o te r e f e r e n c e t o t h e s u b j e c t i n t h e w o rk s o f H i p p o c r a t e s .

S in c e t h e tim e o f N a s s e , h o w e v e r,

i n t e r e s t in th e c o n d itio n h as s t e a d i ly in c re a s e d , and th e l i t e r a t u r e

e n r i c h e d b y many v a l u a b l e c o n t r i b u t i o n s ,

w h ic h h a v e h e lp e d t o c l a r i f y many o f t h e m ore o b s c u r e an d c o n t r o v e r s i a l p o i n t s .

N e v e rth e le s s ,

i t w o u ld a p p e a r

t h a t t h e s u b j e c t dem ands a n i n t e r e s t e v e n g r e a t e r t h a n t h a t a t p r e s e n t show n.

A lth o u g h N a s s e * s o r i g i n a l

o b s e r v a t i o n s w e re made i n 1 8 3 6 , i t

i s in te r e s tin g to

re a d a c e n tu ry l a t e r in th e T ra n s a c tio n s o f th e E d in b u r g h O b s t e t r i c a l S o c i e t y t h a t " u n t i l 1919 w hen O s i e r made h i s s u r v e y , t h e r e was no p u b l i c a t i o n o f n o t e i n t h i s c o u n t r y , a n d e v e n now, t e x t b o o k s on o b s t e t r i c s o r h a e m a to lo g y d e v o te v e r y l i t t l e ( S te v e n s o n 1 9 3 8 ) .

sp ace to t h is s u b je c t.

CHAPTER I I . CLASSIFICATION AND AETIOLOGY 07 ANAEMIA 0 ? PREGNANCY.

A s tu d y o f th e l i t e r a t u r e d e a lin g w ith th e a e tio lo g y a n d c l a s s i f i c a t i o n o f t h e a n a e m ia o f p r e g n a n c y b e a r s o u t th e t r u t h o f I r v i n g fs s ta te m e n t t h a t t h e r e i s a d iv e rg e n c e an d c o n f u s i o n o f o p i n i o n on t h e s e p o i n t s .

A lth o u g h much

l i g h t h a s b e e n th ro w n on t h e a e t i o l o g y o f t h e c o n d i t i o n s i n c e t h i s s t a t e m e n t was m ade, many f a c t o r s a r e s t i l l o b sc u re ,

s u c h a s , f o r e x a m p le , t h e p a r t p l a y e d by p r o t e i n

an d v i t a m i n d e f i c i e n c y i n t h e p r o d u c t i o n o f t h e i r o n d e f i c i e n c y ty p e o f a n a e m ia , a n d u n t i l a p r e c i s e a e t i o l o g y h a s b e e n e s t a b l i s h e d t h e r e c a n b e no f i n a l c l a s s i f i c a t i o n o f t h e p re g n a n c y a n a e m ia s .

S in c e t h e s u b j e c t w as f i r s t

s t u d i e d v a r i o u s c l a s s i f i c a t i o n s h a v e b e e n p u t f o r w a r d , and i t w o u ld b e o f i n t e r e s t t o su m m a rise t h e s e b r i e f l y a s t h e y d e m o n s tr a te how i d e a s h a v e c h a n g e d w i t h a b e t t e r k n o w le d g e o f th e c o n d itio n . The f i r s t c l a s s i f i c a t i o n fro m a c l i n i c a l s t a n d p o i n t was s u g g e s t e d by O s i e r i n 1 9 1 9 . in to

He d i v i d e d th e a n a e m ia s

(1 ) A naem ia fro m p o s t - p a r t u m h a e m o rrh a g e ;

S e v e r e A naem ia o f p r e g n a n c y ;

(2 ) The

(3 ) P o s t - P a r t u m A n a em ia, an d

(I;.) The A c u te A naem ia o f p o s t - p a r t u m s e p s i s .

I t w i l l be

n o t e d t h a t i r o n - d e f i c i e n c y a n a e m ia w as n o t i n c l u d e d i n t h i s c l a s s i f i c a t i o n , n o r was i t

in c lu d e d by S c h u ltz

(1 9 3 3 ) who c l a s s i f i e d t h e a n a e m ia s a s

(1 ) P s e u d o - a n a e m ia

( h y d r a e m ia ) ;

(2 ) T ru e a n a e m ia o f p r e g n a n c y , an d

(3 ) P e r n i c i o u s A n a em ia.

T h a t i r o n - d e f i c i e n c y , h o w e v e r,

was a f a c t o r i n t h e p r o d u c t i o n o f t h e a n a e m ia , h a d a l r e a d y b e e n r e c o g n i s e d by W h itb y (1 9 3 2 ) who p u t f o r w a r d th e fo llo w in g c l a s s i f i c a t i o n :

(1 )

The P e r n i c i o u s t y p e ,

( f u r t h e r s u b -d iv id e d in to a P l a s t i c and H y p o p la s tic v a rie ty ); a n d (3 ) d is e a s e ;

(2 ) The

The I r o n - d e f i c i e n t o r C h l o r o t i c t y p e , A t y p i c a l , d e p e n d e n t on t h e p r im a r y b lo o d

a n d fro m t h i s tim e i r o n - d e f i c i e n c y becam e

g e n e r a lly a c c e p te d as a c a u s a tiv e f a c t o r in th e p r o d u c t i o n o f a n a e m ia o f p r e g n a n c y . d e s c rib e d s ix d i f f e r e n t v a r i e t i e s ,

9

c o n s id e re d im p o rta n t v iz : w i t h h y d r a e m ia ;

%

A m ild ty p e a s s o c i a t e d

(1 9 3 5 ) d i v i d e d t h e a n a e m ia s i n t o

S im p le A naem ia o f p r e g n a n c y ;

o f p re g n a n c y ;

t h r e e o f w h ic h h e

(2 ) H y p o ch ro m ic a n a e m ia , a n d (3 ) S e v e re

A n aem ia, a n d W i t t s (1 )

(1 )

G re e n -A rm y ta g e (1 9 3 5 )

(2 ) P e r n i c i o u s A naem ia

(3 ) A naem ia fro m h a e m o r rh a g e , an d

(ii-) A n aem ia fro m p u e r p e r a l i n f e c t i o n . s p e c ific a lly

He d i d n o t

in c lu d e th e ir o n - d e f ic ie n c y ty p e , b u t

s t r e s s e d t h e im p o r ta n c e o f i r o n a n d i r o n - c o n t a i n i n g fo o d s a s p r o p h y la c tic m e a su re s.

B r i n d e a u a n d T h e o d o r id e s

( 1 9 3 5 ) d e s c r i b e d two d i s t i n c t t y p e s , t h e p h y s i o l o g i c a l and th e p a th o lo g ic a l, d iv id e d in to

t h e l a t t e r b e in g f u r t h e r s u b ­

( a ) The common a n a e m ia o f p r e g n a n c y w h ic h

m ig h t b e m ild o r s e v e r e , a n d (b ) P e r n i c i o u s A n a e m ia . A m e ric a n w o r k e r s h a v e s u g g e s t e d c l a s s i f i c a t i o n s v e r y s i m i l a r t o t h o s e i n t h i s c o u n t r y , and t h e c o n t i n e n t .

A d a i r e t a l (1 9 3 6 ) p l a c e d t h e a n a e m ia s i n t h r e e s im p le c a te g o rie s ,

( 1 ) P h y s i o l o g i c a l A naem ia;

(2 ) M i c r o c y t i c

A n aem ia, w h ic h h e d e s c r i b e d a s t h e p r e d o m in a n t t y p e , an d (3 ) P e r n i c i o u s A n aem ia.

B e th e 11 (1 9 3 6 ) p ro d u c e d a

som ew hat d i f f e r e n t b u t i n t e r e s t i n g c l a s s i f i c a t i o n . c l a s s i f i e d t h e a n a e m ia s i n t o t h r e e m a in g r o u p s .

He In th e

f i r s t h e i n c l u d e d t h o s e c a s e s w i t h b lo o d v a l u e s w i t h i n a c c e p t e d n o rm a l l i m i t s ,

b u t sh o w in g a s l i g h t r e d u c t i o n

i n h a e m o g lo b in an d r e d b lo o d c e l l s . r e d u c t i o n t o p la s m a d i l u t i o n .

He a t t r i b u t e d t h i s

In th e seco n d g ro u p h e

i n c l u d e d c a s e s w i t h s m a l l r e d b lo o d c o r p u s c l e s an d a low c o l o u r in d e x , a t t r i b u t i n g t h e s e c h a n g e s t o i r o n - d e f i c i e n c y . The t h i r d g ro u p c o m p ris e d t h o s e c a s e s w i t h a n o rm a l c o l o u r i n d e x an d r e d b lo o d c o r p u s c l e s o f h i g h n o r m a l, o r d e f i n i t e l y i n c r e a s e d v o lu m e .

He c o n s i d e r e d t h i s l a t t e r

t y p e o f a n a e m ia t o b e d u e t o a p r o t e i n d e f i c i e n c y . th is

i s an a t t r a c t i v e c l a s s i f i c a t i o n i t

W hile

is d i f f i c u l t to

d ra w a c l e a r d i s t i n c t i o n b e tw e e n B e t h e 1 1 ’s f i r s t a n d t h i r d g ro u p s.

A ld e r ( I 92 I4.) d rew a s i m i l a r d i s t i n c t i o n i n

a d e t a i l e d s t u d y o f a s e r i e s o f c a s e s an d c o n c lu d e d t h a t f o u r o u t o f f i f t e e n c a s e s o f p r e g n a n c y a n a e m ia , w h ic h h a d h i g h e r b lo o d v a l u e s t h a n t h e o t h e r s , a n d d i d n o t r e s p o n d t o i r o n , w e re c a s e s o f p h y s i o l o g i c a l a n a e m ia . W h ile p r o t e i n d e f i c i e n c y a s a c a u s a t i v e f a c t o r c a n n o t be d is m is s e d , th e c a s e s in c lu d e d by B e th e ll in h i s t h i r d g r o u p , a l s o h a d h i g h e r b lo o d v a l u e s t h a n w o u ld b e e x p e c t e d i f a n a n a e m ia w ere p r e s e n t , a n d a l s o d i d n o t r e s p o n d t o

ir o n th e ra p y .

It

is d if f ic u lt,

t h e r e f o r e , t o a v o id t h e

c o n c l u s i o n t h a t t h e b lo o d p i c t u r e

in B e t h e l l 's t h i r d

g ro u p m ig h t b e e x p l a i n e d by a p h y s i o l o g i c a l a n a e m ia . I n m ore r e c e n t y e a r s , w i t h a n i n c r e a s i n g k n o w le d g e o f t h e a e t i o l o g y o f t h e c o n d i t i o n , m ore c o m p re h e n s iv e c l a s s i f i c a t i o n s have b een s u g g e s te d . d e s c rib e d f iv e d i f f e r e n t ty p e s . (2 ) (h)

E v an s (1 9 3 7 )

(1 ) D e f i c i e n c y A n a e m ia s;

A naem ia due t o h a e m o rrh a g e ;

(3 ) A naem ia due t o s e p s i s ;

H a e m o ly tic A n aem ia, a n d (5 ) A naem ia i n w h ic h p r e g n a n c y

i t s e l f was a c o m p l i c a t i n g f a c t o r .

TJnder d e f i c i e n c y

a n a e m ia s h e i n c l u d e d t h e m i c r o c y t i c a n d m a c r o c y t i c t y p e s an d d i f f e r e n t i a t e d t h e s e a c c o r d i n g a s t o w h e th e r t h e r e was ( a ) a n o r m a l o r o n ly te m p o r a r y d e f i c i e n c y o f g a s t r i c s e c r e t i o n o r (b ) a p e rm a n e n t d e f i c i e n c y o f g a s t r i c s e c re tio n .

Prom t h i s t i m e , a s h a d b e e n e v i d e n t f o r

some y e a r s p r e v i o u s l y , t h e r e w as a g ro w in g r e c o g n i t i o n o f t h e p a r t p l a y e d by d e f e c t i v e g a s t r i c s e c r e t i o n i n t h e p r o d u c t i o n o f a n a e m ia o f p r e g n a n c y . seen la te r ,

In d e e d , a s w i l l be

i t h a s b e e n r e g a r d e d b y some w o r k e r s a s t h e

p r in c ip a l p re d is p o s in g c a u se .

C la s s if ic a tio n s o f th e

p re g n a n c y a n a e m ia s s t i l l c o n t i n u e d t o e x p a n d and S te v e n s o n (1 9 3 8 ) p r o d u c e d o n e o f t h e m o st c o m p re h e n s iv e c la s s if i c a t io n s to d a te . I.

T h is was a s f o l l o w s

PERNICIOUS ANAEMIA: 1.

A d d is o n ia n A n a em ia.

2.

P s e u d o - p e r n i c i o u s A n a em ia. (a ) P l a s t i c . (b ) H y p o p l a s t i c .

12.

3. II.

T r o p i c a l M a c r o c y tic A n aem ia.

SECONDARY ANAEMIA: 1.

I d i o p a t h i c H y p o ch ro m ic A n aem ia, due t o

2.

iro n d e fic ie n c y .

M i c r o c y t i c H y p o c h ro m ic A n aem ia, du e t o te m p o r a r y i r o n d e f i c i e n c y .

3.

M i c r o c y t i c H y p o ch ro m ic A naem ia, due t o some known c a u s e , e . g . h a e m o r rh a g e , s e p s i s .

III.

PERNICIOUS SECONDARY ANAEMIA: A c o m b in a tio n o f I an d I I .

IV .

V a r io u s t y p e s o f a n a e m ia a s s o c i a t e d w i t h some c o n d i t i o n o t h e r t h a n p r e g n a n c y , e . g . M a l a r i a , S y p h i l i s , T u b e r c u l o s i s , N e o p la sm , L e u k a e m ia . W h ile t h i s c l a s s i f i c a t i o n w o u ld a p p e a r t o c o v e r m o st

o f t h e r e c o g n i s e d a n a e m ia s o f p r e g n a n c y , t h e f a c t t h a t a e t i o l o g i c a l f a c t o r s w e re n o t y e t e x h a u s t e d was show n b y M e y e r-W e d e ll (1 9 ^ 3 ) who s t u d i e d a s e r i e s o f c a s e s an d c la s s ifie d

them a s f o l l o w s : -

d e f i c i e n c y A n aem ia;

(1 ) H y p o c h ro m ic I r o n -

(2 ) M e g a lo c y tic A naem ia;

(3 ) P e r n i c i o u s A naem ia a n d

(b)

V ita m in C. d e f i c i e n c y

A n aem ia, a n d t h i s c l a s s i f i c a t i o n was t a k e n a s t a g e f u r t h e r by E l l i o t t

( I 9I1IO who d e s c r i b e d t h e a n a e m ia s a s

(1 ) P h y s i o l o g i c a l A naem ia; (3 )

(2 ) D e f i c i e n c y A naem ia,

U n p ro v e n A n a e m ia s, w h ic h i n c l u d e d A c u te H a e m o ly tic ,

P r o t e i n - d e f i c i e n c y an d V ita m in B . d e f i c i e n c y a n a e m ia s ;

13. (U)

U n c l a s s i f i e d A n a e m ia s, an d (5 ) A naem ia c o m p l i c a te d

b y p r e g n a n c y i n c l u d i n g T r o p i c a l M e g a lo c y tic A n a em ia. E v an s i n c l u d e d u n d e r t h e D e f i c i e n c y A n a e m ia s,

iro n -

d e f i c i e n c y a n a e m ia , m e g a l o b l a s t i c a n a e m ia , i n c l u d i n g th e p e r n ic io u s and m y e lo b la s tic v a r i e t i e s ,

a n d a m ix ed

i r o n an d p e r n i c i o u s t y p e , a s d e s c r i b e d by S te v e n s o n . The a b o v e summary show s how t h e c l a s s i f i c a t i o n o f t h e a n a e m ia s o f p r e g n a n c y h a s b e e n e x te n d e d an d e n l a r g e d a s new a e t i o l o g i c a l f a c t o r s h a v e come u n d e r r e v i e w , b u t g e n e r a l l y s p e a k in g t h e tw o m ost c l e a r l y d e f i n e d a n d p r e d o m in a n t t y p e s o f a n a e m ia o f p r e g n a n c y a r e t h e I r o n d e f ic ie n c y and P e r n ic io u s v a r i e t i e s ,

t h e l a t t e r b e in g

now commonly r e f e r r e d t o a s t h e M e g a l o b l a s t i c A naem ia o f P r e g n a n c y (D a v id s o n e t a l 1 9 ^ 2 ) .

T h e re i s l i t t l e

doubt

a l s o t h a t b y f a r t h e com m onest ty p e o f a n a e m ia fo u n d i n t h e p r e g n a n t woman i s t h e i r o n - d e f i c i e n c y t y p e .

In th e

p r e s e n t i n v e s t i g a t i o n n o t on e c a s e o f t h e p e r n i c i o u s v a r i e t y was f o u n d so t h a t f u r t h e r d i s c u s s i o n w i l l b e c o n f i n e d t o i r o n - d e f i c i e n c y a n a e m ia , w i t h w h ic h w i l l b e c o n s i d e r e d t h e P h y s i o l o g i c a l A naem ia o f p r e g n a n c y . As f r e q u e n t r e f e r e n c e , h o w e v e r, to

i s made i n t h e l i t e r a t u r e

th e p e r n ic io u s v a r i e t y in c o n n e c tio n w ith i r o n -

d e f i c i e n c y , a f u r t h e r r e f e r e n c e w i l l b e made l a t e r t o t h e s o - c a l l e d P e r n i c i o u s A naem ia o f p r e g n a n c y , c o n c e r n i n g c h ie fly i t s

r e p u t e d p r e v a l e n c e and s e v e r i t y .

E vans

an d S te v e n s o n w e re o f t h e o p i n i o n t h a t t h e tw o v a r i e t i e s m ig h t so m e tim e s c o - e x i s t .

PHYSIOLOGICAL ANAEMIA OF PREGNANCY: A lth o u g h p h y s i o l o g i c a l a n a e m ia o f p r e g n a n c y i s now g e n e r a l l y a c c e p t e d a s a f a c t o r h a v in g a d e f i n i t e on t h e b lo o d p i c t u r e , s u b je c t.

in flu e n c e

t h i s h a s lo n g b e e n a c o n t r o v e r s i a l

I t s e x i s t e n c e was s u p p o r t e d by some o f t h e

e a r l i e s t c o n trib u to rs to th e l i t e r a t u r e ,

(C a se a u x 1 8 5 0 ,

S p i e g e l b e r g a n d G s c h e i d l i n 1 8 7 2 , F e h l i n g 1 8 8 6 , W illc o c k s 1 8 8 1 , B e r n h a rd 1 8 9 2 ) , b u t o t h e r s e q u a l l y d e n ie d t h a t i t p l a y e d a n y p a r t i n t h e p r o d u c t i o n o f a n a n a e m ia d u r i n g p re g n a n c y .

( P e t e r 1 8 7 5 , I n g e r s l a v 1 8 7 9 , M eyer 1 8 8 7 ,

R e in l 1889, D ubner 1890, S c h ro e d e r 1 8 9 1 ).

S in c e t h e n

t h e o c c u r r e n c e o f a p h y s i o l o g i c a l a n a e m ia o r h y d r a e m ia , and i t s

r e l a t i o n t o , a n d i n f l u e n c e u p o n , t h e n o rm a l

h a e m a t o l o g i c a l v a l u e s d u r i n g p r e g n a n c y , h a s b e e n w id e ly d is c u s s e d . The a e t i o l o g y o f t h e c o n d i t i o n i s b a s e d o n t h e t h e o r y t h a t t h e r e i s a d i l u t i o n o f t h e b lo o d d u r i n g p r e g n a n c y d u e t o a n i n c r e a s e i n t h e b lo o d a n d p la s m a v o lu m e , so t h a t a s t a t e o f h y d r a e m ia e x i s t s .

T h is was f i r s t p o i n t e d

o u t b y K e i t h , R o w n tre e a n d G e ra g h ty (1 9 1 5 ) who show ed t h a t t h e b lo o d m ass d u r i n g p r e g n a n c y i n c r e a s e d fro m a n o rm a l o f 8 *8# i n p r o p o r t i o n t o t h e b o d y w e ig h t t o 9 * 5 6 # , w i t h a c o r r e s p o n d i n g i n c r e a s e i n p la s m a v o lu m e fro m 50 c c . t o 58*14. c c p e r k ilo g ra m m e o f b o d y w e i g h t .

L a te r

D ieck m an n a n d W egner (1 9 5 ^ ) p r o v e d c o n c l u s i v e l y t h a t t h e b lo o d an d p la s m a v o lu m e w e re i n c r e a s e d d u r i n g p r e g n a n c y .

T hey show ed t h a t t h i s

i n c r e a s e b e g a n i n th e f i r s t

t r i m e s t e r and by t h e t h i r t e e n t h w eek am o u n ted t o 16# a n d 18# r e s p e c t i v e l y , u n t i l a t te r m t h e a v e r a g e i n c r e a s e i n t h e b lo o d volum e was 23# , an d p la s m a 2 5 # . c o n s id e re d t h a t a s t a t e

T hey

o f p h y s i o l o g i c a l a n a e m ia e x i s t e d

d u r i n g p re g n a n c y a s lo n g a s t h e h a e m o g lo b in l e v e l was m a i n t a i n e d a t 10 gram m es p e r 100 c c o f b lo o d o r m o re . T h is l e v e l was r e g a r d e d a s t h e lo w e r l i m i t o f n o r m a l i t y , b e lo w w h ic h a p a t h o l o g i c a l o r t r u e a n a e m ia e x i s t e d . The w ork o f R i c h t e r , M eyer and B e n n e t t ( 1 9 3 I4-) a l s o s u p p o r t e d t h e d i l u t i o n t h e o r y , a n d Thom son e t a l

(1 9 3 8 )

i n an e x a m in a tio n o f f o u r t e e n n o r m a l p r e g n a n t women fo u n d a n i n c r e a s e i n p la s m a volum e o f 65 # a b o v e t h e a v e r a g e n o rm a l n o n - p r e g n a n t v a l u e , and a c o r r e s p o n d i n g i n c r e a s e o f k 5 * k # i n to ta L b lo o d v o lu m e .

T hey c o n s i d e r e d t h e

d i s p r o p o r t i o n a t e i n c r e a s e i n p la s m a volum e t o b e p r i m a r i l y a c c o u n t a b l e f o r t h e phenom enon o f " h y d r a t i o n " o f t h e b lo o d i n p r e g n a n c y .

B e t h e l l (1 9 3 6 ) e x a m in e d s i x t y s i x

n o rm a l h e a l t h y p r e g n a n t women i n t h e l a s t t r i m e s t e r a n d f o u n d t h e p la s m a volum e t o be i n c r e a s e d by a b o u t 25 # , b u t in a p re v io u s c o n tr ib u tio n

( 1 9 3 5 ) , lie c o n s i d e r e d

t h a t t h e r e s u l t i n g a n a e m ia m e r e ly p e r s i s t e d d u r i n g p r e g n a n c y b e c a u s e o f t h e a b s e n c e o f s t i m u l u s t o i n c r e a s e d b lo o d fo rm a tio n t o g e th e r w ith a r e l a t i v e la c k o f i r o n .

The

phenom enon o f a s t a t e o f h y d ra e m ia e x i s t i n g d u r i n g p r e g n a n c y h a s a l s o b e e n c o n fir m e d by a n im a l e x p e r i m e n t a t i o n . Van Bonk e t a l (1 9 3 k ) i n a n a n a l y s i s o f a n a e m ia o f

16.

p re g n a n c y i n t h e r a t ,

fo u n d t h a t t h e p e r c e n t a g e o f w a t e r

i n t h e b lo o d i n c r e a s e d by a b o u t s ta g e s o f p re g n a n c y .

l$>

d u rin g th e l a t t e r

M i t c h e l l a n d M i l l e r (1 9 3 1 ) i n a

p r e v i o u s e x a m in a tio n o f p r e g n a n t r a t s h a d s u g g e s t e d t h a t t h e a n a e m ia was p r o b a b l y p h y s i o l o g i c a l i n n a t u r e . T h is t h e o r y o f a p h y s i o l o g i c a l a n a e m ia e x i s t i n g d u r i n g p r e g n a n c y h a s n o t a lw a y s m et w i t h u n i v e r s a l a c c e p ta n c e .

E s c h (1 9 3 2 ) i n a n e x a m in a t io n o f 800 p a t i e n t s

a t t e n d i n g a n a n t e n a t a l c l i n i c d id n o t f i n d much e v id e n c e o f h y d ra e m ia i n t h e l a s t m onth o f p r e g n a n c y and W i t t s (1 9 3 5 )

d i d n o t b e l i e v e t h e c o n d i t i o n e x i s t e d i n n o rm a l

h e a l t h y p r e g n a n t women.

I r v i n g (1 9 3 5 ) i n a s t u d y o f

60 c a s e s c o n c lu d e d t h a t t h e a n a e m ia o f p r e g n a n c y was n o t p h y s i o l o g i c a l b u t was due t o t h e d r a i n on t h e i r o n r e s e r v e o f t h e m o th e r by t h e g ro w in g f o e t u s ,

and T o v e ru d (1 9 3 5 )

e x a m in e d 181 p r e g n a n t women i n t h e l a s t t r i m e s t e r a n d c o n c lu d e d t h a t t h e a n a e m ia was n o t p h y s i o l o g i c a l b u t was due to an i r o n d e f ic ie n c y i n th e d i e t .

A g a in , t h e

r e s u l t s o f a n im a l e x p e r i m e n t a t i o n h a v e b e e n p u t f o r w a r d a s e v id e n c e a g a i n s t t h e p h y s i o l o g i c a l t h e o r y .

B e a rd

a n d M yers (1 9 3 3 ) e x a m in e d 87 p r e g n a n t r a t s t h r o u g h 138 p r e g n a n c i e s a n d came t o t h e c o n c l u s i o n t h a t t h e a n a e m ia c o u ld n o t b e w h o lly a c c o u n te d f o r on t h e b a s i s o f h y d r a e m ia .

T hey c o n s i d e r e d t h a t t h e d r o p i n h a e m o g lo b in

i n f u l l y one t h i r d o f t h e c a s e s w as t o o g r e a t t o b e e x p l a i n e d i n t h i s w ay.

N e v e rth e le s s th e g e n e ra l

c o n s e n s u s o f o p i n i o n s u p p o r t s t h e t h e o r y t h a t h y d r a e m ia

17. i s a f a c t o r w h ic h i n f l u e n c e s t h e b lo o d p i c t u r e i n p r e g n a n c y an d one f i n d s f r e q u e n t r e f e r e n c e t o i t lite ra tu re .

in th e

(V aughan 193U, D a v id s o n e t a l 1 9 3 5 , W i l l s

1 9 3 5 , G re e n -A rm y ta g e 1 9 3 5 , F u l l e r t o n 1 9 3 6 , B o y c o tt 1 9 3 6 , S m allw o o d 1936, Browne 19^4-, W h itb y 1 9 ^ 6 ) .

F re q u e n t

r e f e r e n c e t o t h e c o n d i t i o n i s a l s o fo u n d i n t h e lite ra tu re

o f A m e ric a a n d o t h e r c o u n t r i e s .

(B la n d and

G - o ld s te in 1 9 2 9 , B la n d , G o l d s t e i n a n d F i r s t 1 9 3 0 a ., H a lle 1930, S tr a u s s 1932, S tr a u s s and C a s tle 1932, W in tro b e 1 9 3 3 , S t r a u s s 1 9 3 ^ , F e ld m a n e t a l 1 9 3 6 , B u r w e ll 1 9 3 6 , B u r w e ll e t a l 1 9 3 8 , W atson 1 9 3 8 ) .

I n C anada,

Adamson a n d S m ith ( 1 9 3 2 ) , d rew a t t e n t i o n t o t h e c o n d i t i o n , and i n Hew Z e a la n d , M cGeorge (1 9 3 5 ) r e g a r d e d t h e m ild v a r i e t y o f a n a e m ia i n a s e r i e s o f c a s e s s t u d i e d , t o h y d r a e m ia .

a s due

I n t h e c o n t i n e n t a l l i t e r a t u r e many

w r i t e r s make r e f e r e n c e t o t h e c o n d i t i o n i n c l u d i n g A ld e r (1 9 2 14. ) , K u h n e l (1 9 2 7 ) a n d B r i n d e a u a n d T h e o d o r id e s

(1 9 3 5 ).

I n t h e t r e a t m e n t o f a n a e m ia o f p r e g n a n c y w i t h i r o n , many w o r k e r s , n o t a b l y A l d e r , c o n s i d e r e d t h a t t h o s e c a s e s w h ic h d i d n o t r e s p o n d t o t h i s fo rm o f t h e r a p y , w e re p r o b a b l y s u f f e r i n g fro m t h e p h y s i o l o g i c a l v a r i e t y o f a n a e m ia , a n d Adamson a n d S m ith w e n t a s f a r a s t o s u g g e s t t h a t t h e a n a e m ia b e in g p h y s i o l o g i c a l i n n a t u r e , c o n c e iv a b ly do h a rm .

i r o n m ig h t

G a llo w a y (1929 t>), on t h e b a s i s o f

re s p o n s e to ir o n th e ra p y a lo n e , d is m is s e d th e d i l u t i o n th e o r y a s an a e t i o l o g i c a l f a c t o r . From t h e f o r e g o i n g r e v ie w o f t h e l i t e r a t u r e ,

it

is

c o n c lu d e d , i n s p i t e o f t h e e v id e n c e t o t h e c o n t r a r y , t h a t a p h y s i o l o g i c a l s t a t e o f a n a e m ia d o e s e x i s t d u r i n g t h e c o u r s e o f p r e g n a n c y , a n d t h i s f a c t m ust b e b o r n e i n m ind i n an y a s s e s s m e n t o f t h e i n c i d e n c e o f a n a e m ia a s s o c ia te d w ith th e p re g n a n t s t a t e .

The im p o r ta n c e o f

t h i s w i l l b e a p p r e c i a t e d w hen one a t t e m p t s t o e s t a b l i s h n o rm a l h a e m a t o l o g i c a l s t a n d a r d s f o r t h e p r e g n a n t woman. As K e i t h , R o w n tre e a n d G e ra g h ty p o i n t e d o u t , t h i s p h y s i o l o g i c a l s t a t e m ig h t make an a n a e m ia m ore a p p a r e n t th a n r e a l .

W h ile r e c o g n i s i n g t h e s i g n i f i c a n c e o f t h e

c o n d i t i o n , Browne (19i4|.) s t a t e d t h a t t h e te r m " P h y s i o l o ­ g i c a l A naem ia" h a d some h i s t o r i c

in te re s t,

b u t s h o u ld b e

a b a n d o n e d f o r t h e te r m " p h y s i o l o g i c a l H y d ra e m ia o f P r e g n a n c y ."

He a f f i r m e d t h a t t h e l a t t e r c o n d i t i o n c a n

a n d d o e s c o e x i s t w i t h t h e t r u e a n a e m ia o f p r e g n a n c y . I t w o u ld a p p e a r , h o w e v e r, t h a t a n i n c r e a s e i n t h e w a t e r c o n t e n t o f t h e b lo o d i s n o t c o n f i n e d o n ly t o t h e p reg n a n t s t a t e .

K e i t h (1 9 2 3 ) i n a n e x a m in a t io n o f

tw e n ty f o u r c a s e s o f c h r o n i c a n a e m ia , fo u n d t h a t t h e h i g h e s t p la s m a v a l u e s w e re fo u n d i n p a t i e n t s w i t h lo w h a e m o g lo b in p e r c e n t a g e s , a l t h o u g h h e c o u ld n o t d e m o n s tr a te an y a b s o l u t e r e l a t i o n s h i p .

He s t a t e d t h a t " e a r l y i n a

s lo w ly p r o g r e s s i n g a n a e m ia , t h e u s u a l m ech an ism f o r m a i n t a i n i n g a n a d e q u a te b lo o d volum e may b e c a l l e d i n t o p l a y , w i t h a r e s u l t i n g h i g h p la s m a c o n t e n t . "

K e ith * s

r e s u l t s r a i s e t h e i n t e r e s t i n g s p e c u l a t i o n t h a t i f a n a e m ia i s th e e x c itin g f a c t o r in th e c a u s a tio n o f an in c re a s e d

19. p la s m a v o lu m e , t h i s m ig h t h e a n a rg u m e n t a g a i n s t p re g n a n c y p e r se b e in g r e s p o n s ib le f o r th e in c r e a s e , w h ic h m ig h t m e re ly b e due t o t h e i n c i d e n t a l a n a e m ia . I n o t h e r w o rd s ,

i s a n i n c r e a s e i n p la s m a volum e p e c u l i a r

t o th e p re g n a n t s t a t e ,

o r i s t h i s in c re a s e th e e f f e c t

o f a n a e m ia i r r e s p e c t i v e o f p re g n a n c y ?

W h a te v e r may b e

t h e u l t i m a t e c a u s e o f t h e h y d ra e m ia , t h e r e i s no d o u b t t h a t i n t h e e x a m in a tio n o f a l a r g e num ber o f c a s e s ,

one

f r e q u e n t l y f i n d s b lo o d v a l u e s b e lo w t h e a c c e p t e d n o r m a l s t a n d a r d s i n p a t i e n t s sh o w in g no s i g n s o r sym ptom s o f a n a e m ia .

I n t h e s e c a s e s , p a r t i c u l a r l y w h e re t h e c o l o u r

i n d e x r e m a in s a ro u n d u n i t y , a n d s t a i n e d b l o o d - f i l m s r e v e a l no a b n o r m a l i t y , one i s

i n e v i t a b l y draw n t o t h e

c o n c lu s io n t h a t p h y s io lo g ic a l f a c t o r s , p e rh a p s p e c u lia r to th e p reg n a n t s t a t e , a re re s p o n s ib le f o r th e s e ch an g es. IRON-DEFICIENCY ANAEMIA: I r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y h a s b e e n v a r io u s ly d e s c rib e d in th e l i t e r a t u r e

as P h y s io lo g ic a l

A naem ia o f P r e g n a n c y , C h l o r o t i c A naem ia o f P r e g n a n c y a n d S e c o n d a ry A naem ia o f P re g n a n c y D a v id s o n and F u l l e r t o n

(V aughan 19 3 I 4 .).

(1 9 3 8 ) i n a d i s c u s s i o n o f t h e

n o m e n c la tu r e o f t h e c o n d i t i o n ,

r e f e r r e d t o th e te rm s

C h lo r a n a e m ia , C h ro n ic M i c r o c y t i c A n a em ia, I d i o p a t h i c H y p o ch ro m ic A n aem ia, an d S im p le A c h l o r h y d r i c A n a e m ia . T hey c o n s i d e r e d t h a t t h e c o n d i t i o n w as b e s t d e s c r i b e d a s C h r o n ic N u t r i t i o n a l H y p o ch ro m ic A n a em ia.

Irv in g

(1 9 3 5 )

a l s o p r e f e r r e d t h e te r m n u t r i t i o n a l A naem ia o f P r e g n a n c y . It

i s o b v io u s t h a t t h e t i t l e

a d o p te d m ust d e p e n d on t h e

p r e c is e a e t i o l o g i c a l f a c t o r s a c c e p te d , b u t ir o n - d e f ic ie n c y i s common t o a l l ,

and m o re o v e r t h i s t y p e o f a n a e m ia i s

now r e c o g n i s e d a s t h e p re d o m in a n t and m ost f r e q u e n t v a r i e t y fo u n d d u r i n g p r e g n a n c y .

T h is s t a t e m e n t i s b o r n e

o u t by r e f e r e n c e t o t h e w ork o f w e ll-k n o w n a u t h o r i t i e s an d o t h e r w o r k e rs i n t h i s f i e l d .

The h a e m a t o l o g i c a l

c h a r a c t e r s o f t h i s a n a e m ia a r e n o t p e c u l i a r t o t h e p r e g n a n t s t a t e and in d e e d a r e no d i f f e r e n t t o t h o s e fo u n d i n i r o n - d e f i c i e n c y a n a e m ia a p a r t fro m p r e g n a n c y . S t r a u s s an d C a s t l e

(1 9 3 3 ) d e s c r i b e d t h i r t y

cases of th is

ty p e i n w h ic h t h e b lo o d p i c t u r e r e s e m b le d t h a t o f a h y p o c h ro m ic a n a e m ia .

A lth o u g h t r u e m ic r o c y t e s w e re n o t

o b s e r v e d i n a n y o f t h e c a s e s , t h e r e d c e l l s w e re s m a l l a n d d e f i c i e n t i n h a e m o g lo b in , a n d t h e a v e r a g e c o l o u r i n d e x was a ro u n d 0 . 5 .

An i m p o r t a n t d i a g n o s t i c f e a t u r e

o f t h i s a n a e m ia a l s o , a n d one w h ic h h a s a l r e a d y b e e n r e f e r r e d to

(p a g e 1 7 ) ,

i s th e re sp o n se to ir o n th e ra p y .

T r e a tm e n t w i l l b e d i s c u s s e d l a t e r ;

a t t h e moment i t

is

p r o p o s e d t o d i s c u s s t h e m ain a e t i o l o g i c a l f a c t o r s c o n c e r n e d i n t h e p r o d u c t i o n o f t h e i r o n - d e f i c i e n c y a n a e m ia o f p reg n a n cy . The a e t i o l o g y o f i r o n - d e f i c i e n c y a n a e m ia c a n b e s t b e d i s c u s s e d u n d e r t h e f o l l o w i n g h e a d in g s (1 )

P r e - e x i s t i n g a n a e m ia .

(2 )

F o e t a l demand f o r i r o n .

21 .

(3 )

D e fe c tiv e D ig e s tio n .

(h)

D e f i c i e n t i r o n i n t a k e a s s o c i a t e d w i t h eco n o m ic an d s o c i a l f a c t o r s .

(5 )

Number o f p r e v i o u s p r e g n a n c i e s .

PRE-EXISTING ANAEMIA: I n a s t u d y o f a n a e m ia d e v e l o p in g d u r i n g p r e g n a n c y , it

i s d i f f i c u l t t o p ro v e i n a n y p a r t i c u l a r c a s e , w h e th e r

a s t a t e o f a n a e m ia e x i s t e d p r i o r t o c o n c e p t i o n .

If,

t h e s t u d y o f a s e r i e s o f n o rm a l h e a l t h y i n d i v i d u a l s ,

in one

a ssu m e s t h a t no s u c h s t a t e o f a n a e m ia e x i s t e d p r e v i o u s l y , t h e o n ly c r i t e r i o n on w h ic h one c a n b a s e t h i s a s s u m p tio n i s t h e f a c t t h a t t h e h a e m o g lo b in i n t h e m a j o r i t y o f c a s e s , r e t u r n s t o n o rm a l a f t e r d e l i v e r y .

T h is h a s b e e n show n

t o t a k e p l a c e i n women m a n i f e s t i n g a m o d e r a te , a n d i n some c a s e s , a s e v e r e d e g r e e o f a n a e m ia , d u r i n g p r e g n a n c y , a n d h a s b e e n a d d u c e d a s e v id e n c e a g a i n s t a p r e - e x i s t i n g a n a e m ia . (B la n d a n d G o l d s t e i n 1 9 2 9 , F i r s t a n d G o l d s t e i n 1 9 3 0 , B la n d G o l d s t e i n and F i r s t 1 9 5 0 b . W atson 1 9 3 8 ) .

A ld e r ( 1 9 2 I4.)

s t a t e d t h a t t h e r e was n e v e r a p r e - e x i s t i n g a n a e m ia an d t h a t t h e a n a e m ia was a lw a y s due t o p r e g n a n c y p e r s e . M e y e r-W e d e ll ( 19 J4.5 ) c o u l d f i n d e v id e n c e o f p r e - e x i s t i n g a n a e m ia i n o n ly n i n e o u t o f n i n e t y f o u r p a t i e n t s , a n d o n ly f i v e o f t h e s e show ed a n a e m ia d u r i n g p r e g n a n c y . On t h e o t h e r h a n d , F u l l e r t o n

(1 9 3 6 ) w as o f t h e o p i n i o n

t h a t a n a e m ia p r o b a b l y e x i s t e d p r i o r t o t h e p r e g n a n c y , b e c o m in g m ore e v i d e n t a s a r e s u l t o f t h e h y d r a e m ia i n c i d e n t a l

22.

to th e p re g n a n t s t a t e .

S tr a u s s and C a s tle

( 1 9 3 2 ) , w h ile

r e c o g n i s i n g t h e p o s s i b i l i t y o f a p r e - e x i s t i n g a n a e m ia , d i d n o t c o n s i d e r t h a t t h i s w o u ld p r o d u c e an y g r e a t e r d e g r e e o f a n a e m ia d u r i n g p re g n a n c y p r o v id e d t h a t t h e d i e t was a d e q u a te .

O th e r w o r k e rs who h a v e s t u d i e d t h e c o n d i t i o n

a l s o r e f e r t o t h e p o s s i b i l i t y o f t h e a n a e m ia a n t e d a t i n g t h e p r e g n a n c y , a lt h o u g h no p o s i t i v e p r o o f i s p u t f o r w a r d in su p p o rt o f th is th e o ry .

(L yon 1 9 2 9 , M ussey e t a l 1 9 3 2 ,

S c h u l t z 1 9 3 3, B r in d e a u a n d T h e o d o r id e s 1 9 3 5 , B e t h e l l 1 9 3 6 , H a m ilto n a n d W rig h t 19 I1.2 ) . W h ile i t i s i m p o r t a n t i n a n y i n v e s t i g a t i o n i n t o t h e i n c i d e n c e o f a n a e m ia o f p r e g n a n c y t o e s t a b l i s h w h e th e r s u c h a s t a t e o f a n a e m ia d i d i n f a c t e x i s t p r i o r t o t h e o n s e t o f p reg n a n cy , t h i s

i s a p o i n t on w h ic h i t

d i f f i c u l t t o come t o a d e f i n i t e c o n c l u s i o n .

is

I n th e

p r e s e n t s e r i e s c a r e f u l c a s e h i s t o r i e s w e re t a k e n i n e a c h i n d i v i d u a l c a s e u n d e r r e v ie w ,

i n o r d e r t o e x c lu d e t h e

p o s s i b i l i t y o f th e c o n d itio n a n te d a tin g th e p re g n a n c y . FOETAL DEMAND FOR IROff: T h e re i s d e f i n i t e e x p e r i m e n t a l e v id e n c e t o p r o v e t h a t d u r i n g p re g n a n c y a n i n c r e a s e d s t r a i n i s th ro w n o n t h e m a t e r n a l i r o n r e s e r v e s by t h e f o e t u s , w h ic h s t a r e s u p i r o n e s p e c i a l l y d u r i n g t h e l a s t t h r e e m o n th s a t t h e e x p e n s e o f t h e m o th e r .

The e a r l i e r l i t e r a t u r e

d e a lin g w ith t h i s

a s p e c t o f t h e s u b j e c t h a s b e e n su m m a rise d by M ackay ( 1 9 3 1 ) . Bunge (1 8 8 9 ) show ed t h a t t h e m i n e r a l c o n t e n t o f t h e

m ilk o f a dog was i d e n t i c a l w i t h t h e m i n e r a l c o n t e n t o f t h e b o d y o f t h e y o u n g dog w i t h t h e e x c e p t i o n o f i r o n , w h ic h ,

i n t h e b o d y o f t h e yo u n g d o g , was s i x t im e s a s

c o n c e n t r a t e d a s i n t h e m ilk o f t h e m o th e r .

A b d e rh a ld e n

(1 8 9 8 ) show ed t h a t t h e i r o n c o n t e n t o f young mammals was h i g h e s t a t b i r t h , p r o g r e s s i v e l y d im in is h e d d u r i n g t h e m i l k - f e e d i n g p e r i o d , an d d i d n o t i n c r e a s e a g a i n u n t i l t h e a n im a l to o k m ixed f o o d , and t h a t w e ig h t f o r w e i g h t, t h e r e was f i v e tim e s m ore i r o n i n t h e l i v e r o f t h e new­ b o rn th a n in th e l i v e r o f a d u lt a n im a ls . th is

He b e l i e v e d t h a t

immense s t o r e o f i r o n c o u ld o n ly b e d e r i v e d fro m t h e

m o th e r .

H ugounenq (1 8 9 9 ) show ed t h a t i n t h e hum an

f o e t u s , tw o t h i r d s o f t h e i r o n p r e s e n t i n t h e f o e t a l b o d y a t te r m , w as l a i d down i n t h e l a s t t h r e e m o n th s o f i n t r a ­ u te rin e l i f e . T h is t h e o r y a s a f a c t o r i n t h e p r o d u c t i o n o f i r o n d e f i c i e n c y a n a e m ia i s now g e n e r a l l y a c c e p t e d , b u t m o st a u t h o r i t i e s p o i n t o u t t h a t t h i s demand b y t h e f o e t u s f o r i r o n i s o f t e n c o m b in ed w i t h o t h e r d e f e c t s s u c h a s d e f e c t i v e d i e t a n d g a s t r i c d i s t u r b a n c e i n t h e m o th e r . C a s tle

S t r a u s s an d

(1 9 3 3 ) s t a t e d t h a t t h e f o e t a l dem and f o r b l o o d -

b u i l d i n g m a t e r i a l s was u s u a l l y a c c o m p a n ie d by " d i r e c t d ie ta r y d e fic ie n c y o r in d ir e c t d ie ta r y d e fic ie n c y , c o n d i t i o n e d by g a s t r i c a n a c i d i t y and h y p o a c i d i t y ,

or a

f a c t o r a s s o c i a t e d w i t h t h e s e d e f e c t s and f o e t a l b lo o d r e q u ir e m e n t."

F u lle rto n

(1 9 3 6 ) on t h e o t h e r h a n d ,

b e l i e v e d t h a t o n ly a m o d e ra te d e g r e e o f a n a e m ia c o u ld

2k. r e s u l t fro m t h e i r o n dem ands o f t h e f o e t u s .

He b a s e d

t h i s b e l i e f on t h e f a c t t h a t m ost o f t h e p u b l i s h e d w ork d e m o n s tr a te d t h e p r e s e n c e o f a h y p o c h ro m ic a n a e m ia a t o r b e f o r e t h e en d o f t h e s e c o n d t r i m e s t e r ,7 a n d r e c o r d e d 21

jI

c a s e s w i t h a n a v e r a g e g e s t a t i o n o f 6*9 m o n th s a n d a l l

!

w i t h a h a e m o g lo b in l e v e l b e lo w 7C$ H a ld a n e (9 * 6 g ra m m e s ). S i m i l a r l y B la n d G o l d s t e i n a n d F i r s t 58$ o f

k5

(1 9 3 0 b ) show ed t h a t

c a s e s h a d a r e d c e l l c o u n t b e lo w 3*5 m i l l s p e r omm

b e f o r e t h e en d o f t h e

second t r im e s t e r .

T h ese r e s u l t s

w o u ld t e n d t o r e f u t e t h e t h e o r y t h a t a n a e m ia d e v e lo p s i n t h e l a s t t h r e e m o n th s o f p r e g n a n c y a s a r e s u l t o f t h e i n c r e a s e d demand f o r i r o n b y t h e f o e t u s a t t h i s t i m e . I n v ie w o f t h e e v id e n c e p r o d u c e d , one c a n n o t d e n y t h a t t h e f o e t u s m u st p ro d u c e a d r a i n on t h e i r o n r e s e r v e s o f t h e m o th e r , a n d t h i s dem and i s p r o b a b l y m ore m ark ed i n th e l a s t tr im e s te r .

W h ile t h i s f o e t a l dem and f o r i r o n

m u st o b v i o u s l y p l a y a n i m p o r t a n t p a r t i n t h e p r o d u c t i o n o f a n i r o n - d e f i c i e n c y a n a e m ia d u r i n g p r e g n a n c y ,

its

im p o r ta n c e p e r s e s h o u ld n o t b e u n d u ly s t r e s s e d , b u t s h o u ld b e c o n s i d e r e d i n r e l a t i o n t o d i e t a r y d e f e c t an d d i g e s t i v e d i s t u r b a n c e i n t h e m o th e r .

M o re o v e r i t m u st

b e rem em b ered t h a t a n y d r a i n on t h e m a t e r n a l i r o n r e s e r v e s p ro d u c e d by t h e f o e t u s , m u st b e o f f s e t t o a g r e a t e r o r l e s s e r d e g r e e by t h e c e s s a t i o n o f m e n s t r u a t i o n a t t h i s tim e . DEFECTIVE DIGESTION: I t h a s b e e n show n b y M e t t i e r a n d M in o t (1 9 3 1 ) t h a t

i r o n i s m ore r e a d i l y a b s o r b e d fro m a n a c i d t h a n an a l k a l i n e m edium , t h e r e f o r e i t h a s b e e n s u g g e s t e d t h a t a d h l o r h y d r i a o r h y p o c h l o r h y d r i a m ig h t b e f a c t o r s f a v o u r i n g t h e d e v e lo p m e n t o f a n i r o n —d e f i c i e n c y an ae m ia* The a s s o c i a t i o n o f a n a e m ia w i t h a c h l o r h y d r i a i n women o f c h i l d - b e a r i n g a g e , h o w e v e r, was f i r s t p o i n t e d o u t b y F a b e r i n 1909-

H aden (1 9 3 2 ) an d W in tro b e (1 9 3 3 ) r e f e r r e d

to d e fe c tiv e g a s t r i c s e c r e tio n as a c a u s a tiv e f a c t o r in t h e p r o d u c t i o n o f i d i o p a t h i c h y p o c h ro m ic a n a e m ia a p a r t fro m p r e g n a n c y .

S in c e t h e n many w o r k e r s h a v e p a r t i c u l a r l y

s t r e s s e d t h e im p o r ta n c e o f d i g e s t i v e d i s t u r b a n c e i n t h e p r o d u c t i o n o f t h e i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y . S tr a u s s and C a s tle th irty

(1 9 3 3 ) i n a d e t a i l e d s t u d y o f

c a s e s o f h y p o c h ro m ic a n a e m ia o f p r e g n a n c y , shew ed

t h a t 17 o f t h e s e c a s e s h a d a c h l o r h y d r i a a n d 10 h a d h y p o c h l o r h y d r i a , an d c o n c lu d e d t h a t t h e s e f a c t o r s co m b in ed w i t h f o e t a l b lo o d r e q u i r e m e n t s , w ere t h e c a u s e o f t h e a n a e m ia , a l t h o u g h t h e y a l s o p o i n t e d o u t t h a t 21 o f t h e i r p a t i e n t s had b een ta k in g a p o o r d i e t .

In an e a r lie r

s t u d y o f t h e a e t i o l o g y and t r e a t m e n t o f a n a e m ia i n p re g n a n c y , S tr a u s s

(1 9 3 2 ) fo u n d t h a t m ore t h a n h a l f h i s

p a t i e n t s show ed a m ark ed d e c r e a s e o r a b s e n c e o f f r e e h y d ro c h lo ric a c id i n th e g a s t r i c ju ic e d u rin g p reg n a n cy , w ith a r e t u r n to n o rm a l a f t e r d e li v e r y .

T hese p a t i e n t s ,

a lo n g w i t h o t h e r s who h a d b e e n t a k i n g a p o o r d i e t ,

show ed

a n a v e r a g e l o s s o f 12$ h a e m o g lo b in d u r i n g p r e g n a n c y , w h e re a s t h o s e w i t h a l e s s m ark e d d e c r e a s e i n f r e e

26.

h y d r o c h l o r i c a c i d a n d a s a t i s f a c t o r y d i e t l o s t an a v e r a g e o f o n ly 5$ h a e m o g lo b in .

T h re e c a s e s w i t h a

p e rm a n e n t g a s t r i c a n a c i d i t y h a d a n a v e r a g e l o s s o f 18$> h a e m o g lo b in d u r i n g p r e g n a n c y . S t r a u s s a n d Gas t i e

As a l r e a d y s t a t e d

(p a g e 2 3 ) ,

w ere o f t h e o p i n i o n t h a t a n a e m ia o f

p r e g n a n c y o c c u r r e d o n ly i n t h o s e women who h a d h a d f o r a c o n s i d e r a b l e tim e a d e f e c t i v e d i e t o r d i e t a r y d e f i c i e n c i e s c o n d i t i o n e d by g a s t r i c a n a c i d i t y o r r e l a t e d g a s t r o ­ i n t e s t i n a l d is tu rb a n c e s . I n t h i s c o u n t r y , D a v is an d S h e l l e y

( 193 ^ .), e x a m in e d

51 n o rm a l p r e g n a n t women, 6 o f whom d e v e lo p e d a n a e m ia . Of t h e s e ,

5 show ed a d i s t u r b e d g a s t r i c s e c r e t i o n *

had b e en ta k in g a p o o r d i e t , n o r m a l.

a n d one

a l t h o u g h t h e s e c r e t i o n was

I n t h e same s t u d y t h e y o b s e r v e d 20 c a s e s f r a n k l y

a n a e m ic f o l l o w i n g a p r e v i o u s c o n f i n e m e n t .

Of t h e s e ,

18 show ed a d i s t u r b e d g a s t r i c f u n c t i o n i n t h e fo rm o f a c h lo r h y d r ia o r h y p o c h lo rh y d ria and f o u r t e e n had b e e n ta k in g a poor d i e t .

I n t h e co m b in ed g r o u p s t h e r e w e re

ii-5 p a t i e n t s w i t h a n o rm a l g a s t r i c s e c r e t i o n ,

o n ly t h r e e

o f whom h a d b e e n t a k i n g u n s a t i s f a c t o r y d i e t s .

Of t h e

26 a n a e m ic p a t i e n t s e x a m in e d , 15 h a d a c h l o r h y d r i a , h y p o c h l o r h y d r i a an d 18 h a d b e e n t a k i n g a p o o r d i e t .

8 had D a v is

a n d S h e l l e y c o n c lu d e d t h a t i n t h e d e v e lo p m e n t o f h y p o c h ro m ic a n a e m ia o f p r e g n a n c y , g a s t r i c s e c r e t o r y d e f e c t h a d b e e n p ro v e d t o b e t h e m ost i m p o r t a n t s i n g l e a e t i o l o g i c a l fa c to r.

27. T h e se r e s u l t s p r o d u c e d by S t r a u s s and O a s t l e , an d D a v is a n d S h e l l e y a r e c o n v in c in g ,

and h a v e b e e n c o n f ir m e d

b y o t h e r w o rk e rs who h w e i n v e s t i g a t e d t h i s a s p e c t o f th e s u b je c t.

V aughan (193^4-) r e p o r t e d on 35 p a t i e n t s

who d e v e lo p e d a n a e m ia d u r i n g p r e g n a n c y .

Of t h e s e ,

h a d a p o s t - h i s t a m i n e a n a c i d i t y and 12 h a d l i t t l e

19

o r no

f r e e h y d r o c h l o r i c a c i d f o l l o w i n g a l c h o h o l t e s t m e a ls . G re e n -A rm y ta g e (1 9 3 5 ) i n a d i s c u s s i o n o f t h e a e t i o l o g y o f a n a e m ia o f p r e g n a n c y , r e f e r r e d t o t h e r e d u c t i o n i n th e f r e e h y d ro c h lo ric a c id and t o t a l a c i d i t y o f th e g a s t r i c j u i c e , an d W i t t s

(1 9 3 5 ) o b s e r v e d t h a t h y d r o c h l o r i c

a c i d h a d b e e n fo u n d a b s e n t fro m t h e g a s t r i c o f women w i t h a n a e m ia .

j u i c e i n 80%

He p o i n t e d o u t t h a t t h e a c i d

s e c r e t i o n was p a r t i c u l a r l y l i a b l e t o f a i l b e c a u s e o f t h e g a s t r i t i s fro m w h ic h many women s u f f e r d u r i n g p r e g n a n c y . I t may b e a d d e d h e r e , t h a t t o an y o n e c o n t i n u o u s l y e n g a g e d i n t h e r o u t i n e e x a m in a tio n o f l a r g e n u m b ers o f a n t e n a t a l p a tie n ts ,

th e p re v a le n c e o f t h i s

i s e s p e c i a l l y o b v io u s .

" p re g n a n c y g a s t r i t i s "

T o v e ru d (1 9 3 5 ) fo u n d t h a t 60%

o f I4.7 p r e g n a n t women e x a m in e d d u r i n g t h e l a s t t h r e e m o n th s show ed a h y p o a c i d i t y , a n d G -oodall and G o t t l i e b (1 9 3 6 )

d e s c r i b e d a d i m i n u t i o n o r e v e n c o m p le te d i s a p p e a r ­

a n ce o f f r e e h y d r o c h lo r ic a c id d u rin g th e t h i r d t r i m e s t e r . S te v e n s o n (1 9 3 8 ) a l s o r e f e r r e d t o a c h l o r h y d r i a a s a common f i n d i n g i n t h e a n a e m ia o f p r e g n a n c y .

O ut o f

100 c o n s e c u t i v e c a s e s s t u d i e d by M cGeorge ( 1 9 3 8 ) ,

o n ly

tw o s e v e r e a n a e m ia s w e re fo u n d a n d on e o f t h e s e show ed

28. a c o m p le te p o s t - h i s t a m i n e a c h l o r h y d r i a . I n s p i t e of t h e f o r e g o i n g a p p a r e n t l y c o n v in c in g e v id e n c e ,

o t h e r a u t h o r i t i e s do n o t p l a c e s u c h im p o r ta n c e

on g a s t r i c d i s t u r b a n c e a s t h e c h i e f a e t i o l o g i c a l f a c t o r i n t h e p r o d u c t i o n o f i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y . D a v id s o n e t a l (1 9 3 3 ) w h ile a d m i t t i n g i t s

im p o r ta n c e ,

s t a t e d t h a t i t was a m oot p o i n t w h e th e r t h e a c h l o r h y d r i a l e d t o t h e a n a e m ia , o r w h e th e r t h e a n a e m ia by i t s e l f c a u s e d t h e a c h l o r h y d r i a a s a r e s u l t o f p o o r b lo o d s u p p ly to th e g a s t r i c g la n d s . D a v id s o n a n d F u l l e r t o n

In a f u r th e r c o n trib u tio n , (1 9 3 8 ) c o n s i d e r e d t h a t t h e a n a e m ia

i t s e l f w as a s e c o n d a r y f a c t o r i n t h e p r o d u c t i o n o f a c h l o r h y d r i a an d fo u n d l i t t l e

e v id e n c e t o s u p p o r t t h e

t h e o r y t h a t a c h l o r h y d r i a was t h e c a u s e o f h y p o c h ro m ic a n a e m ia , w h ic h i n t h e i r o p i n io n w as due t o a l o n g - s t a n d i n g d ie ta r y d e fic ie n c y .

B e t h e l l (1 9 3 6 ) e x a m in e d t h e

r e l a t i o n s h i p o f a n a e m ia t o g a s t r i c a c i d i t y

i n 15 p r e g n a n t

women an d c o n c lu d e d t h a t t h e te m p o r a r y r e d u c t i o n o f g a s t r i c a c i d i t y d u r i n g p r e g n a n c y was n o t a d i r e c t c a u s e o f lo w e re d b lo o d v a l u e s , a n d G-arry a n d S t i v e n (1 9 3 6 ) c o n s i d e r e d t h a t a c h l o r h y d r i a was n o t a m a jo r f a c t o r i n t h e p r o d u c t i o n o f a n a e m ia o f p r e g n a n c y on t h e b a s i s t h a t a l l a c h l o r h y d r i c s w e re n o t a n a e m ic .

W atso n (1 9 3 8 ) c a r r i e d

o u t g a s t r i c a n a l y s e s on 21*. p r e g n a n t women.

He fo u n d

f o u r p a t i e n t s w i t h a c h l o r h y d r i a an d f o u r w i t h a n o rm a l g a s h ric s e c r e tio n .

S e v e n ty t h r e e p o i n t f o u r p e r c e n t o f

29. t h e t o t a l h a d a low h y d r o c h l o r i c a c i d s e c r e t i o n .

He

d i d n o t c o n s i d e r , h o w e v e r, t h a t g a s t r i c a n a l y s i s p r o v e d a d ia g n o s tic a id in p r e d ic tin g th e c o u rse o f th e h a e m o g lo b in l e v e l d u r i n g ^ p r e g n a n c y , an d c o u ld f i n d no c o r r e l a t i o n b e tw e e n h y p o c h l o r h y d r i a and lo w h a e m o g lo b in le v e ls . Prom t h e a b o v e o b s e r v a t i o n s i t d ig e s tiv e d e fe c t,

i.e .

i s c o n c lu d e d t h a t

a d im in u tio n o r a b se n c e o f g a s t r i c

s e c r e t i o n w h e th e r te m p o ra r y o r p e rm a n e n t, m u st b e c o n s i d e r e d among t h e i m p o r t a n t a e t i o l o g i c a l f a c t o r s f a v o u rin g th e p ro d u c tio n o f an i r o n - d e f ic ie n c y o f p re g n a n c y , a s a r e s u l t o f i t s

e f f e c t on t h e d i g e s t i o n

and a b s o r p tio n o f d i e t a r y ir o n .

I t s h o u ld b e

c o n s i d e r e d , h o w e v e r, m ore a s a c o n t r i b u t o r y , t h a n a s a p rin c ip a l a e tio lo g ic a l f a c to r, p o s s ib le c a u s e s in v o lv e d .

i n v ie w o f t h e many o t h e r

M o re o v e r, i t m ust b e

rem e m b e red , t h a t i n a s tu d y o f i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y , t h e p e rf o r m a n c e o f g a s t r i c a n a l y s i s i s n o t a lw a y s a p r a c t i c a b l e p r o p o s i t i o n ,

e s p e c i a l l y when one i s

d e a l i n g w i t h l a r g e n u m b ers o f normaL h e a l t h y p r e g n a n t women, m o st o f whom a r e e x am in e d i n b u sy a n t e n a t a l c l i n i c s . I t i s n o t s u r p r i s i n g , th e re fo re ^

t h a t i n a s tu d y o f th e

l i t e r a t u r e , t h e t o t a l num ber o f t h e s e e x a m in a t io n s i s fo u n d t o b e c o m p a r a t i v e l y s m a l l , a n d r e s u l t s , h o w e v er c o n v in c in g , p r o b a b ly do n o t w a r r a n t t h e c o n c l u s i o n t h a t d e f e c t i v e g a s t r i c s e c r e t i o n i s a f a c t o r o f m a jo r

30. a e t i o l o g i c a l i m p o r ta n c e .

I t i s n o t s u g g e s te d t h a t s e r i e s

o f c a s e s r e p o r t e d i n t h e l i t e r a t u r e h a v e b e e n i n a n y way s e l e c t e d , b u t t h e r e s u l t s o f r o u t i n e g a s t r i c a n a l y s i s on a much l a r g e r num ber o f n o rm a l p r e g n a n t women, w i l l b e n e c e s s a r y , b e f o r e t h e r e l a t i o n s h i p b e tw e e n g a s t r i c d e f e c t an d a n a e m ia o f p r e g n a n c y , c a n b e a c c u r a t e l y a s s e s s e d . DEFECTIVE IRON INTAKE ASSOCIATED WITH ECONOMIC ADD SOCIAL FACTORS: I r o n d e fic ie n c y h a s b een d is c u s s e d in r e l a t i o n to t h e dem ands o f t h e f o e t u s a n d d i g e s t i v e d e f e c t i n t h e m o th e r .

I t i s now n e c e s s a r y t o c o n s i d e r t h i s d e f i c i e n c y

in r e l a t i o n t o d i r e c t d i e t a r y d e f e c t and to e s t a b l i s h w h e th e r a d e f i c i e n t d i e t i s a n i m p o r t a n t c o n t r i b u t o r y f a c t o r i n t h e p r o d u c t i o n o f i r o n - d e f i c i e n c y a n a e m ia d u r i n g p re g n a n c y .

I n t h i s c o n n e c tio n a ls o ,

t h e im p o r ta n c e o f

e c o n o m ic a n d s o c i a l f a c t o r s w i l l b e c o n s i d e r e d . W iddowson and McCance ( 1 9 3 6 ) , q u o t i n g S h e rm a n ’s f i g u r e o f 15 mgms o f i r o n p e r day a s t h e a v e r a g e d a i l y i n t a k e o f i r o n f o r women, show ed i n a s t u d y o f 63 women t h a t th e to td .

i r o n i n t a k e was o n ly 11 •!+. mgms. p e r d a y ,

a n d t h e a v a i l a b l e i r o n i n t h e d i e t 7*9 mgms. p e r d a y . D a v id s o n an d h i s c o - w o r k e r s (1 9 3 3 ) fo u n d a s i m i l a r low i r o n i n t a k e f o r women, v i z . 11*3 mgms. p e r d a y , a n d D a v id s o n an d F u l l e r t o n

(1 9 3 8 ),

d i e t s o f 115 p o o r f a m i l i e s ,

in an a n a l y s i s o f th e

fo u n d t h a t t h e d a i l y a v e r a g e

i n t a k e o f i r o n was 7*3 mgms. p e r d a y .

M ore r e c e n t l y

31. W i l l s e t a l (1 9 ^ 2 ) i n a s tu d y o f "A naem ia i n Women a n d C h i l d r e n on W a r-tim e D i e t s , " fo u n d t h e i r o n i n t a k e f o r women t o b e 11 mgms. t o t a l

i r o n a n d 7*7 mgms. a v a i l a b l e

iro n p e r day. The d a i l y i r o n r e q u i r e m e n ts d u r i n g p r e g n a n c y h a v e been v a rio u s ly a s s e s s e d .

The L eag u e o f N a t io n s D i e t a r y

Scheme a s q u o te d by McCance e t a l (1 9 3 8 ) a llo w e d 1 2 -7 mgms. p e r day.

G-arry and S t i v e n ( 1 9 3 8 ) , w h ile a d v o c a t i n g a

f i g u r e o f 11*5 mgms. p e r d a y a s t h e s t a n d a r d r e q u i r e m e n t f o r women, c o n c lu d e d fro m a r e v ie w o f d i e t a r y r e q u i r e m e n t s i n p re g n a n c y an d l a c t a t i o n , t h a t t h e n e c e s s a r y i r o n i n t a k e d u r i n g p re g n a n c y w as 18 mgms. p e r d a y , a n d D a v id s o n e t a l (1 9 3 5 )

i n a s t u d y o f n u t r i t i o n a l i r o n - d e f i c i e n c y a n a e m ia

i n p r e g n a n t and n o n - p r e g n a n t women, c o n s i d e r e d t h a t th e optim um i r o n c o n t e n t o f t h e d i e t s h o u ld b e 15 - 20 mgms. p e r day.

McOance c o n s i d e r e d t h a t t h e L ea g u e o f N a t io n s

f i g u r e was n o t s u f f i c i e n t f o r optim um n u t r i t i o n d u r i n g p r e g n a n c y an d s u g g e s t e d t h a t t h e d a i l y i r o n i n t a k e s h o u ld b e b e tw e e n 18 a n d 20 mgms. p e r d a y .

A ssum ing t h e n t h a t

p r e g n a n t women s h o u ld h a v e a n i r o n i n t a k e o f 15 mgms. p e r day o r m o re, a d i e t w h ic h w ould f a v o u r t h e p r o d u c t i o n o f a n i r o n - d e f i c i e n c y a n a e m ia , m u st p re s u m a b ly f a l l b e lo w th is le v e l.

How f a r i s t h i s a s s u m p tio n s u b s t a n t i a t e d

i n a c o n s i d e r a t i o n o f i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y i n r e l a t i o n t o d i e t a r y r e q u i r e m e n ts ? D a v id s o n an d F u l l e r t o n

(1 9 3 3 ) i n an i n v e s t i g a t i o n

o f t h e i r o n i n t a k e i n lj-9 f a m i l i e s ,

c a lc u la te d th a t th e

32. a v e r a g e i n t a k e f o r women w as 7*71 mgms. p e r c o n s id e re d th a t s in c e

75%

of th is

& ey

•

T hey

i r o n was a v a i l a b l e

an d a b o u t 5 0 % a b s o r b e d , t h e t o t a l am ount a b s o r b e d was a b o u t 2*5 mgms. d a i l y .

T h is w as l e s s t h a n h a l f t h e

am ount r e q u i r e d t o m a i n t a i n a p o s i t i v e b a l a n c e i n t h e re p ro d u c tiv e p e rio d .

On t h e o t h e r h a n d , C oons (1 9 3 2 ,

1 935) s t u d i e d 23 i r o n b a l a n c e s i n women a t d i f f e r e n t s ta g e s o f p reg n a n cy .

She fo u n d a n a v e r a g e i r o n i n t a k e

o f 1JU--72 mgms. p e r d a y , and c o n c lu d e d t h a t u n d e r f a i r l y i d e a l c o n d i t i o n s o f d i e t a n d w e l l - b e i n g , i t seem ed p o s s i b l e f o r t h e m a t e r n a l o rg a n is m t o a s s i m i l a t e d u r i n g t h e p e r i o d o f p re g n a n c y e n o u g h i r o n fro m t h e f o o d t o s u p p l y t h e n e w -b o rn i n f a n t w i t h t h e n e c e s s a r y r e s e r v e s . She c a l c u l a t e d t h a t a n i r o n i n t a k e o f g a v e a p o s i t i v e b a l a n c e o f 3*16 mgms.

7 mgms. p e r day T o v e ru d ( 1 9 3 5 ) ,

h o w e v e r, s t a t e d t h a t t h e i r o n r e q u i r e m e n t s o f t h e f o e t u s w e re e x a c t l y one t h i r d o f a n a d u l t p e r s o n ’ s d a i l y re q u ire m e n ts .

He c a r r i e d o u t i r o n m e ta b o lis m s t u d i e s

on 1 0 p r e g n a n t women b e tw e e n t h e s i x t h an d t h e n i n t h m o n th s .

T h ese women w e re k e p t u n d e r observafc io n i n a

home an d w ere g i v e n a l i b e r a l d i e t .

In 8 of th e c a se s

t h e r e t e n t i o n o f i r o n was fo u n d t o be b e lo w t h e c a lc u la te d need s o f th e f o e tu s .

T o v e ru d c o n c lu d e d

t h a t t h e r e w as a n i r o n d e f i c i e n c y i n t h e f o o d d u r i n g t h e l a s t t h r e e m o nths o f p r e g n a n c y .

F u lle rto n

(1 9 3 6 ), i n a

d e t a i l e d s tu d y o f th e i r o n re q u ire m e n ts d u rin g p re g n a n c y , c o n c lu d e d t h a t t h e e x t r a dem and f o r i r o n a m o u n te d t o 2

m gm

33. p e r day.

He d i d n o t c o n s i d e r t h a t t h e m o th e r r e q u i r e d

m ore i r o n t h a n i n t h e n o n - p r e g n a n t s t a t e , am o u n t b e i n g n e c e s s a r y f o r t h e f o e t u s , f o r t h e b lo o d l o s t a t d e l i v e r y .

th e e x tr a

and t o make u p

I t w i l l be n o te d t h a t

a l t h o u g h a n i r o n i n t a k e o f 15 - 20 mgms. p e r d a y i s q u o te d a s t h e optim um r e q u i r e m e n t d u r i n g p r e g n a n c y , n o n e o f th e a u th o r itie s re fe rre d to , le v e l,

q u o te v a l u e s u p t o t h i s

i n f a c t i n m o st c a s e s , w i t h t h e e x c e p t i o n o f G o o n s,

th e y a re c o n s id e ra b ly l e s s .

One m u st a ssu m e , t h e r e f o r e ,

t h a t t h e a v e r a g e d i e t t a k e n by t h e p r e g n a n t woman i s d e f ic ie n t in iro n .

On t h e o t h e r h a n d ,

it

i s c o n c e iv a b le

t h a t t h e s u g g e s t e d d a i l y i r o n r e q u i r e m e n t o f 15 - 20 mgms. d u r i n g p re g n a n c y may b e to o h i g h a n d n o t a t t a i n a b l e u n d e r e x i s t i n g c o n d i t i o n s , b u t i n v ie w o f th e w id e s p r e a d p r e v a l e n c e o f i r o n - d e f i c i e n c y a n a e m ia d u r i n g p r e g n a n c y , o ne w o u ld h a r d l y b e j u s t i f i e d

i n s e t t i n g a lo w e r minimum

re q u ire m e n t. In th e d is c u s s io n o f d i e t e t i c d e fic ie n c y as an a e t i o l o g i c a l f a c t o r in th e p ro d u c tio n of i r o n - d e f ic ie n c y a n a e m ia , m o st a u t h o r i t i e s h a v e d raw n a t t e n t i o n t o t h e im p o r ta n c e o f e co n o m ic an d s o c i a l c i r c u m s t a n c e s . D a v id s o n e t a l (1 9 3 5 ) i n a s t u d y o f n u t r i t i o n a l i r o n d e f i c i e n c y a n a e m ia

fo u n d t h a t t h e i n c i d e n c e o f t h i s

t y p e o f a n a e m ia i n t h e p o p u l a t i o n w as h i g h e s t among p r e g n a n t women.

T hey b e l i e v e d t h i s t o b e due t o t h e

f a c t t h a t t h e p h y s i o l o g i c a l demand f o r i r o n d u r i n g p r e g n a n c y w as n o t s a t i s f a c t o r i l y

s u p p lie d by th e d i e t s

o f many o f t h e women o f t h e p o o r e r c l a s s e s .

D a v id s o n

a n d h i s c o l l e a g u e s c o n s i d e r e d t h a t t h e s e women a s a r e s u l t o f t h e i r f i n a n c i a l c irc u m s ta n c e s ,

c o u ld n o t m eet

t h e i n c r e a s e d dem ands o f p r e g n a n c y , a n d i n t h e i r v ie w , p o v e r t y was t h e p r i n c i p a l c a u s e i n t h e p r o d u c t i o n o f t h i s fo rm o f a n a e m ia .

They d e s c r i b e d t h e d i e t o f t h e s e women

o f t h e p o o r e s t c l a s s e s a s t h e " b r e a d and t e a d i e t " , d e f i c i e n t in e v e ry c o n s t i t u e n t , p a r t i c u l a r l y m in e ra ls v i t a m i n s and a n im a l p r o t e i n s , a n d show ed t h a t i t w as among t h i s c l a s s o f p e o p le t h a t t h e h i g h e s t i n c i d e n c e o f c h r o n i c n u t r i t i o n a l a n a e m ia was f o u n d .

F u lle rto n

(1 9 3 6 ) made a

d e t a i l e d s tu d y o f d i e t e t i c d e f i c i e n c y i n r e l a t i o n t o incom e l e v e l s .

I n ao. e x a m in a tio n o f 232 p r e g n a n t women,

h e fo u n d t h a t 16 I4. i n a low incom e g ro u p h a d a n a v e r a g e h a e m o g lo b in l e v e l o f 73*1% H a ld a n e (1 0 g m s), w h e re a s 168 i n a h i g h e r in co m e g ro u p h a d an a v e r a g e h a e m o g lo b in l e v e l o f 7 9 * 1 $ H a ld a n e (10*9 g®s )»

T h e re was a d i f f e r e n c e o f

6% h a e m o g lo b in (* 9 gms) b e tw e e n t h e low a n d h i g h incom e

g ro u p s.

I n a n a p p r e c i a t i o n o f t h e s e f i n d i n g s i t m ust b e

rem em b ered t h a t t h e women e x am in e d w ere among t h e p o o r e s t c l a s s e s an d c o u ld h a r d l y b e c o n s i d e r e d r e p r e s e n t a t i v e o f t h e p o p u l a t i o n a s a w h o le .

M o re o v e r,

th e i n v e s t i g a t i o n s

w e re c a r r i e d o u t a t a tim e when unem ploym ent and p o v e r t y w e re w id e s p r e a d t h r o u g h o u t t h e c o u n t r y an d l i v i n g c o n d i t i o n s b e lo w a v e r a g e l e v e l .

H ow ever, e c o n o m ic an d

s o c i a l c ir c u m s ta n c e s h a v e b e e n w id e ly s t u d i e d among o t h e r c l a s s e s o f t h e com m unity an d t h e y u n d o u b te d ly e x e r t a n

30: i n f l u e n c e t o a g r e a t e r o r l e s s e r d e g r e e on t h e i n c i d e n c e o f n u t r i t i o n a l a n a e m ia d u r i n g p r e g n a n c y .

A d a ir e t a l

( 1 9 3 6 ) f o u n d t h a t a g ro u p o f h o s p i t a l c l a s s women w e re s l i g h t l y m ore a n a e m ic t h a n a g ro u p o f p r i v a t e p a t i e n t s , an d R e id a n d M a c k in to s h (1 9 3 7 ) i n a n e x a m in a t io n o f 1 ,1 0 8 p r e g n a n t women fo u n d t h a t t h e i n c i d e n c e o f lo w h a e m o g lo b in l e v e l s was g r e a t e s t i n t h e lo w e r in co m e g r o u p s . McOance (1 9 3 8 ) r e p o r t e d t h e r e s u l t s o f a d e t a i l e d an d i n t e r e s t i n g s t u d y on t h i s a s p e c t o f t h e s u b j e c t .

One

h u n d re d an d s i x t e e n p r e g n a n t women w e re d i v i d e d i n t o s i x g r o u p s a c c o r d i n g t o in c o m e , w h ic h v a r i e d b e tw e e n a f i g u r e o f l e s s t h a n s i x s h i l l i n g s p e r h e a d p e r w eek t o a f i g u r e o f f o r t y s h i l l i n g s a n d o v e r , p e r h e a d p e r w e ek .

In th e

l o w e s t incom e g ro u p i t w as fo u n d t h a t t h e a v e r a g e h a e m o g lo b in l e v e l was 7 6% H a ld a n e (10*lj- g m s), an d t h e i r o n i n t a k e 8 mgms. p e r d a y .

I n t h e h i g h e s t incom e g ro u p

t h e c o r r e s p o n d i n g f i g u r e s w ere 90% H a ld a n e (12*ij. gm s) a n d llj. mgms. p e r d a y . ris e

T h e s e f i g u r e s c l e a r l y d e m o n s tr a te t h e

i n h a e m o g lo b in l e v e l an d i r o n i n t a k e w i t h i n c r e a s e

i n in c o m e • I n s p i t e o f t h e a b o v e f i n d i n g s , a n a e m ia o f p r e g n a n c y i s n o t a lw a y s c o n f i n e d t o t h e p o o r e s t c l a s s e s o f t h e p o p u la tio n .

G a llo w a y (1929 1>) e x a m in e d 222 p r i v a t e

p a t i e n t s l i v i n g i n a r e s i d e n t i a l com m unity i n C h ic a g o , a n d show ed t h a t 1J4J4- ( 65 %) d e v e lo p e d a n a e m ia , a n d B la n d , G o ld s te in and F i r s t

(1 9 3 0 b ) i n a s i m i l a r s t u d y o f 200

w a rd p a t i e n t s and 1 0 0 p r i v a t e p a t i e n t s ,

fo u n d t h a t 80% o f

t h e f o r m e r and 62 % o f t h e l a t t e r g ro u p , h a d h a e m o g lo b in l e v e l s b e lo w 75% D are (10*3 g m s ).

T hey c o n c lu d e d t h a t

w h ile b e t t e r e n v iro n m e n t a n d l i v i n g c o n d i t i o n s m ig h t h a v e had a b e n e f ic ia l e f f e c t ,

t h e f a c t t h a t so many p r i v a t e

p a t i e n t s a s w e l l a s w ard p a t i e n t s w e re a f f e c t e d ,

s u g g e s te d

t h a t f a c t o r s c o n c e rn e d d i r e c t l y w i t h t h e p r e g n a n t s t a t e , m ig h t h a v e b e e n r e s p o n s i b l e f o r t h e a n a e m ia .

In re c e n t

y e a r s H a m ilto n an d W rig h t (19^.2) i n t h i s c o u n t r y , e x a m in e d 3 9 2 p r e g n a n t women,

(n o n e o f whom, t h e y s t a t e d ,

c o u ld b e

c o n s i d e r e d p o o r ) , a n d fo u n d t h e i n c i d e n c e o f i r o n d e f i c i e n c y a n a e m ia t o b e 1^0 *3% i n t h e i r u n t r e a t e d c a s e s . (H a e m o g lo b in b e lo w 70% H a ld a n e * 9*6 g m s).

W atso n (1 9 3 8 )

d i d n o t b e l i e v e t h a t e co n o m ic o r s o c i a l f a c t o r s h a d much b e a r i n g on t h e i n c i d e n c e o f t h e a n a e m ia .

He c o n s i d e r e d

t h a t o n ly e x tr e m e s o f p o v e r t y and a d v e r s e l i v i n g c o n d i t i o n s w e re a p p r e c i a b l y r e f l e c t e d i n t h e b lo o d p i c t u r e o f p re g n a n c y .

One c a n n o t , h o w e v e r, d i s m i s s t h e eco n o m ic

f a c to r in a c o n s id e r a tio n o f th e a e tio lo g y o f ir o n d e f i c i e n c y a n a e m ia o f p r e g n a n c y .

P o v e r t y an d r e d u c e d

f i n a n c i a l c ir c u m s ts in c e s , by b r i n g i n g a b o u t a l i m i t a t i o n o f t h e p u r c h a s e o f t h e e s s e n t i a l f o o d s t u f f s , m ust n e c e s s a r i l y c o n t r i b u t e t o a d e g r e e o f m a l n u t r i t i o n w h ic h w o u ld u l t i m a t e l y b e r e f l e c t e d i n t h e b lo o d p i c t u r e .

One

m u st rem em ber, h o w e v e r, when a t t e m p t i n g t o a s s e s s t h e i n c i d e n c e o f t h e a n a e m ia , t h a t among t h e p o o r e s t c l a s s e s , t h e s e same c o n d i t i o n s w o u ld t e n d t o p r o d u c e a s t a t e

of

a n a e m ia a p a r t a l t o g e t h e r fro m t h e c o i n c i d e n t a l e f f e c t

37. of p re g n a n c y . Many o t h e r w o rk e rs h a v e d ra w n a t t e n t i o n t o d e f e c t i v e d i e t a r y a n d eco n o m ic f a c t o r s i n t h e p r o d u c t i o n o f p re g n a n c y a n a e m ia .

T h e i r v ie w s may b e b r i e f l y

su m m a rise d a s f o l l o w s .

M e lla n b y ( 1 9 3 3 ) , e x p r e s s i n g

c o n c e rn a b o u t th e p re v a le n c e o f t h i s

t y p e o f a n a e m ia ,

s t r e s s e d t h e im p o r ta n c e o f a n i r o n r i c h d i e t d u r i n g p r e g n a n c y , e s p e c i a l l y one i n c l u d i n g m e a t, e g g - y o l k , g r e e n v e g e t a b l e s an d c a l f - l i v e r , a n d G -reen-A rm ytage (1 9 3 5 ) i n a p a p e r,

"The I n f l u e n c e o f Food on G h i l d - b e a r i n g , n e x p r e s s e d

a s im ila r o p in io n .

W itts

(1 9 3 5 ) c o n s i d e r e d t h a t a

d e f e c t i v e d i e t , e s p e c i a l l y one d e f i c i e n t i n i r o n , w as t h e com m onest c a u s e o f a n a e m ia i n p r e g n a n c y , an d b e l i e v e d t h a t t h e u n d e r l y i n g f a c t o r was p o v e r t y .

He s t a t e d t h a t among

t h e p o o r e s t c l a s s e s o f t h i s c o u n tr y 50 $ o f m o th e r s w ere a n a e m ic , a n d t h a t no woman c o u ld go t h r o u g h a s e r i e s o f p r e g n a n c i e s on a d i e t o f t e a , b r e a d , jam an d p o t a t o e s , an d r e m a in w e l l .

W il l s (1 9 3 5 ) p o i n t e d o u t th e p r e v a l e n c e

o f i r o n - d e f i c i e n c y a n a e m ia among women o f t h e lo w e r incom e g r o u p s , and c o n c lu d e d t h a t t h e p r e v e n t i o n o f t h i s c o n d i t i o n d e p e n d e d on t h e a v a i l a b i l i t y

o f an iro n r ic h

d i e t , w h ic h was n o t w i t h i n t h e m eans o f a l l c l a s s e s o f th e p o p u la tio n .

Brow ne (1 9 3 7 ) s i m i l a r l y s t r e s s e d t h e

im p o r ta n c e o f t h e i r o n - c o n t a i n i n g f o o d s d u r i n g p r e g n a n c y an d p o i n t e d o u t t h a t ,

among w o rk in g women, a d i e t

c o n s i s t i n g m o s tly o f b r e a d , t e a , m a r g a r in e , p o t a t o e s and f i s h , w as a l l t o o common.

He s t a t e d t h a t th e a v e r a g e d i e t

38. i n t h i s c o u n tr y c o n t a i n e d a b o u t 10 mgms* o f i r o n d a i l y , a n d c o n s i d e r e d t h a t a t l e a s t 20 mgms. w ere n e c e s s a r y d u rin g p re g n a n c y .

R e f e r e n c e h a s a l r e a d y b e e n made t o

t h e w ork o f S t r a u s s and C a s t l e S h e lle y

( p . 2 5 ) , a n d D a v is a n d

( p . 2 6 ) , who s t u d i e d t h e i n c i d e n c e o f a n a e m ia i n

p re g n a n c y i n r e l a t i o n t o f a u l t y d i e t .

A ls o , t h e A m e ric a n

w o r k e r s , R i c h t e r , M eyer an d B e n n e t t ( 19514.) , i n a s e r i e s o f 99 a n t e n a t a l c a s e s , fo u n d t h a t 70 d ie ta ry h a b its ,

Q O fo

had f a u l t y

due t o p o v e r t y o r r e s t r i c t e d f o o d r a t i o n s .

The d i e t s w ere d e f i c i e n t c h i e f l y i n m e a ts ,

fresh f r u it

and v e g e t a b l e s an d m a in ly c o n s i s t e d o f e x c e s s i v e a m o u n ts o f c a r b o h y d r a t e i n t h e fo rm o f b r e a d , p o t a t o e s , an d s w e e ts .

M cGeorge (1 9 5 5 ) i n New Z e a la n d ,

s t u d y o f 1 0 0 a n t e n a t a l c a s e s , fo u n d t h a t ,

c e re a ls

in h is

o f th o s e in th e

a n a e m ic g r o u p , 16 % w ere l i v i n g on v e r y i n a d e q u a t e d i e t s i n c o n d itio n s o f p o v e rty and m a l n u t r i t i o n . The r e c e n t w ar a f f o r d e d a n a d m i r a b l e o p p o r t u n i t y o f s t u d y i n g t h e d i e t a r y r e q u i r e m e n t s o f p r e g n a n t women i n r e l a t i o n t o a n a e m ia , a s t h e r a t i o n i n g o f t h e e s s e n t i a l f o o d s w ould h a v e be e n e x p e c te d t o a l l o w o f a m ore e q u i t a b l e d i s t r i b u t i o n among t h e w h o le p o p u l a t i o n , w i t h a c o r r e s p o n d i n g im p ro v e m e n t i n n u t r i t i o n among t h e p o o re r c la s s e s .

The e f f e c t o f w a r - tim e r a t i o n i n g

in

r e l a t i o n t o t h e a n a e m ia o f p r e g n a n c y w o u ld n o t , h o w e v e r, a p p e a r to be a l t o g e t h e r e n c o u ra g in g .

Kay an d A l s t o n

( I 9 I4.I ) e x a m in e d a s e r i e s o f 819 p r e g n a n t women i n L ondon a n d co m p ared t t e s i r r e s u l t s w i t h a s i m i l a r s e r i e s ,

39. i n v e s t i g a t e d d u r in g t h e y e a r s 1937 - 1 9 3 9 .

T h ey fo u n d

t h a t t h e p r e - w a r i n c i d e n c e o f a n a e m ia o f 5*3$ h a d i n c r e a s e d t o 39$ i n 1 9 ^ 1 , a n d c o n c lu d e d t h a t t h e f o o d t a k e n by p r e g n a n t women i n N o r th London i n 19M h a d b e e n i n a d e q u a t e in iro n .

Thomas (19^-2) came t o a s i m i l a r c o n c l u s i o n ,

f i n d i n g a n i n c i d e n c e o f a n a e m ia o f 52 $ i n 1I4.0 p r e g n a n t women ex am in e d i n L ondon. H a ld a n e =* 9*6 g m s). th is

(H a e m o g lo b in l e s s t h a n 70$

He s t a t e d t h a t i t w as u n l i k e l y t h a t

i r o n d e f i c i e n c y was c o n f i n e d t o t h e L ondon a r e a .

H a m ilto n an d W rig h t ( 1 9 14.2 ) s u g g e s t e d t h a t women o f t h e a r t i s a n c l a s s w ere m ore a n a e m ic d u r i n g p re g n a n c y t h a n b e f o r e t h e w a r, a n d a t t r i b u t e d t h i s t o w a r - tim e d i e t a r y . The e f f e c t o f w a r - tim e c o n d lt i o n s on t h e i n c i d e n c e o f p r e g n a n c y a n a e m ia was a l s o ( 19 J4. 2 ) .

i n v e s t i g a t e d b y M ackay e t a l

She c o n c lu d e d t h a t

th e r e had b een a le v e ll i n g

down o f h a e m o g lo b in l e v e l s i n many c l a s s e s of t h e com m unity d u r i n g t h e w a r, p o s s i b l y due t o a l e v e l l i n g down o f n u t r i t i o n .

She c o n s i d e r e d t h a t t h e r e m ig h t b e

a l e v e l l i n g up o f h a e m o g lo b in l e v e l s among t h e p o o r e s t c l a s s e s o f t h e co m m u n ity , due t o th e d i s a p p e a r a n c e o f u n e m p lo y m e n t, r a t i o n i n g , a n d fo o d p r i o r i t i e s , fo u n d no e v id e n c e o f t h i s

b u t she

in h e r in v e s tig a tio n s to d a te .

S i n c l a i r (1914-2) c o n s i d e r e d t h a t w a r - tim e d i e t s c o n t a i n e d le s s a v a ila b le

i r o n t h a n t h e y d id b e f o r e t h e w a r .

A ls o ,

W il l s e t a l (1 9U2) i n t h e i r s t u d y o f a n a e m ia i n women a n d c h i l d r e n on w a r - tim e d i e t s ,

f o u n d t h a t t h e m ean

h a e m o g lo b in v a l u e s i n women w e re lo w e r t h a n t h e p r e - w a r

to. l e v e l a n d s u g g e s te d a reaL

i n c r e a s e i n a n a e m ia among

women. T h ese w a r - tim e s t u d i e s , t h e r e f o r e ,

t e n d t o show a

m ark e d i n c r e a s e i n i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y , i n c o m p a ris o n w ith p r e - w a r r e s u l t s .

As one w o u ld e x p e c t ,

h o w e v e r, t h e s e f i n d i n g s h a v e n o t b e e n c o n fir m e d by o t h e r w o rk e rs.

D a v id s o n a n d F u l l e r t o n a n d t h e i r c o - w o r k e r s

c a r r i e d o u t a s e r i e s o f i n v e s t i g a t i o n s on p r e g n a n t women d u r i n g t h e w ar y e a r s .

(D a v id s o n an d D o n a ld s o n 1 9 t o ,

F u l l e r t o n , M a ir and TJnsw orth 1 9 to , D a v id s o n , D o n a ld s o n , L in d s a y a n d R o sc o e i g t o ) .

T hey fo u n d by c o m p a r is o n w i t h

t h e i r own p r e - w a r r e s u l t s t h a t t h e d e g r e e o f a n a e m ia among p r e g n a n t women d u r i n g t h e w a r h a d d e c r e a s e d .

In

p a r t i c u l a r , D a v id s o n , D o n a ld s o n , L in d s a y an d R o sco e show ed a n im p ro v e m e n t b e tw e e n t h e y e a r s 19 t o a n d 19 to * T hey fo u n d t h a t t h e a v e r a g e h a e m o g lo b in l e v e l among p r e g n a n t women i n 1 9 to was 77$ H a ld a n e ( 10 * 6 g m s), a s co m p ared w i t h 8 6 *8 $ H a ld a n e

(11*9 gms) i n 1 9 t o .

T hey

a t t r i b u t e d t h i s im p ro v em en t t o t h e i n t r o d u c t i o n o f t h e n a t i o n a l w h e a t-m e a l b r e a d ( 85 $ e x t r a c t i o n f l o u r ) w i t h a n i r o n c o n t e n t o f 0 * 7 mgms p e r o z . , a s co m p a red w i t h w h ite b r e a d (7 0 $ e x t r a c t i o n f l o u r ) w i t h a n i r o n c o n t e n t o f 0*3 mgms. p e r o z .

T hey c a l c u l a t e d t h a t a n a v e r a g e

d a i l y i n t a k e o f 6 o z s . o f n a t i o n a l w h e a t m e a l b r e a d w o u ld r e s u l t i n a n a d d i t i o n a l i n t a k e o f 2 mgms. o f i r o n d a i l y . T h e se f i n d i n g s a r e o f p a r t i c u l a r i n t e r e s t w hen s t u d i e d i n c o n j u n c t i o n w i t h t h e w a r - tim e e x p e r i m e n t s o f W iddow son

k1. a n d h i s c o l l e a g u e s , a n d i t m ig h t h e p r o f i t a b l e t o d i g r e s s f o r a moment t o c o n s i d e r t h e s e e x p e r i m e n t s ,

i f o n ly t o

d e m o n s tr a te s t i l l f u r t h e r t h e w id e d iv e r g e n c e o f o p i n i o n w h ic h s t i l l e x i s t s w i t h r e g a r d t o t h e p a r t p l a y e d by d i e t e t i c f a c t o r s in th e p r o d u c tio n o f th e i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y . W iddowson an d A ld in g to n (1 9 M ) i n a s t u d y o f " M id d le c l a s s D i e t s i n P e a c e and W ar," fo u n d t h a t t h e i r o n c o n s u m p tio n o f t h e d i e t h a d i n c r e a s e d d u r i n g t h e w a r. T hey show ed t h a t t h e t o t a l

i r o n i n t h e d i e t i n 1935 a n d

19^4-1 was 11 - 14. mgms. an d 12*2 mgms. r e s p e c t i v e l y , t h e c o r r e s p o n d i n g f i g u r e s f o r i n o r g a n i c i r o n b e in g 7*9 mgms. an d 9*2 mgms.

T hey c o n s i d e r e d t h a t t h e i r o n a c q u i r e d

fro m t h e i n c r e a s e d b r e a d a n d v e g e t a b l e s , m ore t h a n made up f o r t h e i r o n s a c r i f i c e d by t h e s h o r t a g e o f m e a t.

In

a d d i t i o n , h o w e v e r, W iddowson a n d McCance (19 ii2 ) s t u d i e d t h e i r o n i n t a k e on d i e t s o f w h ite b r e a d a n d brow n b r e a d i n e i g h t s u b j e c t s , f o u r women a n d f o u r m en.

The w h i t e

f l o u r u s e d , c o n t a i n e d 1 -lj.1 mgms. o f i r o n p e r 100 gm s. a n d t h e brow n 3*55 mgms. o f i r o n p e r 100 g m s .,

so t h a t t h e

i r o n i n t a k e on t h e brow n b r e a d d i e t was c o n s i d e r a b l y h i g h e r t h a n t h a t on t h e w h ite b r e a d .

T hey fo u n d t h a t

t h e i r s u b j e c t s a b s o r b e d m ore i r o n fro m t h e w h ite b r e a d t h a n fro m t h e b ro w n , i n s p i t e o f t h e f a c t t h a t i n t a k e s w e re 50$ h i g h e r i n t h e brow n b r e a d e x p e r i m e n t s .

T hey

t h o u g h t t h a t t h e e x p l a n a t i o n o f t h i s d i s c r e p a n c y m ig h t b e th e i n d ig e s t i b le b ran n y p a r t i c l e s

i n t h e brow n b r e a d ,

J+2. and t h e i r la x a tiv e a c tio n , o r th e p re s e n c e in la r g e V

a m o u n ts o f p h y t i c a c i d i n t h e b row n b r e a d , n«hich p r e c i p i t a t e d th e ir o n in th e g u t a s an in s o lu b le s a l t . W h a te v e r t h e e x p l a n a t i o n , t h e e x p e r im e n t show ed t h a t i r o n was a b s o r b e d fro m d i e t s i n w h ic h w h i t e f l o u r c o n s t i t u t e d I4.0 - 50 $ o f t h e t o t a l

c a lo rie s ,

and t h a t ir o n

was n o t a b s o r b e d fro m s i m i l a r d i e t s whoi t h e w h ite f l o u r was r e p l a c e d by one o f 92$ e x t r a c t i o n .

W iddow son a n d

McOance s u g g e s te d t h a t i n s p i t e o f t h e l a r g e a m o u n ts o f i r o n i n w h o le w h e a t, b r e a d made fro m i t m ig h t n o t b e a s g o o d a s o u r c e o f i r o n a s i s generaL l y s u p p o s e d . ( 19 i(.2 ) ,

S in c la ir

in a r e f e r e n c e to th e s e e x p e rim e n ts , p u t fo rw a rd

th e o p in io n , t h a t th e a d o p tio n o f n a ti o n a l w heat m eal b re a d had in c r e a s e d th e l i a b i l i t y a n a e m ia .

to ir o n - d e f ic ie n c y

T h ese f i n d i n g s w o u ld seem t o r e f u t e t h e

c o n c l u s i o n s draw n b y D a v id s o n , F u l l e r t o n a n d t h e i r c o lle a g u e s t h a t th e a d o p tio n o f th e n a ti o n a l w heat m eal b re a d had re d u c e d th e in c id e n c e o f i r o n - d e f i c i e n c y a n a e m ia i n p r e g n a n c y .

In d ee d ,

in s p ite of th e s e

c o n c l u s i o n s , D a v id s o n , D o n a ld s o n e t a l

(1914-3) fo u n d t h a t

t h e h a e m o g lo b in l e v e l s o f p r e g n a n t women e x a m in e d i n E d in b u r g h i n 1 9I4.2 , w ere s l i g h t l y lo w e r t h a n t h o s e o f a s i m i l a r g ro u p e x a m in e d i n A b e rd e e n i n 1935»

The 193 5

g ro u p h a d a n a v e r a g e h a e m o g lo b in o f 78 * 1 $ H a ld a n e (1 0 * 7 gms) a n d t h e I 9I4.2 g r o u p , a n a v e r a g e h a e m o g lo b in o f 75* 8 $ H a ld a n e ( 1 0 *14- g m s).

As a r e s u l t , t h e r e f o r e ,

o f th e

e x p e r im e n ts o f W iddowson a n d M cOance, i t w o u ld b e u n w is e

k3. t o p l a c e t o o much r e l i a n c e on t h e b e n e f i c i a l e f f e c t s o f w h o le m e a l b r e a d a s a p r e v e n t i v e f a c t o r a g a i n s t t h e p r o d u c t i o n o f i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y , a s s u g g e s t e d b y D a v id s o n a n d F u l l e r t o n , u n l e s s f u r t h e r e x p e r i m e n t a l w ork s h o u ld e s t a b l i s h i t s v a l u e . A f t e r a c o n s i d e r a t i o n o f t h e e v id e n c e , t h e r e w o u ld seem t o b e l i t t l e

doubt th a t d e f i c ie n t ir o n in ta k e in

t h e d i e t o f t h e p r e g n a n t woman, p l a y s a l a r g e p a r t i n t h e p r o d u c t i o n o f t h e i r o n - d e f i c i e n c y a n a e m ia so f r e q u e n t l y fo u n d i n a s s o c i a t i o n w i t h t h e p r e g n a n t s t a t e .

W hat i s

n o t s o c e r t a i n , h o w e v e r, i s w h e th e r a v a i l a b l e e x p e r i m e n t a l e v id e n c e c o n c l u s i v e l y p r o v e s t h a t i r o n - d e f i c i e n c y i s t h e p rin c ip a l a e tio lo g ic a l fa c to r.

The r e s u l t s o f m o st

d i e t a r y s u r v e y s w h ic h t e n d t o i n d i c a t e a n i r o n - d e f i c i e n t d i e t a s a c o n c o m ita n t o f a n a e m ia o f p r e g n a n c y , h a v e b e e n fo u n d i n p o p u l a t i o n s , among w h ic h one w o u ld e x p e c t t o f i n d a d e g r e e o f a n a e m ia a p a r t a l t o g e t h e r fro m p r e g n a n c y . I t h a s a l r e a d y b e e n p o i n t e d o u t ( p .3 M

th a t,

in th is

c o u n t r y , t h e s e s u r v e y s w ere c a r r i e d o u t among t h e p o o r e s t c l a s s e s o f t h e com m unity w h e re p o v e r t y was w i d e s p r e a d , an d t h e s t a n d a r d o f l i v i n g w e l l b e lo w a v e r a g e ,

c h ie fly

a s a r e s u l t o f t h e u n em p lo y m en t and i n d u s t r i a l d e p r e s s i o n o f th e in te r-w a r y e a rs .

T h e se c o n d i t i o n s w ould

n a t u r a l l y h a v e t h e i r m o st s e v e r e e f f e c t o n t h e w o r k in g c l a s s c o m m u n ity .

The c l i n i c a l m a t e r i a l s t u d i e d ,

th e r e f o r e , c an h a rd ly be re g a rd e d as r e p r e s e n ta tiv e o f t h e c o u n tr y a s a w h o le u n d e r n o rm a l c o n d i t i o n s .

M o re o v e r,

k b .

t h e r e s u l t s do n o t a lw a y s j u s t i f y t h e c o n c l u s i o n s . F o r e x a m p le , D a v id s o n a n d F u l l e r t o n

(1 9 3 3 ) e x a m in e d a

l a r g e s e r i e s o f women, p r e g n a n t an d n o n - p r e g n a n t a l i k e , fro m t h e p o o r e s t c l a s s e s o f t h e p o p u l a t i o n .

T hey f o u n d

t h a t t h e p r e g n a n t women h a d a n a v e r a g e h a e m o g lo b in l e v e l o n ly 5% lo w e r t h a n t h e n o n - p r e g n a n t , f o r t h e d i f f e r e n t a g e -g ro u p s.

C o n s id e r in g t h e many a e t i o l o g i c a l f a c t o r s

c o n c e r n e d i n t h e p r o d u c t i o n o f i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y , one o f t h e s e a l o n e , v i z . h y d r a e m ia , m ig h t e a s i l y a c c o u n t f o r t h e s m a ll d i f f e r e n c e i n t h e h a e m o g lo b in le v e ls ,

q u i t e a p a r t fro m e c o n o m ic , s o c i a l o r d i e t e t i c

fa c to rs .

H ow ever, f o r t h e r e a s o n s a l r e a d y s t a t e d

( p . 3 6 ),

i t i s c o n s i d e r e d t h a t e c o n o m ic c o n d i t i o n s t e n d i n g t o a s t a t e o f p o v e r t y m ust n e c e s s a r i l y b e a c o n t r i b u t o r y f a c t o r i n t h e p r o d u c t i o n o f i r o n - d e f i c i e n c y a n a e m ia d e v e l o p in g d u r in g p r e g n a n c y . th e d i e t ,

Among t h e p o o r e s t c l a s s e s ,

p r e v i o u s t o t h e a d v e n t o f w a r - tim e r a t i o n i n g

and p r i o r i t i e s ,

m ust h a v e b e e n d e f i c i e n t i n a l l i t s

c o n s titu e n ts , and i t s

q u a l i t y g o v e rn e d b y t h e f i n a n c i a l

s t a t u s o f t h i s c l a s s o f t h e co m m u n ity . d e f i c i e n c y , a s h a s b e e n show n ( p . 3 6 ) ,

B ut ir o n i s n o t o n ly c o n f i n e d

t o t h e p o o r e r c l a s s e s , a n d one m u st f i n d a n e x p l a n a t i o n f o r t h e c o n ti n u e d p r e v a l e n c e ,

and i n some c a s e s ,

in c re a s e ,

o f t h i s ty p e o f a n a e m ia d u r i n g t h e r e c e n t w a r, when t h e i r o n - c o n t e n t o f t h e d i e t im p ro v e d a s c o m p a red w i t h p r e ­ w ar y e a r s .

T h e re i s a l s o t h e a d d i t i o n a l f a c t o r t h a t

d u r i n g t h e w ar y e a r s un em p lo y m en t a n d p o v e r t y a s i t was

known b e f o r e t h e w ar i n t h i s c o u n t r y , l a r g e l y d i s a p p e a r e d , and t h e r e was a r a i s i n g o f incom e l e v e l s co m b in ed w i t h a m ore e q u a b le d i s t r i b u t i o n o f t h e e s s e n t i a l f o o d s t u f f s , e s p e c i a l l y th o s e r i c h in ir o n , so t h a t a d i e t o f a r e a s o n a b l e s t a n d a r d was c e r t a i n l y w i t h i n t h e m eans o f e v e r y member o f t h e com m unity.

The e x p l a n a t i o n may b e

fo u n d i n t h e f a c t t h a t t h e r e c o g n i s e d o p t im a l i n t a k e o f i r o n i n t h e a v e r a g e d i e t o f t h i a c o u n tr y h a s n e v e r re a c h e d th e a c c e p te d s ta n d a r d .

A m ore p r o b a b l e

e x p l a n a t i o n , h o w e v e r, may b e t h e g e n e r a l ig n o r a n c e among t h e p o p u l a t i o n o f t h e s im p le d i e t e t i c r e q u i r e m e n t s o f p r e g n a n c y an d t h e m eans o f p r o c u r i n g t h e s e .

H a m ilto n

an d W rig h t ( 19 I1.2 ) d re w a t t e n t i o n t o t h i s f a c t , a n d s u g g e s t e d t h a t t r a i n i n g i n s im p le d i e t e t i c s s h o u ld fo rm p a r t o f t h e r o u t i n e a n t e n a t a l c a r e o f p r e g n a n t women. On t h e o t h e r h a n d , D a v id s o n e t a l (1 9 I4-2 ) h a v e s u g g e s t e d a d i f f e r e n t e x p l a n a t i o n f o r t h e c o n ti n u e d p r e v a l e n c e o f i r o n - d e f i c i e n c y a n a e m ia d u r i n g t h e w a r y e a r s . o f t h e i r many c o n t r i b u t i o n s on t h i s s u b j e c t ,

I n one " N u tritio n a l

I r o n - d e f i c i e n c y A naem ia i n W a r - tim e " , t h e y c o n s i d e r e d t h a t w h i l e i n p e a c e - t i m e , e co n o m ic s t a t u s was t h e c h i e f f a c t o r in flu e n c in g th e n u t r i t i o n o f in d iv id u a ls , in g , and th e d i f f i c u l t y

" ra tio n ­

i n o b t a i n i n g some u n r a t i o n e d

f o o d s , c o n s t i t u t e t h e c h i e f l i m i t a t i o n s , w h ic h b r o a d l y s p e a k in g , a re o p e r a tiv e ,

i r r e s p e c t i v e o f in c o m e ."

W h ile i t i s c o n s i d e r e d , t h e r e f o r e , t h a t d i e t a r y d e f e c t s i n a s s o c i a t i o n w i t h e co n o m ic a n d s o c i a l c i r c u m s t a n c e s

k6. p l a y a v e r y im p o r ta n t p a r t i n t h e p r o d u c t i o n o f i r o n d e f i c i e n c y a n a e m ia o f p re g n a n c y , o t h e r f a c t o r s a r e d e f i n i te l y o p e ra tiv e .

Some o f t h e s e h a v e b e e n c o n ­

s id e re d in t h i s d is c u s s io n o f a e tio lo g y .

O th e r s o f

m ore o b s c u r e o r i g i n , s t i l l r e q u i r e f u r t h e r e l u c i d a t i o n .

NUMBER OF PREVIOUS PREGNANCIES: The e f f e c t o f a n i n c r e a s i n g num ber o f p r e g n a n c i e s on t h e d e g r e e o f i r o n - d e f i c i e n c y a n a e m ia i s a g a i n a s u b j e c t on w h ic h t h e r e i s c o n s i d e r a b l e d i s a g r e e m e n t .

D a v id s o n

e t a l (1 9 3 3 , 19^4-) c o n c lu d e d t h a t t h e a n a e m ia w as m o st m ark ed i n women w i t h t h r e e p r e g n a n c i e s o r m o re, an d s u g g e s t e d t h a t f r e q u e n t p r e g n a n c i e s c o n s t i t u t e d on e o f t h e m ain a e t i o l o g i c a l f a c t o r s .

F u lle rto n

(1 9 3 6 )

c o n s i d e r e d a n e x c e s s i v e num ber o f p r e g n a n c i e s t o b e a c o n trib u to ry f a c to r ,

o p e ra tin g c h ie f ly a s a r e s u l t o f

e x c e s s iv e b lo o d -lo s s a t p a r t u r i t i o n .

He b e l i e v e d ,

h o w e v e r, t h a t t h e e f f e c t o f p a r i t y was r e a l l y t h e e f f e c t o f a g e , t h e num ber o f p r e g n a n c i e s b e i n g l i k e l y t o b e g r e a te r in th e o ld e r a g e -g ro u p .

D a v is a n d S h e l l e y

(1 9 3 I 4 . )

lik e w is e c o n s id e re d p a r i t y a s a c o n tr ib u to r y f a c t o r . R e id an d M a c k in to s h (1 9 3 7 ) b e l i e v e d t h a t w h ile m u l t i p a r i t y i n g o o d s o c i a l c i r c u m s ta n c e s was w i t h o u t e f f e c t , i n women w i t h f i v e o r m ore p r e g n a n c i e s ,

except

i t was a s s o c i a t e d

w i t h i n c r e a s e d a n a e m ia i n t h e lo w e r incom e g r o u p s . ( 1 9 3 7 ) was m ore d e f i n i t e on t h i s p o i n t ,

s ta tin g th a t

" p r e g n a n c y an d p a r t i c u l a r l y a r a p i d s u c c e s s i o n o f

E vans

h i.

p r e g n a n c i e s , h a s b e e n show n f r e q u e n t l y t o p r e c i p i t a t e s u c h a n a n a e m i a ."

O th e r w o rk e rs i n t h i s c o u n t r y ^ nd

i n C an ad a an d A m e ric a h a v e s u p p o r t e d t h i s v ie w .

(K e rw in

an d C o l l i n s 1926, P e p p e r 1 9 2 9 , G o o d a ll and G o t t l i e b 1 9 3 6 , G o t t l i e b an d S t r e a n 1 9 3 9 , S te v e n s o n 1 9 3 8 , W h itb y 1 9 I4.6 ) . I t i s c o m p a r a t i v e l y e a s y , h o w e v e r, t o p r o d u c e a p p a r e n t l y c o n c l u s i v e e v id e n c e i n s u p p o r t o f th e o p p o s i t e v ie w .

D a v id s o n e t a l (1 9 3 5 ) i n t h e i r m ass s u r v e y on

n u t r i t i o n a l i r o n - d e f i c i e n c y a n a e m ia , fo u n d t h a t h a e m o g lo b in l e v e l s w ere lo w e r a n d t h e i n c i d e n c e o f a n a e m ia h ig h e r,

i n p r e g n a n t a s co m p a red w i t h n o n - p r e g n a n t women

o f t h e sam e a g e g r o u p , b u t t h e y th o u g h t t h a t t h e d i f f e r e n c e m ig h t b e e x p l a i n e d by t h e p h y s i o l o g i c a l h y d ra e m ia o f p re g n a n c y r a t h e r t h a n by a g e o r p a r i t y . B o y c o tt (1 9 3 6 ) c o n c lu d e d t h a t n e i t h e r s o c i a l s t a t u s , a g e o r p a r i t y b o r e a n y r e l a t i o n t o t h e c a u s e o f t h e a n a e m ia . T h is l a c k o f r e l a t i o n s h i p b e tw e e n p a r i t y a n d t h e i n c i d e n c e o f t h e a n a e m ia h a s a l s o b e e n o b s e r v e d by many A m e ric a n an d c o n t i n e n t a l w o r k e r s , m o st o f whom h a v e fo u n d no d i f f e r e n c e i n t h e i n c i d e n c e o f a n a e m ia b e tw e e n p r i m i p a r a e an d m u l t i p a r a e . B la rd , G o l d s t e i n a n d F i r s t

(G a llo w a y 1 9 2 9 b , Lyon 1 9 2 9 ) . (1 9 3 0 ) i n tw o p a p e r s ,

"The

P h y s i o l o g i c a l A naem ia o f P re g n a n c y " an d " S e c o n d a ry A naem ia i n P re g n a n c y a n d t h e P u e r p e r iu m " , r e p o r t e d on t h e i n v e s t i g a t i o n o f 1 ,3 0 0 p r e g n a n t women, a n d show ed t h a t p a r i t y was n o t r e l a t e d t o t h e a n a e m ia . p a p e r s 5! $ o f p r i m i p a r a e an d 58 $

o f

I n one o f th e s e

m u l t i p a r a e w e re

ks. shown t o b e a n a e m ic , an d i n t h e o t h e r t h e i n c i d e n c e was 78*

y jo

a n d 82*8$ r e s p e c t i v e l y .

O th e r A m e ric a n w o r k e r s

h a v e e x p r e s s e d s i m i l a r v ie w s ( N a ll e 1 9 5 0 , M oore 1 9 5 0 , S t r a u s s an d C a s t l e 1 9 3 2 ).

B e t h e l l e t a l (1 9 3 9 ) c o u l d

f i n d "no e v i d e n t r e l a t i o n s h i p b e tw e e n p a r i t y an d t h e i n c i d e n c e o r s e v e r i t y o f t h e a n a e m i a ," a v ie w w h ic h a l s o f i n d s s u p p o r t i n t h e G erm an l i t e r a t u r e

in o b se rv a ­

t i o n s b y K u h n e l (1 9 2 7 ) and E s c h ( 1 9 5 2 ) . Prom t h e f o r e g o i n g r e v ie w i t

i s d i f f i c u l t t o make

a n y d e f i n i t e p ro n o u n c e m e n t on t h i s v e r y c o n t r o v e r s i a l s u b j e c t , b u t one i s

i n c l i n e d t o t h e v ie w e x p r e s s e d by

R e id a n d M a c k in to s h t h a t p a r i t y i s l i k e l y t o e x e r t a n i n f l u e n c e on t h e i n c i d e n c e o f a n a e m ia among t h e lo w e r incom e g r o u p s .

I t is

in t h i s c la s s o f th e p o p u la tio n

t h a t one w ould e x p e c t t o f i n d t h e lo w e s t s t a n d a r d o f n u t r i t i o n , and i t

i s i n t h i s same g ro u p t h a t o n e f i n d s

t h e l a r g e s t num ber o f p r e g n a n c i e s , b u t w h e th e r p a r i t y o r m a l n u t r i t i o n o r p o s s i b l y a c o m b in a tio n o f b o t h , a r e to be re g a rd e d as p r in c ip a l a e t io l o g i c a l f a c t o r s ,

is

s t i l l a d e b a t a b l e p o i n t a n d on e w h ic h i s n o t e a s i l y s e ttle d . DISCUSSION OH AETIOLOGY OP IRON-DEPICIENCY ANAEMIA OP PREGNANCY: The a e t i o l o g y o f t h e i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y h a s now b e e n c o n s i d e r e d w i t h r e f e r e n c e t o t h e

m ore i m p o r t a n t and g e n e r a l l y a c c e p t e d a e t i o l o g i c a l f a c to r s , v iz :

P r e - e x i s t i n g A n aem ia, F o e t a l Demand f o r

I r o n , D e fe c tiv e D ig e s tio n , D e f ic ie n t I r o n I n ta k e a s s o c i a t e d w i t h E conom ic a n d S o c i a l F a c t o r s an d Number o f P re v io u s P re g n a n c ie s .

A t t h e same t im e , w h ile

c o n s id e rin g each o f th e s e f a c to r s in d iv id u a lly ,

on e m u st

a lw a y s b e a r i n m ind t h e n o rm a l e f f e c t o f b lo o d d i l u t i o n , o r h y d r a e m ia , d u r i n g p r e g n a n c y , w h ic h i n i t s e l f may b e a c a u s e o f t h e a n a e m ia .

I t i s c le a r t h a t th e e f f e c t o f

no s i n g l e a e t i o l o g i c a l f a c t o r c a n b e a c c u r a t e l y a s s e s s e d w i t h o u t c o n s i d e r i n g t h i s phenom enon.

It

i s e q u a lly c l e a r

t h a t many c a s e s o f i r o n - d e f i c i e n c y a n a e m ia d i s c o v e r e d d u r i n g p r e g n a n c y , ®ay h a v e e x i s t e d p r i o r t o c o n c e p t i o n , a n d a r e i n f a c t i r o n - d e f i c i e n c y a n a e m ia s o f lo n g s t a n d i n g , w h ic h h a v e o n ly b e e n d i s c o v e r e d on r o u t i n e a n t e n a t a l e x a m in a t io n .

W hile a c o m b in a tio n o f a l l t h e s e f a c t o r s

i s u n d o u b te d ly r e s p o n s i b l e f o r t h e p r e v a l e n c e o f t h e c o n d i t i o n , t h e r e w o u ld a p p e a r t o b e o t h e r p r e d i s p o s i n g cau ses o r d e f ic ie n c ie s o p e ra tiv e ,

i f o n ly b y r e a s o n o f

th e f a c t t h a t n o t a l l c a s e s resp o n d to tr e a tm e n t i n d ic a te d by a c c e p ta n c e o f th e above a e t i o l o g i c a l p rin c ip le s . th e l i t e r a t u r e

F o r i n s t a n c e , r e f e r e n c e i s t o b e fo u n d i n to o th e r m in e ra l d e f i c ie n c i e s ,

v ita m in d e f i c i e n c i e s . b u t th e ir e ffe c t,

and a ls o

( I r v i n g 1 9 3 5 , M e y e r-W e d e ll 19^4-3),

i f a n y , on t h e i r o n m e ta b o lis m d u r i n g

p re g n a n c y , i s n o t s u f f i c i e n t l y c o n c lu s iv e to w a rra n t t h e i r i n c l u s i o n among t h e p r i n c i p a l c a u s e s o f t h i s t y p e

o f a n a e m ia .

M o re o v e r, i t h a s b e e n p o i n t e d o u t a s

r e c e n t l y a s 19^4-7 b y B ra n s by a n d M agee, t h a t f o r e x p e c t a n t m o th e r s " t h e r a t i o n e d fo o d s p r o v i d e e n o u g h o r m ore o f p r o t e i n s , c a lc iu m , i r o n a n d v i t a m i n s A. a n d 0 . "

U n til

f u r t h e r i n v e s t i g a t i o n h a s b e e n c a r r i e d o u t on t h e s e a n d o t h e r a s p e c t s o f t h e s u b j e c t , one m ust be c o n t e n t w i t h t h e c o n c l u s i o n t h a t t h e i r o n - d e f i c i e n c y a n a e m ia o f p re g n a n c y i s due t o a c o m b in a tio n o f one o r m ore o f t h e f a c t o r s a l r e a d y m e n tio n e d , none o f w h ic h c a n b e r e g a r d e d p e r se as th e p r i n c i p a l a e t io l o g i c a l f a c t o r .

O th e r

m in e r a l an d v i ta m in d e f i c i e n c i e s may y e t b e p ro v e d t o p l a y an i m p o r ta n t c o n t r i b u t o r y r o l e .

51. CHAPTER I I I . PERNICIOUS ANAEMIA OF PREGNANCY. As a l r e a d y p o i n t e d o u t ,

( p . 13) n o t one c a s e o f t h e

p e r n i c i o u s v a r i e t y o f a n a e m ia was fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n an d i t i s n o t p r o p o s e d , t h e r e f o r e , d i s c u s s t h i s c o n d i t i o n i n an y d e t a i l . o f t h e w id e ly r e p o r t e d p r e v a l e n c e o f t h e

to

H ow ever, i n v ie w iro n -d e fic ie n c y

ty p e o f a n a e m ia , a d d e d t o t h e f a c t t h a t a l l c a s e s o f a n a e m ia i n t h e p r e s e n t s e r i e s w e re fo u n d t o be o f t h i s ty p e ,

i t i s c o n s id e re d n e c e s s a ry to d is c u s s th e r e l a t i v e

i n c i d e n c e o f i r o n - d e f i c i e n c y a n a e m ia o f p re g n a n c y an d p e r n i c i o u s a n a e m ia o f p r e g n a n c y , a n d t o a s s e s s t h e p r e p o n d e r a n c e o f t h e fo rm e r a s co m p ared w i t h t h e r a r i t y o f th e l a t t e r c o n d itio n . The t i t l e ,

or t it l e s ,

a d o p te d f o r t h i s v a r i e t y o f

a n a e m ia o f p r e g n a n c y , h a s l e d t o a c e r t a i n am ount o f c o n f u s i o n , t h e c o n d i t i o n h a v in g b e e n v a r i o u s l y r e f e r r e d t o a s p e r n i c i o u s a n a e m ia o f p r e g n a n c y , s e v e r e a n a e m ia o f p r e g n a n c y , an d m e g a l o b l a s t i c a n a e m ia o f p r e g n a n c y . The f i r s t te r m i s u n s a t i s f a c t o r y a s t h e a n a e m ia i s n o t o f t h e t r u e A d d is o n ia n t y p e , a n d t h e s e c o n d c o n f u s i n g , b e c a u s e some w r i t e r s r e f e r t o t h e s e v e r e a n a e m ia o f p r e g n a n c y when d e s c r i b i n g a w e ll- m a r k e d s e c o n d a r y a n a e m ia .

I n d e e d , O s i e r (1 9 1 9 ) p o i n t e d o u t t h a t a l t h o u g h

a h i g h c o l o u r in d e x i s t h e r u l e i n t h e s e v e r e t y p e ,

cases

h a v e b e e n r e p o r t e d w h e re t h i s v a l u e w as w e l l b e lo w u n i t y .

52. ■Davidson e t a l ( I 9 I4.2 ) i n a s tu d y o f t h e c o n d i t i o n , c o n c lu d e d th a t i t

s h o u ld h e r e c o g n i s e d t h a t a s e v e r e m e g a l o b l a s t i c

a n a e m ia may o c c u r d u r i n g p re g n a n c y o r t h e p u e r p e r iu m , a l t h o u g h t h e c o l o u r in d e x b e u n i t y o r l e s s .

I n v ie w , t h e r e f o r e ,

o f th e

d i f f i c u l t y i n a s s e s s i n g t h e s i g n i f i c a n c e o f t h e c o l o u r in d e x i n t h e d i a g n o s i s o f t h e a n a e m ia s , te r m ,

i t i s c o n s id e re d t h a t th e

" m e g a l o b l a s t i c a n a e m ia o f p r e g n a n c y " , a s a d o p te d by

D a v id s o n a n d h i s c o l l e a g u e s ,

i s t h e m ost s a t i s f a c t o r y

t e r m in o l o g y , a s t h e u l t i m a t e d i a g n o s i s m u st b e d e te r m in e d by t h e e x a m in a tio n o f t h e b lo o d f i l m . A s tu d y o f th e l i t e r a t u r e

c o n f ir m s t h e v ie w e x p r e s s e d by

many o t h e r w o rk e rs t h a t t h e i r o n - d e f i c i e n c y a n a e m ia i s by f a r t h e com m onest v a r i e t y m et w ith i n t h e c o u r s e o f p r e g n a n c y . E v an s (1 9 2 9 ) i n v e s t i g a t e d t h e r e c o r d s o f Queen C h a r l o t t e ’ s M a t e r n i t y H o s p i t a l f o r t h e y e a r s 1926 - 1 9 2 7 , and f a i l e d t o f in d a s in g le case o f th e p e rn ic io u s v a r ie ty

in

k

, 083 l a b o u r s .

He h i m s e l f r e p o r t e d tw o c a s e s and su m m a rise d t h e l i t e r a t u r e f o llo w s .

as

C h a n n in g ( 1 8 ^ 2 ) r e p o r t e d 10 c a s e s , R ow land (19214-)

2 c a s e s a n d S m ith ( 1 9 2 5 ) , 8 c a s e s .

L a r r a b e e i n 1925 r e p o r t e d

17 c a s e s a n d , t o r e f e r a g a i n t o t h e q u e s t i o n o f t e r m i n o l o g y , 7 o f t h e s e h ad c o l o u r i n d i c e s l e s s t h a n u n i t y .

I n 1 9?7 H o s k in

a n d C e ir i o g - C a d l e r e p o r t e d o n ly o n e c a s e , N e a le 2 an d M urdoch 2.

I n t h e same y e a r B a l f o u r an d McSweeney r e p o r t e d 1 5 0 and

I4.3 c a s e s r e s p e c t i v e l y , m ore p r e v a l e n t .

i n I n d i a , w h ere t h e c o n d i t i o n i s much

B a l f o u r , h o w e v e r, d rew a t t e n t i o n t o t h e

r a r i t y o f th e c o n d itio n in t h i s c o u n try ,

q u o t in g t h e i n c i d e n c e

i n t h e R o tu n d a H o s p i t a l , D u b lin f o r t h e y e a r s 1921 - 1 9 2 3 , a s 1 i n 1 2 ,0 0 0 c a s e s ,

i n Q ueen C h a r l o t t e 's H o s p i t a l (1 9 2 3 ) a s

53. 1 i n 1 ,8 0 0 c a s e s , an d i n t h e Sim pson M e m o ria l H o s p i t a l E d in b u r g h (1 9 2 3) a s none i n 1 , 6 0 0 c a s e s . W h itb y (1 9 3 2 ) a l s o d rew a t t e n t i o n t o t h e r a r i t y

of th is

t y p e o f a n a e m ia i n p re g n a n c y and q u o te d t h e work o f o t h e r a u t h o r i t i e s in su p p o rt o f h is c o n c lu s io n s .

E s c h (1 9 2 1 )

c o l l e c t e d o n ly 23 c a s e s from t h e G-erman l i t e r a t u r e

o f th e

p r e v i o u s tw e n ty y e a r s , a n d Beckm an (1 9 2 1 ) r e p o r t e d o n ly 6 c a s e s o c c u r r i n g i n 6 0 ,0 0 0 l a b o u r s .

B a rd y ( 192 I4.) r e v ie w e d 68 c a s e s

o c c u r r i n g d u r i n g a p e r i o d o f t h i r t y e i g h t y e a r s an d c o l l e c t e d fro m t h e l i t e r a t u r e o f E u ro p e and A m e ric a .

I n 1930 W il l s an d

M eh ta re v ie w e d 50 c a s e s an d M i t r a (1 9 3 1 ) i n v e s t i g a t e d 86 c a s e s o c c u r r i n g i n t h e c o u r s e o f 1 ,8 8 3 l a b o u r s d u r i n g a p e r i o d o f fo u r y e a rs. Prom t h e ab o v e r e s u l t s one c a n c o n c lu d e t h a t t h e p e r n i c i ­ o u s v a r i e t y o f a n a e m ia , o c c u r r i n g d u r i n g t h e c o u r s e o f p reg n a n cy ,

i s a r a r e c o n d i t i o n i n t h i s an d o t h e r c o u n t r i e s ,

w i t h t h e e x c e p t i o n o f I n d i a , an d r e c e n t c o n t r i b u t i o n s t o t h e l i t e r a t u r e s u p p o r t t h i s v ie w .

( W ilk in s o n 1 9 3 2 , B e t h e l l 1 9 3 6 ,

M u sse r 1914-0, D a v id so n e t a l 1 9 ^ 2 , F u l l e r t o n 1 9 ^ 3 , D a v id s o n e t a l I 9I4.8 ) .

I t h a s b e e n s u g g e s t e d , h o w e v e r, t h a t t h i s ty p e

o f a n a e m ia o f p r e g n a n c y m ig h t n o t b e so i n f r e q u e n t a s i s g e n e r a lly su pposed.

S te v e n s o n (1 9 3 8 ) r e p o r t e d t h e f i r s t

la r g e s e r i e s o f c a se s in t h i s c o u n try . i n v e s ti g a t e d d u rin g a s i x y e a r p e r io d ,

T h i r t y c a s e s w ere i n G la sg o w .

D a v id s o n

( 19 ^ 8 ) an d h i s c o l l e a g u e s , h o w e v e r, p o i n t e d o u t t h a t a l l S t e v e n s o n ^ c a s e s m ig h t n o t h a v e b e e n o f t h e p e r n i c i o u s v a r i e t y , a s t h e y w ere i n v e s t i g a t e d b e f o r e s t e r n a l p u n c t u r e

53b. h o s p i t a l p r a c tic e have b een s tu d ie d ,

i t m u st b e c o n c lu d e d

t h a t a v a i l a b l e e v id e n c e s u p p o r t s t h e g e n e r a l l y a c c e p t e d v ie w , c o n fir m e d i n t h e p r e s e n t i n v e s t i g a t i o n ,

th a t

p e r n i c i o u s o r m e g a l o b l a s t i c a n a e m ia i s b u t r a r e l y e n c o u n te re d d u rin g th e c o u rs e o f p re g n a n c y .

5h. CHAPTER IV. NORMAL HAEMATOLOGICAL VALUES IN NON-PREGNANT AND PREGNANT WOMEN AND CRITERIA OP ANAEMIA OF PREGNANCY. NORMAL NON-PREGNANT WOMEN: H a e m a to lo g ic a l s t a n d a r d s f o r n o rm a l h e a l t h y women h a v e b e e n d e te r m in e d by many a u t h o r i t i e s b o t h i n t h i s c o u n t r y an d a b r o a d , a n d a c o n s i d e r a t i o n o f t h e s e a c c e p t e d n o rm a l v a l u e s i s o b v i o u s l y n e c e s s a r y b e f o r e a n a p p r e c i a ­ t i o n c a n b e made o f a d e v i a t i o n fro m t h e s e s t a n d a r d s d u rin g p reg n a n cy .

The d i s c u s s i o n o f t h e s e h a e m a t o l o g i c a l

v a l u e s i n n o rm a l h e a l t h y women w i l l be c o n f i n e d t o h a e m o g lo b in v a l u e , r e d c e l l c o u n t an d c o l o u r in d e x * HAEMOGLOBIN: Pew c l i n i c a l m eth o d s o f i n v e s t i g a t i o n h a v e l e d t o s u c h c o n f u s i o n a s h a e m o g lo b in o m e try , a n d i t

i s a s to n is h in g ,

t h a t a lt h o u g h t h i s a n o m aly h a s lo n g b e e n r e c o g n i s e d , o n ly i n c o m p a r a t i v e l y r e c e n t y e a r s , has been s tre s s e d .

th a t i t s

it

im p o r ta n c e

W illia m s o n (1 9 1 6 ) w r o t e :

" I t has

lo n g b e e n a m a t t e r o f k e e n r e g r e t t h a t t h e v e r y e x a m in a ­ t i o n o f t h e b lo o d w h ic h i s p e r h a p s m o st f r e q u e n t l y made in r o u tin e p r a c tic e , v iz . th e e s tim a tio n o f th e p e r c e n t a g e o f h a e m o g lo b in ,

i s t h e one fro m w h ic h we

g e n e r a l l y d e r i v e t h e m o st u n s a t i s f a c t o r y r e s u l t s ; "

an d

t e n y e a r s l a t e r Brown a n d R o w n tre e (1 9 2 5 ) com m ented t h a t

is

55. " t h e n o rm a l s t a n d a r d f o r h a e m o g lo b in i s a s y e t u n s e t t l e d ; th is

i s som ew hat s u r p r i s i n g i n a s u b s t a n c e so i m p o r t a n t . ” The u n s a t i s f a c t o r y r e s u l t s o f h a e m o g lo b in o m e try

fro m t h e i n v e s t i g a t o r 's p o i n t o f v ie w h a v e u n d o u b te d ly b e e n due t o t h e many d i f f e r e n t t y p e s o f h a e m o g lo b in o m e te r on t h e m a r k e t, and t h e f a i l u r e o f many i n v e s t i g a t o r s t o s t a t e t h e e x a c t m eth o d s o f h a e m o g lo b in o m e try u s e d , t h e i r p u b lis h e d r e s u l t s .

in

O sgood a n d H a s k in s (1 9 3 5 ) d rew

a t t e n t i o n t o t h i s f a c t a n d p o i n t e d o u t t h a t so many f i g u r e s w ere u s e d by m a n u f a c t u r e r s o f h a e m o g lo b in o m e te r s , a s 10C$ h a e m o g lo b in , t h a t t h e p e r c e n t a g e f i g u r e was a lm o s t m e a n in g l e s s .

T hey a d v o c a te d t h e c a l c u l a t i o n o f a l l

r e s u l t s a s grammes o f h a e m o g lo b in p e r 100 c c . o f b lo o d ah d s t r e s s e d t h e im p o r ta n c e o f a lw a y s s t a t i n g t h e m eth o d o f h a e m o g lo b in o m e try u s e d .

S im ila r o b s e r v a tio n s have

b e e n made b y o t h e r w o rk e rs (H aden 1 9 2 2 , 1 9 2 3 , K e rn 192i^, W in tro b e 1 9 5 0 , H a rv e y 1 9 3 1 ). I n t h i s c o u n t r y , t h e H a ld a n e s c a l e

(1 3 * 8 gram m es *

100 $ ) i s t h e g e n e r a l l y a c c e p t e d s t a n d a r d , a n d w i l l b e u s e d f o r p u r p o s e s o f c o m p a ris o n i n t h e p r e s e n t i n v e s t i g a t i o n a s i t i s t h e s t a n d a r d w h ic h h a s b e e n c h i e f l y u s e d i n t h e d e t e r m i n a t i o n o f t h e h a e m o g lo b in v a l u e i n n o rm a l h e a l t h y women.

P ric e -J o n e s

(1 9 3 1 ) i n a

s t u d y ”The C o n c e n t r a t i o n o f H a e m o g lo b in i n t h e Human B lo o d " , e s t i m a t e d t h e h a e m o g lo b in l e v e l i n 100 h e a l t h y women.

He fo u n d an a v e r a g e h a e m o g lo b in v a l u e o f

56. 9 8 *26$ H a ld a n e , e q u i v a l e n t t o 13*6 gram m es h a e m o g lo b in p e r 100 c c . o f b lo o d w i t h a r a n g e o f 90$ - 110$ (12*1;2 gram m es - 15*18 g ram m es).

In a s im ila r in v e s tig a tio n

J e n k i n s an d Hon (1 9 3 3 ) fo u n d a n a v e r a g e h a e m o g lo b in v a l u e o f 99*66$ H a ld a n e , e q u i v a l e n t t o 13*8 gram m es p e r 1 0 0 c c . , w ith a ra n g e o f 77$ - 121$ (1 0 -6 2 gram m es 16*69 gram m es) i n 116 n o rm a l E n g l i s h women;

H a v id s o n

e t a l (1 9 3 5 ) i n a g re e m e n t w i t h P r i c e - J o n e s * f i g u r e , q u o te d t h e v a lu e o f 98$ H a ld a n e (13*5 gram m es) a s t h e n o rm a l h a e m o g lo b in l e v e l f o r a d u l t f e m a l e s .

W ills e t

a l (1 9 ^ 2 ) a l s o a c c e p t e d t h i s v a lu e w h ic h c a n b e a c c e p t e d a s t h e " n o rm a l" f o r h e a l t h y a d u l t women i n t h i s c o u n try . A m e ric a n w o rk e rs h a v e fo u n d h a e m o g lo b in l e v e l s i n women t o b e v e r y s i m i l a r t o t h o s e i n t h i s c o u n t r y . O sgood an d H a s k in s (1 9 2 7 ) e x a m in e d 100 n o rm a l yo u n g women -u sin g t h e a c i d h a e m a tin m eth o d (1 14.• 3 gram m es » 1 0 0$) a n d fo u n d a mean h a e m o g lo b in v a l u e o f 13 * 6 9 gram m es p e r 1 0 0 c c . o f b lo o d w i t h a r a n g e o f 1 0 * 9 8 - 1 6 -If. 9 gram m es.

W in tro b e (1 9 3 0 ) i n a s i m i l a r s t u d y fo u n d a m ean v a l u e o f 13*76 grammes w i t h a r a n g e o f 12*77 - 1^4-*75 gram m es, b u t i n a l a t e r an d much m ore c o m p re h e n s iv e s t u d y

( 1 9 3 3 ) , he

fo u n d a mean v a lu e o f llj.*1 gram m es an d q u o te d t h e r e s u l t s o f v a r i o u s a u t h o r i t i e s a l l o v e r t h e w o r ld , i n c l u d i n g t h e U n ite d S t a t e s o f A m e ric a , D enm ark, G erm any, E n g la n d an d " v a r i o u s p a r t s o f t h e w o r l d ."

T a k in g a n a v e r a g e o f a l l

t h e s e r e s u l t s , h e g a v e a w o rld a v e r a g e v a l u e f o r n o rm a l

h e a l t h y women o f 13*9 grammes h a e m o g lo b in p e r 100 c c . o f b lo o d .

He r e f e r r e d t o t h e c o n f u s i o n i n t h e e x p r e s s i o n

o f t h e h a e m o g lo b in v a l u e , t o w h ic h a t t e n t i o n h a s a l r e a d y b e e n d raw n , s t a t i n g t h a t ,ft h e g r e a t v a r i a t i o n i n t h e v a l u e s em ployed a s t h e e q u i v a l e n t o f 100 p e r c e n t , h a e m o g lo b in by t h e d i f f e r e n t h a e m o g lo b in o m e te rs , r e f l e c t s t h e in a d e q u a t e b a s i s on w h ic h t h e s e s t a n d a r d s h a v e b e e n c h o s e n ."

W in tro b e s t r o n g l y recom m ended t h e e x p r e s s i o n

o f h a e m o g lo b in i n grammes r a t h e r t h a n a s a p e r c e n t a g e , an d s u g g e s te d t h e a d o p t i o n o f t h e f i g u r e o f ll^*5 gram m es a s e q u i v a l e n t t o 100 p e r c e n t h a e m o g lo b in .

S im ila r

f i g u r e s h av e b e e n p u b l i s h e d by o t h e r A m e ric a n i n v e s t i g a t o r s n o t a b l y H aden (1 9 2 2 , 1 9 2 3 ), B e t h e l l (1 9 5 6 , 1939) a n d A d a ir e t a l ( 1 9 3 6 ), t h e l a t t e r ,

h o w e v e r, g i v i n g a s l i g h t l y

lo w e r f i g u r e , v i z . a mean o f 12*76 gram m es i n a n e x a m in a tio n o f 2 ,3 9 9 n o n - p r e g n a n t women.

In c id e n ta lly ,

J e n k i n s a n d Bon i n t h e i n v e s t i g a t i o n j u s t r e f e r r e d t o , c o n c lu d e d t h a t t h e r e was no f o u n d a t i o n

in th e b e l i e f

t h a t E n g l i s h h a e m o g lo b in l e v e l s d i f f e r e d m a t e r i a l l y fro m t h o s e i n A m e ric a .

I n Hew Z e a la n d M cGeorge (1 9 3 5 )

i n a n e x a m in a tio n o f 95 p a t i e n t s a d m i t t e d t o a g y n a e c o lo g ­ i c a l w ard fo u n d a mean h a e m o g lo b in l e v e l o f 13*7 gram m es p e r 100 c c . o f b l o o d . Many c o n t i n e n t a l w o r k e rs h a r e p u b l i s h e d r e s u l t s sh o w in g mean h a e m o g lo b in l e v e l s i n n o rm a l a d u l t women b u t , a s i n a g r e a t num ber o f c a s e s no m e n tio n i s made o f t h e a c t u a l m eth o d o f h a e m o g lo b in o m e try u s e d , t h e f i g u r e s a r e

d i f f i c u l t to a s s e s s .

Gram (1 9 2 0 ) fo u n d a n a v e r a g e

h a e m o g lo b in l e v e l o f 12*0 gram m es i n 14-0 n o r m a l a d u l t women an d Gram and N o rg a a rd (1 9 2 3 ) i n v e s t i g a t e d a s m a l l s e rie s of cases.

T h e i r r e s u l t s u n f o r t u n a t e l y w ere

e x p r e s s e d a s a p e r c e n t a g e an d t h e f i g u r e u s e d a s 100$ h a e m o g lo b in was n o t s t a t e d , a l t h o u g h t h e a u t h o r s d rew a t t e n t i o n to th e c o n s id e ra b le c o n fu s io n i n th e e x p r e s s io n o f h a e m o g lo b in ;

b u t a s su m in g t h a t t h e s t a n d a r d u s e d w as

s i m i l a r t o t h a t o f Gram (1 9 2 0 ) , j u s t q u o te d , v iz .llj- * 3 gram m es * 1 00$, t h e i r mean h a e m o g lo b in v a l u e w as 13*5 gram m es.

A s m a ll c o n t r o l s e r i e s e x a m in e d by K u h n e l

(1 9 2 7 ) g a v e a f a i r l y s i m i l a r f i g u r e o f 13*1 gram m es. A h i g h e r v a lu e was g i v e n by B r i n d e a u an d T h e o d o r id e s ( 1 9 3 5 ) , v i z . 15*3^ gram m es. From a r e v ie w o f t h e a b o v e r e s u l t s , c o n s id e re d f a i r l y r e p r e s e n ta t iv e ,

it

w h ic h c a n b e

i s c o n c lu d e d t h a t

t h e a v e r a g e h a e m o g lo b in l e v e l f o r n o rm a l h e a l t h y women is

i n t h e r e g i o n o f 13*6 gram m es p e r 100 c c . o f b l o o d .

I t h a s b e e n shown t h a t w h e re r e l i a b l e s t a n d a r d s o f c o m p a ris o n a r e a v a i l a b l e ,

in d e p e n d e n t B r i t i s h and

A m e ric a n a u t h o r i t i e s a r e i n v e r y n e a r a g re e m e n t a s t o t h i s f i g u r e , w h ic h w i l l b e t a k e n a s t h e n o rm a l v a lu e f o r th e p u rp o se o f t h i s i n v e s t i g a t i o n . of re lia b le

The im p o r ta n c e

s t a n d a r d s o f c o m p a ris o n c a n n o t b e t o o

s t r o n g l y s t r e s s e d , a n d s u c h s t a n d a r d s w i l l o n ly b e a v a i l a b l e when a u n if o r m m eth o d o f h a e m o g lo b in o m e try ,

59. a d o p te d i n t e r n a t i o n a l l y ,

is in u se .

I t i s in d e e d

s u r p r i s i n g i n v ie w o f t h e many m odern a d v a n c e s i n a l l b r a n c h e s o f c l i n i c a l i n v e s t i g a t i o n t h a t h a e m o g lo b in o m e try a s a n e x a c t m ethod h a s n o t y e t b e e n e s t a b l i s h e d a n d s ta n d a rd iz e d in a l l c o u n trie s ,

and a lth o u g h

t h i s o b v io u s

d i s a d v a n t a g e h a s b e e n p o i n t e d o u t by v a r i o u s w o r k e r s s i n c e t h e b e g in n in g o f t h e p r e s e n t c e n t u r y , we f i n d E l l i o t t w r i t i n g i n 1 9W4- t h a t " i t i s r e a l i z e d t h a t t h e c o m p a ris o n o f h a e m o g lo b in e s t i m a t i o n s made by d i f f e r e n t m e th o d s i s u n s a t is f a c to r y , b u t u n t i l a s ta n d a r d iz e d in s tru m e n t i s u s e d a l l o v e r t h e w o r ld , t h e r e a p p e a r s t o b e no a lte r n a tiv e .”

S u ch an u n s a t i s f a c t o r y s t a t e o f a f f a i r s

c a lls fo r l i t t l e

f u r t h e r com m ent.

RED CELL QOUTO: W h ile i t

i s d i f f i c u l t to a r r iv e a t an e x a c t

c o n c l u s i o n a s t o t h e a v e r a g e r e d c e l l c o u n t i n n o rm a l a d u l t women, r e s u l t s p u b l i s h e d i n t h i s a n d o t h e r c o u n t r i e s a r e i n f a i r l y c l o s e a g re e m e n t;

A m e ric an f i g u r e s t e n d t o

b e s l i g h t l y lo w e r t h a n t h e m ean o f 5*0 m i l l i o n s p e r c .m j^ t h e g e n e r a l l y a c c e p t e d v a lu e i n t h i s c o u n t r y .

A v e ry

b r i e f r e v ie w o f t h e l i t e r a t u r e w i l l h e l p t o d e m o n s tr a te t h i s p o in t. H aden (1 9 2 2 , 1923) i n a s tu d y o f a c c u r a t e c r i t e r i a i n d i f f e r e n t i a t i n g a n a e m ia s g a v e t h e a v e r a g e r e d c e l l c o u n t f o r n o rm a l h e a l t h y women a s i^ '2 6 m i l l i o n s p e r c .m .m .,

a n d Gram an d N o rg a s rd (1 9 2 3 ) i n a n e x a m in a tio n o f 10 n o rm a l fe m a le s u b j e c t s fo u n d a n a v e r a g e c o u n t o f 1|., 6 5 , w ith , a ra n g e

o f l|-*36 — 5*05

num ber o f c a s e s

m illio n s .

in a s im ila r

o f n o n - p r e g n a n t h e a l t h y women K u h n e l

(1 9 2 7 ) fo u n d

an a v e r a g e r e d

c e l l c o u n to f

w ith a ran g e

of

m illio n s .

b-k-2

- 5*1^-

f i n d i n g s show a v e r y c l o s e s i m i l a r i t y .

m illio n s

T h e se l a s t two O sgood a n d

H a s k in s (1 9 2 7 ) r e c o r d e d a r e s u l t i n f a i r l y

c l o s e a g re e m e n t

w i t h t h e s e f i g u r e s , v i z . ij.*8 m i l l i o n s , w i t h a r a n g e o f I4-*07 - 5*55 m i l l i o n s , a n d W in tro b e (1 9 3 0 ) r e c o r d e d a s l i g h t l y h i g h e r v a lu e o f I).*95 m i l l i o n s , w i t h a r a n g e o f U-* 6i+ - 5*22 m i l l i o n s .

The l a t t e r , h o w e v e r,

in h is

l a t e r s tu d y (1 9 5 3 ) r e f e r r e d t o on p a g e 5 6 , fo u n d a m ean r e d c e l l c o u n t o f 1^*82 m i l l i o n s , a n d g a v e a " w o rld v a l u e " o f U*85 m i l l i o n s . I n t h i s c o u n tr y , P r i c e - J o n e s

(1 9 3 1 ) fo u n d som ew hat

h i g h e r r e d c e l l c o u n ts f o r n o rm a l h e a l t h y women.

In

h i s s t u d y o f 100 c a s e s h e r e c o r d e d a m ean f i g u r e o f 5*0 m i l l i o n s p e r c .m m ., w i t h a r a n g e o f 5*9 - 6*0 m i l l i o n s an d M cGeorge i n New Z e a la n d (1 9 3 8 ) g a v e a s i m i l a r m ean v a l u e w i t h a r a n g e o f lj.*llj. - 5*88 m i l l i o n s . f ig u r e s a re th e h ig h e s t re c o rd e d in t h i s

T h ese

s h o r t r e v ie w ,

b u t r e s u l t s p u b l i s h e d by o t h e r w o r k e r s m ore o r l e s s c o n fo rm t o th e a v e r a g e v a l u e s a l r e a d y q u o t e d .

( B r in d e a u

a n d T h e o d o r id e s 1 9 5 5 , B e t h e l l 1 9 3 6 , 1 9 3 9 , E l l i o t t 19 U ) . A p a r t fro m t h e r e s u l t s

r e c o rd e d by P r ic e - J o n e s and

61. M cG eorge, t h e ab o v e f i g u r e s a r e i n f a i r l y a g r e e m e n t.

it

c lo s e

i s f e l t , h o w e v e r, t h a t t h e g e n e r a l l y

a c c e p t e d mean r e d c e l l c o u n t f o r n o rm a l h e a l t h y women fo u n d q u o te d i n m o st t e x t b o o k s on h a e m a to lo g y , n a m e ly 5*0 m i l l i o n s p e r c .m .m .,

i s p ro b a b ly to o h ig h .

t r u e f i g u r e p r o b a b ly l i e s som ew here b e tw e e n

The nnd 5*0

m i l l i o n s , a n d a n a r b i t r a r y mean o f li-*8 m i l l i o n s h a s b e e n a c c e p te d f o r th e p u rp o se o f t h i s a b o v e r e v ie w , a lt h o u g h s h o r t ,

in v e s tig a tio n .

The

i s f a i r l y c o m p r e h e n s iv e ,

and i t w i l l b e n o t e d t h a t t h e l o w e s t r e c o r d e d r e d c e l l c o u n t i s 3*9 m i l l i o n s a n d t h e h i g h e s t 6*0 m i l l i o n s (P ric e -J o n e s ).

No o t h e r w o r k e r s , a b o v e q u o te d , w i t h

t h e e x c e p t i o n o f M cG eorge, a p p ro a c h t h e s e e x tre m e v a l u e s , a n d a lt h o u g h t h e s e a r e n o t c o n s i d e r e d f a r o u t s i d e t h e bounds o f n o rm a lity , n e v e r th e le s s i t

i s th o u g h t t h a t n o t

o n ly d o e s a mean v a lu e o f lj-*8 m i l l i o n s a g r e e w i t h t h e r e s u l t s of th e m a jo rity o f o th e r in v e s ti g a t o r s , b u t a ls o a g r e e s w i t h W in tr o b e ’ s " w o rld v a lu e " o f l4-‘ 85 m i l l i o n s . I t may b e a d d e d t h a t W in tro b e c o n c lu d e d fro m h i s s t u d i e s , t h a t t h e r e a p p e a r e d t o b e no g e o g r a p h ic v a r i a t i o n i n n o rm a l b lo o d v a l u e s w h ic h m ig h t p r e c l u d e t h e e s t a b l i s h m e n t o f a w o rld -w id e " n o r m a l" .

K e rn (192]+) assu m e d a n o rm a l

v a l u e o f ]+*7 m i l l i o n s . noBOHR INDEX; A c o lo u r in d e x o f u n i t y h a s a lw a y s b e e n a c c e p t e d a s t h e n o rm a l s t a n d a r d i n h e a l t h , b u t a s t u d y o f t h e

l i t e r a t u r e show s t h a t a c o n s i d e r a b l e d e v i a t i o n fro m t h i s f i g u r e i s c o m p a tib le w i t h a n o t h e r w i s e n o r m a l b lo o d p ic tu re .

H aden (1 9 2 3 ) com m enting on t h i s a s p e c t o f

h a e m a to lo g ic a l i n v e s ti g a t i o n ,

s t a t e d t h a t v e r y few

c a r e f u l s t u d i e s o f c o lo u r i n d e x h a d b e e n m ade, a n d i t was n o t u n i v e r s a l l y a g r e e d t h a t t h e c o l o u r in d e x o f n o r m a l b lo o d was a lw a y s u n i t y .

He g a v e t h e n o rm a l

v a lu e i n women a s 1*00 b u t i n a l a t e r c o n t r i b u t i o n

(1 9 3 2 ),

h e i n d i c a t e d t h a t a r a n g e b e tw e e n 0*9 an d 1*10 c o u ld b e c o n s i d e r e d a s n o r m a l.

I n t h e i r much s m a l l e r s e r i e s

Gram an d N o rg a a rd (192-3). fo u n d t h e r a n g e o f n o r m a l i t y t o b e 0 .9 7 - 1 • 0l+ w i t h a n a v e r a g e v a lu e o f 1 * 0 1 . P r i c e - J o n e s (1 9 3 1 ) fo u n d a n a v e r a g e c o l o u r in d e x o f 0 * 9 8 f o r n o rm a l h e a l t h y women w i t h a r a n g e o f 0*91 1 * 0 8 , a n d i n A m e ric a B e t h e l l (1 9 3 6 ) r e c o r d e d a mean v a lu e o f 1*00 w i t h a r a n g e o f *93 - 1*ll+.

I n m ore

r e c e n t s t u d i e s D a v id s o n e t a l (1 9 ^ 2 ) s t a t e d t h a t i t was g e n e r a l l y a g r e e d t h a t t h e n o r m a l c o l o u r i n d e x r a n g e was 0*9 - 1 * 0 9 , an d E l l i o t t

(19W 0 fo u n d a r a n g e o f 0 * 8 - 1 * 00

i n a n i n v e s t i g a t i o n o f 20 c o n t r o l c a s e s .

W h itb y (19^+6)

was o f t h e a c c e p t e d o p i n i o n t h a t t h e n o rm a l c o l o u r in d e x was u n i t y , b u t q u o te d O sgood (1 9 3 5 ) who c o n c lu d e d t h a t f i g u r e s fro m *85 - 1*15 w e re n o t a b n o r m a l. t h e s e r i e s s t u d i e d by O sgood a n d H a s k in s

In

(1 9 2 7 ) 90% o f

t h e r e s u l t s f e l l b e tw e e n 0*9 an d 1*10 w i t h a r a n g e Ch * OQ

± O O >— •

*0 OCt^-pjrw^

< T)

4*

t a O

oO

122 . o f 2 0 * 6 $ . a n i n c i d e n c e much h i g h e r t h a n t h a t b a s e d on t h e h a e m o g lo b in l e v e l , t h e r e d c e l l c o u n t, and t h e b lo o d film .

T h is h i g h e r i n c i d e n c e i s n o t s u r p r i s i n g i n v ie w

o f t h e c o m p le te u n r e l i a b i l i t y o f t h i s s i g n a s a d ia g n o s tic c r i t e r i o n th e re fo re ,

( p . 92 and 93) an d i s n o t c o n s i d e r e d

to g iv e an a c c u r a te p i c t u r e o f th e tr u e

i n c i d e n c e o f i r o n - d e f i c i e n c y a n a e m ia o c c u r r i n g i n women d u rin g th e c o u rse o f p reg n a n cy .

I t d o e s , h o w e v e r, draw

a t t e n t i o n t o t h e p o s s i b i l i t y o f an e x i s t i n g a n a e m ia , a n d a s s u c h i s o f v a lu e i n s t i m u l a t i n g f u r t h e r i n v e s t i g a t i o n a n d , w h ere n e c e s s a r y , t h e i n s t i t u t i o n o f e a r l y t r e a t m e n t . INCIDENCE OF ABNORMAL LABOUR: I n P l a t e X I I I . a f u r t h e r a n a l y s i s h a s b e e n made t o show t h e i n c i d e n c e o f a b n o rm a l c o n fin e m e n ts i n t h e t r e a t e d an d u n t r e a t e d g r o u p s , a b n o r m a l i t i e s i n c l u d i n g , f o r c e p s d e l i v e r y , r e t a i n e d p l a c e n t a o r m em branes, p o s t - p a r t u m h a e m o rrh a g e a n d p y r e x i a i n t h e p u e r p e r iu m . P la te X III.

show s t h a t i n t h e w hole s e r i e s t h e r e

w e re 21 a b n o r m a l i t i e s o f l a b o u r and t h e p u e r p e r iu m . Among t h e 300 c a s e s i n t h e c o n t r o l g ro u p t h e i n c i d e n c e o f a b n o r m a l i t y was 1 0 * 1 $ , b u t i n t h o s e c a s e s w i t h a h a e m o g lo b in l e v e l b e lo w 10 gram m es p e r c e n t , A s lig h tly

i t was 25$*

lo w e r i n c i d e n c e o f a b n o r m a li t y was fo u n d

among t h e 150 t r e a t e d c a s e s

( 8 * 6 $ ), b u t w h ere t h e

h a e m o g lo b in l e v e l w as b e lo w 10 gram m es p e r c e n t , i n c i d e n c e o f a b n o r m a l i t y was

k -O /o .

th e

I t w o u ld a p p e a r ,

P l a t e 13

INCIDENCE OF ABNORMAL LABOUR. /

F o rc e p sr tfe b r u m d P L acen ta*f P & t-fx u rtzitn H o u n s]

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1 23 . th e re fo re ,

t h a t a low h a e m o g lo b in l e v e l d u r i n g p re g n a n c y

h a s a b e a r i n g on t h e i n c i d e n c e o f a b n o r m a lity d u r in g l a b o u r a n d t h e p u e r p e r iu m , an d a l s o t h a t t h e a d m in is tr a tio n o f p r o p h y la c tic ir o n d u rin g p reg n an cy h a s no e f f e c t i n r e d u c i n g t h i s i n c i d e n c e . INCIDENCE OP PYREXIA IN THE PITERPERITJH: As a n a e m ia o f p re g n a n c y h a s b e e n c o n s i d e r e d t o h a v e a b e a r i n g on t h e d e v e lo p m e n t o f p y r e x i a d u r in g th e p u e r p e r iu m , a n a n a l y s i s o f t h e c a s e s o f p y r e x i a i n th e p resen t s e rie s ,

i s show n i n P l a t e X I7 . A ll c a se s in . o w h ic h a t e m p e r a t u r e o v e r 100*4 E . d e v e lo p e d d u r i n g t h e p u e r p e r iu m h a v e b e e n i n c l u d e d , w h e th e r n o t i f i a b l e o r n o t,

so t h a t P l a t e XIV. d o e s n o t show t h e t r u e

i n c i d e n c e o f p u e r p e r a l p y r e x i a , b u t o n ly t h e num ber o f c a s e s i n w h ic h a r i s e o f t e m p e r a t u r e t o 1 0 0 *14.° ? . o r o v e r , fro m a n y c a u s e , was known t o h a v e d e v e lo p e d . I t w i l l be n o te d t h a t in th e c o n tr o l s e r i e s th e i n c i d e n c e o f p y r e x i a i n t h e w h o le g ro u p was 3 * 0 $ , b u t i n t h o s e c a s e s w i t h a h a e m o g lo b in l e v e l b e lo w 10 grammes p e r c e n t,

i t was 1 2 * 5 $ .

The i n c i d e n c e among t h e w h o le

g r o u p o f t h e t r e a t e d c a s e s was 3*3# b u t w h ere t h e h a e m o g lo b in l e v e l w as b e lo w 10 grammes p e r c e n t , i t was 20*0$.

The i n c i d e n c e o f a n a e m ia , t h e r e f o r e , w o u ld

a p p e a r t o h a v e h a d some i n f l u e n c e on t h e d e v e lo p m e n t o f p y r e x i a d u r i n g t h e p u e r p e r iu m , a n d t h e a d m i n i s t r a t i o n o f p r o p h y l a c t i c i r o n h a s h a d no e f f e c t i n r e d u c i n g t h i s

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INCIDENCE O F PUERPERAL PYltfXlA.

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124. EFFECT ON THE STILL-BIRTH RATE: P l a t e XV. show s t h e e f f e c t o f t h e a n a e m ia on t h e s till-b irth

r a t e p e r 1 ,0 0 0 l i v e b i r t h s .

g ro u p a s a w h o le t h e s t i l l - b i r t h

In th e c o n tr o l

r a t e was 1 6 *7 , w h e re a s

among t h e a n a e m ic c a s e s i t was 62*5*

In th e t r e a t e d

s e r i e s , t h e f i g u r e f o r t h e w h o le g ro u p was 1 3 *3 , t h e r e b e i n g no s t i l l - b i r t h s among t h e a n a e m ic c a s e s i n t h i s g ro u p .

A naem ia d u r i n g p re g n a n c y may h a v e h a d some

e f f e c t on t h e s t i l l - b i r t h

r a t e i n th e c o n t r o l g r o u p ,

b u t ow ing t o t h e s m a ll num ber o f c a s e s , no d e f i n i t e c o n c l u s i o n s c a n b e draw n fro m t h e r e s u l t s e i t h e r i n t h i s o r th e t r e a t e d g ro u p .

S i m i l a r l y no c o n c l u s i o n s can be

d raw n a s t o t h e e f f e c t o f t h e p r o p h y l a c t i c a d m i n i s t r a t i o n o f iro n , b u t i t

i s u n l i k e l y t h a t i t h a d an y e f f e c t .

EFFECT ON WEIGHT OF THE CHILI): P l a t e XVI. show s t h e a v e r a g e w e ig h t o f t h e c h i l d i n t h e a n a e m ic an d n o n -a n a e m ic g r o u p s .

Among t h e

3 0 0 c o n t r o l c a s e s t h e a v e r a g e w e ig h t was 7 l b s . 4 o z .

i n t h e 16 c a s e s w h ere t h e m o th e r ’ s mean h a e m o g lo b in l e v e l d u r i n g t h e p re g n a n c y w as b e lo w 10 gram m es p e r c e n t.

W here t h e m o th e r ’ s h a e m o g lo b in l e v e l was ab o v e

1 0 gram m es p e r c e n t ,

w as 7 l b s .

t h e a v e r a g e w e ig h t o f t h e c h i l d

10 o z . , a d i f f e r e n c e o f o n ly 6 o z s .

In

t h e t r e a t e d g ro u p t h e a v e r a g e w e ig h ts i n t h e a n a e m ic an d n o n -a n a e m ic p a t i e n t s w e re 7 l b s .

3 o z s. and

P la t e 15

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INCIDENCE OP POST-PARTUM HAEMORRHAGE: As w i l l "be s e e n i n P l a t e X I I , 3 o u t o f 16 a n a e m ic c a s e s i n t h e c o n t r o l g r o u p s u f f e r e d fro m p o s t - p a r t u m h a e m o rrh a g e , a n i n c i d e n c e o f 18*75$*

Among t h e n o n -

a n a e m ic c a s e s i n t h e c o n t r o l g ro u p t h e i n c i d e n c e was 11 o u t o f 28U c a s e s , o r 3 #87$*

Among t h e t r e a t e d

p a t i e n t s 20 $ o f t h e a n a e m ic c a s e s s u f f e r e d fro m p o s t ­ p a rtu m h a e m o rrh a g e and 1|.*1$ o f t h e n o n -a n a e m ic p a t i e n t s . I n t h e com bined s e r i e s o f t r e a t e d and u n t r e a t e d p a t i e n t s It o u t o f 21 (1 9 $ ) a n a e m ic p a t i e n t s an d 17 o u t o f Ii-29 ( 3 *96 $ ) n o n -a n a e m ic p a t i e n t s s u f f e r e d fro m p o s t - p a r t u m h a e m o rrh a g e .

I n o n ly one c a s e was t h e p o s t - p a r t u m

h a e m o rrh a g e due t o a r e t a i n e d p l a c e n t a . T h ese r e s u l t s show t h a t p o s t - p a r t u m h a e m o rrh a g e o c c u r r e d m ore f r e q u e n t l y i n t h e a n ae m ic a s co m p ared w i t h t h e n o n -a n a e m ic p a t i e n t s ,

and t h e a n a e m ia may h a v e h a d

some i n f l u e n c e on t h e i n c i d e n c e o f t h i s c o n d i t i o n . T h e re i s , h o w e v e r, no e v id e n c e t o show t h a t t h e p ro p h y ­ l a c t i c a d m i n i s t r a t i o n o f i r o n had any e f f e c t i n re d u c in g t h i s in c id e n c e .

127.

CHAPTER V I I . D I S C U S S I O N . HAEMOGLOBIN LEVELS IN PREGNANCY.

I n a r e v ie w o f t h e p u b l i s h e d w ork on a n a e m ia o f p r e g n a n c y , a t t e n t i o n h a s a l r e a d y b e e n draw n t o t h e d i f f i c u l t i e s e n c o u n te r e d when a n a tte m p t i s made t o d raw a c o m p a ris o n b e tw e e n t h e r e c o r d e d r e s u l t s o f d i f f e r e n t w o rk e rs.

The d i f f i c u l t i e s a l r e a d y e n u m e ra te d

i n c l u d e t h e many d i f f e r e n t m eth o d s u s e d i n e s t i m a t i n g t h e h a e m o g lo b in l e v e l an d t h e f a i l u r e t o s t a t e t h e s t a n d a r d u sed .

A g a in one i s o f t e n l e f t i n d o u b t a s t o t h e

p e r i o d o f p r e g n a n c y t o w h ic h t h e s a m p le s r e f e r , a n d a s t o w h e th e r m ean v a l u e s r e f e r t o s i n g l e e x a m in a tio n s o f a s e r i e s o f p a t i e n t s a t a f i x e d p e r i o d , o r t o t h e m ean o f s e v e r a l e x a m in a tio h s made th r o u g h o u t t h e p r e g n a n c y . A ls o , a s h a s a l r e a d y b e e n s t a t e d ,

i n r e v ie w in g t h e

i n c i d e n c e o f a n a e m ia o f p r e g n a n c y , a f u r t h e r d i f f i c u l t y a r i s e s due t o t h e a d o p t i o n o f d i f f e r e n t c r i t e r i a o f a n a e m ia by many w o r k e r s , w i t h a c o r r e s p o n d in g v a r i a t i o n in th e re c o rd e d in c id e n c e o f th e c o n d itio n .

In th e

p r e s e n t s e r i e s an a t t e m p t h a s b e e n made t o m e e t t h e s e d i f f i c u l t i e s b y r e d u c i n g a l l h a e m o g lo b in v a l u e s t o gram m es h a e m o g lo b in p e r 1 0 0 c c . o f b lo o d , by s t a t i n g t h e e x a c t p e r i o d o f p re g n a n c y t o w h ic h s a m p le s r e f e r ,

by

i n d i c a t i n g w h e th e r m ean v a l u e s r e f e r t o t h e m ean o f a l l

r e a d i n g s a t a f i x e d p e r i o d o f p re g n a n c y o r t o t h e mean o f one o r m ore r e a d i n g s o b s e r v e d th r o u g h o u t t h e c o u r s e o f t h e p r e g n a n c y , an d by e s t a b l i s h i n g a f i x e d v a l u e , b e lo w w h ic h e x is t.

a t r u e a n a e m ia o f p re g n a n c y i s p re su m e d t o

On t h e s e l i n e s an a tt e m p t w i l l be made t o d raw

a c o m p a ris o n b e tw e e n t h e r e s u l t s r e c o r d e d by p r e v i o u s w o r k e r s , a n d t h o s e fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n , w i t h r e l e v a n t com m ents on t h e s i g n i f i c a n c e o r o t h e r w i s e o f t h e d i f f e r e n c e s fo u n d . Among t h e u n t r e a t e d c a s e s s t u d i e d i n t h e p r e s e n t i n v e s t i g a t i o n , t h e mean h a e m o g lo b in v a lu e d u r i n g t h e p e r i o d o f p re g n a n c y -under o b s e r v a t i o n , i . e . t h e mean o f t h e two r e a d i n g s ta k e n a t t h e b e g in n in g

of th e f o u rth

and t h e end o f t h e e i g h t h m on th, was 1 1 *J4.9

gram m es

h a e m o g lo b in p e r 1 00 c c . o f b lo o d , a n d t h e num ber o f c a s e s sh o w in g a mean h a e m o g lo b in l e v e l b e lo w 10 gram m es h a e m o g lo b in p e r 1 00 c c . o f b lo o d was 1 5 , th u s g i v i n g a n i n c i d e n c e o f a n a e m ia o f 5$*

The c o r r e s p o n d in g i n c i d e n c e

among t h e t r e a t e d c a s e s was 3 #5$»

The a v e r a g e i n i t i a l

h a e m o g lo b in l e v e l f o r t h e e n t i r e s e r i e s was 11*80 gram m es p e r c e n t w i t h an i n c i d e n c e o f a n a e m ia a t t h e b e g in n i n g o f t h e f o u r t h m onth o f l4-#67$ among t h e c o n t r o l s , a n d 2 - 67 $ among t h e t r e a t e d c a s e s .

A t th e en d o f t h e e i g h t h m onth

t h e a v e r a g e t e r m i n a l h a e m o g lo b in v a lu e i n t h e c o n t r o l g ro u p w as 11*18 gram m es p e r c e n t and t h a t o f t h e t r e a t e d g r o u p 1 1 * 7 2 gram m es p e r c e n t , w i t h an i n c i d e n c e o f

129. a n a e m ia o f llj-* 00 $ an d 8 *67 $ r e s p e c t i v e l y .

it

is of

i n t e r e s t t o n o t e t h a t a l l t h e a v e r a g e h a e m o g lo b in v a l u e s r e c o r d e d a r e a b o v e t h e a v e r a g e v a lu e w h ic h h a s a l r e a d y b e e n c o n s i d e r e d t o b e a b o u t t h e a v e r a g e v a lu e f o r h e a l t h y p r e g n a n t women, v i z .

1 1 * 0 0 gram m es p e r c e n t

( p . 7 L ). The f o l l o w i n g a v e r a g e h a e m o g lo b in v a l u e s d u r i n g p r e g n a n c y r e c o r d e d by o t h e r w o rk e rs and a l r e a d y r e f e r r e d to

( p . 66 an d 6 7 ) c a n now b e com pared w i t h t h e a b o v e

r e s u l t s b e a r i n g i n m ind t h e l i m i t a t i o n s o f s u c h a c o m p a r is o n , a t t e n t i o n t o w h ic h h a s b e e n draw n a t t h e b e g in n i n g o f t h i s c h a p t e r . o f a n a e m ia i s a l s o g i v e n .

Where p o s s i b l e , t h e i n c i d e n c e M ackay (1 9 3 1 , 1935) i n tw o

i n v e s t i g a t i o n s , r e c o r d e d a v e r a g e v a l u e s o f 1 0 * 7 6 gram m es p e r c e n t (7 8 $ H a ld a n e ) an d 11*5 gram m es p e r c e n t (8 3 * 5 $ H a ld a n e ) .

I n t h e se c o n d i n v e s t i g a t i o n t h e r e w e re

f i v e c a s e s w i t h a h a e m o g lo b in l e v e l b e lo w 70$ H a ld a n e ( 9 * 6 gram m es) g i v i n g a n i n c i d e n c e o f a n a e m ia o f a p p r o x i m a t e ly l4.* 6$ , b a s e d on t h e lo w e s t l i m i t o f n o rm a lity

( 1 0 gram m es p e r c e n t ) a c c e p t e d i n t h e p r e s e n t

in v e s tig a tio n . in v e s tig a tio n

The r e s u l t s o f M ackayf s s e c o n d ( 1 9 3 5 ) show a s t r i k i n g re s e m b la n c e t o

th o s e re c o rd e d in th e p r e s e n t s e r i e s .

The a v e r a g e

v a l u e s i n h e r e a r l i e r i n v e s t i g a t i o n a r e lo w e r t h a n t h o s e f o u n d i n t h e p r e s e n t s e r i e s , b u t t h e c a s e s m ig h t n o t b e c o n s i d e r e d r e p r e s e n t a t i v e , a l l b e in g u n m a r r ie d p r e g n a n t women.

Lower a v e r a g e v a l u e s w e re r e c o r d e d b y D a v id s o n

130. e t a l (1 9 3 5 ) an d a l s o a h i g h e r i n c i d e n c e o f a n a e m ia v iz .

10*76 gram m es p e r c e n t (78*1$ H a ld a n e ) m t h 17*5$

o f t h e i r c a s e s sh o w in g a h a e m o g lo b in l e v e l b e lo w 70$ H a ld a n e (9*6 g ra m m e s).

T h ese r e s u l t s , h o w e v e r, w ere

f o u n d among t h e p o o r e r c l a s s e s o f t h e p o p u l a t i o n a t a tim e o f u n em p lo y m en t a n d e co n o m ic s t r e s s b e tw e e n t h e tw o w o r ld w a r s .

H ig h e r v a l u e s , h o w e v e r, w ere r e c o r d e d

by M cGeorge ( 1 9 3 5 ) , v i z . 13*0 grammes (95$ H a ld a n e ) b e tw e e n t h e 8 t h and 2 0 t h w eek o f p re g n a n c y , a n d 1 1 * 9 gram m es (87$ H a ld a n e ) b e tw e e n t h e 3 5 th an d 3 8 th w e e k s. The i n c i d e n c e o f a n a e m ia , h o w e v e r, was h i g h e r ,

17$ o f

t h e t o t a l num ber o f c a s e s ex am in e d sh o w in g a d ro p o f h a e m o g lo b in a t some tim e d u r i n g p r e g n a n c y , b e lo w 1 0 * 2 gram m es (7 5 $ H a ld a n e ) , a f i n d i n g som ew hat s i m i l a r t o t h a t o f B o y c o tt (1 9 3 6 ) who r e c o r d e d 11$ o f h i s c a s e s w i t h h a e m o g lo b in l e v e l s b e lo w 70$ H a ld a n e (9*6 g ra m m e s). F u l l e r t o n (1 9 3 6 ) fo u n d t h a t t h e a v e r a g e v a lu e a t t h e 1 2 th w eek o f p r e g n a n c y was 11*14-5 gram m es (8 3 $ H a ld a n e ) , a r e s u l t p r a c t i c a l l y t h e sam e a s t h a t fo u n d i n t h e p re s e n t in v e s tig a tio n .

T h is l e v e l , h o w e v e r, f e l l t o

10*25 gram m es ( 714-*3$ H a ld a n e ) a t t h e 3 7 th w eek .

A

h i g h e r i n c i d e n c e o f a n a e m ia was r e c o r d e d b y R e id and M a c k in to s h (1 9 3 7 ) an d D a v id s s n and F u l l e r t o n

(1 9 3 8 ) who

fo u n d t h a t 1 0 * 2$ an d 1 8 *14$ o f c a s e s i n t h e i r r e s p e c t i v e i n v e s t i g a t i o n s , h a d h a e m o g lo b in l e v e l s b e lo w 70$ H a ld a n e (9 * 6 g ram m es).

A p a rt fro m t h e a v e r a g e h a e m o g lo b in

151. v a l u e s d u r i n g p re g n a n c y , t h i s h i g h e r i n c i d e n c e o f a n a e m ia seem s t o h a v e b e e n f a i r l y g e n e r a l i n t h e p r e ­ w ar p e r i o d .

M e y e r-W e d e ll ( 1 9 ^ 3 ) fo u n d n o t o n ly an

a v e r a g e h a e m o g lo b in v a lu e o f 10*37 gram m es (75*2% H a ld a n e ) , b u t a l s o a n i n c i d e n c e o f 16 $ o f c a s e s w i t h a l e v e l b e lo w 7 0 $ H a ld a n e (9 * 6 g ram m es), a lt h o u g h d u r i n g t h e same p e r i o d Kay and A l s t o n r e c o r d e d r e s u l t s a lm o s t e x a c t l y s i m i l a r t o t h o s e fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n , v i z . a n a v e r a g e h a e m o g lo b in l e v e l o f 1 1 * 6 8 gram m es (81+*7$ H a ld a n e ) w i t h 5*3$ o f t h e i r c a s e s sh o w in g l e v e l s b e lo w 70$ H a ld a n e (9*6 g ram m es). I t w i l l b e o f i n t e r e s t now t o com pare t h e r e s u l t s o f th e p r e s e n t s e r i e s w ith th e r e s u l t s o f i n v e s tig a tio n s c a r r i e d o u t d u r i n g t h e w a r.

Kay a n d A l s t o n ( 19 I+I) i n

a f u r t h e r i n v e s t i g a t i o n d u r i n g t h e w ar y e a r s fo u n d t h a t t h e a v e r a g e h a e m o g lo b in l e v e l o f t h e i r p a t i e n t s h a d d ro p p e d t o 9*69 gram m es (70*8$ H a ld a n e ) an d 39$ o f c a s e s h a d l e v e l s b e lo w 70$ H a ld a n e (9*6 g ram m es), t h u s d e m o n s t r a t i n g a m arked i n c r e a s e o f a n a e m ia d u r i n g t h e w ar y e a r s . t h i s tre n d ,

S in c la ir

( 19 I+2 ) , h o w e v e r, d i d n o t c o n f ir m

r e c o r d i n g r e s u l t s a g a i n a lm o s t t h e same a s

t h o s e fo u n d i n t h e p r e s e n t s e r i e s , v i z . a n a v e r a g e h a e m o g lo b in l e v e l o f 11*6ij- gram m es (85$ H a ld a n e ) w i t h 5 - 9 $ sh o w in g l e v e l s b e lo w 70$ H a ld a n e (9*6 g ra m m e s), a n d W i l l s e t a l (1 9i+-2) f o u n d a m ean v a lu e o f 12*33 gram m es (8 9 * 5 $ H a l d a n e ) .

The l a t t e r , h o w e v e r, fo u n d a h i g h e r

132. i n c i d e n c e o f a n a e m ia v i z . 10 $ b u t t h i s was b a s e d on a lo w e r l i m i t o f n o r m a l i t y o f 80$ H a ld a n e (1 1 * 0 g ram m es), so t h a t t h e a c t u a l i n c i d e n c e may n o t h a v e b e e n much g r e a t e r tr ia n t h a t fo u n d i n t h e p r e s e n t s e r i e s .

C o n tin u in g

w i t h w a r - tim e s t u d i e s we f i n d much lo w e r v a l u e s r e c o r d e d b y H a m ilto n and W rig h t (1 9U-2) .

The a v e r a g e h a e m o g lo b in

v a lu e b e tw e e n t h e 3 r d . a n d 5 t h . m onth o f p re g n a n c y was fo u n d t o b e 10*62 gram m es (7 7 $ H a ld a n e ), 16*8$ o f t h e c a s e s h a v in g a l e v e l b e lo w 70$ H a ld a n e (9*6 g ram m es), w h ile a t te r m t h e a v e r a g e v a lu e was 9*6 gram m es ( 7 0 $ H a ld a n e ) , 1+0*3$ b e in g b e lo w t h i s l e v e l , a n i n c i d e n c e o f a n a e m ia w e l l a b o v e t h a t o f t h e p r e s e n t s e r i e s .

An e v e n

h i g h e r i n c i d e n c e w as r e c o r d e d b y Thomas (191+2) who fo u n d t h a t 52 $ o f c a s e s e x am in ed d u r i n g t h e l a s t tw e lv e w eeks o f p re g n a n c y h a d h a e m o g lo b in l e v e l s b e lo w 70$ H a ld a n e (9 * 6 g ra m m e s).

T h is i s t h e h i g h e s t i n c i d e n c e o f a n a e m ia

o f p r e g n a n c y so f a r r e c o r d e d , b u t t h e r e s u l t s p u b l i s h e d b y t h e C o m m ittee on H aem o g lo b in S u rv e y s

(1 9 ^ 3 ) a g a i n

c o rre sp o n d v e ry c lo s e ly w ith th e r e s u l t s o f th e p r e s e n t in v e s tig a tio n .

The C om m ittee fo u n d a mean h a e m o g lo b in

l e v e l o f 11*67 gram m es ( 8 l+*6$ H a ld a n e ) f o r a l l p r e g n a n t women, i r r e s p e c t i v e o f a g e , p a r i t y o r s t a g e o f p r e g n a n c y an d a n i n c i d e n c e o f 6 *7$ o f c a s e s w i t h a l e v e l b e lo w 7 0 $ H a ld a n e (9*6 g ra m m e s).

Low er f i g u r e s w e re r e c o r d e d

b y D a v id s o n e t a l (1 9i+3) v i z . a n a v e r a g e h a e m o g lo b in l e v e l o f 10*1+6 gram m es (7 5 * 8 $ H a ld a n e ) f o r a l l s t a g e s o f p r e g n a n c y , w i t h an i n c i d e n c e o f 2 l*$ o f t h e c a s e s

133. f a l l i n g b e lo w 70$ H a ld a n e (9*6 g ram m es), b u t F u l l e r t o n e t a l ( 191+1+) fo u n d r e s u l t s c o r r e s p o n d i n g v e r y c l o s e l y w ith th o s e o f th e p r e s e n t s e r i e s , v i z . an a v e ra g e h a e m o g lo b in v a lu e o f 11*39 gram m es (82*6$ H a ld a n e ) w i t h a n i n c i d e n c e o f 3 *9$ o f c a s e s sh o w in g l e v e l s b e lo w 7 0 $ H a ld a n e (9*6 g ram m es).

D a v id s o n e t a l (191+1+) i n

a f u r t h e r i n v e s t i g a t i o n fo u n d a som ew hat h i g h e r a v e r a g e v a l u e o f 11*97 gram m es ( 8 6 *8 $ H a ld a n e ) . F o r t h e r e a s o n s a l r e a d y s t a t e d , t h e mean h a e m o g lo b in l e v e l s a n d t h e i n c i d e n c e o f a n a e m ia j u s t q u o te d a r e n o t in a l l cases s t r i c t l y

c o m p a ra b le w i t h t h e r e s u l t s

re c o rd e d in th e p r e s e n t su rv e y , b u t a re a s o n a b ly a c c u r a te c o m p a r is o n h a s b e e n p o s s i b l e an d t h e r e s u l t s o f t h i s i n v e s t i g a t i o n com pare f a v o u r a b l y w i t h t h o s e o f b o t h p r e - w a r a n d w a r - tim e i n v e s t i g a t i o n s . of cases,

In th e m a jo rity

i t i s fo u n d b y c o m p a ris o n , t h a t t h e i n c i d e n c e

o f a n a e m ia o f p re g n a n c y h a s d im in is h e d an d c e r t a i n l y d o e s n o t a p p ro a c h t h e i n c i d e n c e r e c o r d e d b y H a m ilto n a n d W rig h t (191+2) a n d Thomas ( 19 I+2 ) .

The a v e r a g e h a e m o g lo b in

l e v e l s fo u n d d u r i n g p re g n a n c y a n d t h e i n c i d e n c e o f a n a e m ia , b a s e d on t h e num ber o f c a s e s w i t h l e v e l s b e lo w 1 0 gram m es p e r c e n t , com pare f a v o u r a b l y w i t h t h e r e s u l t s r e c o r d e d b y M ackay ( 1 9 3 1 ) , F u l l e r t o n

( 1 9 3 6 ) , Kay a n d A l s t o n 19 I+1

( p r e - w a r i n v e s t i g a t i o n ) , S i n c l a i r (191+2), C o m m ittee on H a e m o g lo b in S u rv e y s ( 19 I+3 ) , F u l l e r t o n e t a l (19W+) a n d D a v id s o n e t a l ( 19 I+I+).

They show a n im p ro v e m e n t on t h e

13k. r e s u l t s r e c o r d e d i n t h e o t h e r i n v e s t i g a t i o n s q u o te d . On t h e w h o le , t h e a v e r a g e h a e m o g lo b in v a l u e s d u r in g p r e g n a n c y a n d t h e i n c i d e n c e o f a n a e m ia fo u n d i n t h e p r e s e n t s u r v e y a r e m ore s a t i s f a c t o r y t h a n t h o s e fo u n d b e f o r e an d d u r i n g t h e w a r.

T h e re i s a l s o no e v id e n c e

o f a h i g h i n c i d e n c e o f a n a e m ia i n t h e s e r i e s o f c a s e s i n v e s t i g a t e d i f a t r u e a n a e m ia o f p r e g n a n c y i s o n ly c o n s i d e r e d t o e x i s t when t h e h a e m o g lo b in v a lu e f a l l s b e lo w 1 0 gram m es o f h a e m o g lo b in p e r 1 00 c c . o f b l o o d . On t h e a s s u m p tio n t h a t t h e r e i s no g r e a t d i f f e r e n c e b e tw e e n a v e r a g e h a e m o g lo b in v a l u e s i n t h i s c o u n tr y a n d t h o s e i n A m e ric a , a c o m p a ris o n o f t h e r e s u l t s o f t h e p r e s e n t i n v e s t i g a t i o n w i t h t h o s e fo u n d by A m e ric an w o rk e rs,

i s w o rth y o f c o n s i d e r a t i o n .

G a llo w ay (1929 b . )

f o u n d a n a v e r a g e h a e m o g lo b in v a l u e o f 12*5 gram m es d u r i n g t h e f i r s t t r i m e s t e r and 11*3 gram m es d u r i n g t h e t h i r d t r i m e s t e r , b u t h is r e s u l t s r e f e r r e d to b o th t r e a t e d and u n tre a te d c a s e s .

T h ese r e s u l t s a r e h i g h e r t h a n t h o s e

f o u n d i n t h e p r e s e n t i n v e s t i g a t i o n , b u t h e r e c o r d e d an i n c i d e n c e o f a n a e m ia o f 65$ , b a s e d h o w ev er on a lo w e r l i m i t o f n o r m a l i t y o f 11*0 gram m es p e r c e n t .

N o tw ith ­

s t a n d i n g , t h e i n c i d e n c e m u st s t i l l b e c o n s i d e r e d h i g h , a n d i s s u p p o r t e d b y t h e f i n d i n g s o f B la n d , G o l d s t e i n , and F i r s t

(1 9 3 0 a . ) who r e p o r t e d t h a t 58*6# o f t h e i r

p a t i e n t s h a d h a e m o g lo b in v a L u e s b e lo w 9*6 gram m es p e r c e n t.

I n a f u r t h e r s tu d y (1 9 3 0 b . ) ,

th e s e w o rk e rs

fo u n d t h a t 62 $ o f a g ro u p o f p r i v a t e p a t i e n t s h a d l e v e l s b e lo w 10*3 grammes a t te r m , w h i l e t h e c o r r e s p o n d i n g i n c i d e n c e among a g ro u p o f w ard p a t i e n t s r o s e t o 8 0 $ . T h e se f i g u r e s a r e much h i g h e r t h a n an y o f t h o s e r e c o r d e d b y w o rk e rs i n t h i s c o u n t r y . h i s s tu d y o f t r e a t e d c a s e s ,

fo u n d

an

H a l le

( 1930) in

a v e r a g e h a e m o g lo b in

v a lu e th r o u g h o u t p re g n a n c y o f o n ly 9*6 gram m es and M oore (1 9 3 0 ) i n tw o s e p a r a t e i n v e s t i g a t i o n s fo u n d t h a t , in th e f i r s t ,

t h e mean h a e m o g lo b in v a lu e was 10 *9 gram m es

w i t h 16 $ o f c a s e s sh o w in g l e v e l s b e lo w 9 *6 gram m es,

an d

i n t h e s e c o n d , t h e a v e r a g e v a lu e was 10*7 gram m es w i t h 19$ o f c a s e s b e lo w 9*6 gram m es.

A s im ila r a v e ra g e

v a l u e was r e c o r d e d by R i c h t e r e t a l (1 9 3 ^ ) v i z . 9*6 gram m es tw o w eek s b e f o r e te r m .

H ow ever, r e s u l t s som ew hat

s i m i l a r t o t h o s e fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n , w e re r e c o r d e d b y C o r r ig a n and S t r a u s s

(1 9 3 6 ).

T hey

f o u n d t h a t d u r i n g t h e l a s t f o u r m onths o f p r e g n a n c y , t h e a v e r a g e h a e m o g lo b in v a lu e was 1 1* 7 gram m es, a n d A d a i r e t a l (1 9 3 6 ) r e c o r d e d a v e r a g e v a l u e s o f 1 1 -5 6 gram m es a n d 1 1 * 7 9 gram m es i n a g ro u p o f h o s p i t a l c l a s s p a t i e n t s an d p r i v a t e p a t i e n t s r e s p e c t i v e l y .

T hey fo u n d ,

h o w e v e r, t h a t 1 1 - 6$ o f t h e h o s p i t a l c l a s s p a t i e n t s h a d v a l u e s b e lo w 1 0 - 0 0 gram m es p e r c e n t , w ith a c o r r e s p o n d i n g i n c i d e n c e o f 7$ among t h e p r i v a t e p a t i e n t s .

Few o f t h e

A m e ric a n w o rk e r s , h o w e v e r, r e c o r d a v e r a g e h a e m o g lo b in v a l u e s d u r i n g p r e g n a n c y a s h i g h a s t h o s e fo u n d i n t h i s c o u n try .

B e t h e l l (1 9 3 6 ) r e c o r d e d a n a v e r a g e v a l u e o f

136. 1 0 * 6 gram m es w i t h a n o v e r a l l i n c i d e n c e o f a n a e m ia o f

7 0 $ , "but t h i s i n c i d e n c e was b a s e d on a lo w e r l i m i t o f n o r m a l i t y o f 11*3 gram m es.

In a subsequent in v e s tig a ­

t i o n b y B e t h e l l e t a l (1 9 3 9 ) t h e i n c i d e n c e o f a n a e m ia h a d d ro p p e d t o 2 6 ' 6$ when a d i a g n o s i s was made o n ly i n t h o s e c a s e s w h ere t h e h a e m o g lo b in d ro p p e d t o l e s s t h a n 1 0 gram m es p e r c e n t a t some tim e d u r ir g

p reg n a n cy .

The lo w e s t i n c i d e n c e o f a n a e m ia r e c o r d e d by a n A m e ric an w o r k e r was 5$ (W atson, 1 9 3 8 ), b u t h i s r e s u l t s c o u ld n o t b e co m p ared w i t h t h o s e o f t h e p r e s e n t i n v e s t i g a t i o n a s h e c o n s i d e r e d t h e lo w e r l i m i t o f n o r m a l i t y f o r t h e h a e m o g lo b in v a l u e d u r i n g p r e g n a n c y , t o be 7 * 7 gram m es p e r c e n t an d 81$ o f h i s c a s e s h a d v a l u e s b e tw e e n 7 * 7 a n d 10*5 g ram m es.

A lo w e r l i m i t o f n o r m a l i t y

gram m es i s c o n s i d e r e d

t o b e much t o o lo w .

o f 7*7

An a v e r a g e

h a e m o g lo b in v a l u e v e r y s i m i l a r t o t h a t fo u n d by m ost o f t h e A m e ric a n i n v e s t i g a t o r s was r e c o r d e d by th e C a n a d ia n w o r k e r s , G o t t l i e b an d S t r e a n (1 9 3 9 ) v i z . an a v e r a g e v a l u e o f 10*5 gram m es p e r c e n t . Prom t h e a b o v e r e s u l t s i t w i l l be s e e n t h a t t h e a v e r a g e h a e m o g lo b in v a l u e s an d t h e i n c i d e n c e o f a n a e m ia f o u n d among p r e g n a n t women i n A m e ric a do n o t c o r r e s p o n d to r e s u l t s re c o rd e d in t h i s c o u n try .

On t h e w h o le , t h e

a v e r a g e h a e m o g lo b in l e v e l among p r e g n a n t women i n A m e ric a i s lo w e r and t h e i n c i d e n c e o f a n a e m ia i s c e r t a i n l y much h i g h e r .

I t i s d i f f i c u l t t o p u t f o r w a r d an

137. e x p la n a tio n f o r t h i s .

The o n ly c o m p a ra b le B r i t i s h

f i g u r e s a r e t h o s e o f H a m ilto n and W rig h t a n d Thom as, an d t h e s e m u st be c o n s i d e r e d u n u s u a l l y h ig h when co m p ared w i t h t h o s e o f t h e i r c o -w o r k e r s i n t h i s c o u n t r y . Pew c o n t i n e n t a l r e s u l t s c a n be co m p ared w i t h t h o s e o f B r i t i s h a n d A m e ric a n w o r k e rs on a c c o u n t o f t h e a b s e n c e o f c o m p a ra b le s t a n d a r d s o f h a e m o g lo b in o m e try , b u t K u h n e l (1 9 2 7 ) r e c o r d e d a n a v e r a g e v a lu e o f 13*7 gram m es a t t h e e n d o f t h e f i r s t m onth and 1 2* 2 gram m es f o u r w eeks b e f o r e d e liv e ry .

J e rlo v

( 1 9 2 9 ) fo u n d t h a t 2 5 *9$ o f h i s c a s e s

h a d h a e m o g lo b in l e v e l s b e lo w 70$ A u t e n r i e t h , a s t a n d a r d e q u i v a l e n t , a s f a r a s c a n be a s c e r t a i n e d t o 1 0 *i| gram m es p e r c e n t.

A t t h e en d o f t h e t h i r d m onth t h e a v e r a g e

l e v e l was 12*lj. gram m es a n d a t te r m 10*7 gram m es.

A lo w e r

i n c i d e n c e was r e c o r d e d b y E sc h (1 9 3 2 ) who fo u n d t h a t 9 * 28$ o f h i s p a t i e n t s h a d a v e r a g e h a e m o g lo b in l e v e l s o f 1 0* 3 gram m es p e r c e n t o r l e s s , b u t t h e lo w e s t i n c i d e n c e

so f a r r e c o r d e d was t h a t o f S c h u l tz (1 9 3 3 ) who fo u n d t h a t o n ly 2 *6$ o f h i s c a s e s h ad l e v e l s b e lo w 1 0* 3 gram m es p e r c e n t.

A h i g h e r i n c i d e n c e o f 31*5$ was r e c o r d e d by

T o v e ru d ( 1 9 3 5 ) , b a s e d on a lo w e r l i m i t o f n o r m a l i t y o f 75$ S a h l i , b u t u n f o r t u n a t e l y t h e s t a n d a r d u s e d was n o t s ta te d . The num ber o f C o n t i n e n t a l r e s u l t s r e c o r d e d a b o v e i s t o o s m a ll t o p e r m it o f d ra w in g a r e l i a b l e c o m p a ris o n b e tw e e n t h e a v e r a g e h a e m o g lo b in l e v e l s and t h e i n c i d e n c e

138. o f a n a e m ia o f p re g n a n c y among C o n t i n e n t a l women, and t h o s e i n t h i s c o u n tr y an d A m e ric a .

H ow ever, t h e s e

r e s u l t s r e c o r d e d by w o rk e rs on t h e C o n tin e n t do b e a r some r e s e m b la n c e t o t h o s e fo u n d i n t h i s c o u n tr y a l t h o u g h , w i t h one e x c e p t i o n t h e i n c i d e n c e o f a n a e m ia i s h i g h e r t h a n t h a t fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n .

As i n

t h i s c o u n t r y , t h e i n c i d e n c e o f a n a e m ia among p r e g n a n t women on t h e C o n t i n e n t , a s f a r a s c a n b e d e m o n s tr a te d by a s m a ll num ber o f i n v e s t i g a t i o n s , d o es n o t a p p ro a c h t h e h i g h i n c i d e n c e r e p o r t e d by many i n v e s t i g a t o r s i n A m e ric a .

RED BLOOD CELLS: F o r t u n a t e l y , t h e m eth o d s u s e d f o r t h e d e t e r m i n a t i o n o f t h e r e d c e l l c o u n t a r e u n if o r m , an d do n o t p r e s e n t t h e sam e d i f f i c u l t i e s when c o m p a ris o n s a r e a t t e m p t e d . The a v e r a g e i n i t i a l r e d c e l l c o u n t f o r t h e c o n t r o l - s e r i e s , a s s t a t e d i n t h e p r e v i o u s c h a p t e r , was I4-*39 m i l l i o n s , a n d t h e a v e r a g e t e r m i n a l c o u n t was U*02 m i l l i o n s .

The

a v e r a g e r e d c e l l c o u n t f o r t h e w hole p e r i o d o f p re g n a n c y u n d e r o b s e r v a t i o n was I4.*2 m i l l i o n s .

The l o w e s t l i m i t

o f n o r m a l i t y f o r t h e r e d c e l l c o u n t d u r in g p re g n a n c y h a v in g b e e n a c c e p t e d a s 3*5 in c id e n c e o f

a n a e m ia

V eT

c.m .m . o r l e s s , t h e

f o r t h e c o n t r o l s e r i e s was 5$ , b a s e d

on t h e a v e r a g e o f t h e r e d c e l l c o u n ts e s t i m a t e d d u r i n g th e p re g n a n c y .

T h ese r e s u l t s c a n now b e co m p ared w i t h

th o s e of o th e r w o rk e rs.

139. U n f o r t u n a t e l y , n o t many s t u d i e s o f t h e r e d c e l l c o u n t h a v e b e e n r e p o r t e d by B r i t i s h w o r k e r s , an d f o r t h e p u r p o s e s o f c o m p a ris o n , one i s c o n f in e d a lm o s t e n t i r e l y t o r e s u l t s o f A m e ric an i n v e s t i g a t i o n s . Thom son (19014-) r e c o r d e d a n a v e r a g e c o u n t o f 5*0 m i l l i o n s b e tw e e n t h e se c o n d an d t h e 9 t h m onth, a h i g h e r v a lu e t h a n t h a t fo u n d i n t h e p r e s e n t s e r i e s .

G allo w ay (1929 b)

r e p o r t e d a v e r y h i g h i n c i d e n c e o f a n a e m ia b a s e d on t h e r e d c e l l c o u n t, v i z . 65 $ , b u t he c a l c u l a t e d t h i s i n c i d e n c e on a lo w e r l i m i t o f n o r m a l i t y o f I4.*0 m i l l i o n s , a l t h o u g h h e fo u n d t h a t h i s p a t i e n t s i n t h e a n a e m ic g ro u p h a d r e d c e l l c o u n ts w e l l b e lo w t h i s f i g u r e . c o u n t f o r t h e f i r s t t r i m e s t e r was

The a v e r a g e

• 05 m i l l i o n s , a n d f o r

t h e t h i r d t r i m e s t e r 3*87 m i l l i o n s , a v e r a g e v a l u e s w h ic h do n o t show a w id e v a r i a t i o n fro m t h o s e fo u n d i n t h e p re s e n t in v e s tig a tio n .

A g a in , Lyon (1 9 2 9 ) r e p o r t e d a

h i g h i n c i d e n c e o f a n a e m ia b a s e d on th e r e d c e l l c o u n t, 3 2 * 2 $ o f h i s p a t i e n t s h a v in g c o u n ts b e lo w 3*6 m i l l i o n s d u rin g th e t h i r d t r i m e s t e r , F irs t

and B la n d , G o l d s t e i n a n d

(1 9 3 0 b . ) fo u n d t h a t 50 $ o f t h e i r s e r i e s o f w a rd

p a t i e n t s h a d c o u n ts b e lo w 3*5 m i l l i o n s .

The c o r r e s p o n d ­

in g i n c i d e n c e i n p r i v a t e p a t i e n t s was 2 6 $ .

T h e i r s a m p le s

in b o th s e r i e s r e f e r r e d to v a rio u s p e rio d s o f p re g n a n c y . The same w o rk e rs i n a f u r t h e r i n v e s t i g a t i o n fo u n d t h a t

k l* k $

(1 9 3 0 a . )

o f t h e i r p a t i e n t s had re d c e l l c o u n ts

b e tw e e n 2 -6 and 3*5 m i l l i o n s p e r c .m .m . an i n c i d e n c e o f

ito . a n a e m ia w e l l b ey o n d t h a t fo u n d i n t h e p r e s e n t s e r i e s . N a lle

( 1 9 3 0 ) , h o w e v e r, r e c o r d e d r e s u l t s m ore i n k e e p in g

w ith th o se o f th e p r e s e n t s e r i e s . c o u n t d u r i n g t h e t h i r d m onth was

The a v e r a g e r e d c e l l k 93

m illio n s ,

and

d u r i n g t h e n i n t h m o nth, i |.*2 m i l l i o n s , b u t t h e i n c i d e n c e o f a n a e m ia was a g a i n h i g h e r , 22 $ o f h i s p a t i e n t s h a v in g c o u n ts b e lo w 3*5 m i l l i o n s .

M oore (1 9 2 9 , 1930) i n h i s

tw o s e p a r a t e i n v e s t i g a t i o n s r e c o r d e d c o m p a ra b le v a l u e s v i z . a v e r a g e r e d c e l l c o u n ts o f 1^*1 m i l l i o n s an d I4-• 3 m illio n s .

Low er v a l u e s , h o w e v e r, w ere r e p o r t e d by

D a v is an d W a lk e r ( 1 93^4-) who fo u n d t h a t ij-3$ o f t h e i r s e r i e s o f t r e a t e d and u n t r e a t e d c a s e s h a d c o u n ts b e lo w 3*5 m i l l i o n s ,

t h e a v e r a g e c o u n t d u r in g t h e s e c o n d

t r i m e s t e r b e in g 3*53 m i l l i o n s , a n d d u r i n g t h e t h i r d t r i m e s t e r 3*14-5 m i l l i o n s , an d R i c h t e r e t a l (193^-) fo u n d a n a v e r a g e c o u n t o f 3* 8 6 m i l l i o n s a t t h e end o f t h e f i r s t t r i m e s t e r and 3*72 m i l l i o n s tw o w eeks b e f o r e te r m .

An

a v e r a g e v a lu e o f 3*98 m i l l i o n s was fo u n d b y I r v i n g

(1 9 3 5 )

i n a s e r i e s o f u n t r e a t e d p a t i e n t s e x am in e d a t v a r i o u s s ta g e s o f p reg n a n cy . C o r r ig a n and S t r a u s s

S i m i l a r f i g u r e s w ere r e c o r d e d by (1 9 3 6 ) who fo u n d a mean r e d c e l l

c o u n t o f 3 * 8 8 m i l l i o n s d u r in g t h e l a s t f o u r m o n th s o f p r e g n a n c y a n d by A d a ir e t a l (1 9 3 6 ), w hose mean v a l u e d u r i n g p r e g n a n c y was fo u n d t o be 3*77 m i l l i o n s an d Be t h e 11 (1 9 3 6 ) r e c o r d e d an a v e r a g e c o u n t o f 3*9^4- m i l l i o n s d u r i n g t h e l a s t t h r e e m onths o f p r e g n a n c y .

M cGeorge

(NZ 1 9 3 5 ) fo u n d a h i g h e r a v e r a g e v a lu e o f 14*79 m i l l i o n s

^k1. d u r i n g p r e g n a n c y , a n d i n t h i s c o u n tr y M e y e r-W e d e ll ( I 9 I4 3 ) i n h i s s e r i e s o f u n t r e a t e d c a s e s fo u n d t h a t t h e a v e r a g e r e d c e l l c o u n t b e tw e e n t h e 2 7 th a n d 3 2 n d . week was I*.* 18 m i l l i o n s and b e tw e e n t h e 3 3 r d . an d 3 8 th w eek, U-• i-i-5 m i l l i o n s .

Rone o f t h e c a s e s i n t h i s s e r i e s ,

h o w e v e r, h a d h a e m o g lo b in v a l u e s b e lo w 70$ H a ld a n e (9*6 gram m es) a n d t h e r e f o r e do n o t com pare w i t h a n u n s e le c te d g ro u p . I n r e v ie w in g t h e ab o v e r e s u l t s , w h ic h , w ith t h e e x c e p t i o n o f t h e l a s t two i n v e s t i g a t i o n s r e f e r r e d t o , h a v e a l l b e e n r e c o r d e d b y A m e ric an w o r k e r s , one a r r i v e s a t a som ew hat s i m i l a r c o n c l u s i o n t o t h a t fo u n d i n m aking a c o m p a ris o n o f h a e m o g lo b in v a l u e s .

W h ile t h e a v e r a g e

r e d c e l l c o u n t s , w h e th e r f o r t h e w h o le p e r i o d o f t h e p r e g n a n c y , o r f o r s p e c i f i c p e r i o d s , a r e r o u g h ly c o m p a ra b le w i t h t h e a v e r a g e r e d c e l l c o u n ts fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n , th e y a r e on t h e w hole som ew hat l c w e r , b u t t h e s t r i k i n g d i f f e r e n c e i s i n t h e i n c i d e n c e o f a n a e m ia , b a s e d o n t h e r e d c e l l c o u n t.

T h is i n c i d e n c e , a s

r e c o r d e d by t h e s e w o r k e r s , i s c o n s i d e r a b l y h i g h e r , an d b e a r s no r e l a t i o n t o , t h e i n c i d e n c e o f a n a e m ia fo u n d i n th e p r e s e n t s e r i e s ,

i n w h ic h o v e r 70$ o f c a s e s i n t h e

u n t r e a t e d g ro u p h a d

a v e r a g e r e d c e l l c o u n ts o f lj.#0

m i l l i o n s o r m ore t h r o u g h o u t t h e p e r i o d o f p r e g n a n c y -under o b s e rv a tio n .

I t i s a g a i n d i f f i c u l t t o f i n d a n y a d e q u a te

e x p la n a tio n f o r t h i s d is c re p a n c y , b u t th e r e s u l t s i n th e

1^2. p r e s e n t s e r i e s show , b y c o m p a ris o n w i t h t h o s e o f A m e ric a n w o r k e r s , h i g h e r a v e r a g e r e d c e l l c o u n ts among p r e g n a n t women i n t h i s c o u n tr y a n d a v e r y much lo w e r i n c i d e n c e o f a n a e m ia b a s e d on t h e r e d c e l l c o u n t, w h ic h by i t s e l f ,

show s no e v id e n c e o f a s e r i o u s d e g r e e o f

a n a e m ia among t h e p a t i e n t s i n v e s t i g a t e d . An e x a c t l y s i m i l a r c o n c l u s i o n c a n b e draw n fro m a r e v ie w o f a few o f t h e r e s u l t s r e c o r d e d b y C o n t i n e n t a l w o rk e rs.

A ld e r ( 193 ^-) r e c o r d e d a n a v e r a g e c o u n t o f

3*6 m i l l i o n s d u r i n g p r e g n a n c y , an d E sc h (1 9 3 2 ) fo u n d a n a v e r a g e v a l u e o f 3*7 m i l l i o n s i n c a s e s e x am in e d b e tw e e n th e f i f t h

and n i n t h m o n th s, b u t i n h i s s e r i e s t h e

h a e m o g lo b in l e v e l was b e lo w 10*3 gram m es i n e v e r y c a s e . A h i g h i n c i d e n c e o f a n a e m ia was r e p o r t e d by S c h u l t z ( 1 9 3 3 ) , who fo u n d t h a t 50 $ o f h i s c a s e s show ed a d r o p i n t h e r e d c e l l c o u n t t o 3 * 0 m i l l i o n s b e tw e e n t h e s i x t h an d 1 0 th m o n th .

H ow ever, a n e x c e p t i o n t o t h i s h ig h

i n c i d e n c e i s t o b e fo u n d i n t h e s e r i e s e x am in e d by T o v e ru d (1 9 3 5 ) who fo u n d t h a t o n ly 7$ o f h i s c a s e s h a d r e d c e l l c o u n ts b e lo w Ij-* 3 m il l i o n s , and B r in d e a u an d T h e o d o r id e s

(1 9 3 5 ) fo u n d a n a v e r a g e c o u n t s i m i l a r t o

t h a t o f t h e p r e s e n t s e r i e s v i z . 14*19 m i l l i o n s . COLOUR INDEX: The i n i t i a l a v e r a g e c o l o u r in d e x among t h e c o n t r o l g ro u p i n t h e p r e s e n t i n v e s t i g a t i o n was 0 - 9 i4 and t h e a v e r a g e t e r m i n a l c o l o u r in d e x was 0 * 9 3 , b o t h v a l u e s

Ik3. b e i n g w i t h i n t h e n o rm a l r a n g e f o r p r e g n a n t women. T h e re i s p r o b a b ly no o t h e r h a e m a t o l o g ic a l v a l u e , h o w e v e r, w h ic h c a n show s u c h a w id e i n d i v i d u a l v a r i a t i o n , a n d w h ile c o m p a ris o n w i t h t h e v a l u e s fo u n d by o t h e r i n v e s t i g a t o r s w ould be o f i n t e r e s t ,

t h e c o l o u r in d e x

v a l u e i s n o t one on w h ic h d e f i n i t e c o n c l u s i o n s s h o u ld b e d raw n . A v e ra g e c o l o u r in d e x v a l u e s d u r in g p re g n a n c y h a v e a lre a d y b een r e f e r r e d to

( p . 78 and 7 9 ) , b u t a few o f

t h e s e may b e r e p e a t e d t o show how th e y com pare w i t h t h e r e s u l t s o f th e p re s e n t in v e s tig a tio n .

H e n d e rs o n (1 9 0 2 )

r e p o r t e d a n a v e r a g e c o l o u r in d e x d u r i n g p r e g n a n c y o f 0 * 7 8 a n d B lu m e n th a l (1 9 0 7 ) fo u n d t h a t t h e

ran ge

of

v a l u e s e x te n d e d b e tw e e n 0 * 7 and 1 *2 w h i l e t h e a v e r a g e v a l u e r e c o r d e d by Gram (1 9 2 0 ) was 0 * 9 .

R e s u lts

p u b l i s h e d by o t h e r w o r k e r s , h o w e v e r, c o r r e s p o n d on t h e w h o le , m ore c l o s e l y w i t h th o s e fo u n d i n t h e p r e s e n t s e rie s ,

f o r e x a m p le , A ld e r ( 192 I*.) fo u n d an a v e r a g e v a l u e

o f 1*00 w i t h a ra n g e b e tw e e n 0*9 and 1*05* G o ld s te in and F i r s t

(1 930 b ) fo u n d a m ean v a lu e o f 0*9lj.,

b u t S tr a u s s and O a s tle 0*87.

B la n d ,

(1 9 3 0 ) r e c o r d e d a lo w e r v a lu e o f

Somewhat s i m i l a r f i g u r e s w ere r e c o r d e d by N a l l e

(1 9 3 0 ) an d Moore ( 1 9 3 0 ) .

E s c h 's f i g u r e o f 0*7i4- r e f e r r e d

o n ly t o d e f i n i t e a n a e m ic c a s e s , b u t e v e n among a n a e m ic cases,

S c h u l t z (1 9 3 3 ) fo u n d t h a t t h e c o l o u r in d e x r a n g e

w as b e tw e e n 0*9 an d 1 *0 0 , i . e .

w i t h i n n o rm a l l i m i t s ,

and

R i c h t e r e t a l (193U) fo u n d t h a t m ore t h a n h a l f o f t h e i r

144. c a s e s w ere w i t h i n t h e same r a n g e .

A ls o , i n t h e s e r i e s

o f u n t r e a t e d a n a e m ic c a s e s s t u d i e d by D av id an d W alk er ( 1 9 3 ^ ) , t h e a v e r a g e c o l o u r in d e x d u r in g t h e s e c o n d a n d t h i r d t r i m e s t e r was fo u n d t o b e 0 * 9 5 and 0 * 9 6 re s p e c tiv e ly .

O th e r r e s u l t s c o r r e s p o n d in g v e r y c l o s e l y

w i t h t h e a v e r a g e v a l u e s fo u n d i n t h e p r e s e n t s e r i e s , h a v e b e e n r e c o r d e d by C o r r ig a n a n d S t r a u s s (1 9 3 6 ), B e t h e l l ( 1 9 3 6 ), H e l ls tr o m

(1 9 3 7 ) and S te v e n s o n ( 1 9 3 8 ) .

M e y e r-W e d e ll (19^4*3) fo u n d t h a t t h e a v e r a g e c o l o u r in d e x i n h i s s e r i e s o f u n t r e a t e d c a s e s , was 0* 93 b e tw e e n t h e 27t h and

3 2 n d . week a n d 0 * 8 6 b e tw e e n 3 3 r d . a n d 3 8 t h w e ek .

W ith o u t com m enting a g a i n on t h e w ide v a r i a t i o n t o b e e x p e c te d i n t h e c o l o u r in d e x v a lu e d u r i n g p r e g n a n c y a n d o n t h e i n t e r p r e t a t i o n a n d s i g n i f i c a n c e o f any a v e ra g e v a lu e ,

i t may b e s a i d t h a t t h e mean c o l o u r in d e x

an d t h e r a n g e o f v a l u e s fo u n d i n t h e p r e s e n t s e r i e s c o rre sp o n d fa v o u ra b ly w ith th o s e re c o rd e d by o th e r in v e s tig a to rs .

A lth o u g h i t h a s n o t b e e n c o n s i d e r e d

o f an y v a lu e t o make a n a s s e s s m e n t o f t h e i n c i d e n c e o f a n a e m ia b a s e d on t h e c o l o u r in d e x v a l u e , t h e r e i s no e v id e n c e , i n t h e r e s u l t s o f t h e p r e s e n t i n v e s t i g a t i o n , t o show an y s e r i o u s i n c r e a s e i n t h e i n c i d e n c e o f t h e a n a e m ia o r lo w e r in g o f t h e c o l o u r in d e x d u r in g p r e g n a n c y , b e y o n d minimum v a l u e s r e c o r d e d by th e m a j o r i t y o f o th e r w o rk e rs.

1^ 5 .

TREATMENT: A lth o u g h , i n t h e t r e a t m e n t o f i r o n - d e f i c i e n c y a n a e m ia o f p re g n a n c y w i t h m e d i c i n a l d o s e s o f i r o n , some w r i t e r s have re p o rte d u n s a tis f a c to r y r e s u l t s ,

(M ackay

1 9 3 1 , E s c h 1 9 3 2 , A d a ir e t a l 1936, A dcock e t a l 1 9 *4-8 ) , t h e g r e a t m a j o r i t y o f w o rk e rs i n t h i s f i e l d , h a v e c o n c l u s i v e l y p ro v e d t h e a d v a n ta g e s o f t h i s fo rm o f tre a tm e n t,

e s p e c i a l l y i n r a i s i n g t h e h a e m o g lo b in l e v e l

d u rin g p reg n a n cy .

(A ld e r I 92 I4-, J e r l o v 1929, S t r a u s s and

C a s t l e 1 9 3 2 , 1933, 193*4-, W il l s 1 9 3 5 , F u l l e r t o n 1 9 3 6 , T o la n d 1 9 3 6 , B e t h e l l 1 9 3 5 , 19 3 6 , 19 3 9 , W iddowson 1 9 3 9 , G o t t l i e b and S t r e a n 1939, H a m ilto n a n d W rig h t 19 *4-2 , E l l i o t t 19 *44.) .

T h e re c a n b e l i t t l e

b e n e fic ia l e ffe c ts .

doubt of i t s

S i m i l a r l y a l a r g e num ber o f w r i t e r s ,

i n c l u d i n g many o f t h o s e q u o te d , h a v e r e p o r t e d on t h e b e n e f i c i a l e f f e c t s o f ir o n a d m in is te re d in p r o p h y la c tic d o s e s d u r i n g p re g n a n c y , a lt h o u g h Browne ( 1 9 I4J4.) was o f t h e o p i n i o n t h a t t h e i n c i d e n c e o f a n a e m ia o f p re g n a n c y i n t h i s c o u n tr y d id n o t j u s t i f y t h e a d m i n i s t r a t i o n o f i r o n d u r i n g p re g n a n c y a s a r o u t i n e m e a s u re , a n o p i n i o n s u p p o r t e d by t h e r e s u l t s o f t h e p r e s e n t i n v e s t i g a t i o n . T h is p r a c t i c e , h o w e v e r, h a s b e e n a f a i r l y g e n e r a l one th r o u g h o u t t h e c o u n t r y . I n t h e p r e s e n t i n v e s t i g a t i o n , a d e p a r t u r e fro m t h e u s u a l r o u t i n e p r a c t i c e h a s b e e n made by t r e a t i n g p a t i e n t s d u r i n g p re g n a n c y w i t h p r o p h y l a c t i c d o s e s o f i r o n i n t h e

fo rm o f one o f t h e p r o p r i e t o r y p r e p a r a t i o n s w h ic h

her e

becom e p o p u l a r i n a n t e n a t a l c l i n i c s i n r e c e n t y e a r s . The r e s u l t s o f t h i s ty p e o f t r e a t m e n t show t h a t w h ile t h e a v e r a g e h a e m o g lo b in l e v e l o f p r e g n a n t women c a n b e r a i s e d by t h i s m eans, t h e i n c r e a s e i s so s m a ll a s t o be o f l i t t l e

s i g n i f i c a n c e , an d t h e r e i s no e v id e n c e o f

any s u b s ta n tia l b e n e f i t. sam e, i f n o t b e t t e r ,

One m ig h t assum e t h a t t h e

r e s u l t s w ould h a v e b e e n a c h ie v e d

b y t h e u s e o f a much c h e a p e r a n d p o s s i b l y m ore e f f e c t i v e fo rm o f p r o p h y l a c t i c i r o n , e . g . f e r r o u s s u l p h a t e t a b l e t s . I t m u st b e rem em bered, o f c o u r s e , t h a t c o n s t a n t s u p e r v i s i o n c o u ld n o t b e e x e r c i s e d o v e r t h e p a t i e n t s i n th e tr e a te d s e r ie s ,

a lt h o u g h e v e r y e f f o r t was made t o

e n s u re t h e i r c o -o p e r a tio n , and i t i s p o s s ib le t h a t th e maximum b e n e f i t fro m t h e p r o p h y l a c t i c i r o n t r e a t m e n t u s e d , h a s n o t b e en a c h ie v e d .

The same c o n d i t i o n s ,

h o w e v e r, w ould a p p ly t o i n v e s t i g a t i o n s c a r r i e d o u t by o t h e r w o r k e r s , w h ere t h e u s u a l i r o n m e d ic a m e n ts h a v e b e e n e m p lo y e d .

N e v e rth e le s s ,

i t i s n o t c o n s id e re d t h a t

t h e form o f p r o p h y l a c t i c i r o n t r e a t m e n t a d o p te d i n t h i s i n v e s t i g a t i o n , h a s b e e n w i t h o u t v a l u e , a s a s tu d y o f t h e r e s u l t s w i l l show .

A lth o u g h t h e a v e r a g e i n c r e a s e i n

t h e h a e m o g lo b in l e v e l h a s b e e n s m a ll i n t h e t r e a t e d g ro u p , th e r e h a s b een a d e f i n i t e p r o p h y la c tic e f f e c t in c h e c k in g t h e f a l l i n t h e h a e m o g lo b in l e v e l d u r in g p re g n a n c y , n o tic e a b le in th e c o n tr o l g ro u p .

The sam e

lk7. t r e n d i s e v id e n c e d i n t h e r e d c e l l c o u n ts o f t h e t r e a t e d cases.

A n o th e r a d v a n ta g e a t t r i b u t a b l e

t o t h i s fo rm o f

t r e a t m e n t , and t o w h ic h a t t e n t i o n h a s a l r e a d y b e e n d raw n , i s t h e f a c t t h a t i t h a s becom e a " p o p u la r " m ethod o f in g e s tin g iro n ,

and i n t h e w r i t e r ’ s e x p e r i e n c e h a s b e e n

m ore a c c e p t a b l e t o many a n t e n a t a l p a t i e n t s who w ould o th e rw is e r e f u s e p u re ly m e d ic in a l tr e a tm e n t a s a r o u tin e p ra c tic e ,

i n t h e b e l i e f t h a t i t was u n n e c e s s a r y .

The g e n e r a l e f f e c t o f t h e p r o p h y l a c t i c a d m i n i s t r a ­ t i o n o f ir o n in th e p re s e n t in v e s tig a tio n h as been a b e n e f i c i a l one i n t h a t i t h a s d im in is h e d t h e te n d e n c y t o t h e d e v e lo p m e n t o f a n i r o n - d e f i c i e n c y a n a e m ia d u r i n g p reg n a n cy .

A ls o , i n v iew o f t h e c o m p a r a t i v e l y low

i n c i d e n c e o f a n a e m ia r e c o r d e d , ju s tifia b le

i t i s n o t c o n s id e re d

t o i n s t i t u t e p r o p h y l a c t i c m e a s u re s a s a

r o u t i n e p r a c t i c e i n a n t e n a t a l c l i n i c s a lt h o u g h t h e n e e d f o r t h e d e t e c t i o n o f a d e v e lo p in g a n a e m ia d u r in g p r e g n a n c y b y a s im p le r o u t i n e i n v e s t i g a t i o n i n e v e r y case,

is e s s e n tia l.

The lo w i n c i d e n c e o f a n a e m ia o f

p r e g n a n c y r e v e a l e d b y t h e p r e s e n t s u rv e y i s i n s t r i k i n g c o n t r a s t t o t h e g e n e r a l i n c i d e n c e r e c o r d e d b e f o r e an d d u r i n g t h e w a r.

T h is im p ro v e m e n t i s c o n s i d e r e d t o b e

due t o t h e m ore e n l i g h t e n e d a p p r e c i a t i o n o f d i e t a r y r e q u i r e m e n t s d u r i n g p re g n a n c y a n d t o th e m ore e q u i t a b l e d i s t r i b u t i o n o f t h e e s s e n t i a l f o o d s w h ic h h a s t a k e n p l a c e i n t h i s c o u n tr y d u r i n g an d s i n c e t h e w a r.

As

1JU-8* D a v id s o n and F u l l e r t o n

(1 9 3 8 ) p o i n t e d o u t , t h e m ain

l i n e to fo llo w in th e p ro p h y la x is o f ir o n - d e f ic ie n c y a n aem ia i s t o i n c r e a s e t h e i r o n - c o n t a i n i n g f o o d s i n th e d ie t.

O nly when s u c h a d i e t f a i l s

to m a in ta in a

n o r m a l b lo o d l e v e l s h o u ld m e d i c i n a l i r o n b e g i v e n . T h is i s so u n d p o l i c y b o t h fro m a n u t r i t i o n a l an d e c o n o m ic p o i n t o f v ie w a n d i n t h i s d i r e c t i o n l i e s t h e p o s s i b i l i t y o f a f u r t h e r r e d u c tio n in th e in c id e n c e o f i r o n - d e f ic ie n c y a n a e m ia among p r e g n a n t women i n t h i s c o u n tr y .

ANAEMIA OF PREGNANCY IN RELATION TO AGE: I t h a s a l r e a d y b e e n shown i n a n a n a l y s i s o f r e s u l t s t h a t v e ry l i t t l e

r e l a t i o n s h i p h a s b e e n fo u n d b e tw e e n t h e

a g e o f t h e p a t i e n t an d t h e i n c i d e n c e o f a n a e m ia . W illia m s o n (1 9 1 6 ) s t a t e d t h a t t h e am ount o f h a e m o g lo b in i n t h e b lo o d o f n o rm a l p e r s o n s , v a r i e d g r e a t l y a t d i f f e r e n t a g e s , an d one m ig h t assum e t h a t t h e sam e w ould a p p ly t o t h e p r e g n a n t woman, b u t i t i s w o r th n o t i n g t h a t h e fo u n d t h e g r e a t e s t v a r i a t i o n s w ere b e tw e e n b i r t h a n d th e s i x t e e n t h y e a r , and n o t d u rin g th e r e p r o d u c tiv e p e rio d .

D a v id s o n e t a l (1 9 3 5 ) f o u n d t h a t a n a e m ia o f

p r e g n a n c y was m ore p r e v a l e n t d u r in g t h e l a t e r c h i l d ­ b e a r i n g y e a r s , b u t t h i s i n c r e a s e d i n c i d e n c e m ig h t a l s o be e q u a lly a t t r i b u t a b l e to m u ltip a r ity .

The C o m m ittee

on H a em o g lo b in S u rv e y s (1 9 ^ 3 ), h o w e v e r, e x p r e s s e d t h e o p i n i o n t h a t t h e h a e m o g lo b in l e v e l d u r in g p r e g n a n c y v a r i e d w ith th e age of th e p a t i e n t ,

a lt h o u g h o t h e r w o r k e r s

Ik9. h a v e f o u n d no r e l a t i o n s h i p b e tw e e n a g e and i n c i d e n c e o f a n a e m ia ,

(B la n d , G o l d s t e i n and F i r s t 1930 a ,

M ackay 1 9 3 5 , McGeorge 1 9 3 5 , B o y c o tt 1 9 3 6 , R e id an d M a c k in to s h 1937) a n d , a s a l r e a d y s t a t e d ,

th e r e s u l t s

o f t h e p r e s e n t i n v e s t i g a t i o n c o n fir m t h e s e f i n d i n g s . ANAEMIA IN RELATION TO PARITY: The r e l a t i o n s h i p b e tw e e n a n a e m ia o f p r e g n a n c y and t h e num ber o f p r e v i o u s p r e g n a n c i e s h a s a l r e a d y b e e n d is c u s s e d

( p . I4.6) an d a s h a s b e e n p o i n t e d o u t ,

it

is

d i f f i c u l t t o come t o a n y d e f i n i t e c o n c l u s i o n on t h i s p o in t.

A s tu d y o f t h e r e s u l t s o f t h e p r e s e n t i n v e s t i g a ­

t i o n d o es n o t h e lp t o c l a r i f y m a tte r s , a s th e r e s u l t s t e n d n o t o n ly t o b e i n c o n c l u s i v e , b u t a p p a r e n t l y in c o n s is te n t.

T h e re i s no e v id e n c e t o s u g g e s t , h o w e v e r,

t h a t t h e r e e x i s t s a n y d e f i n i t e r e l a t i o n s h i p b e tw e e n t h e i n c i d e n c e o f a n a e m ia o f p re g n a n c y and t h e num ber o f p re v io u s p re g n a n c ie s ,

i n t h e s e r i e s o f c a s e s w h ic h h a s

b e e n i n v e s t i g a t e d , no g r e a t e r te n d e n c y to w a rd s a n a e m ia h a v in g b e e n fo u n d among t h o s e w i t h t h r e e c h i l d r e n o r m o re, a s com pared w i t h women i n t h e i r f i r s t o r s e c o n d p re g n a n c ie s . EFFECT OF ANAEMIA OF PREGNANCY ON THE MOTHER: POST-PARTTJM HAEMORRHAGE. The r e l a t i o n s h i p b e tw e e n a n a e m ia o f p re g n a n c y a n d p o s t - p a r t u m h a e m o rrh a g e h a s b e e n s t u d i e d by s e v e r a l

150. w o rk e rs.

G a llo w ay (1929 b ) i n h i s s t u d y o f t h e

c o n d i t i o n , fo u n d t h a t 16 r e c o g n i s e d a n a e m ic c a s e s ,

out

o f 382 e x a m in e d , a l l l o s t m ore b lo o d t h a n t h e a v e r a g e p a t i e n t , b u t B la n d an d G o l d s t e i n (1 9 2 9 ) who e x am in e d 50 a n a e m ic c a s e s d u r i n g p r e g n a n c y , fo u n d t h a t o n ly one had e x c e s s iv e p o s t-p a rtu m b le e d in g a t d e liv e r y . th e o th e r hand, J e r lo v

On

(1 9 2 9 ) s t r e s s e d th e im p o r ta n c e

o f t h e p r e v e n t i o n o f a n a e m ia o f p re g n a n c y , b e c a u s e h e c o n s i d e r e d t h a t t h e p re g n a n c y i n t h e s e c a s e s a lw a y s t e r m i n a t e d i n m ore o r l e s s p ro n o u n c e d b l e e d i n g .

E x a c tly

t h e o p p o s i t e c o n c l u s i o n was a r r i v e d a t by Adamson an d S m ith (1 9 3 2 ) who fo u n d t h a t t h e i n c i d e n c e o f a b n o rm a l b l e e d i n g a f t e r d e l i v e r y was m o st m arked i n t h e h i g h e r h a e m o g lo b in g ro u p o f p a t i e n t s , a n d B o y c o tt (1 9 3 6 ) fo u n d no r e l a t i o n s h i p b e tw e e n t h e a n a e m ia and an y o t h e r a b n o r m a li t y o f p r e g n a n c y . s e v e re p o s t-p a rtu m b le e d in g . s i m i l a r o p in io n .

O nly two o f h i s c a s e s h a d S te v e n s o n (1 9 3 8 ) was o f a

M e y e r-W e d e ll (191+3), h o w e v e r, fo u n d t h a t ,

o f e i g h t c a s e s o f p o s t - p a r t u m h a e m o rrh a g e i n h i s s e r i e s , f i v e h a d p e r n i c i o u s a n a e m ia a n d t h r e e a v i t a m i n C. d e f i c i e n c y a n a e m ia , a r e s u l t w hich w o u ld s u g g e s t some c o n n e c t i o n b e tw e e n t h e tw o c o n d i t i o n s , b u t E l l i o t t

(19U4-)

d i d n o t f i n d e v id e n c e o f t h e e x i s t e n c e o f any s u c h re la tio n s h ip . I t i s n o t p o s s i b l e t o a r r i v e a t an y d e f i n i t e c o n c l u s i o n fro m t h e ab o v e r e s u l t s , b u t i n t h e p r e s e n t

151.

i n v e s t i g a t i o n i t a p p e a re d t h a t t h e r e was a g r e a t e r te n d e n c y to w a rd s p o s t - p a r t u m h a e m o rrh a g e among t h e a n a e m ic g ro u p o f p a t i e n t s , an d one i s i n c l i n e d t o t h e v ie w o f G a llo w ay an d M e y e r-W e d e ll t h a t some c o n n e c ti o n e x i s t s b e tw e e n t h e tw o c o n d i t i o n s .

What t h i s

c o n n e c ti o n i s , m i& ht b e d i f f i c u l t t o e x p l a i n i n e v e r y c a s e , b u t i s p r o b a b ly r e l a t e d t o t h e u t e r i n e i n e r t i a r e s u l t i n g fro m t h e g e n e r a l m u s c u la r a to n y b r o u g h t a b o u t b y t h e a n a e m ia .

EFFECT ON THE INCIDENCE OF PYREXIA: T h e re was fo u n d t o b e a g r e a t e r i n c i d e n c e o f p y r e x i a d u r i n g t h e p u e r p e r iu m , fro m a l l c a u s e s , among t h e a n a e m ic , a s co m p ared w i t h t h e n o n -a n a e m ic g ro u p o f p a t i e n t s ,

an d

t h i s f i n d i n g i s i n a g re e m e n t w i t h t h e r e s u l t s o f m o st o t h e r w o r k e r s , and m ig h t b e e x p e c te d a s a r e s u l t o f t h e g e n e r a l i l l h e a l t h a n d lo w e re d r e s i s t a n c e b r o u g h t a b o u t b y t h e a n a e m ic c o n d i t i o n .

M ackay (1 9 3 1 , 1935) fo u n d

t h a t t h e r e w ere 11 i n f e c t i o n s c a u s in g p y r e x i a i n a s e r i e s o f 14+ t r e a t e d p a t i e n t s an d 7 i n f e c t i o n s i n 39 c o n t r o l cases,

a n i n c i d e n c e o f 21*6$ f o r t h e com bined s e r i e s .

M e lla n b y (1 9 3 3 ) was o f t h e o p i n io n t h a t a n a e m ia o f p re g n a n c y p ro b a b ly in c r e a s e d th e s u s c e p t i b i l i t y to p u e r p e r a l s e p s i s and D a v id so n e t a l (1 933) w e re q u i t e d e f i n i t e on t h i s p o i n t .

F u r t h e r e v id e n c e i n s u p p o r t

o f t h i s o p i n io n was f u r n i s h e d by D a v is and W a lk e r (1 9 3 4 )

who r e c o r d e d r e s u l t s v e r y s i m i l a r t o t h o s e o f M ackay, v i z . a n i n c i d e n c e 27*9$

i n t h e i r u n t r e a t e d s e r i e s and

11*2$ i n t h e t r e a t e d g r o u p .

T h ese f i g u r e s an d a l s o

t h o s e o f M ackay, show a n i n c i d e n c e o f p y r e x i a d u r i n g t h e p u e r p e r iu m h i g h e r t h a n t h a t fo u n d i n t h e p r e s e n t in v e s tig a tio n .

The im p o r ta n c e o f t h i s a s p e c t o f t h e

a n a e m ia o f p re g n a n c y h a s a l s o b e e n r e f e r r e d t o by o t h e r w o rk e rs,

( B o y c o tt 1936, C a re y -S m a llw o o d 1 9 3 6 , H e id a n d

M a c k in to s h 1 9 3 7 , Ramsay an d D o lp h in 1 9 4 6 ), an d t h e r e i s e v id e n c e t o show t h a t a n a e m ia o f p re g n a n c y s t i l l p l a y s a n i m p o r ta n t p a r t i n p r o d u c in g a n i n c r e a s e d s u s c e p t i b i l i t y to w a r d s t h e d e v e lo p m e n t o f p y r e x i a d u r i i g

t h e p u e r p e r iu m .

T h is f a c t o r m u st a lw a y s b e b o r n e i n m ind a s i n d i c a t i n g y e t a g a i n , t h e n e c e s s i t y f o r t h e e a r l y d e t e c t i o n an d t r e a t m e n t o f p re g n a n c y a n a e m ia . EFFECT,ON THE INCIDENCE OF FORCEPS DELIVERY: The d i f f e r e n c e i n t h e r a t e o f f o r c e p s d e l i v e r y b e tw e e n t h e a n a e m ic a n d n o n -a n a e m ic g ro u p s d o e s n o t a d n i t o f a n y d e f i n i t e c o n c l u s i o n s , a l t h o u g h i n t h e com bined s e r i e s o f t r e a t e d an d u n t r e a t e d c a s e s , t h e u s e o f f o r c e p s was s l i g h t l y m ore f r e q u e n t i n t h e a n a e m ic g r o u p .

The

a b s e n c e o f an y s t r i k i n g d i f f e r e n c e b e tw e e n t h e two g r o u p s i s n o t s u r p r i s i n g i n v ie w of t h e many f a c t o r s w h ic h a r e b ro u g h t to b e a r,

i n d e c i d i n g w h e th e r o r n o t t o t e r m i n a t e

d e l i v e r y b y f o r c e p s i n t h o s e c a s e s w h ic h p r e s e n t e d no d e f i n i t e o b s t e t r i c a b n o rm a lity .

The f o r c e p s r a t e

in

1 5 3. th e c o n tr o l g ro u p , a t l e a s t ,

i s no h i g h e r t h a n t h a t

f o u n d among n o rm a l h e a l t h y p r e g n a n t women.

G a llo w ay

(1929 b . ) fo u n d t h a t o n ly tw o o f h i s s i x t e e n a n a e m ic c a s e s d e v e lo p e d u t e r i n e i n e r t i a , a n d a lt h o u g h Adamson a n d S m ith (1 9 3 2 ) fo u n d a h i g h e r f o r c e p s r a t e i n t h e lo w e r h a e m o g lo b in g ro u p o f p a t i e n t s , R e id a n d M a c k in to s h (1 9 3 7 ) fo u n d t h a t a n a e m ia o f p re g n a n c y a p p e a r e d t o h a v e no i n f l u e n c e on a b n o rm a l l a b o u r a s a w h o le , a n d t h e r e i s no e v id e n c e i n t h e p r e s e n t s e r i e s to s u g g e s t t h a t a n a e m ia h a d a n y s i g n i f i c a n t b e a r i n g on t h e f o r c e p s r a t e . MATERNAL MORTALITY: T h e re w ere no m a t e r n a l d e a th s i n t h e s e r i e s o f c a se s in v e s tig a te d .

One d e a t h , du e t o a n a e m ia o f

p r e g n a n c y , h a s b e e n r e p o r t e d by McLeod a n d W ilso n (1 9 3 2 ) , b u t D o u g la s a n d M cK inlay (1 9 3 5 ) r e p o r t e d t h a t m a t e r n a l m o r t a l i t y i s p ro b a b ly u n a f f e c te d by th e p re s e n c e o f a n a e m ia , o t h e r t h a n t h e s e v e r e m e g a lo c y tic fo r m s . A lth o u g h A d a ir e t a l (1 9 3 6 ) r e p o r t e d two m a t e r n a l d e a th s i n a n e x a m in a tio n o f 906 a n a e m ic women o v e r a p e r i o d o f 3 y e a r s 8 m o n th s , c h r o n i c a n a e m ia was o n ly s u g g e s t e d a s a p ro b a b le f a c t o r in th e c a u se o f d e a th , and

o ts b

o f th e

c a s e s w as fo u n d t o h a v e h a d c a r d i a c d i s e a s e a t p o s t ­ m ortem e x a m in a t io n .

O th e r l a r g e s e r i e s o f c a s e s h a v e

b e e n s t u d i e d w i t h o u t r e v e a l i n g a m a t e r n a l d e a t h due t o a n a e m ia (R e id and M a c k in to s h 1 9 3 7 , S te v e n s o n 1 9 3 8 ), an d

154 . t h e a n a e m ia o f p r e g n a n c y , i n t h e fo rm commonly fo u n d i n t h i s c o u n try , c a n n o t he c o n s id e re d a s e r io u s f a c t o r in m a te rn a l m o r ta lity . EFFECT OF ANAEMIA OF PREGNANCY ON THE CHILD: WEIGHT! W h eth er o r n o t t h e a n a e m ia o f p re g n a n c y h a s an y e f f e c t on t h e h e a l t h o f t h e i n f a n t o r w h e th e r m e a s u re s t a k e n t o com bat t h e a n a e m ia h a v e a i y b e n e f i c i a l e f f e c t on t h e c h i l d ,

i s a q u e s t i o n w h ic h h a s b e e n c o n s i d e r e d

by v a rio u s w o rk e rs.

M ackay (1 9 3 1 ) came t o t h e

c o n c l u s i o n t h a t t h e r e was no e v id e n c e t h a t s u c h t r e a t m e n t a f f e c t e d t h e h a e m o g lo b in l e v e l o f t h e i n f a n t , s u s c e p t i b i l i t y t o i n f e c t i o n o r i t s w e ig h t,

its

and Adamson

a n d S m ith (1 9 3 2 ) fo u n d t h a t t h e a v e r a g e w e ig h t o f t h e c h i l d was s l i g h t l y h i g h e r i n a n a e m ic , a s com pared w i t h n o n -a n a e m ic m o th e r s . little

D a v is an d W a lk e r (1 9 3 4 ) fo u n d v e r y

d i f f e r e n c e i n t h e a v e r a g e w e ig h t o f t h e c h i l d i n

a t r e a t e d s e r i e s o f p a t i e n t s a s com pared w i t h a n u n t r e a t e d s e r i e s , t h e a v e r a g e w e ig h t f o r th e t r e a t e d s e r i e s b e in g 7*6 l b s . a n d f o r t h e u n t r e a t e d s e r i e s

7*4 l b s .

G a llo w a y (1929 b . ) r e c o r d e d r e s u l t s s i m i l a r

t o t h o s e o f Adamson a n d S m ith , b u t e v e n m ore s t r i k i n g . The a v e r a g e w e ig h t o f t h e c h i l d i n t h e t o t a l o f 382 c a s e s s t u d i e d was 7 l b s .

6 o z s . , b u t t h e a v e r a g e w e ig h t i n t h e

16 c a s e s o f d e f i n i t e a n a e m ia i n t h e m o th e r was 8 l b s .

155. G a rry an d S t i v e n (1 9 3 6 ) a n d R e id an d M a c k in to s h (1 9 3 7 ) a l s o r e p o r t e d no d e f i n i t e r e l a t i o n s h i p b e tw e e n t h e a n a e m ia o f p re g n a n c y an d t h e w e ig h t o f t h e c h i l d . A s tu d y o f t h e l i t e r a t u r e d o e s n o t r e v e a l t h a t t h e a n a e m ia o f p re g n a n c y h a s a n y d e f i n i t e i n f l u e n c e on t h e w e ig h t o f t h e i n f a n t , and t h e r e s u l t s o f t h e p r e s e n t in v e s tig a tio n su p p o rt t h is f in d in g .

No s i g n i f i c a n t

d i f f e r e n c e i n t h e a v e r a g e w e ig h t o f t h e c h i l d was fo u n d i n t h e a n a e m ic and n o n -a n a e m ic g r o u p s , n o r d id t h e p r o p h y l a c t i c a d m i n i s t r a t i o n o f i r o n a p p e a r t o e x e r t an y i n f l u e n c e on t h e c h i l d * s w e i g h t. STILL-BIRTHS: No c o n c l u s i o n s c a n b e draw n fro m t h e r e s u l t s o f t h e p r e s e n t i n v e s t i g a t i o n a s t o t h e e f f e c t o f t h e a n a e m ia o f p r e g n a n c y o r i t s t r e a t m e n t , on t h e s t i l l - b i r t h

ra te .

C a re y -S m a llw o o d (1 9 3 6 ) s t a t e d t h a t t h e f o e t a l m o r t a l i t y w as s a i d t o be h i g h e r among a n a e m ic m o th e r s , b u t one c a n fin d l i t t l e

e v id e n c e o f t h i s .

(1 9 3 7 ) fo u n d v e r y l i t t l e

R e id a n d M a c k in to s h

d if f e r e n c e in th e in c id e n c e o f

s t i l l - b i r t h s among a n a e m ic an d n o n -a n a e m ic m o th e r s . S te v e n s o n (1 9 3 8 ) fo u n d a n i n c i d e n c e o f 7# i n 100 c a s e s o f p r e g n a n c y a n a e m ia an d M e y e r-W e d e ll (1 9 4 3 ) r e c o r d e d a n i n c i d e n c e o f 6*8$ o u t o f a t o t a l o f 94 p r e g n a n t women a t t e n d i n g a n a n t e n a t a l c l i n i c , t h i s t o t a l i n c l u d i n g b o t h a n a e m ic an d n o n -a n a e m ic c a s e s .

I t w o u ld a p p e a r ,

h o w e v e r, fro m a s t u d y o f t h e s m a l l num ber o f p u b l i s h e d

156.

r e s u l t s t h a t t h e a n a e m ia o f p re g n a n c y h a s l i t t l e no i n f l u e n c e on t h e s t i l l - b i r t h

or

r a t e and th e r e s u l t s

o f t h e p r e s e n t i n v e s t i g a t i o n , a lt h o u g h i n c o n c l u s i v e , te n d to s u p p o rt t h i s o p in io n ,

PREMATURITY: H a l le

(1 9 3 0 ) c o n s i d e r e d t h a t a n a e m ia d u r in g

p r e g n a n c y was l i k e l y t o p r e d i s p o s e t o p r e m a t u r i t y i n t h e c h ild ,

an d C arey -S m a llw o o d (1 9 3 6 ) was o f a s i m i l a r

o p in io n .

More d e f i n i t e r e s u l t s w ere r e p o r t e d by D a v is

and W a lk e r ( 193 IO who fo u n d t h a t

k*9$>

o f th e i n f a n t s

w ere p r e m a tu r e i n a n u n t r e a t e d g ro u p a s com pared w i t h o n ly 1*1# i n a t r e a t e d g ro u p o f p a t i e n t s ,

and t h e

i n c i d e n c e r e c o r d e d by M e y e r-W e d e ll ( 19 ^.3 ) i n h i s s e r i e s o f 9^ c a s e s , was 3 * 2 $ .

T h e re may, t h e r e f o r e , b e some

r e l a t i o n s h i p b e tw e e n a n a e m ia o f p r e g n a n c y a n d p r e m a t u r i t y a n d i r o n t r e a t m e n t may h a v e some i n f l u e n c e i n t h i s re s p e c t.

As w i l l b e s e e n i n t h e A p p e n d ix li4- (l4.* 6$ ) o f

t h e i n f a n t s i n t h e u n t r e a t e d g ro u p w ere p r e m a tu r e

(b irth -

w e ig h t u n d e r 5 l b s . 8 o z . ) w h e re a s t h e i n c i d e n c e was o n ly 2*6$ (i|- c a s e s ) i n t h e t r e a t e d g r o u p .

T h ese f i g u r e s

co m p are f a v o u r a b l y w i t h t h o s e o f D a v is and W a lk e r. H o w ev er, one c a n n o t d raw a d e f i n i t e c o n c l u s i o n fro m t h e r e s u l t s fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n , b e c a u s e , a s w i l l be n o t e d , f o u r o f th e p re m a tu r e i n f a n t s i n t h e c o n t r o l g ro u p w ere tw in b a b i e s , w h ile t h e r e w e re no t w i n

157. p re g n a n c ie s in th e t r e a t e d g ro u p .

The q u e s t i o n o f t h e

r e l a t i o n s h i p b e tw e e n a n a e m ia o f p re g n a n c y and p r e m a t u r i t y i s o n e w h ic h w i l l r e q u i r e f u r t h e r s tu d y o f a l a r g e s e rie s of cases. The r e s u l t s o f t h i s i n v e s t i g a t i o n r a i s e t h e q u e s t i o n , o f t h e im p o rta n c e o f i r o n - d e f i c i e n c y a n a e m ia o f p r e g n a n c y a s a f a c t o r to be s e r i o u s l y c o n s id e re d w ith in th e b ro a d scope o f a n te n a ta l c a r e .

The p r e v a l e n c e o f t h e

c o n d i t i o n h a s o n ly r e c e i v e d f u l l r e c o g n i t i o n i n c o m p a ra tiv e ly r e c e n t y e a r s , and i t

i s p o s s ib le th a t th e

i n t e r e s t a r o u s e d , an d t h e s u b s e q u e n t l a r g e - s c a l e i n v e s t i g a t i o n s w h ic h h a v e b e e n c a r r i e d o u t , may h a v e l e d t o a n o v e r - e m p h a s is o f i t s s e v e r i t y .

T h is c r i t i c i s m

b eco m es more e v i d e n t when one a c c e p t s f i x e d an d r e a s o n a b l e c r i t e r i a f o r t h e p u r p o s e o f c o m p a rin g t h e r e s u l t s p u b l i s h e d by many i n v e s t i g a t o r s .

In th is

r e s p e c t , t h e m ain c o n c l u s i o n s w h ic h c a n b e draw n fro m t h e f o r e - g o i n g d i s c u s s i o n , a r e w o rth y o f n o t e .

Among

t h o s e c a s e s w h ic h r e c e i v e d no fo rm o f i r o n t h e r a p y d u r i n g t h e p r e g n a n c y , t h e f o l l o w i n g s i g n i f i c a n t f a c t s e m e rg e . (1 )

The a v e r a g e i n i t i a l an d a v e r a g e t e r m i n a l

h a e m o g lo b in l e v e l s w e re ab o v e 1 1 * 0 gram m es h a e m o g lo b in p e r 1 0 0 c c . o f b lo o d , t h e s t a n d a r d a c c e p t e d i n t h i s i n v e s t i g a t i o n a s th e n o rm a l f o r h e a l t h y p r e g n a n t women. (2 )

The i n c i d e n c e o f a n a e m ia , b a s e d on t h e h a e m o g lo b in

l e v e l was l4-*67 $ a t t h e i n i t i a l e x a m n a tio n an d ll 4.*00 $ a t

158. t h e f i n a l e x a m in a tio n *

The i n c i d e n c e b a s e d on t h e mean

o f t h e two e x a m in a tio n s d u r i n g t h e c o u r s e o f t h e p r e g n a n c y , was o n ly 5$ . (3 )

The a v e r a g e i n i t i a l an d a v e r a g e t e r m i n a l r e d

b lo o d c e l l c o u n ts w ere above lj.*0 m i l l i o n s p e r c.m .m . t h e n o rm a l v a lu e a c c e p t e d i n t h i s i n v e s t i g a t i o n f o r h e a l t h y p r e g n a n t women. (I4.)

The i n c i d e n c e o f a n a e m ia b a s e d on t h e mean o f

t h e r e d b lo o d c e l l s c o u n ts d u r in g t h e p re g n a n c y was o n ly 5$ . (5 )

The a v e r a g e i n i t i a l a n d a v e r a g e t e r m i n a l c o l o u r

in d e x v a l u e s w ere b o t h w i t h i n t h e ra n g e o f n o r m a l i t y f o r h e a l t h y p r e g n a n t women. (6)

The i n c i d e n c e o f a n a e m ia b a s e d on t h e num ber o f

b lo o d f i l m s Show ing d e f i n i t e e v id e n c e o f i r o n - d e f i c i e n c y a n a e m ia , a p a r t fro m h y p o c h ro m a s ia , was o n ly 2 *3$ . T h ese f i g u r e s do n o t i n d i c a t e a s e r i o u s d e g r e e o f i r o n - d e f i c i e n c y a n a e m ia i n t h e s e r i e s o f c a s e s i n v e s t i g a t e d , a n d t h e i n c i d e n c e o f a n a e m ia b a s e d on t h e h a e m o g lo b in le v e l,

r e d b lo o d c e l l c o u n t a n d b lo o d f i l m ,

is a

c o n s i d e r a b l e im p ro v em en t on t h e r e s u l t s o f many s i m i l a r i n v e s t i g a t i o n s c a r r i e d o u t b e f o r e and d u r in g t h e w a r. M o re o v e r, t h e r e i s no r e a s o n t o b e l i e v e t h a t t h i s im p ro v e m e n t w ould n o t b e fo u n d i n o t h e r p a r t s cf t h e c o u n try , s in c e i t

i s c o n s i d e r e d t o be due t o a r a i s i n g o f

159.

b a s i c d i e t a r y s t a n d a r d s n e c e s s i t a t e d b y t h e w a r and c o m p u l s o r i l y im p o sed by t h e r a t i o n i n g system *

The

im p ro v e d f i n a n c i a l s t a t u s o f t h e i n d u s t r i a l c l a s s e s may a l s o h a v e p la y e d a p a r t .

I t is f e l t , th e re fo re ,

th a t

w h ile i t i s o f im p o r ta n c e t o c a r r y o u t a h a e m a t o l o g ic a l e x a m in a tio n i n e v e r y p r e g n a n t woman a t a n e a r l y s t a g e o f h e r p reg n an cy , in o rd e r to d e te c t an e x is ti n g o r d e v e l o p in g a n a e m ia , t h e p r e v a l e n c e o f t h e c o n d i t i o n h a s p r o b a b ly d e c r e a s e d .

I t i s c e r t a i n l y n o t one o f t h e

m a jo r d i s a b i l i t i e s o f p re g n a n c y a s m ig h t b e i n d i c a t e d by t h e r e s u l t s o f i n v e s t i g a t i o n s c a r r i e d o u t i n t h i s an d o th e r c o u n tr ie s . Among t h o s e c a s e s w h ic h r e c e i v e d p r o p h y l a c t i c i r o n , t h e r e s u l t s h a v e a l r e a d y b e e n d i s c u s s e d ( p .llj- 5 ) . t h e g en eraL

W h ile

e f f e c t h a s b e e n a b e n e f i c i a l one i n r a i s i n g ,

or a rre s tin g a f a l l ,

i n t h e i n i t i a l h a e m o g lo b in l e v e l ,

t h e l i m i t e d e x t e n t o f t h e im p ro v em en t p r o d u c e d , r a i s e s a n o t h e r im p o r ta n t q u e s t i o n , v i z . t h e a d v i s a b i l i t y o f i n s t i t u t i n g p r o p h y la c tic ir o n th e ra p y a s a r o u tin e m e a su re i n a n t e n a t a l c l i n i c s .

The c o m p a r a t i v e l y lo w

i n c i d e n c e o f i r o n - d e f i c i e n c y a n a e m ia fo u n d i n t h e p r e s e n t i n v e s t i g a t i o n w ould a p p e a r t o i n d i c a t e t h a t t h i s i s a m e a su re which i s n e i t h e r j u s t i f i e d n o r e s s e n t i a l .

A

go o d m ixed d i e t made up o f t h e e s s e n t i a l i r o n - c o n t a i n i n g f o o d s s h o u ld be s u f f i c i e n t t o c a r r y a h e a l t h y woman th r o u g h a n o rm a l p re g n a n c y w i t h o u t t h e d e v e lo p m e n t o f

1 6 0. a n i r o n - d e f i c i e n c y a n a e m ia , a p a r t fro m t h e lo w e rin g o f b lo o d v a l u e s b r o u g h t a b o u t by t h e n o rm a l p h y s i o l o g i c a l p ro c e sse s of p a r tu r itio n .

I r o n t h e r a p y s h o u ld b e

c o n f i n e d t o th o s e c a s e s i n w h ic h a r o u t i n e h a e m a t o l o g i c a l e x a m in a tio n h a s show n a c o n d i t i o n o f d e f i n i t e a n a e m ia t o e x is t,

o r b e d e v e l o p in g .

The e f f e c t s o f t h e a n a e m ia o f p re g n a n c y on t h e m o th e r w ere n o t s t r i k i n g .

T h e re d i d a p p e a r t o b e some

r e l a t i o n s h i p b e tw e e n t h e a n a e m ia and t h e i n c i d e n c e o f p o s t - p a r t u r n h a e m o rrh a g e a n d p y r e x i a i n t h e p u e r p e r iu m . A lso t h e r e

was a te n d e n c y to w a rd s a n i n c r e a s e d

fo rc e p s

r a t e among

t h e a n a e m ic c a s e s , b u t r e s u l t s w ere

not

c o n c lu s iv e .

T h e re was no r e l a t i o n s h i p b e tw e e n t h e

i n c i d e n c e o f a n a e m ia an d t h e a g e o f t h e p a t i e n t an d t h e num ber o f p r e v i o u s p r e g n a n c i e s .

T h e re w e re no m a t e r n a l

d e a th s . T h e re

was no e v id e n c e t h a t a n a e m ia i n t h e

h a d an y e f f e c t

m o th e r

on t h e h e a l t h o f t h e c h i l d i n r e l a t i o n t o

p r e m a t u r i t y , w e ig h t a t b i r t h , s t i l l b i r t h r a t e , o t h e r a b n o r m a l i t i e s show n i n t h e A p p e n d ix .

o r th e

161.

CHAPTER V I I I . S U M M A R Y . (1 )

The c l a s s i f i c a t i o n an d t h e a e t i o l o g y o f t h e a n a e m ia o f p r e g n a n c y h a v e b e e n re v ie w e d an d d i s c u s s e d i n r e l a t i o n to th e f a c to r s o p e ra tiv e in th e p ro d u c tio n o f t h e p r e v a l e n t ty p e o f i r o n - d e f i c i e n c y a n a e m ia . Ho s i n g l e a e t i o l o g i c a l f a c t o r was c o n s i d e r e d t o be r e s p o n s i b l e f o r t h e d e v e lo p m e n t o f th e c o n d it i o n * A c o m b in a tio n o f f a c t o r s ,

com bined w i t h t h e n o rm a l

e f f e c t o f b lo o d d i l u t i o n o f h y d ra e m ia d u r i n g p r e g n a n c y , w ould seem t o b e r e s p o n s i b l e f o r t h i s t y p e o f a n a e m ia . (2)

H orm al h a e m a t o l o g i c a l s t a n d a r d s h a v e b e e n d i s c u s s e d an d r e a s o n a b l e n o rm a l v a l u e s e s t a b l i s h e d a s a p p l i c a b l e to th e n o n -p reg n a n t and p re g n a n t s t a t e .

(3 )

The d e f e c t s o f h a e m o g lo b in o m e try h a v e b e e n p o i n t e d o u t an d a p l e a made f o r t h e i n t r o d u c t i o n o f a n i n t e r n a t i o n a l l y s ta n d a r d is e d in s tru m e n t,

and f o r

t h e e x p r e s s i o n o f a l l h a e m o g lo b in r e a d i n g s i n gram m es h a e m o g lo b in p e r 1 0 0 c c . o f b lo o d . (Ij.)

C r i t e r i a o f a n a e m ia o f p r e g n a n c y h a v e b e e n d i s c u s s e d a n d minimum h a e m a t o l o g i c a l v a l u e s f o r t h e p r e g n a n t s ta te ,

s u g g e s te d .

T h ese c r i t e r i a h a v e b e e n a p p l i e d

a s a b a s i s f o r d i a g n o s i s i n an i n v e s t i g a t i o n o f a

162.

s e rie s of case s. (5 )

P o u r h u n d re d and f i f t y

e x p e c t a n t m o th e rs a t t e n d i n g

a n t e n a t a l c l i n i c s w ere e x am in ed on two o c c a s i o n s d u r i n g p r e g n a n c y , i n i t i a l l y a t t h e b e g in n i n g o f t h e l+th m onth and f i n a l l y a t t h e end o f t h e 8 t h m o n th .

T h re e h u n d re d o f t h e p a t i e n t s r e c e i v e d

no fo rm o f i r o n t r e a t m e n t . an d f i f t y

One h u n d re d

r e c e i v e d a n i r o n su p p le m e n t t o t h e

o rd in a ry d i e t . (6)

Among t h e 300 p a t i e n t s i n t h e u n t r e a t e d s e r i e s l4.* 67 $ w ere fo u n d t o b e a n a e m ic on i n i t i a l e x a m in a ­ t i o n w i t h a h a e m o g lo b in l e v e l b e lo w 10 gram m es p e r 100 c c . o f b l o o d .

A t t h e f i n a l e x a m in a tio n t h e

in c i d e n c e was ll|.* 0 0 $ .

The i n c i d e n c e b a s e d on t h e

m ean o f t h e two r e a d i n g s d u r in g t h e c o u r s e o f t h e p r e g n a n c y , was 5 $ .

The a v e r a g e h a e m o g lo b in l e v e l

a t b o t h t h e i n i t i a l an d f i n a l e x a m in a tio n s w as o v e r 1 1 * 0 0 gram m es p e r 100 c c . o f b l o o d .

(7 )

The i n c i d e n c e o f a n a e m ia i n t h e u n t r e a t e d s e r i e s , b a s e d on t h e mean o f t h e r e d b lo o d c e l l c o u n ts a t t h e i n i t i a l an d f i n a l e x a m in a tio n s was 5$ .

A naem ia

was p resu m ed t o e x i s t o n ly when t h e mean r e d c e l l c o u n t f e l l b e lo w 3*6 m i l l i o n s p e r c .m .m .

The

a v e r a g e r e d b lo o d c e l l c o u n t a t b o t h th e i n i t i a l and f i n a l e x a m in a tio n s w as o v e r i i *0 m i l l i o n s p e r c .m .m . (8 )

The a v e r a g e c o l o u r in d e x v a l u e th r o u g h o u t t h e

1 63. p r e g n a n c y i n t h e u n t r e a t e d s e r i e s was w i t h i n t h e r a n g e f o r n o rm a l h e a l t h y p r e g n a n t women. (9 )

Of t h e 300 u n t r e a t e d c a s e s ,

o n ly 2*3$ show ed

d e f i n i t e e v id e n c e o f i r o n - d e f i c i e n c y a n a e m ia on e x a m in a tio n o f t h e b lo o d f i l m . (1 0 )

C l i n i c a l e v id e n c e o f a n a e m ia was o b s e rv e d i n 2 0 * 6$ o f th e u n tr e a te d c a s e s .

T h is e v id e n c e was n o t

c o n s i d e r e d t o b e a r e l i a b l e c r i t e r i o n on w h ic h t o b a s e a d i a g n o s i s o f a n a e m ia . (1 1 )

The a n a e m ia was fo u n d t o b e o f t h e i r o n - d e f i c i e n c y o r h y p o c h ro m ic ty p e i n e v e r y c a s e .

No c a s e o f t h e

p e r n i c i o u s v a r i e t y o f a n a e m ia was f o u n d . (1 2 )

N e i t h e r t h e a g e o f t h e p a t i e n t n o r t h e num ber o f p r e v i o u s p r e g n a n c i e s a p p e a re d t o h a v e a n y i n f l u e n c e on t h e i n c i d e n c e o f t h e a n a e m ia .

(1 3 )

T h e re a p p e a re d t o be a g r e a t e r te n d e n c y to w a rd s p o s t p a rtu m h a e m o rrh a g e among t h e a n a e m ic p a t i e n t s .

(ll^.)

The i n c i d e n c e o f t h e a n a e m ia a p p e a re d t o b e r e l a t e d t o t h e i n c i d e n c e o f p y r e x i a d u r in g t h e p u e r p e r iu m . T h e re w as a h i g h e r i n c i d e n c e o f p y r e x i a among t h e a n a e m ic p a t i e n t s .

(1 5 )

The u s e o f f o r c e p s was s l i g h t l y m ore f r e q u e n t i n t h e a n a e m ic a s co m p ared w i t h t h e n o n -a n a e m ic p a t i e n t s .

(1 6 )

A b n o r m a l i ti e s o f l a b o u r a n d t h e p u e r p e r iu m w ere g e n e r a l l y m ore f r e q u e n t among t h e a n a e m ic p a t i e n t s ,

(1 7 )

A naem ia i n t h e m o th e r a p p e a re d t o h a v e no e f f e c t on t h e h e a l t h o f t h e c h i l d i n r e l a t i o n t o p rem a­ t u r i t y , b irth -w e ig h t,

s till-b irth

r a t e o r o th e r

a b n o rm a litie s o f b i r t h . (1 8 )

W h ile t h e g e n e r a l e f f e c t o f t h e p r o p h y l a c t i c a d m i n i s t r a t i o n o f i r o n was a b e n e f i c i a l o n e , t h e e x t e n t o f t h e im provem ent d i d n o t j u s t i f y

i t s u se

a s a r o u t i n e m e a su re i n a n t e n a t a l c l i n i c s i n v ie w o f t h e c o m p a r a tiv e ly low i n c i d e n c e o f a n a e m ia fo u n d i n t h i s

in v e s tig a tio n .

I t h ad no i n f l u e n c e

on t h e i n c i d e n c e o f a b n o r m a l i t i e s o f l a b o u r o r t h e p u e rp e r iu m , n o r h a d i t any e f f e c t on t h e h e a l t h o f th e c h ild a t b i r t h . (1 9 )

The i n c i d e n c e o f a n a e m ia fo u n d i n t h i s i n v e s t i g a t i o n show ed a c o n s i d e r a b l e im p ro v em en t on t h e r e s u l t s o f p r e - w a r a n d w a r - tim e i n v e s t i g a t i o n s .

Iro n -

d e f i c i e n c y a n a e m ia i s n o t c o n s i d e r e d t o b e one o f t h e m a jo r d i s a b i l i t i e s o f p re g n a n c y a t t h e p r e s e n t t im e .

The i n c i d e n c e o f t h e c o n d i t i o n i s p r o b a b l y

d e c re a s in g a s a r e s u l t o f th e r a i s in g o f b a s ic d ie ta r y s ta n d a rd s . (2 0 )

The im p o rta n c e o f c a r r y i n g o u t a s im p le h a e m a t o l o g ic a l e x a m in a tio n i n e v e r y p r e g n a n t woman a t an e a r l y s ta g e o f p reg n an cy h a s b een s t r e s s e d .

1 65 .

I am i n d e b t e d t o D r. Ram age, C ounty M e d ic a l O f f i c e r o f H e a l t h , S t a f f o r d s h i r e C o u n ty C o u n c il, f o r p e r m i s s i o n t o c a r r y o u t t h i s i n v e s t i g a t i o n i n t h e c o u n ty c l i n i c s o f S o u th S t a f f o r d s h i r e , an d f o r h i s v a l u a b l e s u p p o r t an d a s s i s t a n c e .

I w ish a l s o t o e x p r e s s my g r a t i t u d e

t o t h e n u r s i n g s t a f f i n t h e a n t e n a t a l c l i n i c s and t o th e m id w iv e s an d h e a l t h v i s i t o r s on t h e d i s t r i c t ,

w ith o u t

w hose c o - o p e r a t i o n i t w ould h a / e b e e n im p o s s ib le t o c o l l e c t much o f t h e i n f o r m a t i o n n e c e s s a r y f o r th e c o m p le tio n o f t h i s w o rk .

My t h a n k s a r e a l s o d u e t o

D r. Dyke o f t h e W o lv erh am p to n R o y a l I n f i r m a r y f o r th e u s e o f l a b o r a t o r y f a c i l i t i e s a n d t o D r. R o se , l a t e a s s i s t a n t p a th o lo g is t a t th e In firm a ry , f o r a s s is ta n c e i n t h e i n t e r p r e t a t i o n o f b lo o d f i l m s .

I am a l s o

g r a t e f u l t o N u rse A ronheim on t h e m id w ife ry s t a f f o f S t a f f o r d s h i r e C o u n ty C o u n c il, f o r v a l u a b l e h e l p i n t h e t r a n s l a t i o n o f t h e German l i t e r a t u r e . The i r o n s u p p le m e n t u s e d i n t h e i n v e s t i g a t i o n was s u p p l i e d a t re d u c e d c o s t by M e s s r s . Cow and G a te L t d . , an d I d e s i r e t o e x p r e s s my a p p r e c i a t i o n o f t h i s v e r y h e lp fu l g e s tu re .

1 66 .

I B L I O G R A P H Y . ABDERHALDEN E:

H o p p e -S e y l Z. 1898 XXVI. 14-9 8 . Q u o ted b y M ackay 1 9 3 1 .

ADAIR F .L . e t a l :

Amer. J o u r n . O b s t e t . and Gyn. 1 9 3 6 , 32;

560 . ADAMSON J .D . an d SMITH F .H : ADCOCK E .W .e t a l :

C a n a d .A m e r.A sso c . J o u r n .1 9 5 2 N .S .

26;

669 .

M o n th ly B u i .M i n .o f H e a l t h a n d P u b . H e a l t h . L a b .S e r v .( A u g ) 19^8 v o l 7 . p .165.

ALDER A:

Z ts c h r. f .

G e b u rts h u .G y n a e k 19 2i+

LXXXVI 505 - 5 1 8 . BALFOUR M a r g a re t I :

In d .M e d .G a z . 1 9 2 7 . 62; i+91 •

BARDY E:

T h ese de P a r i s 1921+..

Q u o ted b y

W hitby 1 9 3 2 . BEARD H .H . and

Amer. J o u m . P h y s i o l . 1 9 3 3 , 10 6 ;

hb9»

MYERS V.C: BECKMAN M:

M onats s c h r

f . G e b u rt sh u . Gynako 1

1921 1V I. 1 1 9 . Q uoted b y W h itb y 1 9 3 2 . BECQTJEREL AND RODIER: BERNHARD L:

A m e r.J o u m .O b s te t.N e w Y o rk I 8 8 I4. p . 130 Q uoted by H e n d e rs o n 1 9 0 2 . Mfihchen M ed.W och.1892 XXXIX. 1 9 7 , 2 2 0 . Q uoted by E v a n s 19 3 7 .

BETHELL F .H :

New Y ork S t a t e J o u m .M e d . 1935 XXXV.7 9 9 .

BETHELL P .H :

J o u rn .A m e r.M e d .A s s o c . 1 9 3 6 .1 0 7 ; 5 6i+.

BETHELL F .H . e t a l :

A nn. I n t e r n .M e d . 1959 • 13;

BLAND P.B.GOLDSTEIN L.

S u r g .G y n .O b s t e t .1930 ( a ) 1;

91. 95 I4-.

a n d FIRST A: BLAND P.B.GOLDSTEIN L.

A m e r.J o u rn .M e d .S c i.1 9 3 0 (b ) 1 79; ML

a n d FIRST A: BLAND P .B . an d

J o u rn .A m e r.M e d .A s s o c .1 929 X C I I I .5 8 2 .

GOLDSTEIN L: BLTJMENTHAL R:

B e itrz .

z . G e b u rts h u . G ynaek.

1907 i i . M M BOYCOTT Jo h n A:

L an c et 1936 i ,

BRANSBY E .R . an d

" R a tio n s an d N u t r i t i o n a l N e e d s " ,

MAGEE H .E:

B r i t.M e d . J o u r n . A p r i l 1 9 t h 19 14.7 .

BRINDEAU A. and

"A nem ie a u c o u r s de l a g r o s s e s s e "

THEODORIDES P . BROWN F . J :

P a r i s 1935 p .6 M A n te n a ta l and P o s tn a ta l C a r e .1937. 1 9 I4J4..

BROWN G .E . and

116 5 .

C h u rc h ill.

A r c h .I n te r n .M e d . 35;

1 2 9 . 1925* ( J a n )

ROWNTREE L .G . BUNGE G:

H o p p e -S e y l Z. 1889* X I I I . 399• Q u o ted b y M ackay 1 9 3 1 .

BUNGE G:

I b i d . 1892 X V I I.6 3 . Q u o ted by M ackay 1 9 3 1 .

BTJRWELL C .S :

S o u th A m e r .J o u r n .1936, 2 9 ;

BURWELL C .S . e t a l :

A r c h . I n t e r n . Med. 1 9 3 8 . 62;

CABOT:

" C l i n i c a l E x a m in a tio n o f t h e B lo o d " 1900.

119M 979*

Q uoted b y H e n d e rs o n 1 9 0 2 .

1 68 . CALLENDER S .T .E

Q u a r t.J o u r n .M e d .1 3 ;

CASEAUX P :

" T r a i t e de I ' a r t d e s A c c o u c h e m e n ts"

75-

Q uoted by H e n d e rs o n 1 9 0 2 . CASEATJX P :

M em oire l u l e 19 f e v r i e r ,

1850;

I ’A cadam ie de M e d ic in e de P a r i s . Q uoted b y E v an s 1 9 3 7 . CHANNING W:

New E n g .Q u a r t.J o u r n .M e d . a n d S u r g . 18U-2 i ;

COMMITTEE ON HAEMO­ GLOBIN SURVEYS (1 9 M ).

1 5 7 . Q uoted by E v a n s 1 9 2 9 .

Med. R e s . C n c l. S p e c . R ep . S e r . No. 252 p . 1 2 5 . H .M .S .O . Lond.

COONS C.M:

J o u r n . B i o l . Chem. 1 9 3 2 . 9 7 ;

COONS C.M:

O aklahom a A g r i c . E x p t. S t a . B u l l . 1935* N o. 2 2 3 .

215.

Q uoted by

F u lle r to n 1936. CORRIGAN J . C . an d STRAUSS M.B:

J o u r n . A m er.M ed .A sso c. 1 9 3 6 . 106; 1088. B r i t . Med.

Jo u rn .

I 9I4-M 1;

DAVIDSON L .S .P . e t a l :

B r i t . Med.

Jo u rn .

1935* i i * 1 9 5 .

DAVIDSON L .S .P . an d

E d in . Med.

Jo u rn .

1938.

FULLERTON H.W:

102, 1 9 3 .

DAVIDSON L .S .P . and

76.

DONALDSON G.M.M:

i.

DAVIDSON L .S .P . e t a l :

B r i t . M e d .J o u rn . 19^2 i i ,

DAVIDSON L .S .P .

B r i t .M e d .J o u r n 1933 i ,

31.

685.

FULLERTON H .W .e t a l DAVIDSON L .S .P . DONALDSON G.M.M. e t a l:

B r i t . Med. J o u r n 19^3 i i , I 9I1I 4.. i i ,

333-

95.

169.

DAVIDSON L .S .P . e t a l :

B r i t . M e d .J o u rn . 1 s t May 19lj-8. p . 8 1 9 . 191+2 i i ,

DAVIES D .T . and

L a n c e t 193^4- i i ,

505. IO 9 I4-.

SHELLEY U: DAVIS M. and WALKER E.W: DIECKMANN W .J. an d W egner C .R : DOUGLAS C.A. and M cK inlay P .L . DUBNER:

New E n g . J o u r n . Med. 193U-. c c x . 1315. A rc h . I n t e r n . Med. 193^-* L l l l . 71. R e p o r t on M a te r n a l M o r t a l i t y i n S c o tla n d E d in . 1935* P* 8 . M unchen Med. Woch. 1890 x x x v i i . 517, 5 3 7 , 5 5 1 . Q uoted by E v an s 1937

ELLIOTT G.A:

J o u r n . O b s t e t . and Gyn. B r i t . Emp. 1 9 I4J4-. 51;

ESCH P :

Z e n tra lb f .

198.

G ynakol 1 9 2 1 . xL v.

3 M . Q uoted by W h itb y 1 9 3 2 . ESCE P .

D e u t. Med. Woch. 1 9 3 2 . L i i .

EVANS W:

L a n c e t 1929 i* 1^*

EVANS E .H .

J o u r n . O b s t e t . an d Gyn. B r i t . Emp. 1 9 3 7 . W+;

PABER K:

1077.

i+17.

Med. C l i n . 1 9 0 9 . v . 1 3 1 0 . Q uoted by E v an s 1 9 3 7 .

FEHLING:

A rc h . f . 332.

PELDMAN H. and VAN DONK E . C . e t a l :

G y n a k o l. 1 8 8 6 . x x v i i i .

Q uoted by E v an s 1 9 3 7 .

Amer. J o u r n . P h y s i o l . 1 9 3 6 . c x v . 69*

170. FIRST A. and

Amer. J o u r n . O b s t e t . 1930 x x .7 0 .

GOLDSTEIN L: FULLERTON H .W .:

B r i t . Med. J o u r n . 1 9 3 6 . i i . 577.

FULLERTON H.W.

19k3.

i.

523,

158.

Id em . 19W4-. 2;

373.

HAIR M. I . an d UNSWORTH P : GALLOWAY C .E :

Amer. J o u r n . O b s t e t . a n d Gyn. 1929 ( a ) . X V II.

GALLOWAY C .E .

8k.

J o u r n . Amer. Med. A s s o c . 1929

( b)

X C III. 16 9 5 . GARRY R .C . an d STIVENS D: GIVEN J.C .M :

N u t r i t i o n A b s t r a c t s a n d R ev iew s 1935 - 3 6 .

855.

J o u r n . O b s te t an d Gyn. B r i t . Emp. 19 0 6 .

GOODALL J . R . a n d

5;

IX .

261.

C anad. Med. A s s o c .J o u r n . 1 9 3 6 . 3 5 ; 5 0 .

GOTTLIEB R: GOTTLIEB R. and

S u rg . Gyn. O b s t e t . 1939* 68;

869.

STREAN G .J . GRAM H .C :

U gesk f o r L a e g e r . 1 9 2 0 . LXXXII. 1 6 0 9 .

GRAM H .C . and

A r c h .I n te r n .M e d . 3 1 ;

16k.

1923.

NORGAARD A: GREEN-ARMYTAGE V .B:

L a n c e t 1935*

HADEN R .L :

Jo u m .A m e r.M e d .A s s o c . 7 9 ; 11+96.1922.

i-

1253.

A rc h . I n t e r n . Med. 3 1 ;

766. 1923.

J o u r n . A r i e r . Med. A s s o c . X C IX .1398. 1932. A rc h . I n t e r n . Med. XLIX. 1 0 3 2 . 1 9 3 2 .

1 71 . HAMILTON H .A . and

L a n c e t 1 9I4.2 .

ii.

18k.

WRIGHT H .P . HARVEY H .E .

A m e r.J o u rn . O b s te t and Gyn. 1 9 3 1 . XXI.

k76.

HELLSTROM N. (1 9 3 7 ):

Q uoted by W il l s e t a l .

HENDERSON J :

J o u r n .O b s t e t an d Gyn. B r i t . Emp. 1902.

HOSKIN T . J . and

i,

19k2.

168.

LANCET 1 9 2 7 .

i.

k33.

CARIOG-CADLE E: HTJGOUNENQ M.L:

C .R . S o c . B i o l . P a r i s . 1899* L i . 3 3 7 . Q u o ted by M ackay 1 9 3 1 .

INGERSLAV E:

Z e n t r a l b f . G y n a k o l. 1879* i i i . 635* Q u o ted by E v an s 1 9 3 7 .

IRVING P .R :

A m e r.J o u rn . O b s te t a n d Gyn. 1935* XXIX. 8 5 0 .

JENKINS C .E . and

J o u r n . H yg. 1 9 3 3 . X X X III. 3 6 .

DON C .S .D . JERLOV E:

A c t. O b s t. e t g y n . s c a n d . 1929* V III,

KAY W.W. an d

356.

B r i t . Med. J o u r n . 1 9 I+.I. i i .

926.

ALSTON J.M . KEITH N.M.

A m e r.J o u r n . Med. S c i . 1 6 5 . 17k 18k.

KEITH N.M. R0WNTREE L .G . a n d GERAGHTY J . T : KERN R .A :

1923.

A rc h . I n t e r n . Med. 1 9 15XVI. 5 k 7 . Med. C l i n . N. A m er. 8; 192k.

821

(Nov)

172.

KERWIN W. an d COLLINS L: KISWISCH P .A :

Am er. J o u r n . Med. S c i . 1 9 2 6 . CLXXII.

5k8.

Neue Z e i t s c h r f . G e b u r ts h 181+8. XXV. llj-3*

K uhnel P .

Q uoted by E v an s 1 9 3 7 .

Z ts c h r f . G e b u rts h u . G ynaek. 1926 - 7 . XC. 511 - 5 k l .

LARRABEE R .C :

Amer. J o u r n . M e d .S c i. 1925* CLXX. 371.

LEBERT H.

(1 8 7 6 )

LUSK.

Q uoted by E vans 1 9 3 7 . T e x tb o o k o f M id w ife ry 1 8 8 2 . Q u o ted by H e n d e rs o n 1 9 0 2 .

LYON E .C :

J o u r n . A m er.M ed .A sso c. 1929* X C II, II.

MACKAY H.M.M.

Med. R e s .C n c l. R ep . No. 1 5 7 . L ondon 1931. L a n c e t 1935*

MACKAY H.M.M. e t a l :

i.

11+31 •

P r o c . R o y .S o c . Med. 1 9 k 2 . V o l . 3 6 . p . 69.

MAGEE H .E .

B r i t . M e d .J o u r n .J u ly 2 6 t h . 191+7. P.1W +.

McCANCE R .A .

Id em . 1 9 3 8 .

McCANCE R .A .e t a l :

J o u r n . H yg. Camb. 1 9 3 8 . 3 8 ;

McGEORGE M.

B r i t . E m p .J o u r n .O b s te t and Gyn. 1 9 3 5 . X L II.

McLEOD D .H . and

L ancet 1932.

i.

191• 596.

10 2 7 . i.

669.

WILSON A: McSWINNEY S .A .

I n d . M ed.G az. 1 9 2 7 . L X II. 1+87.

173. MALLANBY E:

L a n c e t.

METTIER S .R . a n d

Am er. J o u r n . Med. S c i . 1 8 1 .

MINOT G .R . MEYER P . J .

1933.

ii,

1131.

25 ( J a n ) 1 9 3 1 . A rc h . f .

G y n a k o l. 1 8 8 7 . XXXI, 11+5.

Q uoted by E v an s 1 9 3 7 . MEYER-WEDELL L:

J o u r n . O b s te t an d Gyn. B r i t . Emp. 1914-3. 50;

MITCHELL H .S . an d MILLER L:

14-05.

Amer. J o u r n . P h y s i o l . 1 9 3 1 . X C V III. 311.

MITRA S:

I n d . Med. G az. 1931. EXVI. 3 6 3 .

MOORE J .H :

Amer. J o u r n . O b s te t an d Gyn. 1 8 ; 14.2I4..

1929.

Id em . 1 9 3 0 . XX; MURDOCH T .P :

25 I4..

A nn. I n t . Med. 1927 i .

1 3 3 . Q u o ted

by E vans 1929* MUSSER J .H .

Amer. J o u r n . Med. S c i . 19kO. 200; 117.

MtJSSEY R .D . e t a l :

A m e r.J o u rn . O b s te t a n d Gyn. 1 9 3 2 . XXIV. 1 7 9 .

NALLE B .C :

S o u th .M e d . J o u r n . 1 9 3 0 . X I I I . 7 3 .

NASSE H:

Das B l u t . B o n n .1 8 3 6 . Q u o ted by E v an s 1 9 3 7 .

NEALE A.V:

B irm . Med. R ev . 1 9 2 7 . i i .

316.

Q uoted by E v an s 1 9 2 9 . OSGOOD E .E :

A rc h . I n t e r n . Med. 3 7 ;

OSGOOD E .E . and

Id em .

HOSKINS H.D.

1927.

XXXIX.

6 8 5 . 1926.

6k3.

17^. OSLER W:

B r i t . Med. J o u r n . 1919*

0 1SULLIVAN J .V :

L an cet 1932.

PEPPER O .H .P :

Med. C l i n . N. Amer. 12;

ii.

i.

I.

1326. 925 - 9 3 1 .

1929. PETER M:

A rc h . d . T o e . 1875* i i .

95, 2 1 5 ,

2 8 2 , lj.22, 5I4.O. Q uoted b y E vans 1 9 3 7 . PLAYFAIR:

The S c ie n c e and P r a c t i c e o f M id w ife ry . 1 8 9 3 . V o l. i .

Q u o te d by

H e n d e rs o n 1 9 0 2 . PRICE-JONES 0 :

J o u r n . P a t h , an d B a c t . 1 9 3 1 . XXXIV. 779.

PRICE-JOKES C. e t a l :

Idem . 1 9 3 5 . XL.

RAMSAY A.M. and

"M odern T re a tm e n t o f P u e r p e r a l

DOLPHIN A:

S e p s is ."

503.

M e d ic a l P r e s s and

C i r c u l a r . May 2 9 t h . 1914-6. REID W . J . J . and

L a n c e t 1937 i . 14-3.

i i 1389.

M a c k in to s h J.M : REINL K:

B e i t r z . G e b u rts h u . G y n a k o l 1 8 8 9 . Q uoted b y E v an s 1 9 3 7 .

RICHTER 0 . e t a l :

A m e r.J o u rn . O b s te t a n d Gyn.193l4-« X X V III. 514-3.

ROWLAND V .C :

J o u m . A m er. Med. A s s o c . I 92 I4IX X X II. 3 7 2 .

SCANZONI F.W:

L e h rb u c h d e n G e b u rts h W ien. 1 8 6 7 . Q uoted by E v an s 1 9 3 7 .

SCHROEDER R:

A rc h . f . G y n a k o l 1891 XXXIX. Q uoted b y E v an s 1 9 3 7 .

306.

175. SCHULTZ W:

M unich Med. Woch 1 9 3 3 . LXXX. A rc h . G y n ak o l

SHERMAN H .C . 1907;

193k.

157;

679 •

110.

U .S . O f f i c e o f E x p t. S t a . B u l l . No. 1 8 5 .

Q uoted by W iddowson a n d

McCance 1 9 3 6 . SINCLAIR H.M:

P r o c . R oy. S o c . Med. 19^2 36;

k 3.

80.

SMALLWOOD CAREY W:

B r i t . Med. J o u r n . 1 9 3 6 . i i .

SMITH C .T :

J o u r n . S u rg . Gyn. an d O b s te t 1925* XL.

SPEIGELBERG AND GSCHEIDLIN:

57k.

223.

A rc h . f u r . G y n ak o l 1 8 7 2 . B d . i v . p . 112.

Q uoted by H e n d e rs o n 1 9 0 2 .

STEVENSON E.M .K . 1 9 3 8 . (GLASGOW):

T r a n s . E d in . O b s t e t . S o c . 1937 -

STRAUSS M.B:

J o u r n . C l i n . I n v e s t . 1 9 3 2 . 11;

1938.

58;

81.

Id em . 1 9 3 3 .

X II.

J o u m . Am er.

Med. A s s o c .

809.

3k5*

193^-. c i i .

281. Amer. J o u r n . Med. S c i . 1 9 3 0 . CLXXX. 818. STRAUSS M.B. a n d CASTLE W.B:

L a n c e t 1932

i,

1198.

Am er. J o u r n . M e d .S c i. 1 9 3 2 . CLXXXIV. 655,

663.

Id em . 1 9 3 3 .

185;

539.

THOMAS R .C :

B r i t . Med. J o u r n . 19^2

THOMSON W.L:

J o h n s H o p k in s H o sp . B u l l . 1 9 0 I4-. XV. 205 - 2 0 9 .

i,

88.

176.

THOMSON K . J . e t a l :

Aiper. J o u r n . O b s te t a n d Gyn. 1958.

36;

1).8.

TOLAND O .J :

Id em . 1 9 3 6 . XXXI.

TOVERUB K.U:

A c ta P a e d i a t r i c a . 1935* X V II. (S u p p l). 131j

VAN BONK E .C . e t a l :

136.

A m er. J o u r n . P h y s i o l . 193^-* 107,

VAUGHAN J a n e t M:

6ltf>.

616.

The A n a e m ia s.

O x fo rd

U n iv e rs ity P re s s 193^. WATSON H.G:

Amer. J o u r n . O b s te t and Gyn. 1938.

WHITBY L .E .H :

35;

106.

J o u r n . O b s te t an d Gyn. B r i t . Emp. 1 9 3 2 . 39;

WHITBY I . E . H . and BRITTON O .J .C :

267.

D i s o r d e r s o f th e B lo o d 19^4-6. C h u rc h ill.

L ond.

WIDDOWSON E.M:

L ancet

WIDBOWSON E.M . an d

J o u r n . Hyg. Cam b.1 9 3 6 . 3 6 ;

McCANCE R .A : WIBBOWSON E.M . a n d

1939*

L a n c e t 19^4-2 Idem 19*4-1

ii,

i, 2;

^i+O.

588. 361.

ALLINGTON B .K : WILKINSON J . R :

J o u r n . O b s te t a n d Gyn. B r i t . Emp. 1 9 3 2 .

WILLCOCKS P :

L ancet

39;

1881,

293. ii.

9*4^4-.

Q u o ted by H e n d e rs o n 1 9 0 2 . WILLIAMSON O .S :

A rc h . I n t e r n . Med. 1 9 1 6 . x v iii.

505.

13*

WILLS L:

P r o c . R oy. S o c . Med. London 1935* 28 ( P a r t I I ) .

114-03.

J o u r n . H yg. Camb. 19l+2. J+2;

WILLS L:

505.

MACKAY H.M.M. e t a l: WILLS L . an d MEHTA M.M: WIHTROBE M.M:

I n d . J o u r n . Med. R e s. 1 9 3 0 . X V II. 777.

Q uoted by W hitb y 1 9 3 2 .

A rc h . I n t . Med. 1 9 3 0 . XLV. 2 8 7 . B u l l . J o h n s H o p k in s H osp. 1933* L III.

WIUTROBE M.M. and

118.

Idem 1 9 3 3 .

L i i . 387.

SCHUMACHER H .S : WITTS L . J :

M e d ic a l O f f i c e r 1935* I»IV,

151 •

AP ? j 2 J 1 X

0 0 ii T R 0 L S

CONTROLS

Red Blood C e lls per c*m*m*

Hoemoglobin Ho*

Age

Beginning o f 4th.* Para* Month

Beginning o f 4th . Month

End o f 8t h . Month 3 .8 m il ls .

2

83

77

3*9 m i l l s .

2

23

1

79

72

4 .1

3

25

1

72

72

3 .6

4

29

1

78

71

4 .9

it

4 .1

5

24

2

84

78

4 .6

»t

3 .8

6

22

1

76

67

4 .1

"

7

31

2

76

80

4 .2

8

24

2

78

72

4 .0

9

33

4

92

83

10

27

5

85

11

28

1

12

30

13

Blood Film .

1.06

1.01

-

C lin ical Inhour and Puerperium

tcn d itio n o f Child 4 a t B irth .

-

Horaal

Normal

Evidence of Anaemia

, h eigh t of Child a t B irth 8 o ss.

7 lb s .

3 .6

it

0.96

1 .0 0

-

-

Normal

Premature. S t i l l B irth

*t

1.00

0 .9 7

-

-

Normal

Normal

8.

ft

3 .7

0.

"

«

0.86

Beg.

-

Normal

Normal

9

it

0.86

0

"

0.91

1.02

-

-

Normal

Normal

7

tt

ii

2

"

4 .0

ti

0.92

0.83

Beg.

-

Normal

Normal

8

it

8

"

it

0.90

0 .90

-

-

Normal

Normal

7

>t

4 .4

8

"

ti

3 .6

it

0.97

1 .0 0

-

-

Normal

it

4 .0

it

0.95

1.03

-

-

Forceps

Normal

8

it

4 .8

0

"

4 .0

it

3.9

ti

1.06

1 .0 8

Heg.

♦

Normal

Normal

8

tt

85

12

H

92

4 .1

n

4 .9

rt

1.08

0.93

-

-

Normal

Normal

8

•t

89

8

"

76

61

3 .7

«

3 .2

it

1.02

0.95

Bos.

■f

Normal

8

tt

2

8

"

90

79

5 .0

3 .7

it

0.90

1 .0 6

-

-

Normal

Normal

7

8

"

2

n

n

29

14

1

91

85

4 .8

it

4 .1

it

0.94

1.03

-

-

Normal

Normal

7

it

36

8

»

31

3

82

78

4 .1

n

4 .1

1.00

0.95

-

-

Normal

Normal

6

n

15

12

*

21

1

88

80

4 .1

it

3 .7

it

1.07

1 .07

-

-

Normal

Normal

6

it

0

»

16

4 .8

4 .0

tt

0.81

0 .8 0

P o s.

*

Normal

Normal

9

*

78

64

0

17

3

n

it

36

81

4 .2

it

3 .7

ft

0.96

1 .0 6

-

-

Normal

Normal

7

»

79

8

*

4 .1

ft

0.91

1.04

-

Normal

Normal

6

*»

68

it

0

1

4 .8

-

it

86

4 .7

it

4 .1

ti

0.85

0 .9 0

-

Normal

Normal

7

it

74

tej CD CK3 •

26

End o f 8th . Month

Beginning o f 4th . Month

2 nd of 8th . Month

1

Colour Index

0

*

4 .2

tt

3 .7

tt

1.03

1.0 6

Heg.

Normal

7

tt

79

18 19

32 19

2

20

25

2

80

21

25

2

87

«

n

•

Puerperal Pyrexia

Caes. S ection

Premature. Died

2

*

-

k

Hoemoglobin Beginning End o f o f 4th.* 8th . Para fcanth Month

lied Blood C e lls per c*m*m* Beginning End of o f 4 th . 8th . lionth Month

Ho.

Age

22

25

1

87

61

5 .1 m i l l s .

23

37

7

94

84

5 .2

i«

4*6

«

24

20

1

88

84

4 .6

i»

4 .0

25

45

4

93

80

5 .1

it

26

30

2

86

75

5 .0

27

22

1

83

82

26

30

1

76

29

18

1

50

25

31

Colour Index End o f Beginning 8t h. o f 4 th . Mgnth Month

Blood Film .

C lin ic a l Evidence of Anaemia Labour and Puerperium

* - -I

C ondition o f Child at B irth

W eight o f C hild a t B irth

0.85

0.92

Keg.

-

Korina 1

Kormal

8 lb s .

8 ozs

0.90

0 .9 1

-

-

Hormal

Konnal

8

•»

0

n

0.95

1.05

-

-

Kormal

Kormal

7

"

8

4 .4

n

0.91

0 .9 0

-

-

Normal

Kormal

7

"

0

"

it

4 .3

n

0.86

0 .88

Keg.

-

Norne-l

Kormal

8

"

8

"

4 .6

it

4 .3

it

0.90

0*95

-

-

Normal

Kormal

7

"

0

"

71

3* 6

it

3 .7

n

1.C5

0.95

-

-

Kormal

9

»

4

"

80

69

5 .5

it

4.3

tt

0.78

0 .8 0

P o s.

♦

Normal

Kormal

7

"

5

»

2

87

90

4 .5

it

5 .0

it

0.98

0 .9 0

-

-

Forceps

Kormal

8

*

8

*

30

5

96

79

5 .0

t»

3 .6

n

0.96

1.03

Heg.

■f

Kormal

Kormal

9

*

0

■

92

zi

5

82

84

4*2

n

4 .2

tt

0.98

1 .0 0

-

-

Kormal

4

"

8

"

33

26

1

70

60

5 .0

it

4 .1

n

0.70

0 .7 3

P o s.

34

40

3

66

60

4 .9

i>

4 .6

tt

0.87

0 .6 6

Heg.

35

26

1

94

86

4*6

w

4 .0

n

1.02

1 .0 7

35

28

2

100

92

5 .0

tt

4 .3

tt

1.00

37

21

1

85

76

4 .5

tt

3 .9

it

38

22

2

88

76

4 .4

it

3 .6

39

25

2

90

73

5 .0

w

40

20

1

90

80

4*6

tt

81

23

3

91

83

4*8

tt

42

29

1

88

76

4 .9

25

3

88

61

5 .1

!

M It

4 .4 m i l l s .

Forceps.

P.P.H .

Premature.

M ed

"

Kormal

Xoxmal

8

*

0

M

-

Kormal

Korina1

7

*

12

"

-

-

Kormal

Kormal

8

*

8

**

1 .0 6

-

-

Kormal

Premature

5

*

4

"

0.94

0 .9 7

-

-

Kormal

Kormal

6

*

8

"

»

1.00

1.05

-

-

Kormal

Kormal

9

"

12

«

3.5

it

0.90

1.0 3

-

-

Kormal

formal

9

it

8

*

4 .6

tt

0.97

0 .8 6

Keg.

-

Kormal

formal

8

"

0

"

4 .1

»

0.94

1 .0 1

-

-

Kormal

9& »*l

10

"

0

it

mm

forcep s

formal

8

»

3

*

-

Hormal

9

«

0

*

3 .6

tt

1.03

1.05

-

3.3

tt

0 .8 6

0.9 2

Keg.

l

^

Ho.

Age

Hoemoglobin Beginning P ara, of 4 th . Month

> End o f 8th . Month

Bed Blood C e lls per c •m.m. Beginning ] End o f o f 4th . 8t h . Month Month

Colour Index_____ Beginning * End o f 8t h . of 4th . Month Month

Blood Film,

C lin ic a l videnee of Anaemia

Labour and Puerperium

Condition of C hild at Birth

Ih eig h t o f C hild 1 at B irth

S t i l l B irth.Anencephaly|

3 .9 m i l l s .

1.02

1 .0 0

Forceps

tt

4 .7

it

0.98

0 .9 4

Kormal

Kormal

8 Id s.

8 o z s.

n

4 .3

»

0.98

0.98

Kormal

Kormal

8

,f

0 «

4 .6

1.03

;

0.93

Forceps

Kormal

9

"

0 *’

5 .1

it

Kormal

Kormal

7

"

4 '* 8

44

24

2

90

78

4 ,4 m i l l s .

45

26

2

100

89

5 .1

46

43

5

91

85

j

47

38

1

91

95

4 .4

«

46

31

5

97

97

6.2

rt

6 .1

it

0.93

i

0.95

49

29

5

86

66

5 .8

•*

4.2

it

0.74

|

0 .7 8

50

25

1

94

93

4.5

tt

4.5

1.04

Ii i

51

37

90

82

4.3

tt

3 .8

»t

1

1.04

|

.4 .2

it

1 .0 0

t>

I ]

Forceps

Hydrocephalic

9

”

1.03

Kormal

Kormal

5

M

1 .0 7

Foroeps

Kormal

7

*

0

"

1.03

Kormal

Kormal

8 "

0

"

P o s,

"

12

"

52

34

2

90

87

4 .5

it

78

4 .5

it

3 .8

it

0.94

1.02

Kormal

0 *

85

6 "

24

2

Kormal

53

4 .6

tt

4.5

0.90

0.9 2

7

*

8 "

83

Kormal

2

83

Kormal

31

it

5 4

it

77

3 .7

it

3 .7

«

1.04

1.0 4

6 *

77

Foroeps

y

23

1

Kormal

55

tt

3 .6

1.02

1.05

Kormal

Kormal

0 *

94

4 .6

«

1

it

19

76

7

56

3

94

5 .7

it

4 .7

»

0.82

0.84

Kormal

Kormal

1

35

79

8 *

57

80

4 .1

4 .3

tt

1.06

.93

8 "

5 6

87

Kormal

It

1

Kormal

rf

23

88

4 .5

tt

4 .4

0.97

1 .0 0

Kortna 1

Kormal

8 "

2

88

8 "

39

m

59

95

71

5 .3

it

4 .4

n

0.89

0 .8 0

Kormal

0 "

37

3

8

60

75

76

4 .0

tt

1.06

.95

Kormal

Kormal

4

3

3 .5

8 l#

34

tt

61

27

4

4 4

3 .1

tt

62

79

75

3 .7

tt

3 .6

tt

1.06

1 .0 4

Kormal

Kormal

"

8

32

7

9

63

70

4 .5

3 .8

t«

0.68

0 .9 2

Kormal

Kormal

8

0 *

4

60

*

50

tt

64

2

83

85

4 .3

4 .1

n

0.96

1.03

Kormal

Kormal

7

*

36

tt

0

rj 65 .

tt

Keg.

P o s,

P o s,

P ost Partum Haem,

*

"

"

P o s,

0.70

Keg.

*

«

Hoemoglobin 2 nd o f Beginning Para. o f 4 th . 8th . Month Month

Had Blood C e lls Beginning o f ] o f 4 th . ] Month

per o.m.m. And of 8t h . Month

Colour Beginning of 4th . Month

Index Hnd o f 8 th . Month

4 .4 m il ls .

1.01

0.9 2

a o.

Age

66

25

1

87

81

4.3 m i l l s .

67

26

2

89

86

4.9

it

4 .2

tt

0.90

1.02

68

22

1

79

70

4 .8

it

4.5

w

0.82

0.77

69

22

1

83

79

5 .0

tt

4 .2

tt

0.83

70

28

4

85

77

5 .0

»♦

4.5

«

71

23

o

93

89

5 .1

rt

4 .6

72

17

1

92

84

4 .8

it

73

26

2

57

45

4 .3

74

22

1

94

88

75

39

5

90

76

23

2

77

29

78

Blood Film

C lin ic a l 3 vid e nee oj Anaemia

Labour and Puerperium

Condition o f C hild at B irth

-

IXormal

Normal

-

form al

Normal

P os.

4*

normal

0.94

Heg.

-4-

0.85

0.85

Heg.

-

n

0.91

0 .9 6

-

-

4 .0

rt

0.95

1.06

-

-

rt

3 .4

it

0.66

0.66

P o s.

5 .1

it

4.5

tt

0.92

0.97

86

4 .6

rt

4 .6

tt

0.97

94

85

4 .6

rt

4 .1 ,

rt

2

80

84

4 .3

tt

4 .2

23

1

68

55

4 .0

rt

79

22

1

91

83

5 .0

80

44

4

83

81

81

26

1

80

82

28

1

83

30

84

—

h e ig h t o f C h ill at B irth

7 lb s .

12

O Z 3.

10

»t

0

•*

Premature

5

tt

0

•»

Hormal

Normal

6

tt

8

**

Normal

Nozmal

8

t»

0

”

Normal

6

it

o

»

Normal

Normal

7

tt

4

"

•H*

Forcep s

Normal

6

tt

0

»

-

-

Normal

Normal

7

t»

0

"

0.93

-

-

Normal

Nozmal

7

it

5

"

1.02

1.03

-

-

Normal

Normal

5

ii

8

rt

rt

0.93

1 .0 0

-

-

Normal

Normal

?

it

12

"

3 .4

rt

0.85

0 .8 0

P o s.

*

Nozmal

7

tt

8

•»

tt

4 .6

tt

0.91

0 .9 0

-

-

Normal

Nozmal

8

t»

0

**

4 .1

»t

4 .1

it

1.01

0 .9 8

-

-

Normal

Nozmal

6

it

0

«

74

4 .4

rt

4 .1

it

0.90

0 .9 0

-

Normal

Nozmal

7

*t

0

«

79

81

4 .4

rt

4.5

rt

0.89

0 .9 0

Heg.

-

Normal

Normal

9

it

0

"

1

76

69

3 .6

tt

3 .7

rt

1.00

0.93

Heg.

-

Normal

Nozmal

8

it

4

"

1

83

77

4 .4

N

3 .6

«

28

0.94

1 .0 6

-

-

Normal

Nozmal

7

ti

0

«

20

2

68

62

4 .1

tt

3 .6

tt

0.82

0 .8 1

P o s.

Hr

Hormal

Hemal

6

tt

86

0

"

76

4 .6

4 .1

0.87

5

80

tt

26

rt

66

0 .9 2

Heg.

-

Normal

Nozmal

7

H

13

"

20

1

86

74

4 .1

it

3 .6

tt

87

1.04

1.02

Nozmal

7

w

13

»

Puerperal Pyrexia

Puerperal P yrexia

P o st P artu s Haem.

■H' ■' .

Red Blood C e lls p er o.m.m.

Hoemoglobin Beginning o f 4 th . Month

Bad o f 8th . Month

Beginning o f 4 th . Month

Ho.

Age

Para

88

31

2

84

74

4 .1 m i l l s .

89

24

2

85

83

4 .5

90

26

2

92

71

91

30

3

84

92

26

1

93

34

3

94

28

95

Colour Beginning o f 4 th . Month

Bnd o f 8t h . Month

Index Bnd o f 8t h . Month

Blood Film

1.05

-

»»

4 .0

tt

9.94

1.0 3

-

5 .0

n

3 .9

it

0.92

0 .9 1

74

4 .2

tt

3 .5

tt

1.00

84

78

4 .3

it

4 .0

rt

90

84

5 .0

tt

4 .4

5

78

68

4 .4

it

4 .0

21

2

78

70

4 .1

tt

3.5

96

26

1

88

. 74

tt

97

27

2

89

85

4 .7

9 8

21

1

75

67

99

27

2

66

100

22

2

101

33

102

C ondition o f C h ild a t B irth

Weight o f C h ild a t B irth

0 o zs.

Hormal

Hormal

7 lb s .

-

Hormal

Hormal

7

»

12

"

-

-

Hormal

Hormal

7

"

0

"

1.05

-

-

Hormal

form al

7

*

8

"

0.97

0 .9 7

-

-

Hormal

formal

6

"

14

"

tt

0.90

0.95

-

-

Hormal

form al

10

"

3

*»

tt

0.88

0.85

P o s.

-

Hormal

form al

11

»

0

*

rt

0.95

1 .0 0

Heg.

4

Hormal

form al

8

"

0

*

4 .0

rt

0.97

0 .9 2

-

-

Hormal

fo rm a l

8

"

*

1.02

labour and Puerperi urn

HI HI

3 .5 m i l l s .

C lin ic a l Evidence oi Anaemia

it

4 .0

rt

0.94

1.0 6

-

-

Hormal

Hormal

5

*»

11

«

3.5

rt

3.5

rt

1.07

0 .9 5

Heg.

-

Hormal

form al

5

9

14

H

78

4 .8

tt

4 .2

rt

0.93

0 .9 2

-

-

Hormal

form al

9

*»

0

H

81

4 .6

rt

4 .4

rt

88

0.95

0 .92

Heg.

4

Hormal

form al

8

"

0

"

95

93

5.3

«

5 .1

tt

1

0.87

0 .9 1

Heg.

-

Foroeps

Hormal

6

••

11

'»

37

6

78

69

3 .8

it

3 .2

tt

1.02

1 .0 7

P o s.

4

Normal

Hormal

8

”

0

"

103

25

2

77

78

4 .0

«

4 .1

rt

0.96

0 .95

-

-

Hormal

Premature

5

"

104

33

3

98

97

5 .3

n

5 .0

rt

0.94

0 .9 7

-

-

Hormal

Hormal

8

*•

8

106

29

2

77

77

3 .8

n

4 .2

«

1.01

0 .9 1

-

-

Hormal

Hormal

8

"

8 "

106

28

1

89

91

4.5

n

5 .0

n

0.98

0 .9 1

-

-

Hormal

107

31

2

86

74

4 .6

it

4 .1

rt

0 .9 3

0 .9 0

-

-

Hormal

Hormal

8

"

0

••

108*

35

2

61

72

4 .2

it

4 .0

tt

1.96

0 .9 0

-

-

Hormal

Hormal

8

"

0

•»

31

3

82

76

4 .2

rt

109

0.97

0 .9 0

Hormal

Horma 1

8

"

0

»

4 .5

tt

4 .2

4

" '•

S t i l l B ir th . S p .B if.

Hoemoglobin Beginning Para. o f 4th . Month

Red Blood C e lls p er c.m.au End of 8th . Month

Beginning o f 4 th . Month

End of 8t h . Month

Ho.

Age

110

19

1

80

71

4 .2 m i l l s .

111

32

6

93

80

5 .1

rt

4 .4

112

35

2

71

75

3.9

ri

113

27

3

87

69

5 .4

114

3b

3

90

78

115

23

2

83

116

23

1

117

32

118

Colour Beginning o f 4th . Month

Index End o f 8th . Month

Blood Film .

C lin ic a l Evidence oi Anaemia

Labour ana Puerperium

Condition o f Child a t B irth

Weight o f C hili at Birth

0.95

0.93

-

-

Hormal

Hormal

6

lb s .

tt

0,91

0 .9 0

-

-

ilormu 1

Hormal

7

it

0

«i

3 .6

tt

0.91

1.04

-

-

Eoimal

Hormal

7

tt

0

11

rt

5 .0

tt

0 .8 0

0 .6 9

P os.

+

P ost P-*rtun h^em.

Hormal

7

it

0

"

5 .0

rt

4 .1

tt

0.90

0.95

Reg.

+

Hormal

Hozmal

7

tt

10

*»

82

4 .6

tt

4 .5

tt

0.90

0 .9 1

-

-

Hormal

Hormal

9

tt

0

”

68

64

4 .2

tt

3 .8

tt

0.80

0.84

P o s.

+

Hormal

Hormal

7

it

4

"

2

94

86

5 .2

tt

4 .1

tt

0 .9 0

1 .0 4

-

-

Hormal

Hormal

7

tt

0

"

34

1

64

52

4 .5

tt

3 .0

it

0.71

0 .8 6

P o s.

4

Hormal

Hormal

8

It

0

"

119

36

6

76

72

4 .1

tt

4 .0

it

0.92

0 .9 0

-

-

Hormal

Hozmal

6

ft

4

"

120

25

1

82

74

4 .5

tt

3 .7

rt

0.96

1 .0 0

-

-

Hormal

Hormal

6

it

8

”

121

25

1

84

84

4 .2

tt

3 .9

it

1.00

1 .0 7

-

Hormal

Hormal

8

It

0

”

322

31

2

84

74

4 .1

tt

3 .3

tt

1.02

1 .0 8

-

-

Hormal

Hozmal

7

tt

o

«

123

28

1

86

88

4 .0

tt

4 .1

it

1.07

1 .0 7

-

-

Hormal

5

ft

8

"

124

23

1

87

79

4 .1

tt

3 .7

it

1.06

1 .0 6

-

-

Hozmal

9

tt

0

"

125

26

2

73

78

3 .8

it

4 .0

tt

0.96

0 .9 7

-

-

Hormal

8

tt

6

*

126

31

2

64

58

4 .7

it

4 .5

H

0.68

0.6 4

P o s.

4

Hormal

Hozmal

5

tt

6

"

*127

24

2

60

50

4 .0

tt

3 .2

tt

0.75

0 .8 0

Hozmal

Hormal

8

tt

14

»

128

30

2

80

77

4 .3

tt

4 .2

tt

0.93

0 .9 1

-

-

Hormal

Hozmal

8

tt

0

»

129

28

6

79

78

4 .3

tt

4 .5

H

0.91

0 .8 6

Heg.

-

Hormal

Hormal

9

tt

8

»

130

27

1

90

89

5 .0

tt

4 .6

»

0.90

0 .9 6

-

Hormal

Hormal

8

rt

2

"

131

30

2

98

81

5 .4

tt

4 .0

!*

0.90

1 .0 1

Hormal

Hormal

8

it

8

"

3 .8 m il l s .

>ostn| ® ° o s y t o s is ♦

-

Puerperal Pyrexia Hormal P u erperal P yrexia

8 o zs.

Hoemoglob:Ln > Beginning P ara. o f 4 th . Month

Red Blood C e lls per c.m.m.

End of 8t h . Month

Beginning o f 4 th . Month

Ho.

Age

132

28

1

76

72

3*o m i l ls .

133

22

2

72

70

3 .3

134

31

3

80

75

3 .7

135

37

5

73

58

4 .2

136

17

1

89

89

137

27

2

81

138

36

3

139

28

1

140

22

141

22

142

End of 8th . Month

Blood Film .

1.08

1.05

heg.

4

Hormal

Hormal

Beginning of 4th . Month

3 .4 m ills .

I

Index C lin ic a l E vidence o f

Labour und fu e rp e riu n

Condition o f Child at B irth

1/e ig h t o f C hild a t B irth I 8 lb s . 12 o s s .

3 .6

tt

1.09

0 .9 7

Reg.

4

Hormal

Hortnal

7

tt

4

"

3 .4

tt

1.08

1.09

-

-

Hormal

Hormal

9

tt

4

«

»t

4 .4

tt

0.87

0.65

P o s.

4

Hormal

Hormal

8

it

0

•«

4 .8

»t

4 .8

»t

0.92

0.92

-

-

horm al

H ornul

oO it

4

"

68

3 .6

tt

3 .0

tt

1.12

1.13

-

Hormal

normal

7

n

0

"

79

85

4 .2

it

4 .7

it

0.96

0 .9 0

-

-

Hormal

Hormal

6

tt

0

•«

79

76

4 .5

4.2

it

0.87

0 .9 0

Heg.

-

Forceps

Hormal

6

u

0

"

78

78

4 .3

«

4 .0

«t

0.90

0.9 7

-

-

Hormal

Hormal

8

tt

8

"

1

79

78

3.9

t»

3 .8

it

1.01

1.02

-

-

Hormal

Hormal

9

M

8

"

35

3

90

83

5 .3

n

4.5

tt

0.84

0.9 2

-

Hozmal

Hormal

8

It

0

»

143

24

1

87

81

4 .0

tt

4 .1

n

1.08

0 .9 8

-

Hormal

Hozmal

8

It

8

**

144

21

2

80

76

4 .0

tt

3 .3

it

1.00

1.15

Heg.

-

Hormal

Hormal

8

tt

8

*

145

29

1

74

67

4 .1

tt

3 .8

tt

0.90

0.8 8

P os.

4

Hormal

Hormal

6

tt

6

"

146

32

81

74

4 .5

t«

4 .2

tt

0.90

0 .8 7

Heg.

-

Hormal

Hozmal

8

tt

8

»

147

25

5

74

71

4 .0

tt

3.9

tt

0.92

0 .9 1

-

Hormal

Hormal

6

tt

8

"

148

27

1

81

86

4 .2

tt

3 .8

tt

0.96

1 .1 3

Heg.

-

Hormal

8

tt

8

M

149

21

1

70

70

3 .5

tt

3 .6

tt

1.00

0 .9 7

-

-

Hormal

Hormal

8

tt

0

»

150

28

1

87

81

417

it

4 .2

it

0.92

0 .9 6

-

-

Hormal

Hormal

6

It

14

"

tr i

it

End o f 8th . Month

Colour

27

2

55

49

5 .4

tt

4 .6

t%

0,5 0

0 .5 3

formal

7

It

0

**

152

22

1

76

80

3 .7

t«

3 .8

»

1.02

1 .05

-

Hormal

formal

6

It

12

"

1103

31

3

74

68

3 .5

it

3 .1

tt

1.05

1.09

Heg.

Hormal

formal

8

m

0

*

1

1

(

tt

heg •

Heg. -

-

Pfi?crocytos5 .8

4 -

P ost Par tu n . Haem.

P o st Fart urn. Haem.

. iSsfe,.

Hoemoglobin Beginning Para. o f 4 th . Month

$ End o f 8t h . Month

Red Blood C e lls per c.m.m. Beginning o f 4th . Month

Ho.

Age

154

25

5

77

72

3 .6 m i l l s .

155

36

2

70

61

3 .9

156

36

4

93

81

4.3

157

38

6

69

48

4 .3

158

27

2

80

73

159

28

2

78 .

160

28

1

161

27

162

«

End o f 8th . Month 3 .6 m i l l s .

Colour

Index End o f Beginning o f 4 th . 8t h . Month Month

Blood F ilm .

C lin ic a l Inbour and Puerperimn Evidence oi ■ Anaemia

C ondition o f C hild a t B irth

Weij^Lt o f C hild a t B irth

1.06

1 .0 0

-

-

P o st Partim Haem.

Hormal

7 lb s .

4 o z s.

3 .6

it

0.89

0 .8 4

P o s.

-

Hormal

Hormal

9

"

8

14

H

4 .0

i*

1.08

1 .0 1

-

-

Hormal

Hormal

6

"

12

»

It

3 .6

tt

0 .8 0

0 .6 6

P os.

4

Hormal

Hormal

7

"

2

"

3 .7

tt

3 .7

it

1.08

C.98

-

-

Kormal

Hormal

7

"

0

75

4.3

rt

3 .8

tt

0.90

0.99

-

-

Hormal

Hormal

7

*

12

"

82

82

4 .1

tt

4 .2

it

1.00

0 .9 7

-

-

Hormal

Hormal

6

"

0

"

3

77

68

4 .1

It

3 .1

rt

0.93

1.09

Heg.

-

Korina 1

Hormal

7

*»

8

*

25

3

68

61

4 .4

tt

3 .9

it

0.77

0 .7 8

P o s.

♦

Hormal

Hormal

8

**

0

«

163

25

1

73

65

3 .4

tt

3 .6

t*

1.07

0 .9 0

Heg.

-

Hormal

Hormal

6

"

12

"

164

20

1

72

72

3 .7

it

3 .6

it

0.97

1 .0 0

Heg.

4

Hormal

Hormal

7

*

8

»

165

24

1

88

76

4 .2

w

3 .5

tt

1.04

1 .0 8

-

-

Hormal

Hormal

7

"

8

"

166

30

3

86

4 .8

it

4 .3

tt

0.91

0 .9 1

-

-

Hormal

Hormal

8

*

8

"

167

23

2

83

82

4 .4

tt

4.5

tt

0 .9 4

0 .9 0

-

-

Hormal

Hormal

8

"

8

"

168

2 0

1

72

66

3 .7

tt

4 .0

tt

0.97

% 2

P o s.

4

Hormal

Norma 1

7

"

0

"

169

21

1

91

88

4 .4

tt

4 .1

tt

1.03

1 .0 7

-

-

Hormal

Hormal

9

"

4

"

170

35

5

84

77

4.5

tt

4 .1

tt

0.93

0 .9 3

-

Hormal

Hormal

7

"

8

"

171

24

1

81

75

3.5

3.5

it

1.15

1 .0 7

Heg.

-

Hormal

Hormal

6

"

7

"

172

25

1

84

74

4 .5

it

4 .0

tt

0.93

0 .9 2

-

-

Hormal

Hozmal

9

"

5

"

173

27

1

81

79

4 .4

n

4 .8

tt

0,92

0 .8 2

Heg.

-

Forceps

Hozmal

8

"

0

»

174

37

2

80

80

5 .0

*t

4 .2

it

0.80

0 .9 5

Heg.

-

Hormal

Hozmal

8

*

0

»

175

23

1

78

78

4 .1

tt

3 .9

tt

0.95

1 .0 0

Hormal

Hozmal

7

»

0

"

79

n

' ■

.- - .M

*

.

Hoemoglobin Beginning Para, of 4t h . Month

fo

3nd o f 8t h . Montil

Red Blood C e lls per c.m.m. Beginning o f 4 th . Month

Age

176

29

3

88

92

4 .1 m i l l s .

177

39

2

89

85

4* 6

rt

4 .0

178

29

1

75

84

3 .6

ri

179

28

3

76

71

3 .7

180

22

1

75

75

4.5

181

34

5

70

71

5.5

18 2

39

8

77

72

3 .7

«

183

38

3

81

79

4 .2

184

22

3

77

53

C onditio:, o f v h iid a t o, rtii.

«* i ^ i t o f Child a t B irth

Hormal

Hormal (Twins)

5 lb s . 5 h

u

0.9 6

1 .0 6

-

-

Morma1

Premature

5

n

0

»

4 .1

it

1 .0 4

1.02

-

-

Hormal

7

it

0

«

rt

3 .6

rt

1.02

0 .9 8

-

-

horon.l

Hozmal

6

«

8

»

rt

3 .7

rt

0.83

1.01

Meg.

4

Hoimal

Hormal

9

n

0

"

3.5

n

1.00

1 .0 1

-

-

Hozmal

7

t»

4

"

3 .5

rt

1.04

1 .0 2

-

-

Hormal

Hormal

8

n

0

»

rt

4 .0

rt

0.96

0 .9 8

-

-

Forceps

Hormal

5 .5

rt

4.2

rt

0.70

0 .6 3

P o s.

4

Hormal

Hormal (Twins)

7 4 4

it ii it

8 2 4

-

Hormal

Hormal

8

rt

75

4 .6

rt

186

25

2

82

69

4 .4

tt

3 .4

187

35

6

84

75

4 .0

♦t

188

37

2

82

72

4 .0

189

57

6

53

76

190

27

3

77

191

40

6

192

31

4

P o st Po.rtum Haem.

Puerperal P yrexia

0.93

0 .9 1

rt

0.93

1 .0 1

P o s.

4

Hormal

Hozmal

8

3 .8

rt

1.05

0 .9 6

-

-

Hormal

Hormal

rt

4 .1

N

1.02

0 .8 8

Meg.

4

Hormal

3.3

tf

4 .7

«

80

3 .9

«

4 .7

it

0*98

0.85

89

91

4 .5

rt

4 .7

rt

,0 .9 8

0 .9 6

-

-

88

73

4.5

k

3 .6

N

,0.97

1 .0 1

Meg.

rt

Jl.OO

0.95

f'j.1.02

4 .1

193

32

3

70

86

3*5

«•

4 .5

194

24

1

74

79

3 .6

rt

4 .0

2

Labour ,na fuerperium

-

86

36

C lin ic a l Evidence o f Anaemia

-

6

196

Blood Fiha.

1 .0 6

35

1

.And o f 8th . Month

1.0 7

4 .3 m i l l s .

186

30

Index

Beginning of 4 th . Month

2 nd o f 8t h . Month

Mo.

196

Colour

86 70

79 70

5 .0 3 .6

rt rt

rt

4*9

•

3 .9

«•

J

" ” "

4

"

it

2

H

7

t*

0

"

Hormal

7

ti

12

H

P o st.P a rttm . Haem.

Hozmal

9

tt

0

"

Hozmal

Hozmal

8

H

0

w

P u erperal p y rex ia

Hozmal

7

ti

0

«

4

Hormal

Hozmal

8

»

4

»

-

-

Hormal

Hozmal

9

M l

0

N

0 .9 6

-

-

Hormal

Hormal

7

tt

6

"

S f * 86

0*80

Meg.

-

Manual

§ Hozmal

8

rt

8

»

■W>m

1 .0 0

mm

0 .8 0

J

-

0 o z s. 1 »

’ -■

POS.Miorocy- ;o sis f Meg.

4

[

ii

$

End o f 8th . Month

Beginning Para. of 4th . Month

Red Blood C e lls p er c.m.m. Beginning o f 4th . Month

Ho.

Age

197

23

2

73

71

4 .0 m i l l s .

198

34

2

88

78

5 .2

199

30

2

76

72

3 .7

200

36

5

85

73

4 .6

201

26

1

83

74

4 .5

202

27

1

77

72

4 .1

33

3

81

76

4.2

204

27

3

84

79

4 .6

206

29

5

70

73

3 .7

206

33

2

72

76

3 .9

207

21

1

89

89

4 .4

206

31

2

81

69

209

35

4

96

210

22

1

211

35

212

Index End o f Beginning 8th . of 4t h . Month Month

Blood Film .

•e ight o f C hild a t B irth .

-

Hormal

Hormal

7 lb s

8 o z s.

"

0.85

0.8 8

Heg.

-

Normal

Hormal

6

11

7

"

0 .9 0

-

-

Normal

Normal

9

"

0

«

P os.

-♦

Normal

Hormal

7

"

*0 «

-

-

Normal

Hormal

8

*

0

"

6 m m

Normal

Hozmal (Twins)

6

M "

4 12

" "

11

0.92

0 .8 1

h

4 .1

"

0.92

0 .9 0

ft

4 .0

»

0.93

0 .9 0

0.96

0 .8 8

P o s.

rt

C ondition o f C h ild a t B irth

—

4 .5

ii

labour and Puerperium

0 .9 1

1.02

h

C lin ic a l Evidence o f Anaemia

0.91

3 .9 m i l l s . • 4 .4

Colour

3

203

»»

End o f 8th . Month

. O

Hoemoglobin

4 .3

rt

.4 .0

»

0.91

0 .9 8

-

-

Normal

Hormal

8

H

8

"

«

3 .6

"

0.94

1 .0 1

-

-

Hormal

Hormal

8

"

0

«

rt

4*2

"

0 .9 2

0 .9 0

-

-

Hormal

Hormal

6

"

0

"

rt

4 .3

"

1.01

1 .0 3

-

-

Normal

Hozmal

8

"

0

"

4 .3

rt

4 .3

"

0.94

0 .8 0

Heg.

-

Hormal

Hozmal

8

M

8

"

89

5 J5

rt

4 .3

"

0.87

1 .0 3

Heg.

-

Hormal

Hormal

7

**

0

"

77

71

3 .9

H

3 .8

"

0 .9 8

0 .9 3

-

-

Hormal

Hormal

7

"

12

M

2

74

68

4 .6

It

4 .1

"

0 .8 0

0 .8 3

P o s.

+

Hozmal

8

*

0

"

24

2

88

80

4*2

rt

3 .9

"

1 .0 4

1 .02

Hozmal

9

"

o

"

213

27

3

80

73

4 .5

«

4 .0

"

0.88

0 .9 1

Heg.

-

Hormal

Hormal

7

»

0

"

214

17

1

83

79

4 .4

N

3 .8

*

0 .94

1 .0 3

-

-

Hormal

Hormal

6

"

6

*

215

24

1

77

75

4 .2

rt

3 .9

•

0.91

0 .9 6

-

-

Noxmal

Hormal

7

*

8

*

216

28

3

87

87

4 .0

rt

4 .3

"

1.08

1 .0 1

-

-

Hormal

af- Hormal

7

*

8

*

21?

21

1

89

78

4 .6

if

4 .3

*

0 .9 6

0 .9 0

Hormal

| Hozmal is

9

*

0

"

-

Hormal R etained P la cen ta P o st Partum Haem.

■

.

•

.

fc; I k

Hoemoglobin Beginning 'Of 4th . Para *Month

$

End o f 8th . Month

Colour

Red Blood C e lls per c.m.m.

Beginning o f 4 th . Month

End o f 8t h . Month

Beginning of 4 t h . Month

Ho.

Age

218

30

3

72

70

4 .2 m i l l s .

219

25

1

86

81

4 .7

220

23

1

78

78

4 .1

«

4 .3

221

25

3

79

71

4 .3

it

222

34

11

65

61

4 .1

223

34

4

78

78

3 .9

224

22

1

66

74

225

26

1

87

226

34

2

227

36

226

Index End o f 8th . Month

Blood Film .

C lin ic a l Evidence of Anaemia

Labour and Puerperiun

Condition o f C hild at B irth .

height o f C hild a t B ir th .

Hormal

Hormal

6 lb s .

0 .9 4

Hormal

Hormal

5

"

12

•»

0.95

0 .9 0

Hormal

Hormal

6

*

8

w

tt

0 .9 1

0 .9 8

Hormal

Hormal

6

••

4

"

3.9

n

0.79

0 .7 8

rt

3 .8

. ti

1 .0 0

1.02

8

rt *

4 .0

it

4 .2

it

0.82

0 .8 8

81

4 .3

it

3 .8

it

1.0 1

1 .0 6

80

4 .3

4 .5

it

88

1.02

0 .8 8

1

87

67

4 .3

If

3 .5

it

1 .01

34

2

71

79

3*5

It

3 .9

it

x 229

28

2

71

62

3 .7

tt

3 .5

230

27

2

69

69

4 .8

tt

3 .4

231

20

1

96

89

4 .9

rt

232

25

1

79

75

4 .1

233

25

3

89

70

234

26

2

77

233

21

3

236

24

237

0.85

0 .8 7

rt

0.9 1

»

3 .6

M

n

4 .0 m i l l s . 4 .3

Heg.

P o s.

P o st Partum Haem. P uerperal i^ r e x ia

4 ozs

S t i l l B ir th

Hormal

Hormal

6

Hormal

Hormal (Twins)

5 6

" «

8 0

” *«

Hormal

Hormal

6

”

0

«

Heg.

Hozmal

Hormal

7

,f

0

rt

0.95

Heg.

Hormal

Hormal

7

”

0

rt

1.01

1 .0 1

P o s.

Normal

Hormal

6

«

0

rt

it

0.95

0 .7 4

S 9 § fo c y to si

Hormal

Hozmal

8

“

8

rt

tt

0.9 1

1 .0 1

Heg.

Hormal

Hormal

8

"

0

rt

4 .3

19

0.97

1 .0 3

Hormal

Hormal

9

M

2

rt

it

3 .7

It

0 .9 6

1 .0 1

Hormal

Hormal

9

••

0

'*

4 .9

it

3 .6

tt

0 .9 0

0 .9 7

P o s.

Hormal

Normal

7

"

4

«

80

4 .5

tt

4 .0

It

0.85

1 .0 0

Heg.

Hormal

Hormal

^

»

12

rt

94

74

4 .7

n

3 .6

ft

1 .0 0

1 .0 2

Premature

5

•*

0

rt

1

90

85

4 .5

it

4 .4

—■ It

1 .0 0

0 .9 6

Hozmal

6

«

12

«

24

1

89

80

4 .5

tt

4 .8

O - 0.9 8

0 .9 5

Hormal

8

H

2

•*

63#

2

90

78

4 .1

tt /

3 2

3 .6

• -t

1 .0 2

Hozmal

I Hozmal

8

*

8

••

2 3 9

29

1

86

72

4 .6

tt

4*0

*

0 .9 0

Hormal

pezm al

7

"

6

rt

tt

:

.

^

r

.

1.09

“

0,91 _i -

Wm i* ? *

.

Heg.

P o st Partun Haem.

'Hozmal

--- ----- - -

1 Hoemoglobin

2 nd o f 8th . Month

Bed Blood C e lls p er c.m.m. Beginning o f 4 th . Month '

2 nd of 8t h . Month

o

Beginning Para* of 4th.. Month tfU dMAWi -.....

$

Age

240

35

5

81

72

4 .1 m il ls .

241

27

2

77

74

3 .6

»t

3 .6

242

30

1

78

76

4 .4

n

3 .8

! 243

24

1

92

80

4 .9

rt

\ 244

32

1

79

71

4 .3

|

245

30

2

87

73

j 1

246

36

8

78

247

41

6

248

27

249

j j

Colour Beginning of 4 th . Month

i

Index End o f 8th . Month

Blood Film

C lin ic a l Svidence of Anaemia

Labour and Puerperiian

Condition o f Child at B irth .

Weight o f C hild a t B irth

0 .9 8

0 .9 4

-

-

Hormal

Hormal

h

1.06

1.02

-

-

Hormal

Hozmal

8

"

0

"

n

0.8 8

1 .0 0

-

Hormal

Hozmal

8

"

0

"

3 .8 m i l l s .

Heg.

\

10 lb s .

8 OZ8.

4 .3

tt

0.93

0.93

-

-

Hozmal

Hormal

8

"

8

w

tt

3 .8

it

0.9 1

0 .9 3

-

-

Hormal

Hormal

7

"

3

*

4 .5

tt

3 .7

rt

0 .9 8

0.98

-

-

Hormal

Hormal

8

•*

0

"

64

4 .8

tt

3 .8

tt

0 .81

0 .8 4

♦

Hormal

Hozmal

9

"

0

"

76

72

3.9

It

3.9

0 .9 7

0 .9 2

-

Hozmal

Hormal

8

•*

0

»

3

82

68

4 .0

tt

3 .8

tt

1.02

0.89

P o s.

+

Hormal

Hormal

7

"

8

"

24

2

85

82

4 .7

tt

4 .4

tt

0 .9 0

0.93

• -

-

Hormal

Hormal

7

"

8

"

250

21

1

92

84

5 .2

tt

4 .8

tt

0 .6 8

0 .8 7

.98

1 .0 6

-

tt

4 .4

tt

1 .0 1

0 .6 2

P o s.

4 .3

tt

4 .3

tt

1 .0 1

0.95

-

-

Hormal

Hormal

8

»

0

••

8 6

4 .2

N

4 .3

tt

1 .0 4

1 .0 0

-

-

Hormal

Hormal

7

11

0

*t

79

72

3 .7

N

3 .6

tt

1.0 1

-

-

Hormal

Hormal

10.

*

'6

«

2

92

87

4 .6

tt

4 .4

tt

1 .0 0

0 .9 8

-

-

Hormal

Hormal

6

*

12

"

2

89

86

4 .4

tt

4 .2

tt

1 .0 1

1 .02

-

-

Hormal

Hormal

6

•

4

*

•

1 .0 0

fcr. ,

« o

Age

Hoemoglo bin $ Beginning End o f D t 4 th . 8th . Para. ffonth Month

Hed Blood C e lls per c.m.m. Beginning End o f of 4 th . 8th . Month Month

Colour Index End o f Beginning 8t h . of 4 th . Month Month

! Blood Film

>l i n i c a l i•videnee o f inaemia

Labour and Puerperiun

Condition o f Child at B irth

I i j ’'/eigh t of C hild a t B ir th

0.93

1 .0 1

-

-

Hormal

Hozmal

9 lb s .

2 o z s.

tt

' 0.92

0 .9 8

P o s.

+

Horma.1

Hormal

7

"

8

"

4 .0

n

0.92

0 .9 7

-

-

Hormal

Hozmal

7

"

4

"

n

3 .8

tt

1.01

1.0 1

-

-

Hormal

Hormal

9

"

0

"

4 .2

tt

3.9

«

0.92

0.9 3

-

-

Hormal

Hozmal

9

"

4

rt

80

5 .5

it

4 .4

0.83

0 .9 0

Heg.

-

Hozmal

Hormal

7

"

0

«

62

76

4 .1

tt

4 .0

»

1.00

0.95

-

-

Hormal

Hormal

8

"

0

"

3

49

44

3 .0

ft

3 .1

it

0.81

0 .7 1

Hormal

Hormal

6

"

6

*

64

1

83

75

3 .9

tt

5 .6

it

1.06

1 .0 4

Hormal

Hormal

7

"

0

*

271

21

1

82

84

4 .5

it

4 .1

tt

0.91

1 .0 2

-

-

Forceps

Hormal

9

»•

4

"

272

23

2

83

71

4 .0

tt

3 .5

rt

1.03

1 .0 1

-

-

Hormal

Hormal

5

«

11

•

273

31

7

79

72

4 .7

tt

4 .1

it

0 .8 4

0 .8 7

P o s.

■f

Hormal

Hormal

8

*

0

"

274

23

1

86

80

4 .9

»

4 .3

it

0.89

0 .9 3

Heg.

-

Hormal

Hormal

6

"

12

"

275

22

1

84

81

5 .4

tt

4 .9

it

0.77

0 .8 2

P o s.

■f

Hormal

Hormal

7

"

8

«

276

25

1

70

66

3 .7

n

3 .5

tt

0 .9 4 ,

0 .9 4

Heg.

-

P o st Parturn Haem.

Hormal

6

"

0

"

277

27

3

76

71

3 .6

it

3 .5

tt

1.00

1 .0 1

-

-

Hozmal

Hormal

7

”

0

"

278

37

7

85

68

4 .6

tt

4 .1

tt

0.92

0 .9 7

P os.

-

Hozmal

Hozmal

8

•

0

«

279

34

7

59

61

4 .0

n

3*7

It

0.73

0 .8 2

P o s.

-

Hozmal

Hozmal

8

»

8

"

260

23

2

77

71

3 .8

ft

3 .6

tt

1.01

0 .9 8

-

Hormal

Premature

5

*

5

•

261

33

3

87

80

4*9

m

4 .t

It

0 .8 8

0 .8 8

Hozmal

7

"

7

*

262

32

3

95

89

8*2

•*

4*6

N

0*91

0 .9 6

-

-

Hormal

Hozmal

7

»

•

*

262

40

3

69

84

4 .3

■- «

4 .2

It

1.03

1.00

-

-

Hormal

Hozmal

6

*

i

•

*62

42

1°

86

89

4*6 m i l l s .

263

40

4

74

69

4 .0

it

3.5

264

39

3

63

78

43

n

265

27

1

81

77

4 .0

266

26

4

78

73

267

23

2

92

266

24

2

*269

32

270

4 6*^

A.*

.

4 .4 m i l l s .

S'-1'

'■

';

•

A nisosyti >sis J>OS.PoiMloc; rfcosis M icroeyti >sis

-

P os.

4

♦

F orceps.

P uerperal P y rex i n

•A~. .

Hoemoglobin N0 .

Age

Beginning Para* o f 4 th . Month

lfi>

Red Blood 0e l l s per c.m.m.

End o f 8th* Month

Beginning o f 4th* Month

End o f 8t h . Month

Colour Beginning of 4th . Month

Index End o f 8t h . Month

Blood Film

C lin ic a l Evidence o f Anaemia

, Labour and Puerperiun

C ondition o f C hild a t B irth

Weight o f C hild a t B ir th .

0.92

0 .9 0

-

-

Hormal

Hormal

8 lb s •

tt

0.81

0.Q5

P os.

4-

Forceps

Hormal (Twins)

6 5

rt it

3 13

* M

4 .3

tt

0.92

0 .9 6

-

-

Hormal

Hormal

6

n

8

»

it

4 .5

it

0.93

0 .9 3

-

-

Hormal

Normal

8

tt

0

"

4 .4

tt

4.2

it

1.04

1.03

-

-

Hormal

Normal

8

rt

12

11

86

5 .4

it

4 .8

it

0.82

0.89

Heg.

4

Forceps

S t i l l Born

12

tt

0

*

81

64

3*8

it

3 .3

it

1.06

0 .9 6

Heg.

-

Hormal

Hozmal

7

it

0

"

1

93

80

4*6

it

4 .0

it

1.01

1 .0 0

-

-

Hormal

Normal

6

it

9

it

30

4

89

82

4.5

»t

4 .1

it

0.98

1 .0 0

-

-

Hormal

Hormal

5

it

12

*

293

28

3

89

78

4 .4

rt

4 .3

it

1.01

0 .9 0

-

-

Hormal

Hormal

10

rt

0

"

294

35

2

86

84

4 .5

rt

4 .6

rt

0.95

0 .9 1

-

-

Hormal

Normal

6

•i

0

*

295

37

2

71

56

3 .7

tt

3 .6

ft

0.95

0 .7 7

P o s.

+

Hormal

Hormal

6

t*

14

»

296

19

1

89

78

4*6

tt

4 .3

n

0.96

0 .9 0

-

-

Hormal

Normal

9

n

4

"

297

30

4

67

59

3 .9

tt

3 .5

tt

0.85

0 .8 4

Normal

Hormal

7

rt

8

w

298

25

3

87

80

4 .2

tt

4 .0

it

1.03

1 .0 0

-

-

Hormal

Hozmal

7

rt

14

«

299

24

1

76

69

4 .2

tt

3 .7

it

0 .9 0

0 .9 3

Heg.

-

Hormal

Normal

8

M

5

«

300

24

4

80

83

4 .2

rt

4.2

if

0.95

0 .9 8

-

-

Hormal

Nonra.1

8

ft

0

*

284

30

1

104

90

5 .6 m i l l s .

285

18

1

78

68

4*8

n

4 .0

286

31

2

92

83

5*0

t»

287

34

2

95

84

5 .1

288

38

6

92

87

289

20

1

89

290

37

5

291

24

292

c

X

1

5 .0 m i l l s .

?0S.Microoyt >sis 4

712ns showed other eridenoe o r iron^ief oiency ana mia besides hypo chroma a At Case lo s t s i ;ht o f a fte r in lt ,al examin itle n . *

* •

*

6 ozs

I E ON

TREAT

GROUP

I R0 H

Hoemoglot>in Beginning Para, of 4th* Month

fo

Had Blood C e lls per c .m.m.

End o f 8th . Month

Beginning o f 4th . Month

End of 8th . Month

Colour Beginning of 4 th . Month

Ho.

Age

1

30

1

88

90

4 .3 m i l l s .

4 .5 m il ls .

2

24

1

85

86

4 .2

4.2

3

23

1

82

83

4 .3

»t

4

22

2

81

83

3 .9

5

36

1

76

72

6

21

1

89

7

21

1

8

50

9

T R3 A T 3 D

GROUP

Index Blood Film

End of* 8t h . Month

C lin ic a l Evidence of Anaemia

Post Partum Haem. Puerperal Pyrexia

1.02

1 .0 0

-

«

1.01

1.04

-

-

4 .3

it

0.95

0.96

-

-

tt

4 .3

tt

1.03

0 .9 6

-

-

3 .8

it

4 .3

it

1.00

0.83

82

4.9

it

4 .1

ft

0.90

1 .0 0

82

84

4 .0

tt

4.5

tt

1.02

2

74

74

3.9

it

4.5

54

5

75

75

3 .6

10

25

1

84

84

4 .1

11

31

7

79

89'

3 .8

12

39

4

80

68

3 .5

«

13

22

1

77

77

3 .8

29

5

65

73

66

x u

«

Labour and Puerperiun

Condition of Child a t B irth .

. ** r \\ 9 v.eigax ox w iija a t B irth .

Hormal

9 lb s .

0 o z s.

lorm al

Hormal

9

"

4

"

Hormal

Hormal

8

,1

0

"

Hormal

9

!1

0

"

Puerperal Pyrexia

+

Hormal

Hozmal

6

*

0

"

-

-

Hormal

Hormal

6

"

13

"

0 .9 3

-

-

Hormal

Hoxm&l

6

"

8

"

•f

Hormal

Hormal

rt

0 .8 2

Pos.

ijt

0.94

8

"

Hormal

Hormal

6

"

0

«

P os.

3 .7

tt

1.04

1 .0 1

P o s.

+

tt

4.2

tt

1.02

1 .0 0

-

-

tt

3 .7

it

1.03

1 .0 6

Heg.

■f

Hormal

Hormal

6

H

8

"

3 .3

tt

1 .1 4

1 .0 3

Heg.

-

Hormal

Hozmal

9

"

0

•*

tt

4 .1

tt

1.01

0 .9 3

-

Hormal

Hozmal

7

"

0

"

3 .5

it

4 .5

tt

0.92

0 .8 1

Hormal

Hormal

8

•»

8

■

n

3 .2

h

1.03

1.03

Keg.

-

Hormal

7

"

6

«

66

5 .2

n

-

P o st Partum Haem.

,OS.Miorocyt >sis

4

Foroeps. P ost Partum Haeo3 * Puerperal Pyrexia

S t i l l B irth

15

22

1

4 .0

4 .5

0 .8 7

0 .9 2

+

Hormal

»

83

a

0

70

Hormal

»

2

Heg.

rf

32

n

16

it

0.85

0 .9 7

Keg.

4

Hormal

Hormal

*

5 .2

4 .8

0

94

"

2

89

8

33

H

17

rt

0 .8 7

0 .8 7

le g .

9

*

•

5 .5

5 .0

0

87

4

1

96

Hormal

21

tt

18

8

•

0 .9 4

Hormal

*

4 .6

-

f

4 .0

1 .0 8

lormal

8 7

-

1

If

22

87

rt

19

-

-

formal Ijfi .

*

4 .0

1.05

0

4 .3

1 .0 6

W

92

rt

7

3

84

Hormal

3 0

tt

2 0

2 1

20

88

0 .9 7

1 .0 2

4 ••

3 .8

rt

*

4 .5

tt

8

78

•

1 i

P ost Partum Haem.

Hormal «

\

■■

No*

Age

Hoemoglobin % End o f Beginning 8t h . Para Month

Red. Blood C e lls per c.m.m. Colour End o f Beginning Beginning o f 4 th* 8t h . of 4 th . Month Month Month

—

Index End o f 8th . Month

Blood Film

C lin ic a l Evidence o f Anaemia

Labour and Puerperium

Condition o f C h ild a t B irth

Weight o f C hild a t B irth

0.95

0 .9 0

-

-

Kormal

Normal

6 lb s .

0 ozs

tt

0.94

0 .9 6

-

-

Kormal

Normal

9

•«

0

4 .4

tt

0.73

0 .8 0

P o s.

♦

Kormal

Norn&l

5

»

33

»»

rt

3 .9

rt

1.02

0.85

Keg.

-

Forceps

Nozmal

7

"

15

"

4*5

tt

3 .8

rt

0 .91

1 .0 0

-

-

Normal

Nozmal

9

"

0

*

85

4*2

tt

4 .6

tt

1.01

0.9 2

-

-

Nozmal

7

*’

0

•»

78

78

4 .0

tt

4 .5

tt

0 .97

0 .8 6

1

90

80

4 .9

it

3 .8

it

0 .9 1

1.06

34

3

99

99

4 .7

tt

4 .9

tt

1.05

51

24

1

89

90

4 .1

rt

4.5

tt

32

27

2

87

73

4 .9

H

4 .5

33

22

1

76

75

3.5

tt

34

22

1

83

85

3 .9

35

34

3

74

78

21

1

70

37

22

1

3 8

36

39

22

24

1

60

83

4*2 m ills*

23

42

3

89

89

4 .7

tt

4 .6

24

28

2

71

71

4*8

«

25

23

1

74

67

3 .6

26

41

5

82

76

27

20

1

85

28

35

2

29

29

30

4 .6 m i l l s .

C aes. S ectio n

"

¥

Normal

Normal

rj

tt

5

tt

-

-

Normal

Normal

8

"

0

"

1 .0 1

-

-

Nozmal

Normal

9

•»

8

«

1 .0 8

1 .0 0

-

-

Nozmal

Normal

6

*

10

•»

tt

0 .8 8

0 .8 1

-

Nozmal

Normal

8

"

0

rt

3 .7

it

1.08

1 .0 1

-

-

Normal

Nozmal

7

•

o

«

tt

4 .1

tt

1.06

1 .0 3

-

-

Normal

Premature

4

»

8

rt

4 .5

tt

4 .0

tt

0.82

0 .9 7

-

Normal

Nozmal

9

«

0

rt

59

4 .5

If

3 .8

tt

0.7 7

0 .7 7

Normal

Premature

4

"

1 2

rt

87

87

4 .0

tt

4 .1

tt

1.0 8

1 .0 6

—

—

Kormal

Normal

7

"

12

rt

4

74

64

4 .2

it

3 .5

tt

0.88

0 .9 1

Keg.

-

Nozmal

Normal

6

"

8

«

31

2

94

80

4 .5

t«

4 .0

tt

1 .0 4

1 .0 0

-

-

Kormal

Nozmal

7

"

15

rt

40

27

3

79

81

4 .5

tt

4 .0

tt

0.8 7

1 .0 1

Keg.

-

Kormal

lorm al

7

"

8 rt

41

34

2

80

76

3 .9

tt

3 .7

tt

1.02

1 .0 2

-

-

Normal

Nozmal

7

"

0

rt

42

23

1

79

68

3 .7

tt

4 .1

tt

1 .0 6

0.82

Keg.

-

Nozmal

Normal

7

"

33

•»

2

80

77

4 .8

It

4 .4

it

0.83

0 .8 9

Keg.

¥

Normal

Normal

7

•

8

*

* 5 6

43

37

Neg.

Reg.

Keg.

_ A nisocvtc s i s > O S . p 0 i f c i i o c y t o s is Mic rocyt 0 S i 8

4

l L L

Age

No.

Hoemoglobin ^ Beginning ^nd o f 8t h , Para, or 4 th , Month Month

Red Blood C e lls per c.m.m. Beginning Hnd o f o f 4 th , 8t h . Month Month

44

33

3

58

52

3 .2 m i l l s .

43

19

1

96

88

4 .7

%tt

4 .6

46

20

1

77

86

4 .2

n

47

26

2

77

64

4 .1

48

41

5

69

70

49

25

2

86

50

21

1

51

22

52

Colour Index Beginning ilna o f of 4 th . 8th . Month Month

C lin ic a l Evidence o f Anaemia

Labour and Puerperium

C ondition o f C h ild a t 3 ir th

¥ei$rfc o f C h ild a t B irth

0 .9 0

0 .8 1

P o s.

4

Hoimal

Normal

7 lb s .

tt

1.02

0 .9 5

-

-

Normal

Normal

7

it

8

"

4 .2

n

0 .9 1

1.02

-

-

Hormal

Normal

9

it

12

"

tt

3 .2

tt

0 .9 3

1 .0 0

Heg.

♦

Normal

Nozmal

8

it

4

"

3 .5

tt

3 .6

rt

0 .9 8

0 .9 2

Neg.

-

Normal

Normal

7

n

8

"

85

4 .6

it

4 .7

it

0 .9 3

0 .9 0

-

-

Normal

Nozmal

7

H

8

"

85

85

5 .0

tt

4 .5

it

0.85

0 .9 4

Heg.

-

Nozmal

Normal

5

it

12

"

1

87

89

4 .2

»t

4 .8

tt

1.03

0 .9 2

-

-

Normal

Normal

6

tt

4

27

2

82

75

3 .8

n

3 .7

it

1.07

1 .0 1

-

-

Nozmal

7

tt

8

*

53

34

3

73

72

3 .8

it

3 .6

tt

0.96

1 .0 0

-

-

Normal

Normal

7

tt

8

*

54

20

1

89

81

4 .9

tt

4 .4

ft

0 .9 0

0 .9 2

-

-

Normal

Nozmal

7

tt

0

"

55

35

3

77

53

5 .5

tt

4 .5

tt

0.70

0 .5 8

P os.

+

Normal

Nozmal

5

tt

14

*

56

33

2

81

69

5 .4

it

4.5

11

0.75

0 .7 6

P o s.

-

Nozmal

8

t»

8 »

57

24

1

76

79

4 .1

it

4 .1

it

0,92

0 .9 6

“

-

Normal

Nozmal

7

tt

8

*

58

27

2

87

72

4 .0

tt

3 .8

it

1.08

0 .94

-

-

Normal

Normal

8 tt

0

*

59

20

1

84

84

3 .9

tt

3 .8

tt

1.07

1 .1 0

Heg.

-

Normal

Nozmal

7

it

12

"

60

37

7

89

88

5 .5

it

4 .8

tt

0 .8 0

0 .9 1

Heg.

f

Normal

Nozmal

6

tt

0 *

61

27

2

87

93

4 .7

t»

4 .8

tt

0.92

0 .9 6

-

-

Nozmal

Nozmal

8

it

•

*

62

37

3

63

85

4 .5

63

23

1

94

79

64

30

6

91

89

24

1

79

65

,

83

3 ,2 m i l l s .

Blood Pilm

Puerperal Pyrexia

P o st Partum Haem.

3 ozs

"

tt

4 .0

It

0.92

1 .0 6

-

-

Nozmal

Normal

6

i»

12

*

4 .8

ti'. ■

3 .8

It

9 .9 7

1 .0 3

-

-

Normal

Nozmal

6

tt

0

*

5 .6

tt

4 .3

it

0 .8 1

1 .0 3

P o s.

+

Normal

0

*

tt

4 .8

H

0 .8 9

0 #86

8

»

4 .4

a

•'•

Meg.

Forceps

Nozmal Normal

if' l^'

8 it ' 6

«

Ho.

Age

Hoemoglobin Beginning End o f 8t h . Para. o f 4 th . Month . . Month

Bed Blood C e lls per c.m.m. Colour End o f Beginning Beginning of 4 th . 8th . of 4 th . Month Month sCenth

66

30

2

90

74

5 .0 m i l l s .

67

35

1

86

90

4 .0

it

4.5

66

35

2

79

90

3 .9

>t

69

23

1

95

95

5 .2

70

32

2

87 *

89

71

29

4

58

72

20

1

73

32

74

Index End o f 8t h . Month

Blood Film

C lin ic a l 3v id e n e e o f fnaemia

labour and Puerx>erium

Condition o f C hild a t B irth

Weight o f C hild a t B irth

0 .9 0

0.92

-

-

Hormal

Hozmal

9 lb s •

tt

1.07

1 .0 0

-

-

Hormal

Hormal

7

4 .5

n

1 .0 1

1 .0 0

-

-

Hormal

Hozmal

it

5 .2

>t

0 .9 1

0 .9 1

-

-

Hormal

4 .0

»»

4.3

i«

1.08

1.03

-

58

4.5

it

4 .1

tt

0 .6 4

0 .7 0

P o s.

75

84

4 .5

t»

4 .4

it

0.83

0.95

3

69

76

3 .6

it

3 .9

it

0.95

38

4

84

84

5 .0

«

4 .4

rt

75

34

3

82

87

4 .0

rt

4 .7

76

24

1

79

71

3 .7

tt

77

22

1

79

79

4.3

78

21

3

87

87

79

21

1

81

60

25

1

61

28

62

4 .0 m i l l s .

0

ozs

tt

3

«

8

rt

12

"

Hozmal

8

tt

4

"

Hormal

Hormal

7

rt

8

"

+

Hormal

Premature

5

it

1

"

Heg.

-

Hormal

Hormal

7

rt

0

«

0 .9 7

P o s.

+

Hormal

Hormal

7

rt

0

"

0.84

0.95

Heg.

-

Hormal

Hormal

9

tt

8

*

it

1.02

0 .9 2

-

-

Hormal

Hormal

8

n

12

"

3.9

tt

1 .0 6

0 .9 1

-

-

Hormal

Hozmal

8

it

0

«

tt

4.3

tt

0 .9 1

0 .9 1

-

-

Hormal

Hozmal

6

n

12

"

4 .0

n

4.3

rt

1 .0 8

1 .0 1

-

-

Hozmal

Hozmal

7

tt

14

"

91

3 .9

tt

4 .5

rt

1 .0 3

1 .0 1

-

-

Hormal

Hozmal

6

tt

12

"

90

94

4 .9

it

5 .2

tt

0 .9 1

0 .9 0

-

-

Hormal

Hormal

8

it

0

»

3

94

94

4 .7

tt

4 .7

rt

1 .0 0

1 .0 0

-

-

Hormal

lorm al

9

it

0

"

26

5

76

80

5 .4

rt

5 .4

rt

0 .7 0

0 .74

P o s.

+

Hormal

Hormal

6

rt

8

*

83

38

5

85

85

4.5

*t

4 .2

t*

0.94

1 .0 1

-

-

Hormal

Hormal

8

tt

0

*

84

22

2

100

85

5 .2

rt

4 .2

rt

0 .9 6

1 .0 1

-

-

Hormal

Hozmal

5

tt

14

•

65

32

3

87

72

4 .2

it

4 .3

tt

1.03

0.8 3

P o s.

+

Hormal

Hozmal

7

rt

0

*

Hormal

7

N

o

If

Hozmal

6

ttl

0

»

i ;

3

87

20

2

.

94

94

5 .0

if

4 .6

80

90

4 .5

tt

4* 6

t*

> 0.94

0 .9 7

*

0 .9 7

■

■

CD

32

CD . O

86

-

Heg.

-

Hozmal Hormal

&

rr-' .

Hoemoglobin # o ft

Age

Beginning Para. of 4 th . £onth

yo

Sni of 8th . Month

Bed. Blood C e lls per c.m.m. Beginning o f 4th . Month

2 nd o f 8th . Month

Colour Begi nning of 4 th . Month

Inaex ■find o f 8t h . Month

Blood Film

C lin ic a l Evidence o f Anaemia

Labour and Puerperium

C ondition o f C hild a t B irth

Weight o f Child a t B irth

0.96

-

-

Normal

Nozmal

rt

0.89

0.88

Heg.

-

Nozmal

Normal

-7

»

2

"

4 .0

tt

0 .8 7

1.01

Heg.

4

Normal

Normal

6

«

8

"

3 .7

tt

1 .0 6

1 .0 6

-

-

Sorceps

Nozmal

9

"

8

*

4 .0

«t

0 .9 1

0.93

-

-

Normal

Nozmal

9

»

12

*

t»

5 .0

rt

1 .0 0

0.99

-

-

Normal

Normal

8

"

0

"

4 .4

tt

3 .6

it

0.95

1 .0 4

-

-

Normal

Nozmal

6

»

8

"

84

4 .7

tt

4 .4

it

0.84

0.95

Heg.

•f

Normal

Nozmal

7

*

12

"

89

70

5 .4

rt

4 .3

tt

0 #82

0 .8 1

4

Nozmal

Normal

7

"

0

»

4

87

89

4*0

rt

4 .1

tt

1.08

1.08

-

-

Nozmal

Normal

8

"

0

"

25

1

75

77

4 .0

rt

3 .8

n

0 .9 3

1 .0 1

-

-

Normal

Normal

7

"

0

«

99

34

2

80

80

4 .4

rt

4 .4

tt

0 .9 0

0 .9 0

-

-

Normal

Normal

8

»

4

*

100

23

2

81

84

4 .2

tt

4 .2

n

0 .9 6

1 .0 0

-

-

Normal

Normal

8

"

2

"

101

31

2

85

68

4 .4

t*

4 .4

tt

0 .9 6

1 .0 0

-

-

Normal

Normal

7

*

4

"

102

39

1

72

79

3 .9

tt

3 .9

tt

0 .9 2

1 .0 1

-

-

Forceps

Normal

7

"

0

«

103

32

2

73

85

3 .8

tt

4 .5

tt

0 .9 6

0 .9 4

-

-

Normal

Premature

5

»

0

"

104

28

4

77

86

4 .2

t«

4 .3

tt

0 .9 1

1 .0 0

-

-

Normal v

105

40

5

70

80

3 .5

tt

4 .2

tt

1 .0 0

0.95

-

-

Normal

Normal

8

11

0

»

106

24

1

91

84

5*1

tt

4 .4

tt

0 .8 9

0.95

lorm al

Normal

8

*

4

H

107

93

5*0

tt

4 .8

tt

0 .9 1

0 .9 6

-

-

Normal

Normal

8

"

»

2

91

0

28

106

26

2

82

82

3 .9

•*

4 .0

rt

1 .0 5

1 .02

-

-

Normal

Nozmal

7

*

12

*

109

37

6

91

91

4*6

it

4 .7

rt

0 .9 4

0 .9 6

Normal

Nozmal

7

"

4

*

33

2

83

91

4*5 m i l l s .

89

31

2

95

81

5 .3

t«

4 .6

90

20

1

75

81

4 .3

tt

91

28

1

77

79

3 .6

»♦

92

22

2

75

75

4 .1

93

23

1

94

99

4 .6

94

28

2

84

75

95

20

1

79

*96

36

3

97

26

98

■■

I OS.Miorocyt >sis

.

Neg.

S t i l l B irth . Hydrocephai.

6 lb s .

4 ozs

0 .9 2

4 .7 m i l l s .

86

r

Hoemoglobin $ Beginning Bnd of P ara. o f 4 th . 8t h . Month Month

Red Blood C e lls per c.m.m. Beginning Bnd o f of 4 th . 8th . Month Month

Ko.

Age

110

36

3

80

80

4 .0 m i l l s .

111

26

2

83

84

4 .1

rt

4 .2

*

Colour Beginning of 4 th . Month

Index Bnd o f 8th Month.

Blood Film

C lin ic a l Evidence o f Anaemia

Labour and Puerperi um

C ondition o f C h ild at B irth

Weight o f C hild a t B irth

1.00

1.02

Kormal

Kormal

8

lb s .

0

oz

tt

1.01

1 .0 0

Koxmal

Kormal

7

it

0

it

P o st Partum Haem.

Kormal

8

rt

4

n

Kormal

Kormal

7

it

0

it

Kormal

Kormal

7

tt

12

tt

Kormal

Kormal

7

n

4

it

Normal

Kormal

9

rt

0

»i

Kormal

Kormal

9

tt

4

tt

3 .7 m i l l s .

112

23

1

83

86

4 .9

rt

4 .2

tt

0 .8 4

1.02

113

24

1

86

88

4 .3 •

it

4*2

it

1.00

1.04

114

26

2

78

74

4 .2

rt

rt

0.92

0.88

115

25

3

81

82

4 .2

it

4 .5

tt

0.96

0.9 1

116

19

1

71

81

4 .4

it

4 .1

it

* 0.80

0 .9 8

117 x __ _ 116

27

1

85

90

4 .2

tt

4 .6

rt

1.01

0 .9 7

36

4

45

45

3 .8

it

4 .1

it

0.59

0.5 4

119

24

1

83

83

4 .0

rt

4 .1

tt

1.03

1.0 1

Kormal

Kormal

8

tt

12

H

120

31

5

89

87

4 .4

rt

4 .2

it

1.01

1.03

P o st partum Haem.

Kormal

6

tt

8

tt

121

28

1

87

92

4 .8

it

4 .7

it

0.90

0 .9 7

Kormal

Kormal

6

tt

14

tt

122

29

1

84

87

4 .5

it

4.5

tt

0.93

C.96

Kormal

Koxmal

6

tt

14

it

123

32

3

82

89

4 .0

rt

4 .2

it

1.02

1.05

Kormal

Kormal

9

tt

0

ft

124

32

3

75

81

4 .0

it

3 .9

it

0.93

1.03

Kormal

Kormal

7

tt

6

ft

125

31

5

77

69

4 .6

tt

4 .0

tt

0.83

0 .8 6

Kormal

Koxmal

6

it

13

tt

126

20

1

93

93

4 .3

tt

4 .3

tt

1.08

1 .0 8

Kormal

Koxmal

7

tf

0

ft

127

34

3

91

94

4 .5

M

4 .7

tt

1.01

1 .0 0

Kormal

Koxmal

6

tt

8

128

39

9

84

87

4 .1

tt

4 .2

tt

1.02

1.0 3

Kormal

Normal

7

rt

8

129

25

3

74

74

4 .1

ft

3 .9

ft

0.90

0 .9 4

Kormal

Koxmal

7

tt

Q ft

130

32

2

69

73

5 .3

tt

4 .5

rt

0 .6 5

0 .8 0

Koxmal

Koxmal

8

tt

0

4 .2

Keg.

P os.

Keg.

A nisocyto ill s ijcaP oik ilocyi; o s is + MicrocytoJ i s

P os.

P os.

It

It

ft

Hoemoglobin Beginning Para. of 4 th . Month

ft 2 nd of 8th . Month

Red Blood C e lls per c .rn.m. 2 nd o f Beginning 8t h . of 4 th . Month Month

151

32

1

72

64

3 .6 m i l l s .

132

26

3

84

87

4 .5

it

4 .4

133

22

1

77

87

4 .0

it

134

39

5

79

81

4 .2

135

29

3

75

80

4 .1

136

41

4

81

77

137

24

1

80

138

27

1

139

22

140

Hnd of 8t h . Month

Labour ana. lu e rp e riu m

C o n d itio n of C h ild a t B irth

h e ig h t of Child a t B irth

1.00

1 .0 0

Forceps

Hormal

7 l b s . 14 o z s.

tt

0.93

0.99

Hormal

Hormal

7

»»

8

"

4 .3

it

0.96

1 .0 1

Hormal

Hormal

7

••

8

"

3 .9

it

0.94

1.03

»»

4 .0

it

0.91

1 .0 0

Hormal

Hormal

7

"

0

"

4 .3

tt

4.2

tt

0.94

0 .9 1

Hormal

Hormal

7

"

0

M

84

4 .4

it

4 .4

it

0.90

0.95

Hormal

Hormal

5

”

15

"

74

74

3 .6

«

4 .0

it

1.02

0.9 2

Hormal

Hormal

8

"

14

M

1

72

73

4 .0

it

3 .9

it

0.90

0.93

Hormal

Puerperal P y re x ia

tt

0

"

30

2

73

84

3 .8

tt

4 .1

tt

0.96

1.02

Hormal

Hozmal

7

"

a

Age

IncLex

H* O

Ho.

Colour Beginning of 4 th . Month

141

23

1

74

65

3 .8

tt

3 .5

tt

0.97

0.92

Hormal

Hormal

8

"

8

n

142

26

4

74

79

3 .7

ft

4 .1

tt

1.00

0 .9 6

Hormal

Hormal

7

*

0

"

143

32

2

81

87

4.2

tt

4 .2

tt

0.96

1.03

Hormal

Hormal

9

"

5

*

144

42

6

73

84

3 .9

tt

4 .3

it

0.93

0 .9 7

. Hormal

Hozmal

*

4

"

143

23

1

80

85

4 .3

it

4.5

tt

0.93

0 .9 4

Hormal

Hormal

6 *

4

*

146

25

1

78

81

4 .2

it

4 .2

tt

0.92

0 .9 6

Hormal

Hozmal

6

"

14

"

147

25

2

94

88

5 .0

tt

4.5

it

0.94

0 .9 7

Hoimal

Hozmal

9

4

"

146

26

2

75

83

4 .1

t»

4 .3

tt

0.91

0 .9 6

Hormal

lormal

7

*

0

*

149

29

3

71

75

3 .4

tt

3 .9

tt

1.04

0 .9 6

Hormal

Hozmal

9

*

0 '*

150

44

2

85

85

4 .3

tt

4 .3

it

0.98

0 .9 8

3.2 m i l l s .

#

7

k x

711ms rttovoH other evidenoo o f iro»^ iefiol*n oy

aaanri* b«a &** hype j^"

1

'/'S;

-

-V