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FATAL HÆMOLYSIS FOLLOWING TRANSFUSION OF BLOOD.
784 arrived she
was exsanguine and was not breathing. Therei clots in the mouth and nares and signs of vomiting on the clothing. Adrenalin and normal saline solutionL were injected subcutaneously and artificial respiration was employed, but without avail. At the necropsy, which was performed 19 hours after death, both nostrils and the right auditory meatus. were found filled with clotted blood. Below and behind the meatus was a swelling of the size of an olive, over which the skin was ecchymosed. The meninges and brain were normal. The venous sinuses, including the right lateral sinus and bulb, were intact. The whole temporal bone with a large amount of the soft tissues beneath and a portion of the wall of the pharynx were removed and hardened for 48 hours in 10 per cent. solution of formalin. A stream of water could be forced through the carotid canal without finding its way into the tympanum. The soft tissues beneath the bone which contained the carotid artery and jugular veins were infiltrated with bloodi and there was a large hasmorrhagic extravasation which communicated with the pharynx a short distance below the mouth of the Eustachian tube. The extravasation extendedI outward to the angle of the jaw, undermined the subcutaneous tissue, formed the swelling previously mentioned, andl communicated with the lumen of the external auditory canal. The tympanic membrane was intact but was retracted andl united to the promontory, evidently as the result of an oldl perforation. The tympanum and Eustachian tube contained much exudation but no blood. Attached to the walls of thei The attic and tympanum were several small polypi. mastoid cells were filled with exudation but were not necrotic. Microscopic examination revealed the characteristic appearances of chronic suppurative otitis media. The carotid artery was normal but its sheath showed chronic inflammation as far as the first bend in the bony canal, most marked at the entrance of the latter. The sheath for a short distance was infiltrated with blood which had forced its way from the large hemorrhage beneath the temporal bone. The soft tissues in which this haemorrhage had taken place were involved in granulation tissues in which were large areas of pus cells. The wall of thejugular vein which passed through this abscess was necrotic, lined with purulent thrombi, and in places perforated. Sections of the abscess stained by Gram’s method showed numerous streptococci but no other bacteria. were
,
-
.
,
,
INFANT MORTALITY IN HUDDERSFIELD. IT is not without interest to note the apparent effect on infant mortality of the local Act which was passed last year and enacted the early notification of births occurring within the borough of Huddersfield to the sanitary authority. The rate of infant mortality-of deaths under one year of age-in Huddersfield during 1905 was equal to 119 per 1000 births and rose during 1906 to 135 per 1000, the average rate in the 76 large English towns showing an increase from 140 in 1905 to 145 in 1906. Thus the rate of infant mortality in Huddersfield, which was 15 per cent. below the large urban rate in 1905, was only 7 per cent. below the same average in 1906. It must be remembered that the Birth Notification Act did not come into operation in Huddersfield until late in 1906, but bearing in mind the voluntary efforts made by the mayor and sanitary authority to promote early notification of births prior to the passing of the Act the figures noted above were somewhat disappointing. During the first six months of this year the rate of infant mortality in the 76 large towns was equal to 123 per 1000 births and the rate in Huddersfield did not exceed 97 per 1000 ; thus the Huddersfield rate was 21 per cent. below the mean large urban rate. The interesting point for consideration is whether this relative reduction in the rate of infantile mortality in Huddersfield during the first half of this year, compared with the mean
large towns, can safely be attributed to the of the Huddersfield local Act. During the six operation weeks of unsummerlike weather and temperature ending on August lOtb, which has checked the usual fatality of summer diarrhoea., the rate of infant mortality in our large towns has fallen to 96 per 1000, while in Huddersfield it has not exceeded 38 per 1000. The evidence of these statistics seems therefore to point to the successful administration of the Huddersfield local Act since the beginning of this year as the cause of the recent reduction of infant mortality in that town. In view of the new Act making early notification compulsory the effect of the local measure in Huddersfield on infant mortality acquires much importance. rate in other
FATAL
HÆMOLYSIS
FOLLOWING OF BLOOD.
TRANSFUSION
IN November, 1906, Dr. Crile published in the Journal of the American Medical Association an important paper recommending as the best method of transfusion of blood anastomosis of the proximal end of an artery of the donor to the proximal end of a vein of the receiver.1 Since that period the method has been tried in the treatment of anaemia, in America at times with favourable results, at others without much apparent change. In the J01frnal of the American Medical Assl/ciation of August 3rd Dr. William Pepper and Dr. Verner Nisbet have reported a case in which fatal haemolysis followed-an observation of great importance because transfusion of blood has always been regarded as innocuous. A man, aged 33 years, was admitted to hospital on April 16h last. In October, 1906, it was noticed that his naturally pale complexion was becoming paler and tinnitus and nocturnal bleeding from the gums began. The bleeding gradually became more severe and took place both by day and by night for ten days preceding admission. Blood was also passed in the urine and fasces. 11 years before admission the patient had a hard sore on the penis which was followed by a rash, and he was treated for syphilis for six months. On admission the temperature was 98° F. and the pulse was 108. The skin was of a dirty lemon colour. The lymphatic glands in the axillae and groins were palpable. The mucous membranes were very pale and the lips were blood-stained. Blood oozed continuously from the gums. The cardiac dulness extended above the third rib, ta the right one centimetre beyond the sternal margin, and to the left three centimetres outside the nipple line. The first sound was loud and was accompanied at the apex by a rough murmur. A systolic murmur was alsoheard in the third interspace and was not transmitted to the vessels of the neck, over which a humming sound was heard. The pulmonary second sound was accentuated. Blood examination showed 20 per cent. of hoernoand 970,000 red and 3600 white corpuscles per came millimetre. Blood was not found in the urine but was present in the fasces. The bleeding continued and the patient steadily lost ground. The diagnosis was obscure. Of haemophilia there was no history. Scurvy was negatived by the absence of changes in the gums or intramuscular or subdermal effusions. The morphology of the blood excluded pernicious anaemia. On April 26th the patient seemed to be sinking rapidly. A large vein on the left elbow was anastomosed with his wife’s left radial artery at 5 52 P.M. and transfusion was continued until 7.25 P.M. Both husband and wife stood the operation well. The red corpuscles at 5 50 P.M. were 420,000 ; at 7.15 P.M. they were 1,001,000. The bleeding from the gums almost ceased and the patient’s colour improved. On the 28th he was much better and there was merely a trace of haemorrhage from the gums. Transfusion was performed from the
globin
1
THE
LANCET, Dec. 22nd, 1906,
p. 1737.
785
patient’s brother-in-law. This raisedI from 1,270,000 to 1,800,000. In the corpuscles the was and lethargic and perspired flushed evening patient much. The temperature was 102°. On the Z9tih he was very jaundiced. The temperature rose to 104°. The amm were painful and swollen and the hands were edematous. The liver increased in size and became tender and the spleen was palpable. Petechise appeared. The urine contained urobilin, hoemoglobin, blood, and many (}asts. After the first transfusion the urine became slightly reddish and contained a little urobilin, suggesting haemolysis, but this condition had nearly disappeared at the time of the second transfusion. Daring the night after the second transfusion the urine became bloody and subsequently its condition showed a direct relation with the jaundice, oppression, and other evidences of haemolysis. On April 30th the jaundice was worse, the temperature was still high, and the mouth was very dry but not bleeding. Death occurred on May 3rd. The necropsy showed numerous small pulmonary haemorrhages, dilatation of the heart, and acute parenchymatous nephritis with subcapsular ecchymoses. The cases reported by Dr. Crile seem to show that direct transfusion is a safe procedure in hsemorrhage. But the present case indicates that there may be danger of haemolysis in certain pathological conditions.
some varieties of bacteria (typhoid, colcn) followed by a definite immunity to the corresponding infection but this was not the case with the bacilli of anthrax.
by
the red
was
__
TRADE CUSTOMS.
THE term trade customsin some quarters appears to be the modern synonym for malpractices. So many defendants shelter themselves, or attempt to shelter themselves, behind the plea of trade custom that it would be interesting to have a list published of " trade customs." The public have a right to know what trade customs are. We doubt very much if the public know quite so much about them as the trade. Police-court proceedings enlighten us considerably at times, but there are so many " trade customs" that we plead for a glossary of them. We fancy that we should be fairly safe in saying that such a compilation would open our eyes to a string of petty practices designed more or less to cheat the purchasing public : trade customs, in fact, which though approved by the trade are, strictly speaking, illegal transactions. We should like to see appointed " a Royal Commission on trade customs." The selection of the Commissioners, who, of course, would be authorities on the subject, would be interesting and the evidence of the witnesses would at least be amusing if not instructive. The final report would have the word "swindle"written in every one of its conclusions-that is to say, if the ComHYPERSUSCEPTIBILITY AND IMMUNITY. missioners honestly set about their business. These may be THAT nothing in nature is too trivial to be worth recordstrong words, but day by day we read in police-court proing is now a commonplace of science. Light is often shed ceedings how indictment after indictment is met by the on important problems from the most unexpected quarters. sickening excuse of "trade customs." Brown paper is found An instance may, perhaps, be seen in some recent researches in the soles of boots ; it is a trade custom. Silk containing carried out by Dr. M. J. Rosenau and Dr. J. F. Anderson on cotton is sold as pure silk; it is a common practice of the the somewhat obscure phenomena of hypersusceptibility1 trade and therefore a justifiable one, because the trade produced in animals by injections of foreign serum. recognises it. It is also at times the trade custom to call an The observation upon which these studies were based was article brandy which is not brandy, soda-water which the discovery that if an animal were injected with a dose is not soda-water, butter which is not butter, and so on - of horse-serum and subsequently received a second dose of ad Infinitnm, In fine, it will be found that trade customs" the same after some days’ interval serious and even fatal as a rule do not call a spade a spade and things are not symptoms were produced. From further experiments it what they seem. The term trade customs"is a cloak, is appears that the same phenomenon results from thei not in many instances honest, and in an equal number of injection of other albuminous substances, such as white’ instances exists to evade the law. The law should reof egg or even extract of yeast, and that an incognise no trade custom which is not straight dealing. terval of about ten days must elapse before the condition of hypersensibility is fully developed. This condition is transmitted by the mother to her offspring but not THE FREQUENCY OF THE BABINSKI SIGN IN GENERAL PARALYSIS. by the father. The administration of uncooked meat results in the production of some degree of susceptibility to the Dr. Alfred Gordon contributes an interesting paper albumins of the animal eaten, but this result is prevented entitled " A Study of Reflexes of the Lower Extremities by thorough cooking of the meat. The explanation of the in 60 cases of Paresis"to the July (1907) issue of the phenomenon is not very clear, but " profound chemical Journal of Nervous and lklental Disease (America). He changes, perhaps in the central nervous system,.are probably refers to the general agreement by most authorities that the produced by the first injection of a strange serum." The Babinski sign is rarely present in cases of general paralysis. interesting suggestion is made by the writers that the in- Robert and Fournial (Rm.1te Ne1t’l’ologique, Nov. 21, 1906) tubation period of an infectious disease-often a period of reported that out of 66 cases of paretic dementia about ten days, corresponding closely with that needed for the they had only found it present in one patient. As Dr. production of hypersusceptibility-may be explained by the Gordon states, the reason for this infrequency is not existence of some similar action, while the analogy with the easy to explain when it is borne in mind that the involvephenomena seen after injection of tuberculin is obvious. The ment of the motor tract in general paralysis is the rule and still more curious feature seen in some diseases, the occurrence further that the Babinski reflex is unquestionably a sign of of a crisis, may perhaps prove to come under the same law. an involvement of the motor pathway in its central or These observations have also a bearing upon the production terminal ends. Dr. Gordon showed in his first clinical of immunity, the writers holding that a condition of hyper- studiesthat the " paradoxical reflex" is " a sign of irritation susceptibility is probably necessary as a stage in the pro- or early stage of a lesion of the motor tract," and he conduction of immunity to one class of diseases. It corresponds sidered that it would be of some pathogenetic value to study to some extent with the " negative phase" or diminished the relationship of this reflex and the Babinski sign in general resistance seen after inoculation with bacteria or thei) paralysis. He refers to Wyruboff’s work in the revue Neurotoxins. Thus hypersusceptibility produced in guinea-pigi logique, 1900, in which he showed that, from the anatomico1 Rosenau and Anderson: Studies upon Hypersusceptibility and clinical standpoint, all cases of general paralysis can be divided Immunity, Bulletin No. 36, Hyg. Lab., U.S. Public Health and Mar. 1Journal of Nervous and Mental Disease, July, 1906. Hosp. Serv., Wash., 1907. ’
o
-
extracts of
Tadial artery of the
I
was exsanguine and was not breathing. Therei clots in the mouth and nares and signs of vomiting on the clothing. Adrenalin and normal saline solutionL were injected subcutaneously and artificial respiration was employed, but without avail. At the necropsy, which was performed 19 hours after death, both nostrils and the right auditory meatus. were found filled with clotted blood. Below and behind the meatus was a swelling of the size of an olive, over which the skin was ecchymosed. The meninges and brain were normal. The venous sinuses, including the right lateral sinus and bulb, were intact. The whole temporal bone with a large amount of the soft tissues beneath and a portion of the wall of the pharynx were removed and hardened for 48 hours in 10 per cent. solution of formalin. A stream of water could be forced through the carotid canal without finding its way into the tympanum. The soft tissues beneath the bone which contained the carotid artery and jugular veins were infiltrated with bloodi and there was a large hasmorrhagic extravasation which communicated with the pharynx a short distance below the mouth of the Eustachian tube. The extravasation extendedI outward to the angle of the jaw, undermined the subcutaneous tissue, formed the swelling previously mentioned, andl communicated with the lumen of the external auditory canal. The tympanic membrane was intact but was retracted andl united to the promontory, evidently as the result of an oldl perforation. The tympanum and Eustachian tube contained much exudation but no blood. Attached to the walls of thei The attic and tympanum were several small polypi. mastoid cells were filled with exudation but were not necrotic. Microscopic examination revealed the characteristic appearances of chronic suppurative otitis media. The carotid artery was normal but its sheath showed chronic inflammation as far as the first bend in the bony canal, most marked at the entrance of the latter. The sheath for a short distance was infiltrated with blood which had forced its way from the large hemorrhage beneath the temporal bone. The soft tissues in which this haemorrhage had taken place were involved in granulation tissues in which were large areas of pus cells. The wall of thejugular vein which passed through this abscess was necrotic, lined with purulent thrombi, and in places perforated. Sections of the abscess stained by Gram’s method showed numerous streptococci but no other bacteria. were
,
-
.
,
,
INFANT MORTALITY IN HUDDERSFIELD. IT is not without interest to note the apparent effect on infant mortality of the local Act which was passed last year and enacted the early notification of births occurring within the borough of Huddersfield to the sanitary authority. The rate of infant mortality-of deaths under one year of age-in Huddersfield during 1905 was equal to 119 per 1000 births and rose during 1906 to 135 per 1000, the average rate in the 76 large English towns showing an increase from 140 in 1905 to 145 in 1906. Thus the rate of infant mortality in Huddersfield, which was 15 per cent. below the large urban rate in 1905, was only 7 per cent. below the same average in 1906. It must be remembered that the Birth Notification Act did not come into operation in Huddersfield until late in 1906, but bearing in mind the voluntary efforts made by the mayor and sanitary authority to promote early notification of births prior to the passing of the Act the figures noted above were somewhat disappointing. During the first six months of this year the rate of infant mortality in the 76 large towns was equal to 123 per 1000 births and the rate in Huddersfield did not exceed 97 per 1000 ; thus the Huddersfield rate was 21 per cent. below the mean large urban rate. The interesting point for consideration is whether this relative reduction in the rate of infantile mortality in Huddersfield during the first half of this year, compared with the mean
large towns, can safely be attributed to the of the Huddersfield local Act. During the six operation weeks of unsummerlike weather and temperature ending on August lOtb, which has checked the usual fatality of summer diarrhoea., the rate of infant mortality in our large towns has fallen to 96 per 1000, while in Huddersfield it has not exceeded 38 per 1000. The evidence of these statistics seems therefore to point to the successful administration of the Huddersfield local Act since the beginning of this year as the cause of the recent reduction of infant mortality in that town. In view of the new Act making early notification compulsory the effect of the local measure in Huddersfield on infant mortality acquires much importance. rate in other
FATAL
HÆMOLYSIS
FOLLOWING OF BLOOD.
TRANSFUSION
IN November, 1906, Dr. Crile published in the Journal of the American Medical Association an important paper recommending as the best method of transfusion of blood anastomosis of the proximal end of an artery of the donor to the proximal end of a vein of the receiver.1 Since that period the method has been tried in the treatment of anaemia, in America at times with favourable results, at others without much apparent change. In the J01frnal of the American Medical Assl/ciation of August 3rd Dr. William Pepper and Dr. Verner Nisbet have reported a case in which fatal haemolysis followed-an observation of great importance because transfusion of blood has always been regarded as innocuous. A man, aged 33 years, was admitted to hospital on April 16h last. In October, 1906, it was noticed that his naturally pale complexion was becoming paler and tinnitus and nocturnal bleeding from the gums began. The bleeding gradually became more severe and took place both by day and by night for ten days preceding admission. Blood was also passed in the urine and fasces. 11 years before admission the patient had a hard sore on the penis which was followed by a rash, and he was treated for syphilis for six months. On admission the temperature was 98° F. and the pulse was 108. The skin was of a dirty lemon colour. The lymphatic glands in the axillae and groins were palpable. The mucous membranes were very pale and the lips were blood-stained. Blood oozed continuously from the gums. The cardiac dulness extended above the third rib, ta the right one centimetre beyond the sternal margin, and to the left three centimetres outside the nipple line. The first sound was loud and was accompanied at the apex by a rough murmur. A systolic murmur was alsoheard in the third interspace and was not transmitted to the vessels of the neck, over which a humming sound was heard. The pulmonary second sound was accentuated. Blood examination showed 20 per cent. of hoernoand 970,000 red and 3600 white corpuscles per came millimetre. Blood was not found in the urine but was present in the fasces. The bleeding continued and the patient steadily lost ground. The diagnosis was obscure. Of haemophilia there was no history. Scurvy was negatived by the absence of changes in the gums or intramuscular or subdermal effusions. The morphology of the blood excluded pernicious anaemia. On April 26th the patient seemed to be sinking rapidly. A large vein on the left elbow was anastomosed with his wife’s left radial artery at 5 52 P.M. and transfusion was continued until 7.25 P.M. Both husband and wife stood the operation well. The red corpuscles at 5 50 P.M. were 420,000 ; at 7.15 P.M. they were 1,001,000. The bleeding from the gums almost ceased and the patient’s colour improved. On the 28th he was much better and there was merely a trace of haemorrhage from the gums. Transfusion was performed from the
globin
1
THE
LANCET, Dec. 22nd, 1906,
p. 1737.
785
patient’s brother-in-law. This raisedI from 1,270,000 to 1,800,000. In the corpuscles the was and lethargic and perspired flushed evening patient much. The temperature was 102°. On the Z9tih he was very jaundiced. The temperature rose to 104°. The amm were painful and swollen and the hands were edematous. The liver increased in size and became tender and the spleen was palpable. Petechise appeared. The urine contained urobilin, hoemoglobin, blood, and many (}asts. After the first transfusion the urine became slightly reddish and contained a little urobilin, suggesting haemolysis, but this condition had nearly disappeared at the time of the second transfusion. Daring the night after the second transfusion the urine became bloody and subsequently its condition showed a direct relation with the jaundice, oppression, and other evidences of haemolysis. On April 30th the jaundice was worse, the temperature was still high, and the mouth was very dry but not bleeding. Death occurred on May 3rd. The necropsy showed numerous small pulmonary haemorrhages, dilatation of the heart, and acute parenchymatous nephritis with subcapsular ecchymoses. The cases reported by Dr. Crile seem to show that direct transfusion is a safe procedure in hsemorrhage. But the present case indicates that there may be danger of haemolysis in certain pathological conditions.
some varieties of bacteria (typhoid, colcn) followed by a definite immunity to the corresponding infection but this was not the case with the bacilli of anthrax.
by
the red
was
__
TRADE CUSTOMS.
THE term trade customsin some quarters appears to be the modern synonym for malpractices. So many defendants shelter themselves, or attempt to shelter themselves, behind the plea of trade custom that it would be interesting to have a list published of " trade customs." The public have a right to know what trade customs are. We doubt very much if the public know quite so much about them as the trade. Police-court proceedings enlighten us considerably at times, but there are so many " trade customs" that we plead for a glossary of them. We fancy that we should be fairly safe in saying that such a compilation would open our eyes to a string of petty practices designed more or less to cheat the purchasing public : trade customs, in fact, which though approved by the trade are, strictly speaking, illegal transactions. We should like to see appointed " a Royal Commission on trade customs." The selection of the Commissioners, who, of course, would be authorities on the subject, would be interesting and the evidence of the witnesses would at least be amusing if not instructive. The final report would have the word "swindle"written in every one of its conclusions-that is to say, if the ComHYPERSUSCEPTIBILITY AND IMMUNITY. missioners honestly set about their business. These may be THAT nothing in nature is too trivial to be worth recordstrong words, but day by day we read in police-court proing is now a commonplace of science. Light is often shed ceedings how indictment after indictment is met by the on important problems from the most unexpected quarters. sickening excuse of "trade customs." Brown paper is found An instance may, perhaps, be seen in some recent researches in the soles of boots ; it is a trade custom. Silk containing carried out by Dr. M. J. Rosenau and Dr. J. F. Anderson on cotton is sold as pure silk; it is a common practice of the the somewhat obscure phenomena of hypersusceptibility1 trade and therefore a justifiable one, because the trade produced in animals by injections of foreign serum. recognises it. It is also at times the trade custom to call an The observation upon which these studies were based was article brandy which is not brandy, soda-water which the discovery that if an animal were injected with a dose is not soda-water, butter which is not butter, and so on - of horse-serum and subsequently received a second dose of ad Infinitnm, In fine, it will be found that trade customs" the same after some days’ interval serious and even fatal as a rule do not call a spade a spade and things are not symptoms were produced. From further experiments it what they seem. The term trade customs"is a cloak, is appears that the same phenomenon results from thei not in many instances honest, and in an equal number of injection of other albuminous substances, such as white’ instances exists to evade the law. The law should reof egg or even extract of yeast, and that an incognise no trade custom which is not straight dealing. terval of about ten days must elapse before the condition of hypersensibility is fully developed. This condition is transmitted by the mother to her offspring but not THE FREQUENCY OF THE BABINSKI SIGN IN GENERAL PARALYSIS. by the father. The administration of uncooked meat results in the production of some degree of susceptibility to the Dr. Alfred Gordon contributes an interesting paper albumins of the animal eaten, but this result is prevented entitled " A Study of Reflexes of the Lower Extremities by thorough cooking of the meat. The explanation of the in 60 cases of Paresis"to the July (1907) issue of the phenomenon is not very clear, but " profound chemical Journal of Nervous and lklental Disease (America). He changes, perhaps in the central nervous system,.are probably refers to the general agreement by most authorities that the produced by the first injection of a strange serum." The Babinski sign is rarely present in cases of general paralysis. interesting suggestion is made by the writers that the in- Robert and Fournial (Rm.1te Ne1t’l’ologique, Nov. 21, 1906) tubation period of an infectious disease-often a period of reported that out of 66 cases of paretic dementia about ten days, corresponding closely with that needed for the they had only found it present in one patient. As Dr. production of hypersusceptibility-may be explained by the Gordon states, the reason for this infrequency is not existence of some similar action, while the analogy with the easy to explain when it is borne in mind that the involvephenomena seen after injection of tuberculin is obvious. The ment of the motor tract in general paralysis is the rule and still more curious feature seen in some diseases, the occurrence further that the Babinski reflex is unquestionably a sign of of a crisis, may perhaps prove to come under the same law. an involvement of the motor pathway in its central or These observations have also a bearing upon the production terminal ends. Dr. Gordon showed in his first clinical of immunity, the writers holding that a condition of hyper- studiesthat the " paradoxical reflex" is " a sign of irritation susceptibility is probably necessary as a stage in the pro- or early stage of a lesion of the motor tract," and he conduction of immunity to one class of diseases. It corresponds sidered that it would be of some pathogenetic value to study to some extent with the " negative phase" or diminished the relationship of this reflex and the Babinski sign in general resistance seen after inoculation with bacteria or thei) paralysis. He refers to Wyruboff’s work in the revue Neurotoxins. Thus hypersusceptibility produced in guinea-pigi logique, 1900, in which he showed that, from the anatomico1 Rosenau and Anderson: Studies upon Hypersusceptibility and clinical standpoint, all cases of general paralysis can be divided Immunity, Bulletin No. 36, Hyg. Lab., U.S. Public Health and Mar. 1Journal of Nervous and Mental Disease, July, 1906. Hosp. Serv., Wash., 1907. ’
o
-
extracts of
Tadial artery of the
I