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THE STORAGE OF BLOOD FOR TRANSFUSION
1382
CORRESPONDENCE THE STORAGE OF BLOOD FOR
TRANSFUSION
To the Editor
of
THE LANCET
SIR,-Your leading article last week marks the initiation of interest in the employment of cadaveric blood in western medicine; as you say, research in this subject is overdue. On the other hand from " blood universal " donors was preserved a number of employed by surgeons during the war, myself among them. From the latter part of 1917 onward, performance of blood transfusion prior to amputation of a limb was a routine measure, which reduced the mortality-rate for amputation of the thigh by over 14 per cent. in the base hospital of which I had surgical charge. It will be realised that the reservoir of donors was of variable capacity; for this reason, following the experience of Captain Robertson, of the Massachusetts General Base Hospital, American Army, a supply of citrated preserved blood was kept at hand continually; actually the stock was not allowed to fall below six Winchester quarts. As no cold-storage facilities were available, 10 minims of chloroform were added to the Winchester as preservative, and the blood decanted for use ; the sterility was controlled by weekly examinations. To the best of my recollection our experience tallied with that of Robertson, that the preserved blood was valid for use up to 28 days ; no incompatibilities, or reactions more severe than those met with in recently citrated blood, were encountered. Specimens ofblood which had been preserved for two months were sent, I think, to Prof. L. E. Bayliss for examination : he wrote that these appeared to have developed an excess of a toxin of the histamine group, but that some histamine was present in all
citrated blood. For this reason, whole blood, uncitrated, and given via the paraffin-coated tube, was normally employed. I had records of over 400 cases thus transfused ; and have often felt that the credit of the introduction and spread of transfusion in the British Army was not given where it belongedviz., to Mr. D. W. Crile, nephew of his famous uncle, who popularised it in the base hospitals in the Etaples area as
early
as 1915. I am, Sir, yours
Sunderland, June 4th. DISEASES
OF
faithfully, W. GRANT WAUGH. WAUGI-1.
THE PERIPHERAL ARTERIES
To the Editor
of THE LANCET recent review SiR,-The (May 2nd, p. 1012) of my book, " The Diagnosis and Treatment of Diseases of the Peripheral Arteries," prompts me to offer the opinion that the reviewer has evidently been guilty of one or more amputations in thrombo-angiitis obliterans, which I so heartily condemn. My efforts to establish the conservative therapy of this disease in America have apparently not been felt in England as
yet.
However, having already successfully
over-
these stages of opposition in America, I feel sure that it will be only a matter of time when a conservative attitude toward these diseases will be forthcoming in our English colleagues. I am, Sir, yours faithfully, SAUL S. SAMUELS. New York, May 29th. **Our review questioned how far conservatism can be carried in the patient’s interests. The point at which severe suffering is best ended-even at the cost of a mutilating operation-must be left to individual judgment based on a knowledge of endresults. We hope Dr. Samuels will provide further information about the subsequent efficiency of the limbs he has saved from amputation.-ED. L. come
PUBLIC HEALTH The Cost of Syphilis in an Urban Community IN times of economic depression communities as well as individuals have to look to their bank balances and consider whether and where expenditure can be reduced, and whether the money they spend can be put to more effective use. The public health services are no exception to the rule, though it may be a difficult, if not impossible, task to measure their value to the community in terms of pounds, shillings, and pence, especially with regard to particular items : what does ill-health cost the community ? how much of it is preventable and at what expense’? One item in this account has been recently made the basis of a study1 carried out in Baltimore by Drs. W. C. Thompson, W. A. Brumfield, and Lucile Caldwell of the syphilis division of the medical clinic, Johns Hopkins Hospital. The authors’ object was to obtain an accurate estimate of the cost of syphilis in a representative American community, and to see whether the amount spent is adequate to deal with the existing problem, and so allocated as to provide " the combination of maximum benefit for the infected patient and maximum protection for the public health." The investigation was carried out by an analysis of the clinical records of hospitalised patients and by means of cost data of hospital treatment, ambulatory 1 Amer. Jour. Syph., May, 1936, p. 243.
and cost of drugs in 1933. Patients privately treated were ignored. In Baltimore, with a population of about 828,000, they report that some 9000 new syphilitic patients are discovered yearly, of whom about 4000 have early syphilis and 5000 have late syphilis. The total direct cost of that burden in 1933 they assess roughly at$170,000, or, in other words, each new syphilitic patient is responsible for the charitable expenditure of more than$18 per year. A study of the age-distribution of the hospital patients showed that nearly three-quarters of them were under the age of 50 ; as 74 per cent. of the hospital costs were for cardiovascular and neurosyphilis, which usually lead to prolonged invalidism, the authors conclude with reason that most of these patients, in the prime of life, are permanently removed from the possibility of self-support and form an annual charge. On the other hand the sum available for ambulatory clinics they regard as quite inadequate and for many patients they find no treatment at all is available. They urge that if that sum were substantially increased much of the cost of hospital care would be obviated, since the late sequelse of the disease would be prevented and fresh infections reduced. They thus reach the undeniable conclusion that " only by a reduction in the incidence of syphilis can the total expenditure be reduced," and the reasonable though, perhaps, less certain corollary that " only by the
clinics, serologic laboratories,
the year
CORRESPONDENCE THE STORAGE OF BLOOD FOR
TRANSFUSION
To the Editor
of
THE LANCET
SIR,-Your leading article last week marks the initiation of interest in the employment of cadaveric blood in western medicine; as you say, research in this subject is overdue. On the other hand from " blood universal " donors was preserved a number of employed by surgeons during the war, myself among them. From the latter part of 1917 onward, performance of blood transfusion prior to amputation of a limb was a routine measure, which reduced the mortality-rate for amputation of the thigh by over 14 per cent. in the base hospital of which I had surgical charge. It will be realised that the reservoir of donors was of variable capacity; for this reason, following the experience of Captain Robertson, of the Massachusetts General Base Hospital, American Army, a supply of citrated preserved blood was kept at hand continually; actually the stock was not allowed to fall below six Winchester quarts. As no cold-storage facilities were available, 10 minims of chloroform were added to the Winchester as preservative, and the blood decanted for use ; the sterility was controlled by weekly examinations. To the best of my recollection our experience tallied with that of Robertson, that the preserved blood was valid for use up to 28 days ; no incompatibilities, or reactions more severe than those met with in recently citrated blood, were encountered. Specimens ofblood which had been preserved for two months were sent, I think, to Prof. L. E. Bayliss for examination : he wrote that these appeared to have developed an excess of a toxin of the histamine group, but that some histamine was present in all
citrated blood. For this reason, whole blood, uncitrated, and given via the paraffin-coated tube, was normally employed. I had records of over 400 cases thus transfused ; and have often felt that the credit of the introduction and spread of transfusion in the British Army was not given where it belongedviz., to Mr. D. W. Crile, nephew of his famous uncle, who popularised it in the base hospitals in the Etaples area as
early
as 1915. I am, Sir, yours
Sunderland, June 4th. DISEASES
OF
faithfully, W. GRANT WAUGH. WAUGI-1.
THE PERIPHERAL ARTERIES
To the Editor
of THE LANCET recent review SiR,-The (May 2nd, p. 1012) of my book, " The Diagnosis and Treatment of Diseases of the Peripheral Arteries," prompts me to offer the opinion that the reviewer has evidently been guilty of one or more amputations in thrombo-angiitis obliterans, which I so heartily condemn. My efforts to establish the conservative therapy of this disease in America have apparently not been felt in England as
yet.
However, having already successfully
over-
these stages of opposition in America, I feel sure that it will be only a matter of time when a conservative attitude toward these diseases will be forthcoming in our English colleagues. I am, Sir, yours faithfully, SAUL S. SAMUELS. New York, May 29th. **Our review questioned how far conservatism can be carried in the patient’s interests. The point at which severe suffering is best ended-even at the cost of a mutilating operation-must be left to individual judgment based on a knowledge of endresults. We hope Dr. Samuels will provide further information about the subsequent efficiency of the limbs he has saved from amputation.-ED. L. come
PUBLIC HEALTH The Cost of Syphilis in an Urban Community IN times of economic depression communities as well as individuals have to look to their bank balances and consider whether and where expenditure can be reduced, and whether the money they spend can be put to more effective use. The public health services are no exception to the rule, though it may be a difficult, if not impossible, task to measure their value to the community in terms of pounds, shillings, and pence, especially with regard to particular items : what does ill-health cost the community ? how much of it is preventable and at what expense’? One item in this account has been recently made the basis of a study1 carried out in Baltimore by Drs. W. C. Thompson, W. A. Brumfield, and Lucile Caldwell of the syphilis division of the medical clinic, Johns Hopkins Hospital. The authors’ object was to obtain an accurate estimate of the cost of syphilis in a representative American community, and to see whether the amount spent is adequate to deal with the existing problem, and so allocated as to provide " the combination of maximum benefit for the infected patient and maximum protection for the public health." The investigation was carried out by an analysis of the clinical records of hospitalised patients and by means of cost data of hospital treatment, ambulatory 1 Amer. Jour. Syph., May, 1936, p. 243.
and cost of drugs in 1933. Patients privately treated were ignored. In Baltimore, with a population of about 828,000, they report that some 9000 new syphilitic patients are discovered yearly, of whom about 4000 have early syphilis and 5000 have late syphilis. The total direct cost of that burden in 1933 they assess roughly at$170,000, or, in other words, each new syphilitic patient is responsible for the charitable expenditure of more than$18 per year. A study of the age-distribution of the hospital patients showed that nearly three-quarters of them were under the age of 50 ; as 74 per cent. of the hospital costs were for cardiovascular and neurosyphilis, which usually lead to prolonged invalidism, the authors conclude with reason that most of these patients, in the prime of life, are permanently removed from the possibility of self-support and form an annual charge. On the other hand the sum available for ambulatory clinics they regard as quite inadequate and for many patients they find no treatment at all is available. They urge that if that sum were substantially increased much of the cost of hospital care would be obviated, since the late sequelse of the disease would be prevented and fresh infections reduced. They thus reach the undeniable conclusion that " only by a reduction in the incidence of syphilis can the total expenditure be reduced," and the reasonable though, perhaps, less certain corollary that " only by the
clinics, serologic laboratories,
the year