The amount of blood to be transfused in hæmophilia will vary with the age of the patient and according to whether he is suffering from acute anæmia or not. If hæmostatic effects only are wanted, 100 cc. of blood will be enough. If anæmia is also present, the dosage will be governed by the same considerations as have already been discussed in the section on the treatment of hæmorrhage.
Melæna Neonatorum.—Another hæmorrhagic condition in which blood transfusion is of the very greatest value is that known as melæna neonatorum. Severe hæmorrhage takes place from the bowel of an infant, sometimes only a few hours after birth. The cause is quite unknown, but it is found that absolute hæmostasis is usually brought about by blood transfusion. Horse serum has often been successfully used as in treating hæmophilia, but blood transfusion again has the additional merit that the blood which has been lost is thereby replaced. A single transfusion is usually enough, as the hæmorrhage does not tend to recur when once it has been stopped. For a newly born infant, even if in extremis, only a small quantity of blood is needed, so that a transfusion of 50 to 100 cc. is usually found to be enough. Bruce Robertson suggests that, as a good working rule, the amount should not exceed 15 ccm. per pound of body weight. The superficial veins of an infant are exceedingly small, so that the introduction even of a fine needle into the median basilic may be matter of the greatest difficulty. The best method of transfusing an infant, therefore, demands special consideration. A description of this will be found on p. 134 of the present work.
The value of transfusion for melæna neonatorum has not been very generally recognized, but a number of striking cases have been reported. Defibrinated blood had been used in 1873 by Sir Thomas Smith as described in Chapter I, but the first case in which whole blood was used was published by Lambert in 1908. Later, in 1910, Welch, and then Schloss, recommended the subcutaneous injection of serum or of blood, but these measures were clearly not so effective as the intravenous transfusion of blood, as has been testified by numerous observers (Lespinasse, Unger, Vincent, Graham, Bruce Robertson, Lapage, Hutchinson, etc.). The patients may be actually moribund, for a new-born infant can only afford to lose a relatively small amount of blood, but even then transfusion is often successful. Bruce Robertson reports that of a series of forty cases of hæmorrhagic disease of the new-born which were treated by transfusion, all recovered except four; of these two died from associated umbilical sepsis, one from intracranial hæmorrhage, and the fourth had already ceased breathing when the treatment was begun.
It has sometimes been stated that for transfusing an infant either parent can be safely used as blood donor, on the assumption that the serum reactions are not yet developed. This may sometimes be true, but the fallacies and possible dangers of this are explained in a later chapter.
A case was recently reported by R. D. Laurie, who, knowing that he himself belonged to Group IV, drew 20 ccm. of his own blood into a syringe containing five grains of sodium citrate in solution. This he injected into a vein in the infant’s arm; the small size of the vein he had chosen made this difficult, but the treatment resulted in the rapid recovery of the patient.
Purpura.—Of all the forms of hæmorrhagic diseases, the two already described, hæmophilia and melæna neonatorum, are the only ones for which blood transfusion is a really effective remedy. It is probable that under the somewhat general term “purpura hæmorrhagica” are grouped several conditions, all of very obscure origin, none of which are conspicuously benefited by transfusion. Many transfusions have been given for purpuric symptoms, chiefly in America. Several cases are reported by Bernheim, and twelve transfusions were given to seven patients by Peterson. In some of these the treatment produced a temporary improvement, but usually they relapsed after an interval of a few months. One of Bernheim’s patients appears to have owed his life for the time being to a transfusion, but he died subsequently during a recurrence. Two cases are reported by Graham. One was not benefited at all; the other improved for a time, but afterwards relapsed. In a serious case, therefore, transfusion may be worth trying; it has indeed been stated by Ottenberg and Libmann, observers with a wide experience of transfusion, that this treatment is “definitely curative” in severe cases of purpura. At the present time there is little to add on the subject, but it is possible that further advances will be made by proceeding on these lines.
Blood Diseases
Pernicious Anæmia.—Blood transfusion has been advocated for several conditions characterized by alterations in the cells of the patient’s blood. It has been used in the treatment of aplastic anæmia, splenic anæmia, chlorosis, and leukæmia, but in none of these diseases has it been of much avail. In pernicious anæmia, however, transfusion has proved to be of very great service.
It is, indeed, now a recognized form of treatment for this disease, though the numerous reports upon results that have been published have not pronounced unanimously in its favour. Variability in results probably depends to some extent upon the difficulty of distinguishing true pernicious anæmia from some forms of secondary anæmia. It is hardly to be expected that much benefit would follow blood transfusion in the undiagnosed secondary type, since the destruction or loss of corpuscles is continuous until the cause has been removed. In true pernicious anæmia, on the other hand, there may be remissions in the disease, and it is quite clear that these may be initiated or prolonged by blood transfusion. The largest number of consecutive cases that has been recorded was treated in the Mayo Clinic in the years 1915 to 1918 (Archibald, Pemberton, Hunt). It was estimated that in about 60 per cent. of the patients with pernicious anæmia a definite improvement followed transfusion. It is generally agreed that the best results are seen in those who have not yet reached the last stages of the disease, though sometimes patients who are actually in extremis will also show great improvement. A remarkable instance of this has been reported in Norway (261). A man, aged thirty-three, was dyspnœic, semi-conscious, and moribund when admitted to hospital. His red cells numbered 850,000 per cmm., and his hæmoglobin percentage was 19. Immediate improvement followed the transfusion of 900 cc. of citrated blood, the red cells rising quickly to 2,000,000 and later to 3,000,000. Twelve days after admission he was walking about. No case must therefore be regarded as hopeless, though disappointments must be expected.
As a general rule blood transfusion should be given before the more serious secondary manifestations of the disease have shown themselves, that is to say, some time before the condition has become dangerous to life. Probably the disappointing results of this treatment have partly been due to the fact that it has been regarded as a last resort and has often been given at too late a stage. No rule can be laid down as to when transfusion should be given, but common sense suggests that it should be tried as soon as it is evident that the disease is progressing in spite of other methods of treatment. One authority (Anders) even advises that transfusions should be given as soon as an assured diagnosis has been made, but he weakens his case by adding that other methods of treatment should be used at the same time. If the patient is already seriously ill when first seen, the blood transfusion should be tried at once, as its effect, if beneficial, is likely to be more rapid than that of any other form of treatment.