Nephritis.—A single case of nephritis successfully treated by blood transfusion has been recorded by Ramsay. The patient, a man aged 22, had been ill for ten days. He was slightly drowsy and had a furred tongue. His systolic blood pressure was 100 mm. and diastolic 60. His urine had a specific gravity of 1010, and contained much albumin and many granular casts, but no blood cells. Vomiting was incessant. On the second day after admission he passed 2 ozs. of urine and his systolic blood pressure fell to 90 mm., his diastolic to 40 mm. His low blood pressure and the evident imminence of suppression of urine suggested the administration of blood; he was accordingly given 1,140 cc. of fresh blood. His blood pressure immediately rose to 100 mm. systolic, and 50 mm. diastolic, and the other symptoms abated. He passed 24 ozs. of urine during the ensuing twenty-four hours. He was afterwards treated with alkalies, intravenously and by the mouth, and his condition steadily improved. It cannot be inferred from the evidence that his recovery is to be attributed entirely to the transfusion, but it appears to have been initiated by this treatment, which was a reasonable one in view of the symptoms. No other similar cases have as yet been recorded.
Carbon Monoxide Poisoning.—In any condition in which the function of a large proportion of the red blood cells as oxygen carriers has been temporarily destroyed or impaired, it is a rational procedure to replace as many of them as possible with normal red cells. The evidence that transfused blood cells can carry out their functions in their new host has been given on another page. In carbon monoxide poisoning the oxyhæmoglobin has been converted into carboxyhæmoglobin, which is more stable than the oxygen compound, and therefore useless for purposes of respiratory exchange. Undoubtedly the ideal treatment for carbon monoxide poisoning is by putting the patient in a specially constructed chamber in which he can breathe oxygen under a pressure of about three atmospheres. By this means the carboxyhæmoglobin is dissociated and replaced by oxyhæmoglobin. An oxygen chamber is usually not available, though a very useful substitute may be tried in the shape of a Haldane’s oxygen mask. Failing this, there is evidence to show that a blood transfusion is an effective form of treatment. Nevertheless, although poisoning with coal gas is by no means a rare event, this treatment does not seem to have had the attention it undoubtedly deserves. Transfusion was first used for carbon monoxide poisoning by Hüter in 1870, who was able to record a case in which recovery appeared to have been due to the treatment. It was also advocated by Lauder Brunton in 1873. After this date recorded cases are few, but in 1916 Burmeister put this form of treatment on a more scientific basis by direct experiment. Using rabbits and dogs he showed that if the animals treated with coal gas were transfused without a venesection, 75 per cent. of them recovered. Of a series of control animals, which were not transfused, nearly all died.
Most writers on the subject have recommended that as much blood be taken from the patient by venesection as is to be replaced by transfusion. On theoretical grounds this seems to be sound, though it is not supported by the results of Burmeister’s experiments. Nevertheless, in a recent series of seven cases reported by Bruce Robertson, in which 1,000 cc. of blood were removed and the same amount given by transfusion, satisfactory results were obtained. If no venesection is done, there is some risk that the transfusion may put an additional load upon an already over-strained right heart, so that a preliminary venesection is certainly a wise precaution. Transfusion should not be withheld until the patient is in extremis; if no oxygen chamber is available, it should be given at once. A minimum amount of 750 cc. of blood should be taken by venesection, and 1,000 cc. of blood should be given. If the patient’s condition does not then show enough improvement, this should be repeated.
Nitrobenzol and Benzol Poisoning.—Blood transfusion for poisoning with nitro-benzol (C6H5NO2) has been recommended by Hindse-Nielsen, who records a case in which it was successfully employed. The patient, a girl of 19, had taken a tablespoonful of the poison several hours before, and her condition appeared to be hopeless. She was deeply cyanosed, the mucous membranes being of a dark blue colour. Washing out the stomach and inhalation of oxygen were tried without effect. Finally she was bled to the extent of 600 cc., and 1,000 cc. of citrated blood were injected. Her colour at once became more normal and recovery followed. The literature does not contain records of any other cases treated in this way, but the condition is analogous to coal-gas poisoning referred to in the last paragraph, oxyhæmoglobin being in this case replaced by methhæmoglobin, and its treatment by transfusion has, therefore, a rational basis.
A somewhat similar condition is seen in benzol poisoning, though there is an additional destruction of red blood cells. Three cases treated by transfusion have been reported by McClure. One patient, whose red blood cells had been reduced to 1,460,000 per cmm., was extremely ill, but recovered after five transfusions up to a total amount of 1,500 cc.
Diabetes.—Blood transfusion has been used in treating diabetes mellitus, but there is no evidence to show that it is of any service. Ottenberg and Libmann transfused four patients who were already in diabetic coma, but no improvement resulted. Another patient who was transfused by Raulston was actually made worse, as was indicated by an increased output of sugar, acetone, and ammonia compounds.
Pellagra.—The precise ætiology of pellagra being still unknown, treatment of the disease can only be empirical. From this point of view blood transfusion has been tried by Cole, who began using it in 1908. The results in twenty cases have been reported, and are distinctly encouraging. All the transfused patients were in the last stages of the disease, but nevertheless a recovery rate of 60 per cent. was obtained, the usual rate being 10 to 20 per cent. In the present state of knowledge comment is scarcely possible, but if pellagra is, as some observers have suggested, a “deficiency disease,” it may be supposed that the transfused blood provides a temporary supply of the substance that is lacking; the patient is thus enabled to start along the road to recovery.
CHAPTER IV
DANGERS OF BLOOD TRANSFUSION
Appreciation of the dangers attending the practice of blood transfusion has varied greatly at different times. In the seventeenth century a happy ignorance took no account of them whatever. In the eighteenth century they were so greatly feared that transfusion fell into abeyance. In the nineteenth century it was realized that dangers existed, but they were imperfectly understood; when fatalities occurred, a partial knowledge explained them away more easily than our fuller knowledge can to-day, so that transfusion was practised in spite of them. At the beginning of the twentieth century, with the discovery of “blood groups,” it was thought that all danger had been eliminated. At the present time the pendulum is swinging back again, and the problem of the complete elimination of danger is proving more complex than it was thought to be a few years ago.
The chief dangers of blood transfusion are two-fold—that of introducing into the recipient a disease carried by the donor, and that due to the inherent properties of the donor’s blood which may interact in a serious manner with the blood of the recipient. The first of these dangers is obvious, and common sense will suggest what steps should be taken to avoid it. Danger of communicating disease is almost restricted to conditions in which an infective agent is actually circulating in some form in the blood. Inquiry will usually be enough to establish the possible presence in the prospective donor’s blood of an organism such as the malaria parasite. Nevertheless, a case has been recorded by van Dijk, in which malaria was transmitted by injecting into a patient suffering from influenza some serum obtained from another patient who was supposed to be convalescent from influenza, but had been treated for malaria a few months earlier. Another case is reported by Bernheim, who transmitted a double infection of malaria—tertian and æstivo-autumnal—by means of a blood transfusion. Blood infections, such as those due to the exanthemata, may be avoided by the precaution of never employing a blood donor who shows any signs of present illness, even though a raised temperature be the only symptom. In certain cases, when, for instance, the prospective donor may be suffering from tuberculosis in some form or from gonorrhœa, the organism is extremely unlikely to be present in the blood in numbers sufficient to communicate disease. Nevertheless, on general principles, such donors should be eliminated if circumstances permit. The most subtle form of infection, the most dangerous, and the most difficult to eliminate, is syphilis. Definite cases have been recorded in which syphilis has been communicated by blood transfusion. In one instance recorded by Sydenstricker and by Bernheim a father was infected by blood taken from his son, who had refused beforehand to allow himself to be tested. Fortunately such occurrences are rare. Still rarer and still more curious is the transmission of horse asthma recorded by Ramirez. In this instance, in which the disease is to be regarded as a form of anaphylaxis, the patient had received an amount of serum sensitive to horse protein great enough to provide him with the corresponding symptoms for some time afterwards.