Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 136

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

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Chabrol 18 reports the successful serum treatment of a ci- of rheumatic purpura accompanied by intestinal hemorrha: which resisted ordinary treatment, calcium chloride, gelsti: ergot, etc. He gave daily injections of 10 cc. diptheria az .: toxin subcutaneously for five days.

Bigelow 1º reports successful treatment of three cases hemorrhagic disease of the new-born. He states that two of > cases were moribund when treatment was instituted, calice lactate and epinephrinehaving been tried without benefit. To: hemorrhages ceased after subcutaneous injections of 5 # fresh rabbit serum.

Busse 20 reports the use of fresh human serum in the trez- ment of 10 cases of uterine hemorrhage. The dose emple?" was 10 cc. injected intragluteally. Five of his cases he :: garded cured, four were still under treatment at the time his report.

A smaller number of reports have appeared in which the value of serum injections in hemorrhagic disease is dendel The authors of these reports usually advocate the use of jections of defibrinated blood instead of serum or else ti direct transfusion of human blood. Thus Schwartz and Otter- berg 21 report the case of a child 11 days old with mekra hematemesis, hemorrhages from the nose and mouth, icters and ecchymoses. One injection of horse serum (not fre).

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But to have immediately stopped. After some days, how- , bleeding recurred and the patient died.

rosenthal 22 reports a case of melena neonatorum cured by ct transfusion.

wain, Jackson and Murphy 28 report a case of melena latorum unbenefited by 75 cc. of fresh rabbit serum sub- neously and an injection of diphtheria antitoxin. Direct sfusion from the child's father was followed by complete ition of the hemorrhage.

ambert 24 reports a case of melena neonatorum in which sfusion was performed after the hemorrhage had been g on for three days and the child was in a dying condi- An immediate and permanent cure is said to have re- d.

urphy 23 reports the case of a woman 48 years old, who for 'ears suffered attacks of abdominal pain, jaundice, clay 'ed stools and finally a very severe attack accompanied by orrhages from the nose and rectum. Injection of 30 cc. serum was without effect. Injection of 30 cc. fresh rabbit m seemed to control the hemorrhages to a degree, but still bleeding continued to an alarming extent. Coagulation

13 minutes (Brodie-Russell). The patient was then sfused, her husband being the donor. Twelve hours after sfusion the coagulation time was 3-4 minutes and on the wing day the patient was successfully operated on for stones, and was cured.

uke 26 considers that the tendency to uncontrollable bleed- in at least some of the hemorrhagic diseases is due to a nished number or to an absence of blood platelets. He fore advocates transfusion as the only means of supply- he deficit and reports several cases which he considers to been greatly benefitted by this procedure.

'om this review of the literature, which is by no means lete, it is apparent that any treatment of these alarming oftentimes dangerous conditions can be only empirical, the cause of the disorder is determined. Meanwhile the f serum injections, the injections of defibrinated blood, direct transfusion seem to have yielded better results any other measures. As to the choice between these procedures, doubtless direct transfusion would be the method were it not for the technical difficulties.

to the intravenous introduction of defibrinated blood or ¡n serum, one perhaps must feel some apprehension of er, but the condition to be combated is a dangerous one ustifies, in the present state of our knowledge, the risk ay run in carrying out these procedures. Moreover, tically the danger from agglutination in transfusion is ps as great as the danger from thrombosis or hemolysis, ing the injection of defibrinated blood or foreign serum. ' as we are aware no untoward results of a serious nature been reported to follow the latter two measures. Finally, it may be true that certain of the hemorrhagic diseases d upon a lack of blood platelets and that this deficit can be supplied by direct transfusion, still it is more prob-

on their disintegration. These products are doubtless fur- nished just as well in serum or defibrinated blood as in the whole blood. It would seem that injections of serum or of defibrinated blood would answer as well as direct transfusion in all cases except those-if clinically there are such-which depend upon a lack of fibrinogen.

A consideration of great practical importance is, that in the case of injections of serum or of defibrinated blood one knows certainly that he gets the injection into the patient and one can accurately gauge the amount introduced, while in trans- fusion, except in the hands of an expert surgeon, there is much uncertainty of transferring any blood at all, and in no case can the amount transferred be satisfactorily determined.

Our series consists of six cases admitted to the wards of the Johns Hopkins Hospital .* The number is small and no con- clusions should be drawn from them, but the results were so encouraging that the method seems to deserve further con- sideration.

In every case the serum or defibrinated blood was used within 2-3 hours after it was drawn, except in Case 4 where normal horse serum was used.

CASE 1 .- Typhoid Fever. Male, age 31, black, single, laborer. Admitted August 6, 1910.

Complaint: Headache and pain in back.

Family History: Not important.

Past History: Measles at 21; hard work as laborer; alcohol, weekly sprees.

Present Illness: Onset two weeks before admission,-headache and fever, also diarrhea.

Physical Examination :. Well-nourished, muscular man. Tongue coated; general glandular enlargement; spleen palpable; sputum contained some blood clots. Hæmoglobin 100 per cent.

.August 17: Bleeding from gums. Silver nitrate adrenalin chloride and calcium lactate without effect.

August 18: Ecchymoses appeared on conjunctiva and purpuric spots on abdomen. Hematuria. Red blood cells 2,912,000. Hæmoglobin 80 per cent.

August 19: Feces continue to contain blood; 13 cc. defibrinated human blood injected intravenously, followed by headache and restlessness.

August 20: 13 cc. defibrinated human blood, intravenously.

August 21: 17 cc. defibrinated human blood, intravenously.

August 22: 12 cc. defibrinated human blood, intravenously.

Following these injections the bleeding seemed less profuse but the blood count continued to fall and showed on the latter date, red blood cells 1,448,000. Hæmoglobin, 35 per cent.

August 23: In view of patient's desperate condition, 320 cc. of defibrinated human blood from a case of polycythemia was given intravenously. This was followed by headache, chill, extreme abdominal pain and rapid pulse.

August 24: Red blood cells 2,880,000. Hæmoglobin 40 per cent. Patient feeling much better but still slight oozing from gums and blood in his stools. 250 cc. defibrinated human blood was in- jected intravenously, followed by severe shaking chill with eleva- tion of temperature and pulse.

August 26: 20 cc. defibrinated human blood intravenously.

August 27: 200 cc. defibrinated human blood intravenously.

* We are indebted to Drs. Halsted, Barker and Thayer for per- mission to report these cases.

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This injection was well borne, there being no chill or elevation of temperature after it. From this date convalescence was rapid, and no further hemorrhages occurred.

September 26: Red blood cells 3,344,000. Hæmoglobin 72 per cent. Patient discharged well.

In this case two serious conditions presented themselves, one resulting from the other; persistent hemorrhage and grave anemia. Large injections of defibrinated blood were used in this case rather than small injections of serum with the hope that the fibrin ferment introduced would check the hemorrhages and that the foreign red blood cells might con- tinue their normal function in our patient and thereby re- lieve his anemia. The blood counts before and after the first large injection of defibrinated blood seem to indicate that this hope was realized.

It was considered by all those who observed this case that the injections of defibrinated blood exerted a favorable in- fluence and were perhaps the means of preventing a fatal issue.

CASE 2 .- Chronic Nephritis, Myocarditis, Uremia. Male, white, aged 43, married, lumber merchant. Admitted October 13, 1910. Complaint: Weakness, stupor and sour stomach.

Family History: Father dead, aged 73, heart trouble; mother, four brothers and one sister, living and well. Three sisters died of tuberculosis about 25 years ago. Married seven years, no children.

Past History: Whooping cough at 14, measles and gonorrhea at 17. At 36 a diagnosis of tuberculosis was made; patient later was pronounced cured. Malaria at 41. Patient has used alcohol and tobacco until recently, two cigars and two or three drinks daily. Has done hard physical work with much exposure all his life.

Present Illness: Onset six months ago. Started with feeling of weakness, dullness and headache. Within twenty-four hours vomiting, delirium, convulsions. After two weeks patient was well enough to return to work, and kept about his business until one week before admission to the hospital. At this time (Octo- ber 4) again had headache, vomiting and convulsions. Since the first admission, six months ago, patient states that he has been subject to headache, increased urination, dyspnœa, œdema of ankles and impairment of vision.

Physical Examination: Sparely nourished man, dull, urinous odor to breath, vision impaired. Systolic murmur at apex and over body of heart, transmitted to axilla. Well marked arterio- sclerosis.

October 14: Red blood cells 3,100,000. White blood cells 16,800. Hæmoglobin 50 per cent.

October 15: Five hemorrhages from bowels; prior to this date stools contained no blood.

October 16: Five hemorrhages from bowels. Following the last hemorrhage 30 cc. of fresh rabbit serum was injected subcuta- neously into the thighs. Following this injection, there was no further bleeding.

October 17: Red blood cells 1,700,000.

October 20: Patient sank into a deep coma and died.

Although this patient died, it is to be noted that there was an interval of four days between the injection of serum and death, during which no hemorrhage occurred.

CASE 3 .- Cirrhosis of Liver (atrophic) and Hematemesis. Male, white, aged 52, married, banker. Admitted October 19, 1910. Complaint: Weakness, swelling of feet, and vomiting of blood in February, 1910.

Family History: Not important.

Past History: Measles as a child, typhoid at 37, recovery g Very closely confined to business, takes little exercise: 6: cigars daily. Hearty eater. No alcohol. Constipation ! two years.

Present Illness: Eight months ago, when as well x was taken suddenly with a feeling of weakness and roste blood, passing considerable amount of blackish material fre ; rectum. Remained at home for one week and was in hospt. three weeks. Shortly after returning to business was const and had a fecal impaction removed by physician, after wtf a time he enjoyed a feeling of perfect health. Several prior to his present hospital admission he had an attack digestion accompanied by dizziness and vomiting at inter: six or eight hours. Vomitus was at first blood stained.

Physical Examination: Large fleshy man, pale, skin d. yellow, heart enlarged, loud systolic blow over precordin: in axilla. Red blood cells 1,846,000. White blood celsi Hæmoglobin 39 per cent.

November 2: Patient suffered three attacks of hematare was given morphine and calcium lactate.

November 3: Three attacks of hematemesis, vomiting ayr mately one liter of blood. Following the last hematemesis; of fresh rabbit serum was injected subcutaneously.

November 4: Gradual onset of weakness, unconsciousnes. L death.

There was no further evidence of hemorrhage after the. ministration of serum, but at autopsy the stomach was k= to contain a large amount of dark blood.

CASE 4 .- Chronic Pancreatitis, Jaundice, Exploratory Lax omy, Drainage of Gall Bladder. Male, white, aged 30, Admitted to hospital October 20, 1910. Complaint: Sick stomach and jaundice.

Family History: Not important.

Past History: Generally healthy; measles in childhood. Present Illness: Onset, according to patient, ten years ago. ! this time he had pain in the right kidney region after any rke exercise and associated with this was severe pain in the right 13 Four years prior to admission had attack of severe abdon' pain, accompanied by nausea but no vomiting. These atum recurred at intervals for two years; jaundice for the past year

Physical Examination: Negative except for jaundice.

October 26. Exploratory operation for obstructive jamdi: Chronic pancreatitis was found, the head of the pancreas obstre: ing the common duct. Drainage of gall bladder, no stones.

November 7: Eleven days after operation, patient began b bleed from the wound in the abdominal wall. Hemorrhage cock not be controlled by the ordinary means. 20 cc. of normal bors serum (less than one month old) was injected intravenously. fs- lowed by chill and sharp elevation of temperature. There was no further hemorrhage, however, and patient subsequently mal- a satisfactory recovery from his operation.

This is perhaps the most striking case in the series. I .: extremely obstinate nature of the hemorrhages in jaundi- Gases is well known and so alarmed were the surgeons :x charge of this patient that they were unwilling that he shon.3 wait the two or three hours necessary for obtaining perfect! fresh rabit serum.

The hemorrhage ceased after a single injection of normal horse serum and it seems justifiable perhaps to believe that the serum stood in a causative relation to this result.

CASE 5 .- Typhoid Fever. Male, white, aged 17, single. 43 mitted to the hospital November 12, 1910.

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V Trwtory. Always healthy. Seven months prior to admis- operation for appendicitis.

bansent Illness: Began six weeks before admission; headache, teda; and anorexia.

"¿ ysical Examination: Sparely developed and undernourished, ara.le coated. Spleen palpable and soft. Rose spots present.

[ .. . od culture B. typhosus.) Red blood cells 4,900,000. White 15.I cells 6000. Hæmoglobin 75 per cent.

vember 16: Red blood cells 4,600,000. White blood cells Hæmoglobin 63 per cent.

vember 23. Intestinal hemorrhages aggregating approxi-

4 ly 1750 cc.

ovember 25: 15 cc. fresh rabbit serum intravenously. Since there have been no further hemorrhages.

ASE 6 .- Typhoid Fever. Male, white, aged 21, single. Ad- ed to hospital on October 4, 1910.

complaint: Headache.

Imily History: Not important.

:ist History: Mumps with double orchitis, measles; otitis ural times five years ago. Gonorrhea one year ago. Tobacco : alcohol very rarely. Works in open air, exposed to weather. resent Illness: Onset, with drowsiness ten days before admis- 1; six days before admission pain in stomach, headache, sore- s in legs, feverish, anorexia, cough and diarrhea.

'hysical Examination: Well nourished man, tongue coated, pable spleen, rose spots. Red blood cells 6,148,000. White od cells 5080. Hæmoglobin 98 per cent.

ctober 11: There were four intestinal hemorrhages, aggre- ng about 500 cc:

ctober 14: Hemorrhages continued and it is estimated that total loss of blood amounts to approximately 2000 cc. On date patient received 30 cc. of fresh rabbit serum, subcu- tously.

ctober 15-6 a. m .: About 75 cc. of blood was passed from um, but the patient's condition was much improved. 11 a. m, c. fresh rabbit serum injected subcutaneously. 8 p. m., about cc. of dark blood was passed from rectum. Following this e was no further hemorrhage, but on October 19, patient ved signs of perforation and at operation an opening was d in the ileum through which fecal matter exuded.

tober 23: Patient died of acute broncho-pneumonia.

this case on the day following the first injection of serum e was approximately 175 cc. dark blood passed per rectum. possible that this was blood which had been shed into the stine before the serum injection. The subsequent per- tion (four days after) and death (eight days later) of the ent does not detract from the idea that the serum in- ons were successful in combating the hemorrhages.

he series of cases here reported is small and in several in- ces a fatal termination ensued, but it is to be remembered the serum injections were not given in the hope of curing oid fever, nephritis, cirrhosis of the liver, etc., but to com- the hemorrhage which was associated with these condi- ;. If the hemorrhage was stopped by the use of serum :tions, even though the patient eventually died, our hopes fulfilled.

our present state of knowledge, or lack of knowledge, erning the causes of hemorrhages in these various condi- , the treatment is necessarily empirical. The most plausi- xplanation of any good which injections of serum or de-

Muuuu tuto the Circulation.

Since it is known that fibrin ferment (thrombin) readily passes over into an inactive form (meta-thrombin) on stand- ing, it seems advisable to use serum or defibrinated blood as fresh as possible.

We have used rabit serum because it is easily obtained in a fresh condition, is but slightly, if at all, toxic for human be- ings, and if sensitization of the patient follows, the danger is not very great, since it is unlikely that subsequent administra- tions of rabbit serum would take place.

If horse serum is used one has to consider very carefully if the patient may not have been sensitized by a previous in- jection of antitoxin (horse serum) or may not be sensitized to a subsequent injection of antitoxin.

As to choice of methods, it seems advisable to inject directly into the circulation, although in so doing the possibility of causing intravascular clotting must be borne in mind.

If the patient has already been rendered anemic by serious hemorrhage, injection of large amounts of defibrinated blood directly into the circulation may not only check the hemorrhage but combat the anemia. With this end in view human blood should be used, since the red cells from one species cannot functionate in a different species, and it is likely that they would be quickly hemolyzed and give rise to toxic symptoms. In order to insure the best chance of success the donor should be a person from the same group (according to the isoagglu- tination reaction)" as that to which the patient belongs, thus avoiding possible danger from isoagglutination and isohemo- lysis.

In view of the unsatisfactory results attending the use of the ordinary methods of treating the hemorrhage in these con- ditions and the encouraging results from injections of serum and defibrinated blood reported here and elsewhere, we be- lieve the later procedures are deserving of a more extensive trial.

REFERENCES.

1. Howell: The preparation and properties of thrombin, etc Am. J. Physiol., 1910, XXVI, 453.

2. Morawitz and Lossen: Ueber Hamophilie. Arch. f. klin. Med., 1908, XCIV, 110.

3. Weil: L'hémophilie, pathogenie et serotherapie. Presse med., 1905, XIII, 673.

4. Weil: Etude du sang chez les hemophiles. Bull. et mem. Soc. med. d. hôp. de Paris, 1906, XXIII, 1001.

5. Weil: Recherches cliniques et physiopathologiques sur l'hemo- philie d'après six cas. Tribune med., 1906, 678.

6. Weil: L'hemostase chez les hemophiles. Rev. pract. d'obst. et de pædiat., 1907, XX, 65.

7. Weil: Des injections de sérums sanguins frais dans les états hémorragipares. Tribune méd., 1907, 21.

8. Weil and Boye: Essais de prévention et de correction de l'incoagulabilité hirudinique du sang chez le lapin. Compt. rend. Soc. de biol., 1909, 192.

9. Weil and Boye: Action des extraits d'organes sur le sang des hemophiles. Compt. rend. Soc. de biol., 1907, LXI,' 454.

10. Eliçagaray: Des injections de sérums sanguins frais dans les états hémorragipares. Thèse de Paris, 1907.

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JOHNS HOPKINS HOSPITAL BULLETIN.

11. Baum: Der Wert der Serumbehandlung bei Hamophilie auf Grund experimenteller und klinischer Untersuchungen. Mitth. a. d. Grenzgeb. der Med. u. Chir., 1909, XX, 1.

12. Trembur: Serumbehandlung bel Hamophilie. Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1909, XX, 813.

13. Lommel: Ueber Blutstillung mittels Serum bei Hamophilie. Centralbl. f. inn. Med., 1908, XXIX, 677.

14. Class: Serum therapy in purpura hemorrhagica. Arch. Int. Med., 1909, VI, 170.

15. Leary: The use of fresh animal sera in hemorrhagic condi- tions. Bost. M. & S. J., 1908, CLIX, 73.

16. Welch: Normal human blood serum as a curative agent in hemophilia neonatorum. Am. J. Med. Sc., 1910, CXXXIX, 800.

17. Schockaert: Hémostase par le sérum sanguin. Rev. med. de Louvain, 1910, 58.

18. Chabrol: Purpura rhumatoide avec hémorragies intestinales, traitées par des injections de sérum antidiphtherique. Bull. et mém. Soc. de méd. de Vancluse, 1910, VI, 345.

19. Bigelow: Serum treatment of hemorrhagic disease ds new-born. J. Am. M. Ass., 1910, LV, 400.

20. Busse: Die Behandlung von Gebärmutterblutungen nte rum. Centralbl. f. Gynaek., 1909, XXX,1 236.

21. Schwartz and Ottenberg: The hemorrhagic disease of the LA born, with special reference to blood coagulation and sex treatment. Am. J. Med. Sc., 1910, CLX, 17.

22. Mosenthal: Transfusion as a cure for melena neoarra J. Am. M. Ass., 1910, LIV, 1613.

23. Swain, Jackson and Murphy: A case of hemorrhagic deal in the new-born, with direct transfusion. Bost. M. LE. 1909, CLXI, 407.

24. Lambert: Melena neonatorum with report of a case cured; transfusion. Med. Rec., 1908, LXXIII, 885.

25. Murphy: Hemorrhage in jaundice controlled by blood ta fusion. Bost. M. & S. J., 1908, CLIX, 865.

26. Duke: The relation of blood-platelets to hemorrhagic disea J. Am. M. Ass., 1910, LV, 1185.

27. Moss: Studies on isoagglutinins and isohemolysing li Hopkins Hosp. Bull., 1910, XXI, 63.

CONCERNING THE MUCH-HOLZMANN REACTION.

By W. L. Moss, M. D., Associate in Medicine, Johns Hopkins University, AND F. M. BARNES, JR., M. D., Government Hospital for the Insane, Washington, D. C.

(From the Research Laboratory, The Phipps Tuberculosis Dispensary, The Johns Hopkins Hospital.)

Based upon the investigation of a considerable series of cases Much & Holzmann 1 proposed a biological test for the diagnosis of certain forms of insanity (dementia precox and maniacal depressive insanity) which they designate as the " psycho-reaction."

The reaction consists, according to the originators, in the ability of the serum from patients suffering from the two forms of insanity mentioned, to inhibit the hemolysis of normal red blood cells by cobra-venom; the serum from patients with other forms of insanity (epilepsy with circular disturbances excepted) and from normal individuals having no such action.

The authors carried out the test on the serum of 400 in- dividuals and state that 100 per cent of all cases in which a diagnosis of dementia precox or maniacal depressive insanity could be established with certainty, gave a positive "psycho- reaction."

Much ' reports the results of his investigation on additional cases, confirming his previous claims and considers the reac- tion dependent upon a quantitative or qualitative disturbance in the cholesterin content of the serum, due to altered me- tabolism indicating an inherited predisposition.

Bauer' objects to the term "psycho-reaction," as he does not consider the reaction a specific one.

He investigated the action of the serum from umbilical cord blood in 17 cases and found, that in the presence of 14 of these, no hemolysis of red corpuscles by cobra-venom took place, while in one case, only a trace of hemolysis occurred, and in the other two cases the hemolysis was partial.

In the presence of the serum of 16 older children : adults, the hemolysis was either partial or complete in es case; while in the presence of the serum of nine nursings fants no hemolysis occurred in one case, and was either px". or complete in the remaining eight.

Bauer thinks that the explantion of these results ist: sought in a paucity of activating lipoids in the serum haps lecithin) rather, than in an increase of inhibiting Es stances (cholesterin).

Huebner and Selter,“ using the same technic as Much Holzmann, state the following results, which were the outes of experiments with 82 cases of dementia precox, manisai. pressive insanity and other types of functional and orze psychoses and neuroses.

1. The cobra-venom reaction was found not only in ca of maniacal depressive insanity and dementia precor, also in many other diseases, psychoses as well as neuroses . organic brain and spinal cord diseases.

2. The reaction was positive in less than 50 per cent e': positively diagnosed cases of maniacal depressive insanity : dementia precox.

Hirschl and Potzl " found in a number of cases of the be phrenic and catatonic forms of dementia precox, an incre- resistance of the erythrocytes and an increased inhis t- action of the serum against cobra-venom hemolysis. I. reserve their opinion as to the clinical value of the test.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 136

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189