THERAPEUTIC VALUE OF DIRECT TRANSFUSION OF BLOOD IN DISEASES OF THE NEW-BORN

BY VICTOR D. LESPINASSE, M.D.

Instructor Genito-Urinary Surgery, Northwestern University Medical School, Chicago

THE disease in which results have been best has been in the socalled hemorrhagic diseases of the new-born, which, as you all know, are due to an infection which disturbs the liver function so that there is a diminution or even complete absence of prothrombin in the blood. Most of these cases are due to diminution of the prothrombin. A few are due to an excess of the antithrombin. The direct therapeutic indication is to replace the coagulating elements as well as the lost red blood-corpuscles. Of course, you all know that this has been done in a variety of ways, by the use of various sera and products of sera. That side of it we will not go into, but consider only the treatment of hemorrhagic disease by direct transfusion of blood. Technically, at the present time, direct transfusion of blood is comparatively easy. It can be done on any size babe that you would be likely to meet. The smallest one I have had was something over four pounds. Experimentally, in using a dead babe and a live dog, I have transfused a pound-and-a-half babe.

In these cases of hemorrhagic disease the transfusion of live, nonclotted blood will stop the hemorrhage in from one to three minutes. It may seem odd that a child losing blood will stop bleeding when more blood is transfused into its blood-vessels, but such is the fact, nevertheless. Just fill the child's circulating system with blood from the father, or anybody present, and the bleeding stops at once. So soon as the child receives this blood, the blood-vessels are filled with fresh blood and fresh complement, fresh antibody, and the entire content of the normal blood, so that when you are through with the transfusion the child's general condition is much better than if he had not had the hemorrhagic disease. These children are then vigorous. They can nurse at once, and they make rapid gains and hold the gains made.

How much blood is usually put into these babies? We do not

gauge the amount by any set volume or weight, but by the appearance of the babe. Just allow the blood to flow in until the babe is a nice red. If the flow is too fast, the babe becomes blue, first around the feet and hands, and then around the face and neck, but if you stop and give the circulation a chance to catch up, oxygenation takes place, and the child will soon become red. In the ideal cases, when you first see the child it is about the color of white paper; after the transfusion it has the color of a new-born baby or the red of an ordinary scarlet fever case; then the transfusion may be stopped. In weight they will have increased anywhere from three and one-half to fifteen ounces. It may seem strange to you that you can put fifteen ounces of blood into an eight-pound baby, but I did it in one case. In this case the conditions were ideal, I had an excellent anastomosis, the veins were small, and the blood flowed for fifteen minutes.

To verify these weights, I took a seven-and-a-half-pound dog and put the blood of a fifteen-pound dog into him without removing any of the small dog's own blood. The only effect noted was an increase in vigor.

As to the advisability of using this large amount, there may be some question, but you can fill these patients up carefully until they are a good pink, anyway.

My experience with hemorrhagic disease of the new-born includes eighteen cases, and among those were two syphilitic children, both of whom subsequently died. The others all recovered. There was only one with any other complication, and that was a case of Drs. Dwan and Krost, who made a diagnosis of spasmodic pyloric stenosis. The child was three or four days old, and had not retained anything from birth. The peristaltic waves could be seen. The plan was this: The baby was to be transfused to stop the bleeding and also to fortify it for the gastro-enterostomy that was contemplated. What happened was this: The child was transfused, using the father as a donor, and the spasm disappeared. Whether there was any relation between the transfusion and the disappearance of the spasm, I do not know. At least, the spasm was relieved immediately, and, in my opinion, direct transfusion of blood is worthy of a trial. We know that some spasms are due to intestinal intoxication, and so soon as the bowel is cleared out the spasms disappear.

One of the older treatments of conditions of intoxication was

bleeding to remove this intoxication. If these patients are bled, and then the lost blood replaced by normal blood, results should be better, as more blood can be removed than if you did not attempt to replace it, and in babies especially you can even remove all the blood. It is possible in babies to remove absolutely every particle of blood from the baby's circulation and replace it by normal blood from its father. This is not possible in adults, because we would not have enough blood to replace the blood taken. A normal baby, weighing ten pounds, has approximately an ounce of blood to a pound of weight-to-wit, ten to twelve ounces. The ordinary adult may lose that amount and never miss it. This idea occurred to me at the bedside of a week-old baby who had a very intense jaundice, with high temperature, but the people asked me what I could promise, and I said nothing, so they refused to have it done. I contemplated bleeding that baby to the maximum, filling it up, then bleeding it again, and my idea was to do that three times, so as to get rid of as nearly all the toxic blood as possible, leaving the babe's circulation filled with the normal blood of its father.

In acute nephritis cases, in severe intoxications of pneumonia, typhoid, scarlet fever, and diarrhea, or any of the many infections, I think that it is worth while considering this treatment, at least, and in appropriate cases the use of massive bleeding, followed by direct transfusion of blood and removing the infectious body, as described, will prove beneficial. This probably is not as simple as it might seem, from a mechanical standpoint. The toxins and drugs do not always remain in the blood stream. They become bound by certain tissues, in a good deal the same way that tetanus antitoxin becomes bound by the nerves and spinal-cord tissues, so that after a certain time they are not removable.

Another condition where direct transfusion of blood is going to save some lives—a few, of course, but they are well worth saving— is in congenital stenosis of the bile ducts. Post-mortem, there are probably somewhere between twenty to thirty per cent. of these cases in which the defect in the bile-ducts is remediable by operation.

In Boston, some years ago, they tried to operate in these cases, but they died of hemorrhage. That was before the transfusion technic was worked out as well as it is to-day. At the present time the hemorrhage can be controlled absolutely. The transfusion in these cases,

without operation on the bile-ducts, is of only temporary avail. The probable life of the blood transfused is approximately a week. So in any condition like obstruction to the bile-ducts, or of an infection of severe type, like the purpuras, if the patient does not get well in a week he will have a recurrence of the bleeding. Whether that is the individual life of the red blood-corpuscle in health, we do not know, but that has been the experience of several men, particularly Duke, in Boston, who worked up the subject of transfusion in purpuras, and he found that if the temperature did not go down in a week the bleeding recurred, usually preceded by a diminution of the bloodplatelets.

In summing up, I would like to call your attention to the fact that direct transfusion of blood is not a destructive, but a constructive, operation. It is never too late to transfuse; the patient is never too sick. The baby can always stand the transfusion. Transfusion is not a knock; it is a boost. One of the bleeding babies we had here was in such a condition that we could not hear the heart for some minutes before the blood was transfused; that baby is alive and well to-day, about three years after the operation.

First.-Transfusion will save the most desperate cases.

Second. It is worth while to use direct transfusion of blood in cases of obscure spasms, like spasmodic pyloric stenosis.

Third.-In severe infectious cases, scarlet fever, pneumonia, typhoid, a preliminary massive bleeding followed by direct transfusion of blood is of great value.

MASSAGE IN THE TREATMENT OF DISEASES OF THE

BILE PASSAGES, PANCREAS, AND

VERMIFORM APPENDIX

BY GEORGE EDWARD BARNES, B.A., M.D.
Herkimer, New York

As You read the title of this paper, have you an idea that its contents must be a phantom? I assure you that it is a very real thing, and hope that you will join the circle for its consideration, bringing with you your intelligent and active, but kind, scientific judgment. The study of diseases of the upper abdomen is, comparatively, still a recent thing, and even the small coterie of eminent men who have thus far contributed knowledge thereon would quickly admit that more still remains, and perhaps always will remain, to be known. In introducing massage in the treatment of diseases of the bile passages, pancreas, and vermiform appendix I wish to request that the subject be regarded not from the standpoint of the surgeon nor from the standpoint of the physician, but rather from the broad standpoint of a single medical science. Both physicians and surgeons will doubtless find this method of treatment a boon to their patients and to themselves. I hope that every member of the profession who has these cases to treat will assist in establishing definite indications and limitations for this method more fully than I can do at this time.

You are probably wondering how the hand can be applied to the bile passages for their treatment. Biliary massage is effected not by the hand alone, but by a physical manœuvre on the part of the patient. The proceeding must be taught to the patient so that he can perform it alone or with assistance. The patient lies down on the back. The thighs are raised with legs flexed on them. The legs may be crossed at the ankles to give them stiffer support. By drawing up the thighs intra-abdominal pressure is increased by the contraction of the muscles of the anterior abdominal wall, by the tilting upward of the pelvis, and slightly by the pressure of the thighs against the abdominal wall. The right hand is placed with the palmar surface of its base over the region of the gall-bladder which lies just below the costal cartilage of the ninth right rib. The left hand is placed on the right hand to reinforce its action. The lungs are filled by a deep inspiration. The

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