NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
A dissolution of the leucocytes has also been recorded. Duodenal ulcer asso-
ciated with burns has been suspected by Hunter (68) to be caused by the secretion
of toxic substances in the bile as a direct result of the absorption of damaged
blood and tissue cells.
Hæmoglobinuria following transfusion is a well known condition. Diseases
in which hæmoglobinuria occasionally occurs are syphilis, septicæmia, yellow
fever, malignant jaundice, enteric fever, scarlet fever, typhus fever, variola, scurvy,
epidemic hæmoglobinuria of new born infants ; and a few cases have been record-
ed as having been met with in association with influenza, leucocythæmia, pernicious
anæmia, and Wenkel's disease. Other conditions in which it has been known
to occur are sunstroke, exposure to excessive cold, and to the X rays. A condition
of considerable interest, of which unfortunately but little is known, is hæmoglobi-
nuria of horses. This disease, which is only met with in well bred animals, appears
to result largely as the result of rich diet with insufficient excercise. It occurs
when horses that have been stabled for some time are exposed somewhat suddenly
to fatigue. The hæmoglobinuria is associated with congestion and rigidity of the
muscles, especially of those of the hind quarters. Lucet (6) believes the condition to
be a kidney lesion, but there seems little ground for this view.
Poor conditioned horses fed on low diet do not develop the condition in spite
of fatigue or exposure
Hæmoglobinuria following the injection of distilled water into the blood
stream has been described by Ponfick (69) and Hunter (68). Ponfick found it
necessary to use water to more than twice the blood volume before hæmoglobinuria
resulted ; he also noted that before hæmoglobinuria was produced there must
be intense hæmoglobinæmia.
Hunter records hæmoglobinuria in rabbits as the result of the intravenous
injection of quantities up to 70 c. c. of distilled water ; but the hæmoglobinuria
appears to have been transient and its presence shown chiefly by the guaiacum
reaction, and the production of a yellow deposit which Hunter believes to have
been hæmoglobin.
I n t h e s e r a b b i t s i n j e c t i o n o f 7 0 c . c . o f w a t e r w a s , n o t f o l l o w e d b y a n y v i s i b l e
change in the blood or by the presence of ghosts. But the spleen was in some
cases dark and swollen. In the case of one rabbit a large number of red
corpuscles showed bud-like projections, and similar buds were seen free and enclos-
ed in cells.
97
These experiments, it must be acknowledged, scarcely reproduce the condition
of a general lowering of the hæmosozic value of the plasma to such a point
as to cause hæmolysis, but they serve to show the comparatively small effect of
the injection of water unless in very large amount.
A large number of chemical substances destroy red blood corpuscles and many
of these cause within the body intense blood destruction, often associated with
hæmoglobinuria. Some substances cause simple liberation of the hæmoglobin;
others have a special action on this substance converting it into met-hæmoglobin
or other compounds. A close study of chemical and other effects of these poisons
is not necessary except in so far as they are likely to throw light on the nature
of blood destruction in the body and the causation of hæmoglobinuria.
Of experimental work on these lines the most instructive work known to us
is that of Hunter (68). It will be necessary to consider somewhat fully his
results.
Glycerine.
Hunter observed that the injection of a small dose of glycerine into the blood
of rabbits is followed by hæmoglobinuria, though the destruction of corpuscles
may be so slight in amount that scarcely any evidence of it is to be found in the
blood or elsewhere.
Upon this and other facts he bases his conclusion that hæmoglobinuria is
the result of liberation of hæmoglobin in the systemic circulation, however small
the amount may be ; thus differing in his conclusion from Ponfick, whose results
have been alluded to.
Toluylendiamin.
Injection of large doses of this drug into rabbits is attended with great blood
destruction ; but rarely with hæmoglobinuria. In the cat very small doses cause
i n t e n s e h æmo g l o b i n u r i a . I n t h e d o g i t c a u s e s j a u n d i c e wi t h o u t h æmo g l o b i n u r i a .
In rabbits the evidence of hæmolysis is confined to the spleen, except in the
case of large doses when it extends to the portal blood within the liver. No evi-
dence of blood destruction is to be seen in the peripheral blood, either during
life or after death.
In the spleen the red blood corpuscles are seen to throw off buds, and many
stromata and globules derived from the red cells are present. Cells packed with
red corpuscles are noted in some instances. A remarkable fact demonstrated
227 H. D.
2 B
98
by Hunter was that excision of the spleen does away to large extent with the
poisonous effect of toluylendiamin on rabbits. Chemical investigation, however,
did not show that the drug accumulated in the spleen in greater amount than
elsewhere ; but that on the contrary in three hours the amount in the spleen had
become too small to be estimated. From these facts Hunter comes to the
conclusion that toluylendiamin acts in rabbits in some indirect manner.
Pyrogallic Acid.
When injected into rabbits pyrogallic acid leads to intense blood destruction
associated with albuminuria and blocking of the renal tubules with hæmo-
globin. The blood shows enormous numbers of globules derived from the red
cells, and many of the corpuscles are markedly altered. The spleen is swollen,
dark in colour, and contains enormous numbers of splenic cells filled with pigment.
Red cell phagocytosis is also a prominent feature recorded by Celli and March-
iafava (95). The liver cells do not show the pigment seen in toluylendiamin
poisoning.
The part played by the spleen in the blood destruction by pyrogallic acid is
emphasized by Hunter who noted within three minutes after injection a swelling
of the organ sometimes to three or four times its normal volume. Also, as early
as fifteen minutes after injection, cells enclosing many red blood corpuscles, of-
ten only slightly altered in appearance, were seen in the, spleen ; but not in the
liver or elsewhere. The corpuscles in the peripheral blood in many cases were
perfectly normal, showing no crenation, while the plasma was quite free from
granules. In the spleen on the contrary many of the corpuscles were crenated,
of dark colour and exhibited other changes. Unlike poisoning by toluylendi-
amin that by pyrogallic acid was not prevented by excision of the spleen. But
following excision globules derived from the red blood corpuscles were more
frequently seen in the peripheral blood.
These experiments show that pyrogallic acid, which directly affects the
red cells, acts by causing these to be held up immediately by the spleen, and
that evidence of blood destruction and alteration in the peripheral circulation is
very slight.
In the case of rabbits poisoned by toluylendiamin the drug does not act
directly upon the red cells ; but the toxic substances, whatever they may be, are
derived apparently from body cells under the stimulation of the drug.
To the action of other poisons producing hæmoglobinuria it is necessary
to refer only briefly.
99
Most of these substances as a result of direct action upon the blood produce
met-hæmoglobinæmia. A certain number act indirectly like toluylendiamin.
Others have a resemblance in their action to specific hæmolysins,
Saponin Group,
Bodies closely related to the glucosides which act upon the lipoids of the
blood corpuscles. All cause hæmolysis, some in dilutions of 1 i n 1 0 0 , 0 0 0 , S o m e
produce hæmoglobinuria ; others do not. After experimental injection of such
substance a latent period has been observed, lasting 24 hours or more, before
the onset of symptoms of blood destruction.
Snake venom.
The snake venoms are related to the bacterial and specific blood toxins
. They possess in varying degrees a hæmolytic action and in connection with
viperine poisoning in particular, hæmoglobinuria may occur,
Post mortem examination shows changes varying with the venom used,
In the case of daboia venom there is intense edema and extravasation of blood
at the site of the injection, the blood is dark, .and the organs congested, Histol-
ogically are found, in addition to other conditions, vessels plugged with thrombi
composed of more or less hæmolysed agglutinated red blood corpuscles. Lamb
(72) has shown that if an initial small dose of daboia venom is given, coagula-
bility is diminished ; but that when a fatal dose is rapidly absorbed coagulation is
increased.
Bacterial Hæmo-toxins..
Fischer and Adler (73) have obtained an intense anæmia in rabbits after injec-
t i o n s o f c u l t u r e s o f s t r e p t o c o c c i ; a n d G r a w i t z ( 7 4 ) h a s o b s e r v e d a r e d u c t i o n
i n
the red cells to 300,000 in a case of streptococcus septicæmia.
Experimental injection of filtrates or cultures of typhoid, cholera, anthrax,
and megatherium may produce hæmoglobinuria. Special hæmolytic substances
have been isolated from cultures of certain bacteria. Among the best known
are tetanolysin, pyocyanolysin, staphylolysin, and typholysin.
V.—HÆMOGLOBINURIA FOLLOWING 'THE INJECTION 0F SPECIFIC HÆMOLYTIC
SERA.
In the consideration of the toxic hæmoglobinurias we have dealt mainly
with the conditions in which the blood is destroyed in a way more or less
artificial and greatly different from that which is likely to be concerned in Black-
water Fever.
100
The nearest approach to hæmo-toxic conditions likely to arise in the course
of a natural morbid process is to be obtained by the use of specific hæmolytic
sera. In 1898 Belfanti and Carbone (75) showed that the serum of a horse injected
with red cells of the rabbit acquires a special toxicity for rabbits ; subsequently
many other observers extended these observations. It is now generally recognised
that whenever the blood of an animal A is injected into that of another species
B, the serum of the latter becomes capable of causing profound intoxication when
injected into any animal of the same species as A.
Bordet (85), Gruber (85), Ascarelli (85), Landsteiner (85) and Von Dungern (85)
have specially investigated this form of toxicity together with Levaditi (76), Celli,
Cassagrandi and Carducci (77), while the reactions of the same nature, to be
observed in vitro, have occupied a host of workers, prominent among whom are
Ehrlich and Morganroth (78).
It seemed to us important, in order that we might obtain an insight into
the processes concerned in Black-water Fever, to undertake certain experiments
of this kind, and to ascertain if possible the mechanism of the hæmoglobinuria
that can be produced in animals by the use of these specific hæmolytic toxins.
The experiments carried out by us have been made on dogs injected with
the serum of a goat immunised by repeated injections of defibrinated dogs blood.
The goat received a number of such injections repeated at intervals of a few days,
which had the result of producing within a month a serum both hæmolytic in
vitro, and markedly toxic in vivo.
Our experiments with this serum are as follows :—
Dog. 1. Weight 3½ lbs.
6 p . m. 10th February 1908.—Received 4 c.c. goats serum.
8 a. m. 11 th February 1908.—Dog quite well. There is no distinct pallor of tongue
Received another 2.5 c.c. serum.
8 a.m . 12th February 1908.—Tongue pallid. Conjunctivæ pale.
10 a. m 12th February 1908.—Pallor much increased. Blood watery, dog dazed,
resembling a case of acute piroplasmosis. Urine
pale.
11 a m. 12th February 1908.—Autopsy.
[Tissues pale.
[Spleen enormously enlarged. Weight 20 grammes. Firm and
black in colour with a tuberculated surface.
101
Liver not obviously enlarged. Dark in colour.
Kidneys normal in appearance.
Urine in bladder free from hæmoglobin or urobilin.
Mediastinal glands are many of them dark red in colour.
Blood resembles a weak emulsion of corpuscles. That flowing from the
hepatic vein shews to the naked eye an agglutinated appearance. Received
into N/8 salt corpuscles are hæmolysed.
Hæmoglobinæmia as tested by receiving blood in 1 per cent. salt solution
and centrifuging not detectable in any of the following situations:-
•
Peripheral blood.
Heart blood.
Blood from mesenteric vein.
Blood from hepatic vein.
Blood from inferior vena cava.
But blood separated from clot of peripheral blood was rosy red.
Microscopical examination of organs.
Spleen .—In section the organ is seen to be engorged with blood. Beneath
the capsule and near the trabeculæ is a layer of fused red cell substance. In
other parts the splenic sinuses are packed with more or less normal looking
corpuscles. Everywhere are seen large cells gorged with red blood corpuscles.
In films are seen small phagocytes containing each a single red blood corpuscle
more or less normal in appearance. Also very large cells containing a dozen
or more red cells. A count made from blood obtained with a syringe from the
spleen when first exposed as follows :—
Polymorphonuclears and transitional cell
. .
. .
. . 26%
Large mononuclear leucocytes
. .
. .
. . 4%
Macrophages
..
..
..
. .
. .
. . 4.7%
Small mononuclear cells of various types..
. .
. .
. . 26%
Undifferentiated cells and nuclei
. .
. .
.. 34%
Small phagocytes with red cells ..
..
. .
. .
. . .3%
Large macrophages with red cells
..
. .
. . .
. . 2%
The microscopical appearances in these films resembled extremely closely
those seen in films from splenic blood in Black-water Fever.
227 II. D.
2c
102
Liver.—A count of cells. seen in films omitting liver cells gave:—
Polymorphonuclear leucocytes
..
. .
. . .. 36 %
Mononuclear cells and macrophages
..
..
. .
..
3 %
Small mononuclear cells of various types
. .
. . . . 25 %
Undifferentiated cells and nuclei
..
. .
. .
..
33 %
Small phagocytes containing red cells
..
. .
. . .. 4 %
Large macrophages, containing red cells ..
..-
..
. . 1 %
In many of the large macrophages were granules of greenish pigment resemb-
ling that seen in these cells in Black-water Fever.
Kidney. —A few phagocytes with red cells in all cases much. altered.
Bone Marrow.—One altered red. cell only found in a mononuclear cell
after some search.
Peripheral blood. —A leucocyte count gave :—
Polymorphonuclear leucocytes ..
..
. .
. .
. . 74 %
Large mononuclear leucocytes
..
..
. .
. . 4.5 %
Macrophages
..
. .
. .
. .
. . .5 %
Small mononuclear leucocytes
. .
. .
. .
. . 3.5 %
Lymphocytes
..
. .
. .
. .
. . 4.5 %
Transitional cells
. .
. .
. .
. . 12.5 %
There was marked polychromasia an average of 2 or 3 large cells with
central red stained stippling (Giemsa).
Visceral blood. —In the blood from the hepatic veins are large numbers
of small and large phagocytes containing red cells. Some of the latter are more
or less globular with the nucleus deformed and pushed to one side by masses
of included red blood corpuscles. Large scale like endothelial cells containing
red cells and débris are common. The red cells are agglutinated in masses and
between the masses are many stromata.
Dog II .—A somewhat emaciated dog. Had a large spleen resembling that
found in chronic piroplasmosis but no parasites were found. No engulfment of
red cells such as seen in the last case. Macrophages contained only much altered
cells or débris.
Blood received into 5 per cent. citrate,
5 times diluted.
Blood allowed to clot,
No tint of hæmoglobin.
Serum rosy red.
103
Dog. IV.—4¼lbs.
10 a.m., 2nd March 1908.—Received subcutaneously 15 c.c.. goat's serum.
Isotonic point
..
..
.525 salt.
1 p.m., 2nd March 1908.—Dog seedy, shivering.
Ditto
Anæmia, but no hæmoglobinuria or hæmoglobinæmia.
Ditto
Corpuscles in 1 % salt at 37, no hæmolysis in 2 hours.
Ditto
Isotonic point
.. .71 salt.
2 p. m., 2nd March 1908.— Isotonic point shows a trace of colour at .83 salt. No
hæmoglobinæmia.
5 p. m., 2nd March 1908.—Dog killed. Tissues pale, blood watery.
Spleen greatly enlarged, firm, black in colour, surface tuberculated.
A trace of hæmoglobinæmia in the peripheral blood and in the blood from
the splenic and hepatic veins.
Urine in bladder not hæmoglobinous.
H æ m o s o z i s v a l u e v e r y h i g h , b e i n g o v e r 1 . 2
per cent salt.
In this dog hæmoglobiæmia appeared to have only lust supervened.
It was already present in all situations. The, urine was not yet heemogiobinu-
ous.
Dog V.—Weight. 5 lbs.
10 a.m.,. 2nd March 1908.—.Received 3 c.c.. goat's serum intravenously.
Dog dead in 30 minutes.
Tissues pallid,. spleen enlarged, dark purple, soft and not tuberculated as in
dogs. 1 and 4.
Liver dark purple.
Intestine purplish. In the veins can be seen agglutinated masses of cor-
puscles floating in clear fluid plasma.
Ventricles, and auricles filled with pale clot.
Dog VI.—Weight 4½ lbs.
10 a.m., 2nd March 1908.—Received 3 c. c. goat's serum, subcutaneously.
3 p.m., 2nd March 1908.—Isotonic point
.. .. 475 salt.
10 a. m., 3rd March 1908.—Seen to be passing hæmoglobinous urine
Dog; killed.
104
Autopsy —
Spleen enlarged, black in colour, firm consistency, surface tuberculated.
Kidneys dark purple in colour.
Hæmoglobinous , urine in bladder.
Hæmo g l o b i n æmi a i n a l l s i t u a t i o n s .
Blood corpuscles from hepatic vein at 37 in .9 % salt—slight hæmolysis.
Blood corpuscles from engorged spleen at 37 in .9 % salt—marked hæmolysis.
Microscopical appearance
Spleen. Phagocytosis of unaltered red cells extremely marked.
A count of 500 cells gave :—
Small phagocytes
unaltered red cells
altered red cells
..
. .
..
..
. 4
.4 %
Large macrophages containing many altered and many more or less
unaltered red cells
..
.. ..
.. . 6 %
Polymorphonuclear cells containing red cells
altered
unaltered
..
. .
0
. 8
Of large mononuclear cells and macrophages 7 per cent contained red blood
corpuscles. Many contained masses of hæmoglobinous material formed from fused
red cell substance. Many of the cells were so packed as to resemble masses of
hæmoglobin.
Liver—
Small phagocytes 5 per cent, of total cells not including liver, cells.
Large macrophages 2 per cent, of total cells not including liver cells.
Lungs—
Extensive engulfment of red cells. The small macrophages and polymorpho-
nuclear cells containing red blood corpuscles being especially noticeable. A count
of 300 cells gave :—
Small phagocytes containing red cells
. .
. .
. . .3 %
Large macrophages containing red cells
..
. .
.. 3.7 %
Polymorphonuclear cells containing red blood corpuscles were also frequent.
This dog showed that the capillary system of the lungs is the site of very
considerable engulfment of red cells.
105
Dog VII.—Weight 4 lbs.
10 a.m ., 2nd March 1908.—Received 1 c.c. of goat's serum subcutaneously.
11 a.m., 5th March 1908.—Dog for the last few days has been getting more and more
seedy with progressive anæmia. Weakness of hind
legs as in canine piroplasmosis.
1-30 p.m., 5th March 1908.—Isotonic point has risen so that considerable hæmoly-
sis takes place in .83 salt. No hæmoglobinæmia.
2 p .m ., 5th March 1908.—Gave 1 grain quinine sulphate with sufficient diluted acid
to dissolve it. No hæmoglobinuria resulted up to 8 P.M.
8 a.m ., 6th March 1908.—Isotonic point between 1 per cent. and .71 per cent. Dog
not so seedy.
8 a. m ., 7th March 1908.—Anæmia less marked. Dog improving in health. There
is a trace of hæmolysis in .91 per cent. salt but marked
hæmolysis does not occur till the blood was placed in
. 5 2 5 s a l t .
Washed corpuscles in .9 per cent, salt at 37. No hæ-
molysis in 2 hours.
11 a .m ., 7th March 1908.—Gave 1½ grs. quinine sulphate dissolved in diluted acid.
No apparent effect.
8th March 1908.—Isotonic point .71.
9th March 1908.—Isotonic point .55 red cells ; half are nearly all large cor-
puscles and definitely polychromatic cells of large
size average 7 per field.
14th March 1908.—No trace of hæmolysis in .5 per cent, salt. Red cells
normal in appearance.
In spite of a greatly raised isotonic point a dose of quinine sulphate equivalent
to a dose of over 30 grains given to a man had no effect in inducing hæmoglobinuria.
Dog VIII.—Weight 5 lbs.
11 a.m., 5th March 1908.—Received 3 c.c. goat's serum.
4 30 p .m ., 5th March 1908.—Isotonic point at .83 per cent. salt.
Hæmosozic value .876.
8 a.m., 6th March 1908.—Isotonic point at 1 per cent, salt. No tint of hæmolysis
in 5 per cent. salt.
5 p .m., 6th March 1908.—Isotonic point at .91. Dog recovering.
8 a.m., 7th March 1908.--Anæmia still marked but much improved. Dog better.
Washed corpuscles 1 per cent. salt at 37. No
hæmolysis in two hours.
227 H. D.
2D
106
4 p.m., 7th March 1908.—Polychromatic cells average about 10 per field. Marked
contrast between large type of red cell and small
round dark cells.
5 p.m., 7th March 1908.—Autopsy. Spleen dark red, weight 7 grammes. Blood
from hepatic vein. No hæmoglobinæmia. No ten
deny to agglutination.
Hæmoglobinuria not detected. Owing to imperfect arrangements for observ-
ing the urine it cannot be affirmed with certainty that it did not occur in the night
of 5th March 1908.
Dog IX.—Weight 6¼ lbs..
5th March 1908.—Isotonic point below 45 per cent. salt. Hœmosozic value 1.168
per cent. salt.
8 a.m. 6th March 1908.—Isotonic point .425 per cent. salt.
11 a.m., 6th March 1908.—Received 6 c.c. goat's serum subcutaneously.
5 a.m., 6th March 1908.—Isotonic point unchanged. Dog shows no symptoms or
anæmia.
•
8 a. m. 7th March 1908.—Isotonic point at .71 per cent. salt. Washed corpuscles in
1 per cent. salt at 37. No hæmolysis in two hours.
10 30 a.m., 8th March 1908.—Isotonic point at .83 per cent. salt or even a trace at
. 9 1 p e r c e n t . s a l t . D o g q u i e t . A n æ m i a m a r k e d b u t
not profound. Small round corpuscles form the ma-
jority of blood cell. Polychromatic cells average 5
or 6 per field.
Gave 1½ c.c. goat's serum.
•
1-30 a.m., 8th March 1908.—Pallor of tongue greatly increased, dog profoundly
ill. Profound anæmia.
5 a.m., 8th March 1908.—Hæmoglobinuria. Plasma tested showed hæmoglobi-
næmia. Isotonic point showed marked degree of
h æ m o l y s i s a t . 9 1 p e r c e n t , s a l t .
6 a.m , 8th March 1908.—Autopsy. Bladder full of hæmoglobinous urine resem-
bling that in Black-water Fever. Spleen ½ grams,
dark red colour but not black, firm surface not
markedly tubercular.
Liver.—Blood in liver obviously richer in corpuscles being of a normal blood
consistency whereas peripheral blood was extremely watery. Organ not obviously
enlarged or markedly congested. Gall bladder full of bile of the colour of iodine
liniment.
Kidneys.—Dark purple cortex. Medulla pale.
107
Lungs.—Colour a bright brick red, some parts being darker than others.
Heart.—No antemortem clot.
Hæmo-Lymph glands.—None detected in this dog though frequently found
in other dogs.
Hæmoglobinæmia.—Tints obtained by adding 20 c.m. of blood to ½ c.c.
citrate solution compared. The amount in splenic and peripheral blood approxi
-mately the same. The tint in the hepatic and renal veins blood is a little deeper.
Ghosts.
Peripheral blood
—
Red cells 1,496,000 per c.m.
Ghosts 110,000 per c.m.
. .
. .
large cells 42 per cent.
small cells 58
„
Splenic blood—
Red cells 3,080,000 per cm.
Ghosts 308,000 per c.m.
. .
. .
large cells 15
„
small cells 85
„
Hepatic blood—
Red cells 6,164,000 per c.m.
Ghosts 1,782,000 per c.m.
. .
. .
large cells 8
„
small cells 92
„
Renal blood —
Red cells 6,072,000 per c.m.
Ghosts 1, 144,000 per c.m.
. .
. .
large cells 13
„
small cells 87
„
Blood—
From inf. vena and heart clot rapidly.
Clot shrinks quickly, leaving rosy red serum. Diluted in same proportion as
citrate test employed above gives about the same tint. The rosy red serum in
this case is a true indication of the hæmoglobinæmia present.
Hæmosozic value .. .834 per cent salt.
Liver blood received into its own volume of 5 per cent sodium citrate—centri
fugalised and films made of the deposit shows up especially well the agglutination
and the differences between large new cells, small dark cells, and cell shadows.
The blood corpuscles in the hepatic blood were chiefly aggregated in to clumps,
the size of the clumps varying from those composed of a dozen cells to large masses