The effect of human plasma transfusion on the fecal urobilinogen excretion on sickle cell anemia

1. The results of transfusions of whole plasma and blood on the fecal urobilinogen excretion of 5 children with sickle cell anemia have been reported.

2. The phenomenon observed by Josephs—a reduction in urobilinogen outputfollowing plasma transfusions—has been confirmed.

3. It has been observed further that in certain patients the continued use ofplasma transfusions induces a reversal of this phenomenon, namely an increase inurobilinogen output after each transfusion.

4. The possible significance of these phenomena is discussed and attention iscalled to the limitations inherent in accepting urobilinogen excretion as a validindex of hemoglobin destruction in certain disorders in which a defect of hemoglobin metabolism may be present.

     

SOME NEWER CONCEPTS OF THE NATURAL DERIVATIVES OF HEMOGLOBIN: I. GENERAL CONSIDERATIONS II. THE SERUM BILIRUBIN AND BILIRUBINURIA III. THE ERYTHROCYTE PROTOPORPHYRIN

The transition of hemoglobin to bile pigment, at least under normal conditions,is believed to occur via an intermediate biliverdin-globin-iron (verdohemoglobin)and not over the stages of hematin and protoporphyrin. It is probable that thenext step is a reduction to bilirubin with splitting off of iron. There is much reasonto believe that the globin remains attached until the bilirubin passes through theliver cell, bilirubinglobin exhibiting a delayed or indirect van den Bergh reaction andnot being excreted in the urine; the sodium bilirubinate of the bile exhibiting aprompt (1') van den Bergh reaction and being readily excreted in the urine. Theformer type is characteristic of retention, the latter of regurgitation jaundice.

The appearance of bilirubin in the urine is believed to be related to the concentration in the blood of the 1' or prompt bilirubin, rather than that of the totalbilirubin. It is evident that the threshold may be considerably lower at the onset ofjaundice, as, for example, in hepatitis, than during its defervescence. This undoubtedly accounts for the appearance of bilirubinuria prior to recognizable jaundice incertain instances, likewise for its presence in the cases of so-called "hepatitis without jaundice." In retention jaundice marked elevation of the total serum bilirubinis unassociated with bilirubinuria; in these cases the increase of bilirubin is mainlyof the delayed or indirect reacting type. Further evidence is presented of the essential difference between the 1' or prompt, and the T minus 1', or delayed and indirect reacting bilirubins. This consists of a change of the order of reaction at oneminute after adding the diazonium salt. The normal upper limit of the 1' bilirubinhas been shown to be in the neighborhood of 0.2. mg. per 100 cc.; figures well belowthis value are usually obtained.

Further experience with the erythrocyte protoporphyrin in the anemias hasrevealed that this determination, quite apart from its fundamental interest, is attimes of diagnostic value. Thus in several instances a significant elevation of theerythrocyte protoporphyrin has indicated that the initial impression of perniciousanemia was incorrect, and has led to the search for other information. Conversely,a low normal value in the presence of anemia has often correctly indicated or confirmed the diagnosis of pernicious anemia. Marked elevations have aided in confirming the presence of iron deficiency and have given some insight into the degreeof its severity and chronicity. In certain cases, high values for the erythrocyteprotoporphyrin have suggested the possibility of heavy metal toxicity, the existence of which has then been borne out by subsequent study.

     

Prophylaxis of hookworm anemia-deficiency disease

1. In individuals severely infested with Ancylostoma or Necator, it is possible tomaintain the normality of blood value by the administration of a sufficient dose ofan iron salt.

2. The minimum dose necessary to maintain normality of the blood in an individual weighing 45 kilograms, with 1051 helminths, was 0.2. Gm. daily of ferrous sulfate, administered in mixture with manioc flour.

3. The patient observed became clinically normal two weeks after the beginningof blood regeneration up to the end of the trial period one year later. In this period,with the various doses of iron tried, hemoglobin varied from 8.0 to 11.0 per 100ml. of blood.

Note: ACKNOWLEDGMENTWe owe thanks to the kindness of our colleague, Dr. Genard Nobrega, for the case report and electrocardiographic study of the patient.

     

The relationship between carbonic anhydrase activity and zinc content of erythrocytes in normal,in anemic and other pathologic conditions

A good correlation exists between zinc content and carbonic anhydrase activityof the red blood cells under all conditions studied, including anemia and polycythemia. In almost all patients with anemias other than pernicious anemia, bothzinc and carbonic anhydrase levels were lowered in parallel fashion. These changeswere proportional to decreases in hematocrit and hemoglobin levels and erythrocyte counts so that both zinc and carbonic anhydrase values per unit of RBC werein the normal range. In a few instances of anemia associated with leukemia andin one of sickle cell anemia, neither zinc content nor carbonic anhydrase activitywas decreased in proportion to the anemia; in these cases the zinc and carbonicanhydrase levels per unit of blood were both elevated to the same degree.

Patients with pernicious anemia showed no decrease in absolute values for zincand carbonic anhydrase activity in spite of marked lowering of hematocrit andhemoglobin levels and of erythrocyte count. Accordingly, both zinc concentrationand carbonic anhydrase activity per unit of blood were elevated, often to a markeddegree. These increases were parallel, varying inversely with the degree of anemia;when they regressed under treatment, both did so at the same rate.

There are no methods available for estimating carbonic anhydrase concentration;all methods now in use measure only the activity of the enzyme. It is suggestedthat zinc concentration could be used as an indicator of carbonic anhydrase contentof the red blood cells.

Note: ACKNOWLEDGMENTSDrs. Joseph C. Aub and Ira T. Nathanson were kind enough to refer several patients for study. Dr.Byrl J. Kennedy was most helpful in regard to obtaining samples of blood. The technical work wasperformed by Miss Mary Lou Roney, Betty Hickey and Marion Taylor.

     

Congenital hemolytic jaundice; the pathogenesis of the hemolytic crisis

Six cases of congenital hemolytic jaundice with "hemolytic" crises are reported. It is demonstrated that during the development of the anemia an acuteaplastic condition is present in the erythropoietic tissue of the bone marrow withcomplete cessation of the formation of red cells. The reticulocytes disappear fromthe blood; jaundice, serum bilirubin and urobilinuria decrease to normal values;and the serum iron increases. This period is further characterized by leukopeniaand thrombocytopenia.

The spontaneous recovery is caused by a rapid regeneration of the erythropoietictissue resulting in a marked reticulocytosis in the peripheral blood, and there isalso leukocytosis, an increase in thrombocytes and a rapid fall of serum iron.

During the period of severe anemia an increase in the blood urea and uric acidoccurs.

Transfusion experiments revealed an average lifetime of approximately fifteendays for the red cells in congenital hemolytic jaundice, a fact which fully explainsthe development and symptoms of the crisis as a result of cessation in the formation of red cells.

The findings definitely contradict the theory that an acute increase in thehemolytic process is the reason for the crisis.

The crisis should be called aplastic and not hemolytic.

     

STUDIES ON THE PHYSIOLOGY OF THE WHITE BLOOD CELL: THE GLYCOGEN CONTENT OF LEUKOCYTES IN LEUKEMIA AND POLYCYTHEMIA

The technic of determining glycogen in isolated white blood cells was appliedto the study of the different types of leukemia and of polycythemia, in order toobtain information on the physiology of the white blood cell. From this study itis concluded that the granulated leukocyte is the only carrier of glycogen in wholeblood. The "reducing substances" in lymphocytes and blast cells are not consideredas true glycogen.

The glycogen content of wet white blood cells in the rabbit amounts to about1 per cent. In the human being a range of from 0.17 to 0.67 per cent was calculated.In disease higher percentages occur, in polycythemia up to 1.64 per cent and inglycogen storage disease up to 3.05 per cent.

The glycogen concentration of normal white blood cells is within the same rangeas that of the striated muscle.

Note: I acknowledge with gratitude my indebtedness to Dr. William Dameshek for giving me the opportunity of analyzing the blood of some of the patients studied. Miss M. H. Campbell, Miss H. A. Clark,and Miss L. M. Garofalo have aided in carrying out many of the blood counts.

     

Thrombotic thrombocytopenic purpura; hemorrhagic diathesis with generalized platelet thromboses

1. "Thrombotic thrombocytopenic purpura" is the name which we propose fora rare but well-defined disorder which manifests itself clinically as an acute febrileillness and which is characterized by (a) petechiae and ecchymoses, thrombocytopenia, prolonged bleeding time and poor clot retraction, (b) by a severe anemia outof proportion to any observed blood loss, (c) by mild acholuric jaundice, hepato-splenomegaly, (d) by bizarre and intermittent mental and neurologic symptomsand signs, and (e) by a transient leukemoid reaction in the peripheral blood.

2. This clinical picture must be correlated with a remarkable histologic pattern,namely the presence of myriads of platelet thrombi in the small arterioles andcapillaries of almost all organs of the body.

3. Eleven such cases have been described in the literature. One case of our ownis added.

4. The clinical features of this disease are detailed and the differential diagnosisis discussed. It is emphasized that if the physician is familiar with this syndromea correct clinical diagnosis may become readily possible.

Note: Acknowledgment for the support of this work is made to the Hulda B. and Maurice L. RothschildFoundation for Scientific Research.

     

Erythrokinetics: quantitative measurements of red cell production and destruction in normal subjects and patients with anemia

Red cell turnover of 19 normal subjects and 25 anemic patients was measuredwith the following technique: erythroid-myeloid ratio of the marrow, reticulocytecounts, plasma iron turnover, red cell utilization of radioiron, and urobilinogendeterminations. Measurements of blood production and destruction were so expressed as to allow comparison between normal and anemic individuals of different size and different red cell mass. The usefulness and disadvantages of eachprocedure in the study of anemia are discussed.

From studies of various types of anemia, it has become apparent that erythropoiesis must be defined in terms of total quantity of red cells produced and interms of the portion of red cells produced in the marrow which are delivered tothe circulating blood (effective versus ineffective erythropoiesis). A quantitativedefect alone exists when a normal ratio is maintained between effective andtotal erythropoiesis. Here, there are changes of similar magnitude of all erythrokinetic indices, although reticulocyte and urobilinogen values are occasionallydisproportionately high. The normal marrow appears to be able to increase itseffective red cell production to three times normal in acute anemia and six timesnormal in chronic anemia. In many disease states this maximal quantitativeresponse is impaired.

Dyspoiesis of the marrow is characterized by a dissociation of erythrokineticindices. Values which reflect total erythropoiesis (i.e., plasma iron turnover,fecal urobilinogen and erythroid-myeloid ratio of the marrow) are considerablygreater than the reticulocyte level and red cell utilization of radioiron whichrepresent effective erythropoiesis. Such defects may result in the pattern of ahemolytic process or aregenerative anemia, depending on their severity.

Submitted on October 26, 1955 Accepted on December 7, 1955     

THE ANEMIA OF INFECTION, VI. THE INFLUENCE OF COBALT ON THE ANEMIA ASSOCIATED WITH INFLAMMATION

The influence of cobalt on the anemia associated with inflammation has beenstudied in three experiments involving observations in 108 rats.

It was found that by the simultaneous administration of cobalt the anemia associated with inflammation, as produced by the injection of turpentine, could beprevented from developing and polycythemia appeared instead.

This effect was accompanied by hypoferremia and an increase in erythrocyteprotoporphyrin values similar to those encountered when anemia develops in association with inflammation.

Similar, though less marked, chemical changes were observed when only cobaltwas given and polycythemia was produced.

A decrease in plasma albumin was noted in rats injected with cobalt or turpentine, or both, but this was not accompanied by an increased excretion of urinarynitrogen as measured by the urine urea and ammonia.

The observations cited are consistent with the hypothesis that cobalt favorablyinfluences the utilization of iron for the synthesis of hemoglobin.

     

The Urinary Excretion of Orally Administered Tritium-labeled Folic Acid as a Test of Folic Acid Absorption

The urinary excretion of radioactivity following an oral test dose of tritium-labeled folio acid was determined in a group of 40 subjects which includedcontrols and patients with a variety of malabsorptive disorders. The resultswere compared with the occurrence of folic acid deficiency, as detected bysubnormal serum L. casei folate levels, and with a variety of other testsavailable for the evaluation of intestinal absorption, including the determination of folio acid absorption based on the microbiological assay of peakserum Str. faecalis folate concentrations following the oral test dose.

The urinary excretion of H³FA in 15 subjects with normal intestinal absorption ranged from 26.0 to 57.8 per cent of the oral test dose, with a meanof 40.7 per cent. The H³FA excretion in 25 patients with intestinal malabsorption ranged from 1.9 to 38.7 per cent, with a mean of 15.3 per cent.Twenty patients in this group excreted less than 26 per cent. Those five patients who excreted greater than 26 per cent were considered to have normalabsorption of folic acid since absorption studies of peak serum Str. faecalisfolate levels were within the normal range.

The results of the H³FA urinary excretion test correlated well with otherparameters of intestinal absorption, particularly in the instances of severemalabsorption, although three cases with malabsorption were observed inwhich H³FA excretion was subnormal and peak serum Str. faecalis folateconcentrations were normal. Folic acid deficiency was observed in 12 patients and its incidence appeared to be related to the severity of impairmentof folic acid absorption in the majority of cases.

It is concluded that the H³FA urinary excretion test is a simple, rapid andreliable index of folic acid absorption.

Submitted on October 11, 1962 Accepted on December 11, 1962     

THE EFFECT OF DIET ON THE HEMOGLOBIN, ERYTHROCYTE, AND LEUKOCYTE CONTENT OF THE BLOOD OF THE RHESUS MONKEY (MACACA MULATTA)

1. Rhesus monkeys fed purified rations supplemented with adequate amountsof the B vitamins, ascorbic acid, and whole liver substance maintained the following average blood picture:

See PDF for Table

2. Natural diets or purified rations supplemented with liver extract do not support the above blood picture. The hemoglobin is lower and there is an increase inthe range of the total leukocyte count and in the neutrophil-lymphocyte ratioto 2.0 ([unknown]). These figures are similar to the values in the literature and generallyaccepted as the normal.

3. Previous reports have shown the characteristic blood dyscrasias which develop when monkeys are fed certain B vitamin-deficient diets. These changes aresummarized graphically in this paper.

4. The importance of determining the concentration of hemoglobin and theformed elements of the blood as a diagnostic test in nutritional studies has beenshown.

Note: We wish to acknowledge our indebtedness to Merck and Co., Rahway, N. J., for some of the crystalline vitamins; to Wilson Laboratories, Chicago, Ill., for the various liver preparations; and to LederleLaboratories, Inc., Pearl River, N. Y., for synthetic folic acid.The authors are grateful to Miss Ethel Thewlis for aid in determining cellular elements and to Drs.Harry A. Waisman and James H. Shaw for assisting in early parts of the work.

     

A Study of Histamine in Myeloproliferative Disease

1. Whole blood histamine content was measured in 80 patients with myeloproliferative disease. Increased levels were found in 60 per cent of patientswith uncontrolled polycythemia vera, in 7 per cent of patients with polycythemia vera being controlled by myelosuppressive therapy, and in 71 percent of a group with "spent" polycythemia, myeloid metaplasia and myelofibrosis.

2. The excretion of histamine in the urine was measured in 60 patients,30 with elevated blood histamine and 30 with normal blood histamine. Theurine findings paralleled the blood findings in 90 per cent of the cases.

3. Measurements of cell-poor and cell-rich fractions of blood showed thatthe histamine is contained in the white cell fraction. Elevated basophil countswere present in 50 per cent of the patients and occurred with the greatestfrequency in the groups with elevated blood and urine histamine. A roughcorrelation between the basophil count and the histamine content of bloodand white cell fractions was observed in normal subjects and most cases withmyeloproliferative disease. Data obtained in some cases of myeloproliferativedisease suggest that the histamine content of the basophil may be abnormaland that other granulocytes may contribute to the total leukocyte histamine.

4. Myelosuppressive agents produced a reduction in histamine (expressedper 10⁹ myeloid cells) and a decrease in urine histamine as control of themyeloproliferative process was achieved. Treatment with phlebotomy aloneproduced no change in histamine levels.

5. The incidence of pruritus, upper gastrointestinal distress and urticarialmanifestations was increased 7-fold, 4-fold and 12-fold, respectively, in patients with elevated histamine levels as compared with those who had normalhistamine levels.

6. Cyproheptadine, a potent antihistaminic, successfully controlled pruritus,relieved pyrosis and suppressed urticarial eruptions in patients with elevatedhistamine levels. Suppression of the reaction to subcutaneously administeredcodeine (a histamine-releaser) afforded objective evidence that cyproheptadine blocked the effects of histamine release in vivo.

7. The metabolism of histamine and the role of elevated histamine levelsin the clinical manifestations and pathophysiology of myeloproliferative diseaseare discussed.

Submitted on September 23, 1965 Accepted on May 24, 1966     

Chronic hemolytic anemia with erythrocyte fragility to cold and acid. I. Clinical and laboratory data of two cases,with special reference to the cell abnormality

Two cases previously diagnosed as aplastic anemia were found to have abnormal susceptibility of the red blood cells to hemolysis after chilling and afteraddition of acid in the presence of their own as well as control serum. The serumof the patients had no such effect on control erythrocytes. This erythrocyteabnormality was accompanied by a severe anemia of the macrocytic type, slightreticulocytosis, depression of granulocytes and platelets, and erythropoietichyperactivity of the bone marrow in the early stages and hypoactivity in thelate stages. Increased blood destruction was evidenced not by jaundice, but bypersistent hyperhemoglobinemia in the serum and increased iron excretion in theurine, without nocturnal intensification. Chilling in vivo produced hemoglobinuria in Case 1, but only slight evidence of increased blood destruction in Case2. Administration of large doses of ammonium chloride failed to produce hemoglobinuria in either case, although evidence of an increase in blood destruction was detectable. Both patients had historical and serologic evidence ofsyphilis. Autopsy of Case 1 showed, in addition to syphilitic aortitis, markedhemosiderosis of the kidneys, liver, spleen and lymph nodes.

These were clearly not cases of paroxysmal hemoglobinuria é frigore (Donath-Landsteiner). They resembled cases of chronic hemolytic anemia with nocturnalparoxysmal hemoglobinuria (Marchiafava-Micheli), but the erythrocyte fragility to chilling, the absence of nocturnal increase in the hemolytic process andthe presence of syphilis rendered the acceptance of such diagnosis difficult.

     

Pernicious anemia and related anemias treated with vitamin B12

Eleven cases treated with vitamin B₁₂ have been presented. Eight patients withpernicious anemia in relapse responded hematologically. Two patients with mildneurologic involvement were relieved by therapy with B₁₂ alone.

Consideration of the quantities of the crystalline vitamin required to promotemaximal erythropoiesis in pernicious anemia indicates that less than about 0.75µg. daily in doses at intervals of several days will not suffice to establish and maintain blood values as high as does adequate treatment with liver extract. Parenteraldaily doses of 1.0 µg. promoted good erythropoiesis in one patient, although itappears that the maximum rate of hemopoiesis may require the initial averagedaily dose of approximately 3.0 µg.

The reticulocyte count is an unreliable quantitative criterion of activity or adequacy of therapy.

It is suggested that hemopoietic factors in addition to PGA and B₁₂ may berequired by some patients to obtain maximal erythrocyte levels.

Vitamin B₁₂, as well as PGA, effects a reduction in the fecal urobilinogen output of patients with pernicious anemia. The significance of this finding is discussed.

No change in urinary excretion of pteroylglutamate or of porphyrin was detected in patients treated with vitamin B₁₂.

     

Use of antimony in multiple myeloma

The effect of antimony treatment (neostibosan) of multiple myeloma is described.The following observations are reported:

1. Control of bleeding. In one instance of multiple myeloma the presenting symptom was uncontrollable nosebleed of one and one-half years’ duration. The plateletcount as well as the clotting and bleeding time were normal, the only abnormalitywas the failure of the clot to retract. It is possible that the latter abnormality wasconnected with the abnormal protein composition of the blood (hyperglobulinemiawas found).²

Topical treatment, including repeated cauterizations and radium application tothe nasal mucosa, remained without any effect, and constant packing and frequenttransfusions were necessary. Following a course of neostibosan injections therewas gradual diminution of the bleeding, and after one month complete cessationof bleeding was noted. Since that time (6 months at the time of writing) the bleeding did not recur, and the patient was discharged from the hospital. At the sametime a moderate decrease of hyperglobulinemia was observed.

2. Reduction of hyperglobulinemia. In reviewing all other cases treated it was foundthat in all four instances with hyperglobulinemia there was reduction of the serumglobulin content. When a few months later the hyperglobulinemia was rising, arepeated course of antimony was followed again by its reduction.

In three instances without hyperglobulinemia no change of serum globulin wasnoted following the antimony treatment. In four other cases the globulin changeswere not followed.

3. Regression of palpable tumors. Three instances with visible tumors, a rather uncommon phenomenon in multiple myeloma, were observed.

Disappearance of the palpable tumors in two patients after combined antimonyand radiotherapy was reported in a previous communication. In the present paper,almost complete disappearance of palpable tumors following antimony treatmentalone without radiotherapy is reported.

With regard to these observations, the following reservations should be kept inmind:

1. In evaluating the influence of antimony on multiple myeloma it is necessaryto realize the possibility of occasional spontaneous remissions in this disease, aswell as of a prolonged course over a period of years with relative freedom fromsymptoms, and occasional sensitivity to radiation.

2. The number of observations is insufficient to warrant at this point conclusionsas to the therapeutic value of antimony. They indicate merely a possible influence ofantimony on the myeloma tissue and on the disturbed chemistry of myeloma.

     

Uric Acid Excretion in Patients with Malignant Lymphomas

Uric acid blood and urine studies were performed in 12 patients withlymphomas while on a measured low purine diet before, during and after cytotoxictherapy.

Before treatment, urinary uric acid excretion in these patients was significantlyhigher than in normal subjects, although only 2 patients had clearlyelevated blood uric acid levels. There was no correlation between the estimatedsize of the tumor masses and pretreatment uric acid excretion. The responseto treatment could not have been predicted by measurement of thepretreatment uric acid excretion.

In one patient with extensive tumor infiltration of the kidneys, dangerousrenal failure, preceded by marked hyperuricemia, developed during therapy.Mechanical hemodialysis resulted in clinical improvement and marked reductionin the blood levels of uric acid and urea.

The finding of a large increase in uric acid excretion during the early daysof treatment of a patient with lymphoma is indicative of a responsive tumor.Such data also serve as warning of potential obstructive uric acid nephropathyor uropathy before major increases in serum uric acid appear. Small increasesof uric acid excretion in association with treatment could not be correlatedwith objective clinical response.

Accepted on April 3, 1961     

Experimental anemias in the rat; I. Macrocytic anemia in chronic pteroylglutamic acid deficiency and after splenectomy in Bartonella muris infection

1. In agreement with findings by other workers, rats in acute pteroylglutamicacid deficiency showed leukopenia and growth depression followed by death, without any significant change in the red cell picture.

2. In chronic deficiency, however, produced by the addition of small pteroylglutamic acid doses given intermittently, a severe anemia was obtained afterseventy days.

3. The anemia was macrocytic and "normochromic." Price-Jones curves showeda preponderance of macrocytes with anisocytosis. This agreed with findings byother workers for other species.

4. The anemia could be cured by single doses of 40 µg. or more of pteroylglutamicacid.

5. There was no significant difference between sexes to pteroylglutamic aciddeficiency. Reduction in the protein content of the diets, containing 1 per centsulfasuxidine, from 18 per cent to 10.5 per cent, produced no significant differencein the time of onset and severity of the blood symptoms.

6. These results were not due to infection with Bartonella muris. This infectionproduced a macrocytic anemia of a different type, and was curable by treatmentwith neoarsphenamine.

Note: ACKNOWLEDGMENTSWe are grateful to Dr. T. H. Jukes of the Lederle Laboratories for generous supplies of aldehyde-freePGA; and to Dr. K. Folkers of Merck Laboratories for the biotin used in these experiments. We wish tothank Dr. W. Jacobson for his advice during the course of this investigation. Valuable technical helpwas provided by Mr. D. R. Ashby, Mr. S. G. Impey, Miss M. J. Kemp and Mr. P. W. Wilson, to whomthe authors are indebted.

     

Hemolytic disease of the newborn due to anti-A1

1. The authors report clinical, hematological and serological data in a case ofA₁ iso-sensitization of pregnancy.

2. The mother’s serum displayed immune characters specific to A₁ cells immediately after delivery. On the 24th day post partum the specificity extendedto A₂ cells.

3. The disease exhibited by the infant was very mildly hemolytic. It wasmarked by a deep jaundice, repeated alimentary vomiting and a progressive stateof drowsiness. There was no anemia. The direct anti-globulin test was negative.

4. It is shown that the mildness of the hemolytic process in cases of placentaltransfer of immune anti-A or anti-B into the incompatible A or B fetus is probablydependent upon a peculiar "resistance" of the fetal cells. This may be demonstrated in vivo and in vitro. In the present case replacement transfusion withA₁ adult blood resulted in its in vivo sensitization, detectable by the antiglobulintest and eventually leading to hemolytic anemia.

Submitted on September 28, 1953 Accepted on August 15, 1954     

RELATION OF CONTACTING SURFACE AND ANTICEPHALIN ACTIVITY TO THE MAINTENANCE OF THE FLUIDITY AND COAGULABILITY OF BLOOD

A review of the various factors in the blood that have to do with the promotionand the retardation of coagulation is presented.

Circulating blood seems to have within and about itself all the factors requiredto delay or to promote coagulation. The stability of blood (i.e., its tendency toremain fluid) depends on the extent of the dominance of the anticoagulant (fluidity-inducing) group of factors over the coagulant (coagulation-promoting) group.

Among the anticoagulant factors are the natural anticephalin activity of theplasma and the intact vascular endothelium; the latter is simulated by such contacting surfaces as collodion and paraffin films.

Alterations in the stability of blood result from uncompensated increases or decreases in one or more of the anticoagulant or coagulant factors.

The increased stability of hemophilic blood, due to an uncompensated excessof anticephalin activity, enables it to resist activation by cephalin or by contactwith injured walls of blood vessels or with surfaces like glass. Blood obtainedfrom normal individuals after severe hemorrhage has a decreased stability owingto an uncompensated diminution in anticephalin activity; such blood is readilyclotted by cephalin and may not remain stable even when in contact with undamaged vascular endothelium or surfaces like collodion or paraffin.

     

EXPERIMENTAL LEUKOCYTOSIS. THE INEFFICACY OF P-CHLOROXYLENOL AND METHYL ACETAMIDE AS BONE MARROW STIMULANTS

1. Single and multiple injections of CXM (methyl acetamide and p-chloroxylenol) have a similar action in increasing the total number of polymorphonuclearleukocytes in the peripheral blood of a group of 32 rats. No "shift to the left"takes place.

2. There is no stimulation of the myeloid elements of the bone marrow to suggest that this leukocytosis is due to hyperplasia.

3. The evidence suggests that the mechanism for the leukocytosis produced bythe CXM consists of releasing blood cells from depots in the body. This action isselective for the granulocytes as the red cells and platelets are not affected.

4. There is progressive degeneration of the parenchymal cells of the liver aftersingle and multiple injections of these substances.

5. If less toxic combinations of methyl acetamide and para-chloro-xylenol couldbe obtained, they might be of value in the treatment of certain patients withleukopenia or agranulocytosis more particularly when the bone marrow is hyperplastic but the granulocytes are not released.

Note: The author expresses his appreciation to Dr. Oscar Riddle for the generous provision of animal andlaboratory facilities.