THE NATURE, DIAGNOSIS, PROGNOSIS AND TREATMENT OF GENERAL PARESIS

CHARLES R. BALL
1913 Journal of the American Medical Association (JAMA)  
spoken to me about some cases in which transfusion by the union of blood-vessels failed. I suggested that we try to work out some simple methods of transfusion. I am gratified to learn from the discussion here to-day that a good many simple methods have already been used. For instance, Dr. Cooley's method, in which ho used a syringe with an ordinary needle and a method of drawing the blood in at one side, and throwing it out from the other with a "Y" shaped connection, is doubtless a good one.
more » ... btless a good one. Dr. Edwards and I have a method which we think more certain of success and more easy of use than any method yet discovered. I think that all physiologists will agree that it is best to use for transfusion the normal blood. That is the least dangerous. Defibrinatcd or salted blood are departures from the normal. From theoretic considerations, however, the least objectionable salt to use for that purpose would be sodium oxalate. We have performed some experiments on animals, using this salt. It works very well. We draw into the syringe about 0.5 c.c. of a 1.0 per cent, solution of sodium oxalate and then draw the syringe full of blood. When this is done it will not clot. The needles which we have tried on animals are fashioned so that when once inserted they will not come out, neither will they cause laceration of the wall of the vessel. I think that Dr. Cooley is right-wc should not necessarily call in a surgeon to do transfusions. Those living in the country cannot always get a surgeon. They must go ahead and do the simplest transfusion possible. If they employ this syringe method, "they will know how much blood they arc transfusing. Sonic surgeons tell me tha,t when they use the more complex methods they arc not certain how much they transfuse, or indeed, whether or not they transfuse any blood at all. Apparently the* right, tendency is toward a simple method and toward the use of a syringe with the trocar cannula needle. Dr. T. B. COOLEY, Detroit: In regard to the blood necessary for transfusion. Dr. Lespinassc has said that in direct anastomosis methods it is advisable to transfuse babies until they are red. In the case reported, the child was practically dead when we started. We used altogether 20 c.c. of blood, with salt solution between the blood injections. We did not carry transfusion anywhere near the point of redness of the child. The child was still pale, but we could sec a definite improvement; the pulse was becoming stronger and we felt safe in waiting; we knew that we eould transfuse more blood at any time. The child did well. As regards transfusing blood slowly, we used injections of salt solution between the injections of blood. Maybe, if wc luid put in one blood injection after another, we should have gone too fast. The point that I was especially anxious to make was that the doctor in the small town can do transfusion with one of these simplo methods. It is a thing anybody can do who can dissect out a blood-vessel. Nobody answered Dr. Hess' question about anaphylaxis. 1 have been unable to find any reports about anaphylaxis from the use of antitoxin in this way. Those of us who use diphtheria antitoxin extensively know that the proportion of anaphylaxis is slight. When horse-scrum has been used in a large number of hemorrhagic cases, we shall probably hear of some cases of anaphylaxis, There is one thing quite evident in regard to flic etiology of nearly all of these conditions-they arc the result of toxemia of some kind. Toxemia resulting from lack of oxygen is certainly a. possible cause. I was careful to except hemophilia from the conditions in which one gets a permanent cure. I do not think that the addition of oxalate to the blood is necessary or desirable to prevent the blood from coagulating. If one can delay coagulation of the blood a little time, that is all that is necessary. If wc are sure of our teehnic we can do this without any other assistance. Dr. Brooks' needle is much like one which Dr. Vaughan and 1 made, although wc decided that it was not absolutely necessary to have a special needle. The honor of having first discovered a relationship between paresis and syphilis belongs to Esmarch and Jessen. These observers in 1857 reported three cases of paresis, the cause of which they attributed to syphilis. Thus a controversy of this subject began which has lasted for more than half a century. The consensus of medical opinion has held that in the great majority of cases syphilis is the chief etiologic factor which causes paresis. Of the opponents of this doctrine N\l=a"\ckewas the most extreme. He considered a neuropathic inheritance as a most important cause and assigned to syphilis an equal importance among other etiologic factors, maintaining that it often furnished the last offense for the development of the disease. It was not until the discovery of the Wassermann reaction and its regular observance in both the blood and spinal fluid of paretics that the doctrine of no syphilis, no paresis, could be said to have found universal acceptance. Until recently parasyphilis has been regarded as an effect of syphilis, the ashes of a fire which long ago has burnt itself out, the result on the nervous system of a toxin which might be compared to the action oí the toxin of diphtheria in diphtheritic paralysis, when the exciting factor, in both instances, had passed away, but the harmful influence still acted in a progressive manner. A number of reasons may be given why we have so persistently refused to accuse the spiroehetes of occupying the chief rôle in the causation of the symptoms of paresis. The apparent absolute inefficiency of antispecific treatment, the fact thai the pathology of paresis1 was said not to be the pathology of syphilis and the failure to discover the spiroehetes in the tissues of the central nervous system are the chief reasons. Since the discovery of the AA7assermann reaction, however, and its positive finding regularly in paresis, the suspicion has steadily grown that the Spirochaela pallida is actively and directly concerned in paresis. Plant calls attention to the fact that a paretic behaves with référence lo Hie serum reaction similarly to a syphilitic in the active stages and not as a tertiary luetic without symptoms. This indicates, according to Plaut, a more active participation of the spiroehetes in paresis than was formerly thought. lie believes that there is a close relationship between (he activity of the specific virus and the Wassermann reaction. Nonne says that occasionally the blood of a paretic may give a negative AVassermann and thai rarely also all four actions may he negative in tabes. These results usually occur, however, in exceedingly long-standing and chronic cases after the active process and progression of symptoms have long since terminated. This observation of Nonne's would seem to support Plant's contention. The fact that active syphilitic processes in the nature of guinmala and specific eiularteriiis are found both in paretics and in tabetics also argues for a close connection between the spiroehetes and paresis. Recently E.
doi:10.1001/jama.1913.04350150037012 fatcat:4oortfgqinf7zjm6be3snd3dju