occurrence and demonstration of blood group antibodies, anti-C, anti-A1, and a third incompletely identified atypical hemagglutinin, subsequent to multiple whole blood transfusions; (3) the use of exchange transfusion as a therapeutic agent during the most acute phase of intravascular hemolysis,
REPORT OF CASEThe patient, a 15-year-old white girl, was admitted to the hospital for the first time on July 9, 1949, with complaints of generalized weakness and fatigability and of migratory joint swellings. Her first difficulties began seven months prior to admission with a brief episode of lowgrade fever and widespread joint pains which subsided until six weeks before admission, when fever and alternate warm painful swellings of the finger, elbow, and knee points again developed. This was followed shortly thereafter by persistent weakness, occasional headaches, and slight weight loss, together with some loss of appetite. In addition, the patient and her parents had both noticed some increased cloudiness of the urine. She was seen by another physician, who detected the presence of a severe anemia. Her therapy up to the time of admission included iron and salicylates by mouth. There had been no history of a recent infectious process. Physical examination revealed a rather thin pale girl with a temperature of 99 F., pulse rate 100, and blood pressure 112/80. The only other positive finding at the time was a moderately loud apical systolic murmur transmitted up the left sternal border. The results of laboratory examinations were as follows: Urine was cloudy, with specific gravity of 1.013, albumin 1+, no white blood cells, very numerous red cells, and occasional granular and hyaline casts. Blood examination showed hemoglobin 9.4 gm. and white blood cell count 4,650, with a differential cell count of 74% poly¬ morphonuclear leucocytes, 25% lymphocytes, and 1% monocytes. Total serum proteins were 6.75 gm. per 100 cc, of which albumin was 3.5 and globulin 3.25 gm. Blood urea nitrogen was 40.5 mg. per 100 cc. and phenolsulfonphthalein excretion was 25% at the end of one hour. Urine culture demonstrated no pathogens. A first strength tuberculin test (purified protein derivative) was negative. The blood type was ARh-f. Between July 9, 1949, and July 23, 1949, the patient's course remained essentially unchanged and she received no specific treatment except for the correction of her anemia with five transfusions of whole ARh-)-blood, which were compatible by the usual cross matching techniques. However, the presence of "rouleaux" in one cross matched blood was reported (Table 1). Her only reaction was in the form of headache, increased weakness, and listlessness following the fifth transfusion. She was discharged apparently improved on July 23, 1949, with a hemoglobin of 13.5 gm.
