THE JOURNAL OF UROLOGY
Vol. 89, No. 6 June 1963
Copyright © 1963 by The Williams & Wilkins Co.
Printed in U.S.A.
THE IMPORTANCE OF HEMOLYSIS IN TRANSURETHRAL PROSTATIC
RESECTION: SEVERE AND FATAL REACTIONS ASSOCIATED WITH
THE USE OF DISTILLED WATER
C. D. CREEVY
From the Urological Division, Department of Surgery, Medical School of University of Minnesota,
Minneapolis, Minn.
As transurethral prostatic resection became
popular, many resectionists commented upon the
occurrence of postoperative oliguria and uremia,
occasionally with a fatal outcome. This was at-
tributed variously to acute pyelonephritis, ob-
structive diseases from injury to the ureteral
orifices, prolonged severe hypotension (hemor-
rhage, surgical shock, anesthesia), sulfonamide
toxicity, and the transfusion of incompatible
blood. It soon became clear, however, that some
of the reactions occurred in the absence of these
factors. Typically, there might be a chill followed
by cyanosis and restlessness during or imme-
diately after the operation. There then ensued
oliguria, uremia, anemia out of proportion to the
blood lost and, in severe cases, mild non-obstruc-
tive jaundice perhaps with late hypertension.
The effects of surgical shock and hemorrhage
upon the kidneys are well known. Both cause
virtual cessation of glomerular blood flow in the
experimental animal.1 · 2 If prolonged, this leads
to tubular degeneration which soon becomes
irreversible. In the dog, azotemia may accom-
pany a large, rapid hemorrhage even if hypoten-
sion is prevented and replacement of blood is
prompt. 3 The inciting factor appears to be vaso-
spasm with secondary hypoxia of the renal
tubules. 4 It is a reasonable assumption that these
effects will occur at a higher level of blood pres-
sure in the hypertensive than in the normotensive
individual, but this has not been proved.
Accepted for publication November 6, 1962.
Presidential address given before the Minnesota
Academy of Medicine, May 2, 1962.
1 Phillips, R. A., Dole, V. P., Hamilton, P. B.,
Emerson, K., Archibald, R. M. and Van Slyke,
D. D.: Cited by Harrison, Boren and Robison."
2 Van Slyke, D. D.: Cited by Goodpastor, W. E.,
Levenson, S. M., Tagnon, H.J., Lund, C. C. and
Taylor, F. M. L.: A clinical and pathologic study
of the kidneys in patients with burns. Surg.,
Gynec. & Obst., 82: 652, 1946.
3 Corcoran, A. C. and Page, I. H.: Post trau-
matic renal injury; summary of experimental ob-
servations. Arch. Surg., 51: 93, 1945.
4 Maegraith, B. G., Navard, R. E. and Parsons,
D. S.: Cited by Harrison, Boren and Robison. 37
AND M. P. REISER
In a casual conversation in 1946, Foley&
stated that he had seen bright red urine spurting
from the ureteral orifices at the end of a trans-
urethral resection, and surmised that this repre-
sented a hemolytic reaction. Emmett 6 said that
McLaughlin, then a resident in urology at the
Mayo Clinic, had hypothesized that transurethral
resection might lead to hemoglobinemia.
A few days later, E. A. Webb, an associate
of one of us (C. D. C.) working in a private
hospital, removed 45 gm. prostatic tissue from a
good surgical risk aged 68 with a blood pressure
of 160/90, only to be confronted by the syndrome
just outlined. 7 That evening the patient's plasma
was a deep mahogany red (facilities for measuring
the free hemoglobin of the plasma were lacking).
The patient had not received a transfusion of
blood. Five hundred milliliters of 5 per cent
sodium bicarbonate were given intravenously, as
has been recommended in hemolytic reactions
from the transfusion of incompatible blood. 8
Next day he was confused, oliguric and slightly
jaundiced. The hemoglobin had fallen from 87 to
50 (Sahli) with a measured blood loss of 600 ml.;
the plasma was still red. Oliguria continued; the
urea nitrogen had risen to 109 on the seventh
postoperative day. The blood pressure reached
190/104. Peritoneal lavage was instituted and,
while the urea nitrogen fell to 67, auricular fibril-
lation appeared. Digitalization availed nothing,
and the patient died on the twelfth postoperative
day. Application of current knowledge of fluid
and electrolyte balance would doubtless have
resulted in survival. Death was apparently due to
absorption of lavage fluid from the peritoneal
cavity.
Autopsy disclosed peripheral and pulmonary
edema and pleural effusion together with typical
5 Foley, F. E. B.: Personal communication.
6 Emmett, J. L.: Personal communication.
7 Creevy, C. D.: Cited by Harrison, Boren and
Robison. 37
8 Baker, S. L. and Dodds, E. C.: Cited by Har-
rison, Boren and Robison. 37
900
 HEMOLYSIS IN TRANSURETHRAL PR.OSTATIC RESECTION
hemoglobinuric nephrosis. There was no hydro-
nephrosis.
This prompted us to review the causes and
effects of hemoglobinuria. It accompanies black-
water fever,~' 10 severe burnR, 11 obstetrical mis-
haps,12 crush injuries (rn.yoglobin as well as
hemoglobin) 13 and the transfusion of mismatched
blood. There are, of t·ourne, other hemoglobi-
nurias, but they are of infrequent occurrence and
rarely if eYer cause scriotrn renal dysfunction.
The concentration of hemoglobin in the plasma
necessary to cause hernoglobinuria varies with
circum.stances, but is probably well above 100 mg.
per cent;14 the ]eye] which inflicts serious damage
11pon the hitherto normal kidney is much higher:
3700 to 5100 mg. per cent.14, 15 In any case,
hemoglobin is clemonstrnble in the plasma for
about 72 bours, during ,crhich time about a third
can be recovered from the urine of the experi-
mental animal, while t,rn-thirds appear to he
taken up by the reticulocnclothelial system. 14
)1.rrival of any substantial amount of free
hemoglobin in the renal circulation of the experi-
mental animal is signaled by an abrupt shrinkage
of the kidney, 9 , 16 • 17 doubtless clue to Yasocon-
striction which causes, as in hemorrhage or
shock, tubular hypoxia. ,\s a consequence, there
develops degeneration of the renal tubules with
vacuolization, necrosis, and cellular infiltration.
In addition, so many collecting tubules contain
pigmented (heme) casts of uncertain eomposition
as to suggest to some observers8 that renal insuffi-
results from obstruction of the tubules.
However, the same type of renal failure occurs, in
prolonged shock and with some exogenous toxins,
without the pigmented casts. It seems probable
that the damaged tubular epithelium permits
9 Barratt, J. 0. and Yorke, W.: An investigation
into the met.hod of production of blackwater
fever. Ann. Trop. Med., 3: 1, 1909.
10 DeHaan, J. Arch. f. Schiffs u. Trop. Hyg., 9:
1905.
Shen, S. C., Ham, T. H. and Fleming, E. A.:
Studies on the destruction of red blood cells. New
Engl. .L 229: iOl, 1943.
"Paxson, F., Golub, L J. and Hunter, R.
.M.: The crush syndrome in obstetrics and gyne-
cology. J.A.M.A., 131: 1500, 1945.
13 Bywaters, E. G. L. and Beall, D.: Cited by
Harrison, Boren and Robison.37
14 Fairley, N. H. and Bromfield, R. L.: Cited by
Harrison. Boren and Robison. 37
15 Flinlz, E. B.: Certain aspects of hemoglobi-
nemia. Thesis of the Graduate School of Medicine
of the University of Minnesota, 1945.
16 Hesse, E. and Filatov, A.: Cited by Harrison,
Boren and Robison.37
17 Levy, L. · Cited by Harrison, Boren and Robi-
son.37
901
absorption of the glomerular filtrate the inter·
stitial tissues and thus causes oliguria .
Since the high levels of plasma hemoglobin
regarded as necessary to cause
renal failure have not been found after trans-
urethral resection, it seems likel_v that the: effeci·,
of hemoglobinemia therein is "the straw that
breaks the camel's back." Tha.t is to ,my, thcl
average patient ,Yith prostatism
some degree of renal arteriosclerosis and
some hydronephrosis or pyelonephritis, a,JI cl
which probably predispose the kidney to the
type of clamage under discussion, ' 8 and which
potentiate the renal effeets of hemoglobinemia in
the dog. Many also haYe hypertension. ;\lore-
over, the patients are often subjected to
bleeding and to some degree of >N'U""'~""', bnt,h
of which <'an cause renal vasospasm; there: 1s
undoubteclly an additfre effect.
It is unlikely that hemoglobinemia
unless very severe, can caus01 mueh tronblc·. This
is indicr1ted by observations that the intrave-
nous injection of sufficient hemoglobin te> cause
protracted hemoglobinuria in a normal liurnau
has not producecl clinically detectable re1w l
damage.19, zo
The mechanism of hemolysis trm1~-
urethral prostatic resection is pretty C'lcar: l\
Large veins containing blood at 1·ery low pre~-
sures (l to 2 cm. are opcneJ during the
operation if one seeks to make it
the irrigating fluid must come in at a pressure
high enough to wash away the blood
to permit good vision; 3) Lilood hemolyzed in t!w
bladder is driYen into these veins along with
irrigating fluid,
The treatrnent (or eYen
hemolytic reactions has failed to correct or pre·
vent the renal lesions both experimentnlly and
clinically. 15 • 22 Kallner 23 has reported recovery
following heparinization after the transfosion qf
18 Goodwin, W. E., Cason, F. and RcotL,
W. W. : Cited by Harrison, Boren and Re bison."
19 O'Shaughnessy, L., Mansell, H. E. and Slome,
D.: Cited by Harrison, Boren and Robison."
20 Sellards, A. W. and Minot, C. R. · Cited by
Harrison, Boren and Robison. 37
21 Fillman, E. M., Hanson, 0. L. and Gilbc;rt,,
L. 0.: Radioisotopic study of effects of irrigatmg
fluid in tra.nsurethral prostatic resectfon
.J.A.M.A,, 171: 1488, 1959.
22 Walker, J., Jr.: Cited by Goodpastor W. E.
Levenson, S. lvI., Tagnon, H.J., C.
Taylor, F. JVL L.: Surg. Gynec, & 82: 652
1946.
23 Kallner, S.: Thrombosis as a
internsJ diseases. Arch. Int. Med., 81:
902 C. D. CREEVY AND M. P. REISER
incompatible blood, but this is not applicable to
an operation which leaves a raw surface.
A clinical investigation of hemolysis in trans-
urethral prostatic resection was carried out in
1947 and 1948. The plasma hemoglobin was
measured in 78 controls both before and after
open operations outside the urinary tract. It was
unaltered after such operations, whether done
with a scalpel or with surgical diathermy, nor
was it altered by the solutions (glucose, saline)
so often given intravenously after operation.
The plasma hemoglobin and blood sugar were
next measured before and at the end of 106 trans-
urethral prostatic resections with distilled water
for irrigation.
Preoperative Postoperative
Plasma hb. 3.0 mg.% 45.0 mg.%
(high 490)
Blood sugar 87.lmg.% 86.9 mg.%
Four per cent glucose was then used as the
irrigant, and the same measurements were
repeated in 185 cases.
Preoperative Postoperative
Plasma hb. 7.3 mg.% 3.5 mg.%
81.0 mg.% 198.0 mg.%
Blood sugar
(high 1079)
No diabetics were included, and no glucose was
given during operation to those patients whose
blood sugars were measured.
Concomitantly, the blood was cultured just
before and at the conclusion of instrumentation
in 300 cases; all preoperative cultures were
sterile; 60 per cent of those drawn at the end of
resection were positive.
In addition, Dr. E. T. Bell kindly reviewed all
of the autopsies performed up to July 1947 on
patients dying after transurethral resection; pig-
mented casts were found in the renal collecting
tubules of six of them.
These observations appear to prove several
things: 1) Irrigating solution and hemolyzed
blood enter the systemic circulation during opera-
tions done with distilled water; 2) water and
glucose but no free hemoglobin enter the circula-
tion when isotonic glucose is used; and 3) l;iac-
teria may enter in either case.
These conclusions have since been supported
by others. The free hemoglobin of the plasma has
risen after resection with distilled water ;18 • 24- 28
salicylates added to the irrigating fluid have been
found in the blood; 27 the blood sugar rises when
glucose is used ;29 • 30 and the plasma hemoglobin
does not rise if isotonic solutions are employed. 18 ·
30 · 31 The entrance of irrigating solution into the
circulation has also been proved by the following
observations: gain in weight during operation; 32-35
development of hyponatremia in the operative
or immediate postoperative period; 32 · 33 · 35-4o
absorption of radioactive chromium and iodine
added to the irrigating fluid, 21 · 41 contrast agent
instilled into the bladder at the end of operation
and allowed to remain for a few minutes is ab-
sorbed sufficiently to permit visualization of the
24 Biorn, C. L. and Greene, L. F.: Cited by Har-
rison, Boren and Robison. 37
25 Bunge, R. G. and Barer, A.: Cited by Har-
rison, Boren and Robison. 37
26 Garske, G. L., Phares, 0. C. and Sweetser,
T. H.: Cited by Harrison, Boren and Robison. 37
27 Landsteiner, E. K. and Finch, C. A.: Cited by
Harrison, Boren and Robison. 37
28 Woodruff, L. M. and Firminger, H. I.: Cited
by Harrison, Boren and Robison. 37
29 Lane, T. J. D. and Jessop, W. J.E.: Uremia;
a survey of some recent developments. Irish J.
Med. Sc., 275: 707, 1948.
30 Robbins, M. A., Olson, W. H. and Rolnick,
H. C.: Clinical observations on the use of a hemo-
lytic and non-hemolytic irrigating medium for
transurethral prostatic resection. Surgery, 27:
254, 1950.
31 Nesbit, R.: Personal communication.
32 Ceccarelli, F. E. and Mantell, L. V.: Studies
on fluid and electrolyte balance during trans-
urethral prostatectomy. J. Urol., 85: 75, 1961.
33 Ceccarelli, F. E. and Smith, P. C.: Studies on
fluid and electrolyte alterations during trans-
urethral prostatectomy. J. Urol., 86: 434, 1961.
34 Pierce, J. M., Jr.: The treatment of water
intoxication following transurethral prostatec-
tomy. J. Urol., 87: 181, 1962.
35 Taylor, R. 0., Mascon, E. S., Carter, F. H.,
Bethard, W. F. and Prentiss, R. J.: Volumetric,
gravimetric and radioisotopic determination of
fluid transfer in transurethral prostatic resection.
J. Urol., 79: 490, 1958.
36 Hagstrom, R. S.: Cited by Harrison, Boren
and Robison.3 7
37 Harrison, R. H., Boren, J. S. and Robison,
J. R.: Delusional hyponatremic shock, another
concept of transurethral prostatic reaction. J.
Urol., 75: 95, 1956.
38 Hoyt, H. S., Goebel, J. L., Lee, H. I. and
Schoenbrod, J.: Types of shock-like reaction dur-
ing transurethral resection and relation to acute
renal failure. J. Urol., 79: 500, 1958.
39 Maluf, N. S. R., Boren, J. S. and Brandes,
G. F.: Absorption of irrigating solution and as-
sociated changes of transurethral resection. J.
Urol., 75: 824, 1956.
40 Marx, G. F., Koenig, J. W. and Orkin, L. R.:
Dilutional hypervolemia during transurethral re-
section of prostate. J.A.M.A., 174: 1834, 1960.
41 Griffin, M., Dobson, L. and Weaver, J. C.:
Volume of irrigating fluid transfer during trans-
urethral prostatectomy, studied with radioiso-
topes. J. Urol., 74: 646, 1955.
 HEMOLYSIS IN TRANSURETHRAL PROSTATIC RESECTION 903

renal pelves;42 and the urea nitrogen of the blood TABLE 1. Causes of death after transurethral
has risen during operation when urea has been prostatic resection (to December 31, 1961)
added to the isotonic irrigating fluid. 43 In addi-
Number of Deaths
tion, hemoglobinuric nephrosis has been found Diagnosis
by others at necropsy in patients dying after Private Clinic Total
transurethral resection. 26 , 44-47 ------------ ---------
Since some observers currently attribute most Myocardial infarction 4 3 7
adverse reactions during and after transurethral Septicemia 2 4 6
resection to hypervolemia and hyponatremia, it is Uremia 3 1 4
necessary to point out that the two disorders Sudden death-no autopsy 1 3 4
differ in their manifestations. A hemolytic reaction Pneumonia 1 2 3
is characterized by cyanosis, confusion, hemo- Pulmonary embolism 1 2 3
globinemia, anemia out of proportion to blood Cerebral vascular accident 0 2 2
Cerebral damage from shock 1 1 2
loss, oliguria, uremia, mild jaundice and, at times,
Hypervolemia 0 2 2
by late hypertension. The onset of hypervolemia Ruptured abdominal 1 0 l
is usually signalled during operation by hyper- aneurysm
tension and bradycardia. The secondary hypo- Drug poisoning 0 1 1
natremia, if severe, results in confusion, apathy, -- --- --
a rapid pulse, hypotension and, if neglected, to Total 14 21 35
ileus and to edema. Renal failure is not associated
with this type of reaction unless the hypotension Total Cases
is severe and persistent.
Private Per Cent Per cent Com- Per Cent
Berg and Fisher48 have confused the two reac- Mortality Clinic Mortality bined Mortality
tions which, as just noted, are easily differentiated --- --- --- --- ---
from one another. They have quoted the senior 1568 0.82 2317 0.9 3885 0.9
author as attributing the symptoms of hyper-
volemia-hypernatremia to hemolysis; their state-
ment is incorrect. per cent. During the same period the residents in
Strongly suggesting that our assumptions urology at the University Hospitals, while learn-
concerning hemolysis are valid is the mortality ing transurethral resection, have operated upon
rate for transurethral prostatic resections done in 2317 patients, 21 of whom died, a mortality rate
the University of Minnesota Hospitals since the of 0.9 per cent (table 1).
introduction of isotonic irrigating solutions. Up to 1947, the mortality rate here and else-
Between then and December 31, 1961 the writers, where in the hands of experienced resectionists
together with Drs. W. E. Price, B. A. Smith, and ranged from three to five per cent or more and,
E. A. Webb have operated upon 1568 consecutive in many clinics, still does. In an analogous series
patients with 14 deaths, a mortality rate of 0.8 of 2015 cases at the University of Kansas, Valk
and Holtgrewe49 have reported a surgical mortal-
42 Wear, J. B.: Cited by Harrison, Boren and ity rate of 1.6 per cent for the staff and 3 per cent
Robison.3 7 for the residents. They used glycine to make the
43 Pennisi, S. A., Rowland, H. S., Jr., Vinson,
C. E. and Bunts, R. C.: Hyponatremia as af- irrigating solution isotonic, and had 10 deaths
fected by various irrigants used during trans- from pulmonary embolism, while we have had
urethral electro resection of the prostate. J.
Urol., 86: 249, 1961. but three proved cases.
44 Bell, E. T.: Personal communication, 1946. Even if one were to add our "four sudden
45 McGinn, E. J., Miale, J.B. and Frye, J. W.:
deaths-no autopsy" to the three known to be
Hemoglobinuric nephrosis in transurethral pros-
tatic resection; treatment by peritoneal lavage. due to pulmonary embolism, this would make
Urol. & Cutan. Rev., 52: 509, 1948. seven pulmonary embolisms in 3885 cases as com-
46 Stewart, C. B. and Taylor, J. R.: Trans-
urethral prostatic resection; 1000 cases. Canad. pared to 10 in 2015, an incidence of 1.8 per
Med. Ass. J., 65: 29, 1951. thousand as compared to 4.9 in Valk's series, or
47 Wardill, W. E. M.: Cited by Harrison, Boren
and Robison. 37 49 Holtgrewe, H. L. and Valk, W. L.: Factors
48 Berg, G., Fedor, E. J. and Fisher, B.: Physio- influencing the mortality and morbidity of trans-
logic observations related to transurethral resec- urethral prostatectomy; a study of 2,015 cases. J.
tion reaction. J. Urol., 87: 596, 1962. Urol., 87: 450, 1962.
904 C. D. CREEVY AND M. P. REISER

TABLE 2

Preop Admission Postoperative

No. of Days Autopsy
No. Age Dialyses Result Lived
Postop BUN K+ AB BP Transf.
BP BUN
Day Titer
~

- --~ - -- - -- .- --

l 63 110/80 30 6 140 5.8 0 80/? 0 1 Died 11 Hemoglobinu-

ric nephrosis

2 70 ? 21 8 204 7.5 Neg. 180/80 1000 3 Alive - -·-

3 55 120/70 15 10 172 6.1 Neg. 140/95 500 1 Alive - -

4 69 170/90 19 11 157 4.8 0 170/80 0 1 Alive - -

5 69 120/90 NU* 4 120 5.6 Neg. 160/70 3500 4 Died 44 Hemoglobinu-

ric nephrosis

6 74 160/90 NU* 5 213 - - 200/100 900 Not ad- Died 5 Tubular ne-
mitted phrosis
I

* Normal urogram.

2.7 times as high a rate. It is tempting to specu-
late that the difference is due to the use of glucose
in our series and of glycine in his, but there are
too many other variables.
No hemolytic reaction has been encountered
either clinically or pathologically in our 3885 cases.
Despite this rather impressive evidence, some
urologists continue to use distilled water, claim-
ing either that they cannot see unless the blood
is hemolyzed, or that there is plenty of time to use
isotonic solutions after the veins have been
opened; the latter reasoning overlooks the fact
that, because of low venous pressures in the
pelvis, water may enter open prostatic veins for
some time before being noticed. Another favorite
is to "limit resecting time to one hour" to a void
hemolytic reactions from distilled water. It is
more rational to prevent them by using isotonic
irrigating fluid. The hyponatremic syndrome, if it
occurs, is readily recognized and corrected.
The interest of the junior author (M. P.R.) in
the artificial kidney has led to the admission to
the University Hospitals of many patients with
oliguria from. diverse causes. Among these were
five whose renal failure followed transurethral
resection done elsewhere with distilled water as
the irrigating agent. A sixth patient seen by him
in consultation was moribund and was not ad-
mitted, but clinical and autopsy data are in-
cluded. Table 2 lists some facts concerning these
cases. Information available from the hospitals
of origin is incomplete in some respects. This sug-
gests that, despite ready availability of informa-
tion concerning the various types of reactions
which may follow transurethral prostatic resec-
tion, some resectionists are unaware of the possi-
bilities, or ignore them.
Thus there were incomplete records of fluid
intake and output, of daily variations in weight,
and of hematocrit and sodium determinations.
All of these are valuable aids when things go
wrong after such operations. Moreover, only one
patient had the plasma hemoglobin measured in
the immediate postoperative period-it was
610 mg. per cent. Blood losses were not measured;
this simple precaution yields essential information
sooner than does measurement of the hemoglobin
or hematocrit.
Other factors predisposing to renal failure were
present in several cases. Thus, one patient re-
quired norepinephrine for 24 hours postopera-
tively for hypotension. However, hemoglobinuric
nephrosis was found at autopsy, although the
patient had received no transfusion. Three of
the other 4 patients admitted had been transfused
(300 to 1000 ml.), but all had negative antibody
titers, suggesting but not proving that incom-
patible blood had not been a factor in their
untoward reactions. Two of the five had some
elevation of the blood urea nitrogen preopera-
tively, indicating pre-existing renal disease as a
factor predisposing to a hemolytic reaction.
 HEMOLYSIS IN TRANSURETHRAL PROSTATIC RESECTION
There was no evidence of injury to the ureteral
orifices in any of the five. The other patient who
died had the typical renal lesions at autopsy.
The sixth patient, who was moribund when
seen in consultation and so was not admitted,
had received 3500 ml. blood, and thus had other
important factors capable of damaging his kid-
neys. His antibody titer was not determined, but
he had no heme casts in his renal tubules, so that
this may represent the vasospasm of severe and
rapid hemorrhage, perhaps with hypotension.
SUMMARY AND CONCLUSIONS
The factors which may cause renal failure after
transurethral prostatic resection, and attribut-
able to the operation itself, include: rapid, severe
hemorrhage, surgical shock with prolonged hypo-
tension, acute pyelonephritis, injury to the
ureteral orifices, and the entrance of distilled
water containing hemolyzed blood into open
prostatic veins.
The occurrence of the last named has been
proved by a rise in the free hemoglobin of the
plasma during operation; an increase in blood
sugar when glucose is added to the irrigating
fluid; the occurrence of dilutional hyponatremia;
905
a gain in weight during operation; and the ab-
sorption of chemicals, of radioactive isotopes, and
of contrast agents added to the irrigating fluid.
One of the noxious factors-hemolysis-is
easily avoided by using an isotonic irrigating
fluid free from electrolytes. This has apparently
caused a striking reduction in surgical mortality.
Hemolytic reactions continue to cause uremia
and death when these facts are ignored.
Five cases seen by the artificial kidney team
have been briefly reviewed. The two who died
had hemoglobinuric nephrosis without evidence
of reaction to the transfusion of incompatible
blood.
Two had these reactions, one fatal, in the
absence of transfusion.
REFERENCES
ANDERSON, w. A. B., MORRISON, D. B. AND
WILLIAMS, E. F.: Pathologic changes follow-
ing the injection of ferrihemate (hematin) in
dogs. Arch. Path., 33: 589, 1942.
CREEVY, C. D.: Cited by Harrison, Boren and
Robison. 37
CREEVY, C. D. AND WEBB, E. A.: Cited by Har-
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FoY, H., ALTMAN, A., BARNES, H. D. AND KAum,
A.: Cited by Harrison, Boren and Robison. 37
WHISENAND, J.M. AND MosEs, J. J.: Electrolytes
found in irrigating fluids during transurethral
prostatectomy. J. Urol., 85: 83, 1961.