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The Hemorrhagic Diseases

1. Hemophilia is a typical hemorrhagic disease. Its peculiarity being the markedly delayed time of coagulation.

Weil and others have reported most favorable results in the treatment of this condition from intravenous injections of fresh serum.

The severe anemia that follows prolonged and recurrent bleeding. demands transfusion, for no other treatment will take its place.

2. Hemorrhagic diseases of the new born have, until recent years, been intractible as to treatment. The use of serum is most effective in

those cases of moderate severity. Transfusion will, however, save many of those in which the hemorrhage is very severe and do not yield to other measures.

3. In cases of purpura, hemorrhagica and essential hemorrhages, where the loss of blood is alarming, transfusion will frequently turn the tide.

Infective and Toxic Conditions

1. It has been demonstrated by Jajer, Pool and others, that the introduction of whole blood into the veins of patients jaundiced from gall bladder, liver, or pancreatic disturbances, who are to be subjected to operation, markedly shortens the coagulation time of the blood and thereby lessens the well known tendency to hemorrhage in these cases.

2. Crile has resuscitated quite a number of patients in extremus from illuminating gas and carbon monoxide poisoning by transfusion.

3. Various observers have advocated transfusion in poisoning from snake bite, at the same time bleeding the patient from the bitten limb.

4. Experimentally, in animals, transfusion has given good results in instances of alkaloidal poisoning, but has been used but little in the human. However, now with simplified technic and apparatus, it should be practical.

5. Transfusion has been recommended by Cole for the treatment of pellagra, but the series of cases thus far reported are too few to permit of drawing conclusions.

6. Bevan says there is evidence of its value in sarcoma.

7. Certain toxemias (as of pregnancy) are benefited by it.

8. Transfusion is now an established procedure in dealing with acute and chronic infections. Repeated small amounts giving better results than larger ones.

For a time it was held that transfusion of blood had no advantage over intravenous injections of saline solution and that the mere increase in the volume of blood explained the improvement.

Modern hematology, however, has demonstrated that the blood formation is stimulated instances, increasing its coagulating properties. by the introduction of new blood and in certain

The object of transfusion then is to attain a safe, rapid and simple mode of restoring the volume of blood, but more especially its regeneration and active principles from the donor which can improve the impaired metabolism of the recipient. It. therefore, not only operates as an emergency life saver, but as a healer of dis

ease.

useful only when the organs are already in good Intravenous saline injections, however, are

condition and can withstand the immediate and violent stimulation of a large volume of fluid.

It was Bernheim's impression that where urgency was required, it was not worth while attempting the test for hemolysis, more recently Berard, who, during the present war, has em ployed transfusion with and without hemolysis tests for a large series of cases (in which clots, infections, pyrexia and other serious conditions were present) has pointed out that not a single instance of trouble from hemolysis was observed.

Notwithstanding these successes, it must not be forgotten that one is constantly confronted with this danger and that a hemolysis may occur.

For this reason, one is not justified in omitting the tests where time permits. There are undoubtedly many other conditions we encounter where transfusion might be performed to advantage, especially in combination with other treatment, both medical and surgical.

I feel that the usefulness of transfusion is just beginning to be appreciated and that the reports of the next few years will give evidence of its growing popularity and its value as a therapeutic

agent.

Bartlett Bldg.

TRANSFUSION OF BLOOD*

J. I. BYRNE, M. D., St. Joseph, Mo.

The methods of transferring blood from one individual to another have varied, as knowledge of the constituents of the blood and the effect of mixing different bloods has become more certain.

The indirect method was perhaps the first method practiced. This method is alluded to in the writings of the ancient Egyptians. Libavius advocated transfusion by silver tubes in 1615, and from that time down through the history of the operation, indirect transfusion is the only method mentioned until 1883, when Von Bergman declared that only direct transfusion of blood from artery to vein was justifiable, and that here coagulation might occur in the cannula

*Symposium on Blood Transfusion, Buchanan County Medical Society, May 15, 1918.

and result in the death of the patient from thrombus.

To Dr. George Crile of Cleveland, is no doubt due the credit of devising a technique for the direct transfusion of blood which met, in a large measure, the requirements for the successful performance of the operation, and which has been the idea from which all the other methods of direct transfusion have been evolved.

Crile commenced his experiments in 1898, and in 1907 I had the pleasure of hearing him read a paper before the American Medical Association, in which he reported most brilliant results in a large number of cases in which he had practiced transfusion. And it was the results obtained by Crile that led to the quite general use of this life saving measure by many different methods, both direct and indirect, all of which have met with a large measure of success.

Crile's method consists in using a cannula which varies from one and one half millimeters to three millimeters inside diameter; the operator selecting the sizes best suited to the size of the vessels which are being used.

A vein in the arm of the patient is dissected up under local anesthesia for about two and onehalf to three inches. The proximal end is compressed, and the distil end is tied and cut off. A single suture is passed through the free end of the vein, and the thread passed through the cannula. The wall of the vein is then grasped at three points with mosquito forceps, and the cuff turned back over the cannula, and tied with a fine ligature. The radial artery is dissected up in like manner, the lower end tied off, and the upper end compressed. The wall of the artery is grasped by mosquito forceps, and drawn ove the cuff formed by the wall of the vein on the cannula, and made secure by ligature. The compress is removed from both the artery and the vein, and the blood of the donor is permitted to enter the vein of the patient. The vessels are kept moistened by the application of salt sol. The artery will sometimes contract after it has been severed, and it may be necessary to dilate it by inserting a pair of closed mosquito forceps which have been previously anointed with vaseline, and gently separating the blades until the artery is sufficiently dilated to slip over the cuff formed by the vein. The important point in this operation is the fact that the intima of the artery is made continuous with the intima of the vein, and the blood stream is not disturbed by contact with any foreign substance.

After the anastomosis has been made, the blood is permitted to flow until the patient's blood pressure has been elevated to 110 or 120; until his pulse has come down to 140 or 150; provided the donor shows no grave ill effects from the loss of blood which he is giving up.

The impossibility of accurately gauging the amount of blood given by this method is one of the serious objections to it. The enthusiasm engendered by watching the well nigh miraculous effects of the introduction of fresh blood into the vessels of a patient near death, from hemorrhage, or other anemia producing conditions, is prone to lead the operator into injuring or even destroying the life of his patient by giving an overdose of the transfused blood, thereby causing an overdistention of the right heart and a failure of the organ from broken compensation.

Likewise the operator may overtax the donor and draw from him more blood than he can well afford to give, an accident we are most anxious to avoid, out of gratitude and consideration for the welfare of the heroic person who is willing to give his blood that another may live.

I have gone to some length to describe the direct method of Crile, because as I have said, all method, and the principle involved, of bringing of the other direct methods are founded upon this intima into contact with intima, or in lieu thereof, of providing a conduit, so protected within its lumen that the blood stream will not be injured, and clotting thereby produced when passing over its surface.

Elsberg has perfected an ingenious device which is formed upon the idea of Crile's cannula, but instead of a solid tube, the cannula is built like a monkey wrench, which can be adjusted by means of a screw. The jaws of the cannula are placed about the artery, the cuff turned down with the mosquito forceps, the same as in Crile's method; an opening is made into the vein, and the artery slipped into it. The jaws are then separated, thus permitting the flow of blood. This method is perhaps more simple than Crile's. It has the advantage of requiring less dissection of the vein of the patient, and the greater ease with which the more elastic wall of the vein may be distended and slipped over the arterial cuff.

Brewer has used a fine glass tube with a flange on each end, which he has passed into the artery of the donor and into the vein of the patient, and secured in place with ligature. After sterilizing the tube the tube is dipped into liquid parrafin oil, to secure the necessary smoothness for the passage of the blood.

This idea has been enlarged upon and improved by Bernheim, who uses two tubes which fit together and form a smooth joint in the midIde, after the ends have been secured in the artery of the donor and the vein of the patient. This method is to be commended because of the small amount of dissection necessary in order to make the anastomosis.

Horsley has developed sufficient surgical dexterity to enable him to make an anastomosis be

tween the artery of the donor and the vein of the recipient. For the purpose of supporting the vessels and holding the suture, he has devised an instrument which he calls an arterial suture staff, by the aid of which he has been able to make an anastomosis by turning out the intima of the vessels and bringing intima into contact with intima by means of mattress sutures. The idea is practical, and in the hands of one skilled in blood vessel surgery, the method will be successful, but the occasional operator would perhaps better adopt some other method.

So much for the direct methods of transfusion. It will be seen that the direct methods all require considerable surgical skill, and that they are all subject to great danger of transmitting infection from the patient to the donor and from the donor to the patient; and as I have said, the amount of blood transfused cannot be gauged, with the consequent danger attendant thereto. It has devolved upon the investigators of our profession to find some way which these dangers and inconveniences may be overcome, and out of this necessity has grown the indirect methods of

transfusion.

Dr. Edward Linderman of New York, developed the method of indirect transfusion by means of two sets of cannulas; two tourniquets, twelve 20 cc. record syringes, and three assistants. The operation is as follows:

One operator manages the syringe of the recipient, another manages the syringe of the donor; a third stands between the operators; the donor and patient are placed in a comfortable recumbent position. The veins are selected, usually the median basilic. The parts are prepared, the tourniquets applied, a cannula is inserted into the vein of the patient and a syringe filled with normal salt solution is attached, and the salt solution is allowed to flow slowly through the cannula. A cannula is next inserted into the donor and a syringe filled with warm normal salt solution attached. Everything is in readiness for the transfusion. An empty syringe is substituted for the one containing the salt solution, and a syringe full of blood is quickly drawn from the donor. The assistant passes the filled syringe to the operator on the recipient, who removes the saline syringe and attaches the syringe containing the blood. The tourniquet has previously been removed from the arm of the recipient and the blood is permitted to flow into the vein. A little salt solution is injected after each syringeful of blood, and this is kept up until the desired amount of blood has been transfused. With well trained assistants, this operation can be performed with great speed, and the quantity of blood is definitely measured, the veins have not been destroyed and may be used again for subsequent transfusion, and the time between the fill

ing and emptying the syringe is so brief that the blood does not undergo alteration.

A number of other direct methods founded upon this idea of transfusion whole blood have been devised, but time does not permit of their description in this paper. They are all somewhat cumbersome, and require the near presence of the donor and the recipient. This is objectionable, because the donor is frequently a near blood having one whose sympathies are so much inrelative of the patient, and the psychic effect of volved take such an important part in the operation is not conducive to the best welfare of the patient or the donor.

The latest and perhaps the most practical method is known as the citrate method. This method was worked out and brought to its present state of safety and efficiency by Dr. Lewishon of New York. The method is as follows:

The donor is put on a table, a tourniquet is applied to the arm and the vein punctured with

a cannula. The blood is received in a sterile

graduated glass jar containing 25 cc. of 2 per

cent sterile solution of sodium citrate at the bottom. While the blood is running into the glass receptacle it is well mixed with citrate solution by means of a glass rod. After 250 cc. of the blood have been taken, another 25 cc. of citrate solution are added. If more or less than 500 cc. of blood are taken the citrate solution is increased or diminished accordingly. The jar contaning the blood is covered with a sterile towel and set aside until the patient is ready to receive it. The blood will keep without clotting for 48 hours, but the authors are all agreed that it should be used as soon as practicable within at When ready to make the transfusion, the blood may be taken to the recipient's room, or to his home. He may be al

least twelve hours.

lowed to remain in his bed and the blood can be given to him in the same manner we have been giving other kinds of intravenous treatments to our patients. No special surgical dexterity is required. Anybody who is capable of making an intravenous injection, may perform this operation; and thus the great life saving measure of blood transfusion is placed in the hands of all.

The good effects of transfusion by the citrate method are not different than those observed in other methods. The post transfusion reaction is perhaps a little more pronounced, but in bloods that have been accurately matched prior to the operation the ultimate results are the same in this method as the result in other methods.

We have spent over $500,000,000 to clothe our soldiers. Every subscriber to the Liberty Loan has had a part in this care of the Americans who are fighting in France.

POSTANAL DIMPLES

CHARLES J. DRUECK, M. D., Chicago. Associate Professor of Proctology, Post Graduate Medical School.

In the region over the sacrum, coccyx or in the skin back of the anus there occur infoldings of the skin which are congenital in origin as a result of imperfections of foetal development. These skin pockets vary in depth from a shallow cleft in the skin to a sinus two inches long and extending usually toward the anus. These recesses are very difficult to keep clean and become filled with epithelial debris and dirt, which causes chronic irritation and infection and finally abscess (Fig. 1). When seen at this stage and it

Figure I shows discharging point at coccyx.

is rarely found earlier, it may be mistaken for a rectal sinus. If suppuration has existed for considerable time a complete fistula may exist (Fig. 2).

Figure II-Probe passed in at ulcerating point and out again nearer the anus.

Treatment-The postanal dimple is not amenable to the treatment by incision and curettage as performed for external complete rectal fistula, because the postanal dimple is lined with squamous epithelium (normal skin) and not with a pyogenic membrane. Sebaceous glands and hair follicles descend into the wall and must be removed to effect a cure.

Complete excision is the only satisfactory treatment and may be performed under local anesthesia. As a careful complete dissection is necessary, a complete circle of anesthetic wheals must be made around the operative field. first in the integument then in the deeper struc

tures, and finally well under the part to be removed. An elliptical incision is then made. around the sinus. The encircled mass is then grasped with toothed forceps and lifted out of its bed as the incision is carried underneath. Every particle of the infolded epithelium must be removed or a fistula will result. The wound may be closed with deep sutures passing well under the cut surfaces or it may be allowed to granulate as best suits the individual case.

30 North Michigan Ave.

KEEP GORGAS ON OUTPOST DUTY
DR. G. HENRI BOGART, Shelbyville, Illinois.

General Gorgas stands out, today, as the greatest life saver in all history, his salvage of life, happiness and effectiveness applies to the present era, and like the brook, "flows on forever" with constantly increasing volume. His conservation of human life, joy and usefulness outnumbers the frightfulness of destruction of the German junkermism, because that will cease when we have mopped up kaiserism with fire, whereas the prophylactic forces set free by Gorgas will grow and expand without end.

When we occupied Cuba, Havana was the scourge of the tropics, yellow fever and malarial disease ran rampant, as permanent as the tides or sunsets, until Gorgas waved the wand of scientific sanitation and lo, the Pearl of the Antilles became a health resort.

The dream of centuries was to be realized, the oceans were to wed at Panama, the most deadly bit of territory in this hemisphere, where the original railroad was represented by a "corpse. for every crosstie" and hand in hand Gorgas went with Goethals and the pesthouse of the tropics became the most salubrious residential location in America.

After the Boer war had opened the way for co-operation in unlocking the golden land of the Rand, a subtle pneumonia converted the country into a death trap. Britain called for Gorgas who went to South Africa, applied the wizardry of his intelligence and conquered the forces of death and woe.

In the Spanish-American war, more men, 13 times as many died of disease than from the combat, most of them in the home land, and at of disease in concentration camps through imperthat the majority of the death roll were victims

[graphic]
[graphic]

fect sanitation.

In the Civil war, more men died and more were invalided through disease than through combat.

In the present stress of time and of men gathered by millions, the death rate is less in the army than with the same number of like ages in civil life, because Gorgas and those who learned un

der him have taken the entire matter of caring for the physical need of our men.

Sanitary surveys have done for our cantonments and camps what they did for Havana and the Panama zone.

General Gorgas will be automatically retired because of his age, in October, unless Congress shall intervene, by passing such legislation as will leave him at the helm until this war shall have ended.

Germany has placed its old men who have the proper experience at the head, Mackensen was called from the discard and Hindenberg is past the age limit, and they are functioning as the Allies can testify.

General Gorgas with his ripe experience is too valuable to be lost to the cause.

Every doctor who shall read this article should assure himself that it is true, then he should put all the influence he can bring to bear on his congressman and senator to secure the retention of General Gorgas at the head of the sanitation of our armies.

We have spent over $120,000,000 just for staple supplies for our army, such as flour, bacon, rice, etc. Every subscriber to the Liberty Loan helps feed our soldiers.

Medicine in Other Days - The distressing news came in a telegram yesterday that Doctor Hunter, brother of E. R. Hunter, the young physician who went from here a short time ago to volunteer his services in treating victims of the awful yellow fever scourge in Memphis, had himself been stricken with the dread disease. No particulars were given as to his condition, and no reply has yet come to the telegram sent at once by Dr. J. D. Griffith asking for details. A letter written by Doctor Hunter to a friend in this city three days after his arrival in Memphis contains this graphic bit concerning the situation there: "The scene here baffles description. It resembles the ancient Golgotha when the living. were too few to bury the dead. Most of the prominent citizens of Memphis, and practically all of those who had money enough to do so, have fled the pestilence, and those left are the abjectly poor whites and negroes, with comparatively few exceptions. At once on arrival I was assigned to duty in the Fourth Ward. I am a little tired, but otherwise I feel better today than when I left Kansas City. I have seen sixty-six yellow fever cases this morning and am waiting now for my man and buggy to go out again. Have lost only one case thus far. There are three doctors down with the fever in this house. When my own time will come I know not. I am ready for it, however, at any time. Please send me the Kansas City papers, as I can learn nothing here from the outside world."-K. C. Times, Sept. 14, 1878.

A Serum for Influenza-The United States government is advised that Doctor Park of the New York Health Department has discovered a serum which he declares will prevent Spanish influenza.

Uncle Sam, M. D.-"The vast and complex job of making over our peace doctors into war doctors is the nearest thing to 100 per cent achievement that the government has yet performed in this war." In "Uncle Sam, M. D.,” in Collier's for September 21st, Samuel Hopkins Adams tells the story of this job and the way it is being done. It is an article that holds lively interest for every medical man.

War Work for Young Women-The Surgeon General's office, War Department, has issued an urgent call for young women to serve in reconstruction hospitals at home and abroad. The Normal School of Physical Education, Battle Creek, Michigan, which is affiliated with the Battle Creek Sanitarium, wishing to do its share toward winning the war, has inaugurated a course in physiotherapy, which meets the requirements of the War Department. Courses begin Oct. 1st and Feb. 1st. Length of course is 4 months. The curriculum consists of anatomy, physiology, hygiene, bandaging, active and passive movements, hydrotherapy, massage, electrotherapy, and clinics. The medical profession are asked to direct the attention of young women who are planning to engage in war work to this unusual opportunity. Further information may be obtained from Frank J. Born, M. D., Director of the School. ..

A SAD SWALLOW
Oh, he swallowed half a dollar
And it lodged down below the collar,
But by a stroke of scientific skill
The coin was excavated

When the surgeon operated,

And the man "coughed up" a twenty dollar bill!
-Cartoons Magazine.

A VERY ANCIENT STORY

Steadfast eyes in the heaven's blue;

Golden hair in the sunlight's gleams; Unshed tears in the morning dew And the face of her in the dark of dreams.

Tender lips in the rose's blush;

Shy, sweet words in the rippling seas; Soft, pink palms in the dawn's first flush And the touch of her in the summer breeze. But for these, and the swelling hills,

Stars and trees and the clouds above, Birds and flowers and fields and rills,

I would soon forget what I know of love. -Kenneth L. Roberts in the N. Y. Evening Sun.

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