19. Boston Med. and Surg. Jour., 1902, CXLVIII., p. 435. Monatschr. f. Geb. u. Gyn., Berlin XXI., 1905, p. 353. 21. Zeitschr. f. Geb. u. Gyn., Stuttg., 1905.

20.

22. Teacher: Jour. Obst. and Gyn., Brit. Emp., 1903-04. STONELEIGH COURT.

THE EFFECT OF BLOOD TRANSFUSION ON A PATIENT WITH PUERPERAL SEPTICEMIA.

BY

. W. J. STEWART MCKAY, M.B., M.CH., B.Sc.,

Sydney, New South Wales.

Senior Surgeon, Lewisham Hospital for Women.

My object in reporting this case is to show that the rigors of puerperal septicemia may be abolished by the transfusion of blood. I also wish to point out the negative effect of enormous injections of antitoxin in this case, and lastly I wish to describe my method of transfusing blood.

The patient, aged twenty-five years, was sent to my private hospital by a general practitioner, who told me that the patient had been prematurely confined of a seven months' child. The placenta had not come away satisfactorily, so he had introduced his fingers into the uterus, and a few days later, when the temperature rose, he had curetted the uterus. Three days later (the fifth day after labor) she was admitted into hospital. She had a slightly offensive discharge, and was ordered a douche, and antitoxin was injected.

Having found on several occasions that the antidiphtheritic serum seemed to act well when the antistreptococcus serum failed, I ordered her to have 2,000 units of these sera alternately every four hours. As she showed no signs of improvement after thirty-six hours, I administered an anesthetic, and made an examination with my hand covered with a rubber glove. A specimen of the uterine discharge was saved for examination, and the examination showed that it was a streptococcus infection.

The uterus was found to be quite empty, so nothing was done beyond douching it with hot water.

The patient grew steadily worse after the examination, so the antitoxin was increased.

The amount given is shown in the following table:

When the amount of serum injected was small a large syringe was used, but when the amount of serum was large it was found

168,000 units in 7 days.

Fig. 1. Glass cannula. C, glass wings around which the silk ligature that fixes the cannula on the vein may be twisted, so as to prevent the cannula being torn out of the vein. The slight swelling, A, and the neck, B, will both aid in keeping the cannula on the vein.

more convenient to mix it with an equal quantity of normal saline and allow it to run into the axilla from a reservoir. In spite of the number of injections only one small abscess formed.

Rigors. Rigors began on the fourth day after the patient was admitted to the hospital, and continued almost daily until the joint transfusion of blood and saline.* After this transfusion

Τ

Fig. 2.-Cannula, C, is pushed through the opening in the vein, V; the fine forceps, F, holds the lid formed by the incision. S, silk ligature. L, ligature on vein. R, rubber tube connected with the funnel.

in which not more than a few ounces of blood was employedthe rigors disappeared for six days, then began again. Thinking that perhaps the salt solution, introduced with the blood, had brought about the happy result, I opened a vein and gradually introduced 30 ounces of normal saline, to which one ounce of peroxide of hydrogen had been added.† The patient had a most severe rigor forty-eight hours later, the temperature rising to *See temperature chart, letter A. See temperature chart, letter B.

106°. On the day following this rigor blood and normal saline were transfused.* The amount of blood used on this occasion was about ten ounces, and the amount of saline about twenty

Fig. 3.-G, arm of Giver. F, funnel receiving the blood of the Giver. RT, rubber tube going to C, cannula in Receiver's arm, R.

T

Fig. 4. C, Cannula with rubber tube, T, and funnel, F, attached. B, small glass branch to which is attached rubber tube, R, into which enters the radial artery, RA.

Ounces. After this transfusion the patient had no more rigors, so that she was free from April 7 until the day she died, April 19. *See temperature chart, letter C.

During this time the pulse and temperature improved, and the patient progressed so rapidly that she was allowed to sit up in bed supported by a bed-rest; whilst in this posture she fainted and died in a few minutes.

Method of Transfusion.—When I first determined to try transfusion I tried Aveling's method with a syringe, and very nearly killed the patient, for, by some means, I managed to pump some air into her vein, and after a few seconds she cried out, and to all appearances suddenly expired. Artificial respiration was carried out for about fifteen minutes and she gradually revived and regained consciousness.

r

A few days later I determined to try a new plan and this was partially successful, and later on I improved the plan until it became quite successful, and I was able to introduce ten ounces of blood in five minutes. I have since tried this method of transfusion on other patients and now claim it to be a simple and efficient method, not requiring any of the technical skill that must be employed when transfusion is done by joining one vessel to another.

Apparatus Required for Transfusion.—(a). A glass cannula ; (b) four feet of rubber tubing; (c) glass funnel holding six ounces; (d) fixation forceps with fine teeth and a spring catch; (e) scissors, scalpel, silk ligature, flat probe; (f) solution of cocaine; (g) hot normal saline solution.

The glass cannula (Fig. 1) that is introduced into the receiver's vein should be two inches in length. One end is drawn out into a fine point. A little over half an inch from the fine extremity two small nobs of glass are fused into the sides of the tube (Fig. 1c).

Steps in the Operation of Transfusion.—(a) The skin of the Giver is sterilized over the region of the median cephalic and basilic veins; (b) a small quantity of cocaine solution (I per cent.) is injected, and the vein is exposed, after which a flat probe is slipped under it; (c) the arm of the Receiver is prepared in the same way, and the median basilic, or cephalic, vein having been selected, a ligature is placed around the exposed vein and tied. A flat probe is slipped under the vein on the proximal side of the ligature and a silk ligature is also passed under the vein (Fig. 2). (d) An assistant having fixed the rubber tubing to the glass cannula and to the funnel, fills the latter with salt solution, which in turn fills the rubber tube and the cannula. (e)