I

immediate transfusion, and to that of injecting defibrinated blood. consider myself justified in omitting any account of the numerous instruments which have been invented for the purpose of injecting pure blood, since I believe the practical difficulties are too great ever to render this form of operation serviceable. The great objection to most of them is their cost and complexity; and as long as any special apparatus is considered essential, the full benefits to be derived from transfusion are not likely to be realized. The necessity for employing it arises suddenly; it may be in a locality in which it is impossible to procure a special instrument; and it would be well if it were understood that transfusion may be safely and effectually performed by the simplest means. In many of the successful cases an ordinary syringe was used; in one, in the absence of other instruments, a child's toy syringe was employed. I have myself performed it with a simple syringe purchased at the nearest chemist's shop, when a special transfusion apparatus failed to act satisfactorily.

In immediate transfusion (Fig. 204), the donor is seated close to the patient, and the veins in the arms of each having been opened, the silver canula at either end of the instrument is introduced into them (A B). The tube between the bulb and the donor is now pinched (D), so as to form a vacuum, and the bulb becomes filled with blood from the donor. The finger is now removed so as to compress the distal tube (D'), and the bulb being compressed (c), its contents are injected into the patient's vein. The bulb is calculated to hold about two drachms, so that the amount injected can be estimated by the number of times it is emptied. The risk of injecting air is prevented by filling the syringe with water which is injected before the blood.

SCHÄFER'S DIRECTIONS FOR IMMEDIATE TRANSFUSION.

Direct Venous Transfusion.-" Procure two glass canulas of appropriate size and shape (see Fig. 205), and a piece of black India-rubber

tubing, seven inches long, and not less than a quarter of an inch bore, fitted to the canulas. This apparatus could always be improvised.

"Place the transfusion-tube in a basin of hot water containing a little carbonate of soda. Put a tape around the arm of the patient just below the place where the vein is to be opened, and another just above. Expose the vein by an incision through the skin, which should be made transversely if the position of the vein cannot be made out through the skin. Clear a small piece of the vein with forceps, and slip a pointed piece of card underneath it. By a snip with scissors make an oblique opening into the vein, and partly insert a small blunt instrument (such as a wool-needle) so that the aperture is not lost. Remove the upper tape. Next prepare the vein of the giver. To do this put tapes around the arm just below and above the place where the vein is to be opened. Expose the vein by a longitudinal

FIG. 205.

incision through the skin. Clear a small piece of the vessel with forceps and pass a thread ligature underneath. A slip of card may also be placed under this vein. Make a snip into the vein just above the ligature, and then, taking the transfusion-tube out of the soda solution, slip one of the canulas into the vein of the giver, and tie it in with a simple knot, which can be readily untied. Let the giver go to the bedside and place his arm alongside that of the patient. Hold the end of the India-rubber tube with the second canula up a little, and release the lower tape on the arm of the blood-giver. As soon as blood flows out of the second canula pinch the India-rubber tube close to the canula, so as to stop the flow, and, removing the wool-needle, slip the end of the canula into the vein of the patient, hold it there, and allow the blood to pass freely along the tube. Three minutes will generally be long enough for the flow, which can be stopped by compressing the vein of the giver below the canula. Both canulas may now be withdrawn and the ligature removed from the vein of the giver, the cut veins being dealt with in the usual way. Of course, the other tape on the arm of the donor must be removed as soon as the transfusion is over.

"Instead of using the transfusion-tube empty, it may be filled with soda solution, to the exclusion of air. It is necessary to have one or two spring clips on the tube to prevent the escape of the solution. This is a much better plan than the other, for the blood need not be allowed to flow into the tube until the second canula is inserted, and then, by opening the clips, it may drive the soda solution before it into the vein. The small quantity of carbonate of soda solution necessary to fill the simple tube will do the patient no harm."

Injection of Defibrinated Blood.-For injecting defibrinated blood various contrivances have been used. McDonnell's instrument is a simple cylinder with a nozzle attached, from which the blood is propelled by gravitation. When the propulsive power is insufficient, increased pressure is applied by breathing forcibly into the open end of the receiver. De Belina's instrument is on the same principle,

only atmospheric pressure is supplied by a contrivance similar to Richardson's spray-producer, attached to one end. The idea is simple, but there is some doubt of a gravitation instrument being sufficiently powerful, and it certainly failed in my hands. I have had the valves applied to Aveling's instrument, so that it works by compression of the bulb, like an ordinary Higginson's syringe. This, with a single silver canula at one end for introduction into the vein, forms a perfect and inexpensive transfusion apparatus, taking up little space. If it be not at hand, any small syringe with a fine nozzle may be used. The first step of the operation is defibrination of the blood, which should, if possible, be prepared in an apartment adjoining the patient's. The blood should be taken from the arm of a strong and healthy man. The quality cannot be unimportant, and in some recorded cases the failure of the operation has been attributed to the fact of the donor having been a weakly female. The supply from a woman might also prove insufficient; and, although it has been shown that blood from two or more persons may be used with safety, yet such a change necessarily causes delay, and should, if possible, be avoided. A vein having been opened, eight or ten ounces of blood are withdrawn and received into some perfectly clean vessel, such as a fingerbowl. As it flows it should be briskly agitated with a clean silver fork or a glass rod, and very shortly strings of fibrin begin to form. It is now strained through a piece of fine muslin, previously dipped in hot water, into a second vessel which is floating in water at a temperature of about 105°. By this straining, the fibrin and all airbubbles resulting from the agitation are removed; if in no excessive hurry, straining may be done a second time. If the vessel be kept floating in warm water, the blood is prevented from getting cool, and we can now proceed to prepare the arm of the patient for injection.

This is the most delicate and difficult part of the operation, since the veins are generally collapsed and empty, and by no means easy to find. The best way of exposing them is that practised by McDonnell, who pinches up a fold of the skin at the bend of the elbow, and transfixes it with a fine tenotomy knife or scalpel, so making a gaping wound in the integument, at the bottom of which they are seen lying. A probe should now be passed underneath the vein selected for opening, so as to avoid the chance of its being lost at any subsequent stage of the operation. This is a point of some importance, and from the neglect of this precaution I have been obliged to open another vein than that originally fixed on. A small portion of the vein being raised with the forceps, a nick is made into it for the canula.

Injection of the Blood. The prepared blood is now brought to the bedside, and the apparatus having been previously filled with blood to avoid the risk of injecting any bubbles of air, the canula is inserted into the opening made in the vein, and transfusion commenced. It should be constantly borne in mind that this part of the operation should be conducted with the greatest caution, the blood introduced very slowly, and the effect on the patient carefully watched. The injection may be ceeded with until some perceptible effect is produced, which will generally be a return of the pulsation, first at the heart and subsequently at

pro

the wrist, an increase in the temperature of the body, greater depth and frequency of the respirations, and a general appearance of returning animation about the countenance. Sometimes the arms have been thrown about, or spasmodic twitchings of the face have taken place. The quantity of blood required to produce these effects varies greatly, but in the majority of cases has been very small. Occasionally two ounces have proved sufficient, and the average may be taken as ranging between four and six; although in a few cases between ten and twenty have been used. The practical rule is to proceed very slowly with the injection until some perceptible result is observed. Should embarrassed or frequent respiration supervene, we may suspect that we have been injecting either too great a quantity of blood, or with too much force and rapidity, and should desist until the suspicious symptoms pass away. It may happen that the effects of the transfusion have been highly satisfactory, but that in the course of time there is evidence of returning syncope. This may possibly be prevented by the administration of stimulants, but if these fail there is no reason why a fresh supply of blood should not again be injected, but this should be done before the effects of the first transfusion have entirely passed away.

Secondary Effects of Transfusion.-The subsequent effects in successful cases of transfusion merit careful study. In some few cases death is said to have happened within a few weeks, with symptoms resembling pyæmia. Too little is known on this point, however, to justify any positive conclusions with regard to it.

[Transfusion with defibrinated blood was, I believe, first tried in America by Dr. Joshua G. Allen, of Philadelphia, on December 30, 1868, on a woman who suffered from the effects of repeated attacks of uterine hemorrhage. Six fluidounces were injected, and the patient recovered a reasonable degree of health. In 1869, Dr. Allen repeated the operation four times, in two of the cases being associated with Dr. Thomas G. Morton at the Pennsylvania Hospital, and using a double vessel for keeping the blood warm, consisting of a conical cup for holding the blood and a lower vessel for containing warm water, the two being made in one and the temperature ascertained by an outside thermometer. Dr. Morton repeated the experiment on two other patients in 1870 and 1874, the second, a girl of eleven, being operated on twice, at intervals of six weeks, for bleeding from the nose and bladder, the effect of purpura; she entirely recovered. Dr. M. used a set of instruments specially designed for the work, and shown in illustration in the Amer. Journ. of the Med. Sciences, July, 1874, p. 112. Between 1874 and 1886 he repeated the operation on several hospital and private patients.

Intra-venous saline injections are far more readily used, are safer, and are believed from the tests that have been made to be quite as efficacious as blood. What has been called artificial serum consists of 20 grammes of sulphate of soda and 10 grammes of chloride of sodium in 2 litres of water. The solution should be injected into a large vein slowly and in large quantity, as much as a pint or more at a time, and repeated at intervals; the fluid should be blood-warm. Another formula consists of pure common salt 13 fluidrachms, liquor potassæ 1 minim, and pure carbonate of potash 45 grains in two quarts of water.—ED.]

PART V.

THE PUERPERAL STATE.

CHAPTER I.

THE PUERPERAL STATE AND ITS MANAGEMENT.

Importance of Studying the Puerperal State. The key to the management of women after labor, and to the proper understanding of the many important diseases which may then occur, is to be found in a study of the phenomena following delivery, and of the changes going on in the mother's system during the puerperal period. No doubt natural labor is a physiological and healthy function, and during recovery from its effects disease should not occur. It must not be forgotten, however, that none of our patients are under physiologically healthy conditions. The surroundings of the lying-in woman, the effects of civilization, of errors of diet, of defective cleanliness, of exposure to contagion, and of a hundred other conditions which it is impossible to appreciate, have most important influences on the results of childbirth. Hence it follows that labor, even under the most favorable conditions, is attended with considerable risk.

The Mortality of Childbirth.—It is not easy to say with accuracy what is the precise mortality accompanying childbirth in ordinary domestic practice, since the returns derived from the reports of the Registrar-General, or from private sources, are manifestly open to serious error. The nearest approach to a reliable estimate is that made by the late Dr. Matthews Duncan,' who calculated, from figures derived from various sources, that no fewer than 1 out of every 120 women, delivered at or near the full time, died within four weeks of childbirth. This indicates a mortality far above that which has been generally believed to accompany childbearing under favorable circumstances. It, however, closely approximates to a similar estimate made by MeClintock, who calculated the mortality in England and Wales as 1 in 126; and in the upper and middle classes alone, where the conditions. may naturally be supposed to be more favorable, at 1 in 146; more recently he had come to the conclusion from his own increased experience, and the published results of the practice of others, that 1 in 100 would more correctly represent the rate of puerperal mortality.3 In

The "Mortality of Childbed." Edin. Med. Journ., vol. 1869-70. p. 399. * Dublin Quarterly Journ. of Med. Science, 1869, vol. xlviii. p. 256, Brit. Med. Journ., 1878, vol. ii. p. 215.

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