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which has been retained in the instrument beyond the allotted time. The canula, therefore, completely controls the flow of blood from the beginning to the end. This is a modification of Moncoq's canula. The injection of blood can be made by any apparatus connected with the lateral tube; but I have preferred the use of a simple rubber sac which, being secured to it by a ligature, can be easily removed and thoroughly cleansed. A syringe is always open to the objection that the packing must be lubricated for its proper movement and security against the ingress of air. Its walls, therefore, must be contaminated by foreign particles. Rubber, on the other hand, can be made as clean as is possible in any mechanical device. If an open sac be used, it must be held perpendicularly in order to prevent the blood from spilling at the moment that it is caught. The sac can be folded upon itself and rolled up, thus using all the force that is necessary for the injection of the blood, and yet its elasticity will prevent undue violence. But, perhaps, for the better understanding of the instrument, I should describe the whole process in order that its fitness may be fully appreciated. The difficult problem of transfusion has always been the transference of venous blood. The old experiment of using the artery of the donor, though perhaps the best possible method of transference, is clearly impracticable. The donor should certainly be subjected to the least possible risk, and he can furnish the blood by its withdrawal after the well-understood practice of phlebotomy, with this minimum of danger. The prick and the retention of Aveling's needle is therefore an objection to its use. But, before receiving the blood, the canula, with its mandril in place, must be introduced into the vein of the recipient, the median cephalic vein being usually preferred. Even this, however, is a manipulation not always entirely easy. I find, after ligating the arm of the recipient, so as to procure what distention of the vein we may, that raising the skin at right angles to the vein, after the fashion of the hernia nip, and thrusting a sharp-pointed bistoury through its double fold with its back toward the vein, we get a better uncovering of the vessel than by an ordinary dissection. A common cambric sewing-needle, using the blunt
end, furnishes a convenient instrument for raising the vein from its bed in the connective tissue. This should be allowed to remain in place until the canula is fairly introduced through a longitudinal slit in the vessel. The ligature is now removed from the arm and tied loosely around the canula to secure its retention during further manipulation. The recipient will, as a matter of course, be in the recumbent posture, his arm, we shall say the right one, being carried out at right angles to the body, or nearly so. His hand will be grasped by the right hand of the donor, while the latter will bare his left arm for furnishing the blood. This he will hold parallel to and above that of the recipient, so that the blood will fall naturally and easily into a funnel above the rubber sac. This position places the donor and the recipient en rapport with each other in a very natural and easy manner. It is an old maxim in surgery that an operation that is well done is done soon enough; and we certainly, since the days of anæsthesia, have seemed to have laid aside entirely, and very properly too, the rapid sweeps of the so-called brilliant execution of surgical operations which the writhing subject seemed to demand. But this must be an operation against time, and yet it must be conducted with such moderation as to avoid the dangers already described. It becomes, therefore, necessary that the blood should be drawn quickly, and, as the quantity is necessarily small, but a few seconds is all that we require in order to obtain it. In the phlebotomy of the donor it is wise to observe the old rule of uncovering the vein before its puncture. We thus secure a quick flow and avoid thrombus. Everything now being ready, the surgeon, standing behind the patient, draws the blood into the sac, having immediately before withdrawn the mandril. The moment enough blood is obtained, the arm of the donor is bent out of the way, the sac is folded on its top, and, as it is rolled up, the blood is carried forward. All this must be regulated, as regards the time employed, by an assistant, who holds a watch, and who calls it off every ten seconds from the moment the vein of the donor is punctured. At the end of fifty or sixty seconds, the mandril must be thrust forward, thus cutting off further flow from the sac. In so short a time as this, there
should not be carried in more than two or three ounces, and in most cases this quantity is sufficient. If, however, in consequence of extraordinary and sudden loss of blood, more should be required, the removal of the sac and its careful cleansing, and clearing the lateral canula, render the apparatus fit for use without the removal of the canula from the vein. All this will require but a few minutes of time, no more than would be wise in order to avoid the danger of too much rapidity in the introduction of the blood. The same principle can be carried out by an extemporized apparatus. A quill can be used as a canula, a mandril can be made of smooth-polished wood running up through the center of the sac, the sac itself can be made from the cæcum of a sheep, or a bladder turned inside out, using the peritoneal surface. Thus the dweller in rural districts need never be in want of apparatus on occasions of sudden and fearful emergency. His ingenuity will be but slightly taxed if he understand the principles of the method. I have made the operation upon the dog by these extemporized means with entire ease and success.
I arrived at the conclusions with reference to the safety of the method suggested, both as regards the manipulation and the period of time allowed, by experiments upon dogs; for the dog's blood is known to coagulate more rapidly than human blood, and, as near as can be ascertained, in the relation of two to three. No dog, of several that were experimented upon, suffered the slightest injury, although the animals would show a shock somewhat similar to that which is usually exhibited when transfusion is made in the human subject, except in those transfused immediately after great loss of blood from sudden hæmorrhage.
I do not believe that our information is yet sufficiently accurate to determine precisely the character of cases that may
be benefited by transfusion of blood. By common consent, the operation of transfusion is regarded as beneficial immediately after the loss of blood, and also in the anæmia which follows its loss, after considerable intervals of time. It also is probably tiseful in anæmic conditions following exhaustive discharges where the cause of these conditions has been removed. But
we have yet to learn that any considerable benefit is to be expected in cases where the decline of the powers of life is incident to some fixed cause, as tubercle or cancer. It
also be doubted whether it can in any way improve the condition of prostration in any form of fever, such as that of typhoid or an exanthem, unless special depression should arise from sudden hæmorrhage. Large hopes were entertained at one time of the prolongation of life by this method, in phthisis pulmonalis; but its most ardent advocates have ceased to practice it. I do not propose to detail any considerable number of cases, either of my own or of others; and I do not think, as I have before said, that we have cases enough for statistics of much value; but I shall narrate a single case in the service of Professor Behier, of the Hôtel Dieu, reported a few years since in the “ Revue Scientifique,” which presents symptoms that may be regarded as typical in cases of transfusion other than those practiced immediately after the loss of blood. The case is one of such interest, illustrating some new points upon the general subject, that I have thought it best to make a short abstract of it:
The patient, a female, twenty-one years of age, entered the Hôtel Dieu on the 24th of January, 1874. She had given birth to a child six months before, which she continued to nurse up to the time of admission. On the 12th of January, without any known cause, she was seized with a severe menorrhagia. On her entrance, twelve days afterward, her face and skin were blanched, the mucous membranes were without color, the pulse, soft, small, and 120 per minute, and the extremities were cold. The use of perchloride of iron and the horizontal position, accompanied with a tampon, diminished the hæmorrhage, but it reappeared on the 26th, pulse being 132. On the 29th of January, at 10 o'clock, transfusion was made with the apparatus of Moncoq-Mathieu. Eighty grammes of blood, or about three ounces, were introduced. The operation lasted about three minutes. Immediately after the operation, the face preserved its pale aspect but seemed bloated. Respiration was painful and sighing. She became restless, with slight delirium, expressed great alarm, and said she thought she was about to die. The excitement kept on increasing, with dyspnea and cries of pain. In one hour and five minutes after, her cries became still stronger. She complained that her feet were swelling. She displayed more strength, but the crisis through which she was passing was very remarkable. In one hour and ten minutes from the time of transfusion, she was able to raise her head and drank without any difficulty some wine and water, which she retained. The pulse remained imperceptible at the radials. Ten minutes later, the jactitation continued. It seemed to her that the feet were swelling up to the abdomen. The respiration became rapid and panting, recalling that of asphyxia. The face wore a haggard aspect and was slightly cyanosed. These phenomena continued till one o'clock, when a change for the better rapidly developed. The hands became warm, the pulse reappeared with sufficient strength, and the patient declared herself much better. At two o'clock, the strange and haggard expression had disappeared, the face had acquired a slight color, the delirium and jactitation were gone, and the voice was clear and perfectly distinct. At four o'clock, the pulse was strong and resisting; and the patient had been able to take almost a bottle of old wine and some soup, which were retained. She heard, could speak without fatigue, and the headache entirely disappeared. The sanguinolent discharge from the uterus was absent from the moment of transfusion. Two days afterward, it was difficult to persuade her to keep the horizontal position. On the third day, there was marked fever, but the appetite was not diminished. On the fourth day, the fever had subsided, the digestion was perfect, and the appetite insatiable.
We have, in addition to these statements, a measure of the blood-corpuscles before and after transfusion, which throws light upon the cause of the great improvement following the introduction of such apparently insignificant quantities of blood. The estimates were made after the method of Malassez, and the blood of the patient was found to contain 850,000 red corpuscles in a cubic millimetre, which corresponds to 1.6 minim. On the same day, at two o'clock, four hours after the operation, there were 1,110,000 corpuscles. At six o'clock, eight hours after the operation, there were 1,143,900 corpuscles. M. Liouville, who examined the blood with a microscope, observed at