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composed of common salt, 3 iij, and alcohol, 3 j, in one pint of water, of which two pints were introduced into the median basilic vein, at a temperature varying from 100° to 110° F. I repeated the operation when the algid symptoms reappeared. The following solution, recommended by Dr. Gull, in the "Reports on Epidemic Cholera to the Royal College of Physicians,' London, 1854, was used in three cases:
Chloride of sodium...
"By dissolving one hundred and forty grains of this salt in forty ounces of distilled water and filtering, we obtain a fluid having a decidedly saline taste, a faintly acid reaction, and nearly approximative in its composition to the fluid effused, minus the organic substances. These are small in amount, and their loss has apparently no important influence on the constitution of the blood."
To introduce the fluid into the veins, I used a glass funnel connected with a glass tube three feet long, to which a canula was attached, raised three feet above the patient's arm.
Dr. Gull's formula is based upon data, furnished by Carl Schmidt, of the analysis of healthy blood, as follows:
Soluble Salts in 1,000 Parts of the Water of the Liquor Sanguinis in Health.
In Dr. Gull's formula, the sulphate of sodium is strangely omitted. A more accurate formula (the one which I recommend), deduced from Schmidt's analysis, is the following:
Dissolve one powder in 24 ounces of water at 100-5° F. The fluid should enter the vein at a rate not exceeding one ounce per minute, and this can be accurately regulated by means of the stop-cock in the canula. The quantity of fluid to be injected, if a saline solution be used, is from 12 to 24 ounces. The injection may be stopped when the pulse becomes stronger and the temperature of the peripheral parts of the body are more nearly normal.
The arterial injection of fluids has, within a few years, been strongly advocated by Hüter and others, and Halsted, of New York, has reported three successful cases and favors central arterial transfusion in all cases where the operation is indicated.1 The advantages claimed for arterial over venous injections are the following: Air or small clots, accidentally introduced into the blood, are caught and retained in the capillaries and do no harm; there is less danger of overpowering the heart by a too rapid introduction of the fluid; and it is often easier to find an artery (the radial) than a suitable vein. This last advantage, at least, must be conceded.
CASES IN WHICH TRANSFUSION IS INDICATED.-These include all cases of acute anæmia produced by sudden and copious loss of blood in which life is imperilled; and a favorable result may be expected in such cases in persons previously healthy. It is a classical operation, so to speak, in puerperal hæmorrhage occurring during or after delivery; and it should be practiced, not merely to prevent immediate death, but also to avert the danger of blood-poisoning which so often follows the copious loss of blood.
In hæmorrhage from large vessels, as well as in wounds of small vessels where the hæmorrhage is only moderate and yet is
1 Loc. cit.
sufficient to prevent the reaction requisite to enable the surgeon to perform a necessary operation, it is a valuable expedient.
In hæmorrhage from the bowels and stomach, it is contraindicated, except as a dernier ressort, because of the danger of exciting another hæmorrhage by dislodgment of a thrombus; but it may be used in such cases for the anæmia which follows several days after the hæmorrhage has ceased.
In hæmophilia, there is danger of aggravating the hæmorrhage by increasing the force of the heart's action, and there is danger, also, of fresh hæmorrhage from the wound inflicted in the operation. It may be used, however, as a last resource to save life; and Lane has reported such a case, with recovery.1 In purpura hæmorrhagica, it does not promise much, since it can not lessen the danger of new hæmorrhages.
In excessive and persistent vomiting threatening life, whether produced by the use of ether as an anesthetic or by other causes, it may prove of great value. In epidemic cholera it should be more generally used, as well as in acute diarrhoea and dysentery and in some of the low forms of fever threatening speedy dissolution. It may often be employed with advantage in chronic surgical anæmia produced by long-continued suppuration and loss of reparative power. The patient may be brought by transfusion to a favorable condition for an operation followed by recovery. Such a case is reported by Barwell. Halsted has reported3 a case of septicemia from suppurative disease of the ankle and tarsal bones, in which depletory transfusion was practiced, which so improved the patient as to permit amputation of the leg, with recovery. In opium-poisoning, transfusion may produce favorable results, especially if depletory withdrawal of blood from one vein be made simultaneously with the injection of a proper fluid into another vein. The poison would be eliminated, and the fluid remaining in the body would be more diluted and therefore contain a smaller proportion of morphine. In the collapse from poisoning by illuminating-gas, it
1 "The Lancet," London, vol. xvii, p. 185.
3 "New York Med. Jour.," l. c.
has recently proved efficient in the hands of Garrigues, Bull, and Halsted, of New York. In such cases, also, depletory transfusion should be practiced. The operation can not be considered dangerous or reckless, for it has often been successfully performed and followed by recovery under the most adverse circumstances. It should not be resorted to as a last and a desperate remedy. If it be delayed until the patient is moribund, the functions of the circulatory system may be so far impaired that recovery is impossible, and a temporary improvement is almost certainly followed by a speedy and fatal relapse. It is contra-indicated when there is organic disease of the circulatory organs (Quain).
The matter presented in the preceding pages seems to the writer to justify the following conclusions:
1. It appears to be proved, by experiments upon animals and by clinical facts, that corpuscles of transfused blood are short-lived and rapidly excreted; that the reviving power of blood does not reside in the red corpuscles; and hence the danger of excessive loss of blood is not due to the diminution of its corpuscles and other solid constituents.
2. The important element in transfusion is the restoration of fluid to the vascular system, increasing vascular tension and causing energetic contractions of the heart.
3. The intra-venous injection of saline solutions in appropriate cases is a more simple and is a safer operation than transfusion of blood. It can be done without the aid of a skilled assistant, and the materials for injection are easily obtained.
4. If further experience should confirm the favorable results from intra-venous injections that have been recently reported at home and abroad, the operation deserves to be held in the highest esteem, and it is destined to occupy an important position among therapeutic agents.
DISCUSSION ON DR. MOORE'S ADDRESS AND ON DR. HUTCHISON'S PAPER.
DR. T. F. ROCHESTER, of Erie County.-I should like to make a suggestion, based on one or two cases of transfusion which I have witnessed, in which I should think that the quality rather than the quantity of transfused material had to do with the result. About eighteen months or two years ago, I witnessed an operation upon a girl suffering from syphilitic constitutional disturbance, the patient being excessively anæmic and unable to obtain relief from the various measures that had been adopted. Dr. Carey, of Buffalo, made a transfusion of certainly not more than two ounces of blood taken from the arm of Dr. Frederick. The patient suffered scarcely any disturbance during the operation, and rapid improvement took place afterward. It seemed to me that an effect like that from an ounce and a half or two ounces of blood must be due to the quality rather than to the quantity of the transfused liquid. The patient got perfectly well without any further treatment than nutritious diet.
Again, I remember, when in New York in 1849-'50, that patients in the cholera hospitals receiving transfusion of a saline solution, while they were in a state of complete collapse, would be restored, as it were, to complete health for a few hours, but that they finally died. But if nothing more than temporary restoration could be effected in these cases, it was a great deal gained, as it would give time to make a will and to arrange a variety of matters. I think there was a good deal in the quantity represented in the saline solution; but I also think that there was something more than the mere dynamic power represented in the small quantity of blood employed.
The PRESIDENT remarked, with regard to saline injections in cholera, that there was a saying, "Salting a patient and curing him are two different things."