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He Has Two Good Legs

BOTH MADE BY MARKS Although a man may lose both his legs, he is not necessarily helpless. By using artificial legs of Marks Patent he can be restored to usefulness. One of these engravings is from an instantaneous photograph of a man ascending a ladder. He has two artificial legs substituting his natural ones, which were crushed in a railroad accident. With Marks Patent Rubber Feet with Spring Mattress he can ascend or descend a ladder, balance himself on the rungs, and have his hands at liberty. He can work at a bench and earn a good day's wages. He can walk and mingle with persons without betraying his loss; in fact, he is restored to himself for all practical purposes.

With the old method of complicated ankle joints, these results could not be so thoroughly attained.

Over 50,000 in use, scattered in all parts of the world.

Purchased by the United States Government and many Foreign Governments.

Send for MANUAL OF ARTIFICIAL LIMBS, containing 384 pages, with 674 cuts. Instructions are given how to take measurements and obtain artificial limbs without leaving home.

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A. A. MARKS
696-702 Broadway

NEW YORK, U. S. A.
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# Incorporating
The Kansas City Medical Index-Lancet

An Independent Alonthly Alagantne

Vol. XXXVII.

OCTOBER, 1918

No. 10

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The Anemias

1. In acute anemia following hemorrhage, Original Contributions

where the bleeding has been so severe as to en( EXCLUSIVELY FOR THE MEDICAL HERALD.)

danger life, the first indication, of course, is to stop the flow of blood, if the source of hemor

rhage is accessible, and follow this immediately INDICATIONS FOR BLOOD TRANSFUS- by transfusion of whole or defibrinated blood. ION*

If the hemorrhage cannot be checked by direct H. S. FORGRAVE, M. D., St. Joseph, Mo.

measures, as in gastric, or typhoid ulcers or rup

tured extra-uterine pregnancy, one may still reThe idea of the transference of blood from sort to transfusion, with the hope that the hemorthe circulation of one individual to that of an rhage may cease spontaneously and that the blood other through the agency of a carrying system, is introduced may serve in the meantime to prenot a new one by any means.

vent dangerous depletion or at least aid in coaguIt appears to have originated in the minds of lation. several shortly after the discovery of the circu- In such cases great care should be taken not lation of the blood by Harvey.

to introduce enough blood to raise the pressure The history of the development of transfusion to a degree which would tend to cause a conoffers nothing of particular interest and it is

tinuation of the hemorrhage. It is desirable to sufficient to state that since its first employment,

introduce just enough blood to prevent the total, early in the 17th century until the present time. amount in the body falling to a dangerously low it has attracted the attention of numerous in- level. me vestigators.

2. Chronic secondary, anemias are due to Increasing success in its use and the discovery

gastric or duodenal ulcer, epistaxis, hemorrhoids, of broader fields of application have been a stim

metrorrhagia, etc. When of an extreme grade, ulus to its development, until now, with perfected

transfusion may offer the only hope of bringing methods and simplified apparatus, it has become

operative procedure to a successful issue. It

may be done before, during, or after operation, a recognized procedure with a field of application

or at all three times, as indicated in each parand usefulness that is not fully appreciated until we pause to consider its many indications.

ticular case.

3. In pernicious anemia selected cases have A new impetus has been given its employment

shown marked improvement by a series of transby the present crisis in France for many brilliant

fusions at intervals of one or two weeks. The achievements have been reported from its use,

red cells showing a rapid increase and at the especially in dealing with acute anemia from

same time the hemorrhagic tendency is lessened. "hemorrhage, surgical shock and sepsis.

While no permanent benefit has so far been seen, The first transfusions of the seventeenth cen- life is prolonged, the patient is made more comtury were performed to combat the effects of

fortable, and the results on the whole are ensevere hemorrhage and today it is likewise most frequently used for the same condition.

4. In the severe hemorrhages, occasionally One may with some accuracy divide the indi

uracy divide the indi- seen in leukemia and spenic anemia, where serum cations for transfusion into three groups, as fol- injections will not control the bleeding, transfuslows:

ions will usually stop the hemorrhage and relieve 1. The anemias.

the anemia. 2. The hemorrhagic diseases.

5. Before, during and after splenectomy, 3. Infective and toxic conditions.

whenever that procedure is indicated, transfusion, according to Percy and others, does much

toward lessening the risk of operation and assists *Read before the Buchanan County Medical Society, St. Joseph, Mo., May 15, 1918.

materially in the convalescence.

The Hemorrhagic Diseases

Modern hematology, however, has demon

strated that the blood formation is stimulated 1. Hemophilia is a typical hemorrhagic dis

dis; by the introduction of new blood and in certain ease. Its peculiarity being the markedly delayed

arity being the markedly delayed instances, increasing its coagulating properties. time of coagulation. • Weil and others have reported most favorable

The object of transfusion then is to attain a results in the treatment of this condition from

safe, rapid and simple mode of restoring the intravenous injections of fresh serum.

volume of blood, but more especially its regenThe severe anemia that follows prolonged and

eration and active principles from the donor recurrent bleeding. demands transfusion, for no

which can improve the impaired metabolism of other treatment will take its place.

the recipient. It, therefore, not only operates as 2. Hemorrhagic diseases of the new born

an emergency life saver, but as a healer of dishave, until recent years, been intractible as to

ease. treatment. The use of serum is most effective in

Intravenous saline injections, however, are those cases of moderate severity. Transfusion

useful only when the organs are already in good will, however, save many of those in which the

condition and can withstand the immediate and hemorrhage is very severe and do not yield to

violent stimulation of a large volume of fluid. other measures.

It was Bernheim's impression that where 3. In cases of purpura, hemorrhagica and

urgency was required, it was not worth while essential hemorrhages, where the loss of blood is

attempting the test for hemolysis, more recently alarming, transfusion will frequently turn the

Berard, who, during the present war, has emtide.

ployed transfusion with and without hemolysis

tests for a large series of cases (in which clots, Infective and Toxic Conditions

infections, pyrexia and other serious conditions 1. It has been demonstrated by Jajer, Pool Wer

were present) has pointed out that not a single and others, that the introduction of whole blood instance of trouble from hemolysis was observed. into the veins of patients jaundiced from gall

Notwithstanding these successes, it must not bladder, liver, or pancreatic disturbances. who be forgotten that one is constantly confronted are to be subjected to operation, markedly short- with this danger and that a hemolysis may occur. ens the coagulation time of the blood and thereby For this reason, one is not justified in omitlessens the well known tendency to hemorrhage ting the tests where time permits. There are unin these cases.

doubtedly many other conditions we encounter 2. Crile has resuscitated quite a number of where transfusion might be performed to adpatients in extremus from illuminating gas and vantage, especially in combination with other carbon monoxide poisoning by transfusion. treatment, both medical and surgical.

3. Various observers have advocated trans- I feel that the usefulness of transfusion is just fusion in poisoning from snake bite, at the same beginning to be appreciated and that the reports time bleeding the patient from the bitten limb. of the next few years will give evidence of its

of the next few years, 4. Experimentally, in animals, transfusion growing popularity and its value as a therapeutic has given good results in instances of alkaloidal agent. poisoning, but has been used but little in the

Bartlett Bldg. human. However, now with simplified technic and apparatus, it should be practical.

TRANSFUSION OF BLOOD* 5. Transfusion has been recommended by

J. I. BYRNE, M. D., St. Joseph, Mo. Cole for the treatment of pellagra, but the series of cases thus far reported are too few to permit

The methods of transferring blood from one of drawing conclusions.

individual to another have varied, as knowledge 6. Bevan says there is evidence of its value

of the constituents of the blood and the effect of in sarcoma.

mixing different bloods has become more certain 7. Certain toxemias (as of pregnancy) are

The indirect method was perhaps the first benefited by it.

method practiced. This method is alluded to

in the writings of the ancient Egyptians. Li8. Transfusion is now an established pro

bavius advocated transfusion by silver tubes in cedure in dealing with acute and chronic infec

1615, and from that time down through the histions. Repeated small amounts giving better re- tory of the operation, indirect transfusion is the sults than larger ones.

only method mentioned until 1883, when Von For a time it was held that transfusion of Bergman declared that only direct transfusion blood had no advantage over intravenous in- of blood from artery to vein was justifiable, and jections of saline solution and that the mere in that here coagulation might occur in the cannula crease in the volume of blood explained the im

*Symposium on Blood Transfusion, Buchanan County provement.

Medical Society, May 15, 1918.

and result in the death of the patient from throm- The impossibility of accurately gauging the bus.

amount of blood given by this method is one of To Dr. George Crile of Cleveland, is no doubt the serious objections to it. The enthusiasm due the credit of devising a technique for the engendered by watching the well nigh miracudirect transfusion of blood which met. in a large lous effects of the introduction of fresh blood measure, the requirements for the successful into the vessels of a patient near death, from performance of the operation, and which has been hemorrhage, or other anemia producing condithe idea from which all the other methods of tions, is prone to lead the operator into injuring direct transfusion have been evolved.

or even destroying the life of his patient by givCrile commenced his experiments in 1898. and ing an overdose of the transfused blood, thereby in 1907 I had the pleasure of hearing him read a causing an overdistention of the right heart and paper before the American Medical Association, a

ciation a failure of the organ from broken compensain which he reported most brilliant results in a

tion. large number of cases in which he had practiced

Likewise the operator may overtax the donor transfusion. And it was the results obtained by

and draw from him more blood than he can well

a Crile that led to the quite general use of this afford to give, an accident we are most anxious life saving measure by many different methods, to avoida, out or

to avoid, out of gratitude and consideration for both direct and indirect, all of which have met

the welfare of the heroic person who is willing with a large measure of success.

to give his blood that another may live. Crile's method consists in using a cannula

I have gone to some length to describe the which varies from one and one half millimeters

direct method of Crile, because as I have said, all

of the other direct methods are founded upon this to three millimeters inside diameter; the opera

method, and the principle involved, of bringing tor selecting the sizes best suited to the size of

intima into contact with intima, or in lieu thereof, the vessels which are being used.

of providing a conduit, so protected within its A vein in the arm of the patient is dissected

lumen that the blood stream will not be injured, up under local anesthesia for about two and one- and clotting thereby produced when passing over half to three inches. The proximal end is com- its surface. pressed, and the distil end is tied and cut off. A Elsberg has perfected an ingenious device single suture is passed through the free end of which is formed upon the idea of Crile's cannula, the vein, and the thread passed through the can- but instead of a solid tube. the cannula is built nula. The wall of the vein is then grasped at like a monkey wrench, which can be adjusted by three points with mosquito forceps, and the cuff

means of a screw. The jaws of the cannula are turned back over the cannula, and tied with a fine placed about the artery, the cuff turned down ligature. The radial artery is dissected up in with the mosquito forceps, the same as in Crile's like manner, the lower end tied off, and the upper method: an opening is made into the vein, and end compressed. The wall of the artery is the artery slipped into it. The jaws are then grasped by mosquito forceps, and drawn ove separated. thus permitting the flow of blood. the cuff formed by the wall of the vein on the This method is perhaps more simple than Crile's. cannula, and made secure by ligature. The com- It has the advantage of requiring less dissection press is removed from both the artery and the of the vein of the patient, and the greater ease vein, and the blood of the donor is permitted to with which the more elastic wall of the vein enter the vein of the patient. The vessels are may be distended and slipped over the arterial kept moistened by the application of salt sol. cuff. The artery will sometimes contract after it has Brewer has used a fine glass tube with a been severed, and it may be necessary to dilate flange on each end, which he has passed into it by inserting a pair of closed mosquito forceps the artery of the donor and into the vein of the which have been previously anointed with vase patient, and secured in place with ligature. line, and gently separating the blades until the After sterilizing the tube the tube is dipped into artery is sufficiently dilated to slip over the cuff liquid parrafin oil. to secure the necessary formed by the vein. The important point in smoothness for the passage of the blood. this operation is the fact that the intima of the

This idea has been enlarged upon and imartery is made continuous with the intima of

proved by Bernheim, who uses two tubes which the vein, and the blood stream is not disturbed

fit together and form a smooth joint in the midby contact with any foreign substance.

lde, after the ends have been secured in the artery After the anastomosis has been made, the of the donor and the vein of the patient. This blood is permitted to flow until the patient's method is to be commended because of the small blood pressure has been elevated to 110 or 120; amount of dissection necessary in order to make until his pulse has come down to 140 or 150; the anastomosis. provided the donor shows no grave ill effects Horsley has developed sufficient surgical dexfrom the loss of blood which he is giving up. terity to enable him to make an anastomosis be

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