Transfusions During the Civil War Prior to the use of cross-typing of blood groups to determine A, AB, O compatibility From the Medical and Surgical History and the Geo. Tiemann Catalogue 1870's GEO. TIEMANN & CO.'S SURGICAL INSTRUMENTS, TRANSFUSION. Fig. 211.—Fryer's Transfusion Apparatus.   (Extracted from the Medical & Surgical Record, April 15, 1874.)   A few remarks on the Transfusion of Blood, with a modification of the Apparatus of Aveling. By B. E. Fryer, M. D., Surgeon U. S. Army. post-Civil War   To show that the subject of transfusion is one which a large portion of the profession has not yet fully weighed the importance of nor realized the fact that this measure can frequently be made applicable in cases which are now quietly otherwise yielded to death, we have only to call attention to the rarity of reported instances (see below examples) in which the operation has been taken advantage of, and refer to the many obvious ones in which it should be made available. Even in threatening dissolution from the direct loss of blood,—such as from wounds of large vessels, from prolonged epitasis, or, in probably one of the most frequent opportunities met with, from hemorrhage, post-partum, where the restoration of blood by transfusion has been, so to say, legitimatized—but few of us are prepared for the emergency, or if prepared, do promptly act and give the then affected only chance of life.   We will briefly state the kind of cases in which it has occurred to us that transfusion should "be had recourse to without hesitation, and they may be conveniently note under two headings.   We would include in the first class those cases in which a copious blood-loss has occurred and immediate death is threatened. As is well known, it is in these mainly that the measure lias been applied. It might well be tried in coses of injury accompanied by a more moderate hemorrhage, and where it is necessary to do an important surgical operation, and this operation is delayed (often disastrously) for a reaction by ordinary means. Moreover, it should be done before or aftor necessary surgical measures in the astheuic patients, fu order to avoid pytrmia and its allied evils, especially in operations where the peritoneum is involved. After labor, too, where hemorrhage may have been great, but not enough to threaten immediate death, it should be done to avoid septicemia difficulties. For that depression from the loss of blood is a most direct cause of pyemia and its pathological associates, those of us who have had to treat large numbers or gunshot and other injuries, and to operate In these cases, where hemorrhage and other depressing causes had done sad havoc, well know.   But we have in the second class a larger number of cases—diseases both acute and chronic—and bore we more commonly meet with opportunities. In such, transfusion has scarcely been thought of; but it is in these, too, it ought in be, and will Ims, wo think, taken advantage of. Of the acute cases we refer to, those in which natural nutrition is for the time suspended, either from a direct lesion of the blood-making system in one or more of its divisions, or is indirectly affected in consequence of some profound systemic impression, where if we can but bridge over a short period by keeping life's machinery goin^. we niay ultimately bring about a restoration of the healthy nutrition process, and thus save life. To particularize : acute gastric troubles, giving excessive and continuous vomiting; acute diarrlneas and dysenteries; in peritoneal intluiinuatUms, in some of the low forms of fevers where waste is excessive mid the* absorption of nourishment nti. In cholera it should be done more generally than it has been. It might In tried, t"<> in sonic of the acute diseases of young children, particularly ill those' which give convulsive movements and convulsious proper, and which often indicate to us diminished blood-supply to the brain, and tell us that death can again put the nerve-centers quietly at work.   In chronic eases where the blood-making is reduced or nearly destroyed, we might often prolong life by transfusion. Such cases are not frequent, though we need not enumerate them. We might well apply the measure even in some cases of phthisis pulmoimlis.   In regard to the fluid to be transfused. As is well known, human blood is that to be, most desired, after the blood of some of the lower animals may be selected. Hutlder, of Canada, threw into the veins of some of his cholera patients fresh milk, and with excellent results. The writer has experimented with milk injections in the veins of (logs, and though the experiments have not been completed as to a test of the nourishing effects of the milk so given, no bad symptoms have become apparent. If it can be satisfactorily proved, that milk may be safely and generally used in transfusion, and with the desired result, a great advance will Iks mode in the matter, it being nearly always obtainable, while many of the difficulties and inconveniences in the use of blood will be avoided. A saline solution (such as that of Mr. Little*) should be tried to save life, if nothing else is at hand.   The instruments for transfusion are to us is well known, quite numerous, and while many of them are very good, we believe that of Aveling, for immediate transfusion, to be probably the simplest, safest, and most easy of application. We have lately modified it by adding another bulb to the tube, and by having both tube and bulbs cost of the rubber into one piece. By the additional bulb we can save time in doing the operation, and can keep the blood moving along the tube almost continuously. In having the ruin- and bulbs in one, we do away with the metal portions which couples them in Aveling's apparatus, and we thereby diminish the risk of blood lodging and coagulating; while we if necessary, compress the whole apparatus more completely. As in Dr. Aveling's instrument, there are no valves.   The instrument of Aveling is intended for immediate transfusion. We have added a glass vessel which can be fitted to the tube, and the whole then used as a mediate transfuser if desired. The accompanyiug cut gives a good representation of the apparatus.   The manner of using the instrument Is very similar to Aveling's. The canula marked S is placed in the giver's vein, that marked in the vein of the receiver. The tube and bulbs having been filled with warm water. or better, with Mr. Little's saline solution (also warm), are now adjusted to the canulas and the blood allowed to flow into the apparatus. The canula being steadied by an assistant, the tube is to be nipped tightly between the fingers, close to the giver's or efferent end, and then the bulb marked 1 is to Ite compressed, and the lilood of course forced on towards the receiver. While this bulb is still held compressed, the tulie at the giver's side is to bo relaxed, and that portion of it between the bulbs is to be nipped; bulb 1 is relaxed. a.nd No. 2 compressed and held then the tube at the receiver's side is to he seized and held to prevent regurgitation, and the whole apparatus allowed to refill. The same operation to be repeated till sufficient blood is transfused. As suggested bv Dr. Aveling, a few drops of ammonia solution may be injected into the bulbs now and then, by a fine-pointed hypodermic syringe, in order to more effectually prevent coagulation. It will be found that considerable force is necessary in sending blood or other fluids into the veins. This we discovered while doing transfusion twice in a case after hemorrage from gunshot injury, and we have also found it in our experiments on the lower animals. It is a fact that we nave not seen noted in connection with transfusion, and one well worth remembering.   In order to age the apparatus as a mediate transfuser, the vessel marked A in the cut receives the blood, the tube is to be applied, and the instrument used as before directed. If the blood is not deflibrinated and strained, three or four drops of ammonia solution are added, in order to avoid coagulation.   The instrument is made bv Messrs. George Tiemann &, Co., 67 Chatham Street, New York.   We would suggest to those who may become interested in transfusion, that though the operation is a simple one. it requires care, and it should first 'be practiced once or twice on the lower animala no difficulty will then be had in doing It on man when occasion requires.   Fig. 212.—Garrigue's Mediate Transfusion Apparatus.   Draw eight or ten ounces of blood from a healthy person into a clean vessel, whilst it is accumulating whip it with a silver fork, a stick of wood or a bunch of straw, then strain it through a piece of cleanly washed linen into a vessel placed within another containing warm water (about 105 C.) Warm the syringe, put the suction end A into the blood, compress the bulb, and when it flows through the canula, turn the stopcock C.   Having bared the patient's arm, raise a fold of skin over a vein at the bend of the elbow, divide it and pass a probe or thread under the vein thus brought into view. This is now held with a pair of forceps or tenaculum and an incision made with a lancet or pair of fine pointed scissors, carefully avoiding to wound its posterior wall. Now introduce the canula D, open the stopcock and inject slowly.   The bulb contains about three fluid drachms, but by moderate compression about two only are expelled. In most cases it suffices to inject from four to six ounces. If resistance, not due to external pressure be felt, or dyspnoea, or any other untoward symptom appear, the operation has to be interrupted or ended. Dress the wound as after phlebotomy. After use, the instrument must be thoroughly cleansed, which is best done by separating all the parts and washing them in warm water.   A transfusion technique from Samuel Gross's Operative surgery book:     Medical/Surgical History--Part III, Volume II Chapter XII.--Wounds And Complications. Treatment of Haemorrhage.   Two cases of transfusion of blood are found on the records; one, a successful operation, was performed by Surgeon E. Bentley, U. S. V.; the other, a fatal case, by Assistant Surgeon B. E. Fryer, U.S.A. Both are here detailed: CASE 1186.--Private G. P. Cross, Co. F, 1st Massachusetts Heavy Artillery, aged 19 years, was wounded in the right leg, before Petersburg, June 16, 1864, and entered the Grosvenor Branch Hospital, Alexandria, two weeks afterwards. Surgeon E. Bentley, U. S. V., who operated in the case, made the following report:' "The injury consisted of a flesh wound on the posterior aspect of the leg. At the date of the patient's admission he was exsanguineous from previous loss of blood. Owing to his condition no operative measures were adopted, but his languishing vital powers were sustained by stimulating treatment combined with highly nutritious diet. Under this method he slightly improved in strength, but the circulating fluid was so impoverished in quality and reduced in quantity that the face of the wound looked pale and bad, and ultimately, on August 12th, it assumed a gangrenous aspect. Local applications, such as creasote, charcoal poultices, nitric acid, etc., were applied to combat this condition. These means failed to arrest its onward progress, the leg presenting in a short space of time a mass of gangrenous sloughs, horribly fetid. Haemorrhage from the posterior tibial artery again commenced on the afternoon of August 15th, when it was deemed advisable to amputate to prevent further loss of blood. The operation was accordingly performed just at the tubercle of the tibia, the condition of the parts not allowing a flap to be made below that point. Not more than two tablespoonsful of blood was lost; but the patient not seeming to rally, it was determined to test the method of transfusion of blood as recommended by Brown-Séquard. Blood having been obtained from the temporal artery of a strong healthy German, an attempt was made to penetrate the internal saphenous vein, but was unsuccessful on account of its small size; after which an <ms_p3v2_812>opening was made into the median basilic, and about two ounces were transfused by means of a Tiemann's syringe. Immediately after the injection a marked difference was noticed in the patient's pulse, which became stronger and firmer. He was then removed to his bed and generous diet was administered, together with stimulants and tonics, under which treatment he gradually improved, his appetite became better, his strength increased, and the stump assumed a healthy aspect. On October 20th the stump had healed and the patient had so far improved as to be able to be furloughed. At its expiration he returned, and, finally, he was transferred to Webster Hospital, Manchester, January 13, 1865, cured." The patient was ultimately discharged from Central Park Hospital at New York City, June 9, 1865, and pensioned, and afterwards he was supplied with a "Hudson" artificial limb. This pensioner died August 24, 1867.   CASE 1187.--Private J. Mort, Co. E, 105th Illinois, aged 37 years, received a flesh wound in the upper third of the left leg, at Keneeaw Mountain, June 26, 1864, by a musket ball, which lodged between the tibia and fibula. He entered Brown Hospital, at Louisville, nine days after receiving the injury, the missile having been extracted and the wound looking unhealthy and sloughing. During.the night of July 24th the patient had a copious haemorrhage from what was supposed to be the anterior tibial artery, which was arrested. On July 26th bleeding again commenced, the blood welling up from between the bones and from the tissues posterior to them. It was then deemed necessary, in order to save life, to amputate, which was done through the upper third of the leg by the circular method, by Assistant Surgeon B. E. Fryer, U.S.A. Ether was used as an anaesthetic, and three ligatures were applied, the patient reacting very slowly. On the following day it was determined to transfuse some blood into the patient, for which purpose, in the absence of any other suitable apparatus, an ordinary gutta-percha syringe was used, the nozzle of which was filed to fit a small tube having a stop-cock through its centre. The right cephalic vein having been selected, an opening was made carefully into it, and the syringe having been warmed and filled with blood from a healthy man, a little of which was allowed to flow from the syringe before forcing its nozzle tightly into the tube in order that any air might be driven out, the tube was introduced and the stream of blood was slowly and carefully forced in. About sixteen ounces were thus transfused. The first effect upon the patient was to increase respiration from about fifteen to twenty-eight per minute, though it soon returned to its normal number of about sixteen. The pulse ran up from one hundred to one hundred and thirty, which, however, also soon returned to what it had been. The man's general condition was greatly improved. His pulse became fuller and slower; he slept well; his stomach retained food, and altogether the prognosis became more favorable. On August 4th haemorrhage commenced from the face of the stump, the whole surface of which appeared to be involved. From the effects of this, and from chronic dysentery, the patient died on the following day, August 5, 1864; although his condition, from the effects of chronic dysentery and of the haemorrhage at the time of the transfusion, was such as hardly to expect his recovery, the improvement was such as to show that the operation was not only justifiable, but that it was to all intents a success. The history of the case was reported by the operator.