5033

JUN 15 1897

MEDICAL MONTHLY.

VOL. XV. MEMPHIS, JANUARY, 1895.

No. 1

Original Articles.

SUBCUTANEOUS INJECTIONS OF LIQUIDS IN ACUTE

HEMORRHAGE.

Read before Tri-State Medical Association of Ark., Miss. & Tenn., Nov. 14, 1894, BY T. J. CROFFORD, M.D., MEMPHIS, TENN.

Having recently read the report of a series of cases from Guy's Hospital, London, and another from the Johns Hopkins Hospital of this country, in which intravascular injections of a saline solution were practiced in acute hemorrhage, causes me to report some experiences which I have been having for the past few years, and to put forward the advocacy of a method simpler than intravascular transfusion for supplying the system with fluid to take the place of the blood which has been lost. I refer to the subcutaneous injection of fluids in quantities sufficient to supply the deficiencies, or sufficient to tide the patient over the crisis.

The method I have adopted has served the purpose well, and is briefly described as follows: Make a saline solution of two, four or six per cent. of common salt in an ordinary water pitcher. Pour this into an ordinary fountain syringe, into the end of the tube of which an aspirator needle has been inserted. While the water is running out through this needle, thrust it through the skin into the cellular tissue of the flank or back of the patient. It will be observed that several ounces VOL. XV-1

or a pint of fluid will have been deposited under the skin in a short while. The position of the needle can now be shifted to another location without fully withdrawing it, and another quantity of fluid deposited. This can be done several times, till a quart or more of the fluid has been injected without withdrawing the point of the needle from the original puncture made in the skin.

It will be argued that the intravascular injection is directly into the circulation, and is, consequently, on account of its immediate effect, the better applicable to the crises of the acute hemorrhages which need transfusion most. This may be the case when the necessary apparatus and an experienced operator is at hand and ready to do the operation of transfusion. In other words, when you are looking for a hemorrhage and have prepared for it beforehand, it may be best in certain cases, but this has not been the case in any of the cases of hemorrhage with which it has been my misfortune to deal.

When we consider the simplicity of the method which I have above described, that no instruments beyond a fountain syringe and an aspirator needle are required; no operation beyond passing this needle through the skin into the cellular tissue; then when we consider the rapidity with which the fluid is absorbed after hemorrhage, it is very evident that this method is the most feasible, and therefore the most applicable in by far the greater number of cases encountered,whether surgical, obstetrical or medical varieties of hemorrhage be met with.

I have put the method to test in quite a number of cases, but to avoid tediousness I shall report only three, these being quite sufficient to show its efficiency, as well as the ease and certainty with which it can be gotten to work in emergencies.

Case 1. Mrs. V., aged 35, was operated upon May 19th, 1893, for huge pus tubes, likely of long standing, firm and universal adhesions. Upon enucleation the hemorrhage was very great, in spite of my best efforts to control it. By the time the hemorrhage was under control, the incision stitched up and the patient placed in bed, it was found that the pulse had failed at the wrist. Considerable quantities of a saline solution were thrown under the skin. In a short while she rallied, and made ultimately a good recovery.

Case 2. Mrs. L., aged 30, had a tedious delivery on the morning of June 5th, 1894. After the child and placenta were expelled she was found to be flowing profusely. A very few moments later she was quite blanched, and the pulse had failed at the wrist. The clots were quickly turned out of the uterus, and it was irrigated with hot bichloride apple vinegar. With the same syringe a large quantity of mildly saline fluid was injected into the cellular tissue of the back and flank. She rallied nicely, and before twenty-four hours was up, her pulse was 84 beats per minute and of fairly good volume. Recovery perfect.

Case 3. Mrs. M., aged 40, was delivered on Sept. 25th, 1894. A terrific hemorrhage immediately followed. The uterus was emptied. She was at once irrigated with a hot bichloride solution. No abatement of the hemorrhage followed. The uterus was then irrigated with hot bichloride apple vinegar, with still no abatement of the hemorrhage. The patient was now very much exhausted; the pulse was 140 at the wrist. The uterus was again quickly emptied and thoroughly packed with iodoform gauze, which controlled the hemorrhage perfectly. A large quantity of saline solution was injected into the flanks and back, and in a very short while the circulation was restored. Her successful progress was uninterrupted from this time on.

In all probability the first two cases would have died without the transfusion. The third case would likely have recovered without it, but she rallied much more quickly and progressed much more satisfactorily with it. It will be remembered that a large percentage of the patients who die from hemorrhage rally somewhat and then die some hours, or even a day or two later, from cardiac exhaustion incident to the lessened blood pressure.

The operation as above described, if it can be called an operation, is so simple that any assistant or nurse can attend to it while the surgeon or obstetrician is completing his work. No patient who has lost any considerable quantity of blood should be allowed to go without it, especially if the stomach is not in condition to absorb fluid.

When death takes place on account of the sudden withdrawal of a large quantity of blood from the circulation, it is because the heart fails to act. The heart fails to act because there is a sudden fall in the blood pressure, which is its continuous direct stimulus. The diminished blood pressure is relieved, within certain limits, by the vasomotor system of nerves stimulating the blood vessels to contract, thereby adapting the vascular apparatus to the lessened volume of blood. If the hemorrhage is sufficiently slow for the vasomotor contraction of the blood vessels to keep pace with it, then life can be sustained with a proportionately small quantity of blood.

From the foregoing, the interdependence between the blood, the vascular apparatus and nervous system is apparent. The indications, then, are, first, to stop the hemorrhage; second, to increase the volume of the circulating medium; third, to sustain the heart and nervous system during the crisis.

It will be remembered that the middle coat of the blood vessels contains both nonstriated and muscular fibers and yellow elastic tissue; the former predominating in the small, and the latter in the large, vessels. In algid congestions there is a recession of the blood into the large vessels in the interior of the body, leaving a diminished quantity in circulation. It is possible for one to die of all the symptoms of hemorrhage; the blood being poured into the large vessels instead of upon the ground. The remedy for present relief of the two conditions would, theoretically, be the same.

155 Third street.

SOME OBSTETRICAL SINS.

Read before Tri-State Medical Association of Ark., Miss. & Tenn., Nov. 13, 1894, BY WILLIAM W. TAYLOR, A.B., M.D., MEMPHIS, TENN.

The acceptance and adoption of advances in the practice of obstetrics have been relatively slow, compared with what obtains in other branches of medicine. There has been a disposition with many general practitioners, in obstetrical matters, to follow along paths that they trod twenty or thirty years ago, and have been slow to accept methods that have been tested and found good; others, while recognizing and approving some recent advances, have failed of success through