plants. In Vienna, in 1656, a solution of opium in sherry wine was put into a dog's veins successfully. Blood transfusion quickly followed this, but finally it became a panacea, and on account of its misuse laws prohibiting its use were promul gated. Again, in 1777, Regnaudot recommended it anew, and later the Baron de Percy, James Blundell, and more recently De Belina practised it successfully. From the impracticability of mediate transfusion of blood the immediate method was employed. But as even this required the convenience of some willing donor of the human family or the presence of a lower animal, it too was not suitable to general work. A substitute was found in a synthetical preparation containing some ingredients of the blood serum, usually of the inorganic salts with or without albumen. Thomas Latta, inspired by the chemical researches of O'Shaughnessy, injected salt solution into the veins of his patients. Dupuytren, Magendie, and Gaspard followed him in this plan. In 1855 cholera was treated by intravenous infusion of salt solution. The fluid recommended by Little for use in the treatment of this disease was composed of sodium chloride, fifty grains; potassium chloride, three grains; sodium sulphate and sodium carbonate, of each two grains; and water, one pint. Alcohol was added to these preparations in some instances.

The employment of normal salt solution, its field of usefulness broadening as well, gradually increased up to about 1890. Since then its application has rapidly increased, until to-day many surgeons use it almost exclusively for wound irrigations and very largely in other fields, while physicians find its efficacy and the number of its indications constantly increasing. S. C. Gordon, of Portland, Maine, says he remembers Prof. E. R. Peaslee, in 1855 to 1860, was accustomed, in ovariotomy, to wash his hands, to cover his instruments, and to irrigate the abdominal cavity with what he called artificial serum, which was composed of egg albumen, sodium chloride, and water in the proportions in which they occur in the blood. In 1879 Bizzozzero and Golgi injected it into the peritoneal cavity, which gave some brilliant results, but on the whole became unsatisfactory and was abandoned. In 1888 Dastre and Loye studied its effect on the general physiology of animals and recommended it in infectious diseases.

Comparison of Methods.-Its introduction into the body for changing the character and composition of the blood and other purposes has been by five different avenues-viz., intravenous,

subcutaneous, intraperitoneal, rectal enema, and intra-arterial. Each of these is said to have its special indications, which will be considered later. The nature of the individual surgeon's work no doubt influences his preference as to route. The abdominal surgeon will prefer the rectal, intraperitoneal, and subcutaneous, emergency surgeons the intravenous and rectal, while the plastic and general surgeon will elect the rectal and subcutaneous routes. The intravenous, while most rapid and therefore most applicable to the most dangerous cases, is in itself the most dangerous (except the intra-arterial), as referred to again in this paper. Nor is it always quickest. A private letter from a prominent surgeon in New York tells of his vexation in an important case in which two surgeons were thirty minutes in getting the solution to run into the median basilic vein. And, too, apparatuses specially devised for this method are generally arranged for practising the subcutaneous method until the intravenous can be arranged. We believe the intraarterial route, recommended by Dawbarn, should never be used.

Physiological Action.-We are not aware that the physiological action of normal salt solution has been elaborately studied, further than the investigation made by Dastre and Loye, but enough for practical working is known. It increases the volume of the blood and lessens its specific gravity. This, in conjunction with its stimulating effect on the cardiac ganglia and arteries, accelerates the circulation of the blood. By increasing the volume of the blood it increases the arterial tension and thereby increases the blood supply to the heart through the coronary arteries. It stimulates the nerve centres, sometimes causing marked excitement, even when used subcutaneously, as noted by Fourmeaux. The skin, kidney, and intestinal functions are stimulated markedly and other organs are made to do more work. Locally, it does not coagulate albuminous fluids, such as blood serum, but, on the contrary, dilutes them, thus facilitating their removal. It is also a local stimulant, causing contraction of the smaller blood vessels and in that way exerting a hemostatic action. It has a decided stimulating effect on osmosis, and in this way, no doubt, acts to a considerable extent upon the emunctories. Fourmeaux and other French investigators found the weight of the spleen in the lower animals much increased, though no change in its size was apparent. This effect, though not so constant, was also noticed in the liver. According to Hayem, Plouvicz, and

Poiggale, salt solution augments the number of red blood corpuscles. Fourmeaux has also demonstrated this. He found in animals, too, the bone marrow was more fluid after its use, and in one a subarachnoid cerebral edema after ligating both ureters. This same author, whose thesis on this subject is invaluable, found that in the rabbit quantities of less than four milligrammes to the kilogramme of the animal's weight were retained in the system.

We believe its effect on the blood and glandular system is even more marked than physiologists have told. Otherwise, how explain the fact that blood may be abstracted from a healthy animal up to one-nineteenth its weight and life be restored by the immediate infusion of normal salt solution, while such a result does not follow if the water without the salt be employed?

Elimination. The quantity of urine is remarkably increased, being often four times the usual amount during the first few days following operation, and, according to Voit and Rabuteau, the amount of urea excreted is considerably increased. The amount of sodium chloride excreted by the kidneys is enormously increased, and Fourmeaux has noticed on the lips of puerperal septic women that had received large quantities a salty taste and crystals of salt for some days afterward. The reaction of the perspiration becomes neutral and loaded with sodium chloride. In autopsies made shortly after large quantities of normal salt solution had been employed hypodermatically, considerable quantities of thin fluid, rich in sodium chloride, have been found in the intestine. It has also been noticed that in patients treated by large quantities of the solution the dosage for catharsis has been markedly lessened. So it may be said to leave the body by the skin, kidneys, lungs, and intestine, and in the order named as to relative quantity.

Therapeutic Uses.-As previously mentioned, the application of this solution has been in a wide and varied field. In general medicine its principal use has been in diphtheria, scarlatina, uremia, intestinal hemorrhage of typhoid fever, perforation of typhoid ulcers, cholera, cholera morbus, pneumonia, diabetic coma, hemoptysis, ulcerative endocarditis; poisoning by carbon monoxide, by mushrooms, or by alcohol; lead colic, epilepsy, tetanus, toxemia from colon bacillus, arsenical poisoning, pyelitis, renal insufficiency, and numerous other affections. In obstetrical practice sepsis, postpartal hemorrhage, and eclampsia are the conditions that have been most commonly

combated with it. The surgeon has found greater use for it, and probably ninety per cent of the amount used is by surgeons. They employ it to prevent or reduce shock during operation, and in hemorrhage and sepsis. It is also largely used in shock from injury, for irrigation during operations, and for other purposes to be mentioned later.

When the blood is handicapped by the various poisons of infectious diseases, salt solution has been found valuable in the way of "lavage" to carry off the toxins, and by the increased temperature following its use the production of antitoxins is said to be stimulated.1

In the various chemical poisons, as carbonyl, lead, alcohol, and even mushrooms, it is used in combination with abstraction of blood. In the collapse of cholera and cholera morbus the tissues have been drained of serum, and this condition is ameliorated by the prompt use of the saline infusion. In renal insufficiency the compensatory emunctories are stimulated to greater activity, and it has been noted that as free perspiration occurs the renal function is again established. In uremia, in conjunction with abstraction of blood, as recommended some years since by Van Rensselaer, of Washington, the infusion of normal salt solution has proved to be very successful. Grandin has used it in uremia in enormous quantities by colon irrigations with marked success. As soon as intestinal hemorrhage in typhoid fever is thought to have ceased, the use of the solution by hypodermoclysis is strongly advisable. The danger of hypertension of blood vessels by the intravenous infusion, and the difficulty in properly estimating the amount of blood loss in such cases, precludes this method from employment.

In puerperal sepsis it has met with tolerable success, though our experience has been unfavorable. In this condition it has. been used in small quantities subcutaneously and frequently repeated, and by the plan, recommended by Pozzi, of large intravenous infusions. Hanks and Stimson are strong advocates of this latter procedure. It may be said here that this remedy is not intended to exclude the ordinary means of treatment, but as a powerful adjuvant.

In postpartal hemorrhage is found one of the greatest indications for its use. In puerperal eclampsia brilliant success. has attended its use with blood-letting. J. Whitridge Williams has adopted the practice in this condition of abstracting. 'T. F. Reilly: Medical Record, November 12, 1898.

Prentiss: Philadelphia Medical Journal, September 24, 1898.

the better part of a pint of blood and injecting subcutaneously double the amount of normal salt solution, repeating the latter daily until the urine is normal. In some of his cases chloroform and rapid delivery were also practised. He reports ten successful cases. Jewett has successfully employed it alone in

eclampsia.

In surgery, shock, hemorrhage, and sepsis are the principal indications for its use. Its greatest influence in shock is exercised if employed early. If shock be from operation, infusion should be practised on the table in grave cases and immediately after operation in milder ones. Here the subcutaneous method

is best, but the rectal way is especially valuable, one or two litres being easily thrown into the bowel, especially in the Trendelenburg position, and, if the temperature be from 115° to 120° F., exerts a powerful influence in the reduction of shock. For hemorrhage the same plan of treatment is to be followed. Severe hemorrhage, however, affords about the only indication. for intravenous infusion. In abdominal work I almost invariably leave a considerable quantity, one to fifteen litres, of normal salt solution in the abdominal cavity. When it is not necessary to use it during the operation this plan is very convenient and satisfactory. It is particularly good to promote urinary excretion, and to reduce shock by its intimate and prompt contact with the abdominal viscera. Many other indications for its use are found here. When denuded surfaces are left in the pelvic cavity a small amount of the solution floats the intestine and prevents its coming in contact for adhesion to these places. It dissolves the exudate on such surfaces and in that way prevents their becoming agglutinated to other structures. If small foci of infectious material, blood clots, or ovarian or other fluids have escaped the eye of the surgeon, it dilutes or dissolves them and lifts them up into the general peritoneal cavity for more prompt absorption. It prevents formation of coagula from venous oozing. In large quantities. it prevents the collapse incident to the removal of large tumors. Its stimulating action on the large amount of blood vessels of various sizes in the abdominal cavity is remarkable. It prevents the almost unquenchable thirst so common after abdominal operations.

In bleeding fibroids infusion just preceding operation has been practised successfully by Boldt and others. For purposes - of irrigation in general surgery it is far superior to sterile water and is largely used for this purpose.