Transfusion is now practically limited to the intravenous injection of physiologic saline solution. Several varieties of apparatus are used for this purpose, but like the majority of emergency operations, the apparatus is too likely to fail when needed most. Consequently the very simplest apparatus is most reliable.

For the successful performance of this operation all that is necessary is a reservoir for the solution, a rubber tube, and a small glass or metal canula. An ordinary two-quart fountain syringe will answer every purpose provided it be made sterile by boiling before it is used. The canula should be tied firmly into the tubing, to prevent any possibility of its coming out during the operation.

The median basilic or cephalic vein is usually chosen, as for venesection, the arm is surgically cleaned, a bandage tied above the elbow sufficiently tight to impede the return circulation and to make prominent the veins. A small incision is made over the vein chosen, which is isolated and picked up. Two ligatures are passed under the vessel but not tied. At this stage the saline solution should be started running out of the canula to insure the absence of all bubbles, and the required temperature. Next a small, transverse incision is made in the exposed vein, and the canula, dripping its warm physiologic saline solution, is inserted into the vein in the direction of the heart. One of the ligatures passed under the vein should now be tied tightly about the canula to retain it in position, and the other tied between the canula and the distal end of the incision. The bandage should next be removed from above the elbow, and the saline allowed to flow steadily from an elevation of about three feet. When a sufficient quantity has been introduced the canula is withdrawn, the ligature which was around it is drawn tightly and knotted, and the wound closed with one or two skin sutures, and an antiseptic dressing applied. Every detail of this procedure should receive the strictest attention to asepsis.

The temperature of the solution should be about 100° F., and the amount introduced will depend upon the indication as well as upon the symptoms. Naturally more will be required in a case of severe haemorrhage coupled with shock, than if there is simple shock to deal with. The condition of the patient and his pulse give the best indication that a sufficient quantity has been given. The rate at which it may be introduced should not exceed 500 c. c. in fif'teen minutes, and may be governed by the height of the reservoir.

The so-called "normal saline" solution, .6 per cent. NaCl universally used in irrigation and hypodermoclysis is generally used here, but when so introduced directly into the blood stream in contact with the corpuscles there is no question but that it is not isotonic. In other words, it has not a high enough percentage of solids. A .9 per cent, solution is a much better approximation, and this is the percentage which should be used. Probably the nearest approximation to a "physiologic solution" is this modification of Ringer's solution: Na CI .90 per cent.; Kc1 .01 per cent.; Ca Cl .026 per cent.; H20 99.064 per cent.

For practical purposes the following solution added to a quart of water makes, in the present state of our knowledge, the best solution to use:

Transfusion 41

Calcii Chloridi ..................................

.25 gms.

Potassi Chloridi ...................................

.10 gms.

Sodii Chloridi ........................................

9. gms.

Aquae .........................................................

50. gms.

M.

Big

Add to a quart of water.