FIG. 3-Condition after normal external fusion. to be correct, as existing malformations substantiate it. Before, however, uniting with these organs, a subdivision of the depression into anterior and posterior takes place (Fig. 2), the posterior depression uniting with the rectum, the anterior with the vagina and bladder. Fig. 3 shows the condition after fusion. The development of the external organs, therefore, consists in the formation of the clitoris, labia, etc., and the fusion of the external skin with the lower portion of Mueller's ducts. It can now be readily understood how complete atresia can take place—that is, where there is no effort at all toward fusion between the external skin and the internal organsor how the vagina and rectum may have a common opening, due to a failure of division of the depression, so that the vagina may empty into the rectum or vice versa. The term atresia ani-vaginalis, a misnomer, is usually understood as this condition. Similar changes may take place in con nection with the development of the urethra and bladder. In describing the form of atresia which existed in my case I wish also to describe the congenital atresias of the rectum, their mode of development being very similar. Imperforate introitus vaginæ and imperforate vagina are parallel conditions to imperforate anus and imperforate rectum, and may be found associated with each other. The lower portion of the ailmentary canal is not formed by the hypoblast, but by the epiblast; that is, by an involution of the skin which meets the rectum and fuses with it. Should this involution fail to take place, the condition of imperforate anus results, and there will be no attempt whatever at the formation of an anus; where it should be found, there is a continuation of the normat skin. A similar process may take place at the vaginal orifice, when the involution of the skin which fuses with the lower portion of Mueller's ducts fails to develop; as a result the skin is continuous from the perineal body to the urethra. In both the rectal and the vaginal forms the atresia is made up of three layers-the internal or mucous layer, the external skin, and a layer of connective tissue between. I have not found any designation for this form of atresia; the term imperforate introitus vaginæ, which I have used, appears applicable. This is the condition which existed in my patient. Probably the rarity of this form is the reason for its not having any special designation. This form might be mistaken for an imperforate hymen, but the characteristic continuation of the skin is not present in the latter, it always being of a membranous consistency. Imperforate rectum is caused by a lack of development of the lower portion of the alimentary canal, with failure of fusion with the external depression; on examination per anum a short, blind pouch is felt. The corresponding form in the vagina exists when the tube formed by the ducts of Mueller fails to develop sufficiently to meet the external depression at the vaginal orifice, and as a result a transverse atresia forms in the lower third of the vagina. The correct term for this condition would be imperforate vagina. A failure in fusion may take place even when the external depression and the vagina are fully developed, the two canals running in a parallel direction, giving rise to an oblique atresia. in the lower third of the vagina. This condition is rarely met with. The operation in this case consisted of first inserting a probe as guide. The atresia was incised with a knife large enough to admit a finger, then dilated as much as possible. On inspection the mucous membrane had retracted considerably. Considering that the opening established in this manner would not be large enough for the purpose desired, the perineal body was split, leaving only a thin septum between the vagina and rectum. The mucous membrane of the vagina was now loosened and sutured to the external skin and the seat of operation packed with iodoform gauze. A week later the sutures were removed; the opening was large enough to permit the thumb without causing any pain, and undoubtedly large enough to permit sexual intercourse. The patient left the hospital a week later feeling very much improved. The operation was similar to that suggested and performed in one case by Kelly. who, however, did not split the perineal body. This I think should be done in all cases where subsequent contraction is liable to occur. It has the disadvantage, however, of being the possible cause of a prolapsus. In my case I considered it a necessity, and I do not think there is any danger of prolapsus following, at least before childbirth. Two months later I examined the patient and found that the seat of operation was in perfect condition. There was absolutely no tendency to contraction; in fact, the vagina was even more spacious than at the time of operation. During her last two menstrual periods she had menstruated in a natural way, the flow lasting from three to four days and then ceasing entirely. When seen one month later the same conditions prevailed. She had again menstruated normally. I then did not see the patient for about eight months, when I was called to her home and found her suffering from severe labor pains. She stated that she believed herself to be pregnant at about eight and a half months. An examination showed her to be in labor, the head being well down in the pelvis. I transferred her to the West Side Hospital, where I referred her to Dr. Frank B. Earle. I submit his statement as to the condition which prevailed during her period of labor. After she left the hospital I did not see her again, but I have heard that she is doing well. The result in this case has undoubtedly been a most satisfactory one, not only the re-establishment of a vagina of almost normal dimensions, but also the impregnation which followed. A malformation of the uterus existed in this case, to which I believe we can attribute the premature labor. External deformities are almost always associated with deformities of the uterus and its appendages. Following is the report of Dr. Frank B. Earle : Patient admitted to West Side Hospital late in the afternoon with history of having been in labor a number of hours. External examination disclosed the fact that the fetus was presenting by the vertex in the first position, head well engaged in the pelvis. Vaginal examination to determine the progress of labor was made but failed to reveal the location of the os uteri. Patient anesthetized; lower segment of the uterus extremely thin, permitting easy palpation of the vertix and os discovered in posterior vaginal fornix and well to the left. Traction upon the os in order to bring it within the axis of the pelvis resulted in some dilatation and severe hemorrhage. The tampon to control the hemorrhage and assist dilatation was used and allowed to remain in situ for twelve hours. At the end of this time expulsive pains were present and before the patient could be taken to the operating room a fetus was spontaneously expelled. Slight laceration of the perineum which was made during confinement was repaired by Dr. Lee. Convalescence uninterrupted. Normal Saline Solution. (A) When to Use It; (B) How to Use It. BY A. P. HEINECK, M. D., CHICAGO. The name "artificial serum" we discard. It is confusing. It is inaccurate. It might suggest the existence of a similarity of action and of composition between this substance and the various antitoxins. Such a relation does not exist. Normal salt solution is not antitoxic, is not microbicide (Bosc and Vedel, Archives de Physiologie, 1896). Solutions containing only water and Na Clare called simple norma! saline so lutions; those containing in addition to the Na Cl and water sodium sulphate and other salts, are called compound normal saline solutions. 991 Normal salt solution is one of our most valuable therapeutic agents. "The use of saline infusions is as specific in its field of usefulness as that of any drug that we possess. Its field of usefulness is being constantly extended. It is a non-toxic agent. It is not noxious to human tissues. "Normal salt solution has never been shown to have any deleterious influence on the tissues" (Hunter Robb). Vaquez examined the blood of animals that had been subjected to repeated saline injections. He says: "The white corpuscles showed no apparent change of form. The normal proportion of the different forms of leucocytes was not altered. No difference in the reaction of the blood elements to the different stains, especially none to eosine, or hemateine, could be detected." "There is no fear of untoward symptoms from the injection of one or even two litres of saline solution at a time" (J. G. Clark). It does not coagulate albumninous fluid. Its facility of preparation, its cheapness, its harmlessness, its non-toxicity, its manifold indications, its utility as a life-saving agent, all these and other reasons alike commend its use to the physician. There is no toxic dose, there is only a toxic rapidity of absorption. Why is the use of so serviceable a medicament as normal saline solution So restricted among the general practitioners? It is because they ignore the indications and the contraindications to its use; it is because they exaggerate to themselves the difficulties and the dangers, if there be any, of the different methods of administering normal saline solution. Like other therapeutic agents, normal şaline solution must be employed (a) with discernment and prudence, (b) must be employed at the proper time, its use never being delayed until all hope of success is futile; (c) must be used in sufficiently large and repeated doses, the quantity to be used, and the frequency of use, varying with the conditions present in each individual case. The saline solution, 7-1000, is the solution of choice to employ in therapeutics.* "A 5 per 1000 produces the same physiological action and possesses the same therapeutic effects as a 7 per 1000 solution. However, the physiological effects which we consider the most important, as diuresis, thermic reaction, are not as rapidly produced, nor as marked, when the former solution is used as when the 7-1000 is employed" (Bosc and Vedel). For transfusion and infusion purposes normal saline solution has displaced human blood, because the transfusion of blood necessitates a cumbersome and complicated apparatus; because it is difficult to find a donor of blood, hence human blood is not at hand when most needed, and cannot be obtained in sufficient quantity; the technique of blood transfusion is far more difficult than that of normal saline solution: during transfusion of blood very painful symptoms are in some instances experienced; after transfusion there may be alarming prostration, may be hemorrhagic fever; with blood transfusion there is the danger of formation of emboli. Coagulation emboli was often the cause of death when blood transfusion was practiced. The regeneration of the blood corpuscles after transfusion of the blood requires more than double the time required after saline injection. Hunter says, in the "British Medical Journal," 1889: "Any value which blood transfusion possesses over the infusion of saline solution depends upon the presence of the red corpuscles and their hemoglobin in the general circulation." To this he adds: "Any advantages that transfusion of red corpuscles may have over saline injections are counterbalanced by the dangers attending the simultaneous injection of the white corpuscles." In the treatment of hemorrhage, another advantage of saline solutions over blood transfusion is that the hemostatic action of the latter is less than that of the former. "The injection of normal saline solution. is free and safe from all the disadvantages of blood transfusion" (Jno. B. Bullitt). The transfusion into human beings of blood of inferior animals was discarded because it is not infrequently followed by acute nephritis, suppression of urine, hematuria and uremic symptoms. It imperils life and often leads to a fatal issue. Landois, Ponfick and Panum showed conclusively that the blood of one species cannot be injected without danger into another species. The use of human serum for transfusion purposes was abandoned because it cannot be obtained in sufficient quantity. Defibrinated blood should not be used, because "the leucocytes so preponderate in it that transfusion of defibrinated blood is an operation not only dangerous in itself, but one whose practical value by no means compensates for the risks attending it (Hunter). Pure water alters the blood corpuscles. It can, however, in emergencies be used for transfusion. Distilled water, however, must not be used, not only because it is difficult to obtain on immediate notice, but especially because when introduced into the blood it is decidedly toxic to the human organism, provoking blood evacuations, causing degenerative changes in the blood corpuscles, and producing hemorrhages. Bosc and Vedel state that as a result of their laboratory experiments they have come to the conclusion that distilled water, when injected, even in small doses, into the blood, has an energetic toxic action. They say that in a general way distilled water should not be used as a vehicle for substances that are to be introduced directly into the blood. Experiments have been conducted to determine the value of intravenous injections of milk in anemia. These injections have been found to be valueless, to be dangerous. Dr. Joseph Howe (Handbook of the Med. Sciences), in speaking of his experiments upon dogs with the intravenous injection of milk, says that when he had bled seven dogs to a state of syncope, milk was intravenously injected, and not a single recovery took place. The intravenous injection of milk in human individuals is attended with serious accidents. Various solutions are used by different clinicians. The following are the formula most frequently employed: Hayem's formula: water in the proportion of 7 parts of salt to 1000 of water. It can be prepared with reasonable accuracy, when the urgency of the case demands that no time be lost, by dissolving a teaspoonful of salt in a pint of boiled and filtered water. The water is boiled to sterilize it, and thereby avoid infectious phenomena. It is filtered to remove any foreign bodies present. Foreign bodies, when introduced in the vessels, may lead to emboli formation; when introduced in the tissues they irritate them. The other solutions possess no advantage over simple normal saline solution. There is only an infinitesimal proportion of sodium sulphate present in normal blood. Its addition to simple normal saline solution is of no advantage; according to Mazet, it appears to be injurious to the integrity of the blood corpuscles. Simple normal saline solution is the most easily prepared, the most inoffensive and the most widely used of the various saline solutions.' Common salt and water are found in every household. Simple normal saline solution, according to Bosc and Vedel, produces the maximum physiological effects-most profuse diaphoresis and diuresis. It is the solution exclusively employed in Cook County Hospital. USES OF NORMAL SALT SOLUTION. 1. As an inexpensive cleansing spray in chronic hypertrophic rhinitis (Morris J. Asch). As a gargle (Geo. A. Leland). 2. In diphtheria, irrigation of throat with hot normal saline solution gives much relief. Its use can be repeated every four hours. Irrigation removes all the loose membrane (J. H. McCollom). It being definitely understood that its use in this connection is only as a palliative and as a cleansing agent, antitoxin being the specific remedy in this affection. 3. In skin grafting and to douche skin grafts previous to transplanting them. Antiseptics exert a deleterious action on living cells, and when used in skin grafting. endanger the success of the operation. They impair the vitality of the grafts. Antiseptics must be thoroughly removed by prolonged douching with sterilized normal saline solution, from areas that are to be skin grafted.' 4. As an irrigating fluid for wounds. When used for this purpose it must be sterilized. Saline solution used for this purpose should have been boiled half an hour. Normal salt solution can be boiled for sterilization without changing its composition. "Saline solution has a positive antiseptic action" (Tavel). It is less irritating to the hands of the surgeon than the repeated employment of solutions of antiseptics. It does not irritate the tissues. It does not impair their physiological properties. Can be used for irrigation of uterus. Used in abdominal surgery to wash out septic material. Owing to the great absorptive powers of the peritoneum, solutions containing germicidal drugs, when used in abdominal surgery, in addition to their local irritating action, can produce systemic disturbance from the absorption into the system of the chemic irritants which they contain. 5. In diarrheal affections. It is also of great value in gastro-intestinal infections of infancy. Injections of normal saline solution, whether intravenous, subcutaneous or rectal, raise the arterial pressure and hydrate the tissues. They quiet the intense thrist present in these conditions. Emptiness of the circulatory cavities is the cause of the collapse in cholera" (B. J. Richardson). In the following affections the use of normal saline solution will be found very serviceable: (a) Cholera Asiastica (its use in this disease is sanctioned by the best authorities). "Owing to the profuse serous discharges the blood becomes concentrated and absorption takes place rapidly from the lymph spaces. To meet this intravenous injections have been practiced. This is really a valuable method, thoroughly physiological, and should be tried in al severe cases" (Osler). (b) Cholera nostras. (c) Acute enteritis. (d) Dysentery. (e) Gastro-intestinal intoxications of nurslings. In profuse diarrheas the sunken eyes of the patients show how wanting in fluid the tissues are. 6. In the anemic form of asphyxia neonatorum. "The infant is suffering from shock, and the measures which suggest themselves are similar to those we would resort to were we dealing with an adult. Heat to the surface, injection into the rectum of a pint of hot (115° F.) saline solution, the instillation into the mouth of ten drops or so of brandy, such are the primary measures of utility" (Grandin and Jarman, Practical Obstetrics). 7. In surgical and puerperal infections. In these conditions the use of normal saline solution is an adjuvant measure to which must always be associated the habitual therapeutics of these infections. Results following its use in these conditions are often extraordinary. "The subcutaneous employment of large doses of normal saline solution can be resorted to with advantage in infectious states, when symptoms of marked depression are present." The use of normal saline solution raises the arterial tension. This increase of arterial pressure causes increased diuresis. This increased diuresis is attended by an increased elimination of toxins. Tuffier has practiced intravenous injections both for hemorrhage and for toxemia in fifty cases, and found the first effect was to restore the normal arterial pressure and diminish the frequency of the heart's action; the second, to cause diuresis. He says that normal saline solution is of special value in surgical and obstetrical infections. Other authors that highly recommend its use in these conditions are Lejars, Delbet, Duret, Jayle, etc. "In puerperal septicemia, they (saline injections) aid the patient to better withstand the noxious influence of the bacterial toxins" (Michaux, Segond). Infections due to the bacillus coli communis are retarded and combatted by injections of normal salt solution (Bosc, Vedel, Manquat). There is a relation existing between the infectious states and leucocytosis. In infectious conditions there is an increase in the number of leucocytes present in the blood. With the advent of convalescence the number of leucocytes present in the blood diminishes. The use of saline solution, when employed in pathological states, is most always followed by a diminution in the number of leucocytes." "The marked leucocytosis present in most infections diminishes. rapidly after the use of injections of normal saline solution" (Andre Claisse). The same author reports experiments conducted on animals, in which the use of injections. of normal saline solution was followed by |