Arterial Saline Infusion Arterial Saline Infusion 
A REPORT OF THREE ADDITIONAL CASES BY 
THE NEW TECHNIQUE; ALSO, OF A CASE 
OF INFANT DIARRHCEA TREATED 
BY SALINE INFUSION. 
BY 
ROBERT H. M. DAWBARN, M.D. 
PROFESSOR OF OPERATIVE SURGERY AND SURGICAL ANATOMY, 
NKW YORK POLYCLINIC 
Reprinted from the Medical Record, November 12, 1892 
NEW YORK 
TROW DIRECTORY, PRINTING AND BOOKBINDING*CO. 
201-213 East Twelfth Street 
1892 ARTERIAL SALINE INFUSION; A REPORT OF 
THREE ADDITIONAL CASES BY THE NEW 
TECHNIQUE; ALSO, OF A CASE OF INFANT 
DIARRHCEA TREATED BY SALINE INFU- 
SION. 
In the Medical Record of January 2, 1892, and again 
in the Brooklyn Medical Journal for October, 1892, the 
writer has described a new and entirely simple method of 
saline infusion, which in severe cases of hemorrhage, of 
shock, and of cholera, seems destined to replace the 
former cumbersome plan of using a scalpel, searching 
for a collapsed vein, and tying therein a cannula for in- 
jection. 
That plan is, the insertion of a hypodermatic needle into the 
common femoral artery, and through this injecting the salt- 
water, by an ordinary Davidson syringe, directly into the 
circulation. In cases less immediately perilous — not 
almost moribund—the same device is to be used; but 
now the fluid is thrown simply into subcutaneous cellular 
tissues instead of into the artery. Regarding this latter 
method, originality is not claimed. 
Also the writer urged, upon physiological grounds, that 
the salt-zvater used should be very hot, not less than 120° 
F. ; which is as warm as the hand can possibly bear. It 
was shown that no harm could result from less than 40° F. 
hotter than this; and on the contrary, the stimulant effect 
of the hot water upon the heart, and also upon the un- 
striped muscular tunic of the vessels, in restoring their 
lost “ tone,” was almost magical; as demonstrated by 
various kymographic experiments at that time detailed. 
In addition to reports of experiments upon dogs by this 
new plan, in the College of Physicians and Surgeons labora- 
tory, a case was published in the Medical Record where- 
in the patient—moribund from post-partal hemorrhage— 4 
was resuscitated by the intra-arterial salt-water infusion, 
and recovered. 
The only objection (a self-evident one) to the device, 
is the hesitancy naturally felt to pierce so large an artery; 
and this should vanish when one reflects that the most 
prominent plan now used by surgeons for aneurisms so 
placed as to be inoperable by ligation, and yet threaten- 
ing rupture, is that of Macewen, of Glasgow; which is 
needling, and in which long needles are thrust—a dozen or 
so—into the sac, and left for many hours, to cause thicker 
deposits on the walls—and this with benefit, as a rule. 
If a diseased vessel can safely stand such treatment as 
this, it seems a mild inference that a sound artery can 
bear a single needle for a single half-hour. And such has 
been my experience so far. 
Of course, if our patient be not too dangerously weak, 
the salt-water may simply be thrown into the cellular 
spaces beneath the skin, and diffused by rubbing. Also 
a warm saline enema should be given in either instance. 
But in critical cases no one should trust to these slow 
plans alone, but all would prefer to make sure that the 
heart and blood-vessels get the benefit of the injection; 
and here the practitioner must choose between the old 
and cumbersome, and the new and simple. 
How many family doctors will actually, think you, 
take out their unaccustomed scalpel in such cases, hunt 
up that cannula which must be tied in, and then incise 
and search for the collapsed vein ? Echo does not answer. 
I verily believe that many a patient has died from 
bleeding, of one or another origin, who could easily have 
been saved by the simple plan of arterial infusion which 
the writer has devised, and that many such will hereafter 
be rescued thereby. 
All that we need will be always readily at hand : i. A 
hypodermatic needle—largest size preferred. 2. A David- 
son syringe, from which the usual nozzle of metal or 
vulcanite rubber is removed. 3. Boiled water (for asep- 
tic reasons), hot as hand can support, plus a heaped tea- 
spoonful of table-salt to the quart. 
Never omit the salt—it would be fatal to mix plain 5 
water with the blood, as this at once dissolves out the 
haemoglobin from the blood-disks; whereas even so small 
an amount of salt as that named—six parts per thousand 
—renders it safe, and, for practical purposes seems as 
good as the most complicated saline-alkaline formula pos- 
sible. 
I need hardly add here that MW-transfusion, either 
mediate or immediate, has now been dropped by almost 
all surgeons. 
When a person has bled unto death, more than half his 
blood still remains in his body; and if this is properly in- 
creased in bulk by any innocent fluid, this added bulk is 
all that the heart needs to make it resume work. The 
remaining blood-cells support life until nature increases 
their number again, which is done with almost magical 
speed. 
As to the amount of salt-water needed : Here let me 
say that while a pint at a time is enough within the artery, 
the operator cannot seriously err on the side of throwing 
too much into the subcutaneous connective tissues.1 Al- 
most always the mistake is made of injecting less than 
half the right amount—which is usually at least two 
quarts; and a gallon would do no serious harm if prop- 
erly distributed in a dozen or more spots. The half-filled 
arteries of hemorrhage or shock, or the thickened blood 
of cholera, will soon use what is needed. If there be 
an excess over this amount, in a few hours to a day or 
so, it will gradually be taken up from the connective tis- 
sue, meanwhile doing no harm, and the kidneys will dis- 
pose of it. 
1 It seems hardly necessary to remark the absurdity ol a statement 
recently made in the Medical Record, under the head of “ Hypo- 
dermoklysis," to the effect that it is unsafe to inject into the sub- 
cutaneous connective-tissue spaces considerable quantities of the 
normal salt-solution, lest the tissues become “ bathed " and 
“ drowned" (!), because the kidneys cannot fast enough excrete the 
liquid. Many times now, by the Cantani plan, much larger amounts 
of this absolutely unirritating fluid than about a pint (the limit men- 
tioned) have been so injected in treating cholera; and with no such 
bizarre results. If the patient be critically ill, unquestionably much 
prompter and more certain relief follows the infusion of a pint or so 
directly into the blood-current; repeating this again and again if need 
be. The reason for this is obvious. 6 
The doctor makes the mistake indicated (of using too 
little saline infusion under the skin), because he estimates 
only the actual blood lost in a hemorrhage, and seeks 
simply to replace this same bulk of fluid. He forgets 
that because of shock (caused by that bleeding), the ves- 
sels have lost their “ tone ” and are almost completely 
dilated. The patient has bled into his own veins as well, 
and the brain and heart are made doubly anaemic thereby. 
Let us remember that the abdominal veins alone are 
capable, when paralyzed, of holding all the blood of head, 
body, and members 
For the benefit of tho e who did not read the original 
article in the Medical Record, it may not be amiss to 
repeat the technique of arterial infusion. 
The Davidson syringe, needle, and hot salt-water being 
ready, the operator now feels, just beneath the middle of 
Poupart’s ligament, for the femoral artery, here large 
enough in calibre to carry a lead-pencil. If the heart is 
still beating, this great pulse can almost always be felt. 
The aspirating-needle is now forced gently and directly 
into the artery, entering it at right-angles ; not with a sud- 
den plunge, but by a slow, rotary movement. As soon 
as the point is within the lumen, bright-red blood will fill 
the needle instantly; whereupon it is held very firmly 
and steadily in place while an assistant slips over the base 
of the needle the end of the syringe, already filled, and 
ties it in place with a thread. The solution is now 
thrown into the arterial current steadily, and necessarily 
slowly, which last is an added point in favor of this plan. 
It takes about one-half hour for a pint to enter. 
If the subject be very fat, an aspirating needle is pref- 
erable to the hypodermatic, which would here be too 
short to be held in place steadily; though, indeed, lack- 
ing the former long needle, a simple, long incision 
through the fat may be made, enabling one to approach 
the vessel more nearly and readily with the fingers. 
The Davidson syringe, if old, should be disinfected by 
pumping boiling water through it before use. If leaky, 
hold the bulb, and the hand working it, beneath the salt- 
water, to avoid throwing in air. To maintain the tem- 7 
perature at about 120° F. the bowl containing the solu- 
tion should be placed in a larger one, holding much 
hotter water. In this wise, by adding from time to time 
to the heat of the outer bowl or pan, that of the inner 
vessel may easily be kept as hot as the hand can bear. 
As soon as the circulation seems improved somewhat, the 
subcutaneous method of infusion should supplant the ar- 
terial. 
In my original article on this subject the technique in- 
cluded the use of a soft-rubber (Nelaton) catheter, to 
connect needle with syringe. Added experience proves 
this unnecessary, and it is accordingly dropped. 
I have now to report four new cases of saline infusion, 
in three of which the arterial method was used. 
Case I.—Mrs. R •, a patient of Dr. Charles S. Col- 
lins, of this city. She was shot just above the left knee- 
cap some days previous to the date of operation. Every 
symptom pointed to septic infection of the joint, and 
the patient’s general condition was of the worst. Her 
pulse was feeble, her temperature high, her system shat- 
tered from hard drinking. In fact, her husband, for a 
long time previously, had refused to live with her because 
of her drunkenness. 
Operation on February 4, 1892, Drs. F. J. Brockway 
and C. S. Collins assisting. The bullet was found em- 
bedded in the femur and removed. The joint was dis- 
tinctly purulent; it was washed out and a half-dozen 
drainage-tubes inserted where most needed. The patient, 
simple and brief as was the operation, and almost blood- 
less, was now in collapse. She presented every evidence 
of extreme and acute shock, threatening death almost at 
once. The pulse was 160 to r7o, and almost too thready 
to be counted. Strychnine and strophanthus and whiskey 
by needle were employed ; also a hot enema containing 
whiskey, and all the usual methods. These not causing 
rallying, the case seemed to me to call for saline arterial 
infusion at once. Because of shock the patient was 
bleeding into her own veins. 
In fact, it may be remarked that a certain distinct, 
severe, and acute type of shock so closely resembles con- 8 
cealed hemorrhage as to be practically indistinguishable 
from it; and, indeed, the treatment of each should be 
identical. It is well known that gynecologists now sus- 
pect a slipped ligature, and reopen the abdomen, where a 
few years ago the patient believed to have “ shock ” was 
allowed to die unaided, while the open vessel steadily 
drained away her life-blood. 
I am a believer in preventing shock, if possible, rather 
than waiting to treat that grim and deadly enemy after it 
has our patient in its grip. At present, perhaps the best 
single drug for this purpose is strychnine. When shock 
is already present it may wisely, if cautiously, be carried 
to the point of producing moderate tetanism ; and under 
its use the pulse, in favorable cases, falls in frequency 
and rises in strength. But why, if this be a fact, may 
we not wisely give it in fairly full doses for a few days 
before our operation, as a preventive ? 
And why would it not be well, at the end of any and 
every operation grave enough to make shock a probable 
result (though, because of the ether, not yet at hand), to 
inject subcutaneously a quart or two of hot salt-water ? 
It would be painless, the patient not yet being out of an- 
aesthesia. It would certainly be harmless. And I believe 
it would do much to prevent, by maintaining filled blood- 
vessels, an otherwise fatal shock from developing. It 
seems not improbable that we shall ultimately see this 
done as a matter of routine] after all severe opera- 
tions. 
This digression may be pardoned me when we reflect 
that less advance has been made of late years in our 
treatment of shock than in any other subject of prime 
importance in surgery. 
To return to our patient. The hypodermatic needle 
was inserted in her right femoral artery, the vessel being 
found at the first attempt. A pint of hot saline solution 
was thrown in by the fountain syringe—which plan I do 
not like, both because it is impracticable in rooms with 
low ceilings, and because it is impossible to maintain so 
well thereby, as by the Davidson syringe and two dishes, 
an evenly hot temperature in the infusion-fluid. Follow- 9 
ing this first pint, about three pints more were injected, 
this time into the subcutaneous spaces; and the lumps 
(eight or ten) so produced on the thighs were diffused by 
rubbing with the vaselined hand. 
The woman steadily revived. Her heart-beats slowly 
but regularly decreased in frequency. Dr. Collins le- 
mained by her side several hours. At length her pulse 
fell to a trifle under one hundred, and as it was also good 
in quality, he took his departure; feeling that she was 
out of danger and could safely be left a short time. 
Before going he expressly warned her to lie absolutely 
quiet. No sooner had he gone than she demanded 
whiskey. This was produced by a relative. She sat up 
to drink it—and dropped back dead. 
I think it will be admitted that this woman would 
probably have recovered had she obeyed orders, thus 
avoiding this sudden strain on her heart. 
Case II.—Mrs. D , seen on June 28, 1892. This 
patient was one in whom the hemorrhage was due to 
placenta praevia. She was attended by Dr. J. Milton 
Mabbott, of this city, who called me in to use saline 
infusion, because in his judgment her circulation was so 
bad as to require it. The bleeding which followed 
delivery had ceased by the time of my arrival. I found 
her pale and covered with cold sweat, restless in the ex- 
treme, delirious, asking for air—in a word presenting the 
usual, and some unusual, signs of anaemia; but as her 
pulse was not extremely and critically bad, I proposed 
simply to inject the salt-water subcutaneously. 
Dr. Arnold Burkelman was also present, and asked me 
to use the intra arterial technique, as he had never seen 
it. This I accordingly did, the needle entering the 
artery at the first attempt, as shown by the arterial blood 
coming from it. Possibly a pint of hot salt water was 
thus injected, and possibly between one and two quarts 
more subcutaneously—I think more nearly the latter 
amount. The reason I am in doubt is, that in her 
extreme and even violent restlessness she several times 
upset the vessel containing the solution. 
The subsequent history of the case was thus reported 10 
to me by Dr. Mabbott: “ Our patient hung along for 
six days on the ragged edge of dissolution, and then died 
of exhaustion. She had no fever, no further hemorrhage 
of great amount, though Dr. Burkelman was sent for late 
one night because of a certain amount of bleeding. Of 
course any flow was too much in her state. There was 
no involution of uterus appreciable at the end of six 
days; apparent absolute inaction.” 
Case III.—Marie M , a servant, had been bleeding 
steadily from the uterus for six weeks, and had repeated- 
ly refused medical aid, although her mistress was much 
alarmed by her pallid face. At length, on the night of 
September 16th, I was sent for in haste. Marie had 
fainted, and with difficulty had been restored to con- 
sciousness. 
On examination digitally, I found a piece of flesh pro- 
truding from a somewhat dilated cervix uteri. Touch- 
ing it seemed to start bleeding afresh. She claimed 
virginity and was indignant when this was doubted. (.En 
passanl, next morning she admitted pregnancy, and said 
that a mass had “ come away ” some days before, and 
been disposed of in the water-closet.) She was put 
under ether; the uterus was emptied thoroughly by the 
finger and was washed out. It was only about three 
inches in depth; therefore I did not deem it essential to 
tampon its interior, but placed a solid and firm vaginal 
tamponade in place, which easily controlled bleeding. 
The patient was alarmingly weak, as may be imagined 
from the duration of the hemorrhage, as well as its 
amount. I proceeded to use arterial saline infusion. 
The femoral was entered at the first attempt, and a pint 
injected as hot as bearable. Following this, about two 
quarts were thrown under the skin here and there, four 
to six ounces in each spot, and all thoroughly massaged 
with vaselined hands. 
The patient’s pulse gradually gained in vigor. She 
was seen the following day by Dr. F. J. Brockway and 
myself, when the tamponade was removed. She com- 
plained somewhat of soreness wherever the needle had 
been inserted, but otherwise was comfortable. Her 11 
circulation had improved wonderfully. She made an un- 
eventful and rapid recovery. 
Perhaps this point will be as appropriate as another at 
which to refer to a criticism upon the new method of arte- 
rial infusion, which I have more than once heard ; name- 
ly, that it is difficult to find the artery with the needle. 
I can only reply that such has not been my own experi- 
ence. A vessel big enough to contain a lead pencil, and 
pulsating beneath the finger, ought to be an easy mark 
for a steadily and slowly introduced needle. Those who 
have not succeeded must in some respect have failed 
either in delicate tactile sensation or else in technique. 
An example of the latter is a case published by Dr. Onuf- 
Onufrowicz, in the Medical Record for October i, 1892. 
This gentleman very clearly and interestingly reports 
his case, but goes on to state that, upon endeavoring to 
introduce the needle into the artery by my technique, he 
pushed it into his rather fat subject at an angle of sixty 
(not ninety) degrees with the course of the vessel, direct- 
ing it “with its point toward the foot.” Naturally, he 
did not succeed in entering the femoral; although if his 
patient had been thin it is possible that he might have 
done so. 
There can be no doubt as to whether the needle has or 
has not entered the artery. The bright blood filling the 
needle is testimony ; and, then too, no lump is produced 
as a consequence of injecting; whereas a pint, or even a 
quarter-pint, of fluid thrown simply under the skin, would 
cause a very prominent swelling. 
I have now to record one remaining case in which sa- 
line infusion has recently been used, although only subcu- 
taneously. 
Case IV.—On September 20th I was called to Eliza- 
beth, N. J., by Dr. G. H. Bridgman. The patient was 
a baby of five months, suffering from gastro-intestinal 
catarrh, and had had so many watery movements, in spite 
of able treatment, that some hours before I arrived the 
case was regarded as hopeless. 
I found a sunken fontanelle, pinched features, very 
rapid and feeble pulse; and felt that here, just as in 12 
cholera, there was indication enough for the Cantani 
method of treatment, so far at least as saline infusion 
subcutaneously was concerned. This was accordingly 
done : as usual, with very hot salt-water, Davidson syringe, 
and hypodermatic needle. Into both thighs, just be- 
neath the skin, a considerable amount was injected, which 
we estimated to be equal in proportionate bulk to two 
quarts in an adult. In addition I advised rubbing in hot 
cod-liver oil everywhere (except the abdomen) for an 
hour, three times in twenty four. 
A considerable experience with infantile diarrhoea, be- 
gun ten years ago during a residence in the Nursery and 
Child’s Hospital of this city, has convinced me that 
many a little life, otherwise inevitably lost because nour- 
ishment cannot be retained, may in this wise be saved. 
In an hour of firm but gentle rubbing, nearly an ounce 
of the hot oil may be made to pass through the skin; and 
quite commonly the little patient falls asleep meanwhile, 
soothed by the massage. Sometimes hot, melted cacao but- 
ter will even more readily be absorbed than cod-liver oil. 
The next day Dr. Bridgman thought it wise to repeat 
the hot salt-water infusion, and so reported to me. The 
child steadily though slowly recovered from its gastro- 
enteritis. At this date, nearly two months after that of my 
visit, she is delicate, but has long been convalescent. 
A few hours’ investigation of this point, in the New 
York Academy of Medicine library, has convinced me 
that saline infusion in infantile diarrhoea is a treatment 
of extreme rarity. This should not be so. Between 
twenty five and thirty works on paediatrics were consulted, 
and but two of these mentioned its use in this complaint. 
These were Henoch’s “Lectures on Children’s Diseases,” 
vol. ii., p. 44 (1889), and Revue des Maladies de PEn 
fance, p. 348, Juillet, 1892. 
105 West Seventy-fourth Street, New York.