A CLINICAL REPORT 
ON 
INTRAVENOUS SALINE INFUSION 
IN THE 
WARDS OF THE NEW ORLEANS CHARITY HOSPITAL 
FROM JUNE, 1888, TO JUNE, 1891. 
BY RUDOLPH MATAS, M. D., VISITING SURGEON. 
Reprinted from the July, 1891, number of the New Orleans Medical and Surgical Journal. 
L. GRAHAM & SON, 99, 101, 103 GRAVIER ST., N. O. A CLINICAL REPORT 
ON 
INTRAVENOUS SALINE INFUSION 
IN THE 
WARDS OF THE NEW ORLEANS CHARITY HOSPITAL 
FROM JUNE, 1888, TO JUNE, 1891.* 
RUDOLPH MATAS, M. D., VISITING SURGEON. 
Reprinted from the July, i8c>r, number of the Ne-w Orleans Medical and Surgical Journal. 
While the records of the Charity Hospital point to the 
fact that intravenous saline infusion was practised during the 
earlier and devastating cholera epidemic that prevailed in this 
city, and a dim indication is also met here and there of the direct 
and indirect transfusion of blood in the surgical practice of 
this institution (though I have no official information or record 
to that effect), it is, I believe, historically correct to state that no 
attempt prior to July, 1888, had been made to infuse intraven- 
ously a saline solution for the relief of acute anaemia. 
I have undertaken, therefore, as a matter of domestic his- 
tory as well as of general medical interest to present the records 
of all the cases that have been subjected to this procedure since 
that time, in this institution, and to draw from them such con- 
clusions as the nature of the cases and the results warranted. 
In so doing I have gathered nineteen observations of a purely 
surgical character, which represent all the instances in which, 
after diligent inquiry, I have been able to ascertain that this 
method of treatment had been practised. I have, furthermore, 
•Read before the Louisiana State Medical Society, May, 1891. 2 
included one medical case occurring in my own practice, which 
I have added to sum up the total of my personal experience with 
the method which is represented by five cases, all of which 
are embodied in this report. The other remaining cases oc- 
curred in the services of other members of the staff to whose 
courtesf I am indebted for the reports, especially as they are 
almost all unpublished histories from the ward books. 
In several cases the conditions which gave rise to the in- 
dication for saline infusion were rare and of unusual interest, 
and outside of their therapeutic aspect are worthy of record,, 
and for this reason I regret that in some instances I was not 
able to obtain more full and detailed information. 
After the presentation of the clinical observations I shall 
avail myself of the text furnished by them to direct your at- 
tention to the indications, the advantages and life saving 
properties of saline infusion, believing that after the recital 
of several of these critical experiences you will concur with me 
in the belief that it is impossible to overestimate the great 
value of this mode of therapeutic relief in all cases in which its 
exhibition is appropriately called for. 
I. 
OBSERVATION I.— SERVICE OF DR. R. MATAS (WARD 8). 
Mixed Cavernous Sarcoma of Thigh, Simulating Aneurism 
of the Femoral—Amputation at Upper Third—Profound 
Shock—Saline Infusion Twice Repeated—Death. 
R. C., aet. 26, admitted July 12, 1888; Louisianian ; farmer; 
temperate; no hereditary history; no syphilis. History: about 
fifteen years ago patient fell from a pine tree and drove a 
sharp stump about four inches deep into the flesh of the inner 
side of thigh. Three years ago noticed a small tumor at a 
spot corresponding to the apex of Scarpa’s triangle. It was 
seen by Dr. F. (a practitioner in his native place who first 
examined him and who is here now and confirms the state- 
ment), who noticed a pulsation and believes he also heard a 
murmur. The doctor was so thoroughly convinced that the 
tumor was an aneurism that in sending him to the hospital 
later he advised the patient to carry with him a strong elastic 3 
bandage, with the instruction to constrict the limb above the 
tumor in case it should burst before reaching surgical assistance. 
Status PrcBsens: The patient is thin, apparently poorly 
nourished and careworn from anxiety, but not noticeably 
cachectic. He is a man of moderate height, about 5 feet 6 
inches, and shows traces of a past robust and vigorous physique. 
On examination of right thigh, a large tumor at once at- 
tracts attention, lying with its longitudinal axis parallel to the 
long axis of the thigh and right over the course of the femoral. 
The tumor is ovoidal in shape, projects considerably above 
the thigh; the skin over the tumor is tense, adherent, and over 
the center presents a livid color. The tumor measures in 
length over 9 inches, beginning at a point 3% inches from 
Poupart’s ligament, and reaches a point 4 inches above the 
internal condyle. The transverse diameter is over 9 inches. 
The tumor did not appear to spring from the bone, though 
it originated deeply in the thigh and, though very well out- 
ined in the soft parts, was not distinctly encapsulated, but 
blended gradually with them at the periphery; in the most 
prominent portion of the tumor a slight bloody ooze was 
noticeable, owing to a fissure in the tense and livid skin. 
The tumor, though quite firm throughout, had, in some parts, 
a semi-solid feel just like a sac filled with clot. No pulsation 
was visible, or recognizable by palpation; no thrill; no mur- 
mur. Firm pressure over the femoral at groin causes very 
little difference in size of tumor, but the application of the 
elastic bandage reduces it considerably, fully inches, by 
measuring the circumference of the limb. 
Puncture with an exploring needle draws a syringeful of 
pure blood. 
This last result of the examination causes considerable 
hesitation in the diagnosis. The traumatic history, the state- 
ments of the first medical attendants and above all the reduc- 
tibility of the growth by elastic compression all seem to point 
to aneurism; still the size of the tumor, the absence of all pul- 
sation, thrill, murmur and above all the slight effect of the 
compression of the femoral above the tumor and absence of 
varicose veins tend to discredit the diagnosis of aneurism 
and rather favor that of malignant disease. 4 
With considerable doubt in my mind as to which was the 
real condition, I decided to give the patients the benefit of an 
operation that would first clear the diagnosis, and second per- 
mit of an attempt to remove radically either an aneurism or 
malignant tumor. 
The apparent break in the most prominent part of the 
tumor and its bloody discharge indicated the necessity for 
prompt action. Therefore, on July 14, 1888, the patient 
was taken to the amphitheater, where, with the aid of Dr. La- 
place and other members of the staff, the patient was anaes- 
thetized (chloroform followed by ether) and an Esmarch 
bandage applied from the foot to the groin, where it was se- 
cured just below the groin. An exploratory incision was now 
made, following the long axis of the tumor, which at once pen- 
etrated to the center of the growth and revealed its true neo- 
plastic character. The “appearance of the section, however, 
was rather novel. As the knife entered the tumor a consider- 
able amount of dark venous blood spurted out in a surprising 
manner. 
Sponges were instantly applied, and as they were cautiously 
removed it was seen that the hemorrhage had stopped, and 
that large cavities existed in the tumor, which had evidently 
•contained the blood that had given rise to the alarming hem- 
orrhage. 
It was evidently a cavernous growth, the large spaces being 
occupied by a serous, in some by a colloidal, and in most by 
a venous fluid. The caverns were hollowed in a stroma con- 
sisting of mixed osseous, chondroid and soft sarcomatous tis- 
sue. 
In attempting to dissect the integument from the surface 
of the tumor it was found that the two were thoroughly ad- 
herent throughout the convex surface of the growth, and that 
a very large loss of skin would have to be incurred, even if 
the tumor allowed of enucleation in its deeper surfaces. On 
further exploration it became evident that the whole femoral 
sheath was involved and imbedded in the neoplastic mass. 
The tumor, however, appeared to be independent of the femur. 
In the presence of the complications, it was plain that con- 
servatism was out of the question, and I decided to amputate 5 
the thigh at its extreme upper third. Fearing that any slip in 
a constrictor at the thigh would prove fatal to the already 
exhausted subject, the ligature of the common femoral at 
the level of Poupart’s ligament was undertaken and quickly 
accomplished. The elastic constrictor was now removed and 
the thigh amputated by a short anterior and long posterior 
mixed flap amputation (Lister’s). 
The hemorrhage was comparatively slight (not over three 
ounces) the vessels in the posterior flap being readily controlled 
with the able assistance of Dr. Laplace. The patient was kept 
under the influence of the anaesthetic (chloroform followed by 
ether) over one hour and fifteen minutes. 
Notwithstanding the really small loss of blood (excepting 
that first loss when the loculi of the tumor were first opened) 
the patient was in a condition of profound shock when he was 
placed in bed; the pulse being then very small, shallow and 
rapid. Brandy and ammonium carbonate were administered 
and heat applied to the body and extremities. The patient re- 
covered consciousness in the course of an hour and spoke in- 
telligently; he vomited, or rather strained, with nausea con- 
siderably. 
Six hours after the operation I visited the patient and found 
him perfectly rational and talkative, though profoundly pros- 
trated, the pulse being intermittent and exceedingly shallow 
and rapid. Notwithstanding the persistent application of heat 
the patient was growing colder, and a clammy sweat bathed 
the surface. I now decided to try the effects of an intrave- 
nous saline injection. 
Two pints of a common salt solution, made by boiling one 
drachm of common salt in a pint of distilled water, were 
slowly injected into the right median basilic. The fluid was 
infused warm (about ioo° F.) A few seconds after the 
injection had commenced the patient gave utterance to ex- 
pressions of increasing comfort and grateful well being. He 
had complained of a “fire” or “heat” which was consuming 
his vitals, “and a great, burning thirst.” Now, as the water 
flowed into the vein, he felt as if a delightful cool wave was 
gently spreading over his body, and was giving him new 
strength and life and wonderfully appeasing his thirst. The 6 
pulse in the meantime improved immensely; it became fuller, 
more resistant to the finger, then slower, and finally quite 
strong and regular, the pulsation having been reduced from 
150 to 100, and less when the injection was stopped. 
Next day, July 15, the patient had been very cheerful and 
expressed himself as having passed a comfortable night, but 
toward morning the prostration had reasserted itself and he 
had slept but little ; he was not as thirsty as yesterday, but the 
extremities were cold and his pulse was evidently undergoing 
a change for the worse. It was again shallow, compressible 
and rapid, about 128-130, and showed a tendency to rapid 
deterioration. Nourishment—beef tea, brandy, milk, and 
digitalis, had been regularly given during the night and had 
been kept up since. 
Evening.—The patient is evidently relapsing into the same 
condition as before saline injection, the beneficial effects of 
which are now no more perceptible; the pulse is practically 
imperceptible at the wrist and a cold, clammy sweat bathes the 
surface; he is manifestly sinking. I again inject nearly two 
pints of the same saline solution into the left median basilic. 
This time the pulse responds more slowly to the influence of 
the injection and it requires more fluid than the first time to fill 
it up. After the second pint the pulse, however, rallies and 
becomes hard and the patient revives. 
The beneficial effects of this injection are more transitory 
than the first. The newly improved pulse is maintained only 
a quarter of an hour, the pulse becoming rapidly faster and 
weaker so that in the course of three or four hours it becomes 
imperceptible, consciousness lost and the patient expires in the 
morning of the 16th. The wound at no time after the oper- 
ation gave reason for anxiety. After death the stump was 
found in excellent condition. 
Remarks: In this case we must note (1) that the cause of 
the prostration was mainly shock and not hemorrhage, the latter 
being insufficient alone to account for death. 
(2) That the man had been for a long time prior to the op- 
eration in a state of great nervous tension and worry, and that 
this added to the legitimate shock of the prolonged operation 
and were the true factors that led to the fatal result. 7 
(3) The relief afforded by the saline infusion was prompt 
and decided, and without the two injections it is certain that 
life would have ended at least 36 hours before the time that it 
did take place. 
(4) That not only was life prolonged, but great comfort 
given the patient by the saline infusions. 
(5) That no attempt was made to regulate the quantity of 
liquid by a predetermined dosage, but that quantity injected 
was regulated by the visible or perceptible effect on the general 
condition and particularly by the pulse. 
OBSERVATION 2. SERVICE OF DR. A. B. MILES, HOUSE SURGEON. 
Stab Wound of the Right Axillary Artery—Axillary Abscess 
—Profuse and Repeated Hemorrhage after Opening Ab- 
scess—Syncope—Intravenous Infusion of Saline Solution 
— Recovery. 
“ H. M., get. 26 years, bricklayer, white, came to the hos- 
pital November 28, 1888, with large pectoral abscess a<nd par- 
tial paralysis of left arm. Patient gave a history of having 
been stabbed two weeks previously; knife entering about one 
inch from insertion of great pectoral muscle. Abscess was 
opened and found to contain a.large quantity of pus and blood 
clots. About two hours after opening of abscess patient had a 
hemorrhage from this wound. Compress applied and patient 
put to bed. Several hours later a second hemorrhage oc- 
curred, and like the first appeared to be venous in character. 
Compress was reapplied more firmly, and hemorrhage tem- 
porarily checked. Patient complained of intense thirst and 
was given to drink warm milk and tea. Three hours later a 
third hemorrhage occurred, much more profuse than either 
of the others, and unmistakably arterial. Patient was almost 
in a state of cellapse. 
“ Dr. Miles was summoned and decided to ligate bleeding 
vessels immediately, as would not check the 
hemorrhage. On opening the axilla the knife was found to 
have divided the median nerve and cut half through the ax- 
illary artery, which was gaping wide and bleeding profusely. 
Hemorrhage was controlled by pressure upon the subclavian 
and a ligature put around each end of the wounded vessel. 8 
****** Patient’s pulse was now 170 per minute 
and scarely perceptible at wrist. At the suggestion of Mr. 
Borde, R. S., one pint of saline fluid (5i to pint of warm 
water) was injected through the median basilic vein. This 
had an immediate and beneficial effect; pulse became full, 
more regular and less frequent. 
“ Patient was taken back to the ward. No further hemor- 
rhage occurred. Wound had almost healed and he will soon 
be restored to his normal state of health. 
“ There is no doubt that the injection had much to do 
with saving the patient’s life. The hemorrhage had been pro- 
fuse, and there was scarcely blood enough in his body to stim- 
ulate the heart to proper action. * * * In this case, as 
soon as the fluid was injected a marked change was percepti- 
ble.” 
[Extract from hospital report by Dr. E. D. Martin, then 
Ambulance Surgeon, Charity Hospital, in New Orleans Med- 
ical and Surgical Journal, February, 1889.J 
OBSERVATION 3. AMBULANCE CASE, ATTENDED BY DR. A. B. 
MILES. 
Idiopathic Epistaxis.—Simply a note in the preceding re- 
port by Dr. Martin to the effect that infusion had been prac- 
tised in the case of a little girl, aet. 12, who had lost so much 
blood from nasal hemorrhage, that no pulse could be detected 
at the wrist. Half a pint of saline fluid was injected and al- 
most immediately the pulse was restored, the patient recover- 
ing permanently. 
OBSERVATION 4. SERVICE OF DR. R. MATAS (wARD 2). 
Syme s Amputation for Tubercular Arthrites of Ankle and Tar- 
sus—Secondary Hemorrhage—Syncope—Intravenous In- 
jection of 12 oz. of Saline Solutio?i—Recovery. 
J. C., negro, male, aet. 42. Admitted in ward 2, July 5, 
1889. Ankle and foot very much swollen; pus in the ankle, 
one or two sinuses leading to tarsal bones. Shortly after ad- 
mission Syme’s amputation was performed. The cavity of the 
stump is stuffed with iodoform gauze, the operation having been 
performed with careful antiseptic and aseptic precautions. 9 
There were few spouting vessels after the removal of the 
Esmarch, but more than the usual general ooze. Hot water 
sponging appears to control this. The day after the operation 
the dressings are removed because of much soaking with blood. 
On removal of gauze considerable hemorrhage in region of 
posterior tibial which seemed to be of a venous character. The 
interne of the service packs the wound carefully with iodo- 
form gauze and apparently the hemorrhage is arrested. 
The dressing is removed two days after and is still found 
considerably soaked with blood. In removing the dressing 
serious hemorrhage again takes place, which still presents the 
same dark color; packing again resorted to and with apparent 
success. Owing to continued oozing Dr. M. removes the 
dressings and makes a careful search fora bleeding vessel, but 
the attempts made to control the points of greatest oozing with 
catch forceps fail, and owing to excessive pain complained of 
by the patient the attempt is abandoned and a firm tamponnade 
and dressing to the stump is applied, while preparations are 
made to administer an anaesthetic and permanently arrest 
the hemorrhage by ligating the bleeding points. Before the 
anaesthetic is administered the patient sinks in syncope, with 
a faint, collapsed, irregular pulse, the body being bathed in a 
profuse cold and clammy sweat. Stimulants, ether, auto-trans- 
fusion by bandaging the extremities, digitalis and brandy, 
hypodermatically, are resorted to promptly, but the patient gives 
no sign of rallying, and death appears imminent from collapse. 
Infusion is now appealed to; the left median basilic is ex- 
posed and twelve ounces of the saline solution (warmed) same 
as used in Case i are injected. The effect is magical; the 
pulse improves, pari -passu with the flow of the solution in 
the vein, and the patient awakens rapidly, expressing himself as 
infinitely improved. The pulse having been brought from 
150-160 to 90. 
The stump was not touched; no further search made for 
bleeding points, as no further tendency to hemorrhage was 
manifested by stump from that day. 
This patient finally left the hospital completely restored to 
health and walking on a very firm and excellent stump.—[From 
notes furnished by Dr. Saizan, R. S.,then interne of service.] 10 
OBSERVATION 5. SERVICE OF DR. A. B. MILES. 
Gunshot Wound of Arm and Head—Meningitic Sym-ptoms— 
Profuse Epistaxis—Saline Infusion—Transitory Ben- 
efit—Death. 
J. B., male, set. 32, admitted April 15, 1889. The wound 
in the arm was of little consequence. The wound of the head 
very serious, the ball penetrating below right orbit, and 
ranging upward and inward, passing deeplv to base of skull, 
probably penetrating through the basilar process of occiput. 
Some pieces of bone were removed through wound in 
face; the eye did not appear to be injured, yet the patient 
had been blind since the injury; he could not even see a 
candle held before him. There had been some epistaxis on 
admission. Temperature for a week following admission 
oscillated between 102 deg. and 104 deg. F.,but was declining, 
when a tremendous epistaxis occurred. The posterior nares 
were plugged and the hemorrhage finally stopped. The next 
day it commenced again in spite of plugging, and as he was 
sinking from vascular depletion, Dr. Bloom, assistant house 
surgeon, infused over three pints of an extemporized saline 
solution into the arm. While the injection was flowing the 
patient appeared to rally, but Dr. Bloom discontinued the injec- 
tion when he saw almost the pure and colorless salt water com- 
ing through the nose. The vascular depletion appears to have 
been extraordinarily complete, and it is almost incomprehensible 
how the patient survived long enough even to receive the 
intravenous injection. Notwithstanding this profound oligo- 
hcEmia it is remarkable that the temporary plethora produced 
by the infusion kept the patient alive for several hours after the 
operation. 
It is much to be regretted that no autopsy could be obtain- 
ed in this case, and that the true cause of the tremendous and 
fatal epistaxis could not be positively ascertained; still the 
venous character of the blood and the course of the ball lead 
the attendants to suspect the hemorrhage to come from one 
of the sinuses at the cranial base 
Strange to state, the amaurosis which had existed on 
admission disappeared some time before death, as the patient 11 
could see plainly before the epistaxis took place, just as the 
fever began to decline. No autopsy was granted in fhis case. 
—[From notes kindly furnished by Dr. Cocram, then interne, 
and Dr. Bloom.] 
OBSERVATION 6. 
Avulsion of Right Arm by a Propeller After Falling from a 
Skiff into the River. 
A white man, aged about 50 years, was upset while in a 
skiff in the Mississippi river and was caught by the rapidly 
rotating propeller of a steamer. The right arm was completely 
torn away in a perfectly circular manner about the middle 
third of the arm. The patient had lost a very large quantity 
of blood and was nearly drowned when rescued. When 
brought to the hospital he was practically pulseless from the 
profound shock, anaemia and asphyxia. Dr. Bloom availed 
himself of one of the large gaping veins in the stump, and, after 
securing the main arteries, injected about 20 ounces of extem- 
porized saline solution. The pulse was temporarily restored, 
and while the vascular distention lasted the patient appeared 
to rally and improve. The tonic action of the injection was 
not sustained, however, as the patient again sank and died 
several hours after the infusion. In this case shock appeared 
to be the prominent factor in determining the exitus letalis. 
The temporary and decided benefit of the infusion in this 
case was very marked, as the patient was practically dead when 
brought to the hospital. 
[This case is reported from a verbal communication of 
Dr. Bloom]. 
OBSERVATION 7. SERVICE OF DR. E. LAPLACE. 
Overlapping Fracture of the Femur—Re fracture with Chisel 
through External Incision—Profuse Venous Hemorrhage— 
Grave Syncopal Symptoms—Saline Infusion—Recovery. 
This case is reported in detail by Dr. E. Laplace, visiting 
surgeon, who performed the operation, in the Medical News 
for November 2, 1889. In this case the hemorrhage appeared 
to come directly from the chiseled bone, and the beneficial 
effect of the injection was truly remarkable. Sixteen ounces 
of the saline solution were injected. 
[Ambulance case attended by Dr. Bloom, Assistant House Surgeon.] 12 
OBSERVATION 8. SERVICE OF PROF. E. S. LEWIS, M. D. 
Ovarian Fibro-cystoma—Ovariotomy—Hemorrhage and Shock 
during Operation—Threatened Collapse in Spite of En- 
ergetic Stimulation—Saline Infusion—Recovery. 
L. F., white, age 43, admitted in hospital Oct. 29, 1889. 
Abdominal tumor of three years’ duration. The tumor had 
attained enormous proportions, interfering with respiration, 
digestion and defecation. Patient exceedingly weak, ema- 
ciated, with a very poor, small, pulse at time of operation. 
Operation performed about ten days after admission by Prof. 
Lewis. The cyst was multilocular and contained over (?) 
gallons. It was universally adherent. In consequence of 
these adhesions much unavoidable hemorrhage occurred and 
operation prolonged. 
At the conclusion of operation, the pulse could not be 
felt at the wrist; the arteries of the neck appeared to be carry- 
ing hardly any blood. Stimulation with hypodermatic injec- 
tions of ether, brandy and ammon. carb. and digitalis did 
some good while operation was in progress, but at its conclu- 
sion failed totally to revive the patient. Saline infusion was 
practised by Dr. Miles, and nearly two pints of an extempo- 
rized salt solution were injected into the median cephalic. The 
effect was magical; in five minutes her pulse could be felt at 
wrist, and in ten minutes could be counted very easily and 
beating about 86-90 per minute. The patient left the hospital 
December 15, 1889, perfectly restored to health.—[Notes 
kindly furnished by Dr. Wm. Armstrong, then interne.] 
OBSERVATION 9. SERVICE OF DR. MATAS (WARD 2). 
Multiple Radiating and Comminuted Fracture of Cranium 
from Blow in Right Temporal Region—Laceration of 
Main Trunk of Right Arteria Meningea Media—Coma 
with Diffuse Cortical Symptoms—Trephining and Re- 
moval of Large Fragments of Vault—Threatened Col- 
lapse during Operation—Saline Infusion—Temporary 
Improvement—Death. 
B. C., negro, adult, aged 29 (about); was struck in dis- 
pute with a heavy club on right side of head. The man was 
struck senseless by the blow and brought in an unconscious 13 
state to the hospital, where he was seen several hours after 
admission by Dr. Matas. 
The patient lay motionless in apparent sleep; no stertor; 
could not be roused by questioning or pinching him; could 
swallow a little water when placed in his mouth with a spoon. 
By pricking skin of feet or legs reflex movements were elicited, 
which after deeper and more vigorous stimulation with the pin 
gradually extended to upper extremities. These reflex 
movements appeared to be particularly active in the right half 
of the body, corresponding to injury; the left side did not re- 
spond as actively as right when thus stimulated. There ap- 
peared to be a slight paresis of the two extremities; the pupil 
on the same side appeared to be a little more dilated, though 
both were widely dilated and responded indifferently to lights; 
the pulse was slightly irregular, but pretty full; no spontaneous 
evacuation of faeces or urine had taken place since admission. 
On examination of the head it was noticed that the right 
eye and lids were slightly ecchymotic and puffy; the right tem- 
ple also fuller than the left. No external visible wound could 
be detected, but on percussion a decided “ crack-pot” sound 
was elicited over the right temporal and parietal regions. No 
distinct depression could be felt, nothing certainly pointed to 
the enormous fracturation subsequently detected. After con- 
sultation with Dr. Bloom and with his assistance I proceeded 
to perform an exploratory operation. After due antiseptic 
preparation of the field of operation a curvilinear incision was 
made in temporal region over the line of the superior temporal 
ridge, extending from the external process of the frontal to a 
point about half an inch above the base of the mastoid. A 
perpendicular incision carried down vertically to the zygoma 
bisected the original curved line. By these incisions the tem- 
poral aponeurosis was detached almost completely above and 
bisected at its most resistant portion; the temporalis was also 
divided to the bone and readily peeled away from the temporal 
fossa. As soon as this was done the extensive character of the 
injury was immediately recognized. The squamous plate had 
been completely fractured, and was the starting point of 
several long fissures which radiated toward the vertex—one 
to bregma, another toward parietal foramen, extending across 14 
the sagittal line, and another shorter, backward in the 
direction of the lambda. A number of large fragments, which 
were readily detached, represented the squamous portion of the 
temporal; some of these fragments were much depressed and 
imbricated. All the fragments were liberated; trephining had 
to be resorted to in two places to facilitate the elevation of a 
larger piece, after the removal of all the broken fragments. 
A large space, representing the squamous area of the tem- 
poral, existed in the lateral region of skull and exposed a con- 
siderable mass of clot and the underlying dura mater; this was 
washed out and gently sponged, and it was seen that the dura 
was not resistant and flabby. An incision was made through 
it, which allowed a little sero-sanguinolent fluid to escape and 
revealed the temporo-sphenoidal lobe almost in a state of pulpi- 
fication. The finger could be readily pushed into the brain sub- 
stance almost to the lateral ventricles. The brain substance 
had almost a mushy consistence. After this revelation I has- 
tened to wash gently with warm, boiled water, replace some of 
the fragments and sew the wound. As the man had shown a 
disposition to restlessness during the operation some chloro- 
form was given to quiet 1 im. It was not necessary to administer 
much. The hemorrhage was readily controlled, as the vessels 
were divided by the pressure of assistant’s finger and by ar- 
tery forceps ; the hemorrhage was certainly moderate consid- 
ering the excessive vascularity of this region. Still while the 
sutures were being introduced the assistants in charge of the 
pulse remarked that the pulse was becoming very irregular; 
more shallow and almost imperceptible. 
The patient was very cold and clammy and appeared to 
be in collapse, and it was plain that he was about to die on the 
table. Heat, stimulants and digitalis were applied hypoder- 
matically, but without any effect. Infusion was then resorted 
to and I injected over 20 ounces of extemporized saline solu- 
tion into the median basilic vein. The result on the pulse was 
extraordinary; it was reduced to its normal beat and strength, 
and though the patient was unconscious he ceased to present 
his former collapsed and moribund appearance. The dress- 
ing was finished leisurely and the patient returned to his ward. 15 
He survived till the next day, over 18 hours after the explora- 
tory operation. 
OBSERVATION 10. MEDICAL CASE, ATTENDED BY DR. MATAS. 
Acute Dysentery in an- Aged Male Subject—Profound Ex- 
haustion—Af'parent Death—Saline Infusion—Restora- 
tion to Consciousness—Life Prolonged Live Hours. 
Dr. S., male, white, about 60 years; much exhausted by 
mental worry and physical work. Came to the city for treat- 
ment, suffering with a most violent and foetid dysentery of 
over one week’s duration. When seen by writer, patient was 
pinched, shriveled and cadaverous in appearance; had small, 
strained, mucous actions of a most offensive character and 
dark color every fifteen or twenty minutes. Patient had at- 
tempted to treat himself, but very ineffectually, with enemas 
of morphia solution and no internal treatment. Pulse exceed- 
ingly small and rapid, over 130 per minute. Placed at once on 
stimulants, ether and digitalis, with small doses of saline and 
morphia. Enemata of Labarraque’s solution and suppositories 
of opium, belladonna and iodoform. Temporary relief. Seen 
with Dr. Castellanos in consultation later, next day, and strych- 
nia added to treatment. The evacuations appear to be 
improved considerably, but the pulse is growing weaker in 
spite of the most systematic stimulation. The mind becomes 
perceptibly affected; some delirium with lucid intervals. The 
dysentery becoming apparently better, almost all therapeutic 
efforts are directed toward restoring the cardiac strength. 
At night, find patient in stupor, cold and clammy, pulse im- 
perceptible at wrist, evidently moribund. 
In response to the distressing appeals of family to try some- 
thing, the writer practises saline injection, assisted by Mr. 
Parker, R. S. A very large quantity of saline solution is injected 
while the patient is absolutely pulseless in the extremities and the 
respiration is barely perceptible; the patient being totally un- 
conscious. Over two pints were injected before a decided im- 
pression could be noticed in the patient, but after this the 
pulse came back rapidly, filling up and becoming tense and 
regular as the third pint was being emptied. The pulse now 16 
beat about ninety times per minute; the respiration was about 
twenty-five, and the patient revived sufficiently to ask “ What 
is the matter?’* and to survey his surroundings. Nearly three 
pints had been injected when this occurred and the canula 
was withdrawn from the median basilic vein. As was feared, 
the beneficial effect of the injection was only temporary. In 
half an hour the pulse became more rapid, the lethargic stupor 
began to reassert itself, and the moribund state returned. 
Life was prolonged, however, until 2 a. m., when death took 
place, five hours after the infusion had been practised. 
OBSERVATION II. 
Wound of the Internal Mammary Artery Complicated -with 
Penetration into the Pleura and Pericardium with enormous 
Hcemo-thorax—Syncopal Symptoms Preceded by Great 
Dyspnoea—Saline Infusion—Temporary Benefit—Death. 
A. B., male, negro, ast. 25,was brought in the ambulance, 
suffering with a stab wound of the chest, implicating some 
large vessel. Much external hemorrhage had taken place at the 
time the stab had been inflicted. When brought to hospital pa- 
tient very pale and evidently in profound shock; breathing short, 
rapid ; pulse intermittent, very rapid and almost imperceptible. 
Consciousness retained. Complains of a feeling of great op- 
pression in chest. Messrs Armstrong and Martin, Ambulance 
Surgeons, immediately injected an extemporized salt solution 
into the median cephalic. The pulse improved as fast as the 
•fluid flowed in veins, and almost the normal rhythm and num- 
ber of beats had been reached when the injection was stopped. 
About two pints were injected. Though the pulse was very 
notably improved the respiration still remained quite rapid and 
short. The general effect on the patient was most remarkable, 
he appeared greatly relieved of his previous distress and he 
expressed himself as being very much better. The effects of 
the injection were only temporary, however; the patient suc- 
cumbed about four and a half hours after. 
The post mortem examination revealed an enormous hcemo- 
throax, caused by a completely divided left internal-mammary 
artery. The pericardium had also been perforated,but the 17 
heart was intact. In this case vascular depletion, anaemia 
and apnoea from the complete disability (from compression)> 
of the left lung were the causes of death. Still, in spite of these 
eminently lethal conditions, it can not be doubted that life was 
prolonged at least three or four hours.—[From notes furnished 
by Dr. Armstrong, R. S.] 
OBSERVATION 12.— SERVICE OF PROF. E. S. LEWIS, M. D. 
Supra Vaginal Hysterectomy for Enormous Uterine Myoma of 
Nine Tears' Duration—Profuse Hemorrhage from Gen- 
eral Adhesions—Profound Shock—Collapse—Saline In- 
fusion—Marked Temporary Improvement—Survival of 
Three Days After Operation.—Death from Exhaustion. 
(Clinical History by Dr. Saizan, R. S., then Interne of Service.) 
Mr. B., aet. 46; married; Ipara. Noticed small swelling 
in hypogastrium nine years before admission into hospital. 
Admitted February 5, 1890. Tumor grew slowly the first five 
years, but in the last two it enlarged in a very rapid manner. 
The abdomen is enormously distended, and there is great in- 
terference with the respiratory functions. On February 11, 
1890, laparotomy was performed under ether. Incision ex- 
tended from above umbilicus to pubis; universal adhesion 
with abdominal walls and viscera. Much hemorrhage and time 
required to separate the mass from its connections. The 
uterus amputated on level with cervix; this portion being at- 
tached as pedicle to the abdominal wound. Operation lasted 
one and one-half hours. During the latter part of operation, 
and after the tumor had been removed, the patient became 
pulseless at wrist, pulsations barely perceptible at carotids, and 
could hardly be counted, and estimated at about 160 or 170. 
liq. ammon. carb., brandy, digitalis, etc., were injected hy- 
podermatically, but with little benefit. The breathing was 
very shallow at this time, and the heart failing most rapidly. 
Saline infusion was immediately practised by Dr. Bloom,, 
who assisted Dr. Lewis. The solution was extemporized 
(5i—Oj). After the introduction of a small quantity of solution 
there was a marked improvement in the patient’s general con- 
dition, the pulse commencing to show the beneficial effect 
first. When six ounces had been injected, the beats came 18 
down to 104 per minute; and after eight more ounces had 
been infused, the pulse beat at the rate of 84 per minute, 
the respirations 23. 
The pulse continued good for two or three hours after 
operation, though it again showed an ugly tendency to rise six 
hours after, when it rose to 130 per minute; the temperature 
99 1-20 F. 
On the third dav, at 2 p. m., she expired apparently from 
exhaustion. 
OBSERVATION 13. — SERVICE OF DR. MATAS (WARD 2). 
Laparotomy for Perforating Gunshot Injury of Abdomen— 
Perforation of Liver, Stomach, Duodenum and Pancreas, 
the Bullet Lying in the Retroperitoneal Connective 
Tissue over the Left Crus of Diaphragm—Secondary 
Shock—Infusion of Saline Solution—Death—Autopsy. 
A. B., negro, male, aet. 36 or 38, brought to the hospital 
in the Charity wagon, Tuesday, September 23, 1890, at 10:30 
a. m. The patient, a strong, healthy, muscular laborer. He 
stated that on the night preceding admission he had eaten a 
hearty supper at 7 p. m. At 11 p. m. (three hours after) he 
became involved in a difficulty and was shot in the abdomen, 
at a very short distance, with a revolver carrying a 32-caliber 
bullet. Shortly after the shooting he repeatedly vomited large 
quantities of a black coffee-ground stuff mixed with some 
ingesta. The vomiting was repeated often during the night 
and continued the next morning when admitted to the ward. 
Shortly after admission he was carefully examined by the 
writer together with Drs. Parham, Michinard and Bloom, with 
the following result: 
A bullet wound was found in the upper epigastrium situat- 
ed at a point midway between the xyphoid cartilage and the tip 
of the left tenth rib. This was the only visible wound in the 
body. On percussion and palpation the whole epigastrium 
was found full, tympanitic and tender, especially in the vicinity 
of the wound. 
The remainder of the abdominal surface appeared to be 
normal. The pulse was full and regular, beating at the rate of 
98 to 100 per minute. Temp. ioo° F. The urine clear. 19 
Mind fully conscious and intelligent. The general condition in 
every way favorable. 
In view of the evidence of perforation and signs of be- 
ginning peritonitis we decided that there should be no delay 
in opening the abdomen. The dangers of his condition were 
fully explained to the patient and with his consent he was anaes- 
thetized (chloroform) and placed on the operating table. 
After a thorough preliminary antiseptic preparation of the 
abdominal surface, a slightly curvilinear incision, four inches 
in length, was made, starting from a point slightly below the 
xyphoid cartilage, extending downward in a direction parallel 
with the costal arch. This immediately exposed the lower 
margin of the left lobe of the liver, and at once exposed a 
perforation situated about three-quarters of an inch from the 
margin and one inch to the left of the median line. The 
anterior surface of the stomach then rolled into view immedi- 
ately, presenting a perforation about the center of the body of 
the organ, which allowed a probe to pass into it. The stomach 
was moderately distended with gas. Some blood was found 
diffused in the peritoneum, but no perceptible ingesta. The 
wounded surface having been gently drawn over, the wounded 
area was isolated by large abdominal sponges and the wound 
readily closed with a few Lembert stitches. After closing this 
wound it became necessary to examine the posterior surface, 
and for this purpose the great omentum was torn through pos- 
teriorly, with the result of exposing a bullet wound which per- 
forated the posterior wall of the stomach, which, being larger 
and more irregular than the first, allowed gases and ingesta to 
escape freely into the lesser cavity of the peritoneum. 
Further examination of the lesser cavity revealed that 
some extravasation of blood and ingesta had taken place,though 
not in large quantity. It was furthermore discovered that the 
bullet had again perforated the ascending layer of the trans- 
verse meso-colon and had found its wav into the retro- 
peritoneal space at a point immediately over the abdominal 
aorta, which had, however, miraculously escaped injury. A 
ragged and ugly wound was also seen to involve the very ter- 
minus of the duodenum and the pancreas close to the superior 20 
mesenteric artery, and allowing the escape of chymous matter 
into the peritoneal and retro-peritoneal tissues. 
Further examination through an enlarged incision (two' 
inches mor6) revealed considerable accumulation of blood in the 
infra-colic and left lumbar region. A careful search was made 
for a bleeding vessel, but as none was found and there being 
no evidence of active hemorrhage it was deemed advisable 
close the duodenal wound. This was done with some diffi- 
culty owing to the great depth of the wounded parts, but was 
finally accomplished. The abdominal peritoneal toilette was; 
then attended to with scrupulous attention, the whole cavity 
being repeatedly flushed with hot sterilized water. About one- 
hour was consumed in this work and the patient’s condi- 
tion grew unfavorable. The pulse was tolerable, but 
meteorism of the stomach and intestines was developing visibly 
and causing considerable respiratory disturbance and annoying, 
tension in the wounded area. 
After carefully drying the abdomen, a glass drainage tube 
was inserted at the lower angle and the wound sutured.. 
After the dressings had been completed the patient, who had 
been on the operating table over two hours, was bathed in a. 
profuse sweat, the pulse over 120 and small. 
The patient was now put to bed and warmed with artificial 
heat and hypodermatic injections of brandy. Seven hours 
after, the pulse was 98, very regular, strong and fine, and the 
temperature 100 F. 
The patient was quite conscious but restless, and was very 
thirsty. Every half hour the abdominal glass drain is tested 
with a glass syringe, and any excess of fluid in the tube is 
drained away, and in this manner a considerable quantity 
(about 4 to 6 ounces) of bloody serum is removed from the 
cavity; the bloody serum also flows freely from the drain 
into the dressings, showing its efficiency. 
September 24 (second day), at 6 A. m., Mr. Fortier, in- 
terne of the service, noticed that the pulse was becoming more 
rapid and compressible, and patient more restless. A tea- 
spoonful of hot water is given every hour and a hypodermic 
of 10 minims of tincture of digitalis. Temperature, sub- 
normal. 21 
At ii a. m. Patient is evidently moribund; stuporous 
state ; pulse could be counted at wrist, and skin covered with 
a profuse sweat. I decided to infuse salt solution. With the 
able assistance of Dr. Bloom and other members of the house 
staff, over 50 ounces (about 3 pints 3 ounces) of warm salt 
solution (1 teaspoonful to a pint) are injected into the right 
basilic vein. 
The immediate effect of the infusion in this case was not 
as favorable as anticipated. The patient was roused from the 
stupor into which he had fallen, but constantly complained of 
thirst and a great heat all over his body, which appeared to in- 
crease rather than diminish with the steady flow of the infused 
fluid. The pulse became slower but could not be reduced 
lower than 120 in spite of the large quantity of fluid that had 
been poured into the vascular system; finally the agitation 
and sensation of general heat increasing to even alarming 
extent the further injection of fluid was stopped. About ten 
minims each of the tr. digitalis and aromatic spirits of ammonia 
were injected thirty minutes before and thirty minutes after the 
saline infusion. 
The immediate effect of the saline infusion was decidedly 
puzzling in this case, specially the remarkable sensation of 
■“ burning heat” complained of by the patient, and the increas- 
ing restlessness. The behavior of this patient was indeed a 
striking contrast to patient No. 1, who appeared to be delighted 
with the cool and soothing stream that diffused itself all over 
his body, and so kindly quenched his burning thirst. 
In this case I was certainly surprised at the results, and 
expected that the patient would die one or two hours after the 
injection. 
Sept. 25. Third day after operation. Much to my sur- 
prise I learned that the patient was still alive, though he had 
been very delirious during the night. In fact, late at night he 
eluded the vigilance of the night nurse and jumped out of bed, 
saying that he was all right and only wanted to eat and drink. 
He had been forced back to bed with difficulty and had been 
strapped down to keep him there. Of course he was now 
much more exhausted. The pulse is 140 and shallow, yet 22 
the general condition of the patient, especially the mind, is 
apparently much better than it was yesterday either before 
or after the infusion of the salt water. The temperature since 
the operation has never risen above ioo deg. F. There has 
been no vomiting and no tympanites or abdominal tenderness. 
In spite of all the great excitement there was no unfavor- 
able change in this respect. The dressings were changed, 
but the drain allowed to remain, though partially plugged with 
a Miculicz’s iodoform gauze drain. The condition of the 
wound appeared to be satisfactory. 
Black coffee and Ducro’s Elixir were given with tr. digitalis 
by enema every three hours. Notwithstanding this and other 
efforts at stimulation, the man succumbed at 6 p. m., about 
fifty-four hours after the laparotomy and about thirty hours 
after the infusion of saline solution. 
A careful autopsy held by Dr. P. E. Archinard, deputy 
coroner, confirmed the condition of affairs reached at the time 
of the operation. The bullet was found lying loosely in the re- 
troperitoneal connective tissue behind the transverse duodenum 
to the left of the vertebral column. There were evidences of 
slight peritonitis limited to the lower cavity and no hemorrhage. 
In this case the direct cause of death was not peritonitis, 
not hemorraage, but circulatory failure, which came on, not as 
shock comes, immediately after the operation, but fully four 
hours after complete and satisfactory post-operative reaction 
had taken place. 
Furthermore, this circulatory failure appears to have been 
benefited by saline infusion sufficiently to prolong life at least 
twenty-four hours, though the immediate effects of the infu- 
sions were far from comprehensible in that light. 
OBSERVATION 14. SERVICE OF DR. F. W. PARHAM. 
Fracture of Olecranon—Phlegmonous Erysipelas—Disarticu- 
lation at Shoulder—Shock—Exhaustion—Saline Infusion 
—Death. 
(Clinical History by Mr. E. D. Fenner, R. S., Interne of Service.) 
I. C. S., male, ast. 24. Patient fell and fractured the 
olecranon of right arm, on November 6,. 1890. Arm was put 
upon a slightly flexed anterior tin gutter splint, which had to 23 
be reapplied on third day on account of pain and swelling with 
great ecchymosis. On sixth day he returned, very pale and 
weak, with marked fever which was found to be due to ery- 
sipelas of the broken arm and the whole right side of the trunk. 
He was transferred to erysipelas ward, where he remained till 
November 26, when he was sent down to wrnrd 9. 
At this time his condition was pitiful. He was emaciated 
and very weak, with a distressing cough which brought up 
extremely offensive sputum. Long incision in the arm gave 
exit to quantities of dirty, creamy pus. The elbow joint was 
opened and the brachial artery exposed and its outer coat 
sloughing for several inches. Suspension and the bi-chloride 
drip was tried for two days, when it became apparent that 
amputation at the shoulder was his last chance. Ether was 
given, preceded by atropine, grain fy and brandy 5ss, sub- 
cutaneously. The parts wrere then quickly cleansed and digi- 
tal pressure made upon axillary vessels. A vertical incision 
was made down the outer side of shoulder, and from this an 
ellipitical cut was carried around the arm just below the joint, 
but not severing the axillary vessels. The bone was now 
rapidly disarticulated, the vessels grasped in the flap, the cir- 
cular incision completed and the vessels seized with forceps. 
Meanwhile the patient had become very weak. Respira- 
tions w'ere very feeble and shallow; pulse very weak and 200 to 
the minute. Large injections did not improve his condition, 
and saline infusion was done, the stump being stuffed with 
gauze and covered with hot towels. After a pint of fluid had 
been introduced, pulse became much stronger and a great 
deal slower and the operation was completed, the stump being 
packed with gauze and a fewr retentive sutures put in. Patient 
was put to bed, and surrounded by hot cans. He died, how- 
ever, in a few hours. 
Compound Comminuted Fracture of Femur—Amputation — 
Shock — Hemorrhage — Prophylactic Saline Infusion — 
Recovery. 
[Clinical report by Dr. H. J. Scherck, chief of clinic.] 
John McC., aet. 31 years, white,was conveyed to the Charity 
OBSERVATION 15. SERVICE OF DR. SAMUEL LOGAN. 24 
Hospital by the ambulance, on January 6, 1891, suffering from 
compound comminuted fracture of thigh, having been run over 
by wheels of baggage car. Before the arrival of the ambulance 
he had lost a very large amount of blood, so much indeed that 
upon examination in the amphitheatre he was nearly pulseless 
and unconscious; there was also an element of shock in his 
case, but the extreme condition was without doubt due to the 
hemorrhage that had taken place; his pulse could barely be 
felt, but it was about 190 per minute. 
The assistant house surgeon considered that the operation 
of amputation, under the existing circumstances, would be use- 
less, so it was determined to give him the benefit of intra- 
venous injection of saline solution to see if his condition could 
be benefited sufficiently to operate. Between three and four pints 
were thrown into the circulation through the median basilic 
vein; the effect was immediately perceptible, indicated by 
his pulse, which soon fell to 90 per minute. It was then 
that amputation was performed, at the upper third of the 
thigh; he regained consciousness before the beginning of the 
operation and chloroform was administered. His general con- 
dition for several days afterward was only fair, occasionally 
unconscious, but after the fourth or fifth day he gained strength 
and his condition improved steadily. His temperature at the 
time of operation was which reached 103! on the night of 
the same day, but this steadily came down to normal on the 
fifth day. 
The stump did fairly well, a small portion of the under 
flap sloughing; other than this there was no particular trouble 
with it. 
This case furnishes another link in the chain of good re- 
sults following the intravenous injection of saline solution. 
This patient would, beyond a shadow of a doubt, have died 
from exhaustion from hemorrhage had it not been for the 
injection. Again, the great and prompt effect of this agent 
as a reactive agent or stimulant is beyond question ; further 
than this it is without danger and should be employed in like 
cases. 25 
OBSERVATION l6. SERVICE OF DR. F. W. PARHAM. 
Compound Fracture of Leg Communicating With Ankle Joint 
—Fracture of Ribs and Destruction of Right Eye— 
Secondary Hemorrhage from Seat of Fracture—Ampu- 
tation of Leg—Prophylactic Injection of Saline Infusion 
—Death. 
(Clinical history by Mr. E. D. Fenner, Interne of Service.) 
Thos. Byrnes, male, 42 years, white. Patient suffered a 
badly comminuted compound fracture of leg, communicating 
with ankle joint. Several of his ribs were broken, and his 
right eye so badly injured as to require enucleation. Suppura- 
tion occurred, and on January 6, under chloroform, the open- 
ings were enlarged and numerous fragments of bone removed. 
Amputation was advised and was now urged, but was stoutly 
refused. On the 12th the man was told that his leg must come 
off or he would lose his life. He then consented to have it 
done next day. 
During the night, secondary hemorrhage took place, and 
nearly drained the circulation before it was discovered, at 
about 7 o’clock in the morning. The man was then uncon- 
cious and almost pulseless. Digitalis was given beneath the 
skin, and hot bottles put around him ; at 9 o’clock his pulse 
was somewhat better, but he was still unconscious. He was 
now taken to the amphitheatre and the limb was amputated 
just below the tibial tubercle. Prior to the operation infusion 
of saline solution was commenced, and continued during the 
operation; after about a pint had been injected in the right 
median basilic, the vein became occluded with a clot. The 
canula was removed and inserted in the other arm, into 
which nearly as much more fluid was allowed to flow. 
Digitalis and whiskey were injected, too, and under the in- 
fluence of these stimulants the man regained consciousness 
for a while. He was taken back to the ward with a forlorn 
hope for life, but died in about an hour. 
OBSERVATION 17. SERVICE OF DR. E. S. LEWIS PYOSALPINX 
Laparotomy—Hemorrhag e—Shock—Exhaustion—k> aline In- 
fusion—Death. 
(Clinical history by Mr. A. G. Bloch, R. S., Interne of Service.) 
L. S., a frail, delicate woman aet. 23 years, entered the 26 
gynaecological ward of the Charity Hospital, February u, 
1891, complaining of severe pelvic pains. Upon examination a 
large fluctuating tumor was found in the left side, apparently 
attached to the uterus; on the right was another but freely mov- 
able. The diagnosis being unquestionable, Dr. L. suggested 
the removal of the diseased organs as the only means of cure. 
Having received the consent of the patient, on February 16 she 
was anaesthetized and her abdomen opened. A large pus tube 
was found on the left side, bound securely to the pelvic floor 
by strong, adhesive bands. The intestines were also bound to it 
by similar bands, making its removal exceedingly difficult. Dur- 
ing the process of enucleation the tube burst, and, though 
every precaution had been taken, a small quantity of pus 
escaped into the abdominal cavity. The abdominal cavity 
was thoroughly irrigated, the corresponding ovary and tube 
were also removed for disease though not near as extensive. 
The pelvic and abdominal cavities were closed, a glass 
drainage tube left in situ, and an antiseptic dressing placed 
over the wound. Patient experienced no shock from the opera- 
tion; she was free from pain, though no anodyne had been 
given. Three hours after the operation my attention was 
called to the patient by the nurse, who stated that blood was 
running through the dressing. Upon removing same I found 
there was a constant flow of blood through the tube; I re- 
moved this with a syringe, cleansed the cavity with hot water, 
and gave ergot and digitalis hypodermically. 
This I found of no benefit. Every two hours two to three 
drachms of blood were drawn; the patient was becoming 
very weak and exsanguinated. Having exhausted all means 
of controlling this hemorrhage except re-opening the abdo- 
men, on February 19, with the permission of the house 
surgeon, I proceeded to infuse salt solution intravenously, 
patient’s pulse being 178 and her temperature I in- 
jected il/2 pints of a salt solution into the cephalic vein ; 
the heart immediately improved to the increased pressure, the 
pulse falling in fifteen minutes to 140, and changing from a 
thready, almost imperceptible pulse to a full, though a still 
compressible one. The following day patient, while being mo- 
mentarily unattended, arose from her bed and ran across the 27 
ward. Being so weak, she fell; she was put immediately to 
bed, but her fall was irremediable. She was badly shocked; 
in the fall she must have struck the drainage tube; her pulse 
almost disappeared, and there was a decided hemorrhage 
again from the wound. From that time patient grew steadily 
worse and died on the night of February 21. The -post 
mortem showed a cavity full of pus. There was a large blood 
clot around the left pedicle, the intestines were infected—in 
fact, patient died of both hemorrhage and suppurative peri- 
tonitis. 
OBSERVATION l8. AMBULANCE CASE ATTENDED BY DR. J. D. 
BLOOM. 
Stab Wound of Arm at Bifurcation of Brachial, Severing 
Vessels and Median Nerve—Profuse Hemorrhage— 
Saline Infusion—Recovery. 
(Clinical history by Mr. J. J. Ayo, R. S., Interne of Service.) 
Governor Jackson, colored, born in Catahoula parish, 
get. 18, and for the last three months a student at the Leland 
University, New Orleans, was brought to hospital by ambu- 
lance, Tuesday, April 8, 1891, at about 3 o’clock in the evening. 
The following history was obtained: While engaged in a 
fight with one of his schoolmates, patient was stabbed just be- 
low the bend of the elbow. When ambulance arrived patient 
was bleeding profusely, and was very much exhausted, and 
pulseless at the wrist. A tourniquet was applied and brandy 
and digitalis were administered hypodermatically. 
When patient arrived at hospital, Dr. Bloom’s assistance 
was immediately called for. Dr. B. immediately resorted to 
saline infusion. The patient’s pulse at the temporal was 130 
to the minute. About thirty ounces of a solution of common 
table salt and water were infused. Each time that six ounces 
were transfused a remarkable difference was noticed in the 
pulse, it having fallen respectively from 130 to 114, 108, 100, 
90, 84. The wound having been thoroughly examined, it was 
ascertained that all the important veins had been severed; also, 
that the radial and ulnar arteries had been cut at their origin; 28 
the median nerve aud pronator radii teres being likewise di- 
vided. All the vessels injured were ligated, the muscle and 
median nerve sutured, while the wound was closed and dressed 
antiseptically. 
Patient was sent to ward, put to bed, and his arm was 
surrounded by cans filled with hot water. Shortly he regained 
his strength, his pulse never rising above 120 to the minute. 
Three or four days after accident, patient had fever ranging 
between 101 deg. and 102 deg. ; this led us to suppose that pus 
had accumulated in the wound, and the dressings were 
removed. None of the sutures had united, and considerable 
pus escaped. Patient was afterward dressed daily, and when 
he was discharged the wound was nearly completely healed 
up, but there was slight impairment of motion in the thumb, 
index and middle fingers. 
OBSERVATION 19. SERVICE OF DR. MATAS (WARD 2). 
Gunshot W ound of Thigh, with Comminuted and Radiating 
Fracture of Femur—Dissecting Purulent Infiltration— 
Foufncaux Jordan s Disarticulation at Hip—Shock— 
Saline Infusion During Operation—Death from Shock 
Two Hours After Operation. 
(From notes furnished by Mr. J. J. Ayo, Interne of Service.) 
Albert C., male, aet. 36, colored, laborer; native of In- 
diana; strong and vigorous. While on his way to New 
Orleans he was shot with a pistol bearing a 38-calibre ball. 
The ball penetrated the middle of the thigh in antero-posterior 
direction, shattering the middle third of the femur. When 
patient was admitted in the hospital, May 11, 1891, the day 
following the accident, the patient was immediately attended 
by Dr. Bloom, assisted by members of the ambulance corps. 
A small opening of entrance was discovered from which con- 
siderable venous blood oozed; there was no aperture of exit, 
the ball being evidently imbedded in the thigh. A marked 
semi-solid swelling of the thigh had taken place and there was 
considerable lividity of the limb, indicating that considerable 29 
concealed hemorrhage had taken place. The circulation of 
the foot and leg was well maintained, however, and as the pul- 
sation of the dorsalis pedis could be faintly felt it was decided 
that only venous hemorrhage had taken place and that the main 
vessels had not been directly injured. After carefully applying 
an occlusive iodoform-bichloride dressing to the wound, a 
padded Liston’s splint, permitting of extension by weights 
and adjusted with a liquid glass dressing, was applied by Dr. 
Bloom, assistant house surgeon. 
The next day the swelling of the thigh increased and the 
oozing of the blood through the opening continued, indicating 
that hemorrhage had continued. The liquid glass bandage 
which covered the thigh became intolerably tight and had to 
be divided to give comfort to patient and avoid risk of strang- 
ulation. The antiseptic dressing over wound was also soaked 
with blood and had to be removed. A flat bag of shot being 
placed directly over the dressing was, by its weight, able to 
control excess of ooze. 
The general condition of the patient was comparatively 
fair considering the gravity of the injury, the pulse and tem- 
perature simply indicating a subdued condition of irritability, 
which was remarkably disproportioned to the great devasta- 
tions that were subsequently revealed. 
On the 20th the wound had not healed, and for the first 
time discharged a purulent ooze that called for immediate 
action. 
The patient was anaesthetized (chloroform followed by 
ether) and a free exploratory incision carried to the seat of 
fracture was made by Dr. Matas. About one quart of grumous, 
bloody pus at once escaped through the incision, several frag- 
ments of bone were disengaged and removed by the exploring 
finger, which at once discovered that the pus had burrowed 
upward toward the adductor region and backward to the inter- 
space between the hamstrings. It was further discovered that 
the femur had sustained a longitudinal fracture which split it 
almost in two halves and extended in a direction upwards toward 
the great trochanter. In the presence of these revelations, 
the parts were packed with antiseptic dressings and the anaes- 
thesia stopped. 30 
The exploratory operation had been conducted in the ward 
and it was now decided to take the patient to the amphitheatre 
where the disarticulation of the femur at the hip could be more 
advantageously performed. Here the patient was stimulated 
with whiskey and the anaesthesia renewed. The Esmarch was 
applied, and aided by Wyeth’s needles hemostasis secured to 
groin. Fourneaux Jourdan’s incision was adopted, the circular 
division of the thigh being effected a short distance above the 
the seat of fracture. The vessels were secured without any 
loss of blood and the bone enucleated from the soft parts without 
difficulty. The disarticulation was very difficult, however, even 
after a complete separation of all the external ligamentous at- 
tachments. After the disarticulation the patient gave evi- 
dences of profound shock verging on complete collapse. About 
one and a half quart of saline solution was now infused by 
Dr. Bloom into the left median basilic vein. In the meantime, 
ether, ammonia, digitalis and brandy were exhibited liberally 
both fer os and hypodermically. The patient’s pulse improved 
very markedly as the saline fluid was injected and fell from 
160 to no per minute. 
When the pulse reached this point an attempt was made 
to introduce a few deep silver sutures in order to hold together 
the lips of the huge wound left by the disarticulation, but the 
patient commenced to scream with pain and had to be given 
a few inhalations of chloroform-ether. The effect of the 
anaesthetic on the pulse was immediate and most depressing, a 
few inhalations raised it to 140, and of course they had to be 
discontinued. 
The wound was therefore packed with iodoform and 
sublimate gauze and the stump covered with the usual dress- 
ings. 
The patient was quickly brought to bed and efforts made 
to restore him with dry heat and stimulants. 
He became conscious shortly after returning to bed and 
pulse appeared to improve markedly. About half hour after 
the operation it beat at about 120 per minute and he gave 
encouraging evidence of positive improvement. Two hours 
afterward, however, he suddenly collapsed and died. 31 
6 
fc 
Immediate 
indication. 
X 
C/3 
o5 
be 
< 
Race. 
Immedi- 
ate ef- 
fect. 
Final 
result. 
Quanti- 
ty of 
fluid. 
Operators. 
Nature of injury or 
operation. 
Date. 1 
Remarks. 
i 
Shock—hem- 
M. 
26 
W. 
Very 
Death 
Oj; Oij 
Matas 
Sarcoma of thigh. Amp. 
July 12, 1888. 
Injected twice at different Sittings. 
orrhage. 
26 
good. 
upper third. 
2 
Hemorrhage. 
M. 
W. 
Very 
Recovery 
O j 
Miles 
Wound of axillary art. 
Nov. 28, 18S8. 
good. 
Secondary hemorrhage. 
Idiopathic epistaxis. 
3 
Hemorrhage. 
F. 
12 
W. 
Very 
Recovery 
8 ozs 
ifiRR 
good. 
4 
Hemorrhage. 
M. 
42 
C. 
Very 
Recovery 
12 OZS... 
Matas 
Syme’s amp. Secondary 
July J, 1889. 
good. 
hemorrhage. 
S 
Exhaustion— 
M. 
32 
W. 
Good .. 
Death 
48 ozs... 
Bloom 
Gunshot wound of head; 
April 15,1889 
Hemorrhage uncontrollable. Effect of infusion 
hemorrhage. 
Death .... 
wound of cerebral sinus. 
very temporary. 
6 
M. 
5° 
W. 
Good ... 
20 OZS... 
Bloom 
, 1889 
Shock the dominating element of danger. 
orrhage. 
7 
Hemorrhage. 
M. 
40 
w. 
Very 
Recovery 
16 OZS... 
Laplace 
Overlapping fracture of 
, 1889. 
good. 
Recovery 
lemur; osteotomy. 
S 
Hemorrhage. 
F. 
43 
w. 
Very 
43 ozs... 
Lewis 
Ovariotomy—for fibro 
Oct. 29,1889. 
—shock. 
good. 
cystoma. 
9 
Shock 
M. 
29 
c. 
Very 
Death 
32 ozs... 
Matas 
Multiple fracture of 
J une, 1890. 
Infusion practically resurrected this patient and 
good. 
Death 
skull with laceration ; of 
arteria meningea media. 
prolonged lif 24 hours. 
10 
Exhau s ti0 n 
(acute). 
M. 
60 
w. 
Very 
good. 
50 ozs... 
J uly, 1S90. 
Life prolonged over 5 hours by infusion. 
Death 
11 
Hemorrhage. 
M. 
25 
c. 
Good ... 
32 ozs... 
Armstrong- 
Stab of int. mammary 
1S90 (?) 
Lesion only discovered post mortem. 
Martin .. 
artery. 
12 
Shock— hem- 
orrhage. 
F. 
46 
w. 
O 
>1 O 
S3 br 
> 
16 ozs... 
Feb. J, 1890. 
Survived 3 days after infusion. 
Death 
tomy tor myoma. 
13 
M. 
36 
c. 
56 OZS... 
Laparotomy for gunshot 
of abdomen. 
Sept. 23, 1890. 
\\ hile the pulse appeared to be favorably impressed 
toward the end of infusion, the patient appeared 
factory. 
Death .... 
disagreeably affected. 
14 
Exhaustion— 
M. 
24 
w. 
Good ... 
(?) 
Parham 
Fracture of olecranon; 
Nov. 28,1890. 
shock. 
erysipelas, suppuration. 
Disarticulation of 
shoulder. 
is 
Hemorrhage 
M. 
31 
w. 
Very 
Recovery 
0 3-4 — 
Logan 
Amputation upper third 
Jan. 6, 1891. 
The amputation was performed in this case apter 
—shock. 
good. 
of thigh. 
infusion. 
16 
Exhaustion— 
M. 
42 
w. 
Good ... 
Death 
Oij 
Parham 
Comp, fracture of leg; 
Jan. 12, 1891. 
Prophylactic infusion ; 1 pint in each arm. 
hemorrhage. 
secondary hemorrhage. 
Amp utation. 
Infusion practiced by Mrv Bloch, Feb. 19, for 
17 
Exhaustion— 
F. 
23 
w. 
Good ... 
Death 
Oiss 
Lewis 
Pyosalpinx; laparotomy. 
Feb. 16, 1S91. 
hemorrhage. 
April 7, 1891. 
hemorrhage and exhaustion. 
is 
Hemorrhage. M. 
iS 
c. 
Very 
good. 
Good ... 
Recovery 
30 ozs.. 
Bloom 
Stab of brachial at elbow. 
19 
Shock 
M. 
30 
c. 
Oiij 
Disarticulation of hip 
for multiple, commi- 
May, 1891. 
Infusion allowed patient to be removed alive 
from operating table. 
nuted gunshot fracture 
of fen ur. 
REPORT OF CASES OF INTRAVENOUS SALINE INFUSION IN THE CHARITY HOSPITAL SINCE JULY, 1888. 32 
SUMMARY OF THE CLINICAL REPORT. 
1. Total number of cases, 19. 
2. Most urgent indication.* 
Hemorrhage 
Hemorrhage-shock 2 
Shock-hemorrhage 3 
Shock 3 
Exhaustion, acute 1 
Exhaustion—hemorrhage 3 
Exhaustion—shock . 1 
Total . ...19 
(6) Hemorrhage: 5 recoveries; 1 death (uncontrollable hemorr- 
hage) = 6 
(2) Hemorrhage-shock : 2 recoveries = 2 
(3) Shock-hemorrhage: 3 deaths ...= 3 
(3) Shock: 3 deaths = 3 
(1) Exhaustion : 1 death = 1 
(3) Exhaustion-hemorrhage: 3 deaths = 3 
(1) Exhaustion-shock: x death = 1 
Total 19 
Recoveries, 7; deaths, 12. Percentage recoveries, 36f$; percentage 
deaths, Sex, males, 15; females, 4. Age, from 12 to 60 years; average, 
33.-)- years. Race, 13 white, 6 colored. Quantity of fluid injected from 8 to 
50 ounces. Immediate effects, always good, with one solitary exception, in 
which, while the objective result was good, the subjective sensations were not 
satisfactory. 
* In specifying the immediate indications that led to the saline infusions, 
the writer has adopted the method of classifying the dominant indication in 
mixed or complicated cases, by prefixing the most obvious cause of depression 
in a complicated condition. PART II—REMARKS. 
Reprinted from the August, i8qi, number of th3 New Orleans Medical and Surgical Journal. 
In the preceding clinical report it will be noticed that in no 
case has areal transfusion been performed,and that in all cases in 
which transfusion of blood would possibly have been indicated 
intravenous saline infusion has been uniformly substituted and 
preferred. The practical and theoretical reasons for this pref- 
erence while admitted by many are still the subject of conten- 
tion, and deserve, if for this reason alone, some passing 
consideration and explanation. 
It should also be remembered that the term transfusion 
should be restricted, as Roussel first indicated, to that method 
of intravascular medication by which the blood of one person 
or animal is transferred from the vascular system of one into 
the vascular system of the other and that the term infusion 
(intravenous, intra-peritoneal or subcutaneous) should be re- 
stricted to all cases in which other solutions or media than 
blood are introduced. The injection of blood also, if not done 
directly into vascular system as in the subcutaneous injection 
of blood (e. g., Karst’s or V. Ziemessen’s method), can not 
properly be called transfusion. 
Long ago, in the earlier years of the century, the need for 
a liquid and neutral menstruum that would be able to dilute 
the thick clogging blood of choleraic patients who were mani- 
festly dying asphyxiated not for a want of oxygen-carrying 
corpuscles but simply because these could not be floated to 
their destination, owing to the dehydration of the blood and 
tissues, suggested the use of intravenous saline infusions which 
were first sucessfully practised by Joenichen, of Moscow, 
in 1830.* 
But the later experiments of Schiff and Gaule, which 
*Vide Menard, Art. Transfusion, Diet. Dechambre. 34 
proved the stimulating and re-animating influence of saline so- 
lutions on the frog’s heart when severed from the body, and 
the subsequent experiments on exsanguinated animals by 
Jolyet and Laffont, and the still later and confirmatory observa- 
tions of Kronecker, Hayem and Fournac, led to the clinical 
adoption of saline infusion as a restorative method in cases of 
acute surgical anaemia. Bischoff, who saved a woman mori- 
bund from post-partum hemorrhage, after injecting 1250 
grammes of salt solution, and the subsequent successes achieved 
by Kustner, Kocher, Kussmaul, Pellacani, and W. Bull, not 
only established the clinical utility of saline infusions, but also 
demonstrated that the respiratory and haemic value of trans- 
fused blood was not as essential to the complete restoration of 
persons dying from the effect of acute traumatic anasmia as 
had been at first supposed. * 
* * 
Without attempting to establish a lengthy parallel between 
the older practice of transfusion and the more modern method 
of saline infusion for the restoration of patients threatened with 
death from the rapid depletion of their vascular system, we 
may at once ask : is this saline infusion a true rival or a mere 
succedaneum of blood transfusion? We must answer yes and 
no, according to certain circumstances. 
We must at once state that mechanically or physically, 
saline infusion are the rivals or equivalents of blood transfusion, 
while physiologically they never can rival or equal the value 
of blood. 
In speaking of blood as a medium for transfusion we mean, 
of course, only pure, entire, living blood and not the altered 
pathological material known as defibrinated blood. We also 
mean blood of the same species and not that derived from 
heterogenous sources. 
Now the superiority of entire and living blood is based on 
three qualities, viz: Its nutritive. 2. Its respiratory. 3. Its 
hemogenic value. 
None of these qualities, except the last perhaps, are pos- 
sessed by, the inorganic saline solution. Consequently we 
need not discuss further the physiological superiority of blood 
which is here unhesitatingly admitted. 35 
But it happens in surgical practice that in many, if not the 
vast majority of the cases of acute anasmia in which fatal syn- 
cope threatens life through vascular depletion, that the cry of 
the moment is not for physiological restitution so much as for 
the mechanical dilution of the blood remaining in the vascular 
system and tissues of the individual; under these circumstances, 
the true value of saline solutions is made clear and its position 
as a true rival of the more costly blood can be readily ap- 
preciated. * 
* * 
The question of the utility of neutral saline solutions and 
their ability to save the life of patients apparently moribund 
from loss of blood having been decided in the affirmative by 
superabundant clinical experience a more important problem re- 
mained to be solved and that was, what was the limit of this life- 
saving power. When could the action of the saline solution be ex- 
pected to be permanent and when only transitory or ephemeral ? 
This problem was easily solved by the physiologist in his 
experimental laboratory but not so readily by the clinician. 
The physiological limit of blood loss compatible with life 
has been the object of interesting and serious experimental 
study. From the earlier studies of Herbst (1822) to those of 
Renaut, Hayem, Wanner and Kermisson to the latest calcula- 
tions of Rosenberg, we may admit that animals can survive the 
rapid loss of two-fifths of the total quantity of their blood, 
while the loss of more than two-fifths and less than one-half is 
usually, and more than one-half absolutely fatal. In his experi- 
mental use of the .7 per cent, salt solution this investigator was 
led to think that the injections only temporarily prolonged life 
in hemorrhages beyond one-half the total quantity of blood. 
This, he believed, was due to the reduction of the absolute num- 
ber of corpuscles in a given bulk, resulting in a qualitative 
anasmia. 
If we calculate with Bayard Holmes on Rosenberg’s data, 
“and assume that a loss of one-half of the blood is ultimately 
fatal, even if infusion and resuscitation is practised, we should 
have a reduction in the corpuscular elements to one-half, a fatal 
reduction. As there are ordinarily 5,000,000 corpuscles to a 
cubic millimeter of blood, a loss of one-half the blood and a 
restoration by infusion of its bulk to the full amount would re- 36 
duce the corpuscles to 2,500,000. This number has been found 
clinically to be compatible with life, and a fair degree of 
vitality. Patients recover with a presence for months of less 
than 2,000,000 corpuscles per cubic millimeter. But a reduc- 
tion beyond 1,500,000 is usually rapidly fatal, and death occurs 
before the number falls below 1,000,000 to a cubic millimeter.” 
While this estimate of Holmes may be correct for an acute 
experimental or surgical anaemia it is possible that the number 
of corpuscles may even suddenly be reduced below these 
figures, and the condition be still compatible with life. In this 
connection the interesting: observation of William Hunter 
should be remembered* as he has found that in certain haemo- 
lytic diseases of the blood, such as chlorosis and pernicious 
anaemia, “the number of red corpuscles may be reduced to 
500,000 or 600,000 instead of the full 5,000,000 to the cubic 
millimeter which characterize health, and yet the respiration 
of the individual will not appear to be perceptibly affected.” 
* 
* * 
But while admitting that the physiologist may determine 
the precise limit of life compatible with blood loss, and thus 
equally determine the critical conditions in which life may be 
permanently or ephemerally maintained by simple dilution, it 
is otherwise with the clinician, who is almost invariably called 
upon to rescue a patient who is laboring under a complexity of 
conditions that are far from representing the simple condition 
of the laboratory experiment. 
It must be generally conceded that there are few cases, 
indeed, of acute traumatic anaemia in which death is threatened 
from pure asphyxia due to corpuscular defficiency and the 
consequent respiratory inadequacy of the blood. Death, in 
the majority of the cases, we repeat, is threatened and will 
actually take place long before the corpuscular limit has been 
reached. It is syncope, initial circulatory failure, and not 
asphyxia from lack of corpuscular respiration, that kills in 
acute traumatic anaemia and it is this condition that the clinician 
endeavors to antagonize by the timely exhibition of the saline 
plethorifacient. 
Hunter,* a justly eminent English authority, has very cor- 
*On Transfusion; its Physiology, Pathology, Practice, three lectures delivered before the 
Royal College of Surgeons, by Wm. Hunter, M. D., etc. British Med. Jour., April io, 18S9. 37 
rectly stated the case in a recent contribution: ( i) “ The value 
possessed by transfused blood in such cases is almost solely in 
virtue of its -physical properties. The chief physical property 
of blood for purposes of transfusion is undoubtedly its volume. 
The immediate source of danger from sudden loss of blood is 
the fall of the blood pressure to a point where the circulation 
is unable to be maintained. The obvious indication, therefore, 
is to raise the pressure within the vessels. In health, the blood 
pressure is dependent mainly upon peripheral resistance. 
“The effect of the loss of blood on the blood pressure is, 
up to a certain point, completely neutralized by an increase in 
the peripheral resistance, due to the stimulation of the vaso- 
motor centers. It is only after very severe hemorrhage that 
the relation between the vessels and the amount of fluid they 
contain necessary for carrying on the circulation is disturbed. 
The pressure then falls rapidly and suddenly, and death will 
ensue unless means be taken to meet the threatened failure 
of the circulation. The readiest way in which this can de done 
is to replace the lost blood with a certain bulk of fluid. To 
meet the danger thus arising the amount of blood is more im- 
portant than its quality. 
“ In an emergency, the infusion of ordinary water (Coates) 
has been followed by results as successful as any ever obtained 
after transfusion of blood. Bulk for bulk, pure or defibrinated, 
blood must possess certain advantages over neutral saline solu- 
tions free from organic constituents. This doubtless possesses 
a certain physiological as well as physical value, inasmuch 
as blood must have a greater and more immediate effect 
in restoring the tone of the vaso-motor centers than saline 
solution. 
“ These advantages are more than neutralized by other and 
greater disadvantages, namely, (i) The difficulty of obtaining 
blood in sufficient quantity or with sufficient rapidity as com- 
pared with the ease with which simple saline solution can be 
prepared. (2) The dangers attending the transfusion of blood 
compared with the absolute freedom from danger possessed by 
the solution, and (3) the doubtful value of the transfusion, 
whether hcemogenic or physical, when compared with saline 
solution.” 38 
The physiological need of blood as a medium for the res- 
toration of the vascular equilibrium in acute traumatic hem- 
orrhage having been largely disproved and the physical reason 
for intravascular injection in such cases being better understood, 
we can easily appreciate the growing popularity and general 
substitution of salt water for blood media. 
Returning now to the clinical aspect of this subject we 
must note that a certain amount of shock is almost inseparable 
from the acute anaemia that the surgeon is called upon to meet, 
and we may at once state that it is the proportion in which 
this element of shock is added to the anaemic element that, as 
a general rule, decides the permanency of the therapeutic ben- 
efit obtained by saline infusion. From the limited experience 
furnished by the nineteen cases reported in the first part of 
this paper, and a careful consideration of many other cases 
scattered in the literature of this subject, I have been struck 
with the importance of the role played by shock in deciding the 
final issue of the case. So forcibly have I been impressed with 
this observation that I believe we may safely formulate this 
proposition, viz: That the greater the shock complicating a 
case of surgical anaemia the less the benefit of infusion and 
conversely, the more uncomplicated the anaemia the greater 
the probabilities of final and permanent recovery with infusion. 
The reasons for this fatal influence of shock is readily under- 
stood when we consider that the most striking manifestation of 
this condition is a cardio-vascular inhibition, amounting to a 
true circulatory paresis or even complete paralysis in the fatal 
cases. Shock not only weakens the cardiac pump itself but 
interferes most injuriously with the contractility of the 
peripheral vessels, and thereby with the compensating mechan- 
ism which plays so important a part in maintaining a safe de- 
gree of vascular tension in uncomplicated hemorrhage. 
Previous exhaustion preceding operative procedures from 
acute or chronic suppurative and septic processes are also 
certain to neutralize the permanent benefits of saline infusion 
when applied for the relief of the vascular depletion consequent 
upon traumatisms. 
These statements are well illustrated in the cases detailed 39 
in the preceding pages. Thus the effect of pure shock com- 
plicating hemorrhage is well shown in cases i (Amputation of 
Thigh for Sarcoma), 8 (Multiple Fracture of Skull), 6 (Avul- 
sion of Arm), 12 (Supra-vaginal Hysterectomy for Myoma), 
13 (Laparotomy for Gunshot Injury of Abdomen), 19 (Dis- 
articulation of Hip for Comminuted Gunshot Fracture of Fe- 
mur). While the exceedingly transitory benefit of infusion in 
uncontrolled hemorrhage is particularly well exhibited in cases 
4 (Gunshot of Head, Wound of Cerebal Sinus), 11 (Unrecog- 
nized Stab of Internal Mammary Artery). 
The effect of acute or chronic exhaustion (from suppura- 
tion or sepsis, etc.) as unsuccessfully met by infusion are also 
shown in cases 9 (Acute Dysentery), 14 (Disarticulation of 
Shoulder for Fractured and Suppurating Limb), 17 (Ampu- 
tation of Leg for Fractured and Suppurating Limb). 
On the other hand, the brilliant and permanently beneficial 
effects of saline infusion in cases of syncope from pure and 
less complicated hemorrhages are admirably illustrated in 
cases 2 (Wound of Axillary), 3 (Idiopathic Epistaxis), 4 
(Secondary Hemorrhage after Syme’s Amputation), 7 (Sec- 
ondary Hemorrhage after Osteotomy for Overlapping Fracture 
of Femur), 18 (Stab of Brachial Artery). 
From the further analysis of the cases here reported it is 
seen that the immediate or temporary effects of saline infusion 
were always good, no matter what was the cause of the vascu- 
lar depletion. In the majority of the cases patients apparently 
moribund were revived, and in at least two instances practicallv 
dead patients whose hearts had ceased beating perceptibly, and 
who even had ceased breathing, were resurrected and made to 
return to life and consciousness by the timely stimulation of the 
circulatory centers and organs through the agency of the infu- 
sion. This impressive result was obtained in case 9 especially, 
though in both instances the brilliant result was only temporary, 
though sufficiently prolonged to have permitted the patients to 
recognize their surroundings and to have made a final disposi- 
tion of their affairs, had they so desired it. 
It can not, furthermore, be doubted from the evidence fur- 
nished by these observations that in all cases in which life is 
threatened by cardiac syncope, i. e., in which the arteries are 40 
empty, whether due to vascular depletion or to loss of the con- 
tractile energy of the heart, whether from hemorrhage, shock 
or exhaustion, that saline infusion is a most potent restorative, 
producing almost invariably an immediately favorable effect. 
The question of the permanency of this effect is, however, as 
already indicated, far from being so satisfactory, as is also well 
shown by this report. Here so many factors of a physiological 
and pathological character intervene in the solution of the prob- 
lem that it is practically impossible, in many cases, to be able 
to foresee with certainty the ultimate effect of this mode of 
therapeutic intervention. Nevertheless, a -priori reasoning 
and the results of experience have taught us what to expect 
from saline infusion in the majority of cases, so that the indi- 
cations and final prognosis may be pretty accurately defined, 
as we have attempted to do, in the following conclusions 
which we have drawn as the result mainly, of our hospital 
experience. 
CONCLUSIONS. 
1. In all cases in which life is threatened by circulatory 
failure, from any cause, saline infusion may be depended upon 
as a temporary restorative. 
2. Saline infusion will act as a permanent as well as tem- 
porary restorative in all cases of syncope due to simple and 
uncomplicated hemorrhage. 
3. In all cases of uncontrollable hemorrhage, in which the 
flow of blood can not be arrested, the beneficial effect of 
saline infusion must necessarily be ephemeral, though even 
under these circumstances an artificial circulation of short 
duration will be maintained which may sustain life long enough 
to be of value. 
4. Saline infusion may restore permanently, as well as 
temporarily, in cases in which syncope threatens life from 
mixed vascular depletion (hemorrhage) and cardio-vascular 
paresis (shock) though the permanency of the effect will 
depend largely on the degree of the shock. The greater the 
shock the less permanent the beneficial effect. 
5. In all cases in which syncope is due only to 
cular paresis or paralysis (shock) the effect of infusion is of 41 
very doubtful value and is almost always extremely ephemeral 
and rarely permanent. 
6. In all cases in which syncope is due to organic (nutri- 
tive) as well as dynamic alterations in the cardio-vascular 
apparatus (e. g., exhaustion from disease) the effect of infusion 
will always be ephemeral and never permanent, though even 
in these cases the restorative effects of infusion are worthy of 
remembrance. * 
* * 
Having stated the reasons for preferring the method of 
saline infusion for that of blood infusion, and its indications, 
let us now consider its technical application. 
- Much stress has been laid lately On the superiority of 
subcutaneous infusion over the intravenous method. My 
friend, Dr. Bayard Holmes, of Chicago,* has proven himself 
an able advocate of the subcutaneous method, and there is no 
doubt that by availing ourselves of the Allen surgical pump, 
which he recommends for the purpose, the injection of salt 
water .into the subcutaneous tissue is indeed an easy and safe 
procedure. But while admitting that subcutaneous infusion is 
an easier and possibly safer procedure in the hands of the in- 
experienced, I can not admit that it is altogether superior, or 
even equal in any way to intravenous infusion when this is 
practised by a careful operator. Among the now salient 
advantages of the intravenous method we must recognize, (i) 
its immediate penetration into the circulation and certainty of 
absorption; (2) it is almost unrestricted in its possibilities, as 
far as the quantity injected ; (3) it is comparatively much less 
painful than the subcutaneous method; (4) it requires the 
simplest and most readily improvised apparatus for its perform- 
ance. In our hospital practice we have generally used a very 
simple contrivance, which was first mounted by Dr. F. W. 
Parham when assistant house surgeon of the institution. It 
consists simply of a large glass funnel to which a long drainage 
tubing is attached, the lower end being inserted to an elongated 
metallic tip which serves as a nozzle.f The flow in the tube is 
controlled either by the finger of an assistant or by an ordinary 
wooden spring clamp. The tip also may be improvised very 
*Vide Ne-w Orleans Medical and Surgical "Journal for March, 1891, p. 695-701. 
|The use of a glass funnel with these accessories is probably a very old one. The instru- 
ments of Beilina, Colin, Galabin and Cripps suggest the same plan. 42 
successfully by utilizing the fine end of a long, narrow glass 
nozzle, such as is found in most fountain syringes. Nothing, 
therefore, can be easier to prepare than this simplest of trans- 
fusion instruments. 
Now as to the modus operandi. This is equally simple: 
(i) Disinfect thoroughly the bend of the elbow with soap, hot 
water, ether and sublimate. (2) Expose a subcutaneous vein, 
the most prominent in sight, either the median cephalic or basilic. 
The exposure should be effected by making a linear incision 
inches parallel to the vein, so that the cut can be readily 
placed over the vein by simply sliding the loose skin over the 
vein. (3) Isolate the exposed vein by passing a groved direc- 
tor under it. (4) Ligate the vein with catgut one inch below 
(peripheral side of) the proposed puncture. (5) Introduce a 
silk or catgut ligature under the vessel about one-half an inch 
above (cardiac side of) the proposed puncture and leave it 
without tying. (6) Open the exposed vein by making a small 
valvular nick in it with sharply-pointed scissors, the anterior 
vein-wall being pinched up for the purpose by a fine-bladed 
dissecting forceps. (7) Introduce the canula of the apparatus, 
after having previously allowed the saline solution to flow out 
of the tip, so as to secure the complete exclusion of air. (8) 
Tie the proximal end of the vein with the second ligature that 
was ready for the purpose, and include the tip of the apparatus 
in the ligature. (9) Now allow the liquid to flow. 
In the practice of saline infusion it is also important that 
(1) the receptacle destined to contain the fluid be perfectly 
aseptic; (2) that the fluid to be injected be throroughly steril- 
ized; (3) that the solution be clear and heated to about ioo°; 
ioo|° F., (Hayem) ; 104° F., (Esmarch) ; 104° F., (Lorain); 
107.6° F., (Lotta); (4) that the solution of salt in water 
do not exceed 7 to 1000 parts; (5) the fluid should not 
be injected too rapidly, the velocity of the stream being 
regulated by the length of the conveying tube and the 
height of the apparatus. Esmarch estimates that three 
fluid drachms per second should constitute the rate of injec- 
tion; (6) the quantity injected should depend upon the general 
effect, especially upon the circulation, guided by the pulse. 
The rule should be to inject for the effect; i. e., the return of 43 
the normal arterial tension without special regard to quantity, 
fifteen to thirty ounces being usually the quantity required in 
adults to produce a satisfactory impression. 
In this connection,I should notice that larger quantities of 
salt solution are required and tolerated by the vascular svsttm 
than in blood transfusion. Worm-Miiller, Landois, Lesser, have 
been able to double, even treble the total amount of the systemic 
blood mass without dangerously increasing the intra-vascular 
pressure. In these cases the injections have been made very 
slowly. Ore (Jaccoud’s Diet.) as a result of numerous exper- 
iments on dogs established the fact, based on the circulation 
that the total blood weight is equal to i-io the total body 
weight, that 1-20 of the total blood (or 1-200 of body weight) 
could always be transfused without any perceptible incon- 
venience. 
Any way, in saline solution there are none of the dangers 
encountered in the injections of blood, and for this reason the 
amount injected should be almost entirely regulated by the 
effect on the pulse. When the pulse becomes nearly normal 
in frequency and volume, then stop. 
No more striking illustration of the receptive capacity 
of the vascular system writb reference to saline infusion 
could be quoted than the case recently reported by Dickinson 
to the London Medical Society, February 28, 1890. (British 
Medical Journal, March 8, 1890.) 
The case was one of diabetic coma in a woman aged 25 
years. Intravenous infusion with a solution consisting of 
sodium chloride, potassium chloride, sodium sulphate and 
bicarbonate dissolved in water. This was slowly injected by 
means of a syringe, first into the right arm, then into the left 
until, in the course of one hour and a half, 106 ounces had 
been introduced. About ten minutes after the conclusion of 
the operation consciousness began to return and soon became 
so complete that the patient was able to converse with her 
friends and was able to take food in a natural manner. 
But she relapsed into drowsiness, and the next day was as 
comatose as before the operation. The injection was now re- 
peated into one of the veins of the leg, into which the fluid was 
allowed to flow from a funnel. Under the operation which 44 
required a little chloroform, the patient’s condition appeared 
to improve, and with this encouragement the injection was 
continued until increasing fullness of the superficial veins and 
some general appearance of conjestion were taken as indica- 
tions to stop; there was as yet no return to consciousness, in 
the hope of which, the proceeding had been continued. It 
was now found that no less than 350 ounces, or imperial 
pints, had passed in. This was a much larger quantity than 
had been intended, but the process was allowed to go on under 
the encouragement which the former attempt seemed to afford, 
and in the absence of prohibitive symptoms until the increas- 
ing conjestion was thus interpreted. Three-quarters of an 
hour alter this second injection, consciousners returned and 
lasted without drowsiness for nine hours, after which, she be- 
came drowsy, but was for the most part sensible; thirty hours 
after which there was a lapse into coma, which was final and 
fatal. In this case, therefore, a total of 456 ounces of saline 
solution were infused into one patient in the course of about 
twenty-four hours. 
This is certainly more than the estimated average total 
amount of blood in the adult body and bears out thoroughly 
the experimental evidence furnished by Muller, Landois and 
Lesser. 
Finally, to conclude with the technique, I will state that 
the best results have been obtained in our practice with extem- 
porized solutions of common salt (about one teaspoonful to one 
pint) and in view of this experience it is unnecessary to refer 
to the numerous and complicated formulas that have been 
recommended by various authors, (e. g. Schmidt's, Lotta’s, 
Colson’s, Beaumetz’s, Jenning’s, Hayem’s, Schwartz’s, etc.), 
anything more than a neutral solution of common salt being 
in all probability superfluous. 
We should also add that at the end of the operation the 
wound in the arm should be accurately closed and dressed 
antiseptically. By the careful observance of these rules none 
of the cases in our hospital practice have been followed by the 
least sign of phlebitis or local disturbance, the operation being 
so free from complications and operative sequelae that it may 
be regarded as being practically innocuous.