Intravenous Transfusion of 
Saline Solution with a 
New Apparatus. 
BY 
ELY VAN DE WARKER, M. D., 
SYRACUSE, N. Y. 
REPRINTED FROM THE 
Neb) STotfc HJeUfcal journal 
for December 12, 1S96. Reprinted from the New YorTc Medical Journal 
for December 12, 1896. 
INTRAVENOUS 
TRANSFUSION OF SALINE SOLUTION 
WITH A NEW APPARATUS. 
By ELY YAK DE WARKER, M. D., 
SYRACUSE, N. Y. 
The intravenous transfusion of saline solutions is 
such a simple operation that ordinarily no special ap- 
paratus is necessary. Every surgeon knows, however, 
that it is sometimes these very simple procedures that 
are difficult. In a case of extreme collapse, when the 
veins have no existence, physiologically speaking, and 
exist only anatomically as collapsed tubes, without 
radial pulse—when no amount of cording will cause the 
empty vein to fill, and when a lost minute may be meas- 
ured by a lost life—it is very convenient to have a simple 
apparatus at hand that will expedite even so simple 
an operation. In these extreme cases I believe it is 
necessary to transfuse into the veins; subcutaneous 
transfusion is too slow with the vital forces so nearly 
suspended. Saline rectal enemata, a method of great 
value, for the same reason is too slow to furnish the 
necessary stimulus to a heart nearly inert for the need 
Copyright, 1896, by D. Appleton and Co^anY. 2 
INTRAVENOUS SALINE TRANSFUSION. 
of a fluid to act upon. The apparatus here figured is a 
composite affair that was gradually put together from 
time to time as the need of transfusion occurred, until 
it reached its present perfected form. 
While nearly every surgeon has had occasion to test 
the merits of saline transfusion, I doubt if any one has 
had the satisfaction of demonstrating its value as a 
lifesaver more thoroughly than I have had. With the 
object of inducing some one who has never tried it 
to be prepared to use it with a strong reliance upon its 
certainty of action, I will narrate briefly the following 
cases: 
Case I.—Miss M., of Irish nativity, aged forty-three 
years, large ovarian cyst of several years’ duration, had 
suffered no unpleasant symptoms other than those due 
to abdominal distention. While nursing a sick relative, 
which caused very unusual exertion, she was suddenly 
attacked with severe abdominal pain and tenderness, 
with chills and subsequent fever. I saw her at the home 
of her relative about one week after the outbreak. The 
abdomen was of a dimension equal to a pregnancy at 
term, very tender on palpation, with frequent attacks 
of pain. Temperature, 103°; pulse, 110. I advised 
immediate operation, but it was nearly a month after my 
visit that she was admitted to the Central New York 
Hospital for Women for operation. During that in- 
terval the symptoms had gradually augmented, and at 
the time of her admission she was in a deplorable con- 
dition. She was greatly emaciated and too weak to walk. 
Section showed a monocyst almost universally adherent. 
The contents of the cyst were about twenty pounds of 
extremely foetid pus. The adhesions were easily broken 
down, and the operation in particular difficult, lasting 
about forty minutes to the completion of the toilet. 
She was taken off the table in fair condition. It was 
soon noticed by the nurse that she was growing cold and INTRAVENOUS SALINE TRANSFUSION. 
3 
the pulse racing, and in a few minutes she appeared 
to he in a dying condition—pulseless, gasping respira- 
tion of the dying, with complete surface anaesthesia. 
Intravenous transfusion of a one-per-cent, salt solution 
at 105° was at once made, using about twenty ounces 
of fluid. In this case it was very difficult to find and 
enter a vein, so complete was the collapse of the vessel. 
My trocar and cannula greatly expedited the operation. 
The result of transfusion was prompt and lasting and 
the patient’s life was saved. The operation was very 
nearly bloodless, the adhesions showing no disposition 
to bleed as they were broken up. The conditions lead- 
ing to collapse in this case were interesting, as demon- 
strating that it is not blood loss previous to, during, or 
subsequent to operation, hut that any condition equiva- 
lent to blood loss will precipitate the moment of col- 
lapse. Here high temperature, arrested nutrition, and 
blood poisoning were those equivalent conditions. 
Case II.—A woman, aged thirty years, married, 
demiblonde. number of children unknown. In the serv- 
ice of one of the staff of the Woman’s and Children’s Hos- 
pital of Syracuse. Abdominal section reached a right pel- 
vic haematoma due to what was supposed to he an extra- 
uterine pregnancy. An old clot was turned out of the 
pelvis equivalent to about a pound in weight. It was 
dense and tarlike in color, and at the time the lesion oc- 
curred, must have represented a quart, or possibly more, 
of blood. The phlegmon developed about six weeks previ- 
ous to the operation, but its history was obscure. The 
loss of blood due to the operation was small. The pa- 
tient was upon the table about forty minutes. After 
being put to bed in a fair condition of pulse, she sur- 
prised us by passing quickly into extreme collapse. She 
was algid, with complete surface anaesthesia, eye and other 
reflexes abolished, pulseless, and the veins completely 
collapsed. The respiration was gasping and shallow. 
At the request of the operator I performed transfusion. I 
was about to abandon the operation on account of the 
impending death, hut as she was yet gasping and the 4 
INTRAVENOUS SALINE TRANSFUSION. 
trocar nearly in the vein, I persevered, and in less than 
a minute the solution was being transfused. The effect 
was rapid, and the patient passed from a condition of 
inevitable death to one of comparative safety in about 
three hours. She made an uneventful recovery. 
Case III.—As amemic shock is not the only form 
with which the surgeon has to contend, it is well to 
refer briefly to the following case with a view to con- 
trast: 
Miss , aged twenty-one years, single, had always 
been a delicate girl. At seventeen years she had not 
yet menstruated. Her physician detected a pelvic mass 
extending like a ridge from side to side. As she was 
bedfast and rapidly failing, laparotomy was advised and 
consented to. She was admitted into the Woman’s 
and Children’s Hospital of Syracuse. The mass was 
made up of the lower border of the omentum fusing 
into the right tube and ovary, all of which were re- 
moved. She made a prompt recovery, and improved 
very considerably in general health. The pelvic con- 
dition was regarded as tubercular, although I am not 
sure that it was verified by the microscope. Four years 
after she was readmitted with symptoms of intestinal 
obstruction. At the request of her physician, a col- 
league on the staff, I did the operation. The intestines, 
large and small, were greatly distended. At first it was 
supposed that the obstruction was at the sigmoid, but 
in the Trendelenburg position it was seen that what 
appeared to be a constricted part of the colon was a 
cyst of tubal origin which was tied off. At this point 
a serious accident occurred. The intestines, which had 
been retained in the abdominal cavity only by great 
care and watchfulness, through the momentary inad- 
vertence of the assistant were allowed to escape. As 
usual in such a case, the intestines were reduced with 
extreme difficulty and loss of time. They were at last 
returned and the search for the obstruction resumed. 
It was found not far from the ileo-csecal region, and 
consisted of a globular mass surrounding and obliterat- INTRAVENOUS SALINE TRANSFUSION. 
5 
ing the intestine. It was found necessary to resect the 
intestine at a healthy portion and insert a Murphy but- 
ton. The operation lasted about an hour. She was put 
to bed in fair condition; pulse about 120; respiration, 
18; temperature, 99.5°. This was at 3 p. m. While 
at dinner in the evening I was called to the hospital 
by my colleague in consultation in the case. I saw her 
at 7 p. m. Temperature, 104°; respiration, 30; pulse 
racing. At 8.30 p. m., pulseless at the wrist; tempera- 
ture, 104.6°; respiration, Cheyne-Stokes. At the re- 
quest of my colleague I made transfusion in the hope 
that an increased volume of fluid would stimulate the 
fast failing heart. Owing to the carelessness of a nurse 
the amount transfused is not known. It had no effect 
upon the circulation. She died at 10 p. m. with a tem- 
perature of 106°. 
The case is given somewhat in detail as it demon- 
strates in a striking manner the limits of saline-solution 
transfusion. The three cases serve to define three forms 
of shock. First, we find shock due to inanition, fever, 
and chronic sepsis, precipitated by operation. Second, 
shock due to blood loss prior to operation, and both 
forms to amend to transfusion. In the third, the fatal 
condition, or shock, comes from suspension of inhibitory 
nerve centres that functionally control the heart and 
heat centres. The train of conditions that led up to 
this is clear when we recall the eventration, and all that 
it implied to the nervous system. The entire nervous 
congregation of organic life was roused into fatal over- 
stimulation through the irritation of the greater and 
lesser splanchnic nerves, and the brain and spinal cen- 
tres implicated through the great sympathetic, quickly 
resulting in suspension of inhibitory centres. Thus, 
while saline transfusion was able to supply the defi- 6 
INTRAVENOUS SALINE TRANSFUSION. 
ciency in loss of circulating fluid, it was unable to sup- 
ply what was necessary in the other. Clinically the two 
types stand in marked contrast: In the first, advancing 
algidity; in the second, augmenting pyrexia. In the 
first, surface anaesthesia increases as surface heat is 
lost; in the second, only as the brain ceases to func- 
tionate. In the first, consciousness is lost in the same 
ratio as the pulse is lost and the heart’s action fails; 
in the second, rather with the increasing pyrexia. In 
the first, torpor from the beginning, intensifying cold, 
death. In the second, restlessness, intensifying heat, 
death. One is as much deserving the name of shock as 
the other, and we have no other name for either. As 
intravenous transfusion has now a status as a life-saving 
operation beyond all controversy, it is well to be able 
to define just in which type of shock we may expect 
the&e results, and as a contribution to this knowledge 
I have ventured to overstep the limits of the paper and 
introduce the third case. 
In several instances in which the apparatus has been 
exhibited before societies, several gentlemen suggested 
that just as prompt results could be gained from rectal 
or subcutaneous injection. I have no doubt that is 
so in cases in which function is not too seriously de- 
pressed. But in cases in which death is near and time a 
serious matter, I would not advise any to trust to it. I have 
had some experience that has practically taught me this 
lesson. I have found rectal hot saline injections of great 
value in supplementing intravenous transfusion when 
the radial pulse is re-established and the reaction ap- 
pears to drag; then the injection appears to augment 
the effect of the transfusion. When reaction is estab- 
lished to this degree, the rectum in my experience offers INTRAVENOUS SALINE TRANSFUSION. 
7 
as favorable a channel as the subcutaneous route, and 
leaves no painful sequelae 
The physiological study of intravenous injections 
has begun to awaken keen interest. MM. Bose and 
Vedel, in the Journal des praticiens, July, 1896, have 
reached the following conclusions from their study of 
the subject: Large intravenous transfusions are not 
toxic even when transfused as rapidly as forty to eighty 
cubic centimetres a minute. These injections produce 
an abundant diuresis in half an hour after the trans- 
fusion. While this is, no doubt, true in physiological 
experiments, I have not observed it in cases of extreme 
collapse in the human subject. There is no elevation 
of blood pressure and no albuminuria, but there is in- 
creased heart action and an elevation of the central and 
peripheral temperature—febrile reaction. They quote 
Mayet that in the compound saline solution—chlo- 
ride and sulphate of sodium—the sulphate is of no 
value and should be avoided, as it affects the blood 
globules, although the authors say there is no difference 
between the effects of the two solutions. Fasting ani- 
mals appear to be more susceptible to large injections, 
but even when apparent death results the animals quick- 
ly recover. In these experiments it was shown that 
the physiological effects were not in proportion to the 
temperature of the solution and the rapidity with which 
the injection was made. The authors recommend a 
simple saline solution, one hundred and five grains of 
sodium chloride to thirty ounces of water to be the pref- 
erable proportion. In the hasty approximation of the 
operating room, a teaspoonful to a quart of water is a 
good working formula. 
In the employment of the intravenous injections 8 
INTRAVENOUS SALINE TRANSFUSION 
after the haemorrhage of typhoid fever—and it ought 
always to be used when collapse threatens—it has re- 
cently been shown that the beneficial effect is not con- 
fined to merely increasing the volume of the circulat- 
ing blood. There is a far-reaching and profound effect 
that can not he measured in this mechanical way. M. 
Claisse, in the Comptes rendus de la Societe de biologie, 
1896, has made his study upon the blood from the fact 
that in many infectious diseases increased leucocytosis 
is a constant attendant. “ In a case generalized puru- 
lent streptococcus infection an intravenous injection of 
fifteen hundred grammes of saline solution was followed 
in an hour and a half by a rise of temperature from 
102.9° to 105.8°, while the number of red blood-globules 
to the cubic millimetre was reduced from 3,968,000 to 
3,596,000, and the number of white blood-corpuscles 
from 13,547 to 7,804. In the course of three hours 
the temperature had declined to 98.6°. In the case of 
an old man of sixty-four years with a diffuse phlegmon 
of the arm, a subcutaneous injection of a litre of saline 
solution was followed by a diminution in the number 
of red blood-corpuscles from 3,565,000 to 3,255,000, and 
of the colorless corpuscles from 26,660 to 11,346. In 
a case of profound puerperal infection an intravenous 
injection was immediately followed by an alteration in 
the relation between the red and colorless blood-cor- 
puscles—1 to 228 to 1 to 344.” In the comment of the 
Medical Record, from which this extract is taken, 
it is pointed out that the depression of temperature, 
diminished leucocytes, and amendment of the symp- 
toms of infection with a status of reaction are similar 
to those following the injection of antitoxine in diph- 
theria. “ A splendid field for research is thus opened INTRAVENOUS SALINE TRANSFUSION. 
9 
up, and one that possibly will render the animal serums 
useless in the treatment of specific infections.” I am 
strongly of the opinion that in view of the enormous 
renal stimulation following intravenous injections of 
saline solutions, and the marked kidney implication 
in diphtheria, together with the profound effect of the 
injection upon the corpuscular elements of the blood, 
this will prove an accepted treatment of diphtheria 
in the near future. In typhoid fever, in view of this 
report by Claisse, the saline transfusion has a double 
indication in hsemorrhagic cases. In puerperal infec- 
tion I shall certainly try it. In cases of the nearly 
functionless kidneys of eclampsia and with the poison- 
laden blood it is positively indicated, and, I believe, 
has already been tried, hut I have lost the reference. 
From this brief abstract of what has already been ac- 
complished in the therapeutics of saline solutions trans- 
fused directly or indirectly into the blood, it is evident 
that its usefulness in the future may he broadened far 
beyond the expectations of those who have heretofore 
limited its use to the treatment of shock or haemorrhage. 
In fact, to the physician, rather than to the surgeon, 
will we look for this more important demonstration 
of its utility. Simple as the operation of intravenous 
transfusion may he, yet an apparatus that renders it easy 
to perform,aseptic and accurate in operation, will contrib- 
ute an important element to this more extended employ- 
ment of the method. To the physician who is hut sel- 
dom called upon to make any surgical operation, the little 
apparatus here figured will prove of great usefulness. 
The apparatus consists, first, of a glass container 
large enough to hold from three pints to two quarts of 
solution (Fig. 1), fitted with a sufficient length of pure INTRAVENOUS SALINE TRANSFUSION. 
10 
gum tuhing given off from the bottom of the con- 
tainer. In the figure the tuhing is represented as con- 
nected with the stopcock C, Fig. 2, with the cannula 
D, Fig. 2 attached, and in the condition in which it 
is when in use, the cannula inserted in the vein and the 
J. REYNDERS & CO. 
Fig. 1. 
stopcock open. The glass has a scale of ounces etched 
into its side, so that the quantity of fluid transfused 
at any stage of the operation may he readily ascertained. 
The second part of the apparatus (Fig. 2) consists of 
a cannula D, the trocar B, and the stopcock C. One 
end of the cock is corrugated so as to he firmly held 
hy the distal end of the tuhing. The other end of the 
cock, as seen in the figure, is slightly tapered so as to 
slip into the head of the cannula, which is beveled 
to correspond, so that when connected with the can- INTRAVENOUS SALINE TRANSFUSION. 
11 
nula an airtight taper joint is formed. The trocar B 
has a head sufficiently large to be easily grasped by the 
Fig. 2. 
fingers and withdrawn when the cannula is inserted 
into the vein. 
The operation is done by the use of this apparatus 
as follows: After the vein is exposed, the only instru- 
ment not here figured is a small mouse-tooth forceps 
to pick up the vessel, which is quite necessary; hut any 
small forceps will serve the purpose. The container has 
been filled and the stopcock connected with the tub- 
ing is held by an assistant. The cannula and trocar 
together are inserted into the vein, which is held up 
by the forceps, so as to offer a slight shoulder to the 
sharp point of the trocar which is thrust into the lumen 
of the vein, being careful not to transfix. The stopcock 
is now opened, and the solution allowed to escape until 
the tubing is thoroughly warmed and the solution dis- 
charges at a proper temperature. You are now ready 
to withdraw the trocar and thus open the cannula, 
through which the blood flows more or less freely. The 
stopcock, still open and the solution discharging, is at 
once connected with the cannula by the taper joint—- 
simply thrusting the two together. It is thus seen that 
the two currents, one of blood from the cannula and 
the other of saline solution through the cock, are joined 12 
INTRAVENOUS SALINE TRANSFUSION. 
without the possibility of the entrance of air. The 
flow of solution is regulated by the cock as well as by 
the height at which the container is held above the point 
of delivery. In the case of collapsed veins after a very 
exhausting haemorrhage or extreme shock, no blood will 
escape from the cannula after the trocar is withdrawn. 
Fig. 2 represents that part of the instrument somewhat 
shorter than the actual length and about half the 
diameter. The New York Medical Journal. 
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