Now and Then, the History of Parenteral Fluid Administration

The use of blood and intravenous fluid therapy is now considered routine therapy. The level of sophistication that we now perceive as standard has resulted from centuries of legends, religious beliefs, pseudo-science, nonscientific supposition, experimentation and error.

From the earliest history of medicine to the days of Galen, blood and other body fluids have held a mystical quality. Blood represented life and was therefore regarded as the greatest gift, and hence the custom of sacrificial offerings to the deities. Long before William Harveys description of the circulation, ancient healers across many cultures debated and speculated the nature of mans blood circulation. In the ancient cult ure of Mesopotamia the liver, being most vascular, represented the center of life. Ancient Chinese medicine was perhaps the closest to describe the modern circulation accurately. The medical compendium of Nei Ching, an ancient Chinese medical text, describes that all the blood is under the control of the heart, the blood current flows continuously in a circle that never stops. Imenhopt I, an ancient Egyptian physician, described the metu or channel theory where air, blood and other body fluids traveled together in body channels and were eventually excreted through the anus. Aristotle believed that blood was manufactured in the heart then distributed to other tissues. Galen, however, believed that blood was made in the liver, then moved back and forth until it was consumed, this continued to be the theory regarding circulation for many years to follow.

Dawning of Intravenous Therapy

Perhaps the first hint of intravenous (IV) therapy lies in the classical story of the Argonauts. Ovidius, a Roman poet, relates that princess Medea rejuvenated her husbands father Aeson by a magic potion. She was said to have cut the elders throat, emptied his veins then refilled the vessels with her solution. In 1492, the ailing Pope Innocent VIII, 250th successor of the A postle Peter was given blood from three healthy youths in an attempt to save his life after a stroke, but all died. Although a few historical references refer to this incident as first attempt at blood transfusion, most texts believe blood was given orally as was the custom at that time.
Earliest Attempts at Intravenous Therapy

The journey starts at the end of the 16th and the beginning of the 17th century. William Harveys report on the circulation coupled with the curiosity, patience and dedication of other scientists allowed the first steps towards establishing IV therapy. More than half a century later, frustration and disappointment from poor outcomes resulted in the cessation of efforts at IV and transfusion therapy throughout the 18th century. Bloodletting and the medicinal use of leeches reached unprecedented popularity and sophistication. This continued until the end of the century when Pierre Alexander Louis (1787 1872), a French physician, performed the first literature review and analysis of the practice of bloodletting and showed it to be harmful.
Interest Revived

The early part of the 19th century was quiet until the outbreak of the cholera epidemic sparked a renewed interest in the use of parenteral therapy. It would take physicians and scientists almost 3 years to recognize that the sequelae of cholera were a result of dehydration and not a blood disease. Cholera started in India in 1827, spread to Russia in 1829, England in 1831, and the US in 1832. The impact of the disease was devastating with approximately 15,000 cases reported in England alone in 1832, a third of whom died. Perhaps the best description of cholera is illustrated in figure 1, Tilted Blue Stage of Spasmodic Cholera, originally published in the Lancet on February 4, 1832 , by William OShaughnessy, who later founded principles on IV fluid therapy. In 1885, Went published the views of Hayem, a famous hematologist of that era summarizing the views of that century.

Although the importance of IV solutions was well recognized, the complications related to access and sepsis made progress slow in the first half of the 20th century. IV feedings, as they were called, were only given to critically ill patients. Fluids were poured into an open glass flask covered with gauze, in the neck was a rubber stopper attached to glass tubing then rubber IV tubing. Various methods of introduction of IV fluids were employed including proctoclysis in which a liter of fluid would be poured into the rectum of supine patients. Hypodermoclysis or subcutaneous injection of large amounts of fluid was also popular although limited since only isotonic fluids could be successfully used.
Final Success

The 20th century started with a breakthrough in transfusion therapy with Landsteiners discovery of the blood groups. News of successful cases of human to human transfusion encouraged the use of transfusion therapy during World War I. Later, the introduction of citrate as an anticoagulant, the discovery of pyrogens in 1923 and the introduction of plastic bags, then shortly thereafter the plastic needle would take transfusion and IV fluid therapy to another level. The advent of the Second World War allowed clinical and useful application of IV and transfusion therapy and would once and for all establish an indisputable role for IV therapy as routine medical practice. The second half of the 20th and the st beginning of the 21 century were marked for their continued sophistication both scientifically and technically. In 1990 it was estimated that 185% of hospitalized patients in the US needed IV accesses and some form of IV fluid therapy. About 40 million patients in the US alone receive IV therapy annually. About 32,000 units of packed red blood cells are transfused daily and 23 million units of blood products yearly. Today there are over 40 different IV fluid preparations and at least 15 different blood and blood components. As for the future, research continues targeting different aspects of IV and transfusion therapies, the use of oxygen carriers; enzyme-converted O red blood cells and solvent detergent treated frozen plasma are some of the examples of current ongoing research. As we review the history of blood transfusion and IV therapy, we wish to acknowledge the hundreds of scientists who dared to question and pursue their dreams. We commend their efforts which allow us to practice medicine as we now know it.