Elsevier

Clinical Nutrition

Volume 27, Issue 2, April 2008, Pages 179-188
Clinical Nutrition

Review
The history of 0.9% saline

https://doi.org/10.1016/j.clnu.2008.01.008Get rights and content

Summary

Background & aims

We aimed to trace the historical origins of 0.9% saline, how it came to be used so commonly today, and to consider whether its continued use can be justified.

Methods

We searched the Medline, Science Citation Index, ScienceDirect and Google™ databases using the key words saline, physiological, salt solution, sodium chloride, 0.9%, intravenous, injection, fluid, cholera, resuscitation, parenteral, history, historical and origins.

Results

The use of 0.9% saline is believed to have originated during the cholera pandemic that swept across Europe in 1831. However, an examination of the composition of the fluids used by the pioneering physicians of that era reveals solutions that bear no resemblance to 0.9% or so-called ‘normal’ saline which appears to have very little scientific or historical basis for its routine use, except for Hamburger's in vitro studies of red cell lysis.

Conclusions

The currently used 0.9% saline solution is without convincing historical basis. Given that the composition of 0.9% sodium chloride is dissimilar to most solutions used in the past, and is in no way ‘normal’ or ‘physiological’, our current practice may be based on historical fallacy and misconception.

Introduction

Each year nearly 10 million litres of 0.9% sodium chloride (saline) are infused intravenously in the UK (data from Baxter Healthcare, UK). Despite being one of the most frequently used crystalloids for resuscitation, replacement and maintenance, the origins of 0.9% saline remain obscure.

The use of saline is believed to have originated during the cholera pandemic that swept across Europe and reached England in 1831.1, 2, 3, 4, 5, 6, 7, 8, 9 However, the solutions used by Latta,10 Jennings11 and other pioneers of that era show little similarity to 0.9% saline. How, therefore, did 0.9% saline come into use and when did it become accepted as ‘normal’ or ‘physiological’? The aims of this review are to trace the historical origins of 0.9% saline, how it came to be used so commonly today, and to consider the justification for its continued use.

Section snippets

Search strategy

We performed internet-based searches of the Medline (Ovid, PubMed, Embase) and Science Citation Index databases, historical journals on ScienceDirect and the Google™ search engine using the key words saline, physiological, salt solution, sodium chloride, 0.9%, intravenous, injection, fluid, cholera, resuscitation, parenteral, history, historical and origins in various combinations with the Boolean operators AND, OR and NOT. We also hand searched key journals, medical history textbooks and the

Early history: the arrival of cholera

The Indian Blue Cholera pandemic reached Sunderland in northeast England in October 1831 and stimulated the first developments in intravenous fluid therapy. Owing to the limited knowledge base at the time, 76 different and ineffective or damaging treatments were advocated for cholera,12 including bloodletting as a means of “diminishing the venous congestion”, emesis to rid the body of “poisons” and the inhalation of the protoxide of azote (laughing gas, nitrous oxide) to “remedy the absence of

The evolution of saline solutions

Less than 7 weeks following O'Shaughnessy's recommendations19 the first cases of cholera were treated with intravenous saline solutions. Robert Lewins, a physician in Leith, Edinburgh, reported the results of this new treatment to the Central Board of Health in London and published them in the Lancet of 26th May 1832.20 He describes witnessing this treatment in three of six patients treated by Thomas Latta to whom he ascribes the “merit of first having recourse to this practice”. Lewins

Composition of salt solutions

To understand how a concentration of 0.9% saline came into general use, a hand-search was undertaken of the literature from the 19th and early 20th centuries. The constituents of the solutions were described in traditional chemical terms (Table 1) and apothecary's measures (Table 2). We have recalculated the composition of the various solutions3, 6, 10, 20, 22, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and have expressed the ionic composition in mmol/l (Table 3).

It was

Dissent in the medical profession: saline treatment does not prosper

Having heard of the use of intravenous saline injections by Latta and Lewins, O'Shaughnessy thought the results exceeded his “most sanguine expectations”.43 Supporters of this new treatment, however, were few and articles describing the failure of saline injections appeared.44, 45, 46 Latta felt the need to defend his practice against “members in the profession guilty of scribbling on medical subjects in the newspapers of the day” and felt “this was a crime for which they have no excuse”.47

‘Indifferent’, ‘physiological’ or ‘normal’ saline

Interest in the composition of salt solutions was given further impetus by 19th century studies of isolated frog nerve and muscle. Perhaps the best known of these were performed by Sydney Ringer33, 37, 42, 49, 50 which led to the development and subsequent modification of Ringer's solution, the basis of the modern solutions such as Hartmann's.37, 38, 51, 52, 53 Ringer set out to “ascertain the influence each constituent of the blood exercises on the contraction of the ventricle”37 and, having

Hamburger: forgotten father of 0.9% saline?

None of the intravenous saline solutions described between 1832 and 1895 bear any resemblance to 0.9% saline (Table 3). The first reference to a solution similar to 0.9% saline appeared in 1896.60 In his article W.S. Lazarus-Barlow cites Hamburger as the main authority for suggesting that a concentration of 0.92% saline was ‘normal’ for mammalian blood.60

Hartog Jakob Hamburger was a Dutch physiological chemist, appointed lecturer in physiology and pathology at the Utrecht Veterinary School in

Acceptance into routine practice and modern day problems: abnormal saline

Fluid therapy with saline solutions, in the form of proctoclysis and hypodermoclysis, became routine in the early 20th century. In 1911 Evans64 stated his intention to “sound a note of warning against the thoughtless and indiscriminate use of this remedy” and to dispel the erroneous belief that the administration of ‘sodium chlorid’ solutions was harmless just because the salt was present in all foodstuffs, in body fluids, and incorrectly thought to be readily excreted by the kidneys. Having

Conflict of interest statement

None of the authors has a conflict of interest to declare.

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