Part 1

THE CHOLERA GAZETTE.

VOL. I. _WEDNESDAY, AUGUST 1st, 1832._ No. 4.

_Injection of Saline Solutions into the Veins._

The following documents relative to the treatment of cholera by the copious injection of a saline solution into the veins, communicated to the Central Board of Health of Great Britain, are of so interesting a character that we hasten to lay them before our readers; though we are far from participating in the sanguine estimate of the curative powers of the remedy, entertained by Drs. Lewins, Latta and others. The measure has been resorted to in New York, and on the whole, with but slender success, and the results of trials of it, in this city, so far as we have been able to obtain authentic information, have not been very encouraging. Some of the symptoms have been relieved, but we know as yet of no cure effected by it.

No. 1.

SIR,--I conceive it to be my duty to let you know, for the information of the Central Board of Health, that the great desideratum of restoring the natural current in the veins and arteries, of improving the colour of the blood, and recovering the functions of the lungs, in cholera asphyxia, may be accomplished by injecting a weak saline solution into the veins of the patient. To Dr. Thomas Latta, of this place, is due the merit of first having recourse to this practice. He has tried it in six cases, three of which I have seen, and assisted to treat. The most wonderful and satisfactory effect is the immediate consequence of the injection. To produce the effect referred to, a large quantity must be injected--from _five to ten pounds_ in an adult--and repeated at longer or shorter intervals, as the state of the pulse, and other symptoms, may indicate. Whenever the pulse fails, more fluid ought to be thrown in, to produce an effect upon it, without regard to quantity. In one of the cases I have referred to, 120 _ounces_ were injected at once, and repeated to the amount of 330 ounces in twelve hours. In another, 376 ounces were thrown into the veins between Sunday, at 11 o’clock, A. M., and this day (Tuesday) at 4 P. M.; that is, in the course of 53 hours, upwards of 31 pounds!

The solution that was used consisted of two drachms of muriate, and two scruples of carbonate, of soda, to sixty ounces of water. It was at the temperature of 108 or 110 degrees.

The apparatus employed in injecting was merely one of Reid’s common syringes, (the fluid being put into a vessel rather deep and narrow,) with a small pipe fitted, that it might easily be introduced into an incision in the veins of the usual size that is made in bleeding. It may, however, be well to keep in mind, that, in the event of the operation being frequently repeated, it may be adviseable to inject by different veins.

I forbear at present to enter further into the particulars; nor have we had sufficient experience to speak decisively on the subject. I may, however, mention, that the idea of having recourse to this remedy in cholera, occurred to Dr. Latta, from being convinced, (which I am also,) that the evacuations upwards and downwards are in reality the serum of the blood; that it is the duty of the physician to replace it, as speedily as possible, by injecting a fluid, as similar to the serum as can be formed artificially, directly into the veins, which has been done here with wonderful, and, so far as we can yet judge, excellent effect. An immediate return of the pulse, an improvement in the respiration and in the voice, an evolution of heat, an improvement in the appearance of the patient, with a feeling of comfort, are the immediate effects. The quantity necessary to be injected will probably be found to depend upon the quantity of serum lost--the object of the practice being to place the patient in nearly his ordinary state, as to the quantity of blood circulating in the vessels.--I have, &c.

(Signed)

ROBERT LEWINS, M. D.

TO W. MACLEAN, Esq. _Secretary to the Central Board of Health._

No. 2.

SIR,--I did myself the honour to address a letter to you lately, on the effects of injecting a saline solution into the veins of a patient labouring under cholera. We have not frequent opportunities of trying this, which I denominate, admirable remedy, as the disease is decidedly less frequent here; but I have seen it employed in two other cases, in the course of the last two days, with the same excellent effect. Sixty ounces are generally thrown in at once, and repeated at the end of three or four hours. In a case to-day, where I saw fifty-eight ounces injected, (being the third time of performing the operation,) the patient’s pulse, at the commencement, was 180, very small, and very feeble. She was excessively restless, with a feeling of great weakness and tormenting thirst. Before twelve ounces were injected, the pulse began to improve; it became fuller and slower, and it continued to improve until, after 58 ounces had been injected, it was down to 110. Before I left the patient, (a woman,) her condition was altogether amazingly amended. There was a fine glow and a slight perspiration on her face; the veins on the back of her head were well filled; the restlessness was removed, the feeling of excessive weakness gone, and the thirst ceased. The pulse was under 100, free, full, and soft! Verily, sir, this is an astonishing method of medication, and I predict will lead to wonderful changes and improvements in the practice of medicine! I have addressed you upon the subject, as the organ, from your high official station, of disseminating a knowledge of the extraordinary facts referred to. It will, of course, give me great pleasure to enter further into particulars upon any particular point on which you may require information, in reference to the cases that have come under my observation.--I have, &c.

(Signed)

ROBERT LEWINS, M. D.

TO W. MACLEAN, ESQ. &c. &c.

In the hands of a man of ordinary dexterity, the common injecting apparatus alluded to in my last will be found to answer the purpose perfectly well; but if the practice I recommend is, as I hope it will be, generally adopted, it will, I conceive, be expedient to advise that a regular and perfect transfusion apparatus be used; at all events, to warn those who inject to beware of allowing air to get into the vein. The tubes, of course, must be filled with fluid, as well as the pipe in the vein, before commencing, and considerably more fluid than it is intended to use ought to be in the vessel from which it is pumped.

R. L.

No. 3.

_Leith, May 23d, 1832._

Sir,--My friend, Dr. Lewins, has communicated to me your wish for a detailed account of my method of treating cholera by saline injection into the veins, with which I now most willingly comply. My scope for observation, since I commenced this treatment, has been too limited to allow me to be very copious on the subject, but I think I can adduce sufficient proof to the unprejudiced, not only of its safety, but of its unquestionable utility. I have never yet seen one bad symptom attributable to it, and I have no doubt that it will be found, when judiciously applied, to be one of the most powerful, and one of the safest remedies yet used in the second stage of cholera, or that hopeless state of collapse to which the system is reduced.

Before entering into particulars, I beg leave to premise, that the plan which I have put in practice was suggested to me on reading in The Lancet, the review of Dr. O’Shaughnessy’s report on the chemical pathology of malignant cholera, by which it appears that in that disease there is a very great deficiency both of the water and saline matter of the blood. On which deficiency, the thick, black, cold state of the vital fluid depends, which evidently produces most of the distressing symptoms of that very fearful complaint, and is, doubtless, often the cause of death. In this opinion I am abundantly borne out by the phenomena produced on repletion by venous injection.

So soon as I learnt the result of Dr. O’Shaughnessy’s analysis, I attempted to restore the blood to its natural state, by injecting copiously into the larger intestines, warm water, holding in solution the requisite salts, and also administered quantities from time to time by the mouth, trusting that the power of absorption might not be altogether lost; but by these means I produced, in no case, any permanent benefit; but, on the contrary, I thought the tormina, vomiting, and purging, were much aggravated thereby, to the further reduction of the little remaining strength of the patient; finding thus, that such, in common with all the ordinary means in use, was either useless or hurtful, I at length resolved to throw the fluid immediately into the circulation. In this, having no precedent to direct me, I proceeded with much caution. The first subject of experiment was an aged female, on whom all the usual remedies had been fully tried, without producing one good symptom; the disease, uninterrupted, holding steadily on its course. She had apparently reached the last moments of her earthly existence, and now nothing could injure her--indeed, so entirely was she reduced, that I feared I should be unable to get my apparatus ready ere she expired. Having inserted a tube into the basilic vein, cautiously--anxiously I watched the effects; ounce after ounce was injected, but no visible change was produced. Still persevering, I thought she began to breathe less laboriously; soon the sharpened features, and sunken eye, and fallen jaw, pale and cold, bearing the manifest impress of death’s signet, began to glow with returning animation; the pulse, which had long ceased, returned to the wrist; at first small and quick, by degrees it became more and more distinct, fuller, slower, and firmer, and in the short space of half an hour, when six pints had been injected, she expressed in a firm voice that she was free from all uneasiness, actually became jocular, and fancied all she needed was a little sleep; her extremities were warm, and every feature bore the aspect of comfort and health. This being my first case, I fancied my patient secure, and from my great need of a little repose, left her in charge of the hospital surgeon; but I had not been long gone, ere the vomiting and purging recurring, soon reduced her to her former state of debility. I was not apprised of the event, and she sunk in five and a half hours after I left her. As she had previously been of a sound constitution, I have no doubt the case would have issued in complete reaction, had the remedy, which had already produced such effect, been repeated.

Not having by me the number of THE LANCET containing Dr. O’Shaughnessy’s analyses, I adopted that of Dr. Marcet, only allowing a smaller proportion of saline ingredients. This I now find to be considerably less than natural, according to the more recent analyses. I dissolved from two to three drachms of muriate of soda, and two scruples of the sub-carbonate of soda in six pints of water, and injected it at temperature 112° Fah. If the temperature is so low as a hundred, it produces an extreme sense of cold, with rigors; and if it reaches 115°, it suddenly excites the heart, the countenance becomes flushed, and the patient complains of great weakness. At first there is but little felt by the patient, and symptoms continue unaltered, until the blood, mingled with the injected liquid, becomes warm and fluid; the improvement in the pulse and countenance is almost simultaneous; the cadaverous expression gradually gives place to appearances of returning animation, the horrid oppression at the præcordia goes off, the sunken turned up eye, half covered by the palpebræ, becomes gradually fuller, till it sparkles with the brilliancy of health, the livid hue disappears, the warmth of the body returns, and it regains its natural colour--words are no more uttered in whispers, the voice first acquires its true cholera tone, and ultimately its wonted energy, and the poor patient, who but a few minutes before was oppressed with sickness, vomiting, and burning thirst, is suddenly relieved from every distressing symptom; blood now drawn exhibits on exposure to air its natural florid hue.

Such symptoms, so gratifying both to the sick and the physician, must never allow the latter to relax in his care--the utmost vigilance is still necessary. At first the change is so great, that he may fancy all is accomplished, and leave his post for a while. The diarrhœa recurring, he may find his patient, after the lapse of two or three hours, as low as ever. As soon as reaction by the first injection is produced, mild warm stimulants, such as weak gin toddy, mixed with some astringent, should be freely and assiduously administered. An attempt should be made to fill the colon with some astringent fluid. That such is requisite, is evident from the watery diarrhœa returning with violence, and if not restrained, death will ultimately make sure of his victim, therefore, so soon as the pulse fails, and the features again shrink, the venous injection must be repeated, taking care that the fluid in use retains its proper temperature. The injection should be carried on very slowly, unless the patient is much exhausted, when it may be used more rapidly at first, until a little excitement is produced, after which it should not exceed two or three ounces per minute, and now is the time for the exhibition of astringents by the mouth, which will be retained; for in general the sickness entirely leaves during the operation.

Such remedies must be persisted in; and repeated as symptoms demand, or until reaction is permanently established. I have witnessed no violent symptoms accompanying the rapid injection of the fluid; but I have thought that the hasty repletion of the system was followed by great increase of the evacuations, and, consequently, a more sudden depression of the powers of life. The quantity to be injected depends on the effect produced, and the repetition on the demands of the system, which generally vary according to the violence of the diarrhœa; the greater the degree of collapse, the greater will be the quantity needed, though not uniformly, for a very slight loss produces much depression in some systems; hence there is often great collapse, without much vomiting, purging, or cutaneous discharge.

Although in every case, even the most desperate, the cholera symptoms were removed, some of my cases failed, which I attributed to one or other of the following causes--either the quantity injected was too small, or its effects were rendered abortive by extensive organic disease, or its application was too late.

I have already given an instance where deficiency in quantity was the cause of failure, which I will now contrast with one in which it was used freely. A female, aged fifty, very destitute, but previously in good health, was on the 13th instant, at four A. M., seized with cholera in its most violent form, and by half-past nine was reduced to a most hopeless state. The pulse was quite gone, even in the axilla, and strength so much exhausted, that I had resolved not to try the effects of the injection, conceiving the poor woman’s case to be hopeless, and that the failure of the experiment might afford the prejudiced and the illiberal an opportunity to stigmatize the practice; however, I at length thought I would give her a chance, and in the presence of Drs. Lewins and Craigie, and Messrs. Sibson and Paterson, I injected one hundred and twenty ounces, when, like the effects of magic, instead of the pallid aspect of one whom death had sealed as his own, the vital tide was restored, and life and vivacity returned; but diarrhœa recurred, and in three hours she again sunk. One hundred and twenty ounces more were injected with the same good effect. In this case three hundred and thirty ounces were so used in twelve hours, when reaction was completely reëstablished; and in forty-eight hours she smoked her pipe free from distemper. She was then, for better accommodation, carried to the hospital, where probably, from contagion, slight typhoid symptoms were produced. She is now, however, convalescent.

The second cause of want of success is the presence of organic disease; this, probably, renders the possessor very liable to attacks of cholera; and the latent evil, which previously gave but little uneasiness, suffers aggravation in all its symptoms, more especially after reaction has been produced, and has evidently, in many cases, been the cause of death. A delicate young female, of strumous habits, who had been for some years subject to pectoral complaints, was rescued from a state of collapse by the injection of sixty ounces of the saline fluid, administered in separate portions, within the space of twelve hours. After lingering for ten days she died; the heart was found in a state of atrophy, covered with strong evidence of the existence of ancient disease, and floating in eight ounces of pus. In another case every internal organ was diseased; some of them so much so, that it was astonishing the individual lived so long.

The third case of the occasional want of success, is the late application of the remedy. Hitherto I have had opportunity of injecting only in extreme cases, after every other means had entirely failed, cases which apparently soon would have proved fatal. Here the obstacles to be overcome have been of no ordinary kind, notwithstanding the result of the practice is of the most encouraging nature, and the number of cases now convalescent or doing well highly gratifying. In every fatal case we have had an opportunity of examining, independent of organic disease, I have found a large quantity of fibrine in the cavities of the heart, especially on the right side, where it had extended from the auricle through the ventricle in the pulmonary artery. Such deposition must have formed a certain obstacle to recovery, and is, no doubt, from the interruption it gives to the pulmonary circulation, the cause of the heavings of the chest, and the inordinate action perceptible in the centre of circulation many hours before death. Now surely it is reasonable to suppose, that if this, the most simple of all remedies, were applied early, before the blood drained of its water has collected in the larger vessels, in fact before such fibrinous depositions have taken place in the cavities of the heart, is it not reasonable to suppose that such would be entirely prevented?

But not only is early injection adviseable on this account, not only is stagnation of the blood prevented by it, and the laborious breathing, and the præcordial oppression, the intense sickness, the burning thirst, the extreme depression of the vital powers, and the chances of aggravating chronic disease, or of producing new organic lesion, in a great measure avoided: but it is rational to suppose that the consecutive fever will be rendered much milder, and that this is the case, is supported by my own experience, even though the remedy has not been applied earlier, indeed the fact is very evident. In an ordinary attack of cholera, much fluid is lost; and if the individual is so fortunate as to get out of the stage of collapse, if consecutive fever of typhoid type comes on, the system, left to its own resources to replace the lost serum, must be but ill fitted for the task, for the debility is extreme, absorption goes on slowly, the fever will be much aggravated by the irritation of internal congestion; local inflammation will thereby be produced, and the chance of recovery will be but small. Much of this evil is to be mitigated or entirely avoided by injection into the veins, of which circumstance I can adduce living instances; and where the patient, who had been injected, has sunk under organic disease, the usual marks of congestion are not perceptible.

The apparatus I have used, is Reid’s patent syringe, having a small silver tube attached to the extremity of the flexible injecting tube. The syringe must be quite perfect, so as to avoid the risk of injecting air; the saline fluid should never be injected oftener than _once_ into the same orifice, and the vein should be treated with much delicacy to avoid phlebitis. The wound should be poulticed and carefully watched, if it does not heal by the first intention.

I am, sir, your most obedient servant,

THOMAS LATTA, M. D.

(To be continued.)

_Origin and Progress of Cholera at Albany._

The following report made by the medical staff of Albany to the Board of Health, furnishes some interesting information relative to the origin of the epidemic, and the character of the diseases which preceded its appearance in that city.

“In presenting to the Board of Health the following tables, showing the bills of mortality of this city from the 22d ult., when the board directed the deaths to be recorded, up to this day, we deem it our duty to make some remarks relative to the health of the city during the above period, and likewise in relation to our future prospects, and the measures we consider useful to accelerate the departure of the pestilence from among us.

“We stated in our last report to the board, that immediately prior to the breaking out of the epidemic, our city was unusually healthy. Until about the 20th of June, few diseases prevailed, and the mortality was less than common. From the 22d of June to the 3d of July, only eleven deaths occurred--of those, six were children. In a population of twenty-six thousand, an average of less than one death a day for near two weeks, indicates a degree of health almost without a parallel. From the 30th of June to the 3d of July, _not one single death was reported_. It was, however, but the calm which precedes the storm. All other diseases gave way to the silent but the irresistible march of the epidemic.

“Although but few deaths took place from the 20th of June to the 3d of July, there was considerable sickness; and experienced physicians foresaw the coming danger, in the usual prevalence of diarrhœa, and common cholera morbus--hence it was that your board was urged to make all ready--to be prepared with hospitals, physicians, nurses, &c. and to this timely warning, and the preparations made in consequence, we may, under Providence, attribute the limited ravages of this fell pestilence.