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.