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.