How the cholera epidemic of 1831 resulted in a new technique for fluid resuscitation.

Cholera was a much feared disease as it spread across Europe in 1829–1830. The Lancet on the 19 November 1831 charted its progress and even published a fold out map of Europe to allow its readers to monitor its approach. The epidemic reached Sunderland in October 1831. On the 3 December 1831 a Dr W B O’Shaughnessy delivered a lecture to the Westminster Medical Society on the “Blue epidemic cholera”, as it was then known. As there was still no known “remote” cause of the disease, he considered it legitimate to look at the effects of the disease and to treat these instead. He had observed that, “universal stagnation of the venous system, and rapid cessation of the arterialisation of the blood, are the earliest, as well as the most characteristic effects.” He then posed the question, “What is the best mode by which this artificial arterialisation can be effected ..?” At the time most physicians favoured venesection. Others, “Recommend the inhalation of oxygen gas, or of a mixture of oxygen and atmospheric air, or of the protoxide of azote, ... “laughing gas”...” He went on, “Now it might rationally be imagined that the success or failure of these methods should afford us a touchstone of some authority, in deciding on the rationality of the principles on which they are practised ...” and concluded that there was some evidence in favour of venesection, if done in time and no other problems were encountered. He found no evidence in favour of oxygenation and conceded that venesection might also fail. In vitro physiology studies had shown that venous blood could be arterialised by agitation in atmospheric air, or contact with highly oxygenised solids or fluids. This led him to suggest the idea of intravenous injection of nitrate or chlorate of potash, “salts which contain the greatest quantity of oxygen”. A trial of the technique in a mongrel dog showed that it was safe. O’Shaughnessy suggested that his method should only be used in patients in extremis. He recommended introducing a small tube, “which should be of gold or ivory” into the external jugular vein, rather than the veins in the ante cubital fossa, because of its proximity to the superior vena cava and because of the reduced risk of air embolism. Later, O’Shaughnessy analysed the blood from a cholera patient and noted that, “It has lost a large proportion of its water .... it has lost also a great proportion of its neutral saline ingredients”. He also recorded that there were only 860 parts water in 1000 parts serum, but made no comment as what was considered normal. A reduction in the water content of blood in a cholera victim was also recorded by W R Clanny in Sunderland. His patient’s blood had a water content of only 644 parts per 1000 compared with 765 parts per 1000 in the blood of a sailor (presumably acting as a control). The patient also had an increased proportion of “colouring matter”. By 1832 O’Shaughnessy’s work had resulted in a “Report on the chemical pathology of malignant cholera”, which was published by the Central Board of Health. The reviewer in the Lancet commented that for the treatment of the most severe cases, “the author recommends the injection into the veins of tepid water, holding a solution of the normal salts of the blood; his experiments having, we presume, led him to abandon his former ideas respecting the superiority of highly oxygenated salts for this purpose”.