Magic Carpet IV: Asiatic Cholera, IV Fluid Therapy, and Dr. Thomas Aitchison Latta

            In this edition of the Magic Carpet, Magic Carpet IV, we travel back to the early 1800s, 1831-1832 C.E. to be exact, to visit with Dr. Thomas Aitchison Latta, a physician who began clinical practice in 1822 in the town of Leith, which is located in the north of Edinburgh, Scotland. Importantly, Dr. Latta would succumb to consumption just 11 years later, on October 19th, 1833. [1,2] However, in this short period of time, Dr. Latta (and countless others in Great Brittain) would be confronted with unimaginable death and desperation caused by Asiatic cholera, and from this experience would demonstrate and publish on the successful use of IV fluid therapy and associated clinical observations relative to resuscitation that are as true today as they were then. A word of caution, given what was happening in Great Brittain at the time, and in Leith in particular, we will keep this trip short, and if you become thirsty, by all means, drink either BOILED water or beer, which can be purchased at The King’s Wark, which is located at 36 Shore, Leith, in a building first constructed in 1434. [3,4,5] Here we go…

            Though the arrival of Asiatic Cholera to Great Brittain in 1831 was not a surprise, it nonetheless landed first with a lethal vengeance in Sunderland, during the week of October 20th. According to Ashworth Underwood, Newcastle would be next, with the first cases documented on December 7th, 1831. Between December and the summer months of that year, over 1330 people in Newcastle would fall ill from Cholera of whom 801 would succumb (60% mortality).[6] It was at this time, that the Royal College of Surgeons of London would urgently dispatch an Irish physician, Dr. William Brooke O'Shaughnessy MD FRS to Newcastle to “study the blood of cholera victims.” [2] Dr. O'Shaughnessy reported the following findings: [7,8]

1. The blood drawn in the worst cases of the cholera is unchanged in its anatomical or globular structure.

2. It has lost a large proportion of its water, 1000 parts of cholera serum having but the average of 860 parts of water.

3. It has lost also a great proportion of its neutral saline ingredients.

4. Of the free alkali contained in healthy serum, not a particle is present in some cholera cases, and barely a trace in others.

5. Urea exists in cases where suppression of urine has been a marked symptom.

6. All the salts deficient in the blood, especially the carbonate of soda, are present in large quantities in the peculiar white dejected matters.

“…denoting a great but variable deficiency of water in the blood in four malignant cholera cases; a total absence of carbonate of soda in two; and a remarkable diminution of the other saline ingredients. Again in the dejections passed by one of the patients...we find preponderance of alkali, and we recover the other saline matters deficient in the blood.” [2,9]

Based on these findings, Dr. O'Shaughnessy suggested that, in the absence of understanding the cause of Cholera, supportive care should at least include:

“1st. To restore the blood to its natural specific gravity; 2nd. To restore its deficient saline matters. The first of these can only be affected by absorption, by imbibition, or by the injection of aqueous fluid into the veins. The same remarks...apply to the second.” [2,9]

In less than two months of publication, [10], Dr. Thomas Latta of Leith would recognize Dr. O’Shaughnessy for his work and bravely implement his published suggestions in an “aged female” who, in his estimation, was near death, as described in a letter to the Central Board of Health in London [2,10,11,12]:

“...finding thus, that such, in common with all the ordinary means in use [oral and colonic fluid administration], was either useless or hurtful, I at length resolved to throw the fluid [“two to three drachms of muriate of soda and two scruples of the subcarbonate of soda in six pints of water”]immediately into the circulation [using a Read’s patent syringe]. In this, having no precedent to direct me, I proceeded with much caution… 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 effect; 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 six pints had been injected she expressed in a firm voice that she was free from all uneasiness . . . her features 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.” [2,10,11,12]

Dr. Latta went on to publish additional observations based on the care of several more patients and detailed that IV fluid therapy was not a cure, that it required frequent administrations based on symptoms, that if the fluid was cold, the patient would both feel cold and experience rigors and if too warm the heart would become ‘excited’ and the “countenance flushed.” [10] Importantly, Dr. Latta noted that fluid therapy failed under the following clinical scenarios, which are as true today as they were then: [2,10]

1.     Too little fluid injected

2.     Fluid injected too late in the course of the disease

3.     The presence of extensive organic disease

Also true today, Dr. Latta’s exemplary work would be celebrated (and repeated) by many and rebuked by others. His observations regarding the physiologic response of volume responsive patients to fluid therapy were spot on, his descriptions of when fluid therapy didn’t work demonstrate that he was a keen observer and a brilliant clinician. Sadly, just about one year later, Dr. Latta would die of “Pulmonary Consumption” [Tuberculosis] on October 19th, 1833.

Before we leave Leith, let’s give special thanks to Dr. William Brooke O'Shaughnessy, Thomas Aitchison Latta, Dr. David Barry, Dr. William Russel, Professor Delpech of Montpellier, the members of the Royal College of Surgeons of London, the members of the London Central Board of Health, and undoubtedly many other physicians and lay people of the day, John Read, for their incredible contributions to medicine, surgery, pharmacology, and physiology, and of course the amazing individuals who have so well documented this history: A.H.B Masson, Neil MacGillivray, E. A Underwood, B.A. Foex, and authors N Barsoum and C Kleeman. Thank you all.

Dr. Latta, with every IV insertion, with every fluid challenge, with every physical assessment and measurement, with every [appropriate] fluid readministration you are remembered, honored, and celebrated.

I encourage you all to dive deeper into the incredible pioneering work of these individuals. Until next time….

References and Sources

[1] Masson AHB. Dr Thomas Latta. Book of the Old Edinburgh Club 1972; 33:143–49.

[2] MacGillivray N. Dr Latta of Leith: pioneer in the treatment of cholera by intravenous saline infusion. J R Coll Physicians Edinb. 2006 Mar;36(1):80-5. PMID: 17146955.

[3] The King’s Wark. https://www.thekingswarkpub.com

[4] Antmann FM, Flynn JM. When Beer is Safer than Water: Beer Availability and Mortality from Waterborne Illnesses. [Cited on May 30, 2024] Available from: https://spot.colorado.edu/~antmanf/AntmanFlynn-BeerWaterborneIllness.pdf

[5] The King’s Wark. https://www.tripadvisor.com/Restaurant_Review-g186525-d1775053-Reviews-The_King_s_Wark-Edinburgh_Scotland.html

[6] UNDERWOOD EA. The history of cholera in Great Britain. Proc R Soc Med. 1948 Mar;41(3):165-73. PMID: 18905493; PMCID: PMC2184374.

[7] O’Shaughnessy W.B. Experiments on the blood in cholera. Lancet. 1831;17:490. doi: 10.1016/S0140-6736(02)94389-8

[8] Nalin DR. The History of Intravenous and Oral Rehydration and Maintenance Therapy of Cholera and Non-Cholera Dehydrating Diarrheas: A Deconstruction of Translational Medicine: From Bench to Bedside? Trop Med Infect Dis. 2022 Mar 12;7(3):50. doi: 10.3390/tropicalmed7030050. PMID: 35324597; PMCID: PMC8949912.

[9] O’Shaughnessy WB. Report on the Chemical Pathology of the Malignant Cholera. London: Highley;1832;40.

[10] Masson A. Latta—pioneer in saline infusion. Br J Anaesth 1971;43:681–6

[11] (1831-32a). Malignant cholera: documents communicated by the Central Board of Health, London relative to the treatment of cholera by the copious injection of aqueous and fluids into the veins. Lancet, 2, 274.

[12] Letter from Dr Latta to the Secretary of the Central Board of Health, May 23, 1832, published in the Lancet 1832; 2:295.

-Foëx BA. How the cholera epidemic of 1831 resulted in a new technique for fluid resuscitation. Emerg Med J. 2003 Jul;20(4):316-8. doi: 10.1136/emj.20.4.316. PMID: 12835338; PMCID: PMC1726137.

-John Read’s Patented Enema Syringe. [Cited on June 1, 2024] Available from: https://upload.wikimedia.org/wikipedia/commons/a/a1/Read%27s_New_Patent_Improved_Lavement_Apparatus_%28IA_ReadsLavementApparatus1853%29.pdf

-Barsoum N, Kleeman C. Now and then, the history of parenteral fluid administration. Am J Nephrol. 2002 Jul;22(2-3):284-9. doi: 10.1159/000063775. PMID: 12097754.