TREATMENT OF CHOLERA. 101 



acknowledged failure of this promising plan of treatment in materially 

 reducing the death rate from cholera, in spite of the miraculous, but 

 very temporary, improvement resulting from it. 



I have also tried large and repeated intravenous injections of normal 

 saline solution (1 drachm to the pint or 0.65 per cent jSTaCl) controlling 

 the amounts injected by their effect in raising the blood pressure to about 

 the normal, but with the same want of success which has baffled all 

 previous workers on the same lines. It then occurred to me that the 

 desideratum to be aimed at was to raise or maintain a high salt content 

 in the circulating blood which might be effected by using hypertonic saline 

 solution. On rapidly increasing the strength to double that formerly 

 used (2 drachms of sodium chloride to the pint, or 1.35 per cent, to 

 which 3 grains of calcium chloride may be added) a most gratifying 

 degree of success was obtained. At the end of a year, in spite of epi- 

 demic prevalence, such as is usually accompanied by an exceptionally high 

 mortality, the death rate at the Calcutta Medical College Hospital during 

 1908 has been reduced from an average of 61 per cent during the four 

 previous years before transfusion was commonly employed to 32.5 per 

 cent in 186 recent cases, or to barely one-half of the average death rate 

 before hypertonic transfusion was used. In the course of the outbreak 

 I have made a number of estimations of the total percentage of chlorides 

 in the blood, with very instructive results. The patients were almost all 

 Bengalis, in whom Captain D. McCay, Indian Medical Service, has shown 

 that chlorides are higher than in Europeans, namely, nearly 1.0 per cent. 

 This fact must be borne in mind in considering the results, which showed 

 that in the worst cases of cholera, the chlorides of the blood are nearly 

 always actually below the normal, having averaged only 0.79 in the fatal 

 ones, and 0.9 in the recovering ones including those treated with hyper- 

 tonic solutions. Further, if the chlorides are raised to 1.0 per cent or 

 over, recovery from the collapse stage almost always ensues. In several 

 cases less than 0.7 per cent was found, and in some of these the blood was 

 actually commencing to haemolise, the serum after centrifuging being 

 stained with dissolved hgemoglobin. In one instance haemorrhages were 

 also found in the mucous membrane of the cascum at the post-mortem 

 examination. On examining the blood immediately after raising the 

 salt content by hypertonic transfusion, the serum was found to be quite 

 clear. In the cases which proved fatal from collapse, in spite of transfu- 

 sion, the chlorides after the injection were still below 1.0 per cent and this 

 was true in all cases except one, an old man who apparently died of lieart 

 failure. 



The great reduction of chlorides in the blood in the worst cases of 

 cholera, is doubtless associated with the presence of these salts in con- 

 siderable quantities in the rice water stools, as pointed out long ago by 

 Edmund Parkes. I also have found them commonly to contain as 

 much as 0.5 per cent of chlorides and sometimes even more. 



