1 02 ROGERS. 



The above observations show the imperative necessity of replacing the 

 lost ?alts as well as the fluid, for in the severest cases of cholera over 

 two-thirds of the chlorides have been lost from the blood, and presumably 

 nearly a similar amount from the tissues. This can most rapidly be 

 done by the use of hypertonic intravenous saline injections, although in 

 mild cases, with still a fair pulse and infrequent stools, the solution may 

 be administered by the bowel. The transfusions were carried out by. 

 Captain Maxwell Mackelvie, Indian Medical Service, to whom I am ex- 

 tremely indebted for trying my plan.^ 



QUANTITY OF FLUID REQUIRED. 



By estimating the percentages of serum and corpuscles with the 

 hsemocrite and taking the specific gravity of the blood, both before and 

 after intravenous transfusion, the effect of the introduction of different 

 quantities of saline solution, to replace the fluid already lost, can be 

 ascertained. The object to be aimed at is to dilute the blood to at least 

 its normal condition, or preferably a little below this, in order to allow for 

 any later concentration caused by further diarrhoea, and to replace the 

 fluid and salts lost from the tissues. In cases requiring transfusion my 

 observations show that from three to four pints are required for this 

 purpose; usually the larger amount is necessary. Occasionally the 

 injection of still further quantities is indicated, but rarely at one time. 

 The amounts above mentioned have occasionally to be repeated on the 

 following day if diarrhoea has persisted, but this is not very often the case 

 when hypertonic solutions have been employed. Eigors and a rise of 

 temperature not infrequently follow the injections, but do not appear to 

 be harmful. Such large amounts as three or four pints can not be given 

 very conveniently subcutaneously in cholera, and if no pulse at all can 

 be felt at the wrist, they are sometimes not absorbed. Moreover, with the 

 utmost care abscesses too often follow, owing to the great lowering of the 

 vital resistance of the tissues in this disease. The intravenous injections 

 require a fair amount of skill owing to the collapsed state of the vessels, 

 while great watchfulness is necessary to avoid such dangers as the entry 

 of air. Therefore under Indian conditions their use is frequently not 

 feasible. Again, when the epidemic has appeared unexpectedly and has 

 become widely prevalent it is generally impossible to find time to 

 administer large intravenous injections to all the patients who require 

 them since at least half an hour is necessary for each treatment. Under 

 such circumstances a more simple and rapidly performed method of 

 replacing the loss of fluid would render the use of hypertonic solutions 

 a much more practicable and generally available life saving treatment 

 in cholera. 



'Indian Med. Oaz., (1908), 43, 165. 



