1908.] Composition of the Blood in Cholera. 293 



On thinking over the causes of this comparative failure, the following 

 possible explanation occurred to me. The great loss of fluid through the 

 stomach and bowels produces a concentration of the blood, which might be 

 expected to increase the proportion of salts it contains, and therefore present 

 a greater osmotic resistance to further draining off of fluid through the 

 damaged intestinal mucous membrane. Thus, a conservative process, tending 

 to check the diarrhoea, would come into action, which would be interfered 

 with by the injection into the blood stream of large quantities of normal salt 

 solution of lower salt content than the now concentrated hypertonic blood- 

 serum. The drain through the bowel would therefore be restarted, and the 

 restored fluid and blood-pressure rapidly lost again, as is so commonly seen in 

 actual practice. If this view is correct, the indication would be to inject 

 hypertonic salt solutions, so as to supply sufficient fluid to restore the 

 circulation, and at the same time maintain the conservative beneficial 

 hypertonicity of the blood, which would tend to carry more fluid into the 

 circulation, instead of removing it through the damaged bowel wall. In 1907 

 I had an opportunity of discussing this point with both Sir Lauder Brunton, 

 73art., F.E.S., and Prof. Buckmaster, who were of the opinion that moderately 

 Hypertonic salt solutions might safely be injected intravenously. 



The unusually great prevalence of cholera during the first half of 1908 in 

 Calcutta furnished abundant opportunities for testing the value of intravenous 

 transfusions of hypertonic salt solutions, for a trial of which I am greatly 

 indebted to Captain Maxwell Mackelvie, I.M.S., who had in the meantime 

 succeeded to the charge of the cholera wards. At first, 0'95-per-cent. sodium 

 chloride solution was tried, and, as the results appeared to be distinctly 

 more favourable than with the previously used 0'65-per-cent. one, it was soon 

 raised to l - 35, or 2 drachms to the pint. The quantities injected were also 

 raised by Captain Mackelvie to 3 or 4 pints at a time. In a note (3) published 

 in the ' Indian Medical Gazette ' in May, 1908, we recorded the results in 

 72 consecutive cases, in which transfusion with the above strength was used 

 in all who required it, with a mortality of only 27'8 per cent:, as compared 

 with an average during the five years preceding the revival of transfusion at 

 the hospital of 61 - 2 per cent. Moreover, at a neighbouring hospital, during 

 the same period as our cases were treated, the mortality was just twice as 

 great, intravenous injections not being used there, although their previous 

 mortality during a series of years was practically the same as at the Medical 

 College Hospital, namely, 63 against 61 per cent. At the present time our 

 cases number 175, with a death-rate of 33 per cent., including moribund and 

 complicated ones, which is but a very little over half that of the pre- 

 transfusion period, although the mortality is always exceptionally high in 



