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Sheffield, South Yorkshire Asylum.—M.O. £400.Snrzethwiek, Cornwall TY’orlcs Dispensary.—M.O. £600.South London Ilospital for n’omen, Clapham Common, S.W.—

H.P. 100.Truro, Royal Cornwall Infirmary.—H.S. £170.University College Hospital, Gower-street, W.C.—Clin. Asst. for

Ear, Nose, and Throat Dept. House Amesthetist. £150.Also Hun. Ophthalmic S.

University College Hospital Medical School, University-street,W.C.—Asst. to Professor of Pathology. 500.

Wakefield, Middleton-in-Wharfedale Sanatorium, near Ilkley.-Res. Asst. M.O. £325.

West End Hospital for Nervous Diseases, 73. Welbeck-street, Tt’.-Hon. Registrar.

Western Australia Lunacy Dept.—Jun. A.M.O. £432.Western Ophthalmie Hospital, llcrrylebone-road, N.W.—Hon.

Aagt. S. 100 guineas.West London Hospital, Hammersmith-road, W.—H.P. and Two

H.S.’s. Each 100.Westminster Hospital.—Asst. -iNI.O. to Elec. Dept. £200.Wolverhampton and Midland Counties Eye Infirmory.—H.S. £200.The Chief Inspector of Factories, Home Office, London, S.W.,

announces the following’ vacant appointment : Walton-on-Xaze (Essex).

Births, Marriages, and Deaths.BIRTHS.

JEPSON.—On March 6th, at Longridge-road, Earl’s Court, S.W.,the wife of Dr. W. B. Jepson, M.C., of a daughter.

MEREDYTH JONES.—On March 2nd, 1923, at Croydon, to Muriel,the wife of C. Meredyth Jones, F.R.C.S.—a daughter.

PETTY.—On March 7th, at St. Mary Bourne, near Andover,Hants, the wife of Dr. David Petty, of a son.

RICHARDSON.—On March 10th, at Belgrave-road, S.W., thewife of Captain D. T. Richardson, M.C., R.A.M.C., of a son.

ROBERTS.—On March 10th, at Oak-road, Woolston, Southampton,the wife of Dr. P. M. Roberts, of a son.

WEBSTER.—On Feb. 24th, at Holcombe, near Bath, the wife ofFrancis Webster. L.R.C.P. & S.L, of a son.

DEATHS.DALTON.—On March 9th, at Fellows-road, Hampstead, Norman

Dalton, M.D., F.R.C.P., late Senior Physician to King’sCollege Hospital, aged 65. I

MEREDYTH JONES.—On March 9th, 1923, at Croydon, Muriel,the wife of C. Meredyth Jones, aged 27 years.

N.B.—A fee of 7s. 6d. is charged for the insertion of Wotices ofBirths, Marriages, and Deaths.

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Notes, Comments, and Abstracts.THE USE OF SALINE SOLUTIONS

INTRAVENOUSLY.*

By SiR W. M. BAYLISS, F.R.S.,PROFESSOR OF GENERAL PHYSIOLOGY, UNIVERSITY COLLEGE,

LONDON.

: As is indicated by the title of my remarks, they will belimited to the discussion of artificial solutions. It will,however, be necessary to refer incidentally to some propertiesin which they are comparable with blood as used for trans-fusion. We have first to remember that such artificialsolutions merely increase the volume of the blood incirculation without adding to its important constituents.We may ask: What, then, is their value ?To begin with the foundations of the problem. It is

scarcely necessary to point out that the tissues need acontinual supply of certain things which we call, in generalterms, " foods," of which the most vital is oxygen. This iscarried by the red blood corpuscles, and must be affordedat a certain minimal rate if the cells are to be preservedfrom the effects of want of oxygen. Thus, if the blood isdiluted, it must be sent at a faster rate to make up for thelower concentration in corpuscles. Now when the totalvolume of the blood is deficient the blood pressure is lowbecause the heart does not receive enough by the veins tosend on. Hence the tissues actually do suffer from want ofoxygen, although the blood may be of normal constitution.Looked at in another way-at the moment of systole theventricles contain a certain fraction of the whole blood ;hence, if this is smaller than the normal amount, theventricles can only propel in unit time less than they shoulddo. The amount flowing through any particular vascularregion is therefore diminished.When the volume of the blood is brought up to its normal

value by the addition of an indifferent fluid a much largervolume circulates. Although this diluted blood does notcontain so large a percentage of corpuscles as that whichwas circulating very slowly before the injection, it has beenfound by experiment that the greater rate of supply muchmore than compensates for the dilution. In other words,the number of corpuscles passing a particular cell in unittime is greatly increased and the supply of oxygen becomessufficient. This is briefly the justification for the use ofintravenous injections. The incidental rise of blood pressureis of subsidiary importance. Such a rise can be effected byadrenalin, but only at the cost of restricting the supply ofblood to the larger number of organs.An interesting question arises as to how far the decrease

of corpuscles can be effectively replaced in the way described.From experiments on animals it appears that the number ofcorpuscles in the body may be reduced by hæmorrhage toone-third or less. This would mean an enormous loss ofblood in man.

The Nature of the Solution Used.We may consider the nature of the solution to be used.

In theory, of course, blood itself seems the obvious thing toreplace blood which has been lost, except perhaps intraumatic shock without loss of blood, where the corpusclesare merely stationary in the capillaries until carried againinto the effective blood-stream. But in any case, blood isnot always available at a moment’s notice, and there arecases where prompt action is of vital importance. Physio-logical saline (0.9 per cent. sodium chloride in water) wasnaturally the first solution to be tried. It was known to beinnocuous, and had been found effective for isolated organsand for the preservation of blood corpuscles. But it wasfound useless for replacing lost blood in the whole organism.Measurements showed that it had disappeared from thecirculation in 2U to 30 minutes or less. Why is this thecase ? Here we cannot avoid referring to the difficultquestion of osmotic pressttre. With regard to the explanationof the way in which osmotic pressure is produced evenexperts are not agreed. Thus we must be content with abrief consideration of the facts. Suppose that we have abag of a material, such as parchment paper or collodion,which is pervious to water, but whose pores, althoughlarge enough to allow salts and sugar to pass through, aretoo small for the large particles of colloids, such as theproteins of the blood. Let us fill this sac with blood andimmerse it in water. The salts soon pass through andbecoming practically equal on both sides may be neglectedfor our present purpose. But the colloids remain inside.

This difference between iaside and outside causes in some! way the attraction of water to the interior. The force of this

* Lecture given at the Children’s Clinic, Marylebone-road,London, on March 6th. 1923.

576

attraction is proportional to the concentration of the colloidsand in normal blood is of the value of 35 to 40 mm. ofmercury pressure. This is known as the osmotic pressureof the blood colloids. If we put pressure on the contentsof the sac so as to try to force water out of the sac by filtra-tion, none will escape until the pressure applied exceeds theopposing osmotic pressure of the contents of the sac.The walls of the blood-vessels, in so far as we are concerned

with their permeability, have properties like those of parch-ment paper and normally do not allow passage to colloids.Hence the conditions are present for these colloids to exerttheir osmotic properties of attracting water with a certainforce. But in the arteries and the first part of the capillariesthe blood pressure is higher than this. There is accordinglyfiltration of fluid (= lymph). As we proceed towards theveins, the blood pressure diminishes and reaches a valuebelow that of the osmotic pressure of the blood colloids.Reabsorption begins here and most of the previous filtrateis taken back again. What remains is carried to thethoracic duct by the lymphatic vessels.We have seen that the value of the osmotic force is

proportional to the concentration of the colloids in the blood.Hence, if we dilute the blood by the addition of a solutionwhich contains no colloids, we reduce the force opposingfiltration and the blood has also to travel further along the Icapillaries before the blood pressure is reduced sufficientlyto allow reabsorption. Both causes combine to producean excessive filtration, which will continue until the bloodreturns to its normal osmotic pressure-that is, until theliquid injected has disappeared.

The obvious conclusion is that some colloid with anosmotic pressure equal to that of the blood colloids must beadded to our injection solution. What are the colloidswhich it is possible to use ? Serum proteins from foreignsources cause haemolysis and anaphylaxis. Gelatin serveswell, but is liable to contain tetanus spores and may causetrouble by setting to jelly in the tubes of the apparatus.On the other hand, gum arabic or acacia answers all require-ments. It is quite innocuous and in a concentration of6-5 to 7 per cent. in 0-9 per cent. sodium chloride has anosmotic pressure equal to that of the colloids of the blood.Its viscosity also is practically identical with that of theblood, although this is not of great importance. The salt isnecessary because the blood corpuscles and tissue cells areimpermeable to salts, hence their osmotic pressure must bebalanced. Such solutions have in practice been found tocause a permanent increase in the volume of the blood. Anessential point is that the gum must be good, in clearnearly colourless lumps, such as is sold as "Turkey elect."Powdered samples seem to be adulterated. At the instanceof the Medical Research Council, Messrs. Evans, Lescher,and Webb supply a sterilised solution ready for use. Messrs.Martindale prepare a concentrated solution for dilution asrequired. It is to be noted that the heating in an autoclavereduces the viscosity somewhat. Thus the rise of bloodpressure produced by a given volume is not so great as withthe full viscosity. But this may be an advantage, since itreduces the work of the heart.

The Indications for Intravettous Injection.Passing on to the conditions in which intravenous injection

may be of value, we may call to mind the several ways inwhich the volume of the blood in actual circulation may bereduced. By actual haemorrhage from wounds or post-partum ; by great loss of water from the intestine, as incholera, infantile diarrhoea, &c. ; by dilatation of thecapillaries and stasis therein, as in traumatic shock. Inoperations, haemorrhage and shock may combine and gumsaline should always be ready for use. It has been found ofmuch value in this way at the Women’s Hospital in NewYork. It is rather remarkable that it has the property ofrestoring the renal function in blackwater fever, probablyby raising the blood pressure. After haemorrhage the rateof formation of new blood corpuscles is hastened. It islikely that this depends on a due supply of blood to thebone marrow.

Certain objections have been made to gum saline. It issometimes ineffective, as in severe traumatic shock. In thisstate the capillaries have become permeable even to thecolloids of the blood and transfusion of blood itself is useless,as was found in the casualty clearing stations in the war.Experiments on animals suggest, however, that repeatedsmall doses may restore otherwise hopeless cases. When noblood has been lost, and the reduced volume is due tostasis in the capillaries, it would seem reasonable that afurther supply of corpuscles is not needed, provided thatthose in a stationary condition can be washed into thecirculation. So-called " chills " have been met with, butnot more frequently than with blood or simple saline.Agglutination of corpuscles occurs in the cat, but does notappear to be present in man. It is harmless, even in thecat-a deposit of agglutinated corpuscles can be injectedand is at once resuspended. There is no haemolysis.

Misstatements are often made. Prejudice attributesanything that happens after a gum infusion to its use. Acase came under my notice in which it was stated thatcapillary embolism had been produced by gum. On lookingup the notes of the autopsy, it was found that there wasnothing of the kind, and indeed nothing pathological thatcould be attributed to the gum. The possibility ofunpleasant feelings during recovery of the nerve centresfrom their anæmia is not to be overlooked. The indicationis to inject slowly.

In conclusion, an interesting physiological state may bereferred to in which neither blood nor gum saline causes morethan a brief rise in blood pressure. This is the low bloodpressure resulting from section of the spinal cord just belowthe bulb. No explanation has been found for the fact.

PUBLIC HEALTH IN CALCUTTA.*THE total population of the city of Calcutta was found to

be 896,067 at the census of 1911, males numbering 607,674and females 288,393 ; and on these figures the statisticsare calculated for 1920. Hindus numbered 606,382 andMohammedans 211,587, and of the remainder 27,659 werenon-Asiatics and Anglo-Indians. The general death-rate was39-3 per 1000 in 1920, being a slight improvement on that ofthe previous year (42.2), but considerably above that ofthe preceding quinquennium (30-8) ; for the three years,1918-20, the average was 38.8, as compared with 25-6 forthe previous three years-that is, since influenza sweptthrough the city in 1918 the ratio has risen by 50 per cent. ;Bombay and Madras, however, had higher ratios (46-80and 41-30 respectively). The medical officer of health, Dr.H. M. Crake, considers that the high ratio, especially from" all other causes," appears to be indirectly due to therepeated epidemics of influenza, and the resultant loweringof vitality and diminution in the power of resisting disease." All classes of the community, whether living in the slumswhich, in Lord Curzon’s famous phrase, ’skulk behind afringe of palaces,’ or in the ’palaces’ of the first-classresidential areas, suffered to a greater or less extent."Every ward in the city returned deaths greatly above theaverage. In the various wards the mortality ranged from15-4 per 1000 in Park-street, 18-2 in Bamun Bustee, and 20in Waterloo-street, to 54.3 in Entally and 76-8 in Kidder-pore. The death-rate among males was 33-8, while amongfemales it was 50-9. Hindus had a mortality of 41-4,Mohammedans 37-1, and "non-Asiatics and Anglo-Indians" 26-2 per 1000. Dr. Crake draws attention to the highfemale mortality between 15 and 40 years of age, as com-pared with that of males in the corresponding periods ; theratios for the year were, for males, 15-0, 17-6, and 22-4 per1000 for ages 15-20, 20-30, and 30-40 ; while for femalesthe corresponding ratios were 27-9, 28-9, and 30-8. Thechief diseases causing this excess female mortality weretuberculosis (3-6 per 1000), respiratory diseases (11-4),dysentery and diarrhoea (4-8), and malaria (2-0); thecorresponding male mortality ratios being 1-7, 7-9, 2-8, and12. This heavy incidence of tuberculosis among femalesis intimately associated with the purdah system : " in orderto secure privacy the zenana is inevitably the darkest andworst ventilated portion of the house, as it must be screenedfrom observation on all sides."The infantile mortality (386-0 per 1000 births) was

higher than in the previous year (357-8), and much in excessof the years immediately preceding, 249-1, 239-2, and 280-&in 1916-17-18; it was higher than in any year since 1902 ;but Dr. Crake considers that this increase is largely dueto defective birth registration in the last two years ; inFenwick Bazar Ward (No. 13) the birth-rate declined from6-8 in 1919 to 5-2 in 1920, the infantile mortality ratiorising from 450 to 786 per 1000 births ; in Bow Bazar Ward(No. 10) the birth-rate fell from 12-7 to 8-1, while themortality rose from 438 to 637 per 1000 births ; in CollingaWard (No. 15), where the birth-rate fell from 13-6 to 10-1,the mortality rose from 380 to 617 per 1000 births. " It isall very baffling, and it seems to be of very little use tryingto make any general deductions from these data." But itis clear that it is the urban wards that have the highestratios ; " babies have a very poor chance of surviving inthe slums of Bara Bazar." Of the total 5935 infantile-deaths, 1798 (30 per cent.) occurred during the first weekof existence ; the chief causes were debility at birth (854),premature birth (508), and tetanus neonatorum (335).From one week to one month there were 900 deaths (15 percent. of total), of which 436 were from tetanus. This isdue to " dirty midwifery," and is absolutely unknownamong cases attended by the municipal midwives. AmongMohammedans the infantile mortality was 449, and amongHindus 381 per 1000, the ratio for non-Asiatics and Anglo-Indians being 227, and the same for native Christians. Thehigh rate for Mohammedans is due to the purdah systemand to the neglect of medical attendance ; it is surprising

* Calcutta: Corporation Press, October, 1921.