ACID INTOXICATION IN ASIATIC CHOLERA. 67 



In connection with, these carbon dioxide determinations of the blood, 

 it is interesting to note that Wittstock ( 5 ) has reported a decrease in 

 the absorption of oxygen by the lungs and a decreased output of carbon 

 dioxide in cholera. 



EFFECT OF ALKALINE SOLUTIONS. 



The results of alkaline therapy in diabetes have been of some value 

 in the study of acid intoxication. Perhaps the simplest interpretation 

 of these results is that, although an excessive amount of acid is usually 

 present^ yet it is probably not the sole aetiologic factor in the produc- _ 

 tion of coma. The conditions in cholera in some respects are unusually 

 favorable for observing the action of alkalies. For the most part, the 

 patients are obtained after only a few hours of illness and before any 

 symptoms of acid intoxication are present. 



It has already been found that alkalies in large quantities produce 

 a prompt excretion of urine in the stage of reaction. The most desir- 

 able period at which to commence the injection of alkalies and the 

 most suitable concentrations were not definitely determined and there- 

 fore these questions have been given especial consideration in the fol- 

 lowing group of cases. In the main, two procedures suggest them- 

 selves. An apparently satisfactory plan would consist in the use of 

 salt solution during the stage of collapse, followed by alkali in case 

 the anuria persists during the stage of reaction. This has the disad- 

 vantage of requiring a considerable increase in the amount of fluid 

 injected. For example, a patient receiving 5 to 10 liters of salt solu- 

 tion during the first day of collapse may require perhaps an additional 

 five liters of alkali to start the excretion of urine. There are also certain 

 theoretical objections to delaying the injection of alkali until the toler- 

 ance toward it has become well established. Such a delay would tend 

 to favor the production of ammonium salts in the body. The toxicity 

 of these salts in acid intoxication has been suggested by MendeK^) 

 and by Carlson and Jacobson. (7) Furthermore, if acids are allowed 

 to accumulate, they may produce a permanent injurjr to the tissues 

 which can not be remedied by the removal of the acids by neutraliza- 

 tion. This suggestion has l)een offered in explanation of the merely 

 temporary improvement after the use of alkalies in diabetic coma. A 

 somewhat analogous condition may occur in cholera. It was noted in 

 the ursemic stage, that the late administration of alkalies would cause 

 a prompt excretion of urine and apparently prolong life for several 

 days, although death ultimately took place. The free diuresis, fol- 

 lowing the bicarbonate injections when the stage of reaction appears, 

 would afford better opportunities for elimination than could be effected 

 bv the intestinal tract alone. 



