364 SELLARDS. 



loss of large quantities of fluid " from the body gives rise to a con- 

 siderable mechanical disturbance in the circulation of the blood; it 

 has been suggested that this disturbance might be responsible for all 

 of the symptoms of cholera. However, there are fulminating cases of 

 cholera "sicca," where the loss of fluid is negligible ; also, the early relief 

 or prevention of the mechanical disturbance by the administration of 

 fluid to the body, often fails to control the disease. 



The principal evidence indicating serious metabolic disorder is the 

 rather high percentage of cases which die in uraemia, amounting in 

 some epidemics to 20 per cent (2). Consequently, the treatment of 

 this complication becomes second in importance only to the treatment 

 of collapse. The development of nephritis and uraemia may be de- 

 pendent both on the toxaemia and on the mechanical disturbance. Mild 

 cases of cholera, with insignificant loss of fluid, not infrequently de- 

 velop a fatal uraemia. Also, Czerny (3) has shown that when laboratory 

 animals are rapidly deprived of water, recovery takes place on the 

 restoration of fluid, but a temporary albuminuria develops. The fol- 

 lowing investigation will consider the possible relation between uraemia 

 and certain symptoms of acid intoxication occurring in Asiatic cholera. 



The material on which the following data are based consisted of a series 

 of cholera cases occurring almost exclusively among the Malay races in Manila 

 from September, 1909, to January, 1910, inclusive. The total number of cases 

 was distributed with fair uniformity throughout this period. The disease was 

 widely scattered over the city and outlying districts. There was apparently 

 no direct communication between the individual foci of infection, neither was 

 any common source of infection located. The outbreak was rather more endemic 

 than epidemic in character. Of the total of 340 cases, 147 were found dead by 

 the municipal medical inspectors and the remaining 193 were required by the 

 regulations of the Bureau of Health to be transferred to the San Lazaro Hospital. 

 Bacteriologic examination of all cases for the isolation of the cholera vibrio in 

 pure culture was performed by the biological laboratory of the Bureau of Science. 

 Only the cases where the injection of salt solution was indicated, 111 in number, 

 were studied in this investigation. It gives me much pleasure to acknowledge 

 the many courtesies of Dr. A. P. Goff, chief of the San Lazaro Hospital Division 

 of the Bureau of Health. 



2 The loss of fluid is measurable in liters. The desiccation of the tissues is 

 very general, but the effect on the blood is most noticeable. Rogers ( 1 ) found 

 that, instead of the corpuscles forming about 45 per cent of the total volume of 

 the blood, their volume may rise to as much as 60 to 80 per cent, and the 

 fluid content of the blood may be reduced as much as 64 per cent of the total. 

 The viscocity of the blood becomes so great that circulation through the capil- 

 laries is effected only with the greatest difficulty. This increased viscocity is 

 probably sufficient to account for the rapid pulse rate, even in the absence of 

 fever. With the continued loss of fluid, the blood pressure in the brachials 

 very commonly falls to zero and the peripheral arteries may remain pulseless 

 for many hours. 



