372 SELLARDS. 



four hour specimen measuring 370 cubic centimeters. On the second 

 day after the first test, an intravenous injection of 1,000 cubic centi- 

 meters of a 1.5 per cent sodium bicarbonate solution was given according 

 to the routine used in the cholera cases. Only one alkaline specimen of 

 urine was obtained, and this was the first sample voided after the 

 injection. The acid reaction of the urine returned within two hours 

 after the injection and all succeeding specimens for the next twenty-four 

 hours had an acid reaction. The total volume of urine for the next 

 twenty-four hours increased to 600 cubic centimeters. 



While these results are by no means conclusive, yet they might 

 suggest that tolerance was most likely to occur in those cases of nephritis 

 where suppression of urine has developed. 



CLINICAL SIGNS OF ACID INTOXICATION. 



During the stage of reaction in cholera it is not uncommon to see 

 an almost abnormally bright color of the mucous membranes associated 

 with a type of dyspnoea approaching air-hunger. Such patients usually 

 have either a partial or complete suppression of urine and an increase 

 in the blood pressure which is sometimes as high as 200 millimeters 

 of mercury. In cholera, the symptoms of acid intoxication become so 

 intimately related to those of uraemia that differentiation is hardly 

 possible. Indeed it has been suggested by Senator (9) that uraemia 

 from any cause whatsoever is only an acid intoxication. 



INDICATIONS FOR TREATMENT. 



The symptoms which indicate an increased production of acid in 

 cholera are as follows : 



(1) The tolerance for alkalies is well marked; (2) the ammonia 

 coefficient is almost constantly increased; (3) clinically, there is a 

 stage in which many cases develop an abnormally bright color asso- 

 ciated' with dyspnoea; (4) as reported in the literature, the blood 

 shows a diminution in alkalinity. 



This evidence is hardly sufficient to constitute a proof of acid intoxica-- 

 tion. Perhaps the most important point is the increased tolerance 

 for alkalies. Even if we assume that the alkali injected is neutralized 

 in the body by acid, it does not necessarily follow that the acid existed 

 preformed in the body in sufficient quantity to effect neutralization. 

 However, in addition to this group of symptoms, the period of starva- 

 tion in cholera also offers a possible etiologic factor for the production 

 of acid intoxication. Although the period of starvation is relatively 

 short, amounting only to a few days, yet this means not only absolute 

 deprivation of food, but perhaps a' much greater tissue waste than 

 would occur in a normal individual when starved. 



There is another explanation depending upon a somewhat different 

 basis which should also be considered. Although alkalies are rapidly 

 excreted by the kidneys in normal individuals, yet the anuria of 



