TOLERANCE FOR ALKALIES IN ASIATIC CHOLERA. 373 



cholera may permit their retention for a longer or shorter period and 

 thereby possibly give rise to opportunities for the formation of alkali 

 albumen. If we assume, for example, that alkali albumen is formed 

 during a period of anuria, then even after the secretion of urine has 

 commenced, any additional alkali which might be injected could be 

 neutralized in the body by the acid properties of the alkali albumen 

 already formed. The conditions bearing upon the possibility of the 

 formation of alkali albumen were as follows: The concentrations of 

 bicarbonate before injection varied from 1 to 2 per cent. Estimating 

 the quantity of the blood as one-twentieth of the body weight in cholera 

 patients, the maximum concentration of alkali after injection would 

 be about 0.8 per cent. In certain cases where the loss of fluid had 

 been replaced by sodium chloride solution, the quantity of blood may 

 be estimated as normal, and. the minimum concentration calculated for 

 the 1 per cent solution of bicarbonte would be about 0.3 per cent after 

 injection. The duration of the period of anuria was rather long in 

 some instances, for example, fifty and forty hours in numbers 23 and 

 51, Table II. On the other hand, several cases which showed a definite 

 tolerance were excreting rather freely, for example, numbers 54 and 

 56 in Table II. Hence, it is hardly probable that the formation of 

 alkali albumen could be the sole factor in explaining the differences 

 between the control individuals and the cholera cases. 



Lastly, it may be noted that the condition known as acid intoxication 

 is but imperfectly understood and that there is no standard method 

 for its diagnosis. 



The essential feature to be determined in regard to treatment, is 

 whether this apparent tendency toward acid intoxication is a protective 

 mechanism which should be encouraged, or whether it is a deleterious 

 condition which should be opposed. During the intense cyanosis of 

 collapse, the use of alkalies, theoretically, has relatively little value. 

 On the other hand, the stage of reaction constitutes an entirely different 

 condition. In the administration of alkalies the principal points to 

 be determined are, namely : ( 1 ) How early does the tolerance for 

 alkalies develop and at what stage should their administration be com- 

 menced? (2) In what form should alkali be employed and in what 

 amount may it be used ? 



The symptoms of acid intoxication become more pronounced as the 

 disease progresses. The tolerance for alkalies apparently did not reach 

 its height before the third or fourth day. The ammonia coefficient 

 was usually not excessively increased during the first and second day. 

 During collapse there was intense cyanosis and the bright, flushed color 

 did not appear until patients were well along in the stage of reaction. 

 As to the period at which the administration of alkalies must be begun 

 in order to prevent the appearance of acid intoxication, this must be 

 determined by more or less empiric methods. 



