TOLERANCE FOR ALKALIES IN ASIATIC CHOLERA. 379 



injected. The secretion of urine commenced promptly after the first 

 injection and continued until death. The blood-pressure, after the first 

 injection, fell from 140 to 115 millimeters of mercury. The color 

 continued very bright and the respirations were deep, but the rate was 

 normal. On the eleventh day of the disease, examinations of the stools 

 showed them to be free from vibrios. Death occurred four days later. 

 At autopsy the small intestine was found to be almost gangrenous. 

 There was no attempt at reparation of the intestine, the lower half of 

 the ileum being almost entirely denuded of the mucosa. In some areas, 

 only the muscularis and serous coats remained. 



The total duration of the disease in this patient is in marked contrast 

 with the series of cases treated with sodium chloride in which seven days 

 was the maximum course for the fatal cases. 



If the percentage of mortality is considered in this group, it must be 

 noted that four of the cases were almost moribund on admission. Oc- 

 casionally, the secretion of urine did not commence very promptly after 

 the injection of acetate. After secretion was established, the amount 

 voided was usually about normal, although the nitrogen output as judged 

 by the urea content was frequently rather low. However, some of the 

 cases with low urea output made very satisfactory recoveries. Although 

 in normal individuals acetates are oxidized almost completely to alkali, 

 yet it does not follow that cholera patients would effect the complete 

 oxidation of excessively large quantities of acetate. However, no acetate 

 could be detected in the urine by the ferric chloride or ethyl acetate 

 tests, although these reactions were rather unsatisfactory when applied 

 to urine. In three cases where the acetate was given in 80-gram quan- 

 tities, the distillation of the strongly acidified urine showed only a trace 

 of volatile acid. 



A third group of cases was studied, abandoning any attempt at a 

 routine for all patients. The general plan of treatment was to use 

 sodium chloride solution for the stage of collapse, starting the sodium 

 bicarbonate as soon as the stage of reaction commenced. The bicarbonate 

 was used when indicated for patients who did not go into collapse, its 

 indication being judged by the dyspnoea, the flushing of the cheeks and 

 mucous membranes, the suppression of urine and the rise of blood 

 pressure. For those cases where the loss of fluid- was moderate and it 

 seemed probable that only one or two injections would be required, the 

 bicarbonate was used for the first injection. 



In addition to the oases recorded in Table VII, there were also five other cases 

 which were placed in the bicarbonate series on admission. These died under 

 sodium chloride treatment before the stage of reaction was reached; consequently 

 they received no alkali, as there was no definite indication for its use. In the 

 outline which follows later, these five cases are included with the number of 

 deaths from collapse occurring under alkaline treatment, for otherwise the alkali 

 series would represent selected cases. 

 98151 2 



