388 SELLARDS. 



CONCLUSIONS CONCERNING TBEATMENT. 



The behavior of these various groups of cases has led to the following 

 conclusions : 



1. The choice of alkali for treatment may vary somewhat in the 

 different stages of cholera. The chief advantage of the normal carbonate 

 would depend upon its ability to absorb carbon dioxide, but apparently 

 few deaths occur primarily from failure of the internal respiration. 



2. Sodium, acetate may have some advantages, especially for the stage 

 of collapse. As much as 80 grams within twenty-four hours have been 

 injected, but perhaps this amount is slightly excessive in certain cases. 



3. As a general routine, sodium bicarbonate has been the most effective 

 of the three salts. Its administration in collapse has several advantages 

 and, in selected cases, concentrations of 1 or 1.5 per cent may be used. 

 A weaker solution could probably be chosen which would be suitable for 

 routine use in all cases of collapse. Early in the stage of reaction, at least 

 as much . as 60 grams may readily be given within twenty-four hours. 

 The most important indication for discontinuing its administration is 

 the development of muscular cramps or twitchings. These symptoms 

 may appear, although the urine remains acid, and may be considered as 

 a reaction to the alkali. Several cases in which excessive amounts of 

 alkali were tolerated without the appearance of this symptom, terminated 

 unfavorably. There was a wide variation in' the amount of alkali which 

 resulted in the production of' muscular contractions. The quantity ap- 

 parently varied in direct proportion to the severity of the disease although 

 Loeb (16) has shown that the precipitation of the calcium salts by 

 carbonates gives rise to muscular contractions. If administration of 

 alkalies is delayed until uraemic symptoms develop, secretion of urine 

 follows promptly after injection of sodium bicarbonate, but the final 

 termination is usually unaltered. 



4. In no case was the urine kept constantly alkaline. Indeed, in the 

 majority of cases an alkaline reaction was never obtained, and it is 

 difficult to conjecture what the effect might be of maintaining a constantly 

 alkaline urine throughout the course of the disease. 



5. The most important single factor in determining the amount and 

 frequency with which alkali should be injected is the quantity of urine 

 excreted. Sodium bicarbonate in 1.5 per cent solution in 2-liter quan- 

 tities has been injected as soon as patients come out of collapse and 

 repeated at twelve to twenty-four hour intervals until a free secretion 

 of urine follows. Aside from mild convulsions, the only other untoward 

 symptoms following the injection of alkali was a temporary hematuria. 

 This occurred in 3 of the 55 cases. It was slight in amount and 

 persisted for from two to four days. 



6. In comparing the two groups of cases, namely, those treated 



