Water and Electrolyte Studies in Cholera *

Abstract

Rational treatment of cholera cannot be provided without precise knowledge of the water and electrolyte losses which occur in this disease; such information is not available in the literature. Studies prior to 1900 usually reported electrolyte concentrations in whole blood, not in plasma, and sodium and chloride were frequently reported as NaCl. Since 1900 there have been many reports of electrolyte concentrations in plasma or fecal excreta but only one preliminary report (1) relates fecal losses to plasma levels in the same patient. However, this report suffers, as do all others on cholera, from the fact that oral intake was not restricted and it is not certain to what extent fecal electrolytes had been diluted with oral fluids.The 1958 cholera epidemic in Bangkok, Thailand, provided the opportunity to perform quantitative, volumetric studies of water and electrolytes in plasma, feces and urine for the first 24 hours after admission in patients suffering from cholera. During this period oral food and fluids were withheld and the dehydration and acidosis were treated by intravenous fluids. The effect of water and sodium loading on electrolyte exchange was also observed and whole blood and plasma analyses were repeated on each patient in convalescence. MATERIALSTwenty-five patients with diarrhea were admitted to a study ward provided by the Chulalongkorn University Medical School at the Bangkok Red Cross Society Hos-* The opinions and assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. Care was taken to avoid spillage of feces. A large bore rectal tube was used for the first 24 hours in addition to a cholera bed in which the patients' buttocks were placed over an opening in the bed frame and excreta collected in five gallon containers. Retention catheters were placed in the bladder for the first 24 hours to facilitate urine collection. Urine and feces were measured in graduated cylinders to the nearest 5 ml. Aliquots of fecal material were filtered through glass wool and a Seitz filter. Blood samples were heparinized and the plasma separated immediately after a sample for duplicate hematocrits and whole blood specific gravities had been obtained. Fecal specimens and blood for plasma CO2 content were collected under oil and analyzed within 20 minutes. During the first 24 hours of observation and treatment, patients were given nothing by mouth with the exception of four who were given carmine dye with 100 ml. of water in order to measure bowel transit time. After 24 hours, fluids were given ad libitum and a diet of rice gruel, boiled eggs and milk was allowed. All patients received an antibiotic, either chloramphenicol or a tetracycline derivative, after the 24 hour observation period and had at least one cholera-negative stool culture prior to discharge. Patients 13 and 18 probably had cholera but repeated attempts to culture the V. comma were unsuccessful.1879

The Nephrology Quiz and Questionnaire

“…Notwithstanding, our patient (and many others like him [1]) has normal arterial pH, Pco 2 and plasma HCO 3 Ϫ concentration (P HCO3 ). Question 1A.…”

“…The normal value largely is due to the net negative charge on plasma albumin. Because he has the same amount of albumin, which now is contained in less than half the plasma volume, he will have approximately twice the albumin concentration in plasma (1). This alone should more than double the contribution of the anionic charge on albumin to the plasma anion gap.…”

Some Observations on the Clinical Approach to Metabolic Acidosis

“…Similarly, the presence of a severe degree of metabolic acidosis was missed in patients with massive diarrhea as a result of cholera, because the P HCO3 was in the near-normal range. 5 Again, this error was revealed by calculation of the content of HCO 3 Ϫ in the ECF compartment. 6 Failure to recognize the presence of metabolic acidosis led to a severe degree of acidemia when the ECFV was re-expanded with a solution that did not contain HCO 3 Ϫ 7 or one of its precursors, organic anions that undergo metabolism to neutral end products.…”

Post-genomic challenges for collaborative research in infectious diseases

“…Only when similar studies were performed at the site of an epidemic in Asia did it come to light that Virchow's specimens had deteriorated in transit and that the cholera bacillus did not damage the mucosa 30 . Analysing the composition of rice-water stools at an epidemic site in Thailand in the 1950s was the first step towards understanding the need to replace electrolytes during a bout of cholera, and paved the way for the simple but effective rehydration protocols that are used today 31 . Thus, the value of "taking science to where the diarrhoea is" (ReF.…”