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some cases for remarkably long periods, and this persistence was more commonly noted in children than in adults. One German patient took thirty-one days to become vibrio-free. The data relating to the value of inoculation against cholera are not extensive enough to allow any conclusions to be drawn. Bacteriological records are available on 500 of the 517 cases. Of these 500 cases 349 proved to be vibrio positive, 151 vibrio negative. Some of the vibrio positive cases were only found to be so on a second or third examination. That is to say, 61 per centum of all cases sent in as cholera were bacteriologically proved to be so, while 30 per centum never proved to be cholera. There is little doubt that most of the 30 per centum group were suffering from cholera because 48 per centum of this group died of the disease whereas 52 per centum recovered. Of the proved positive group 40 per centum recovered and 60 per centum died. The figures in tabular form are as follows:-
Table II.
Deaths Recoveries Vibrio-ve. Vibrio + ve. Vibrio-ve. Vibrio + ve. Male 46 145 57 80 Female 26 66 22 58 Total 72 211 79 1387. In a small group of 106 patients who stated definitely that they had not been inoculated, thirty-nine died and sixty-seven recovered. The mortality rate in this group was, therefore, 37 per centum. In a group of twenty-six patients who stated that they had been inoculated this year, only three died. The mortality rate here was 12 per centum. It is fair to say that the poor class Chinese did not avail themselves very widely of the facilities offered them for inoculation against cholera, and they are, of course, the people who suffer more than any other class from the disease. It was distinctly rare to find better class patients suffering from cholera.
8. The points on which most stress has to be laid in the treatment of cholera are these: the fluid loss must be made good as rapidly as possible and the toxaemia must be diminished by all available means. If the fluid loss be not made good at the earliest opportunity, then the suppression of urine which invariably occurs in the stage of collapse may readily develop into an anuria which will lead to a rapidly fatal issue. Suppression occurs when the blood pressure drops below 70 systolic, and it is therefore one of the aims of treatment to raise and to keep the blood pressure above that level. But if the restoration of the fluid loss be brought about too rapidly the result is apt to be equally fatal for this reason. Saline solution is being poured into the veins of a profoundly dehydrated and collapsed man. The viscosity of the patient's blood is about 1,004-1,070, his extremities are blue and cold, his rectal temperature 104°. The circulation in the walls of the intestine has been in abeyance, if not absolutely at any rate relatively, for many hours. The blood viscosity is rapidly reduced towards the normal figure by the infusion, the circulation is restored and the immediate result is the absorption of a possibly lethal dose of toxin from the small intestine. That this is the course of events is shown very clearly by a study of the half-hourly rectal temperatures taken during infusions. The rise of temperature is frequently sudden and if controlling measures are not to hand may cause disaster. Ice is very much more useful in cholera wards than hot water bottles. Truly did the early Anglo-Indian writers on the disease say that the reactionary stage was even more dangerous than that of collapse. Rogers quotes Calcutta figures to show that over a certain time period, no case of recovery was recorded in Europeans whose temperature rose above 103 in the stage of reaction. This statement is happily not true in Hong Kong if one considers the rectal and not the skin temperature. Of the five