M 97
European cases which occurred in this epidemic, one died of anuria and right-sided cardiac failure, the other four recovered, one after a stormy illness in which his rectal temperature rose to 104° on several occasions.
9. It is difficult on occasion to decide whether to restore the lost fluid rapidly, to preserve renal function and to kill the patient rapidly by inducing hyperpyrexia or to give salines slowly and watch the patient perish before he gets out of the collapse stage.
10. A happy mean must be struck and scrupulous observation of the patient's reactions to every infusion must be made. Both skin and rectal temperatures should be plotted throughout the disease, the skin temperature being taken in the axilla as the mouth is useless for this purpose in cholera. The gap between these two temperatures on admission serves as a rough guide to the degree of toxaemia which already exists, and the severity of the febrile reaction to each infusion gives a rough measure of the body's success or failure in combating this toxaemia.
11. Kaolin and permanganate have both been given by mouth as a routine during this epidemic. Their efficacy remains in doubt. 1/100 gr. of atropine sulphate was also given as a routine measure to all cases on admission. It seems that this does help to diminish the incidence of pulmonary oedema, a complication which can be induced only too readily by too rapid infusion of saline.
12. Theoretically it would seem that hypertonic saline was contraindicated because it could only induce a greater flow of fluid from the gut into the blood stream. This would mean that even more toxin would be absorbed and the subsequent reaction would be a violent one. Admittedly, whatever solution is used, there would be some increased absorption from the gut; but as it is desirable to reduce this to a minimum normal saline was chosen as the routine infusion.
13. Until a bacteriologically verified series of the same size has been observed and treated with hypertonic saline, it would be premature to compare the two methods. While it must be readily admitted that the mortality in Hong Kong does not approach Roger's Calcutta figures, it is pertinent to observe that a scrutiny of the 1938 Indian cholera figures shows beyond a peradventure that the mortality rate of cholera in India today is just what it is in the rest of the world, namely 50 per centum. Shanghai is, of course, exempted from this generalisation. It is felt that not even India, has yet claimed a mortality rate of 7 per centum.
P. B. Wilkinson, M.R.C.S., L.R.C.P. (Lon.), M.B., B.S. (Lon.), M.R.C.P. (Lon.), Medical Officer.
Note. The average monthly percentage humidity in Hong Kong in 1938 varied little from 77 in January to 85 in March, 80 or above until September then falling to a minimum of 67 in November and rising to 76 in December.
There was no obvious correlation between the percentage humidity and the monthly incidence of cholera.
The average maximum temperature readings rose from 66°F in January-with a slight transient fall to 63°F in February--to 83.5°F at the commencement of the outbreak in May reaching a peak (89°F) in June and then gradually falling below 80°F in November and to 70°F in December.
The fastigium of the outbreak in 1938 occurred in July, after the temperature curve had reached its maximum for the year in the previous month; but the incidence fell rapidly in spite of the fact that both temperature and humidity showed inappreciable change until November.
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M 97
European cases which occurred in this epidemic, one died of anuria and right-sided cardiac failure, the other four recovered, one after a stormy illness in which his rectal temperature rose to 104° on several occasions.
9. It is difficult on occasion to decide whether to restore the lost fluid rapidly, to preserve renal function and to kill the patient rapidly by inducing hyperpyrexia or to give salines slowly and watch the patient perish before he gets out of the collapse stage.
10. A happy mean must be struck and scrupulous observation of the patient's reactions to every infusion must be made. Both skin and rectal temperatures should be plotted throughout the disease, the skin temperature being taken in the axilla as the mouth is useless for this purpose in cholera. The gap between these two temperatures on admission serves as a rough guide to the degree of toxaemia which already exists, and the severity of the febrile reaction to each infusion gives a rough measure of the body's success or failure in combating this toxaemia.
11. Kaolin and permanganate have both been given by mouth as a routine during this epidemic. Their efficacy remains in doubt. 1/100 gr. of atropine sulphate was also given as a routine measure to all cases on admission. It seems that this does help to diminish the incidence of pulmonary oedema, a complication which can be induced only too readily by too rapid infusion of saline.
12.
Theoretically it would seem that hypertonic saline was contraindicated because it could only induce a greater flow of fluid from the gut into the blood stream. This would mean that even more toxin would be absorbed and the subsequent reaction would be a violent one. Admittedly, whatever solution is used, there would be some increased absorption from the gut; but as it is desirable to reduce this to a minimum normal saline was chosen as the routine infusion.
13. Until a bacteriologically verified series of the same size has been observed and treated with hypertonic saline, it would be premature to compare the two methods. While it must be readily admitted that the mortality in Hong Kong does not approach Roger's Calcutta figures, it is pertinent to observe that a scrutiny of the 1938 Indian cholera figures shows beyond a peradventure that the mortality rate of cholera in India today is just what it is in the rest of the world, namely 50 per centum. Shanghai is, of course, exempted from this generalisation. It is felt that not even India, has yet claimed a mortality rate of 7 per centum.
P. B. Wilkinson, M.R.C.S., L.R.C.P. (Lon.), M.B., B.S. (Lon.), M.R.C.r. (Lon.), Medical Officer.
Note. The average monthly percentage humidity in Hong Kong in 1938 varied little from 77 in January to 85 in March, 80 or above until September then falling to a minimum of 67 in November and rising to 76 in December.
There was no obvious correlation between the percentage humidity and the monthly incidence of cholera.
The average maximum temperature readings rose from 66°F in January-with a slight transient fall to 63°F in February--to 83.5°F at the commencement of the outbreak in May reaching a peak (89°F) in June and then gradually falling below 80 F in November and to 70°F in December.
The fastigium of the outbreak in 1938 occurred in July, after the temperature curve had reached its maximum for the year in the previous month; but the incidence fell rapidly in spite of the fact that both temperature and humidity showed inappreciable change until November.
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