Asiatic Cholera is believed to be the purest type of an infection whose serms are borne by drinking water and hence, also by accidental contamination of food. In respect to mode of conveyance, it is commonly associated only with typhoid but it is probable that dysentery of both amoebic and bacillar types should be placed in the same category. On the other hand, it is not unlikely that, with greater opportunity for study, cholera will prove to be conveyed to a considerable degree by flies, dust and direct contact.

Prophylaxis includes personal cleanliness, especially with regard to the hands when eating after contact with patients or fornites but. especially, the avoidance of all raw food and unboiled drink, during an epidemic. The water used for washing dishes and food and even that used for personal cleanliness, should have been boiled.

As the cholera spirilla (comma bacilli) are unfavorably influenced by acid media, lemonade, especially reinforced with hydrochloric, sulphuric or phosphoric acid, lime juice, vinegar, sour pickles etc., may be used quite freely but not in sufficient quantities or at improper times, so as to disturb digestion. All forms of indigestion should be avoided, gastric subacidity especially should be treated with dilute hydrochloric or phosphoric acid and rich, indigestible food should be avoided. It is often taught that anything liable to cause diarrhoea favors the development of cholera but it is doubtful whether there is any special tendency in this direction.

During the first period of premonitory diarrhoea, it is probably best to abstain altogether from nourishment, though acid drinks, especially aromatic sulphuric acid, are indicated. If there seems to be special indication to nourish, light broths, meat extracts, gruels, whey with hydrochloric acid, buttermilk and milk partially predigested by adding hydrochloric acid rather than by pancreatic alkaline predigestion, should be used.

In the second stage of serous diarrhoea, nourishment by either the mouth or rectum is out of the question. Cracked ice, lime water, champagne, Vichy and other carbonated waters may be given, also clear coffee or tea as a stimulant, and the acid drinks may be continued. Inunction and hypodermic nutrition may be employed.

In the third or algid stage, hot saline enemata may be employed, if they can be retained even for a few minutes, but hypo-dermoclysis and, theoretically, the author's method of adding dextrose to the salt solution, is the mainstay.

In the reactionary stage, rectal alimentation may be used if the bowel is retentive and feeding by mouth may be gradually resumed, at first using teaspoonful doses of peptonized milk, beef juice, koumiss, with or without alcoholics, as thought best. The diet appropriate for typhoid may be instituted after a week or so, then that suitable for convalescence from typhoid, but the return to full diet should be very gradual, often covering a period of a month or more.

Cholera Nostras

There is considerable bacteriologic evidence especially in the line of agglutination experiments, to indicate that cholera nostras, particularly affecting infants (Cholera Infantum is not strictly a distinct disease), is due to the infection of the small intestine rather than the large, with dysentery bacilli, at least of one strain. On the other hand, the identification of bacteria by morphologic and chemic tests, even by agglutination, is liable to fallacies, and it seems inexplicable that specific dysenteric infection should occur so commonly in this clinical type without the occurrence, at least with considerable frequency, of typic dysentery. At any rate, cholera nostras, including cholera infantum, whether specific or not, is due to increased germ life in the intestine.

Hence the prophylaxis includes the avoidance of tainted foods, the boiling of water, pasteurization or sterilization of milk 20 and the limitation of the diet to the standard ration of easily digested foods, thoroughly sterilized by recent cooking, excepting for the use of such fresh fruits and vegetables, in moderate quantities, as are least likely to be sources of infection. The disturb-ance of digestion by irregular use of soft drinks, and especially the use of ice cream, milk shakes etc., should be avoided, and even ice water may inhibit digestion, allow saprophytosis to gain the ascendancy and start a diarrhoea.

In the case of infants, breast feeding, under aseptic precautions, as previously discussed, is the best prophylactic of cholera infantum and weaning should be anticipated or delayed so as to avoid a change to cow's milk during the hot months. The great majority of cases of cholera infantum occur in artificially reared infants and especially those of the slums, in which gross dietetic errors, milk originally tainted or in which delay and lack of refrigeration, have allowed bacteria to multiply, and the use of improperly sterilized bottles and long feeding tubes, favor alimentary saprophytosis.

In every case of cholera nostras developing in a previously vigorous individual, with due allowance for extremes of age, the plain indication is to stop feeding and to purge the bowels, usually with divided doses of calomel followed by a saline. In infants, castor oil is often preferable, and many physicians prefer it also for adults. Lavage of the lower bowel also expedites the process of disinfection which, of course, is never absolute from the bacteri-ologic standpoint.

It is difficult to draw the line between ordinary transient diarrhoea with intestinal saprophytosis and a true cholera nostras or enteritis. So, too, from the anatomic standpoint, unless opportunities for direct investigation are afforded, as, fortunately, they rarely are except in young children, it is difficult to use the terms gastritis, gastro-enteritis and entero-colitis, with positiveness.

With these qualifications, it may be said that a previously healthy adult, with a mild attack of cholera nostras, may require no dietetic change except the abstinence from a few meals, although he should avoid rich and indigestible foods upon recommencing to eat.