i8io 



THE CHOLERAS 



examination of the bowel contents reveal the true nature of the 

 disorder. 



Complications.— In rare cases hyperpyrexia has been noted during 

 the attack, but usually all the complications occur during the stage 

 of reaction, and are due to secondary infections. The most common 

 are pneumonia, enteritis, and inflammation of the kidney. Preg- 

 nant women always abort, and the foetus may show signs of the 

 disease. The reason of this abortive tendency is, according to 

 Schiitz, because cholera has a powerful effect upon even the non- 

 pregnant uterus, causing haemorrhage during the stage characterized 

 by muscular cramps. 



Sequelae.- — After such a severe illness, it is usual to find more or 

 less permanent damage to the health of the victim. Thus anaemia, 

 inflammation of the parotid, gangrene, ulceration of the cornea, 

 astigmatism, or other errors of refraction, a tendency to diarrhoea, 

 and digestive disturbances, may persist for a long time. 



Diagnosis. — The diagnosis is easy during an epidemic, but it may 

 be very difficult in the period when there are only a few sporadic 

 cases preceding the outbreak. 



So closely may cholera be simulated by ptomaine poisoning as 

 regards the collapse, and by infections with germs of the Aertrycke- 

 Gartner group, which we have seen produce typical rice-water 

 motions, that it is perfectly useless in a sporadic case to attempt 

 to make an accurate diagnosis without a bacteriological examination, 

 and even this has to be performed with the greatest care, as there are 

 many vibrios which are undistinguishable without special tests from 

 the Vibrio cholercB Koch. We recommend the following method:- — 



1. Make films from the rice-like flakes, and stain with diluted 

 Ziehl carbolic fuchsin (i in 50) for ten minutes, or with Loffier's 

 blue, five minutes. If a large number of curved rods be present, 

 cholera may be suspected; but a definite diagnosis should never be 

 based on the simple microscopical examination, as comma-hke 

 germs are found in many cases of ordinary diarrhoea, and even in 

 normal stools. 



2. Inoculate four tubes of peptone water with the suspected 

 stools, the first with J c.c, the second with Jc.c, the third with 

 I c.c, and the fourth with 2 c.c; or inoculate each of two Erlen- 

 meyer flasks, capped with sterile filter-paper without wool-plugs, 

 with I c.c. of the stools. The formation of a scum on the surface 

 of the medium within eight to ten hours is suspicious of cholera. 

 The pellicle and the upper portions of the medium should be ex- 

 amined microscopically for the presence of vibrios, and a micro- 

 scopical agglutination test carried out, mixing one loopful of the 

 culture with one loopful of diluted cholera serum (i in i,coo). The 

 peptone water should be tested for the presence of indol, adding a 

 few drops of pure sulphuric acid. In true cholera the indol reaction 

 is generally present eight to ten hours after inoculation. From the 

 pellicle and upper portion of the peptone-water tubes ordinary agar 

 and MacConkey agar plates should be made, and any suspicious 



