For the prevention of cholera in times of epidemic, the following rules should be observed: (1) Raw food, such as vegetables and fruits, should not be eaten, as it may have been washed in water that had been contaminated. (2) All water used for cooking, for washing dishes, glasses, and cooking utensils, should be sterilized. Beer, ale, soda-water, or artifical mineral water made from water not sterilized should not be used. (3) Water used in brushing the teeth or cleansing the mouth should be sterilized. (4) Ice should not be put into water that is to be drunk, or on vegetables or fruits, as it may contaminate beverages or foods that are otherwise wholesome. (5) Food of all kinds must be protected from contamination by flies. (6) Acid drinks should be taken freely, for they are inimical to cholera germs. It is probable that the acid state of the stomach in health is one cause of the immunity that many persons enjoy. Lemonade acidified with dilute sulphuric acid - from ten or fifteen drops of the latter to the glass - has been extensively used during epidemics of cholera. Dilute hydrochloric acid may be substituted for the sulphuric, or tartaric or citric acid may be used. A palatable acid beverage may be made by dissolving one-half ounce of tartaric acid in a quart of sweetened water. The contents of the stomach, kept hyperacid by these drinks, will escape from time to time into the duodenum and make it temporarily acid. The growth of the cholera bacillus may thus be inhibited or prevented.

Indigestion should be avoided by careful eating, or, if existing, should be corrected at once. Disturbance of the stomach, especially such indigestion as causes diminished acidity or alkaline fermentation, opens an avenue for the entrance of the specific infection.

During a cholera epidemic those foods that are liable to produce indigestion or diarrhea must be avoided. All food should be in a perfect state of preservation and well cooked. Care should also be taken not to overeat and not to overfill the stomach, even with pure water, for the latter will only dilute the contents of the stomach and make them less acid, and thus less capable of digesting food, or of destroying the cholera microbe which may chance to find its way there. Food must also be cooked simply. Fried dishes, those served with rich sauces, or made very sweet, should be avoided, as they are a common cause of indigestion.

Treatment

During an attack of cholera very little food can be given, for it often aggravates vomiting, and, if retained, forms a culture-medium for the cholera bacillus and therefore a source of more toxin. In the stage of premonitory diarrhea, and in the stage of resolution, a moderate quantity of food is permissible. In the first, if vomiting does not prevent, a little pancreatinized milk, bouillon, whey, gruel, or matzoon may be given. No attempt should be made to give much food, for it is very easy to overtax the stomach and do harm.

Acid beverages should be given as freely as possible. Those recommended as prophylactic may be employed. During the epidemic of cholera in Paris, in 1892, the Council of Hygiene recommended water acidulated with lactic acid. Hayem first demonstrated the utility of lactic acid in the green diarrhea of infants. Dujardin-Beaumetz prescribed this formula: Lactic acid, 10 grams; simple syrup, 90 grams; essence of orange or lemon, 2 grams; water, sufficient to make 1000 grams. It was to be taken in doses of a dessertspoonful or tablespoonful every quarter of an hour. However, in this and subsequent epidemics the utility of lactic acid was variously estimated by clinicians. In France, such men as Peter, Sireday, Delpeuch, and Barie found it useful. Others believed it worthless. It is probably of some value, at least in mild cases.

When the strong acids are given, they should be taken through a glass tube in order to save the teeth. Sometimes acid drinks seem too strong and are quickly vomited. However, if they are given in sips, and a bit of pure ice is taken after each sip, they will often be retained when they would not be under other circumstances.

Acid drinks taken in sips, iced lemonade, or Seltzer often check vomiting. Sinapisms on the epigastrium and various anti-emetics may also be tried to relieve it.

Water must be regarded in the treatment of cholera as both a medicine and a food. Enteroclysis has been employed in numerous epidemics. It was used extensively and regarded with favor by the physicians of Hamburg in 1892. Water should be introduced into the rectum as high as possible by inserting into it a long rectal tube. As much as two quarts of hot water should be injected at a time, slowly, and under moderate pressure. Cantani recommended the addition of three grams of tannic acid to the water. Others used a 4 per cent, solution of boric acid, and still others soap and water or sodium chlorid solution. The rectal tenesmus is usually lessened or removed by this treatment. Most of those who have used such treatment believe that not only is the bowel cleansed, but that some water is absorbed, replacing a part of the fluid that is constantly drained from the blood-vessels and removed from the body by purging and vomiting. Acid drinks and the acid enemata constitute the most important items of treatment in the first stage of the malady.

Although the attempt has been made to destroy cholera microbes by acid drinks and to remove them by enemata, or rarely by gastric lavage, it has seldom been more than partly successful. It is as important to remove the toxins as to destroy and remove the bacillus of cholera. This can best be accomplished by diluting the blood and the interstitial fluids with water, and by promoting rapid elimination through the kidneys; for, on account of the rapid elimination of fluid by the bowels and stomach, the blood becomes concentrated and the interstitial tissues grow comparatively dry. This rapid draining of the tissues is the first, though not the only, cause of the collapse that is so often present in this disease; collapse is ultimately and chiefly due to poisoning by compounds produced by the germs of cholera, and held in solution in the blood. It is, therefore, necessary, not only to restore water to the blood-vessels and tissues, but to flood them with it in order to dilute the toxins and to stimulate the kidneys. Enemata help to accomplish these objects, but are often unavailing, partly because of frequent purgations, and partly because absorption from the intestines is very imperfectly performed. In 1830 Joehuichen (Moscow) first used intravenous injections of water. He acidulated it. In 1832 Latta (Scotland) advocated a solution of common salt. This has been found the most useful. Intravenous infusion is recommended when patients are in a state of collapse - that is, cold and pulseless at the wrist. Some physicians resort to it whenever the radial pulse is too small to feel. However, the mortality has been reduced so slightly by this means that it is doubtful if the few men apparently saved by it would not have gotten well without it. The immediate effect of intravenous infusion upon patients apparently moribund is often remarkable and most satisfactory. Hayem says: "One seems to aid at a genuine resurrection." The best solution to use is that recommended by him:

Of this mixture, from one and a half to two liters (quarts) should be used. It should have a temperature of from 3 8° to 390 C. (100o° to 1020 F.). The intravenous injection should be made with the strictest aseptic precautions, and no air should be admitted to the vein. At least five minutes, and, better, a longer time, should be taken to inject the water into the vein. Although the happiest results often follow venous infusion, it is an operation not without danger. The admission of air to a vein, the production of pulmonary emboli, the admission of septic germs, phlebitis, lymphangitis, and gangrene are some of the dangers incurred.

In 1883 the much safer and almost, if not quite, equally efficacious procedure, hypodermoclysis, was devised nearly at the same time by Samuels (Konigsberg) and Michael (Hamburg). The results of hypodermoclysis are less prompt and less brilliant, but often more permanent than those of intravenous infusion. The hypodermic injection of a salt solution is comparatively free from danger. The same aseptic precautions must be taken as in intravenous infusion. Hayem's solution is one of the best to use. It should be injected into the loose cellular tissue of the body, in amounts varying from 150 to 450 c.c. (5 to 15 ounces). These injections may be repeated several times in one day, and for several days in succession. The temperature of the fluid should be that of the blood. The injections should be given as soon as the algid state develops or threatens. Do not wait too long.

B. W. Richardson advised the intraperitoneal injection of hot, sterile milk (about 430 C. or 1090 to 100° F.) for the double purpose of supplying fluid and heat. He selected milk as an animal fluid less likely to be irritating than an artificial blood serum, and with the hope that it might likewise be an aid to nutrition. The procedure has not been sufficiently practised to permit an estimate of its value.

Although water administered in various ways is so essential, food, because it is rarely retained or assimilated, is not of much utility during the height of the disease. When recovery begins, peptonized milk and broth may again be tried, at first in doses of a teaspoonful. If the food is retained, it may be given in the same way every fifteen minutes. After a few hours the quantity may be very slowly increased. There is great danger of overtaxing a stomach already extremely irritable, and from which absorption is imperfect, even with a very small quantity of nourishment. When food is tolerated, milk not predigested may be tried. From this time on, the same gradual change in the amount and character of food must be made as during convalescence from typhoid fever.

Body temperature should be maintained so soon as it falls below normal, by heat applied to the outside, by hot water botties, or sometimes by immersing a patient for hours in a bath of hot water. This last procedure also makes possible the absorption of some water by the skin.