PRELIMINARY REPORT ON THE CHOLERA EPIDEMIC OF 1926. GENERAL SURVEY. About the middle of May information reached us that a few cases of Asiatic cholera had occurred among residents of the Chapei District in Shanghai, but nothing official was declared until June 8. when the Settlement authorities reported their first authentic case of cholera which had been admitted into hospital four days previously. From that date onwards the infections began to accumulate until the summit was reached about the week August 1-8, during which 2481 cases were reported as having been treated at the two Chinese Summer Diseases Hospitals. Altogether no less than 20,000 cases have occurred in the Shanghai district alone. Serious outbreaks were reported in almost every city in the Yangtse area such as Nanking, Soochow, Wusieh, Huchow, Anking, Hankow, Wuchang, etc. as well as further south in such centers as Foochow, Amoy, Swatow, Canton, Hainan, etc. The country of Siam reported 5000 in deaths alone. It may be remembered that a similar outbreak of cholera, affecting several thousand victims, occurred in Shanghai the year previous (1925). I happened to be then in that city in August and secured samples of water from the Chapei Water-works (Soochow creek, filter-beds and tap) and requested the Municipal Health Laboratory to make a bacteriological examination of same for cholera. The report was that although suspicious vibrios were cultivated from every sample they were probably not of the pathogenic variety. In July of this year, when the cholera situation was becoming acute, Dr. Noel Davis, the Health Commissioner, had samples of the Chapei Water-works bacteriologically examined and reported that in every one (intake from Soochow creek, effluent from filter-beds and a tap from the mains) specific cholera vibrios were isolated, Much acrimonious controversy has since arisen because of that discovery, but it seems to me that the real problem before the health authorities of the International Settlement and Chinese Area is effective co-operation in (a) An intensive study of suspected sources throughout the year, including water, carriers, etc. (b) Early preventive measures to be undertaken early in the spring. (c) Mass prophylactic inoculations. (d) Early notification to non-endemic centers, so as to limit the spread to other localities. (e) Other problems, e.g. mass fecal examination at ports, railway centers. No unprejudiced person will deny that the present loose laws regarding notification and quarantine, which were probably devised half a century ago, need urgent revision. For the sake of all concerned, in cluding the various foreign authorities and commercial bodies in China, it is hoped that a Cholera Prevention Conference will soon be held in or near Shanghai so that all cards may be placed on the table and really effective preventive measures may be devised against this almost yearly visitation of an easily controllable disease. Should a proper system be established, such incidents as when the British steamer Lienshing tried to smuggle a dying cholera patient ashore on August 3 might not occur. A fine of $250 was meted out to the captain besides 12 months rigorous imprisonment to both the first and second compradores. We may now proceed to a study of the epidemiological and clinical data before us. As has been said above, the first case was officially declared in Shanghai on June 8, though it was clear that isolated cases had occurred since the middle of May. A state of epidemic was not reported until July. In the meantime, ports in Chekiang, Fukien, and Kwangtung as well as the Yangtze valley had been invaded. The first cases apparently did not reach the northern cities until the third week of July, though Tientsin reported its first case on June 15. The following table showing (a) when quarantine was first declared at various northern cities and (b) when the first case occurred in them respectively, is highly illuminating : The Japanese authorities at Dairen enforced fecal examination of passengers and crews of steamers arriving from infected ports on July 22. Up to September 30, they had examined The South Manchurian Railway authorities also enforced fecal examination of railway passengers arriving from the north from Aug. 23; this was stopped on September 18. The above table shows among other things: (a) That quarantine measures were in most cases applied much too late, (b) That even with this delay the first cases in each center appeared after a considerable interval, (c) That cholera outbreaks when they did occur were of comparatively short duration, the end coinciding often with the coming of cold weather. The whole 1926 cholera epidemic probably claimed only 1,500 victims in Manchuria as compared with over 10,000 in 1919; this is specially marked in the case of Harbin which had 4,500 in 1919 and only 280 in 1926. The only severely affected centres were Antung (480). Kirin (320), Harbin (280), Changchun (210), Yingkou (167). Other cities of Manchuria show a corresponding decrease. This satisfactory state of affairs may be traced to: (a) Early preventive measures by the medical administrations. (d) Effective educational propaganda among the masses who willing- (e) Perhaps prevailing wet weather during the second half of the summer. Turning now to our Harbin experiences, we may class them under three headings, namely: A. Epidemiological study, B. Cholera notes from Pinchiang Hospital, C. Laboratory Reports. The data gathered are not complete but we hope to supplement these in a later article. It is hoped that each section may contribute something to the knowledge of this disease in China, particularly the ease with which the disease may be bacteriologically diagnosed early in an epidemic, and also the successful result of the hypertonic saline infusion. Lastly the need for detecting early carriers, especially at sea and river ports, seems to us all important. For this reason we support the policy of mass fecal examination adopted in Dairen for passengers and crews of steamers arriving from infected localities. WU LIEN TEH. A. EPIDEMIOLOGIC STUDY OF THE Mortality figures. (TO BE READ WITH TABLES I-XIV). As can be seen from Tables I and II there is a great difference in the mortality observed in our hospital (17.3) and that of the patients admitted in the Municipal Hospital (54.5) while the Railway Hospital takes an intermediate position with 34.5% fatal cases. A similar discrepancy between our records and those of the Russian hospitals was evident also in the epidemic of 1919 (57.77 and 14.11). This appeared fully accounted for by the differences of therapy used, our favourable results being due to the use of hypertonic intravenous salt infusions while the Russian doctors at first stuck to subcutaneous administration of normal saline. Though, as will be shown later, the question of the therapy employed played probably a role also in the 1926 epidemic. this factor alone cannot account for the differences of mortality observed. In this epidemic hypertonic intravenous infusions were also given in the Municipal and Railway hospitals. Specially the doctors of the former took great pains to ascertain our methods of treatment and to adopt them for their patients. When analysing the records of the 1926 epidemic we have to consider that possibly a better resistance of Chinese patients against cholera may account for our results. In fact in the Municipal Hospital where both foreigners (mainly Russians with a few others like Jews, Poles, Armenians and one Korean) and Chinese were admitted, the former had a mortality of 57.5%, the latter of 50%. In the Railway Hospital this is still more striking, the figures being 43.5% and 28.1% respectively (see Table I). Since cholera is a rare visitor of North Manchuria and Shantung (which supplies the majority of our coolies) and a natural immunity cannot be expected, allowance must be made for the existence of a stronger resistance among Chinese. However, in our opinion this cannot wholly explain the great difference in the figures for two reasons: i. The mortality among the Chinese admitted in the two other What other factors could then have been at work? In order to elucidate this question it will be well to analyse step by step the figures available. Table III shows that in the Municipal Hospital more foreign females were admitted than males (65.0% as against 35.0%). Naturally the thought arises that perhaps a greater mortality among the former might account for the high total mortality. Table IV, however, shows just the contrary. Also in our and the Railway hospitals the mortality of males was perceptibly, though no so markedly, higher than that of females. This table also shows that both in the Municipal and the Railway Hospital the mortality of foreign males was considerably higher than that of the Chinese. This might be explained in part by the better resistance of the latter. Other factors are probably at work as well: these will be discussed later on. b. Age incidence. While scanning the records of age incidence (see Tables V & VI) we find no differences worth considering. Both among Chinese and foreigners the incidence of the disease and the mortality are highest in the young adult. c. Occupation. A study of the occupational incidence (unfortunately only limited figures are available) does not teach us much (see Table VII a & b). The most striking figures in the Russian table are these recording, an outbreak among 12 patients who were in the general hospital and two hospital employees. This will be discussed separately but we may state here that the mortality among the patients was even slightly lower than that of the outside admittances (see Table VIII). The incidence among persons out of work is comparatively high (22.5%-Table VII b) However, here also the mortality is not above the average (about 50%). d. Time of admission. A fundamental difference existed in 1926 in regard to the system of admission in Pinchiang on one hand, in the Special Area (Municipal and Railway Hospitals) on the other. In the Special Area the patients were mainly brought compulsorily to the hospital and kept there-if necessary by force as long as deemed necessary (see Table IX). In Pinchiang we did not even attempt to adopt such a rigid scheme. Our policy was to appeal to the population to seek our aid by all available means (personal urging through our sanitary inspectors, distribution of hand bills, posters, etc. all over the Chinese Town etc.). That our campaign was successful may be gathered from several facts : i. 76% of 85 patients for which we have exact data, sought admittance during the first two days of illness (see Table X). ii. A comparatively large number of patients came who suffered not from cholera but from other bowel complaints (see Table |