666 THE INDIAN MEDICAL GAZETTE [Dec., 1932

THE TREATMENT OF BACILLARY always written up by the physician in charge BY BACTERIOPHAGE of the case himself. Several cases had to be omitted as so much of the patient's history By F. H. McCAY, m.a., m.d. (Cantab.) ?y was missing. Late Resident Medical Officer, Presidency General and were Hospital, Calcutta Patients of all nationalities ages admitted with dysentery, but the greatest num- The source the clinical material the of for ber were young adult Englishmen, with Anglo- present investigation Indians next in order. One Indian, a hospital The notes of all patients admitted to the sweeper, is also included in the series and was Presidency General Hospital, Calcutta, who nursed in the hospital. It will be noted that were diagnosed as suffering from dysentery there were many more male than female during each of the four years 1928, 1929, 1930 patients. This was due to the fact that there and 1931, have been collected and analysed. were many more male beds available, which Cases of terminal dysentery complicating some reflects in turn the considerably greater number other disease, of simple amcebiasis with no of European men as compared with women in history of passing blood or mucus, of true Calcutta. Especially is this the case during the amcebic dysentery, acute or chronic, and of hot and rainy seasons when dysentery is at its mixed have been excluded from the highest incidence and many of the ladies have analysis, and only referred to for purposes of gone off to the more salubrious climate of the comparison. hills. The notes were the work analysed mainly The average Englishman in the East, in con- of the and house of the registrars surgeons trast to those at home, is generally very good hospital and varied considerably, both in at going straight to his doctor when he is ill. the essential quality and quantity. Usually Many of the cases in this series however were points in the history and progress of the case admitted several days after they first passed were given, but often the general condition of blood and mucus. This was due to various the and other details were patient important causes; some patients for instance developed and for instance not, unnecessary particulars, dysentery far out in the mofussil, or at sea, those concerning the patient's family history, and did not reach Calcutta for several days. of stools sometimes appeared. The number Others were treated by their own private doctors was noted on the passed daily temperature more or less successfully for a few days before of chart and details pathological and bacterio- it became apparent that hospital attention was logical investigations and of treatment and diet advisable. were given separately. The diagnosis, dis- Mild cases of can as a rule be charge and result' of treatment were nearly dysentery treated quite successfully in bed at the patients' own homes, and the average case of bacillary dysentery in Calcutta is of this type. For the more severe cases, however, hospital treatment, especially the trained nursing provided, is very much more satisfactory. In addition to the many patients suffering from bacilliary dysen- tery who could not afford private medical attention in the first place, there were during the year a considerable number of room patients in the hospital who were sent in by their private doctors for this reason. In nearly every case there was a clear history of passing blood and mucus, and the more observant patient with bacillary dysentery noticed that he passed pure blood and mucus only and no faeces at all from the very begin- ning of his illness, whereas this did not as a rule happen to the patient with amoebic dysentery until later, i.e., when an ulcer had opened up. Usually diarrhoea was also present ?in bad cases severe diarrhoea, and in extreme- ly toxic ones incontinence. Some patients seemed to make a habit of calling for the bed- pan almost every few minutes, while others probably more seriously ill could control them- selves for much longer intervals. I did not therefore consider it necessary to go too much into individual detail as regards the number of stools passed during the day. In the case notes Dec., 1932] TREATMENT OF BACILLARY DYSENTERY : McCAY 667 the degree of diarrhoea was given to the near- General treatment est ten stools in the hours passed twenty-four General treatment consisted in and the maximum the actual always nursing figure during stay- the in bed till the in hospital has been taken. Abdominal pain, patient strictly temperature was down and the stools had become normal. tenesmus and toxaemia were present in many In incontinent cases the bed linen of the cases to a greater or less completely extent, depend- was in others it was ing on the stage and severity of the disease. changed half-hourly; insisted that the should always be used Unfortunately their presence or absence was bed-pan until orders to the were issued. The not always mentioned in the notes. Generalized contrary diet given was fluid during the acute abdominal tenderness with rigidity was, as a invariably stage and if toxaemia was great the patient was rule, more severe in cases of amoebic rather fed a nurse. I used to order than of because by Personally, bacillary dysentery, probably fluid diet of 6-ounce feeds of a of intestine and also its protein consisting greater length large citrated bael-fruit part was more often involved in the milk, whey, Oxo, sherbet, proximal three hours for adults with former condition. marmite, etc., every ftcxner which were commoner than Diagnosis any other sort because the B. jiexner does not There was usually a considerable improve- thrive so well in a protein as in a carbohydrate ment in the condition he was medium. If the culture came back patient's directly ' report put at rest in bed, and sometimes quite a long B. shiga present', I used to give the patient interval before he passed a stool. Unless it a fluid carbohydrate diet in which the feeds seemed a clear-cut case of one sort of dysentery were citrated milk alone or flavoured with tea, rather than the other, I used to withhold every- coffee or chocolate, lemonade, barley water, thing except sips of water until this first stool arrowroot and the like?the shiga variety of in hospital had been passed and seen by some dysentery bacillus preferring a protein to a competent person. If necessary an enema was carbohydrate medium. In other infections and given or a faecal smear obtained from a catheter in acute amoebic dysentery fluid feeds, i.e., both introduced into the . Once the stool had protein aid carbohydrate, were exhibited. In been seen and a definite macroscopic diagnosis the next dietetic stage and in mild cases por- made, which at any rate in early cases was ridge, beaten up egg and milk puddings were quite feasible and only rarely had to be cor- added; next fish and minced meat and finally rected later, routine treatment for either full convalescent diet prior to discharge. amoebic or was commenced. bacillary dysentery Patients were usually allowed to begin to get Some their to have physicians preferred patients up and about directly they felt inclined that treatment?for the example purgatives?from way, provided their temperature was down and start. they had no diarrhoea and-were not passing any In all the cases in a of my series, specimen blood or mucus. If they passed blood or mucus a stool was sent down to the pathological after they were allowed up, i.e., if they relapsed, for examination and culture?in laboratory they were put back to bed and treatment was many cases several stools. The microscopical continued until their motions became complete- examination of the cellular exudate of a dysen- ly normal. Often a little mucus, and sometimes teric stool a an forms rapid and, with practice, quite a large amount, continued to be passed of a easy way arriving at diagnosis. Macro- although the patient looked and felt perfectly cells however have to be phage distinguished well. This was particularly the case in amoebic very carefully from free forms of Entamoeba dysentery but it sometimes occurred in bacil- histolytica; Charcot-Leyden crystals should be lary as well. In the notes of this series of cases for looked and the numbers of blood and pus the dates given for the stools to become normal cells also a present form useful guide. For are taken, like the other details, from the time successful completely bacteriological results the patient was admitted to hospital till the stools must be examined and while fresh plated first stool containing neither blood nor mucus ?at any rate within 4 hours of being passed. was seen by the surgeon or house surgeon, and stool Unfortunately any passed after the labo- this fact was duly charted. I has been closed Occasionally, ratory for the day had to am afraid, this was not until some time after wait till the next and failed to usually grow the event had really occurred, or even not at bacilli. were any dysentery Fresh stools always all, but most of the cases treated with bacterio- sent however when available a and positive phage are detailed fairly well. If a relapse culture result was obtained in a high proportion occurred and a stool containing blood or mucus of cases. Other investigations performed in was passed during convalescence, this fact is were numerous instances routine blood films for taken into account and the extra days are added malarial if the on admis- parasites temperature although many quite normal stools may have sion was over 100?F., blood pictures, especially been passed in the interval. I considered the useful in amoebic (I did not see a desirability of taking all details of the disease case of single intrahepatic ), Van from the very beginning of the attack, but den in Bergh reactions to help the diagnosis of although an accurate history was easily obtained the same and urine condition, analyses and from many patients this was certainly not the cultures. case in many more and so I have adhered 668 THE INDIAN MEDICAL GAZETTE [Dec., 1932 throughout to the facts as definitely checked cases, unsuccessful from the 'phage point of and noted while the patient was in hospital. view, in which only one or two doses were at different of the illness among treatment given stages Specific others in which a full 'phage course was given Specific treatment in the form of mixed anti- alone and from the start of the dysenteric dysenteric serum was given intramuscularly and attack. I have usually found that if bacterio- of intravenously in quite a large proportion phage was going to have any effect at all this cases, usually in conjunction with purgative usually occurred almost at once. I frequently treatment. The best results were obtained continued giving bacteriophage until the tem- when it was given early and in massive doses perature came down to normal as this was from 40 c.cm. upwards. Serum seemed to me generally the first definite sign of the patient's on to have a definite effect at almost any stage recovery. the general tox?emia in both B. jlexncr and B. shiga infections although, as we have seen, Saline treatment some authorities say flexner serum cannot be Foremost the various methods of useful as the toxin produced is intracellular. among treatment of acute with treatment was not tried in any of the bacillary dysentery come the numerous well-tried acute cases surveyed in this thesis, but reserved drugs purgative remedies. and sodium in for a few chronic and relapsing ones?usually Magnesium sulphate drachm four or at shorter inter- with fair success. doses, hourly vals, and sometimes more drastic purgatives Bacteriophage treatment were given until the stools ultimately became The other form of specific treatment employed almost completely watery, when treatment was was bacteriophage and it is my object in this stopped. In mild cases it was often not neces- paper to try and find out the efficacy of this sary to continue until this result was obtained substance, and compare the results obtained as the patient soon stopped passing blood and when using it with those of the other older mucus, and a cure was effected by the flushing methods. The bacteriophage used was a clear out of the bowel. One objection to this well- amber-coloured fluid and was manufactured by established and popular line of treatment is the Government Research Institute at Shillong that at times it is terribly drastic. The wretched and sold in 2 c.cm. glass ampoules. This patient complains to his doctor that he is ' particular brand' of bacteriophage is made having a stool every few minutes and naturally from a large number of strains of dysentery he wants this state of affairs to cease; instead bacilli, and in vitro is found to be potent of this, the actual diarrhoea is definitely made against all the strains commonly encountered in worse by the doctor's treatment although its Calcutta. When it first appeared the makers duration may be curtailed?a fact that the recommended giving one ampoule morning and patient does not usually appreciate. In young evening in an alkaline solution, and these and otherwise-healthy people the recovery from instructions were usually carried out; later excessive purging is very quick; they are often however the bacteriophage was given more constipated for a few days afterwards, but this frequently, and in very toxic cases I think it is usually seems to them to be a welcome relief. really best to give it ad lib. with occasional In aged persons however collapse may easily alkaline draughts of sodium bicarbonate, 5 grains occur and must always be carefully guarded to one ounce of water. It was always tolerated against. Terminal dysentery with death due very well. Bacteriophage works best in an to toxaemia and with the actual dysentery not alkaline medium and other drugs, such as at all severe is, I think, more common in bismuth, kaolin, and potassium permanganate, Calcutta than terminal . Older tend to inhibit its action and so should not be patients do not stand purgative treatment well given concurrently. In fact, although unfor- nor in my opinion did anti-dysenteric serum tunately I was not always successful, I endea- seem to have such a beneficial effect on them voured to have as many patients as possible as on equally severe infections in younger treated with bacteriophage, and bacteriophage people. alone, or, if they were very badly dehydrated, But, apart from any other consideration and bacteriophage by mouth and intravenous saline. on a priori grounds only, purgative treatment Frequently, purgative treatment had been begun seems wrong to me because it is definitely before I saw the in cases an patient and mild this stimulating already inflamed organ. It is have had as may much to do with the curing nearly as bad a crime as giving diuretics in a of the condition as the few doses of bacterio- case of nephritis or exercise and movements to phage given. an acutely-inflamed joint. Acute dysentery, Although a single dose of bacteriophage may either amoebic or bacillary, is different from to take all appear away the toxic and other acute ptomaine poisoning or ; in the symptoms in a case of dysentery, I do not think former, the wall of the is exten- it that fair to say bacteriophage treatment has sively inflamed and the organisms responsible been ineffective unless at say least 3 doses have for the disease are already established in been for firmly given. Nevertheless, the purpose of the tissues of this wall; in the latter, cellular this I have had to include a analysis number of involvement is only secondary to some direct Dec., 1932] TREATMENT OF BACILLARY DYSENTERY : McCAY 669

still in the lumen of the small irritant, mainly quicker and more certainly than if given by and this irritant can and should be intestine, mouth. This was actually tried in a few rid of treatment. got by purgative Many instances but I could not draw any definite and are of course organisms toxins present in conclusions as to its value. It is sometimes the large intestine in dysentery cases but I difficult to make toxic patients submit to the cannot can help feeling that most patients be strain entailed by this treatment and if the gut left to rid of this material themselves. safely get itself seems to be valiantly trying to cure the If no bacteriophage treatment has other claim disease, interference by the physician is surely to success at rate it cannot be said that it any not necessary. makes the patient's diarrhoea worse than it was or in stimulates his intestinal tract. any way Progress Purgative and bacteriophage treatment, if not of in the condition of directly, are at any rate partially antagonistic; Criteria improvement purging probably removes the bacteriophage patients suffering from dysentery may be rather from the gut too quickly for it to have time indefinite, especially in mild cases, but usually to work efficiently. the disease runs a fairly clear-cut course. Thus the severity of the attack may as a rule be Other drugs useful for symptomatic treat- judged fairly accurately by unprejudiced figures ment include, tincture of opium which usually indicating the period of fever from the time of seemed to be effective in reducing the patient's admission, and the severity and duration of the pain and worry even if it had a minor only diarrhoea. The fever is probably entirely due effect on the diarrhoea, atropine for spasm and to, and is in most cases a very accurate gauge tenesmus, strychnine in collapse, and digitalis of, the toxamiia. It is better to accept this as for elderly patients' hearts. an indication than to try to assess, the toxaemia In severe cases to 4 of bacillary up pints by other means, as here the personal factor intravenous or alkaline as hypertonic saline, must inevitably play an important part. The Khan recommended by Asheshov, and Lahiri severity of the diarrhoea can be expressed as (1931) for the treatment of , were given; the maximum number of stools passed in a the relative proportions of each depended on single period of 24 hours in hospital and is here the degree of dehydration or toxamiia present. given to the nearest 10, and its duration as the This treatment seemed to me to be more number of days in hospital prior to the passing effective than anything else in these cases. of normal stools. In cases of relapse this figure The differential diagnosis between severe will have to be increased to. include the whole and when there is no stool dysentery cholera, period up to the final disappearance of this present to help one, can be extremely difficult symptom. It must be remembered that purga- and a very similar death from toxaemia can tive treatment in many cases temporarily result from each disease. The saline should be increased the patient's diarrhoea. The time given slowly?3 pints in the hour is about the taken for all symptoms to disappear is obvious- correct rate?and its effect should, and usually ly dependent on the severity of the disease last to to did, long enough allow bacteriophage process but it is also influenced by other factors, reach the large intestine and in many instances the most of which, in my opinion, is important" " influence the disease process. The clinical the psychical make-up of the patient?the picture before and after intravenous saline is so-called will-to-get-well. In this respect I sometimes more dramatic than in the case of a noticed a great difference between the average successful blood transfusion. It may have to English and Anglo-Indian patient, greatly in be repeated in very severe cases, but never to favour of the former. the same extent as in cholera. Bacteriophage The number of days spent in hospital is liable can be in the saline solution but I am afraid put to a very as it often I did not have of this to provide misleading figure, enough experience influenced by factors quite apart from the re- come to any conclusion as to whether its pre- covery of the patient. For instance, he sence or not. Most of the might helped patients not have been discharged for several after transfused were days already having bacteriophage, he was fit to go as he have had to wait mouth. may by for dental treatment or his boat did Bowel wash-outs with saline or alkaline or perhaps not leave at a convenient time. On the other other solutions were often useful in extremely hand, lie might have been in a to go and the later stages of the in some hurry attack, especially discharged himself at his own risk against instances when given Plombiere's method. by medical advice, or there may have been a this means mucus was often rid this By got of; shortage of beds to account for his somewhat method is even more useful in amoebic dysen- premature departure. Some also Even in the earlier when diar- physicians tery. periods preferred to proceed rather more with rhoea is not severe I think wash-outs from below slowly their patients than did others and this un- be useful in the of harm- may ridding patient doubtedly influenced the time spent in ful more useful than wash- hospital material, perhaps in many instances. all these factors from above with Bacterio- Luckily outs purgatives. tend to cancel out each other also could be into the alkaline wash- against especially phage put when a large number of cases is considered. out and would then be able to act surely Another criterion of obvious importance is the 670 THE INDIAN MEDICAL GAZETTE [Dec., 1932 mortality rate, even though it is in this series as a whole. Thus, in table I, which gives the of cases fairly low compared to other regions of numbers of dysentery cases of each sort admit- India and the world in general. It must be ted for the years 1928 to 1931 inclusive, it will remembered of course that most of the patients be seen that the cases of amoebic dysentery treated at the Presidency General Hospital were actually outnumber those of bacillary although well nourished and had very reasonable recu- the latter disease is very much commoner in perative powers. the East. This discrepancy is, I think, due to The result of treatment has in the vast the fact that most dysentery cases admitted majority of instances described been a cure, at were isolated ones from different reasonably- any rate in the opinion of the physician in clean European houses, whereas in Indian charge of the case. Surprisingly few examples villages considerable B. fiexner epidemics fre- of chronic bacillary dysentery have been found quently occur and soon become widespread among the notes examined but one or two are owing to the extremely poor hygienic conditions. described when prolonged treatment for many It will be noticed that mixed infections weeks seemed to make no and impression, amount to nearly 9 per cent, of the total of blood and mucus continued to be passed day my series of cases. after some of these were well day. Fortunately The admissions of each of enough to be invalided home or at any rate to variety dysentery month in 1931 are in table II and a cooler climate. Relapsing cases were also per given the rise in the numbers the month of rare, perhaps rarer than cases of reinfection, during is shown even more when probably with some different bacillus. While August up clearly these are set out an attack of dysentery certainly seems to con- figures graphically. fer specific immunity, at any rate for a short Monthly dysentery admissions P.P.6.H. 6.H. Calcutta /33t./33/. time, it often leaves the general resistance of dysentery the gut much lower than before. I had no experience of more-or-less healthy carriers of bacillary dysentery, but I believe many were A diagnosed and treated at the School of Tropical Medicine in Calcutta; B. pseudo-cavolinus I am informed was the organism usually found A and treatment consisted of an autogenous vaccine course. In spite of the difficulties outlined above of / showing the exact progress of patients with / / v acute bacillary dysentery I consider that indi- vidual variations have been almost completely cancelled by taking, as I have, a reason- number of cases. From the detailed Jan. Feb ably large Mar. Apl. May. June.July, fug- Sep{. Oct. Nov Dec. . Amoebic. ?? ? statistical results following I hope that some . BBacillary. acillary. general idea of acute bacillary dysentery in Calcutta may be and that the obtained, efficacy Table II of the old and new methods of treatment can be compared. Dysentery admissions month by month in 1931 Table I Amoebic Bacillary Mixed Cases admitted Year 1 6 Bacillarv Amoebic Mixed Year's January 11 dysentery infection total February dysentery March 10 April 5 6 192S 46 58 9 113 May June 9 1929 47 57 17 121 9 1930 70 57 8 July 135 14 19 1931 68 99 15 182 August September 9 6 October 6 5 November 6 4 Totals 231 271 49 551 December 8 2

results Analysis of Totals 99 68 15 In assessing the various results obtained by analysing the case notes, it must be remembered that only European and Anglo-Indian patients The distribution as regards age of the 231 are admitted to the Presidency General Hos- patients admitted with bacillary dysentery is pital, Calcutta, and that my figures are there- shown in table III and the race incidence in fore bv no means the same as those for India table IV. Dec., 1932] TREATMENT OF BACILLARY DYSENTERY : McCAY 671

Table III Age incidence

Years 0?10 11?20 21?30 31?40 41?50 51?60 61?70 71?80

Number of cases 36 40 70 42 23 14 6

Percentage of total 15 16 35 16 10 6 2

Age distribution per centum of all 15 11 25 18 13 11 5 patients in hospital.

Table IV Altogether there were nineteen deaths which a rate of 8.2 cent, for the Race incidence gives mortality per 231 cases of bacillarv dysentery. Eleven deaths Race distribution ?over half the total number?occurred in per centum of children under five of I should like Number Percentage years age. all patients in to emphasize once more that dysentery in hospital childhood is a dangerous disease which should be treated as early as possible and preferably in European . 165 72 61 hospital. I did not find that cases were neces- Anglo 61 26 36 shiga Indian. sarily more severe than flexner, either as regards toxaemia or degree of diarrhoea; in four Asiatic of the cases that died B. shiga was isolated from the stools, and in six others B. jiexner. As regards the sex incidence there is a three Comparison of results of treatment to one preponderance of males and this corre- Of the 231 cases of des- sponds exactly with the figures for the malaria bacillary dysentery cribed, 111 had them and cases admitted to the hospital during the same bacteriophage given 120 had no Some had four years. bacteriophage. patients only very little 'phage and some had it after The causal organism was isolated in very many other methods of treatment had been 50 per cent, of the total number of cases nearly tried I have nevertheless and J3. flexner was found three times as unsuccessfully. placed them all with the more treated ones as reasonably often B. shiga?table V. There seem to ' in the same The be three extra cases in this table but this is due bacteriophage' category. control cases received various treatments; thus to more than one grown from organism being some had another the stools of two patients. forty purgatives only, sixty had serum as well, and many in each of these Table V two classes also had bowel wash-outs. The Bacteriological findings remainder either had general treatment, or serum, or drugs such as kaolin, or were given intravenous saline. They also have all been Number Percentage ' grouped together into the same non-bacterio- phage' category. B. flcx7icr 75 32 Table VI B. shiga 25 10 Severity of infection B. enteritidis 11 4 Average day Average B. 2 Percentage of pseudocarolinus 1 of disease on degree i.c. positive which diarrhoea, No cultures maximum specific organism isolated 121 53 admitted daily stools

The of B. to B. cases proportion jiexner shiga Ill eases treated 51 14 does not tally with that usually found in India with bacterio- as a whole and again this is probably due to phage. 120 cases not there no 46 4.4 13 being widespread dysentery epidemic treated with the white of Calcutta and among community bacteriophage. the surrounding district. Incidentally, although only five Asiatic with patients?all Japanese?were admitted The two groups, although they both contain bacillary dysentery during the whole period, widely varying individual details, are certainly four of them grew B. shiga and I think probably in as ' ' my opinion comparable regards severity carried the organism with them from Japan. of infection. This is well shown in table VI L 672 THE INDIAN MEDICAL GAZETTE [Dec., 1932

when the average figures are taken and are immediately successful and some were quite seen to approximate very closely. As regards impressed with taking first the dose of alkali the average degree of diarrhoea in hospital, the and then the not-unpleasant broth culture. Most figures shown were obtained by dividing the of the patients who had had dysentery before total number of stools on the day on which the and had been treated with serum and drastic

Table VII Results of treatment

Average number of days

Number of I Percentage for tempera- for stools to deaths ture to in mortality become spent become hospital normal normal

Ill cases treated with bacteriophage 6 5.4 3.5 9 23

120 cases not treated with bacteriophage 13 10.8 3 7.3 17 patient passed the maximum number by the purging greatly preferred being treated with total number of cases in each category. bacteriophage. In table VII the results of as treatment, Table VIII shown by the criteria of improvement already referred to, are given for the two main groups. Results of treatment in cases that responded to The mortality rate of the cases treated with bacteriophage to be half that of the bacteriophage appears Average number of days cases not treated in this way and yet convales- cence seems to be about 20 per cent, longer. for tempera- not think much more should for stools Personally I do ture to in to spent be deduced from this table than that the results become become normal hospital of treatment are approximately the same in normal each group. I cannot help feeling that even if some of the cases that were not treated 33 cases treated 2.9 6.6 15.3 with 'phage and died had had bacteriophage with bacterio- a fatal result would still have occurred, phage. and also that really there is not a great deal of difference in the period of con- Conclusions valescence of the two groups. Better figures could of course be made out for either side, 1. That bacteriophage treatment is still in perhaps especially for the 'phage cases, by not its early stages. including patients that had many different 2. That bacteriophage is well tolerated by methods of treatment tried unsuccessfully on patients suffering from bacillary dysentery. them; there is, however, a danger in thus 3. That bacteriophage was successful in selecting cases. Actually only 33?or 30 per effecting a speedy cure in 30 per cent, of the cent.?of the cases treated with bacteriophage cases in which it was used. definitely responded to it. In the remainder 4. That in the remaining 70 per cent, it bacteriophage appeared to have no appreciable appeared to have very little effect clinically. effect, but was always tolerated well. Some of Acknowledgements the successfullly-treated 'phage cases responded like to one dramatically and at once, not only as regards I should thank every at the their general condition, but their local as well. Presidency General Hospital, Calcutta, for their In others, although the toxannia disappeared co-operation in the treatment of the patients, and the temperature become normal, the diar- in the collecting of these case notes and in the rhoea and blood and mucus continued for three preparing of this paper. I am particularly or four days. As a matter of interest I grateful to the ward sisters and house surgeons ' ' give the recovery figures for these 33 patients in for their loyal assistance and close co-operation table VIII. during the whole period that I was working in the hospital. Very few of my cases were cured, with one dose of in the same single bacteriophage way Reference that most of Professor d'Herelle's seem to have I. N., S., and M. N. (1931). been. Most were well satisfied Asheshov, Khan, Lahiri, patients with The Treatment of Cholera with Bacteriophage. Indian even when it was 'phage treatment not Med. Gaz., Vol. LXVI, p. 179.