instance; but the conditions under which the disease, i. e., a violent intestinal catarrh with copious serous exudation, took place in animals experimented upon, bore no resemblance to those conditions under which cholera takes place in man. If, for example, the intestine of an animal is first bruised, or the common bile duct is tied, or opium is administered, or large quantities of alcohol are ingested, or the stomach is rendered alkaline, before introducing the cholera virus, it is clear that these conditions differ widely from those that nature presents; and whether successful or unsuccessful, such experiments are only of relative and conditional value, especially since other bacteria besides the cholera microbe have been demonstrated to possess the same deleterious action on the animals under like conditions.

Our chief source, then, of information about the cholera process will be, as heretofore, clinical and anatomo-pathological evidence. And what does this teach? The symptoms, as well as the post-mortem finding, point to an intense poisoning process. Indeed, unless an epidemic is plainly established, it is very difficult, and often impossible, to make a differential diagnosis between the symptomatology and (I have no doubt under certain conditions) even the morbid anatomy, of poisoning by arsenic, e. g., and other substances, without a concomitant bacteriological examination. The only man capable of diagnosing positively a case of cholera when he sees it, and to whom bacteriology seems to be a superfluous adornment to medicine, is a "cholera expert at present in the service of the government. If the papers have correctly reported, he deemed a bacteriological examination useless after he had made the clinical diagnosis.

To revert to our subject. The r、semblance to a poisoning process is duc, according to Koch and most of the modern observers, to a specific putrefactive process in the upper part of the small intestines, the chemical product of which has the power of causing, when absorbed into the circulation, the dreaded and notorious nerve symptoms, and anatomically producing a necrosis of the epithelia of the intestines as well as of the secretory organs, especially the kidneys, in consequence of which anuria results. Some, however, believe that the grave nervous

symptoms are not caused by any cholera toxines, generated as metabolic products by the specific bacteria, but that those symptoms are due to inspissation of the blood by the excessive loss of water, the blood retaining all the offal products generated by the fever and the ordinary wear and tear of the body; while still others are of the opinion that the cadavers of the cholera vibrions, their decomposition and the absorption of the products of this decomposition respectively, are responsible for the symptoms of the choleraic attack.

All

Very naturally, a number of investigators went to work to extract and isolate the supposed poisonous substance. The results have been far from harmonious, which is perhaps due to the fact that the bodies purported to be cholera toxine, were obtained under different conditions of virulence; some, no doubt, from the absolutely harmless microbes that had grown in a liberal supply of oxygen. of the toxines, however, obtained by the various experiments of Brieger, Villier, Pouchet, Klebs, and others, when injected into animals, produced some, but not all, of the symptoms of cholera, principally paralysis and tremor. There is, however, at present too much discrepancy in the results to attach any great importance to any of them; and although poisonous substances have been obtained from cholera vibrions cultivated in eggs, with the above-mentioned result of increased virulence, it cannot be said that the cholera toxine has been discovered. Here, too, science is still in the dark.

I have in the preceding remarks touched only a few of the mooted points in the cholera question. Of course there are a great many more, and the farther science advances and the deeper the human mind penetrates into the mysteries of nature's workshop, the more riddles will present themselves for solution in this as in other branches of the natural sciences.

In consideration of these many harassing doubts and balking uncertainties, it is refreshing to see how some writers inside and outside the profession, especially the latter, seem to know all about the cholera, even its prevention and cure. The charming positiveness with which such authorities as Edwin Arnold pronounce themselves about the effects of quarantine and hydrochloric acid, is

quite a relief from the depressing consciousness of the often mentioned doubts and uncertainties. Unfortunately it is only the most ignorant in medical, as in other matters, that are the most positive in their assertions; and literateurs in particular have, ever since the illustrious examples were set by such men as Goethe and Carlyle, the uncontrollable impulse, when giving their opinion of medicine and doctors, to bring to the surface a portion of that asininity which lurks in the composition of the average man.

Sea-quarantine, whatever may be its inconvenience, seems to be a success, especially in the light of recent events; and if it should prove only a partial one, and cholera break through the barriers after all, it will be a success. Time gained, everything gained, is the parole in the present epidemic, when winter is near at hand.

Whether it is a wise plan to take hydrochloric acid as a prophylactic, should cholera make its appearance, is to my mind very questionable. Many persons do not bear it; it produces catarrh of the stomach in some, and aggravates existing ones in others, while in still others it has the well-known curative effect.

Should one drink the pure waters that are advertised as germ-free in case cholera should come to us?—Yes, provided they are boiled, when they may prove as good as our Mississippi water after having gone through a similar process.

It is a laudable and eminently proper undertaking that all over the country intelligent citizens are forming committees for the purpose of improving the sanitary condition of their cities. St. Louis has perhaps the best sanitary advantages of any of the large cities, the world over. If these advantages are rightly comprehended and utilized, the danger of a possible cholera invasion seems minimum. But there is a standing menace to the health and fair name of our city in case a serious epidemic of any kind should break out.

Time and again our city hospital has been branded by the daily press as a nuisance, and stigmatized as a burning shame on a rich and powerful commonwealth like ours, and I am afraid that, in case of an epidemic, whose danger is not by any means removed as yet, the scenes of horror witnessed in the hospitals of Hamburg would not only be duplicated,

but thrown in the shade. The conditionthen, of that institution, on whose ca, pacity and efficiency would above all depend the success or failure of barring and crushing out the invading enemy, an institution about whose inadequacy all the succeeding superintendents of the last twenty years have in vain complained, ought to receive the attention of those who, in spite of magnanimity, have taken upon themselves the Ne quid detrimenti respublica capiat.

The discouraging report of the Hamburg epidemic shows that, when once established, cholera generally braves all remedies, inoculation included. This should be an extra stimulus to work in the proper direction.

A CASE IN WHICH THE TAPELINE SHOWS
IMPROVEMENT IN CONDITION
BY EXERCISE.

BY HENRY CLARK, M.D.

THE case mentioned in the paragraphs following derives its interest from the circumstance that the improvement made has been registered in tapeline values. The patient was, during the time cited, under the care of a gymnastic director.. I knew the man by a former acquaintance with him. His measurements were first taken by the director and after awhile by myself, as a test of what results had been reached. I cannot make an exhaustive report on the subject, but as the patient was early a subject of mine, I have much knowledge of him. "M" "was, I presume, a dyspeptic, well enough to be about some business, yet not in a condition to enjoy what he had to do. FROM SEPT. 2, 1892, TO

5 MONTHS.

FEB. 2, 1893,

"M" has been having general gymnastic exercise, and says he feels much better for it. It includes what is ordinarily given to his pupils by this trainer, so far as I know; i. e., the so-called machinework of every kind; the stretch of the shoulders, in diagonal parallel bars, on pull-down horizontal-bar to chest, and to feet; the "quadrant;" the rowingmachine; pull-weights, with a bath and rub-down after exercise; 20 impulses in each exercise with light weights, about

half the average weight used by other

men.

Schedule of dimensions No. 1 (on beginning his training).— Weight, 126 lbs. ; stature, 684 in.; neck, 13 in.; right shoulder, 151⁄2 in.; left shoulder, 15 in.; circumference around shoulders, 3834 in.; chest, natural, 33 in, expanded, 34 in.; waist, 281⁄2 in.; hips, 34 in.; right thigh, 181⁄2 in.; left thigh, 181⁄2 in.; right calf, 131⁄2 in.; left calf, 13% in.; right bicep, 10 and 11 in.; left bicep, 10 and 11 in.; right forearm, 934 in.; left forearm, 934 in.

Schedule No. 2 (after five months' exercise. Weight, 1271⁄2 lbs.; stature, not observed, presumed to be unchanged; neck, 131⁄2 in. ; right shoulder, 161⁄2 in. ; left shoulder, 161⁄2 in.; circumference around shoulders, 3834 in. ; chest, natural, 334 in., expanded, 331⁄2 in.; waist, 291⁄2 in.; trochanters (answering to "hips" in preceding dimensions), 34% in.; right thigh, 191⁄2 in.; left thigh, 193% in.; right calf, 13 in.; left calf, 131⁄2 in.; right bicep, 10% and 11% in.; left bicep, 10 and 1034 in.; right forearm, 10% in.; left forearm, 102, in.

In schedule I the girths of calf and neck 13, 131⁄2 are so similar in value as to indicate a not unevenly developed man, as to proportion between upper and lower half.

He appears to the eye rather slight than full in his make-up, rather thinner above than below the waist, as compared with good men. His dimension "hips" is, as far as learned, taken at about the same level as the dimension "trochanters," which is the girth around the trochanter-major, on the level of the swell of the buttock, and this value shows the comparative vigor of the patient as indicated by his ability to stand up on his feet. He stands well.

Now as to his general improvement; it may be seen, on comparing the two schedules, that he has gained in weight from 125 to 1271⁄2 lbs., or 21⁄2 lbs. This This extra weight, by inference, is distributed quite evenly. There is a gain in neck of 1⁄2 in.; right shoulder, 1 in. ; left shoulder, 11⁄2 in.; chest, 4 in.; waist, 3/4 in.; hips or trochanter girth, 1⁄2 in.; thighs, about 1 in.; forearms, about 3/4 in.

As

to the significance of this actual gain, we have less play of chest (4 instead of 1); and this gives me opportunity to mention a singular phenomenon following vigorous and persistent exercise. My own

observation shows that the value "play of chest" will always decrease when a man has exercised for some time in a gymnasium; a result, I suppose accounted for by the lessened elasticity of the pectoral muscles, or of those muscles which resist the respiration. That the extra girth is small is accounted for by the fact that only a real building up increase is to be expected in this case, since the patient has gained his growth, being twenty-four years old this year.

While it is not possible in every example to compare ordinary growth, as indicated by the tapeline, with development under exercise, it is fortunately so in this case, as I have before me now the notes I made in 1884, when the lad was fifteen years of age.

Schedule No. 3, Dec. 12, 1884.- Weight clothed (from his own recollection) subtracting 7 lbs. for clothing, net, 103 lbs.; stature, approximately, 66 in.; chest, 30% to 314 (play 14) in.; trochanter girth, 32 in.; right thigh, 18 in.; right calf, 13 in.; left calf, 13 in.; right biceps, 10 in.; left biceps, 91⁄2 in.

Here are the dimensions of a lad somewhat debilitated, and in not so good condition as at the latest examination, since he had then gained some energy by his training. But the changes, compared with the latest schedule, show a gain of 23 lbs. in weight; in stature, 334 in.; in neck girth, I in.; chest, 234 in.; trochanters, 21⁄2 in.; thigh, 11⁄2 in.; calf, none, right biceps, none. He therefore gained the most in stature, chest, and trochanters. It is to be regretted that we have not yet learned just what the particular changes are which occur in the growing boy as he reaches puberty. I have several very interesting values at a later period, for several cases which boys have been willing to give me opportunity to attain, yet none, unfortunately, which furnish exact answers to this question.

Reviewing these figures once more, we find ourselves certified of a few facts: 1. That the growing boy in gaining young manhood grows taller and somewhat thinner proportionately; 2. That in some lines of development, growth gives much more variation than exercise; and 3. That judicious building-up exercise should be light in order to give a better condition. It can then be depended on for the best results.

SURGICAL SIGNIFICANCE OF DUST.

DURING the first years of the antiseptic era, the atmosphere was held responsible for many of the septic conditions developed in wounds which we have since learned to attribute to other causes. In those times, no operation, however trivial, was undertaken without the use of the spray, and the utmost attention was paid to keeping the wound protected from the air. The perfection of our antiseptic technique and the excellent results of the septic method have served to relegate the doctrine of air infection to the background, as is evidenced by the almost universal abolition of the spray during surgical operations. Thanks to the advance made in bacteriology, it is now recognized that the sources of wound infection are far more often to be sought in neglect of cleanliness, unclean hands and instruments, and improperly prepared dressings, than in an impure condition of the atmosphere. In other words, the doctrine of direct contagion has supplanted that of infection through the air. It cannot be denied, however, that the condition of the air in operating rooms and sick chambers exerts some influence upon the healing of wounds; and it will, therefore, be of interest briefly to review the results obtained by Dr. Carl Hægler (Beitrage zur Klinischen Chirurgie, Bd. 9, 1892), who has made the question of aerial infection the subject of an elaborate bacteriological investigation. stimulus to undertake this extensive work was furnished by two cases of erysipelas, for which no cause save aerial infection could be assigned. An examination of the air and dust of the ward occupied by these patients revealed a number of pathogenic organisms, chiefly staphylococci and streptococci, the virulence of which was shown by inoculation experiments on animals. Want of space forbids us from going into the details of the author's subsequent investigations of the air of operating theaters, hospital wards, lecture rooms, laboratories, etc., which were undertaken with extreme care. In all these places, pathogenic microbes were found in comparatively large numbers, and in view of this fact, Hægler concludes that the air must be considered as one of the factors of wound infection, although not a prominent one. The manner in which

The

these organisms are disseminated in the air is not difficult to understand. Staphylococci and streptococci occur in normal saliva and nasal mucus, and by spitting and sneezing become mixed with atmospheric dust. atmospheric dust. They are found on the superficies of the body, in the normal urethra, in the finger nail dirt, etc. They reach the air, however, in far larger numbers from the surface of suppurating wounds or dressings which have been in contact with them.

Since the dry aseptic method of wound treatment has come into vogue, and moist dressings are less employed, the danger of admixture of pathogenic organisms with atmospheric dust is greater than formerly, owing to the fact that during the removal of the dry dressing, particles of desiccated pus are frequently carried into the air, while this is less likely to happen if the wound be kept moist. Although these sources of atmospheric contamination are acknowledged by many authorities, most of them assume that the organisms are so rapidly destroyed in the atmosphere that they cannot prove injuri

ous.

He

Hægler's experiments show, however, that streptococci and especially staphylococci preserve their vitality for a long time in the air in a dry state. remarks that atmospheric infection frequently becomes a contact infection, the germs falling into the wound from the air, the hair, and the clothes of the operator and assistants, and being rubbed into the tissues by instruments, sponges, etc.

From his experiments the author deduces the practical conclusion that a thorough moistening of the air with steam -not by an atomizer-frees it almost completely from microbes within a comparatively short time; and that wetting the floor, walls, and furniture of the room prevents a fresh contamination of the air. The time required to purify the air will depend upon the rapidity with which the room can be filled with steam. During removal of dressings, especially if they be dry, there should be as little movement in the room as possible, so as to avoid stirring up dust. If dry dressings have been employed, they should be moistened before removal, so that particles of pus crust may not be disseminated in the air, and the dressings should be placed in moist receptacles and burned. - International Journal of Surgery.

[THE articles in this department are prepared expressly for this journal.]

TREATMENT OF HEPATIC DISORDERS-CIRRHOSIS.

BY DUJARDIN-BEAUMETZ,

Member of the Academy of Medicine, Physician to the Cochin Hospital, Paris.

Translated by J. H. Kellogg, M. D.

(Continued.)

IT is always at the beginning of the cirrhosis that a cure is obtainable, but in proportion as the contraction of the connective tissue is developed, thus destroying the hepatic cells, recovery is less likely to occur. Semmola, indeed, maintained that when the liver has become atrophied and deformed, a cure is no longer possible. It is then true, as Hanot and Gilbert have said, that it is in cases of cirrhosis in which the liver is large that we find the greatest chance of cure. Those are, in fact, the only ones which have been cured. The case which I have previously cited is a remarkable example of this. There have been hyperplasia of connective tissue, but the hepatic cell itself was not destroyed, and the liver weighed 2.700 kilograms (5.09 lbs.).

Can we, during life, recognize by positive symptoms, the state of the hepatic cell, and, aside from physical signs which enable us to determine the volume of the liver, have we other symptoms by which we may be guided in our prognosis? The most important evidence is to be drawn almost exclusively from an examination of the urine. In an excellent article upon alcoholic cirrhosis, Mérigot, of Treigny, observed that the more scanty the urine, and the less effect obtained from ordinary diuretics, the more grave is the prognosis. An examination for urobilin should also be made. Two other symptoms give indications respecting the state of the hepatic cell, namely, the quantity of urea secreted in twenty-four hours, and alimentary diabetes. more importance should not be attached to these indications than they really possess. As regards urea, patients suffering from cirrhosis, especially in the

from such disturbances of nutrition that the small quantity of urine is easily accounted for without considering the condition of the hepatic cells. According to Semmola, when in a patient suffering from cirrhosis the quantity of urine is found to increase under an exclusive milk diet, the prognosis is favorable.

As regards diabetes, you will recall that it has been advised, in cases of cirrhosis, to administer syrup of glucose, and to examine for the presence of glucose in the urine. Sugar will be found, as a rule, when the hepatic cell is destroyed. But the problem is here more complex than it might be thought to be, and I have already called attention to the fact that when hepatic cirrhosis occurs in a diabetic, the diabetes disappears, and that even when starchy food is used. It is easily understood that this is the natural result of the destruction of the glycogenic functions of the liver. There is no contradiction between these two facts. If glucose is administered to a person whose hepatic cells have been destroyed, the glucose is not stored in the liver, and may appear in the urine. In a diabetic, on the contrary, who, in consequence of the exaggerated functions of the hepatic gland, makes a greater quantity of glucose than can be used physiologically, the appearance of the malady which destroys the glycogenic functions of the liver causes the diabetes to disappear, notwithstanding the use of starchy food.

In fact and in practice, the most important sign is the more or less rapid appearance of ascites. When a fluid reappears slowly after removal by tapping, or fails to reappear, this fact is evidence that in spite of the alterations in the liver, a sufficient portion of the gland remains. intact to enable the portal circulation to be reëstablished, and the functions of the liver to be resumed. But the fact of the disappearance of ascites in cases of chronic alcoholism raises another question which must be considered, namely, Is ascites, in these cases, always due to cirrhosis?

Clinical facts have replied to this question. Lancereaux, in 1863, Thomeuf, in 1869, and Leudet and Hilton-Fagge later, affirm that in cases of chronic alcoholism there may exist a chronic peritonitis with ascites. It is easily comprehended how