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temperature; that it may be destroyed by putrefaction; that it may live or die in water. In running water it is very difficult for these germs to develop.
In studying the etiology of a case during an epidemic of cholera, it is necessary to take into account the biological properties of its germ, and the conditions necessary for its existence and multiplication. Carried from locality to locality by man, either in the alimentary canal or in soiled clothing, it may gain a footing in polluted surroundings, filthy ponds, cesspools, etc., and there become a center of infection from which numerous other cases may spring. It is evident that the filthy condition of habitations offers very favorable conditions for the development of various germs, as well as the bacillus of cholera. Cleanliness is therefore absolutely necessary to fight the invasion of this enemy.
Treatment. - Two forms of treatment have been recommended, a preventive and a curative form. As preventive measures of a medical character, vaccination has been recommended, first by Ferran, of Spain, and since by various other more authoritative scientists.
I need not dwell on this question here, as it has been treated in preceding numbers of this journal. Neither do I need to enter into a discussion of hygienic, prophylactic measures, which have also been treated etiologically and otherwise in this journal. It is only necessary to mention that the exclusion of the germs from the alimentary canal is the only positive safeguard, and this cannot be done without the strictest care to ingest nothing that has not been thoroughly cooked. It is also necessary to disinfect the mouth every day, and the intestines at times, by antiseptic agents.
As a curative treatment, salol is proposed. This recommendation is based on the antiseptic property of this substance, and the fact that a great quantity of it may be taken at a given time. Owing to the fact that muriatic acid destroys the germ of cholera, we would say, theoretically at least, that both as a curative and a preventive measure, the drinking of small quantities of muriatic acid, very largely diluted, or other acids having a similar property, would prove beneficial. I only mention these indications as based on the biology and physiology of the germ. It is not my purpose to go into any
practical details. Of late, other medical journals have published numerous modes of treatment. Every practitioner should bear in mind that no treatment is likely to be successful unless the microbic invasion is stopped before any septic complications have taken place.
EXPLANATION of plate.
FIGURE 1.- - Different forms of cultures of cholera on agar-agar and gelatine plates (after Cornil and Babes). a, Colony on gelatine after 24 hours; b, colonies after 48 hours; c, colonies after 48 hours at a temperature of 68° F.; d, colonies after 3 days; e, colonies after to 6 days; f, g, h, colonies developed at about 61° F. during 5 or 6 days; i, colonies on agar-agar developed in 24 hours at about 99° F. I and 2, other aspects of cultures on gelatine.
Fig. 2. Living culture cholera bacilli (Cornil and Babes). a, b, c, d, Forms of the bacilli exhibited in their growth and development; f, g, i, their segmentation; k, mass of bacilli; l, m, n, elongated and comma forms; o, p, q, bacilli that remained united after their segmentation; r, s, t, u, v, undulated filaments; y, z, filaments segmented in bacilli remaining united.
Fig. 3. Bacteria obtained after the first culture from cholera fæces (Cornil and Babes). c, c, Cholera bacilli; b, straight rod; a, other rods and filaments larger than cholera bacilli; m, other bacteria with extremities more deeply stained.
Fig. 4. Section of a portion of the inferior part of the intestine intersecting a gland of Lieber-Kuhn in cholera (Cornil and Babes). c, v, Tumefied and hyaline cells of the gland; between the cells and the reticulated tissue of the mucous membranes exist a number of comma bacilli; c, r, granulous cells of Ehrlich.
Fig. 5.-Section of the cæcal appendix in a case of cholera (Cornil and Babes). b, Surface of the intestine showing diverse species of bacteria; s, superficial tissue having become hyaline with spaces containing a quantity of little bacilli; g, e, a tubular gland showing a hyaline state of its epithelial cells; the bacteria penetrate in a crevice between the epithelial cells and the basic membrane of the gland; t, r, reticulated tissue situated in the depth of the mucous membrane. (Magnified 300 diameters.)
CONTRIBUTION TO THE STUDY OF PROGRESSIVE MUSCULAR ATROPHY.
BY W. H. RILEY, M. D., BATTLE CREEK, MICH. Member of the American Neurological Association.
In a case well advanced, the prominent symptoms of weakness and wasting of the muscles, together with a history of the gradual progression of the disease and the almost complete absence of sensory symptoms, leaves little that is uncertain in the diagnosis. But in the beginning of the disease, when the weak
ness and wasting is slight, and limited to a few muscles, a diagnosis becomes much more difficult. Under these circumstances we are to distinguish between it and the following conditions:
1. An inflammation of a nerve in some member, which may be done by the limitations of the nerve, the rapid onset of the inflammation, and the accompanying sensory symptoms. 2. A multiple neuritis. In this we meet with the greatest difficulty, especially in those cases where the neuritis is limited almost entirely to motor branches of the nerve. In an ordinary case of multiple neuritis, the rapid onset of the disease, the usual simultaneous affection of the corresponding parts, i. e., its symmetry, the accompanying sensory symptoms of pain, hyperæsthesia, anææsthesia, etc., a history accompanied usually by an obtrusive cause and a tendency usually to improvement is sufficient in most cases to make a distinction. 3. A pachymeningitis. In the latter the wasting is more rapid, and is always accompanied by sensory symptoms of pain and anæsthesia, frequently of irregular distribution. 4. Idiopathic muscular atrophy. Sometimes this is rather difficult. When several cases of muscular atrophy occur in the same family in childhood, it is most probable that they are idiopathic, and not spinal. Indeed we rarely see the spinal form of muscular atrophy under the age of twenty, and unless there are distinctive spinal symptoms, the idiopathic from is to be suspected. 5. Local atrophies are sometimes said to occur from the excessive use of the smaller muscles of the hand, but such cases must be extremely rare, and should be suspected only on the clearest indications. Prognosis. From the nature of the disease, the prognosis must from the first be grave. The tendency of the disease is to progress until it has become wide in extent and extreme in degree. Seldom does the disease cease spontaneously until an advanced stage is reached; but little is gained by this, as nothing is left but a mere helpless existence.
In those muscles that have been the seat of a slow and progressive wasting for six months or more, there is little hope of improvement, although the disease may be arrested by treatment. The prospect of any recovery depends somewhat on the rate at which the disease has advanced. Recent rapid loss of power, especially
where the muscles present the reaction of degeneration, may in some cases be partially recovered from. The prospect for arrest seems greater in those cases where the disease affects corresponding parts of the body simultaneously, rather than in cases where the disease has advanced to a good degree on one side before the other side is affected.
One of the chief dangers to life is an involvement of the muscles of respiration. Bulbar paralysis is also a serious complication. While the outlook from the beginning is most serious, the patient is entitled to some encouragement and hope, as not infrequently the disease may be arrested, if not permanently, at least its onward progress may be stayed for a time by proper treatment. The outlook is more favorable in cases of middle life than in old age, and in those cases where the paralysis exceeds the atrophy and the reaction of degeneration is present in the muscles.
Treatment. While the nature of the disease is such that nothing very brilliant can be looked for in most cases from treatment, much can be done to check the disease, and thus prolong life, even though an absolute cure is not accomplished, and in a disease attended with such serious results, nothing should be left undone that offers any possible encouragement or hope to the patient. The patient should be under as favorable hygienic conditions as possible. It is important that he should have plenty of fresh air, sunshine, a wholesome, nutritious diet, a moderate amount of exercise, and plenty of rest. In every case the cause should be sought for, and as far as possible removed. It is important to keep in mind the primary seat and nature of the disease, that the seat of the disease is in the spinal cord, the nature of which is the fault of the nutrition of the essential nerve elements. Any treatment, therefore, tending to improve nutrition, and especially nutrition of these parts, will be in the right direction. The nutrition of the spinal cord may be influenced by the application of (1) heat, (2) cold, (3) electricity, and (4) exercise.
When heat is applied along the back directly over the spine for any length of time, the temperature of the tissues beneath is raised, more blood is brought to the parts, and the nutritive processes are modified and hastened. The application
of heat to the spine may be made by the use of fomentations or a rubber bag long enough to reach the whole length of the spine, filled with hot water or water as warm as can be borne by the patient. The temperature should not be more than 120° F. This application of heat should continue from one half to three quarters of an hour, and be made daily; and if the patient is not so weakened by the disease as to produce fatigue, two applications daily are better than one.
When cold is applied to the tissues for any considerable length of time, heat is abstracted, and the temperature of the tissues is lowered. This calls forth an effort on the part of nature to maintain the normal temperature of the parts, and in this effort there must of necessity be an increase in the nutritive changes. These changes are hastened, and this may finally lead to the establishment of a more healthy nutrition in the parts that are the seat of the disease. The application of cold to the spine should be made in a similar way as that of heat, except that the spine bag is filled with ice water instead of hot water. The ice bag may be kept on the spine from ten to twenty minutes at a time, and the applications may be made once or twice daily, as the patient is able to bear. Too long an application of cold to the spine may result in depression, and do harm instead of good.
In most cases, the application of heat to the spine will, I think, be found more beneficial than the ice bag, especially in those cases where there is much weakness and emaciation. In some cases good results may follow from the use of the ice bag. Its effects on the patient should be carefully watched, and treatment modified if necessary.
In the application of electricity to the spine, the galvanic or continuous current should be employed. In making these applications, it is important that the current should pass directly through the spinal cord. In order to accomplish this effectually, a large electrode sufficient in size to cover the whole abdomen should be joined to one pole of the battery (preferably the negative), while to the positive pole is joined an electrode about three inches in diameter, or of such size as will well cover the spine transversely. The patient then lies on the large electrode, face downward, so as to make a good
contact with the abdominal surface, and the small electrode is applied up and down the back over the spinal cord. By this arrangement, the current must pass directly through the spinal cord, and by using the electrodes of unequal size, the current is heaped up, so to speak, around the smaller, which is directly over the spinal cord; and thus whatever influence the current may have is brought to bear directly on the diseased tissues. With these sizes of electrodes the current strength should be from twenty to thirty milliamperes. Each application should last from ten to fifteen minutes, and in most cases the treatment may be given daily.
Exercise will undoubtedly have some influence on the nutrition of the motor cell and fiber which are the primary seat of the disease under discussion. Whenever the nervous impulses travel from brain to muscle, the nerve fibers all along the motor path, as well as the motor cells in the spinal cord, are brought into activity.
This is not the place to discuss the probable changes which take place in the nerve fiber when it is traveled by a nervous impulse, but it is a well-established fact that functional activity on the part of any tissue or organ is quite essential to the maintenance of a healthy condition, and this is not less true in the case of nervous tissue than of the muscles or any other organ.
Now by exercise, nervous impulses are made to travel over these nervous fibers and motor cells which are the seat of disease. As we have stated, this func-tional activity tends to maintain the nutritive processes, and to retard the morbid changes, the tendency of which is to bring the tissues still lower in the scale of degeneration. While exercise, `properly directed, will result in good, it is important that too much exercise should not be taken. In order to determine best the amount of exercise that is adapted in any particular case, the strength of the different muscles of the body should be carefully measured, and the case closely watched. It should be remembered that the nutrition of the spinal cord is lowered, and that the resistance of the nervous elements is less than in health; and while a moderate degree of exercise may improve this, too much may do harm by taxing the nerve cells and fibers beyond their
capacity. The above, of course, applies only to cases that are able to take exercise. When the disease becomes well advanced, and the patient is entirely helpless, any exercise will be impossible. The patient should have plenty of rest, and should avoid exhaustion.
The application of heat and cold alternately to the spine, often does good by acting as a general tonic. In this case the heat should be applied for about five or ten minutes, followed by a cold douche for about five minutes, and these applications kept up alternately for about one half hour. In many cases, cold spray or a cold wet sheet rub will result in much good. This treatment should be applied carefully, so as to avoid a shock or chill, and in such a way as to be followed by a good reaction. The beneficial effects come in two ways: 1. It has a general tonic effect on the body; 2. It has a special action on the spinal cord by acting through the afferent nerves.
When cold is applied to the skin in this way, impulses traveling along the afferent nerve by reflex action, reach motor cells and fibers and stir them up to increased functional activity. The stimulation produced by this means is undoubtedly greater and more beneficial than is usually accredited to it.
Along with the treatment that is directed especially to the spine, the muscles should not be neglected. Their nutrition may be acted upon and improved by the use of the massage and the application of electricity in the form of faradic and galvanic currents. As a rule, better contractions will be obtained in those muscles that are the seat of paralysis and wasting by the use of the galvanic current, and not infrequently contractions will be obtained from its use when it is impossible to obtain contractions with the faradic current. The adaptability of the current in any particular case may be determined by a careful examination. When the galvanic current is used for treating the muscles, my practice is to use a large electrode at some indifferent point, as over the lower part of the back or over the abdomen, and the current is applied to the muscles with a smaller electrode, the current being rapidly interrupted. Usually better contractions will be obtained by applying the negative pole over the muscles. If, however, the destruction of nerve is rapid
and in excess of the wasting of the muscles, the anodal closure contraction may be as great as the cathodal closure contraction, and there may be no choice as to which pole is used.
The electrical treatment of the muscles should be given at least on alternate days, and may in some cases be given daily; each treatment should occupy about twenty or thirty minutes in its application.
The use of massage with active and passive movements is beneficial to the nervous system as well as to the muscles. Its effects on the patient should be carefully watched, for when used excessively, may break down muscle instead of building it up. The method of its application and the skill of the manipulator have much to do with its beneficial effects.
The beneficial effect of exercise on the nervous tissue has already been referred to. What has been said in this connection will apply with equal force to the muscles. The voluntary contraction of the muscles improves their nutrition, causes more rapid changes in the circulation of the blood through them, and tends to hinder their wasting.
Warm baths will be found useful in
It is very doubtful if much good comes from the use of drugs in this disease.
We would hardly be doing justice to the subject, however, if we did not call attention to the treatment recommended by Dr. Gowers, of England. He claims that he has been able to arrest the disease in more than fifty per cent of the cases he has treated, by the use of hypodermic injections of nitrate of strychnine. The injections are made once daily in any part of the body. The dose first used is one hundredth of a grain, rapidly increased to one fortieth of a grain daily. In seven consecutive cases treated by this method by Dr. Gowers, the disease was arrested in a month, and the arrest was permanent in all except one. Dr. Gowers claims that it is important that the drug be used hypodermically in order to get the best results. When the malady is apparently arrested, it is well to intermit treatment one week in three or four.
We cannot speak from any personal experience with the above treatment, but if such favorable results can be obtained in a disease so serious, and so unyielding to the usual treatment, it is certainly worthy of a faithful trial.
TRANSLATIONS AND ABSTRACTS quantity of sugar eliminated in twenty
[THE articles in this department are prepared expressly for this journal.]
GLYCOGENIC FUNCTION OF THE LIVER.
BY DUJARDIN-BEAUMETZ. Member of the Academy of Medicine, Physician to the Cochin Hospital, Paris.
TREATMENT OF DIABETES.
Translated by J. H. Kellogg, M. D.
In the preceding lesson (see BACTERIOLOGICAL WORLD AND MODERN MEDICINE, December, 1892, page 438), I have shown the influence of the nervous system upon the production of sugar. The fact of this influence finds confirmation in therapeutics; and drugs which diminish the excitability of the cerebro-spinal axis, act favorably in diabetes. Formerly, opium in large doses was advised in these cases, but the disorders of the digestive functions produced by this drug have led to its abandonment. Félizet has advised bromide of potash, but here also, in spite of the real advantages obtained by the bromide, certain inconveniences attend the use of the drug, which counterbalance its advantages. I refer to the depression of the vital forces which accompanies the employment of the bromides, and the eruptions produced by them.
Worms has highly recommended sulphate of quinine, which gives, we must admit, some results which are often advantageous. But here, still, the prolonged use of this salt produces, in certain patients, gastric troubles; and it should never be forgotten that all medication which compromises the digestive functions of a diabetic patient, must be abandoned. For myself, I give preference to antipyrine. The effects observed The effects observed by G. Sée, by Panas, and by Huchard, have shown the favorable influence of antipyrine in the polyuria of diabetes. I say diabetic polyuria, because it is especially against the excess of urine that antipyrine acts; and as by diminishing the amount of urine excreted daily, it does not increase the quantity of sugar, it is easily understood that a favorable effect is obtained by diminishing the
As drugs which diminish the excitability of the spinal cord are favorable in the treatment of diabetes, it is easy to understand that an excessive amount of work, and all circumstances which tend to increase the excitement of the brain and spinal cord, are dangerous. Disappointments, a prolonged amount of work, and violent emotions are also aggravating in cases of diabetes; and it may be said that when the sugar reappears in the urine of a patient, without any violation of the rules of his regimen, it may safely be affirmed that the cause is some mental or moral influence which has profoundly disturbed the cerebral and spinal functions; hence the conclusion that it is necessary for the diabetic to avoid overwork, violent emotions, and cares and anxieties of all sorts.
I now pass to the consideration of the diathesic treatment of diabetes. The diathesis which predisposes to diabetes, is the arthritic, and in the majority of these patients you will find gout and calculi in their heredity. By means of appropriate treatment, we are able to act upon this diathesic origin of the disease, and it is here especially that arsenic and the alkalies render us great service.
How do the alkalies act? The opinion. of Mialhe, who maintained that the blood of diabetics is acid, is to-day recognized as wholly erroneous. It is by favoring the oxidation of organic substances that