VOL. V. TOPEKA, KANSAS, APRIL, 1893. Notes on Asiatic Cholera. Read before the Topeka Academy of Medicine and Surgery, February 13, 1893, No. 4. that if the film is thick, the spirillum may survive as long as thirteen days. Sunlight exerts a deleterious effect. He also found that the thermal death point is 52° C. or 125.6° F. in ten minutes. By MAGGIE L. MoCREA, M.D., Topeka, Kas. At 60° C. or 140° F. the spirillum is de The subject of Asiatic cholera is one which at present interests every progressive member of the medical profession. stroyed in a very brief time. It will be inferred from such facts that cholera disinfection is comparatively easy. It would seem quite possible to exclude the disease by an efficient quarantine. Prof. von Pettinkofer, in the Munchener Medicinische Wochenschrift, November, 1892, The appointment by the New York says that the etiology of cholera is an Academy of Medicine of a national quaranequation with three unknown quantities, tine committee to secure necessary legislanamely: (x) a specific germ disseminated by tion for the protection of this country against human intercourse; (y) a factor dependent an invasion of Asiatic cholera is an action on place, which he calls "local predisposi-worthy of that association. tion"; and (2) the individual predisposition. The requisite local precautions consist in The key to the solution of this equation good drainage and general cleanliness. must depend on the biological characteristics of the specific germ x. Having learned this, we may be able to decide what constitutes the "predispositions" of y and z; also what is necessary to neutralize the same; in a word, the necessary prophylaxis. The coma bacillus, discovered by Koch, is now almost universally accepted as the specific cause of the disease. There is no necessity of any community suffering from an epidemic of cholera if such is not desired. Neither is it necessary for any healthy individual to suffer from the disease if proper precautions are observed. The disease can only be contracted by the introduction of the coma bacillus into the stomach or intestinal canal. If introduced into the stomach, the acid condition of the gastric juice will, or should, destroy them. All indiscretions in diet should of course be scrupulously avoided. Also avoid fatigue, sudden changes of temperature, extremes of heat or cold, nervous excitement, or anything which will tend to depress the normal The theory advanced by Prof. M. Peter, that the bacillus coli communis may become either cholerogenetic or dysenterogenetic, according to circumstances, I regard as untenable. He finds these so-called coma bacilli in the blood, which is not the case with the spirillum of Asiatic cholera. No equilibrium of health. In short, be just as such evolution as would be required by this calm and happy and lazy as if sickness and theory has ever been demonstrated in any suffering and death did not exist, and you other bacteria or in any organisms of a will certainly escape the dreaded scourge. larger development. If proven, it would be It is advisable to eat only foods which. a microscopic demonstration of Darwinism. have been thoroughly cooked, and to drink After a study of the biological character-boiled water or acidulated drinks, avoiding istics of the cholera spirillum, Dr. Sternberg all alcoholics. informs us that dessication will kill it in a Inoculation of cholera vaccine, according few hours if the stratum is a thin one; but to Ferran's method, appears to be a reason able prophylactic measure. The objection about two minutes, dehydrate by dipping that it will not give immunity because it is not introduced into the alimentary tract is not sustained. for a few seconds in absolute alcohol, wait a few minutes until they are dry, and examine under a microscope with a power of The disease is evidently the result of one-fifteenth water immersion, or, better toxines or ptomaines, generated by the still, a one-twelfth oil immersion. bacilli, not by the mere presence of the bacilli. Although the above method is exactly the one used by Koch, we may fail to find any characteristic bacilli. Through the kindness of Dr. Edward K. Dunham, I am able to present to you a specimen of the coma bacillus, taken from one of the cases occurring on Swinburne Island last September. I must confess that after studying the specimen, I find the written descriptions of the bacilli more accurate than the appearance under the microscope. Those who prefer this method of obtaining immunity may, however, introduce the culture into the stomach a la Profs. von Pettinkofer and Emmerich. The objection to this method is that the result of such inoculation is a mild case of Asiatic cholera, with the same dangers of infection that any other case of cholera would present. The differential diagnosis of the disease must depend upon the demonstration of the pręs- Another method which Dr. Stubb conence of the spirillum of Asiatic cholera. siders better is as follows: Place a drop of Koch's bacilli are smaller and have more of rice-water discharge upon a cover glass and the corkscrew shape than that of cholera put the latter with the drop of fluid downnostras or the curved bacilli of old cheese, ward upon a shallow glass cell. If this susdiscovered by Dr. Deneke. Dr. Lewis' pended drop, which may be stained with any bacillus, found in the mouth, will not grow of the basic anilene dyes, is examined under in an alkaline medium, and is also larger than the coma bacillus. The only spirillum for which it may be mistaken is that of recurrent fever. a powerful immersion lens, we will find a large quantity of bacteria alive. Among these the cholera bacilli will appear like a swarm of mosquitos, and among these oc Dr. Stubb describes three methods of ex- casionally a few spirilla of a wave-like form. amining for cholera bacilli: This is the description by Koch of a drop of artificial beef-tea culture, and Dr. Stubb has no doubt that the same may be observed from rice-water discharges after the patient has been sick for some time. The surest method suitable for diagnostic purposes will be the cultivation with nutritive gelatine upon glass plates, provided we are able on short notice to obtain the necessary nutritive gelatine of slightly alkaline reaction. The following formula is the most convenient one which I have been able to find: First, seventeen ounces good chopped meat, added thirty-four ounces distilled First, take two cover glasses, sterilize in the usual way, and dry them. Then place a drop of the rice-water discharge upon one of the glasses with a sterilized spatula, and spread the drop of rice-water discharge out upon the cover glass. Place the second glass upon the first and draw them asunder in order to cause an even and uniform spread of the material upon both glasses. As soon as they are thoroughly dry, draw them slowly three times through the flame of an alcohol lamp, holding them with a pair of forceps. Then take home and heat in a test tube a small portion of a watery solution of water and well stirred, remains standing in gentian violet or fuchsin. As soon as the the ice-box twenty-four hours. Afterward fluid begins to smoke, pour some of it into the whole is strained through gauze by a watch glass and drop the cover glasses means of a press, and enough distilled water into the fluid with the side containing the added to make thirty-four ounces. suspected material downward. Let them must be added two and one-half drachms swim for about ten minutes, take them from table salt and one and one-half to three the fluid, wash in sixty per cent. alcohol ounces of the finest gelatine; allow the To this an extent that the whole of the gelatine will have flowed off from the object glass, whole to dissolve by gentle heat, neutralize look like a mass of irregularly-shaped, with sodium carbonate and add a little of highly-refractive granules, which Koch the latter in excess to give the mass a compares to a little pile of small pieces of slightly alkaline reaction, sufficient to turn glass. Within twenty-four hours the gelared litmus paper slightly blue. The neu- tine becomes fluid in the immediate neightralized solution must be boiled an hour borhood of the colony, and the latter sinks upon a water bath, and, still hot, filtered into the gelatine. A small funnel-shaped through paper. The filtrate boiled again impression is formed, in the midst of which and afterward put upon ice; must be clear the colony may be seen as a small whitish and transparent. During the boiling pro- spot. For the purpose of making these obcess a turbidity may appear, caused by servations, the glass plate must be placed phosphates, which, however, will disappear under a microscope with a power of about as soon as the gelatine has been cooled upon eighty diameters. In order to make these ice. Supposing we are in possession of the cultivations, a temperature not lower than necessary gelatine and desire to make the 68° F. is necessary. cultivation as above mentioned. For this In case we have to deal with a cultivation purpose take an object glass, according to of the bacilli of cholera nostras, we shall the size of the stage of the microscope, to find discs of a regular, even shape, and enable us to examine the same in all direc-within thirty hours a funnel one centimeter tions with a lens. Put some of the nutritive in diameter will have formed, which in two gelatine in a test tube and warm it in hot or three days will have widened out to such water until the gelatine becomes fluid; then by means of a pipette, carefully transfer some of the gelatine to the object glass. Before we have completed these observaThe portion of the gelatine transferred must tions, however, it will be necessary to have be a few millimeters thick and no part touch done something for the relief of the patient. the edge of the object glass. Then take, The degree of vigor with which treatment with a sterilized platinum wire, a drop from is inaugurated must depend upon the prothe rice-water discharges, inoculate the gress which the disease has already made. gelatine by making a few strokes upon it of The first symptom of the disease is usually not sufficient depth to reach the glass below a very free movement of the bowels without the gelatine. The longer the object glass, pain. The patient believes that he never the more strokes we shall be able to make, felt better in his life. In an hour or two and the easier it will be to recognize and there is another copious .stool, still without differentiate the colonies of bacteria which pain. Perhaps there is another, then nausea will grow there. After the gelatine has if felt; soon vomiting ensues, followed by been inoculated, the plate of glass must be more stools, which assume the characteristic put under a bell glass, whose walls should rice-water appearance, due to the large be dampened inside with distilled water. quantity of exfoliated epithelium. Cramps Eighteen hours afterward we shall observe supervene, cyanosis, shallow respiration, the result of the inoculation by the growth anuria and all the concomitant symptoms of of the different species of bacilli. In case of Asiatic cholera, we should observe in the early stage of the growth a small, pale drop, not of a perfectly circular appearance, such as most colonies of bacteria present, but diagnostic points, however, is the absence with irregular rough edges. From the very beginning of its growth it has a granulated appearance. A few hours after the first appearance of these drops upon the gelatine, the granulations appear more marked and collapse. The attack may be preceded by an acute indigestion, in which case I suppose there would be the pain which usually accompanies such a condition. One of the of pain up to the danger line. The absence of nausea is also stated to be characteristic; the vomiting being of a regurgitant character without the usual nausea. The treatment should always be prompt and vigorous. Astringents and opium are An enteroclysis, consisting of one to two contra-indicated, except for the relief of per cent. solution of tannic acid, having a pain. If preceded by indigestion, castor oil temperature of 113° F., was also employed. or magnesium sulphate is advised to remove For an adult, two quarts may be given; for the undigested food. Otherwise no purga- an adolescent, one quart. The solution tive should be given. The popular idea at should be introduced very slowly, taking present seems to consist chiefly in stimula- not less than ten minutes time. By this tion and asepsis. The methods advanced careful administration it is claimed that in for obtaining the desired asepsis are very a majority of cases the fluid will pass the numerous. Salol is highly recommended by ileocæcal valve. Dr. Hare and others. As salol is not dissolved in the stomach, but in the duodenum is decomposed into its component parts, phenol and salicylic acid, its use is certainly based on rational grounds. Washing out the stomach with a solution of tannic acid is also advised. Camphor and ether are advised as stimulants; also deep hypodermatic injections of whisky. Sulphuric acid is antagonistic to the In case of extreme collapse, intravenous coma bacillus, and is also astringent. Dr. injections of the normal salt solution is adTodd advocates the free use of hot water, vised. Dr. Pilchner gives a very full deacidulated with sulphuric acid, for the relief scription of the technique of this operation of the intense thirst. It seems a more in the Brooklyn Medical Journal of October, rational method than the administration of 1892. ice and iced drinks. In the same journal Dr. Dawbarn advocates transfusion into the femoral artery in extreme cases. Non-Malignant Growths of the Nose. Read before the N. E. K. M. & P. Association at Netawaka, Dr. Daland informs us that in the treatment of the cases in Swinburne Island Hospital the patient was first immersed in hot The subject of Asiatic cholera is, however, water, then given a subcutaneous injection altogether too broad to be treated fully of hot sterilized water, containing six-tenths within the limits of one short evening. I per cent. of sodium chloride and one per have attempted only to touch upon some of cent. brandy. This procedure is known by the leading points, hoping to elicit a disthe name of hypodermoclysis. The first in-cussion on a theme which now occupies such jection in an adult may be one or two quarts. a prominent position in the current literaIn but one of the eleven cases did an abscess ture. form. In favorable cases absorption took place in thirty to forty-five minutes, but in those where collapse approached death, as long as four hours may be required. The rate of absorption is therefore of great prognostic importance. The best position for these subcutaneous injections is in the flanks, in the region of the floating ribs, in the median axillary line, although it may be administered in the gluteal region or the inner aspect of the thigh. Ordinarily a hypodermoclysis may be repeated every two hours, and in severe cases it may be well to inject one quart in each flank, repeating the operation so soon as it has been absorbed. The solution should have a temperature of about 104° F. A good working rule is as follows: For an adult, two pints; for adoslescent, one pint; for an infant, half a pint. BY W. E. MCVEY, B.S., M.D., Topeka, PROFESSOR OF LARYNGOLOGY AND RHINOLOGY AND DIS- Non-malignant tumors of the nasal cavities are the class of tumors we are most frequently called upon to deal with. The importance of our interference in these cases is directly dependent upon the conditions in which they are found and the conditions produced by them in the nasal cavity or accessories. If there be at the time of observation no direct interference with the function of the tend to increase in size are obstruction to nose, the probability of future disturbance the nasal passage and interference with should be carefully considered. drainage, or occlusion of one of the accessory sinuses and pressure upon the adjacent structures. The nature of the growth, its location with reference to the more important structure of the nose, and its tendency to rapid development are points which should be carefully investigated. It is usually safe and in most instances advisable to remove any neoplasm occurring in the nasal cavity, whether there be interference with the function or not, if it be not a malignant growth. It is, however, not always an easy matter to decide as to the character of these tumors. Frequently a growth in the nose, which has every appearance of being benign, will recur after removal and present a wellmarked type of malignancy, and in some such cases, noted pathologists, after careful microscopical examinations, have pronounced tumors benign, which upon recurrence they have by a similar examination found to be malignant. These are the conditions we will be called upon to relieve and which render the existence of such a growth of any serious consequence. We also find that disturbance of the func tion of other organs, usually associated case, and to pressure by an enlarged mid- Probably the most common tumor seen in the nose is that which we most readily recSometimes also a growth, which has, the ognize as an hypertrophied turbinate. gross appearance of a malignant tumor, and While this is simply a hyperplascia of conwhich presents other conditions tending to nective tissue and has not the characteristics confirm such opinion, will, upon microscop- of a new growth, it may nevertheless propical examination, show none of the appear- erly come in the category of tumors, in that ances of such a tumor, until after its removal its results are essentially the same. and a recurrence. A hypertrophy of the lower turbinate usually So we may say that while a microscopical presents, upon inspection, a rounded, reddish examination should always be made where mass lying along the outer and lower porthere is any question, we must not rely alto- tion of the cavity, partially or completely gether upon the results; but where the his- obstructing the passage. This mass is tory and appearance indicate a malignant usually of a dark red color and covered with character, even though contradicted by the a mucous or muco-purulent discharge. microscopical appearance, we should rather We may be deceived as to the real amount base our opinion upon these evidences. The of hypertrophy existing by the size of the question as to the removal of malignant tumor. The venous sinuses, which form an growths we have no desire to discuss in this important part of the turbinate bodies, are under the vaso-motor control, and their reWhile there are quite a variety of non-laxation and the consequent effusion of malignant tumors of the nose, they are all serum into the tissues most readily occurs somewhat closely allied, and so far as inter- upon slight irritation, so that much of the ference with the function of the nose is con- size of the tumor may be dependent upon cerned, they all produce like results. The this effusion, and the amount of hypertrophy conditions which most seriously demand be in reality small. In order that we may operative interference and which are pro- ascertain the true condition, the use of coduced alike by all forms of neoplasms which caine is of inestimable value. paper. |