of cholera promptly might result in incalculable consequences with regard to the dissemination of the disease, because the necessary measures of isolation and disinfection are neglected. The early and certain recognition of the first case of cholera especially is, therefore, of the greatest importance. The same clinical picture as Asiatic cholera gives rise to is encountered also in cases of European cholera, and in some instances of poisoning, especially with antimony and potassium tartrate, arsenic, mercuric chlorid, mussels, fungi, veratrum, colchicum. In the differential diag nosis the bacteriologic findings alone are decisive. Confusion is possible, further, with incarceration of the bowel; the various sites of hernia should, therefore, be carefully examined. If the presence of Asiatic cholera is established, it can be readily determined from the symptoms whether cholera-diarrhea, cholerine, or asphyctic cholera exists. Prognosis. The prognosis of Asiatic cholera is in all cases grave, for there is no certainty that in spite of all precautions even mild attacks may not be converted into severe attacks. Naturally, the prognosis of cholera-diarrhea is more favorable than that of cholerine, and that of the latter better than that of asphyctic cholera. In general the mortality ranges between 50 and 60 per cent. Anatomic Alterations.-The choleraic facies remains conspicuous even in the dead body. Often the muscles of the extremities are sharply outlined beneath the skin, and give the extremities unusual attitudes, which have been designated fencing attitudes. It is noteworthy that occasionally the muscles exhibit post-mortem contraction, so that even some of the fingers, and even entire extremities, may be engaged in movement as late as two and a half hours after death. Occasionally the body is said to have been found in an entirely different position than it had occupied, and this naturally has afforded some support for the tradition among the laity as to apparent death. All of the internal organs exhibit pallor and dryness. The serous membranes (pleura, pericardium, peritoneum, meninges) feel as if smeared with soap. The heart contains only a small amount of inspissated blood. The pallid, bloodless lungs appear emphysematous. The stomach, but especially the intestines, contains an abundance of rice-water-like fluid. The epithelium of the intestinal mucous membrane is in many places detached, and floats in the intestinal contents. The mucous membrane appears hyperemic upon the summit of the folds and villi, especially in the ileum, but less so in the large intestine. Often the intestinal follicles are slightly enlarged. The intestinal serosa presents an actively injected appearance and a rosy discoloration. The spleen exhibits no peculiar alteration, nor does the liver, but the gallbladder contains little bile of rather mucous consistency and gray ish color. The kidneys are notable for their anemia and the flaccidity of their tissues. On microscopic examination of the viscera the epithelial cells of the intestinal mucous membrane will be found in various stages of necrosis and degeneration. In the interstices of the intestinal glands, and between their epithelial cells and the membrana propria of the gland-tubules, the cholera-bacilli will be encountered. The latter are occasionally present, also, in other situations, as, for instance, in the biliary passages, the kidneys, the spleen, and the subarachnoid spaces of the brain. The blood-vessels of the intestinal mucous membrane and the serosa are dilated and greatly filled with blood. Between the glandular cells and in the submucosa abundant round-cell accumulation is evident. In the kidneys especially the often extensive epithelial necrosis in the convoluted uriniferous tubules will attract attention, resulting probably rather from the action of toxins than from circulatory disturbances. Treatment. Individuals with Asiatic cholera, even with the mildest form of the disease, should remain in bed until complete recovery has taken place, as otherwise a severe attack of cholera may readily develop. The food should be restricted to fluids, particularly tea, cooled coffee, and meat-soup with rice or sago. For the relief of thirst small bits of ice should be permitted to melt in the mouth, or small amounts of boiled, and subsequently cooled, water swallowed, and to which a few teaspoonfuls of cognac or half as much red wine is added. The ingestion of large quantities of fluid always increases the nausea and the vomiting. Should symptoms of collapse appear, mulled wine, eggnog, or champagne should be prescribed. The abdomen should be covered with a hot cataplasm. The treatment thus far outlined is applicable to all varieties of cholera. Among drugs, preparations of opium enjoy a not undeserved reputation in the treatment of cholera-diarrhea and cholerine; as, for instance : R Tincture of opium, Ethereal tincture of valerian, each, 5.0 (75 minims).-M. In the treatment of asphyctic cholera the use of opium has rather been advised against in recent epidemics, and calomel recommended instead, for the purpose of rapidly expelling the cholera-bacilli from the intestine, and possibly also of destroying them. Nevertheless, I should suggest a combination of opium and calomel: To relieve the frequent vomiting, as well as the painful muscular spasms, subcutaneous injection of morphin should be employed: 0.3 (4) grains); R Morphin hydrochlorate, Glycerin, Distilled water, each, 5.0 (75 minims).-M. Dose; From 4 to 8 minims subcutaneously. Frictions of the skin with alcohol, solutions of mustard, camphor, or other spirituous solutions are less efficacious in the relief of the muscular spasm. If the body is cool, an effort should be made to render it warm by means of hot-water bottles, which may be placed in large number on either side of the body. Any bottle or jar may be used for this purpose, being filled with hot water and securely stoppered. Naturally, too great a degree of heat is to be avoided in order to prevent burning of the skin. Cholerapatients have also been placed for considerable lengths of time in hot baths at a temperature of 40° C. (104° F.), for the purpose of averting dangerous cooling of the body. As an undeniably great danger to life resides in the loss of water from the body, efforts have been again made in recent epidemics of cholera to furnish the cholera-patient with considerable amounts of water through the skin, the blood-vessels, or the intestines. Thus, subcutaneous infusions of physiologic salt-solution (0.75 per cent.)-so-called hypodermoclysis-have been advised, the fluid being warmed and one or two liters (quarts) being permitted to flow beneath the skin upon the lateral aspect of the chest or the abdomen through a funnel and tube. Warmed physiologic solution of sodium chlorid has been employed also for intravenous transfusion. Although the patients improved temporarily, permanent results were generally wanting, and the mortality was not diminished. Solutions of tannic acid (tannic acid, from 3.0 to 10.0: 2000; gum arabic, 30.0-1 ounce; tincture of opium, 20 drops, at a temperature of from 30° to 40° C.-86° to 104° F.) have been recommended for intestinal infusion-enteroclysis. V. Genersich permitted as much as 15 liters of solution of tannic acid (from 0.1 to 0.2 per cent.) at a temperature of 40° C. (104° F.) to flow into the bowel, so that the entire digestive tube was filled -a procedure that he has designated diaclysmosis. No specific remedy for the treatment of cholera is known. Experiments with blood-serum therapy have been unattended with success. In the stage of reaction of cholera extensive use should be made of hot baths. In the prophylaxis it is of great importance to recognize promptly the first case of cholera with certainty in order to institute the necessary isolation of the patient and disinfection of the stools, the vomited matters, and the linen. It is advisable to exercise sanitary supervision of travellers from places where cholera is prevalent, and to interdict the use of articles of food from such places. Complete quarantine of infected from healthy places would constitute a certain preventive measure, but it cannot be thoroughly carried out without causing serious interference with travel and commerce. Supervision of commerce at the boundary is important. During the prevalence of cholera in India rigid sanitary scrutiny of vessels passing through the Suez Canal is necessary in order to prevent the introduction of the disease into Europe; but in Europe also, at times when cholera prevails, the movements of vessels upon the rivers should be placed under the supervision of the sanitary authorities, as cholera may be readily disseminated by this means. At times when cholera prevails all persons should avoid dietetic errors and excesses of every kind. Only boiled and subsequently cooled water should be drunk, and this may be made more palatable by the addition of lemon-juice. Patients suffering from cholera can be best taken care of in special hospitals. Vomited matters and intestinal discharges should be disinfected with equal parts of milk of lime, and the linen should be immersed for twenty-four hours in a 5 per cent. solution of carbolic acid before being sent to the laundress to be washed. The bodies of those dead of cholera should be wrapped in linen cloths saturated with a 5 per cent. solution of carbolic acid, and be placed in hermetically sealed coffins. The possessions of the patient and the sick-room should be disinfected in the customary manner. Every community should endeavor to provide a perfect watersupply and drainage, for every deficiency in this connection may be followed by incalculable results at a time when cholera is prevalent. EUROPEAN CHOLERA (CHOLERA MORBUS: CHOLERA NOSTRAS). During the summer months attacks of a disease occasionally occur, at times in sporadic, at other times in epidemic, distribution, that resembles Asiatic cholera in all its manifestations from cholera-diarrhea to asphyetic cholera. One factor only, however, is never present in European or indigenous cholera, namely, the comma-bacillus of Koch. In all probability European cholera likewise is dependent upon bacteria, but these are as yet unknown. Death occurs but seldom, and as a rule only in reduced and aged persons. The treatment is the same as that for Asiatic cholera. Among the causative factors dietetic errors especially are to be mentioned, as, for instance, the ingestion of putrid water, spoiled meat, and unripe fruit and vegetables. In the differential diagnosis the forms of poisoning mentioned on p. 417 must be taken into consideration, in addition to Asiatic cholera. The designation Weil's disease has been applied to a peculiar form of infectious jaundice, which generally occurs in the summer months. It sets in with chilliness or a chill, which is followed by elevation of temperature to 40° C. (104° F.) and above. The patient complains of pains in the muscles, particularly in the calves, becomes comatose and delirious, and presents jaundice and enlargement of the liver and the spleen. The urine contains biliary coloring-matter, generally albumin, not rarely, also, blood and tubecasts. The stools are not rarely free from biliary coloring-matter. In the course of one or two weeks the temperature gradually declines, but relapses frequently occur. The disease has often been observed in butchers, although it has occurred also after the swallowing of sewage and after bathing in the Danube near Ulm. The causative agent of the disease is unknown. On post-mortem examination granular clouding and fatty degeneration have been found in various organs. Recovery occurs as a rule. At the beginning of the disease a large dose of calomel (0.5—7 grains) has been recommended; but subsequently the treatment should be confined to regulation of the diet. VI. INFECTIOUS DISEASES ATTENDED WITH LOCAL LESIONS OF THE SEXUAL ORGANS. GONORRHEA. Etiology. The designation gonorrhea is applied to every variety of inflammation that is excited by definite micro-organisms, namely, the gonococci discovered by Neisser in 1879. The condition most frequently encountered is gonorrhea of the urethral mucous membrane, so that it has become customary to imply gonorrhea of the urethral mucous membrane when the designation gonorrhea is employed. Gonorrhea of the rectal mucous membrane, of the cervix uteri, of the conjunctiva, and of the buccal and nasal mucous membrane also occurs. In the following description reference will be made exclusively to gonorrhea of the urethral mucous membrane. Gonococci can be readily isolated from the usually purulent secretion from the mucous membranes. A drop of pus, for instance, from the infected urethra is placed upon a cover-glass, upon which a second cover-glass is gently permitted to fall, so that the pus shall be distributed in a thin layer between the two glasses. Then the cover-slips are drawn apart and exposed to the air with the surface of pus upward until dry. Now each slip is held between the thumb and the index-finger and is drawn with moderate celerity through a gas-flame or a spirit-flame for from six to ten times. A few drops of carbol-fuchsin, or of solution of gentian-violet or of methylene-blue, are poured upon the surface of the pus, and the cover-slip is rinsed after five minutes in water, is again dried by being passed several times through a flame, and is then embedded in a drop of xylol-Canada balsam that has been placed upon a slide. The preparation is now ready for microscopic examination. Gonococci are generally collected together in groups, and are in part free and in part contained within cells (p. 422, Fig. 72). It is especially this enclosure within cells, whose nuclei appear eroded, that is characteristic of |