boro. The patient being under ether we could feel a well-marked, hard bunch in the region of the gall-bladder. Incision revealed not only a distended gall-bladder, but evident malignant disease of the liver, much modulated, quite hard, and much hypertrophied. The condition was so grave we deemed it not best to attempt opening the gallbladder, as it was very adherent and so much distended by fluid as to make it difficult to detect stones, so the abdominal incision was closed after breaking up the lesser adhesions.

She vomited very much for a week, but gradually recovered, and she has been entirely free from pain of any kind, and the liver cannot be felt at all. Her general health has much improved, and the doctor telephoned me a week or two ago that she was able to do quite a good deal.

I have no doubt the manipulations changed the condition for a time. How long it will last we are unable to say.

Case IV.-Mrs. D., aged about 60. Has suffered more or less from colic attacks since fifteen years ago. Has had several years of interval without any pain. Has traveled a good deal; lived in Europe two or three years, and was perfectly well all of the time. Within the past year has had three or four severe attacks, accompanied by peritonitis of quite severe type.

I advised operation several years ago, but being unwilling to have it, on account of such long intervals of good health, I did not insist until this winter, when a second, of two very severe ones, coming near together, decided her to submit, and December 18th I operated, and removed one large stone. The adhesions of the gall-bladder were quite extensive and strong to omentum and liver. I sewed the bladder to abdominal incision, closing wound below, and in just four weeks the fistula closed, and the patient returned to her home. I believe that this case could have been closed with perfect safety.

Case V. Mrs. H., aged 64. Had suffered for about fifteen years from repeated attacks of intestinal indigestion and jaundice. A constant invalid.

Within about a year she has had several attacks of biliary colic, jaundice of a deep hue, and general emaciation due to lack of appetite and digestion. I operated February 17th and found adhesions everywhere. With much difficulty I succeeded in finding the atrophied gall-bladder, which was buried under the colon. It contained several small stones, and the common duct contained one large one, which I had difficulty in removing. The parts were so much changed by inflammation that it was almost impossible to separate them. I re

moved the bladder and stitched the duct to the abdominal wound. She did well for a week, when a most profuse hæmorrhage came on, and she died from repeated attacks within the next twelve hours.

I feel sure that had this operation been done years before, that her health would have been restored and life much prolonged.

Dr. C. O. Hunt, Superintendent of the Maine General Hospital, reports a series of operations for gall-stones at the hospital for several years past, and in each case where the bladder was closed the result was much better than where it was left open and drained. The abdominal wound, however, was not closed, but in no one of the cases did any leakage occur from the gall-bladder, showing that it would have been safe to have closed the wound.

These cases reported, and quite a number of others operated upon previously, led me to the following conclusions:

First.-Operations should be performed after it is well established, by repeated attacks, that gall-stones are present.

Second.-Gall-stones may be present in the gall-bladder for years without giving colic, but are a cause of more or less digestive disturbance and impairment of the general health.

Third. From my experience in one or two cases, and from reports from the Maine General and other hospitals, I am satisfied that many cases are better treated at the time of operation, by closing the bladder. dropping it back into the cavity, and closing the abdominal wound.

Fourth.-Cases treated by drainage are, in many instances, slow to recover, and liable to be left with biliary fistula for a long time. Fifth. Great care should be used to cleanse the bladder before closing it, rendering it as nearly aseptic as possible.

Sixth. While cases of recurrence of gall-stones may follow operation, I believe they are no more liable to after closing than after drainage.

157 High Street.

TO CONTRIBUTORS AND SUBSCRIBERS.

Articles and letters for publication, books and articles for reviews, exchanges, and communications in regard to the editorial management, should be addressed to Dr. J. Duncan EMMET, 91 Madison avenue, New York City.

Communications in regard to subscriptions should be addressed to Dr. J. Duncan Emmet, 91 Madison avenue, New York. Remittances may be made by check, money-order, draft, or registered letter.

Communications in regard to advertisements should be addressed to Dr J. Duncan Emmet, 91 Madison avenue, New York.

Authors desiring reprints can procure the same by FILLING OUT THE BLANK FORM WHICH ACCOMPANIES THE AUTHOR'S PROOF. THE PROOF SHOULD BE RETURNED WITHIN TWO DAYS.

Each contributor will be supplied with a number of copies of the JOURNAL on application. Photo-engravings will be furnished free of cost if proper drawings or negatives are provided, and electrotypes or engravings will be furnished at cost.

Alterations in the proof will be charged to authors at the rate of sixt cents an hour, this being the expense that the JOURNAL incurs by such changes.

HEREAFTER, we will present, post-paid, on request, to each Contributor of an Original Article twenty (20) copies of the JOURNAL containing such article in lieu of separate reprints.

If reprints are desired they will be furnished to the author at cost price.

If extra copies of the JÕURNAL are desired same will be furnished at 35 cents each.

EDITORIAL.

SOME POINTS IN THE ETIOLOGY AND PROPHYLAXIS OF SUMMER DIARRHOEA.

Dr. F. J. Waldo in the Milroy lectures recently reported in The Lancet has given us a very exhaustive study of summer diarrhoea; especially in regard to ætiology and prophylaxis there are a number of points that deserve careful consideration. Hitherto comparatively little significance has been attached to the communicability of the disease. This communicability seems entirely possible though it must depend upon close personal contact with an environment infected with diarrhoeal stools, in much the same manner as is necessary in the case of typhoid fever. To quote the writer: "In the case of enteric fever medical men are so used to tracing the disease to the agency of water or milk that they are apt to overlook such obvious sources of danger as that of a poor patient lying day after day in bedclothes and bedding soaked with bowel discharges." This may be the case in England but we should be sorry to think that such a statement would apply to medical men in this country, though it is only fair to admit that in certain circumstances physicians are quite unable to control the surroundings of their patients. However that may be, granting that summer diar

rhoea may be communicated in the same manner as typhoid fever, many things would favor such an occurrence. The patients being chiefly infants, their evacuations are much more liable directly to infect their surroundings; the hands of their attendants become soiled and in turn pollute furniture, door handles, everything with which they come in contact; while the washing of the diapers in or near the house must create many fresh sources of infection. So although it is difficult in a given case to show in what particular manner the disease was communicated we can feel reasonably certain that, especially in families or in hospital wards, it is frequently in some one or more of these ways that the spread of infection has taken place; and that by the elimination of all these possible factors of contagion by as careful methods as are followed, in this country at least, in the hospital treatment of typhoid fever we may very materially limit such contagion. Clinically, the fact that better conditions, cleaner wards, more separate rooms and a greater number of attendants result in fewer and less serious epidemics points to the same conclusion. While we agree with the writer that the communicability of the disease must play a small part in its ætiology compared with the existence of some common source of infection, precautions in this regard should not be neglected upon such grounds; for the avoidance of even a few cases is amply worth while and, so long as our knowledge of the bacteriology and ultimate causes of the disease. remains so unsatisfactory, it is fitting to eliminate all sources of infection that are even possible.

The point which the author most desires to emphasize is that already advanced by many observers, namely, that polluted dust is the chief source of infection. But he makes it with this modification, that it is the surface dust that is at fault rather than the deeper layers of the soil, however much the latter may be contaminated with organic matter. He believes also that the specific polluting element of this surface dust is horse dung. Such an hypothesis, while at present unsusceptible of proof, would amplify the explanation of many facts hitherto noted in connection with the aetiology of the disease. In the first place, as to the greater prevalence of summer diarrhoea in towns and cities, though it is true that country roads are more dusty than city roads (being in general macadamized-in this country not even that-while city streets are usually paved), the dust remains fairly clean; but there is no lack of dust in city roads, whether paved with asphalt, wood or stone; it is made up of small particles worn from the surface by the continual attrition of vehicles and horses' feet, of the gravel with which at times the streets are sprinkled, of the soot and dust of the atmosphere but

chiefly of horse dung, which latter element marks the essential difference between city and country dust. The effect of rain is to convert this dust into mud, part of which is washed away and part of which is splashed by traffic upon adjoining walls and buildings, to be reconverted into dust with the coming of dry weather; while the sweeping of dry streets raises clouds of dust sometimes as high as twenty feet. Streets with an impervious pavement like asphalt of course collect the dust less and are more readily cleansed than those paved with wood or stone; while macadamized streets, when such exist in a city, give rise to much more dust than paved streets and to dust that is far more polluted than that of country roads and permit of little really efficient cleansing. Again, if the streets be narrow, the sunlight, to whose germicidal power considerable importance has been ascribed, is unable to penetrate into them; in any case its influence is slight upon dust in thick layers or lying in crannies. All this dust then is blown about and otherwise disseminated as widely as possible, penetrating into houses and even into larders, so that it is not remarkable that all foods and especially milk, which forms so good a culture medium for many germs, should be infected at every stage of transportation and even in the house of the consumer; while all the air that is breathed is full of the same germ bearing dust.

Such an hypothesis would, moreover, explain why summer diarrhoea is so much less frequent in wet seasons than in dry, especially in seasons characterized by frequent heavy showers, since the fall of rain serves to flush the streets; it would give an additional reason for the prevalence of the disease among young, artificially fed children, whose food is so liable to contamination from this ever-prevalent and penetrating dust of cities; why the disease is more common in narrow and illventilated streets, courts and passages and less so in streets that are steeply graded and swept by steady winds that clear out the dust rather than merely raise and redeposit it. Especially is this theory rendered. tenable by the noteworthy decrease in the disease since the streets have been systematically flushed. An equally marked decrease has been observed in New York City since the block pavement of so many streets. has been replaced by asphalt and the streets have been swept and flushed regularly.

The bacteriology of summer diarrhoea is still in too unsettled a state to give us much assistance. Extended bacteriological investigations of horse dung are also wanting but it has been shown that one gramme of moist horse dung contains as many as ten million bacteria, while thus far thirty-one different varieties have been isolated, most of which are