The depressed bone was so wedged in its new posi- Dr. T. Grange Simons, of Charleston, for further treattion that it was found impossible to insinuate the point ment. His condition was aggravated by the railroad of an elevator beneath it. A button of bone was there- travel, and on his arrival, he was suffering with constant fore removed with the trephine, its edge including the nausea, sore throat and intense headache. His expres. depressed bone. The elevator was then applied and sion was that of anxiety and suffering, and his intellect the depressed fragments removed as they were so much cloudy and sluggish. He answered questions slowly splintered and detached that it was deemed unwise to and reluctantly and his pupils moved sluggishly with a leave them. The sharp edges and spicule were removed tendency to dilatation; both legs were partially paralyzed with Hoffmann's ronguer forceps; the duramater was but the loss of power was most marked in the arm and not injured, but was exposed one and one-fourth inches leg of the left side. He was unable to stand and he was antero-posteriorly and about three-fourths of an inch barely able to draw his lower limbs up in bed, with the from above downwards. There was considerable bleed- assistance of his hands. The patella reflexes were abing from the wound. The temporal artery that was cut sent on both sides, there was no deflection of the uvala by the first incision was secured with hemostatic forceps or apparent contraction of the facial muscles. and tied. The chief bleeding came from a branch of the meningeal artery and it could be controlled only by plugging with a bit of soft wood. Drainage was provided and the wound closed and dressed antiseptically. Nausea and retching came on, as the patient recovered from the anesthetic, but was soon relieved by small quantities of hot water. On February 13, sixth day, the drainage-tube and stitches were removed, the wound having united without suppuration. February 16, ninth day; the patient was discharged, and has had no trouble up to date, April 16, 1893. CASE VII.-FRACTURE OF THE SKULL.-PARALYSIS.- S. R., white, fifteen years of age, a native and resi dent of Bamberg, S. C., received a wound from a brick bat on the right side of the head on the morning of November 23, 1892. The bowels were costive,-a micturition was not affected, there being neither retention nor incontinence. The temperature was depressed, ranging between 97° anfl 98° and his general condition anemic. I saw the case in consultation with Dr. T. Grange Simons, February 14, 1893. On examination the wound was found to have healed, except a circular opening about one fourth of an inch in diameter, surrounded by flabby granulations, and giving exit to a small amount of watery pus, -just such an opening as is found commonly leading from dead bone. By palpation over the thin depressed cicatrix, a fissured fracture of the skull was easily demonstrated. After a careful consideration of the history and present condition of the case it was decided to make an exploratory incision, having for its ultimate object the removal of the cause of the pressure upon, and irritation of the brain. At the request of Dr. Grange Simons I performed the operation February 20, 1893. A horseshoe incision was made following nearly The missile impinged on an area bounded by the tem the temporal ridge to the middle of the supra-orbital poral ridge above, the continuation of this ridge in front ridge on the right side. The tissues were dissected up with the external angular process of the frontal, behind and the pericranium raised with the elevator to fully by the union of the anterior inferior angle of the parietal expose the seat of fracture. A fissured, depressed frac and frontal, and below by the line of junction of the ture was found, the depressed bone being triangular in great wing of the sphenoid and the frontal bone. The shape, the sides measuring an inch, the apex directed wound was about an inch in length and the hemorrhage forward, the base corresponding to a line formed by the was profuse. The surgeon who had him in charge anterior border of the parietal bone; the upper border brought the edges of the wound into apposition by being about one fourth of an inch below the temporal means of strips of adhesive plaster and dressed it anti-ridge. The depressed bone was fissured and splintered septically. Healing was rapid under this treatment, and was carious. without the appearance of any constitutional trouble. There were no symptoms of concussion or compression and the boy went about his affairs as usual. About January 20, 4893, two months after the date of the injury, he cut up a quantity of wood and carried it home on his head, having previously enjoyed his accustomed good health. A few days after this occurrence he was seized with severe headache and fever. The almost cicatrized wound became inflamed and the scalp surrounding was swollen. In about a week this inflamma tion and swelling in and around the wound subsided, but the patient complained however, of a feeling of general lassitude and of an elongated palate. By the end of the next week he began to lose the use of his lege and found exercise painful. He was now sent to It was so firmly impacted in its new position that it was impossible to insinuate the point of an elevator to raise it into its proper place. The crown of a small trephine was applied close to the lower border of the fracture and a button of bone removed,-thus affording working room. The depressed bone was cut away with. Hoffmann's ronguer forceps. It was soft and yielded to the instrument readily. The skull in the neighborhood of the fracture, although not broken, was depressed in a circumference of one half inch or more, so that it became necessary to remove much more than the bone actually fractured. This having been accomplished the dura mater was examined carefully to decide the question as to whether it should be incised for a further examination of the brain. It was decided not to proceed further, as the dura-mater did not appear to be much case, although there were no immediate symptoms of thickened by inflammatory deposit, nor was it depressed brain injury or compression, the depressed bone was or adherent so far as could be discovered. The flap removed, and at the present time, more than two months was adjusted, a drain of catgut having been previously since the injury, the patient is perfectly well, and in the put in position, from one angle to the other of the in- enjoyment of all his faculties. cision, and held in apposition by silk sutures. wound was then dressed with iodoform gauze and ab sorbent cotton. Case 4, is the only one of the series in which the patient presented symptoms of compression when he was admitted into the hospital. He had been injured one week before he was brought to the clinic, and had been unconscious and paralyzed on one side of the body since a few hours after the accident. There were no external signs of fracture of the skull, and none of the symp February 23. The improvement in the condition of the patient was marked; there was almost entire absence of headache and nausea. Digestion was improved end his general expression was more cheerful. March 2. He was able to lift his legs unaided and toms usually accepted as indicating fracture at the base. to cross them. March 3. He was carried down stairs. March 6. He was able to walk across the room and return. His gait however, was still unsteady, but improving. The wound was healed, except at the point of the opening of the old sinus. March 8. All dressing of the wound discontinued. Sensation and motion good, but the patella reflexes were still somewhat impaired. March 12. The patient was able to walk about as he pleased, up and down stairs, and in the street. He was discharged restored to health. Cases 3, 4, 5, and 6, together with that reported by me at the last meeting of this Association, show conclusively that serious and extensive fractures of the skull with depression of bone, may occur with no immediate serious effects upon the brain, and unaccompanied with symptoms of compression. The history of the case showed that he had walked home after the accident, and that the symptoms of compression supervened slowly. These facts seemed to warrant the inference of hemorrhage within the skull and the operation of trephining was perrormed on a diagnosis, based upon this evidence. The trephine was applied as nearly as possible to that portion of the surface of the skull, described as overlying the convolu tions supposed to preside over motion in the upper and lower extremities. The extravasation of blood was found between the skull and dura mater and also in the brain itself. It would seem to be not assuming too much to think that, had this operation, now almost genunder such circumstances, been performed within a few erally admitted by surgeons, to be justifiable and proper been compressed, and altered beyond all hope of recov hours after the injury, before the brain substance had ery, the result might have been different. Case 3, illustrates the serious nature of the complica tion of fracture of the skull by wound of the dura-mater, -"because it admits germs and irritant fluids to the cranial cavity, and thus leads to septic meningitis, the great cause of death in compound fractures, not immed iately fatal from injury to the brain.” The facts presented by these cases sustain the theo. retical proposition made by Druitt that, "It must be Asepsis in this case was impossible, because the parare for a depression of the skull to cause great diminu- tieut did not come under treatment for some hours after tion of the brain cavity, so, although such diminution is the injury, and the wound had probably become more or very sudden, it does not seem likely that mere depres- less infected, to such an extent, that justifiable antisep sion of fragments often lying loose on the dura-mater, tic measures were not sufficient to arrest it. Drainage, is a frequent cause of compression. Insensibility, if the only resource under such circumstances, was not atpresent, is much more probably due to concussion or hemorrhage." tainable, as no counter opening could be made. Dis. charge gravitated to the more dependent part of the cavity of the skull, and there underwent putrefactive changes, and on the fifth day, the symptoms of septic infection became manifest, and the patient rapidly suc cumbed. Cases 6 and 7, were almost precisely similar injuries in location, in extent, and in general features of the fracture. In one case, the injury was inflicted by the kick of a horse; in the other by a blow from a brick, but the effect of the violence upon the skull was almost The problem of securing proper drainage under these identical. These two cases clearly indicate the results cirbumstances is most important and interesting, and following operative and non-operative treatment. In the case that was threated without operation, the wound was dressed and allowed to heal over a fracture of the skull, because there were no symptoms of compression or injury to the brain. In two months the irritation of the dura-mater and brain, brought about by the depressed fragments resulted in paralysis. In the other upon its solution depends the successful result in cases of which Case 3 may be regarded as a type. I would take this occasion to acknowledge the efficient work of the staff of the hospital, Drs. Linley, Fike Smith, and Heyward, and of my assistants, Drs. Mullally and Barbot, during these operations, and in the aftertreatment of the cases. EDITORIALS L. T. RIESMEYER, M.D., EDITOR. PUBLISHED BY THE MEDICAL REVIEW ASSOCIATION. Yearly Subscription, $3.50. Single Copies, 10 Cents. TO CONTRIBUTORS AND CORRESPONDENTS. All letters whether intended for publication or not must contain the writer's name and address, not necessarily for publication. No attention will be paid to anonymous communications. Secretaries of medical societies will confer a favor by keeping us informed of the dates of the meeting of their respective societies, and of officers elected. Members of the profession who send us information of matters of general interest to our readers will be considered as doing them and us a favor, and we shall take pleasure in inserting the substance of such communications. secretion to the bile ducts alone, but a diffusion into the lymph channels takes place by virtue of a loss of their retention power. In a similar way albumin is not retained completely by the epithelial cells of the kidney but partially passes into the urine. A It has been observed in many cases of icterus where Do obstruction to the flow of bile could be detected that either all or at least many of the liver cells presented more er less advanced retrograde metamorphosis. The icterus which is caused by the inability of the cells to retain their secretion Liebermeister proposes to call akathektic icterus (from akathectos-unretained. great many cases that cannot be explained by bile-ob. struction could be explained by this, the akathectic form of icterus; but the hematogenic theory for some kinds of icterus cannot, with our present knowledge, be entirely done away with. Of this form of icterus we would have to think particularly in cases where hemoglobinuria exists. Also in cases of acute yellow atrophy and acute parenchymatous degeneration where the liver All communications for the editor, and all books for review, should cells are entirely disintegrated. be addressed to the editor, 914 Locust street. All letters containing business communications or referring to the publication, subscription, or advertising department of this REVIEW, should be addressed to 914 Locust Street, St. Louis. Entered at the St. Louis Postoffice as Second-class Matter. Icterus. in order to come to a conclusion. Often an exact differ. entiation may be impossible, since cases occur in which both forms exist at the same time. The differential diagnosis between obstruction icterus and akathectic icterus may sometimes be very difficult. As a rule it may be said that the higher degree of icterus the more likely it is due to obstruction. When, for instance, an intense icterus is accompanied by discolored stools and a total destruction of the liver cells or total loss of function may be excluded, we may with certainty diagnose a total obstruction of the flow of bile. But if, on the contrary, the icterus does not reach a very high degree and the stools contain some bile-pigment, it may Icterus occurs when bile-pigments enter the blood be uncertain whether we have to deal with an incomand are deposited in the tissues. Whenever the flow plete obstruction or an akathectic icterus and other cırof bile is obstructed the pressure within the biliary cumstances would have to be taken into consideration ducts and liver cells becomes so great that bile enters the blood directly or indirectly by first passing into the lymphatics. But icterus may also occur when there is no obstruction to the flow of bile. In many cases where an obstruction to the flow of bile could with certainty be excluded, bile pigment and bile salts have been found in the blood. As physiology teaches that bile is only formed in the liver, it seems at first sight paradox ical that the bile-pigment and salts should occur in the blood without an obstruction of some kind. The theory has been advanced that there is a hematogenic icterus in contradistinction to the hepatogenic icterus, but this has not been conclusively proven. Liebermeister (Deut. Med. Woch., April 20, 1893), gives the following physiological explanation for the occurrence of icterus without obstruction of the flow of bile. It is a peculiar property of the liver-cells, of which, however, we find an analogon in the behavior of other glandular cells, that they are capable of retaining the bile formed by them and of preventing its entrance into the lymphatics and blood-vessels. For this function of the liver cells by virtue of which the bile can only pass into the bile ducts, complete integrity of the cells is a necessity. Whenever the integrity of the cells is interfered with by pathological changes they no longer furnish their tic variety. We must also consider that in consequence of bileobstruction the liver cells are damaged and that when an obstruction icterus has existed a long time an extensive degeneration and disintegration of the liver cells frequently takes place. Even after weeks or months of obstruction an extensive disintegration of the liver cells may take place and destroy the life of the patient, while in others a complete obstruction may last for years before grave symptoms make their appearance. Akathectic icterus may be caused by poisons, phosphorus, chloroform, arsenic, mineral acids, and snake bites. To this category also belongs the icterus caused by infectious diseases, for instance, yellow fever, epidemic icterus. The icterus which occurs in many diseases accompanied by fever, pneumonia, malaria, pyemia, typhoid, typhus, febris recurrens may in a few instances be due to an obstruction in consequence of a duodenal catarrh or a catarrh of the bile ducts, but in the vast majority of cases it must be explained by a degeneration of the liver cells. The icterus caused by great emotions also belongs in all probability to the akathec Considerations Concerning Asiatic In an editorial of the REVIEW of June 3, 1893, entitled "The Sanitary Condition of the City of St. Louis, With Suggestions as to Its Improvement" we have drawn attention to some prophylactic measures against cholera, which were based opon the most recent researches upon this subject. Under the title of this article we find in the Dietetic and Hygienic Gazette of July, 1893, an abstract of a paper by A. C. Abbott, M D., First Assistant, La. boratory of Hygiene, University of Pennsylvania, in which the same views are expressed in a more elaborate way and, considering the subject one of the greatest im portance and interest, we reprint the same in its full text as follows: The modern teaching in relation to cholera is that it is an infectious disease, depending for its existence and propagation upon a specific microorganism that is located within the intestinal canal of all individuals affected with this disease. This microorganism is now generally believed to be that described by Koch, com monly known as the "comma bacillus" of Asiatic cholera. Though there were for a time after Koch's announce ment certain objections to accepting his teachings in relation to the etiology of cholera, these have now practically disappeared, and the weight of opinion is incontestably in favor of the doctrine that he taught. When the announcement that a definite materies morbi, most probably standing in causul relation to this disease, had been found, the attention of the medical world was at once directed to it, and on all sides efforts were made to become familiar with the characteristics of this organism and the means commonly employed for its identification. In so far as the morphological and cultural pecu liarities of the organism are concerned, Koch left but little room for addition to his original description, but this represented only the foundation upon which was to be built a superstructure so rich in experimental data as to warrant our claiming acquaintance with the behavior of this organism under the manifold conditions of environment that it finds, not only when located within the intestinal canal, but when outside the body as well; and it is through investigations of this character that we receive the teaching upon which our plans of public quarantine and of domestic and personal prophylaxis are to be based. In epidemics of cholera, manifestly, the danger against which we are to guard exists in the evacuations of the afflicted individual; and if the evacuations from each and every such individual were disinfected immediately upon being passed, it is safe to predict that the ap pearance of the disease in an epidemic form would be a thing unknown. Unfortunately, however, this precaution, simple as it is, is more often neglected than employed, and the consequences of such neglect are those that are causing the present agitation. The question, then, that arises is: If these evacuations do not receive the proper attention at the hands of the attendant, are they likely, after having gained access to sewage or water courses, to cause a dissemination of the trouble? Among the facts earliest demonstrated in connection with the organism of cholera, was, that it belonged to the group of bacteria known as facultative parasites, that is to say, it is an organism that is by nature parasitic, but which can exist for a time outside the body of a living host, and lead a saprophytic form of existence. Perhaps the first observation that conclusively settled this point was the finding by Koch, in a a water tank, at Sahab Bagan, Calcutta, on February 8, 1884, of living comma-bacilli, which could be continuously demonstrated in this water up to the 23rd of the same month. With this observation in hand, preparations were at once begun for determining accurately the conditions that favor the life and development of the organism in water, and though the results of these investigations are conspicuous for their lack of uniformity, they, nevertheless, demonstrate the possibility of this organism, not only retaining its vitality but multiplying, as well, in the purest of natural waters; and, contrary to what would a priori have been supposed, its growth is not only not favored by gross pollution of the water, but when the contamination is excessive the effect is to shorten the length of time that the cholera-spirillum may live in it. Among the first to take up this study was Koch himself, who states that in ordinary spring water or well water the organism of cholera retains its vitality for thirty days, whereas in the canal water (sewage) of Berlin it died after six or seven days; but if this microbe be mixed with fecal matters, it retains its vitality for but twenty-seven hours; and in the undiluted contents of cesspools it is impossible to demonstrate it after twelve hours In the experiments of Nicati and Rietsch it retained its vitality in sterilized distilled water for twenty days; in Marseilles canal water (sewage), for thirty-eight days; in sea water, sixty-four days; in harbor water,eighty-one days, and in bilge water, thirty-two days. In the experiments of Hochstetter, on the other hand, the cholera spirilla in distilled water died in less than twenty-four hours in five of seven experiments; in one of the two remaining experiments they were alive after a day, and in the other after seven days. In one experiment with the domestic water supply of Berlin the organism retained its vitality for 267 days; in another for 382 days, notwithstanding the fact that many other organisms were present at the same time. There is no single ground upon which these variations can be explained, for they depend apparently upon a number of factors, which may act singly or together. Though considerable variation is seen in the results of these experiments, they, nevertheless, agree in the single point, viz., that the cholera-organism can live, and does multiply, in natural waters. As water is one of the elements essential to life that is ordinarily used in common by all the individuals composing a community, it is probably the agent most frequently con cerned in the propagation of epidemic outbreaks of been received. Unpleasant as this thought is, it is, diseases of which Asiatic cholera and typhoid fever nevertheless, one that we cannot ignore. Though only may be taken as types. this character it is neither wise nor safe to use milk that has not been subjected to the action of heat, either by boiling or steaming, and though prejudice exists, particularly in this country, against the use of cooked milk, it is, nevertheless, our duty to recommend it. hot water may be employed in the kitchen, there is still In very recent times we have heard a great deal about the possibility that the milk supplied from the dairy the part played by water in the dissemination of disease may at the time of delivery be acting as a cultureand while what we have heard is, in the main, true, it medium for the organism against which efforts at home is only partly true, and in consequence, the public, are being directed. This need not, of necessity, be due while awake to the possible danger from this source, to dishonest dilution of the milk with water, but may does not, I fear, quite appreciate the point or points at arise from the water with which the milk cans were which the greatest danger is to be anticipated. The rinsed, and in this connection dairymen should under result is that precautions are taken in one direction, and no circumstances ship their milk in cans that have not neglected in another of equal or more importance. To been thoroughly scalded immediately before the milk is define more clearly at what I am driving: many indivi- placed in them. In times of epidemics of diseases of duals will say with confidence that they have no fear of cholera entering their household, and will give as a reason that only boiled water is drunk, but if the individual is asked if only boiled water is used in washing his green salads, or for rinsing his milk jug, or if he is certain that boiled water is employed in the manipulation of the dairy from which he receives his milk supply the probabilities are vastly in favor of his reply being in the negative. The danger is not alone in the drinking of waters polluted by disease producing elements, but also, and probably to a greater extent, in the gene ral use of such water about the household. A very vivid example of the part that polluted water may play in the production of diseases, even though it be not drunk, is the outbreak of typhoid fever in the Third Brandenburger Regiment, described by Gaffky. Every source of infection was excluded except a pump, the water of which was used in rinsing dishes, beer mugs, etc. Investigation showed that the well of this pump was in direct connection through the soil with a privy pit, a short distance away, into which the evacuations of a typhoid patient had some time previously been thrown. As stated the water from this pump was not used for drinking-purposes, but was employed only about the scullery. Koch's experiments, and more recently those of Uffelmann, have demonstrated that the comma bacillus is not robbed of its vitalily by freezing, and the investiga tions of Fraenkel in Germany, and of Prudden in this country, have shown that natural ice may contain any. where from a few hundred to several thousand bacteria per cubic centimetre. While the bulk of these bacteria are ordinary, innocent saprophytes, there is, nevertheless, a possibility of ice being a source of danger. I do not mean to discountenance the general use of ice, but rather the putting of natural ice into water to be drunk. Still further, in this connection, is a consideration of domestic water filters. While the results obtained by their use are desirable from an esthetic standpoint, they nevertheless furnish a false sense of security. The best of them are reliable for only a few days, four or five at the most, and unless they are properly cleansed by scrubbing and "burning out," the condition of the water, from a bacteriological standpoint, after this period is far worse than that of the unfitered water. When filters must be used, the water to be absolutely safe, should be boiled after filtration and not before, as is often the practice. A relatively small amount of water used in the average household goes for drinking purposes, the most being used for kitchen and bath purposes, and of that employed in the kitchen a large amount is subjected to the disinfecting influence of heat. A certain proportion, As the danger against which we are to guard in however, greater than that used as drink, is not heated, cholera exists in the evacuations of afflicted individuals but is employed for rinsing, diluting etc., and in one it is manifest that by careful attention to these matters way or another comes in contact with food stuffs, some we have in our power the means par excellence for liof which are rendered free from danger through cook- miting its spread. A great deal is said and written as ing, while others come to the table in a raw state. The to disinfection and disinfectants, and just now the food-stuffs from which the greatest danger in this con-makers of these preparations are busy preparing for an nection is to be feared are milk and salads that are active trade in the near future. Fortunately, the orused in an uncooked condition. The rinsing of a milk ganism causing the disease is among the least resistant jug with water consumes ordinarily far more water than of any of the known pathogenic bacteria. It does not the average individual takes at a draught, and if the form spores; it is highly sensitive to the action of water be but very slightly polluted with disease produc acids and alkalies, and it is killed in five minutes when ing organisms, the amount taken as drink may not be cultures of it are exposed to a temperature of 65°C. sufficient for the production of disease, but if a single pathogenic germ adheres to the sides of the vessel that From this it is plain that it is easily within the reach of has been cleansed for the reception of the milk, it rapid all those concerned in the treatment or care of cholera ly multiplies into many thousands after the milk has patients to render the evacuations of these patients |