ST. MARY'S HOSPITAL.
2
315 lieved by opiates, and the quinine continued, but the appetite failed, the wound began to look unhealthy, and the patient became much more feeble. The attack gradually subsided after a few days, the appetite returned, and, wine being ordered, the wound assumed a more healthy aspect. The pro- jecting portions of omentum were touched with nitrate of silver and dressed with dry lint and strapping. She rapidly improved, took no medicine after October 28th, and at this time came down-stairs for a few hours daily. The patient steadily gained strength, and the whole wound was perfectly cicatrised in ten days more, with the exception of a very small opening, which would just admit a very common silver probe, about two inches from the pubis. The discharge, however, gradually diminished, and on the 26th of November, eight weeks after the operation, the wound was perfectly healed. MaM’s.—The disease which exists in the sacrum appears to have continued over many years, as the patient says she has had the recto-vaginal fistula ever since she was a child. The fits of pain, attended with rigors and vomiting, to which she is subject every few weeks, are no doubt the result of small abscesses which keep forming; but as I was not at first aware that I had this mass of diseased bone to contend with, I was led to suspect some kidney affection, which the symptoms closely resembled. The success of the operation depended no doubt upon its having been undertaken before any symptoms of exhaustion appeared, and also to there having been no attempt made to deliver by craniotomy, thus avoiding any injury to the parts; and considering that, after all, it was a breech presentation, I think it was fortunate it was not at- tempted. The great thing to fear, in my opinion, with regard to the patient in this operation, where performed early, is the supervention of peritonitis, and the plan of anticipating it, by giving small doses of calomel and opium soon after, and thus preventing it, seems to me to afford a better chance than any treatment that can be adopted after severe peritonitis has set in. I In conclusion, I have to express my thanks to the medical gentlemen present at the operation for the rea,dy and valuable assistance then afforded me, and the interest evinced subse- quently during the treatment of the case. Bradford-road, Dewsbury, 1857. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. ST. MARY’S HOSPITAL. FRACTURE OF THE PELVIS, WITH SEPARATION OF THE SACRO- ILIAC SYNCHONDROSIS ; RUPTURE OF THE BLADDER ; LACE- RATION OF MUSCLES AND NERVES. DEATH IN FOUR DAYS ; AUTOPSY. (Under the care of Mr. URE.) Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter seeomparare.->4loaesc+rm. De Sed. et Cau.. Morb.lib. 14. Proo3mium. FRACTURES of the pelvis very seldom occur without the ap- plication of tremendous violence, such as the falling from a considerable height, being run over by some heavy vehicle, or jammed between two opposing bodies, such as the buffers of a railway carriage. They are injuries at all times of the gravest character, not less so than fractures of the skull, and demand the anxious consideration of the surgeon. We may truly say that this form of injury is not common, but now and then an instance presents itself to our notice in the London hospitals. Within the last four months, two very remarkable examples were to be seen ; one at St. Mary’s Hospital; the other at the Westminster, under Mr, Holthouse’s care, both of which we Tecord to-day. In the subjoined case, which we have taken from the hospital case-book, there was not only very exten- sive fracture, but separation of the bones at the sacro-iliac synchondrosis. The fracture extended through the acetabulum, but without displacement; hence the absence of symptoms of fracture of the cervix femoris, which are sometimes observable when the head of the bone has been jammed into the pelvis. The other injuries besides those to the pelvis were of the most serious character, such as a rupture of the bladder, and, as might be expected, a fatal result ensued. The presence of blood in the urine on admission was a grave symptom, taken with others ; and its absence from the rectum showed that that viscus had escaped. In some clinical remarks made by Mr. Ure on this case, he observed, " that the indications here, were the evacuation of the contents of the injured bladder at frequent intervals ; the exhibition of opium in suitable doses, to assuage pain; the use of revulsives, to abate, if possible, peritoneal inflammation ; and the due employment of cordials to sustain the flagging powers of life. The appearances revealed after death, the wide-spread peritonitis, the rent of the bladder with its sloughy edges, and the extensive injury of the pelvic bones, all went to show that none other but a fatal result could have en- sued. It is remarkable, indeed, that the woman should have lived upwards of four days after the serious hurt she had sus- tained. Harriet C-, aged twenty-seven, admitted Oct. 17th, 1856. She was a spare, delicate-looking woman, and had arrived from the country the day previous in quest of a situation as domestic servant. Her brother-in-law was driving herself and sister through the town. All of a sudden the light spring-cart in which they were came into violent collision with a waggon, and they were precipitated into the road; the man fell some seven feet in front of the vehicle, the two women directly un- derneath it. The subject of the present case appeared to have sustained the weight of the cart transversely across the pelvic region. Her two companions were but slightly hurt. When carried into the hospital, within a quarter of an hour of the occurrence of the accident, she was in a state of partial collapse ; the pupils were extremely contracted, each aperture not being larger than the point of a pin; the pulse was small and run- ning ; the skin cold and clammy. She complained of intense pain across the iliac, and particularly the hypogastric regions. The hypogastrium was slightly bruised and exquisitely tender, so that she dreaded the slightest pressure, more especially just below the umbilicus. She was unable to stand, and said that the bones forming the pelvis seemed loose, and that " she could feel them slip about." On grasping the spines of the ilium on each side, an unnatural mobility was perceptible, but no cre- pitus could be detected. Firm pressure on the ilium gave great pain, but chiefly on the pubic portion of the right side. The patient had not voided urine since the morning ; the bladder was consequently full at the time of the accident. On being asked to pass urine, she found herself unable to do so. A catheter was accordingly introduced, and about six ounces of £ bloody urine were drawn off. She was without delay placed in bed, and presently began to shriek from the urgency of pain. She had forty drops of laudanum; poppy-head fomentations were applied to the abdomen; the opiate was repeated after the lapse of an hour, after which she seemed soothed, and re- mained comparatively quiet until about six o’clock the follow- ing morning, when she complained of very acute pain in the hypogastrium, which caused her to utter piercing cries. Thill region was extremely sensitive to pressure; the pulse was 94, soft. Forty minims of sedative solution of opium were admi- nistered, and the poppy head fomentations were replaced by warm turpentine epithems.-Ten o’clock A.M.: She still come plained of great pain, which seemed to have spread over the whole abdomen; the tongue was dry and furred; the pulse 106, soft and small; the skin warm, but not very dry; thirst urgent. It was directed that the urine should be drawn off at frequent intervals; the catheter had been already employed thrice, and small quantities of pale, natural-looking urine, un- tinged with blood, withdrawn each time. There was no action of the bowels. Great tenderness was experienced in the course of the descending colon. The resident medical officer pre- scribed a turpentine injection, and a grain of opium with two of calomel every other hour.---Two o’clock P.lII.: The patient was still suffering excessive pain, referred mostly to the hypo- gastrium ; there was also much diffused tenderness of the abdo- men. The countenance was expressive of agony; the pulse 125, soft and weak. It was directed that a grain of opium should be administered every hour until the pain was miti- gated, and a blister applied to the abdomen. Oct. 18th.-Ten The hypogastric pain was much less acute than before; the pulse low and running; the tongue very dry, brown, and furred; the pupils were contracted ; the face
Transcript of ST. MARY'S HOSPITAL.
315
lieved by opiates, and the quinine continued, but the appetitefailed, the wound began to look unhealthy, and the patientbecame much more feeble. The attack gradually subsidedafter a few days, the appetite returned, and, wine beingordered, the wound assumed a more healthy aspect. The pro-jecting portions of omentum were touched with nitrate ofsilver and dressed with dry lint and strapping. She rapidlyimproved, took no medicine after October 28th, and at thistime came down-stairs for a few hours daily. The patientsteadily gained strength, and the whole wound was perfectlycicatrised in ten days more, with the exception of a very smallopening, which would just admit a very common silver probe,about two inches from the pubis. The discharge, however,gradually diminished, and on the 26th of November, eightweeks after the operation, the wound was perfectly healed.
MaM’s.—The disease which exists in the sacrum appearsto have continued over many years, as the patient says she hashad the recto-vaginal fistula ever since she was a child. Thefits of pain, attended with rigors and vomiting, to which sheis subject every few weeks, are no doubt the result of smallabscesses which keep forming; but as I was not at first awarethat I had this mass of diseased bone to contend with, I wasled to suspect some kidney affection, which the symptomsclosely resembled. The success of the operation depended nodoubt upon its having been undertaken before any symptomsof exhaustion appeared, and also to there having been noattempt made to deliver by craniotomy, thus avoiding anyinjury to the parts; and considering that, after all, it was abreech presentation, I think it was fortunate it was not at-
tempted. The great thing to fear, in my opinion, with regardto the patient in this operation, where performed early, is thesupervention of peritonitis, and the plan of anticipating it, bygiving small doses of calomel and opium soon after, and thuspreventing it, seems to me to afford a better chance than anytreatment that can be adopted after severe peritonitis hasset in. IIn conclusion, I have to express my thanks to the medical
gentlemen present at the operation for the rea,dy and valuableassistance then afforded me, and the interest evinced subse-quently during the treatment of the case.
Bradford-road, Dewsbury, 1857.
A Mirror OF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
ST. MARY’S HOSPITAL.
FRACTURE OF THE PELVIS, WITH SEPARATION OF THE SACRO-ILIAC SYNCHONDROSIS ; RUPTURE OF THE BLADDER ; LACE-
RATION OF MUSCLES AND NERVES. DEATH IN FOUR DAYS ;AUTOPSY.
(Under the care of Mr. URE.)
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumetdissectionum historias, tam aliorum proprias, collectas habere et interseeomparare.->4loaesc+rm. De Sed. et Cau.. Morb.lib. 14. Proo3mium.
FRACTURES of the pelvis very seldom occur without the ap-plication of tremendous violence, such as the falling from aconsiderable height, being run over by some heavy vehicle, orjammed between two opposing bodies, such as the buffers of arailway carriage. They are injuries at all times of the gravestcharacter, not less so than fractures of the skull, and demandthe anxious consideration of the surgeon. We may truly saythat this form of injury is not common, but now and then aninstance presents itself to our notice in the London hospitals.Within the last four months, two very remarkable exampleswere to be seen ; one at St. Mary’s Hospital; the other at theWestminster, under Mr, Holthouse’s care, both of which weTecord to-day. In the subjoined case, which we have takenfrom the hospital case-book, there was not only very exten-sive fracture, but separation of the bones at the sacro-iliac
synchondrosis. The fracture extended through the acetabulum,but without displacement; hence the absence of symptoms offracture of the cervix femoris, which are sometimes observablewhen the head of the bone has been jammed into the pelvis.The other injuries besides those to the pelvis were of themost serious character, such as a rupture of the bladder, and,as might be expected, a fatal result ensued. The presenceof blood in the urine on admission was a grave symptom, takenwith others ; and its absence from the rectum showed thatthat viscus had escaped.
In some clinical remarks made by Mr. Ure on this case, heobserved, " that the indications here, were the evacuation ofthe contents of the injured bladder at frequent intervals ; theexhibition of opium in suitable doses, to assuage pain; the useof revulsives, to abate, if possible, peritoneal inflammation ;and the due employment of cordials to sustain the flaggingpowers of life. The appearances revealed after death, thewide-spread peritonitis, the rent of the bladder with itssloughy edges, and the extensive injury of the pelvic bones, allwent to show that none other but a fatal result could have en-sued. It is remarkable, indeed, that the woman should havelived upwards of four days after the serious hurt she had sus-tained.
Harriet C-, aged twenty-seven, admitted Oct. 17th, 1856.She was a spare, delicate-looking woman, and had arrived fromthe country the day previous in quest of a situation as domesticservant. Her brother-in-law was driving herself and sisterthrough the town. All of a sudden the light spring-cart inwhich they were came into violent collision with a waggon,and they were precipitated into the road; the man fell someseven feet in front of the vehicle, the two women directly un-derneath it. The subject of the present case appeared to havesustained the weight of the cart transversely across the pelvicregion. Her two companions were but slightly hurt. Whencarried into the hospital, within a quarter of an hour of theoccurrence of the accident, she was in a state of partial collapse ;the pupils were extremely contracted, each aperture not beinglarger than the point of a pin; the pulse was small and run-ning ; the skin cold and clammy. She complained of intensepain across the iliac, and particularly the hypogastric regions.The hypogastrium was slightly bruised and exquisitely tender,so that she dreaded the slightest pressure, more especially justbelow the umbilicus. She was unable to stand, and said thatthe bones forming the pelvis seemed loose, and that " she couldfeel them slip about." On grasping the spines of the ilium oneach side, an unnatural mobility was perceptible, but no cre-pitus could be detected. Firm pressure on the ilium gavegreat pain, but chiefly on the pubic portion of the right side.The patient had not voided urine since the morning ; thebladder was consequently full at the time of the accident. Onbeing asked to pass urine, she found herself unable to do so.A catheter was accordingly introduced, and about six ounces of £bloody urine were drawn off. She was without delay placedin bed, and presently began to shriek from the urgency of pain.She had forty drops of laudanum; poppy-head fomentationswere applied to the abdomen; the opiate was repeated afterthe lapse of an hour, after which she seemed soothed, and re-mained comparatively quiet until about six o’clock the follow-ing morning, when she complained of very acute pain in thehypogastrium, which caused her to utter piercing cries. Thillregion was extremely sensitive to pressure; the pulse was 94,soft. Forty minims of sedative solution of opium were admi-nistered, and the poppy head fomentations were replaced bywarm turpentine epithems.-Ten o’clock A.M.: She still comeplained of great pain, which seemed to have spread over thewhole abdomen; the tongue was dry and furred; the pulse106, soft and small; the skin warm, but not very dry; thirsturgent. It was directed that the urine should be drawn off atfrequent intervals; the catheter had been already employedthrice, and small quantities of pale, natural-looking urine, un-tinged with blood, withdrawn each time. There was no actionof the bowels. Great tenderness was experienced in the courseof the descending colon. The resident medical officer pre-scribed a turpentine injection, and a grain of opium with twoof calomel every other hour.---Two o’clock P.lII.: The patientwas still suffering excessive pain, referred mostly to the hypo-gastrium ; there was also much diffused tenderness of the abdo-men. The countenance was expressive of agony; the pulse125, soft and weak. It was directed that a grain of opiumshould be administered every hour until the pain was miti-gated, and a blister applied to the abdomen.
Oct. 18th.-Ten The hypogastric pain was much lessacute than before; the pulse low and running; the tongue verydry, brown, and furred; the pupils were contracted ; the face
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WBS ’8líghtly flushed. The patient was distinctly under the in-jSuence of the naltmtic. The opium was discontinued, and shewaa ordered small quantities of brandy in hot water at frequentintervals.
19th.-Ten A.M.: The pain had returned; the pulse wasrapid and small; there was a tendency to vomit, and duringthe night she had vomited some dark-green liquid. To havetwo grains of opium occasionally to allay the pain.-Ten r.nt.:She was very low and prostrate; the nervous sensibility wasdulled; the pupils were dilated; the pulse was 136, very feeble.The urine, which was drawn off frequently, seemed natural inrespect of colour and general characters. The bowels remainedunmoved, although three turpentine injections had been suc-’cessively administered. She was ordered an injection of barley-water with assafcetida.20th.-Two r. M. : There was no amendment; indeed, the
patient was very low, and distressed by nausea and hiccup.She was ordered brandy in large quantities; eggs beat up inmilk; and small doses of cajeput oil to allay, if possible, thehiccup.
Early next morning she began to sink, fell into an uncon-scious state, and died at noon, having survived the accidentabout ninety-seven hours.
Cadaveric inspection twenty-six laours after death.-The bodywas thin, emaciated, sallow; the abdomen was slightly tumidand discoloured as if by a bruise below. On laying open theabdomen by a vertical incision, the omentum was found to bethickly infiltrated and covered with patches of yellow, soft,recent lymph, forming adhesions with the abdominal walls.The parietal peritoneum was, in like manner, studded withpatches of fresh lymph. The whole mass of intestines wasglued together in a compact and coherent manner by the samesubstance, which was interposed between the coils of intestine,and effused into the layers of the mesentery. The cavity ofthe abdomen contained from eight to ten ounces of flaky, fibri-nous serum, having an urinous admixture and odour. Mr.Hart, the resident medical officer, ascertained the presence ofurea in very appreciable quantity, by the addition of nitricacid, and by boiling. The bladder showed an irregular raggedopening, the size of a shilling, on the posterior aspect of the
superior fundus; in the serous investment slight rents could bediscerned radiating from the opening. The torn edges wererather sloughy, showing the absence of any attempt at repa-ration. The viscus was empty and contracted. The liver wassmall; its capsule coated with recent lymph. On examiningthe bones of the pelvis, it was discovered that the right sacro-iliac synchondrosis was widely severed, so that two fingersmight be placed in the gap; the fibres of the posterior sacro-iliac, or interosseous ligament, were partially rent; some of thefibres of the psoasmagnus muscle were ruptured and lacerated;the ilio-lumbar nerve was torn across. A fracture was, more-over, detected traversing the right thyroid foramen, the hori-zontal ramus of the pubis above, and the anterior part of thetuberosity of the ischium inferiorly. The outer surface of theuterus was slightly ecchymosed ; there was evidence of inci-pient cystic disease in the ovaries, especially in the left one.The lungs were tolerably healthy; there were some small re-mains of long-standing tubercle of the grey and yellow varieties.There was considerable hypostatic congestion. The liningmembrane of the trachea and bronchi was much congested andvery vascular; and there were indications of commencingbronchitis. The heart was natural; the right cavities werefilled with coloured fibrinous clots; the left contracted andempty.
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WESTMINSTER HOSPITAL.
FRACTURE OF THE PELVIS, WITH EXTENSIVE WOUNDS, FOLLOWEDBY SLOUGHING, EXPOSING LACERATION OF THE ABDOMINALMUSCLES ; SYMPTOMS OF DELIRIUM TREMENS; DEATH FROMPYÆMIA ON THE FOURTEENTH DAY; AUTOPSY.
(Under the care of Mr. HOLTHOUSE.)IN the previous case the injury sustained arose from being
run over by a vehicle; in the present it was from a jump out ofa window thirty feet from the ground; and notwithstandingthe great disproportion in the nature of the immediate excitingeause, the subject of the following case was by no means soseverely injured as the female. Rupture of the bladder orother pelvic viscera occurs most commonly when the violenceis directly applied, as in the woman’s case; but in the sub-joined instance these viscera escaped, as the violence to the Ipelvis was more indirect, especially as the fall took place on ’
the side, the soft abdominal walls coming in for a considerable i
share of the concussion. The result; of course, was fatal. Mr.Holthouse, in some clinical remarks on this case, alluded to thesymptoms of pysemia which made their appearance a few daysbefore the patient’s death, and conjectured that the firm coagu-rlum found within the iliac vein was probably the result of ab,sorption of pus, some of which was found in the exterior of thutvessel. Mr. Henry Lee has shown that on the entrance of pMor decomposing material into a bloodvessel, the blood imme.diately takes the alarm, and becomes coagulated within thevessel, so that the further ingress of the morbid matter is pre.vented.The condition of the brain of this patient was well worthy of
notice. A more bloodless brain Mr. Holthouse never saw, andassociating this with the high maniacal excitement under whichthe patient laboured during lifetime is of great interest andpractical importance, entirely confirming the views of Dr.Forbes Winslow, as expressed in the current number of thePsychological Journal in the following words :-" In insanity,the 1’is vitce is often reduced to the lowest possible condition.In the great mass of acute cases of disordered mind which thephysician is called upon to treat, particularly in our publicasylums, the nervous system is in a state of positive exhaustionand debility. The furor, the violence, the maniacal excite-ment, the muscular resistance, so often associatedlwith insanity,are generally symptomatic of profound nervous and vascular-depression. "The notes of this case were taken by Mr. Ford, the dresser
of the patient :-I George C-, aged twenty-nine, a carpenter, was admitted’January 22nd, 1857, having thrown himself from the windowof his bedroom, a height of thirty feet, coming down on hisside on some flat iron railing. He was in a semi-collapsed con-dition, with great nervous excitement, very much resemming-delirium tremens, talking incoherently. He complained ofpain in the right side of the chest and abdomen. About halfway between the last rib and the crest of the ilium were twopunctured wounds, an inch and a half apart, from whichvenous blood was flowing, and on introducing a probe theywere found to communicate with each other, but not to extendinto the peritoneal cavity; a hard substance was felt by the-probe, and, on slightly enlarging one of the wounds, this wasremoved, and found to be a piece of bone. The following his-tory was obtained from the patient’s landlady :-He is a nativeof Suffolk, and was advised to come to London five or sixmonths ago, to break off a contemplated matrimonial engage-ment which his friends disapproved of. This matter seems tohave preyed on his mind; yet since his residence in London hehas always conducted himself in a respectable, steady, well-behaved manner; he was not given to drink, did not keep latehours, and worked regularly at his business. On Sunday,January 18th. he intimated to his landlady his intention of re-turning home the next day, and at once set about making pre.parations for that purpose. His manner was observed to bealtogether changed; he was cold and unsocial, and apparentlysuspicious of people in the house. He slept away one night ata coffee-house, where he left his watch and purse, and on re-turning to his lodgings he locked himself in his bedroom, contrary to his usual custom. To-day (Jan. 22nd) he was seen bypeople in the street, vociferating loudly at the window, anddeclaring that parties in the house had conspired to do himmischief. On some persons going up-stairs to him, and burst-ing open the door, he, under the impression that they werecome to murder him, jumped out of the window.On admission into the hospital, he was put to bed, hot bottles
were applied to the feet, and small quantities of brandy admi-nistered frequently; wet lint was applied to the wound, andten grains of calomel and colocynth were given to him beforehe was seen by Mr. Holthouse.-Eight P.M.: Reaction to some,extent has come on, though the pulse is still feeble; he is lessexcited; there is abdominal tenderness, and he shrieks outwith pain on coughing. He was ordered an anodyne draught.
Jan. 23rd.-The patient has’ not been quiet all night, andearly in the morning got out of bed, and was very violent.Blood is still oozing from the wounds; pulse 104. He lies withhis legs extended, and his aspect does not indicate any peri.tonitis. The bowels have not acted, and castor oil was orderedhim by the house-surgeon, and to take an effervescent draughtwith ammonia, and brandy every four hours.24th.-He has passed a quieter night, and is now more com-
posed, and not disposed to talk; the skin around the woundsis somewhat ecchymosed; haemorrhage has ceased; his bowelshave not yet acted; yet he passes urine freely; pulse 108,feeble.25th.-He was very restless last night, talking and attempt.
