1902 BMJ (Clinical Research Edition)  
Reported by E. LAURIE ROBINSON, M.R.C.S.Eng., Surgeon to the Hospital.) J. P., aged 6o, a native of Alderney, was admitted into the hospital on September 24th, I900. History.-He had always enjoyed good health, except that of late years he had suffered somewhat from asthma and rheumatism. On September 22nd, 1900, in Alderney, he was riding a cart horse bareback. The horse bolted with him, and after being jolted up and down several times, in consequence of the animal stopping suddenly, he was
more » ... wn about two feet up in the air and fell back again on the horse's neck. He suffered severe pain and felt very faint, and was helped down by some neighbours. State on Examination.-At first there was not much to be seen, but on the following morning he was found to be suffering from extravasation of urine into the scrotum. Arrangements were made to send him as soon as possible to Guernsey, and he was admitted into the hospital about I A.M. on September 24th. State on Admission.-He was suffering somewhat from shock, and from a sharp attack of bronchitis. He stated that he had not passed urine since the accident, and that he could not raise his right leg without great pain. His scrotum was found to be very swollen, distended, and discoloured. The pelvic bones were separated from each other to the extent of 24 inches. The left bone was nearly in the middle line, but the right was displaced outwards fully 2a inches. There were extensive bruises in the gluteal and lumbar regions, and a large haematoma over the sacrum. There was also a slight abrasion of the sphincter ani on the right side. He was put under an anaesthetic, and incisions were made into the scrotum and perineum, letting out about a pint and a-half of bloody urine. A catheter was passed into the bladder without any difficulty, and a drainage tube attached to it, the free end of which was placed in a receiver under the bed, containing a solution of carbolic acid. Sandbags were placed on either side of the body in order to support the pelvis. It was impossible to put a binder round the body on account of the bruising of the soft parts. It was soon discovered that in addition to his other injuries he had paralysis of the sphincter ani, resulting in absolute incontinence of faeces, and it was only through the ceaseless care and attention of the matron and nurses that he was saved from extensive bedsores, and his life preserved. Operation.-After he had been in the hospital about a month I cut down upon the pubes, drilled the bones in two places, and wired them together. They united by first intention in spite of the fact that a few days after the operation urine was found to be coming through the lower part of the skin wound; this had to be opened, and cyanide gauze was stuffed into the wound. This extravasation was due to the separation of a slough from the right side of the urethra; up to that time by means of the catheter all extravasation had been prevented. Progress.He had several rigors, and also suffered from two alarming attacks of angina pectoris, and developed extensive phlebitis of the veins of the right leg. At the end of four months from the time of the accident the wounds were quite healed, and he was able to retain his water, but it was quite two months more before he regained control over the sphincter ani. At the end of the sevenmonths he was quite well except that he walked rather feebly. And now. just a year since the accident, he is able to take long walks without the help of crutches or sticks. REMARKS.-I believe that such an accident must be very rare. Of course rupture of the uretbra is common enough, but not separation of the pubic bones. I have no doubt that there was some laceration of the sacro-iliac joints, especially the right one, with injury to the sacral nerves, especially the fourth, causing the loss of control over the sphincter ani and partial paralysis of the lower extremities. He was most fortunate in that he never suffered from cystitis although the catheter was retained nearly four months. A NATIVE scout was admitted into hospital on September i6th, I90I, suffering from a gunshot wound of the abdomen, inflicted by a Lee-Metford bullet at thirty yards range, seven hours and a-half before admission. Condition on Admission.-He was in a state of great collapse, and complained of dull aching pain in the abdomen, more acuteat the entrance and exit wounds. He passed normal urine and a little flatus and bloody faeces immediately after admission. The abdomen was hard and boardlike, especially over its lower half. The entrance wound was situated 2 inches tcx the left of the umbilicus on a line between it and the anterior superior iliac spine. It consisted of a very small hole, around which was a local area of dulness. Some haemorrhage hac occurred from the wound. The exit wound was I inch below and I inch behind the right anterior superior iliac spine; the bullet had thus probably passed through that bone. It was very small in size, nearly the size of the entrance wound. The liver dulness was normal. Breathing was almost entirely thoracic. Shock was treated in the ordinary way, nothing being given by the mouth except ice to suck. Morphine gr. l was given that evening. On the next day shock had to a great extent passed off. On examination the liver dulness was found to be absent, and some gas escaping from the entrance wound. It was accordingly decided to operate. Operation.-Median laparotomy was performed. Nothing abnormal was discovered until the peritoneum was cut down on, when it was seen to bulge into the wound. The peritoneum was carefully picked up and incised, when a quantity of foul gas escaped. The intestine was then carefully taken out, coil after coil, and seen to be very red and inflamed and covered with recent lymph. Two small holes were found in the small intestine, and these were covered by means of Lembert sutures. What was taken to be one of the appendices epiploicae was then discovered, but on careful examination was seen to be moving, so was caught hold of and was found to be about i foot of an ordinary tapeworm. The anaesthetist then said that the patient was getting collapsed, and so an opening, was made in the posterior wall of the abdomen and a drainage tube inserted. The whole peritoneal cavity was well flushed out with lukewarm weak boric lotion and the anterior wound sewn up. The patient was then put to bed and rallied well from the operation, but sank and died fourteen hours after. Necropsy.-The whole peritoneal cavity was red and inflamed, and the intestines covered with recent lymph. Three more small holes were found in the small intestine, and one large hole, I inch in diameter, found close to the ileo-caeca) valve, and from it protruded the remains of the tapeworm. REMARKS.-This condition of a living tapeworm in the peritoneal cavity is described in books as a sign of perforation of the intestine, but it was thought that a recorded case might be of interest. Another point of interest was that although the bullet was fired at short range, and passed through the bone, the size of the exit wound was nearly the same as that of entrance, although on post-mortem examination the ilium was found very much splintered. This might possibly be due to the thick muscular covering of the ilium at this spot. RAILWAY HYGIENE IN ITALY.-A committee was appointed some time ago by the Italian Minister of the Interior to study the question of railway hygiene, and draft a scheme of legislation on the subject. The following are the points which are to be considered:-(i) Ventilation, heating, furnishing, cleansing, and disinfection of rolling stock; (2) tuberculosis, cutaneous and infectious diseases, the transport of the sick; (3) hygiene of stations, offices, etc.; ((4) medicine cases and surgical nstruments, and dressings for emergencies. [FERB. I, Io902.
doi:10.1136/bmj.1.2144.268 fatcat:q6nrly2zufckllzhkmx44pqhna