NOTES ON A CASE OF FRACTURE OF THE SPINE

J. Peploe Cartwright
1879 The Lancet  
THE patient, a strong, well-nourished, grey-haired man, Harried, aged fifty-seven, a farm labourer, fell from a haystack .6.ve yards high on July 30th, 1878. Circumstantial evidence 'from his companion on the stack suggested the probability -of his falling on a brick, his left side being nearest the -ground, the brick causing extension of the vertebral column. He had always been a strong man, working hard, and, as th<? usual concomitant, was a free drinker; remembered no previous illness except
more » ... ious illness except very slight attacks of bronchitis the iast few winters; is father of sixteen children. On examination, four hours after the accident, he wss found lying on his back on the bed, perfectly sensible, slightly bruised about the head; motor power in both lower limhs completely suspended ; could move arms and breathe I -easily. There was loss of sensation over the gluteal and ciatic regions and over the backs of the legs, but sensation was beautifully delineated and marked the cutaneous supply of all the branches of the anterior crural down to the inner ankle and the cutaneous supply of the small sciatic to the inner side of the posterior aspect of the thigh and of the inferior pudendal nerve. On examining the spine, 110 disl?1,ceent of the spinuu processes was found, but there was 'teuderness over the twelfth dorsal and first lumbar spines ; 'Lt<< swelling. A catheter was passed and the uriue drawn Gir, which process he could not feel. 1"wIII the position of the iujury and the symptoms I pre-';:';IHtHd there must be a fracture of the spinal column about itte eleventh or twelfth dorsal vertebra, with pressure on 't.h.e cord either by displaced bone or effusion of blood. 'There being no deviation in the continuous regularity of the 'spiaous processes, and taking into consideration the patient's «.ge, I decided that it was not advisable to attempt to trephine. The patient was placed on a water-bed, and the catheter ,used twice daily. On rlugit5t 2nd the bowels were moved after a dose of castor oil ; much constipated, quite involuntary ,action, no power over sphincter. On the 4th, beef-tea, ;bra,ndy and eggs were administered. Temperature 984°; ptdse 80 ; respiration 2t. Bowels open, but very constituted. Patient had a slight cough, with slight mucous expectoration ; dulness on percussion over posterior surfaces of hoth lungs. On the 10th, the bowels not being open, a dose of oil was administered, which produced a large constipated stool, this being only the third motion since his accident on -July 30th. Tongue furred ; urine acid, sp. gr. 1020, no albumen. Catheter passed as usual. From this time to his death, on October 27th, he mic-'turated into a urinal, and his bowels were open regularly every morning about the same hour, there being no indication of this to the knowledge of the patient. On August 30th, a month after the accident, bedsores formed over the seat of fracture and over the sacrum. 'Though his appetite was fairly good, and he partook well i ,of eggs, brandy, milk, beef-tea, &c., he gradually grew I weaker, and the bedsore over the sacrum a fortnight before his death extended over the whole of that bone (where necrosed bone could be felt) and over the lumbar vertebrae, and this in spite of every care to prevent their spread, they being carefully and frequently dressed with unguentum 'e",il1ae and charcoal poultices. Oct. 27th.-After gradually sinking, the patient died this morning, the bowels having been open yesterday, and the I urine voided, as it has been since August 10th. AgM-o/jsy.—The eleventh dorsal vertebra was found to be I , fractured through the base of the spinous process, the fracture extending through the left lamina to the articular portion and into the body, the posterior part of the lamina beiug crushed and pressing in upon the lower portion of the -spitial cord and nerves surrounding it. There was entire absence of union at the seat of fracture. The bladder was diealthy. Pc3rucrlcs.-The points of interest in this case seem to me to be : Firstly, whether the fracture was caused by the extension of the spinal column from his falling on the brick, or whether, from the crushed state of the lamina, it was not rather caused hy direct violence through the lamina coming in contact with the edge of the brick. Secondly, whether, considering the only partial loss of sensation, and that the strength of the patient was comparatively good, it would have been advisable to trephine. Thirdly, the extraordinary passage of urine and fseces, and the healthy state of the bladder and urine, even to the end. Can the regular everyday movement of the bowels after the first ten days of the illness be attributed to a rhythmical action of nature to perform the functions of habit tutored by the training of fiftyseven years of regularity, although all voluntary motion, control over, and knowledge of, the action of the sphincters had been suspended ? And how can it be accounted for that the urine kept acid, constantly passed at specified times, and set up no irritation to cause cystitis, uretitis, or pyelitis ? Lymm, Cheshire. CASE OF RUPTURE OF THE FALLOPIAN TUBES. , aged forty, was first seen by me after her being twelve hours in labour. I found her very feeble, with a pale anxious expression of countenance, and sickness of stomach. On examination the os was dilated about an inch and a half, but very rigid and unyielding to the effort of dilatation with the finger. I waited about two hours, during which time the labour became weaker, and vomiting more troublesome, but the os had decidedly given way a little, and the head advanced into the pelvis. As the woman complained of great sinking, as if she were dying, I proposed to relieve her with the forcepa, but which she strenuously objected to. However, after about another hour, she revived a little, and, with a brisk pain, gave birth to both foetus and placenta, the child being dead. I left her soon aftac with a good contraction of the uterus. Six hours afterwards I was hurriedly sent for to see the patient, who was suffering, and had been through the interval, with incessant vomiting and faintiugs. This was slightly relieved with ice and small quantities of brandy, so long as no attempt was made to give any kind of food, which would be immediately rejected. At the end of fortyeight hours no urine had passed, nor was there the least inclination for so doing. I administered an enema of warm water, which brought a quantity away from the bowels, but no action of the bladder ensued. Soon after, I passed a male catheter, but found the bladder empty, the catheter passing so freely to nearly its full length that I suspected a rupture of the viscus. Having tried every remedy to allay the sick stomach without avail, she gradually sank, and died on the sixth day. My curiosity to know the real cause was so aroused that I made a request of the husband to grant me a post-mortem examination, which he very reo luctantly acceded to on condition that he should superintend it. Post-1ILa/.tern exa2iaat-ion. -My first move was to the uterus, which I found impacted in the pelvis, about the size of a very large cocoa-nut, having a black and bruised appearance on the right side about the size of the palm of the hand. The Fallopian tube was ruptured about two inches from the uterus, together with the broad ligament as far as the ovary. The tube itself was about the thickness of the little finger, presenting the appearance of a firm blood-clot. Turning to the left side, I found the Fallopian tube in the same condition, but not the uterus. Cutting into its substance on the right side, I found the organ perfectly healthy, also its cavity. On lifting it out of the pelvis I discovered about four ounces of blood. The bladder was quite empty, and the mucous lining showed considerable inflammation of a chronic character. The stomach was healthy, with the exception of congestion of the vessels on its inferior margin. Having satisfied myself that all the other abdominal viscera were healthy, I came to the conclusion that I had found the cause of death, and, very much to the relief of the husband, concluded my search. I congratulated myself in this case on not having applied the forceps, as most assuredly the cause of death would have been attributed to it. This was a temperate and healthy woman, with five children, up to the time her labour com-
doi:10.1016/s0140-6736(02)46464-1 fatcat:vop37q7d3rcvvfb6ko4smsyhcy