Mat
CASES FROM PRACTICE.
1,1867.]
Liver studded with numerous pyaemic patches of whitish grey softening, each rather smaller than the tip of tlie little finger, and extending about quarter of an inch into the substance of the liver There is a superficial rent on the posterior thick margin of the right lobe, and two others on the under surface. There is also a dark line along the upper and anterior surface, which is apparently another superficial rupture nearly healed. Spleen.?With two ruptures in its posterior edge, the upper one extending deep into its substance. Left Kidney.?At its upper end is a very extensive rupture running up into the hilus. The areolar tissue surrounding the
CASE OF RUPTURED LIYER, SPLEEN, AND KIDNEY, WITH FRACTURE OF ONE ARM, AND COMPOUND DISLOCATION OF THE OTHER; DEATH FROM TETANUS ON THE 17th DAY. Bx Baboo Gopal Ciiunder House
Surgeon,
Medical
Eoy, L.M.S.,
College Hospital.
Ram Lali, aged 25 years, a Hindoo confectioner, was admitted into the Medical College Hospital, nnder Dr. Fayrer, on the 20th February, 1867, with simple Colles's fracture of the left forearm, and compound dislocation of right wrist-joint, produced by a fall from a tamarind tree from a height of thirty-five or forty feet. He was stunned by the accident, and could not say whether lie struck against anything as he fell. There was a contused wound on the inner and anterior aspect of the right, wrist-joint, about an incli in length, through which tho styloid process of the ulna protruded, but it was neither fractured nor denuded of The radio ulnar
periosteum.
ligaments were torn, and the bones were consequently freely moveable. The left radius was broken just above its lower epiphysis, and the styloid process of the ulna was detached, giving to the wrist the peculiar deformity of a Colles's fracture. Pulse very weak. Ordered.?Tr : opii ra xxv. immediately, and stimulant mixture every two hours, and brandy. The dislocation was reduced, and the arm put on a straight, splint and bandaged ; pistol-shaped splint applied to the loft forearm. 21 st.?Complaining of pain in the hypogastrium. Passed urine once after the accident, which was uniformly bloody, but contained no clots. A catheter was passed with ease into tho bladder, and a little more bloody urine withdrawn ; no fracture of the pelvic bones could be detected. Pulso feeble. Repeat stimulant every hour ; hot bottles ; milk and soojee,
and soup.
Wound beginning to became stronger day by day. Hsematuria ceased. Pain in the hypogastrium subsided, but fever continued persistent. Extensive suppuration occurred ; the wrist swelled, and free incisions were made to prevent any burrowing of pus. On the 28th the extremity of the ulna was found denuded to the extent, of half an inch, and dead. Considering it to be the source of irritation, the end of it was removed with the bone
bloody urine again. unhealthy aspect. The pulse
22nd.?Passed
assume an
forceps. Although
the fever abated in its severity in two or three days, the wound still looked foul, and occasional starting of the limb foreboded the approach of graver mischief. Nor was the worst anticipation long in being realized, for within twenty-four hours symptoms of tetanus fully set in. The wound was examined again, and the joint was found to be disorganized; and the radius, recrossed at itslower end, protruded through the wounds. Amputation at the middle of the forearm was performed, on the 4th March, 1867, by Dr. Fayrer. It is here to be remarked that the tetanic spasms were limited to the muscles of the jaw, of deglutition and of respiration, the extremities being completely free from the disease. a Brandy and soup were administered every hour, and pill composed of opium gr. j. and tobacco 9j. smoked every two hours. An injection of castor-oil, turpentine, sulphuric ether, and assafoetida given every six hours. Stump kept wet with opium solution. On the day of the operation the fits became less frequent, and the patient could swallow food and medicine better than before, but the spasms afterwards increased, and he died on the 8tli March, 1867, four days after operation, and sixteen days after accident. Post Mortem Examination
(19
hours after
death.)
Lungs healthy and crepitant. Firm, decolourized clots in the right ventricle, passing into the pulmonary artery. Left ventri-
cle very much contracted. A small decolourized cloc in the aorta. The following notes are taken from Dr. Colles, Professor of Physiology and Comparative Anatomy in the Medical College, after his examination of the specimens forwarded to him.
121
vessels at their entrance into the hilus was dense from infiltration of blood Nearly three-fourths of the kidney, including its upper and nearly all its posterior surfiice, and a great part of its anterior, is of a pale buff colour, and soft and doughy to the touch. The posterior, so affected, is separated from the sound part by a dark coloured wavy line of demarcation, which can be seen extending through tho deep as well as the superficial structures on the surface of the incision made obliquely into the anterior surface of the organ. About two ounces of blood clots lay on the great omentum, which was folded and wrinkled upwards in a mass. About same quantity of blood coagula was found over the left kidney and left side of pelvis; 110 peritonitis. Bladder healthy. Kemarks.
\
The above furnishes a rare instance of a case of rupture of spleen, liver, and kidney, surviving for many days after accident; and were it not for the unfavourable changes that occurred in the dislocated wrist, irrespective of the injury to tho internal organs, I may venture to state the case might have progressed satisfactorily. The symptoms were so vague in their nature that the existence of such extensive internal lesion was not suspected until tho post mortem examination revealed the real stato of affairs. Beyond liajmaturia of a few days' duration, we had no data on which to ground our diagnosis. That the blood had come from the ruptured portion of the kidney, and found its way though the ureter into the bladder, was evident from the fact of there being absence of bleeding from the urethral canal, absence of blood clots in the bladder before and after death, and urine uniformly bloody throughout. As this case is such a singular one, I doubt not much misgiving will arise in the minds of medical jurists, before they accept it as a fact. Whoever is incredulous may, however, satisfy himself by inspecting the specimen in the Medical College Museum. The gangrenous patches in the liver, whilst the lungs were free from such changes, can be accounted for as the result of embolism arising from the surface of the ruptured spleen, the emboli having been carried by the splenic vessels to, and arrested in the liver. But it is to be remarked tlmt two of the ruptured organs presented patches of local death. Might not such local death be the direct influence of the pyaemic poison generated from the suppurating wound in the ruptured the injury they organs, whose vital balance was disturbed by sustained ?
Army Medical Depertment.?List of successful candidates for Assistant-Surgeoncies in the British Medical Service, February 7th, 1867. Makes. i o
3 4
5 6 7 8 9 10 11 12 13
R. E. Bredon E. J. Fairland Thomas O'llcilly J. A. Bloxam R. P. Murphy E. Townsend T. S. Cogan James O'Reilly D. J. O'Flynn Jos. Gray R. C. Parkinson J. Williams D. L. Olden
...
...
...
...
...
...
... ...
...
...
...
...
...
2320 2215 2195 2120 1955 1885 1770 1730 1700 1G95 1690 1625 1580
Mabks.
14 15 16 17 18 19 20
21 22 no
25 26
J. F. Supple N. Wade G. C. Irving J. H. Moore W. J. Wheeler J. R. Croker A. W. Roche T. C. Tolmie B. S. M'Aleny ( J. W. Morgan I G. C. Purcell R. J. P- Holmes M. A. Kilroy
Maximum of marks obtainable Minimum required to pass T. G. Logan,
...
...
...
...
...
...
... ???
...
...
???
... ...
1575 1540 1520
1505 1495 1450 1340 1310
1270 1240 1240
1220 1180
???
Inspector-General.
CASES FROM PRACTICE.
1,1867.]
Liver studded with numerous pyaemic patches of whitish grey softening, each rather smaller than the tip of tlie little finger, and extending about quarter of an inch into the substance of the liver There is a superficial rent on the posterior thick margin of the right lobe, and two others on the under surface. There is also a dark line along the upper and anterior surface, which is apparently another superficial rupture nearly healed. Spleen.?With two ruptures in its posterior edge, the upper one extending deep into its substance. Left Kidney.?At its upper end is a very extensive rupture running up into the hilus. The areolar tissue surrounding the
CASE OF RUPTURED LIYER, SPLEEN, AND KIDNEY, WITH FRACTURE OF ONE ARM, AND COMPOUND DISLOCATION OF THE OTHER; DEATH FROM TETANUS ON THE 17th DAY. Bx Baboo Gopal Ciiunder House
Surgeon,
Medical
Eoy, L.M.S.,
College Hospital.
Ram Lali, aged 25 years, a Hindoo confectioner, was admitted into the Medical College Hospital, nnder Dr. Fayrer, on the 20th February, 1867, with simple Colles's fracture of the left forearm, and compound dislocation of right wrist-joint, produced by a fall from a tamarind tree from a height of thirty-five or forty feet. He was stunned by the accident, and could not say whether lie struck against anything as he fell. There was a contused wound on the inner and anterior aspect of the right, wrist-joint, about an incli in length, through which tho styloid process of the ulna protruded, but it was neither fractured nor denuded of The radio ulnar
periosteum.
ligaments were torn, and the bones were consequently freely moveable. The left radius was broken just above its lower epiphysis, and the styloid process of the ulna was detached, giving to the wrist the peculiar deformity of a Colles's fracture. Pulse very weak. Ordered.?Tr : opii ra xxv. immediately, and stimulant mixture every two hours, and brandy. The dislocation was reduced, and the arm put on a straight, splint and bandaged ; pistol-shaped splint applied to the loft forearm. 21 st.?Complaining of pain in the hypogastrium. Passed urine once after the accident, which was uniformly bloody, but contained no clots. A catheter was passed with ease into tho bladder, and a little more bloody urine withdrawn ; no fracture of the pelvic bones could be detected. Pulso feeble. Repeat stimulant every hour ; hot bottles ; milk and soojee,
and soup.
Wound beginning to became stronger day by day. Hsematuria ceased. Pain in the hypogastrium subsided, but fever continued persistent. Extensive suppuration occurred ; the wrist swelled, and free incisions were made to prevent any burrowing of pus. On the 28th the extremity of the ulna was found denuded to the extent, of half an inch, and dead. Considering it to be the source of irritation, the end of it was removed with the bone
bloody urine again. unhealthy aspect. The pulse
22nd.?Passed
assume an
forceps. Although
the fever abated in its severity in two or three days, the wound still looked foul, and occasional starting of the limb foreboded the approach of graver mischief. Nor was the worst anticipation long in being realized, for within twenty-four hours symptoms of tetanus fully set in. The wound was examined again, and the joint was found to be disorganized; and the radius, recrossed at itslower end, protruded through the wounds. Amputation at the middle of the forearm was performed, on the 4th March, 1867, by Dr. Fayrer. It is here to be remarked that the tetanic spasms were limited to the muscles of the jaw, of deglutition and of respiration, the extremities being completely free from the disease. a Brandy and soup were administered every hour, and pill composed of opium gr. j. and tobacco 9j. smoked every two hours. An injection of castor-oil, turpentine, sulphuric ether, and assafoetida given every six hours. Stump kept wet with opium solution. On the day of the operation the fits became less frequent, and the patient could swallow food and medicine better than before, but the spasms afterwards increased, and he died on the 8tli March, 1867, four days after operation, and sixteen days after accident. Post Mortem Examination
(19
hours after
death.)
Lungs healthy and crepitant. Firm, decolourized clots in the right ventricle, passing into the pulmonary artery. Left ventri-
cle very much contracted. A small decolourized cloc in the aorta. The following notes are taken from Dr. Colles, Professor of Physiology and Comparative Anatomy in the Medical College, after his examination of the specimens forwarded to him.
121
vessels at their entrance into the hilus was dense from infiltration of blood Nearly three-fourths of the kidney, including its upper and nearly all its posterior surfiice, and a great part of its anterior, is of a pale buff colour, and soft and doughy to the touch. The posterior, so affected, is separated from the sound part by a dark coloured wavy line of demarcation, which can be seen extending through tho deep as well as the superficial structures on the surface of the incision made obliquely into the anterior surface of the organ. About two ounces of blood clots lay on the great omentum, which was folded and wrinkled upwards in a mass. About same quantity of blood coagula was found over the left kidney and left side of pelvis; 110 peritonitis. Bladder healthy. Kemarks.
\
The above furnishes a rare instance of a case of rupture of spleen, liver, and kidney, surviving for many days after accident; and were it not for the unfavourable changes that occurred in the dislocated wrist, irrespective of the injury to tho internal organs, I may venture to state the case might have progressed satisfactorily. The symptoms were so vague in their nature that the existence of such extensive internal lesion was not suspected until tho post mortem examination revealed the real stato of affairs. Beyond liajmaturia of a few days' duration, we had no data on which to ground our diagnosis. That the blood had come from the ruptured portion of the kidney, and found its way though the ureter into the bladder, was evident from the fact of there being absence of bleeding from the urethral canal, absence of blood clots in the bladder before and after death, and urine uniformly bloody throughout. As this case is such a singular one, I doubt not much misgiving will arise in the minds of medical jurists, before they accept it as a fact. Whoever is incredulous may, however, satisfy himself by inspecting the specimen in the Medical College Museum. The gangrenous patches in the liver, whilst the lungs were free from such changes, can be accounted for as the result of embolism arising from the surface of the ruptured spleen, the emboli having been carried by the splenic vessels to, and arrested in the liver. But it is to be remarked tlmt two of the ruptured organs presented patches of local death. Might not such local death be the direct influence of the pyaemic poison generated from the suppurating wound in the ruptured the injury they organs, whose vital balance was disturbed by sustained ?
Army Medical Depertment.?List of successful candidates for Assistant-Surgeoncies in the British Medical Service, February 7th, 1867. Makes. i o
3 4
5 6 7 8 9 10 11 12 13
R. E. Bredon E. J. Fairland Thomas O'llcilly J. A. Bloxam R. P. Murphy E. Townsend T. S. Cogan James O'Reilly D. J. O'Flynn Jos. Gray R. C. Parkinson J. Williams D. L. Olden
...
...
...
...
...
...
... ...
...
...
...
...
...
2320 2215 2195 2120 1955 1885 1770 1730 1700 1G95 1690 1625 1580
Mabks.
14 15 16 17 18 19 20
21 22 no
25 26
J. F. Supple N. Wade G. C. Irving J. H. Moore W. J. Wheeler J. R. Croker A. W. Roche T. C. Tolmie B. S. M'Aleny ( J. W. Morgan I G. C. Purcell R. J. P- Holmes M. A. Kilroy
Maximum of marks obtainable Minimum required to pass T. G. Logan,
...
...
...
...
...
...
... ???
...
...
???
... ...
1575 1540 1520
1505 1495 1450 1340 1310
1270 1240 1240
1220 1180
???
Inspector-General.
