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Medical Annals
of the
DISTRICT OF COLUMBIA
Volume III JANUARY, 1934 Number 1
ACCIDENTS AND INJURIES
A Comparative Study of Their Causes Among Various Groups
John P. H. Murphy, M.D.
Senior Medical Officer, St. Elizabeth’s Hospital, Washington, D. C.
If one would attempt to make an exhaustive study of the subject of accidents and injuries he must of necessity cover an extensive and widely varied field, for accidents and injuries are to be found along every path of construc- tive endeavor and to a greater or lesser extent in every walk of life. The literature is over- flowing with material written for the purpose of showdng how to avoid the loss of life or limb, and the conservation of property has been the topic over which human intellect has pondered for centuries. The insurance com- panies who carry casualty risk are ever on the alert to familiarize themselves with details pertaining to the habits, occupation, environ- ment and physical condition of the prospect, governing the premiums accordingly and ac- cepting or rejecting as the case may be. Nu- merous fraternal organizations protect the members by accident and death benefit insur- ance and large corporations quite often auto- matically take out a policy on each employee in order to defray the expenses of injury and offset the probability of suit.
Causative Factors
But accidents and injuries seem to happen when apparently every known precaution has
* Read before the Section on Nervous and Mental Diseases of the Society, December 7, 1933.
been put into effect to prevent their existence. Individual temperament, defects in eyesight or hearing, carelessness, improperly adjusted or faulty machinery, alcoholic intoxication, poor roads, inclement weather, improperly constructed building material, lack of atten- tion and failure to obey orders, the thought- lessness of youth and childhood, confusion in moments of stress or emergencies, are all fac- tors which at times lead to accidents.
In every-day life among so-called sane or normal people, the criminal is ever present, and crime in all its protean manifestations is forever being suppressed. In his book en- titled “Crime and Criminals,” Dr. William A. White reminds us that crime is due to a dis- turbance of the emotions. He further states that back of every event of a psychological nature, there can be found other events out of which it grew and which give it meaning. Acts follow one another logically and no ap- peal from an intellectual standpoint has much effect on disordered mental functioning. Some malefactors, however, rate high on the mental tests, but as crime in itself is an indicator of poor judgment and lack of forethought, the commission of such is evidence that impulse or emotion was uppermost in consciousness. In some criminals it would seem, however, that there is a constant struggle between the ego ideal and the unconscious historic past with its instinctive cravings. Webster gives as his definition of crime, “The omission of a duty commanded or the commission of an act forbidden by a public law: A violation of a public right or the rights of an individual.” Thus, crime is always a source of injury to
1
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Medical Annals of the District of Columbia
others no matter how trivial or serious the act may be. Again, as stated by White, if we consider that the fundamental instinctive drives that move man to action are love, hate and guilt, I think it may be shown that under the heading of crime almost any conceivable accident or injury may happen, be it corporal or mental. Love as an ideal is the theme of poets, artists and musicians, but where no re- ciprocation is returned, happiness is often at- tained in some form of sublimation. Ambi- tion may lead to forgetfulness and the ego is satisfied by constructive or creative activity. But the emotions have the capacity for a mul- tiplicity of utilizations, and the spurning of love may be the precipitating factor of sui- cide, homicide, infanticide or a host of other antisocial acts. Hate, as we know, is the am- bivalent of love. Egoistic in its bitterness, how often has it attained the pinnacle of de- struction and satisfied the sadistic by deeds of violence; how often indeed has this same drive been the instrument of humiliation and in- jured feelings. Guilt, with the often accom- panying conflict of emotions, may bring about a mental state from which relief can only be secured by self destruction or a flight from reality in a psychosis. On the other hand, however, crimes have been committed with a deliberate purpose, in the hope that punish- ment will be meted out and the inward pres- sure relieved. Then again, religion may solve the problem and the monastery or clois- ter take the place of prison walls.
Fear and rage each play a part in the pro- duction of accidents and injuries for when reason is entirely overshadow'ed by such in- fluences, responsibility is cast to the winds. It is true that man through the process of evo- lution has reached a high plane of civilization and culture, yet he is not immune to the de- fects in his own make-up, and the thin veneer which he presents to the world is easily shat- tered when emergencies arise. Man has formed society by necessity, as illustrated by the various trade unions, who despite their ideals and principles have often been the cause of considerable physical violence.
Accidents in the District of Columbia
Turning now to the chief subject at issue in this paper, I hope to convey some idea of the accidents and injuries occurring among the public at large as compared with those met with in some of the hospitals for the insane. During the year 1930 the population in the District of Columbia was estimated as 486,- 869. The annual report of the Health Officer for the fiscal year ended June 30, 1932, showed that the death rate for the calendar year 1931, and by this I mean deaths from external causes, was as follows:
Accidents, accidental poisoning, falls, burns, firearms, infanticide, skull fracture, explosions, etc. :
White 555
Colored 239
Total 794
Included in this number were suicides:
White 112
Colored 15
Total 'vfl
Among the suicides, death was brought about by the following means:
tthite: Cases
Codein poisoning 1
Sodium cyanide 1
Strychnine poisoning 2
Veronal poisoning 3
Carbolic acid poisoning 2
Potassium cyanide 1
Irritant poisoning 1
Mercuric chloride 1
Lysol poisoning 4
Inhalation of illuminating gas 34
Monoxide gas poisoning 3
Hanging by the neck 10
Drowning 5
Firearms 30
Stab wounds 5
Jumping from Taft Memorial Bridge 3
Jumping from buildings 6
Colored:
Lysol poisoning 1
Inhalation of illuminating gas 4
Drowning 1
Firearms 5
Jumping from Taft Memorial Bridge 2
Jumping from buildings 2
Medical Annals of the District of Columbia
3
Included in this number also were homi- cides, the death toll being 29 white and 48 colored. The means of destruction were classified as follows:
White: Cases
Firearms 17
Stab wounds 2
Inhalation of illuminating gas 1
Septic abortion 2
Drowning 2
Fracture of skull 5
Colored ;
Firearms 32
Cutting 9
Traumatic assaults 7
Classifying the above from the standpoint of sex, there were in the group:
Cases
White males 21
White females 8
Colored males 38
Colored females 10
During the year 1932 the statistics for the District of Columbia show that the micro- analyst handled for the Police Department in connection with crime detection, 104 cases including murder, death by falls, collision while intoxicated, drowning while intoxicated, suicides by gas, gunshot cases, hanging while intoxicated, drug cases, rape, abortion, death by drinking polluted river water, 2 cases of practicing medicine without a license and 1 case of violation of the drug law.
It might be of interest at this point to note that during the year 1931, according to the Metropolitan Life Insurance Company, 33,000 people were killed and 1,000,000 injured in automobile accidents. In the Statistical Bul- letin which this company issued during Octo- ber, 1933, the following comments were made: “Homicide in its wide prevalence throughout the United States presents one of the unsolved social problems of the country. Why should the homicide rate in our white population be 3 times as high among us as across the border among our neighbors in Canada, and 10 or 11 times as high as in England? The correct, answ'er is not as yet forthcoming, although it
would not be difficult to say why Nevada has the highest rate among white persons, viz., 16.5 per hundred thousand, while the New England states have a very low homicidal rate. As might be supposed, however, homi- cide is mainly an urban problem, as rural areas show a uniformly lower rate.
From the Emergency Hospital in this city with a bed capacity of about 250, through the courtesy of the Superintendent I have secured the following data:
Number of emergency cases for comparative purposes:
|
1931 |
14,363 |
|
1932 |
16,682 |
|
1933 |
18,221 |
Number of ambulance calls made during the year June 1, 1932, to July 1, 1933 — 8,240.
As a number of cases received at the Emer- gency Hospital and some other hospitals in the District of Columbia are the aftermaths of automobile accidents, I quote the following which I have received from the Major and Superintendent of the Metropolitan Police:
|
DATE |
DEATHS |
MINOR INJURIES |
PROPERTY DAMACIE |
MINUS * |
TOTAL NUMBER OF ACCIDENTS |
|
July, 1932 |
11 |
292 |
287 |
42 |
548 |
|
August, 1932 |
6 |
255 |
263 |
46 |
478 |
|
September, 1932 |
11 |
307 |
312 |
47 |
583 |
|
October, 1932 |
12 |
360 |
403 |
41 |
734 |
|
November, 1932 |
13 |
348 |
368 |
35 |
694 |
|
December, 1932 |
8 |
334 |
377 |
41 |
678 |
|
January, 1933 |
6 |
314 |
469 |
29 |
760 |
|
February, 1933 |
7 |
267 |
409 |
29 |
654 |
|
March, 1933 |
4 |
304 |
429 |
35 |
702 |
|
.\pril, 1933 |
7 |
323 |
397 |
41 |
686 |
|
May, 1933 |
6 |
386 |
428 |
69 |
751 |
|
June, 1933 |
3 |
330 |
366 |
40 |
659 |
* More than one person injured in the same accident.
Total deaths were 94, minor injuries 3,820, property damage 4,508, minus 495, making a grand total of accidents during the fiscal year of 7,927. The above will show that while the death rate may be very slightly decreasing, the remainder of the figures are about the
4
Medical Annals of the District of Columbia
same throughout the months from July 1, 1932, to and including June 30, 1933.
Accidents in the x\rmy
I am indebted to Lieutenant Colonel George F. Lull, iSI.C., United States Army, for his as- sistance in securing information concerning accidents and injuries in the military service, the salient points of which I will mention, to- gether with some remarks from a paper en- titled, “Automobile Casualties” written by the Colonel for the Military Surgeon in De- cember, 1932. From the annual report of the Surgeon General, United States Army, 1932, we learn that during 1931 there were 623 deaths among officers and enlisted men, this being the highest rate since 1920. Of these, 289 resulted from external causes. A survey of causes during the 20-year period excluding 1917 to 1920, inclusive, and ending with 1929, showed that suicide was the leading cause in 16 of the 20 years and tuberculosis in the re- maining 4. The fatalities from automobiles, it was said, had increased so greatly during the past 2 years, that deaths from this cause headed the list. In a large number of such cases, faulty driving brought on the fatality, since excessive speed often caused the cars to leave the road, more especially when passing around curves. The report for 1931 discloses that there were 1,851 admissions to hospitals in the service during that year as a result of automo- bile accidents, together with 1 motorcycle ac- cident and 6 auto collisions with railroad trains. Only a very small percentage of the men involved were on duty at the time of the accident, and the great majority of mortalities resulted from privately owned or hired cars. A report from the Bureau of Census revealed that although the accident rate from automo- biles in the Army during 1930-31 had in- creased materially, that for the civil popula- tion remained practically stationary. Of course, as set forth by Lieutenant Colonel Lull, there are more automobiles in use today than there were 10 years ago, but this factor alone does not account for the increase in ac-
cidents. With reference to the Air Corps, the Colonel writes, there are constant efforts being made to decrease the flying hazard by perfecting the airship and by reducing the personnel deficiency to a minimum through careful physical examinations combined with constant observation of pilots. As a result of this, the number of casualties has been re- duced. Thus, during the 5 years ending De- cember 31, 1930, the crash fatality rate among aviation officers was less than one-half as great as during the 5 years ending December 31, 1925. In the annual report from the Xavy, submitted in 1932, it was stated that the total death rate in 1931 was 391. Of these, 216 were due to traumatism, 81 of which re- sulted from automobile accidents, while the remainder included explosions aboard ship, anti-aircraft gun explosions, target practice mishaps, earthquakes, drowning, submarine accidents and the like. As in the Army, how- ever, a very great percentage of injuries and casualties resulted from motor vehicle acci- dents and the great majority occurred when the men were absent from command. As might be surmised, nevertheless, in the Navy the leading cause of death was given as drown- ing, the rate being given as 35 per 100,000.
Accidents in Public Schools
During the school year, 1931-32, there were 140 mentally retarded pupils examined in the District of Columbia, and 97.1 per cent were found to have some physical defect. It might also be well to add that 82 crippled children, 51 white and 31 colored, were enrolled in schools for cripples who would be liable to al- most any type of accident or injury if left to their own resources.
Accidents in Institutions for the Men-
T.LLLY DeR.LNGED
In the annual report submitted by the De- partment of Mental Hygiene of the State of New York from July 1, 1930, to June 30, 1931, it was stated that at the beginning of the fiscal year there were on the books 52,030 patients
Medical Annals of the District of Columbia
5
with mental disease in the civil state-hos- pitals, 1,861 in the hospitals for the criminal insane and 2,605 in private licensed institu- tions, making a total of 56,496. The ad- missions for the year, including transfers, numbered 15,839 in civil hospitals, 230 in hos- pitals for the criminal insane and 785 in pri- vate institutions, making a total of 16,854. The cases discharged from the civil state-hos- pitals, exclusive of transfers, numbered 5,565. Of those 2,236 were pronounced recovered, 1,362 much improved, 1,180 improved, 630 unimproved and 147 not insane. In the Craig Colony for Epileptics there were on the books at the beginning of the year, 1,777 patients, 100 of whom were on parole. During that year 8 patients were discharged as recovered, 23 improved, 67 unimproved and 1 non-epi- leptic, making a total of 99. There were, however, also 18 deaths. In the 4 State schools there were 9,046 pupils at the begin- ning of the year. The discharges were 395 improved, 137 unimproved. There were 13 licensed institutions for the feeble-minded also carrying a total of 425 patients. The institution for defective delinquents at Xapa- noch, caring for male patients over 16 years of age, charged with crime, at the beginning of the year contained 772 patients. The num- ber of accidents and injuries reported and in- vestigated in the State institutions through- out New York was given as 1,042. There were 532 among the men and 510 among the women. In the hospitals for the criminals, 25 men and 1 woman were injured; in Craig Colony, 43 men and 27 women; in the State schools, 55 males and 26 females; and in the private institutions 46 men and 15 women. In all these institutions, death followed the ac- cidents in 43 men and 22 women. All cases where doubt as to the cause of death existed were reported to the coroner. These included 14 suicides among the men and 2 among the women.
As to the accidents and injuries which have occurred at St. Elizabeth’s Hospital with a patient population of a little less than 5,000
to date, during the period from January to September, 1933, inclusive, the figures clas- sified according to the various services are as follows:
|
z < |
a u |
X o X < s |
X X < |
> < s |
U z D |
>• |
O X < |
H a. u (/> |
|
|
Group 1 — !Male: |
|||||||||
|
Howard Hall |
7 |
2 |
11 |
9 |
4 |
4 |
4 |
2 |
2 |
|
Detached |
24 |
24 |
17 |
22 |
11 |
11 |
11 |
6 |
1 |
|
West Side |
14 |
23 |
24 |
29 |
27 |
12 |
19 |
17 |
14 |
|
Group 2: |
|||||||||
|
Richardson Group |
7 |
3 |
11 |
6 |
8 |
4 |
7 |
8 |
13 |
|
Receiving Male |
3 |
6 |
0 |
2 |
3 |
1 |
8 |
4 |
6 |
|
^ledical and Surgical. |
4 |
6 |
10 |
5 |
19 |
16 |
2 |
9 |
10 |
|
R Building |
8 |
10 |
12 |
9 |
15 |
9 |
22 |
14 |
8 |
|
Group 3 — Female: |
|||||||||
|
Women’s Service |
14 |
8 |
18 |
12 |
20 |
9 |
14 |
10 |
13 |
Total men 624
Total women 118
Total men 624
Total women 118
As the Medical and Surgical Department is the central receiving unit of the hospital, in a report from October, 1932, to September, 1933, I found that such injuries as fractures, dislocations, severe lacerations and contusions, with an occasional emergency case from the outside, were by month as follows:
October, 1932. . . November, 1932. December, 1932 . January, '1933. . . February, 1933. . March, 1933 . . . .
April, 1933
May, 1933
June, 1933
July, 1933
.\ugust, 1933
September, 1933
UEN
WOMEN
5
8
5
5
4
6
5
6 5 2 3 2
3
7
8
3
4 1
4 0 1
5 2 1
Total
56
39
Grand total
837
As to employees I may say that during the past 3 years 1,800 injuries have been re- ported among this group, making an average
6
Medical Annals of the District of Columbia
of about 600 per annum. During the past 25 years I believe that 4 also have met deaths at the hands of patients. In the year 1922 the annual report of the Superintendent of this hospital showed the number of minor injuries to patients and employees to be 520, including colored and white of both sexes. The num- ber of patients here during the fiscal year was given as 3,900. In 1923, the injuries were 736, the patient population being 3,982. In 1924, the injuries totaled 179, but the patient popu- lation had risen to 4,207.
The Prevention of Accidents
The question naturally arises — what is be- ing done to prevent, or at least reduce, the number of accidents and injuries? In ci\dl life the education of the masses, especially the younger generation through instruction in the public schools; and in this connection the Boy Scouts and patrol boys seem to be serv- ing a very useful purpose. Then again, the building inspectors and traffic bureaus throughout this and other countries are ever on the alert to enforce the existing regulations and devise new ones in the interests of safety. Modern construction and invention have ac- complished wonders in the conservation of life and property, but the human mind does not remain stagnant and improvements along many lines are being brought to light almost every day. In every organization a record should be kept of all accidents and injuries, each specific case should be investigated and the responsibility fixed upon the party or par- ties at fault so that those involved may learn, through experience, the folly of repetition. The National Safety Council, Inc., wdth of- fices in the Civic Opera Building, 20 North Wacker Street, Chicago, Illinois, organized for the safety of people at work, on the street and in the home, is conducting a very effective campaign in the Engineering Department of the United States Army among 20,000 work- ers employed on the rivers, harbors, and in- land waterways. This educational organiza- tion, through the distribution of the Safety
Magazine, issued monthly, together with the displaying of posters in conspicuous places and the placing of notices in the pay enve- lopes of employees and enlisted men, is forever striving for the cause and promoting the ideal by meetings, discussions and constructive propaganda. As might be expected, of course, the service is also open to industrial organiza- tions, private or governmental, for the benefit of employees.
As a sound mind in a healthy body is one of the greatest assets to mankind, I shall de- vote the few remaining pages of this paper to suggestions for the prevention of accidents and injuries met with in hospitals for the insane. As stated elsewhere in these pages, this class is governed almost entirely by emo- tional swings, as it would appear that judg- ment or discretion do not seem to have much weight in conduct reactions among psychotics. It is necessary, therefore, that new and differ- ent action patterns be established if possible along hygienic and constructive lines. A posi- tive transference on the physician, by those not too deteriorated to understand, is of ma- terial assistance, as irritability is reduced, more contentment brought about and quite often hope awakened. One must not forget also the proper lines of approach in the vari- ous forms of mental disorders and bear in mind the reactions usually to be expected. Many patients appreciate cleanliness, exten- sion of privileges and a more congenial social atmosphere, the granting of which often elim- inates quarrels and injuries which might other- wise have occurred. The cafeteria system recently established at this institution has been gratefully accepted by many patients and in my opinion is a very valuable step in the right direction. The careful selection of prospective employees cannot be overesti- mated, and instruction under competent su- periors may produce very suitable material. The attendant or nurse should be among the patients, should be assigned to a ward long enough to know those entrusted to his charge, and be taught how to make suitable groupings
Medical Annals of the District of Columbia
7
according to certain traits and behavior re- actions which he may observe. He should be shown how a patient may react to an hallucinatory experience, how a paranoid may project upon some entirely unsuspecting or innocent party, or how an epileptic in his impulsive anger may attack with very little warning or provocation. Overcrowding among patients has been the cause of many accidents and injuries, and when such a situa- tion arises, selection in transferring is the only logical course to pursue. Accidents and in- juries may often occur in large congregate dining rooms during the rush of meal hours, but this disagreeable feature may to some ex- tent at least be offset by strict attention to duty on the part of the attendants. Skin infec- tions by the irritation which some produce are often the etiological factors in the production of quarrels, and it is, of course, the duty of the physician and nurse to see that such conditions are promptly treated. Hydrotherapy in the form of packs, showers and tub baths has done much to quiet disturbed patients, and by this means many accidents and injuries are avoided, and often general improvement is noted. In my experience, patients who are occupied sel- dom quarrel, and I believe, therefore, that occu- pation in some form most suitable is one of the best therapeutic agents in bringing about im- provement or effecting a cure. Some patients have, however, shown dangerous tendencies, even going so far as to assault one of their asso- ciates or the attendant in charge over them. For this reason it is most imperative that the physician not only make very careful selection in the t\q)e of person employed, but he should see that each is properly clothed and is physically able to perform the character of work assigned. Indiscretion on the part of employees should be immediately corrected, and no patient should be needlessly overburdened because of the indo- lence or indifference of the one responsible. The establishment of the various amusement halls, beauty parlors and the Red Cross have contrib- uted to the betterment of hospital life for pa- tients, since they create an atmosphere of ex-
pectation and enjoyment. The close scrutiny of all patients’ mail matter sent out from any institution is of vital moment, since there are some t\q)es of individuals who in their efforts to gain publicity or notoriety do not hesitate to make false statements which in some cases precipitate unnecessary investigation and an- noyance to officials and personnel. iMany per- sons have been benefited through the work of life adjustment centers and rehabilitation clinics, and I believe that these constructive units are of prime value to those who seek the aid they offer.
In conclusion, I do not hesitate to say that many important points bearing on the reduc- tion of accidents and injuries may not be in- cluded in thisarticle,butl trust nevertheless that time, study and observation will lead the way to a better understanding of the problem.
VOLVULUS*
A Re\tew with an Illustr.a.tr'e Case \\Tllla.m B. M.arbury, M.D., F.A.C.S.
AND
Edward M. Ptckford, M.D.
Washington, D. C.
Examination of the literature reveals no com- prehensive re\’iew of this subject since the clin- ical lecture on volvulus by Power, delivered at St. Bartholomew’s Hospital, April 26, 1916. The malady, however, is by no means a newly recognized one, as evidenced by a quotation from the writing of Fienus (Hurst) (A New and Need- ful Treatise of Spirits and Wind Offending Man’s Body, 1668), in which he says “So the excre- ments being by degrees very dry, stop the pas- sage against themselves and the wind, and cause the colick often, but convolvulus sometimes, and other great symptoms.” Nevertheless, interest, as evidenced by volume of writing, has been active only in the past 10 years.
Volvulus, as defined by Power, is a twisting of the intestine upon its long axis until there is sufficient interference with the blood supply to
* Read before the Society, November 15, 1933.
8
Medical Annals of the District of Columbia
cause strangulation unless relief is afforded. The necessary factor is a congenital or acquired defect in the intestinal attachment allowing of a free mobility.
Statistics
From 1899 to 1915, 25 cases were operated on at St. Bartholomew’s Hospital. Of these 14 men and 11 women, 21 died and 4 recovered. From St. Thomas’ Hospital, Corner and Sargent, reporting volvulus of the cecum, the more be- nign type, reported 57 cases, of which 19 re- covered after operation and 38 died, 21 post- operatively. Muller, writing of volvulus of the iliac colon states that 1 out of 40 cases of all acute intestinal obstruction is caused by colonic volvulus. He adds that volvulus and intestinal bands are rarely seen together. Deaver and Magoun, reporting from the Lankenau Hospital, had 5 cases in 12 years; 3 males, 2 females, 2 operative deaths. From the above figures there is a mortality, after operation, ranging from 40 to 52.5 per cent; in both operated and non- operated cases of 66 per cent.
Etiology and Pathology
Although volvulus has been demonstrated in the new-born, it is so rare at that age that such occurrence may be classed among surgical curios- ities. Volvulus is most frequently a malady of early and middle adult life, and, as such, permits the theory that it is concomitant with either prolonged moderate constipation or obstipation of shorter duration. As Power says, there is required “a loop of bowel lying less closely packed than usual in the abdominal cavity, a loaded bowel and irregular peristalsis.” If we accepted the frequently used theory, the intes- tine, in its endeavor to move a large and obsti- nate fecal mass, develops an irregular peristaltic action, unusual in timing and increased over normal limits in intensity. There is thus pro- duced an increased drag upon the mesentery, which may be congenitally long or may be in- creased in length by the persistent taxis of the over-rigorous peristalsis. The added weight
of the large intestinal content, and of the intes- tines themselves, must be added to the forces tending to produce increased mesenteric length, as shown by the fact that volvulus in adults is most common at the cecum or sigmoid, in infants at the jejunum or ileum. Quoting Power again, he believes that a long-axis twist of less than one and one-half full turns is usually capable of spon- taneous relief, although cases are reported in which one turn, or one and one-half turns, have been adequate to strangulate sufficiently to pro- duce gangrene. Certainly operative and post- mortem examination tend to show that natural efforts to relieve turns of over one and one- half merely augment the volvulus. The direc- tion of the torsion, clockwise and counter- clockwise, seems a matter of mechanical force only, and no preponderance of one or the other can be elicited from case reports.
Symptoms and Signs
Volvulus may be sudden and unexpected in onset in persons whose past life has been of quite ordinary health, but chronic constipation, frequently with attacks simulating acute obstruc- tion, is more the rule, as evidenced by the re- ports of Brocq, Hurst, and Muller. That volvu- lus can be chronic in nature, and that frequent subacute attacks can be sustained without need of operation, is brought out notably by Fern- strom in his article on chronic volvulus, espe- cially of the sigmoid flexure.
Muller states that volvulus is very frequent among Russian peasants. Deaver reports 5 cases seen at the Lankenau Hospital in the last 10 years, 3 of which were males and 2 females. In reports of 6 cases collected by us, all patients were males. That the history of injury to the abdomen by sudden blow or fall frequently ap- pears is significant and may fit in with the ap- parent preponderance of volvulus in males.
Age incidence, as Power brings out, shows vol- vulus to be essentially a product of early and middle adult life, with old age, childhood and infancy figuring in decreasing frequency in the order named. Leaver’s 5 cases occurred be- tween the ages of 20 and 64 years. The pa-
Medical Annals of the District of Columbia
9
tients in 6 cases previously mentioned by us vary from 15 to 60 years in age.
A history of abdominal operation is obtained in a relatively large number of cases. Pelle reports total volvulus of the jejunum following peritonitis resulting from a rupture of a duodenal ulcer. This had been treated by closure of the ulcer and gastro-enterostomy. Cabot removed 29 cm. of small bowel in a boy operated on 3 times previously for traumatic cyst of the pan- creas. The volvulus appeared 10 months after the third operation.
The onset is usually fairly acute, coming with- out warning, or it may follow some injury to the abdomen. If the process is low down in the alimentary canal, progress is steadily down hill, but if the cecum, or worse still, the small bowel, is involved, there may be an emptying of the distal bowel to relieve intra-abdominal tension and mask symptoms. There is persistent local pain, with exacerbations dependent upon the vigor of peristaltic action. Degree of pain, however, is moderate at the start and accounts for the number of cases thought at first to be simple ^'stomach-ache.” When sufficient ret- rograde peristalsis is present, vomiting ensues, is persistent and rapidly becomes fecal in nature.
The general appearance of the patient, unless the case is seen when quite far along, does not indicate marked systemic shock. Pulse, tem- perature and respiration remain relatively un- changed. There is distention limited at first to the area over the involved bowel. There is no rigidity until muscular stasis is sufficient for serosal lymphedema and exudation of fluid. Pain on pressure is not marked prior to perito- neal involvement.
Diagnosis
Conditions to be ruled out are acute perfora- tion of the stomach or duodenum, kidney pa- thology, obstruction by a band, strangulated hernia, acute hemorrhagic pancreatitis and thrombosis or embolism of the mesenteric ves- sels. For practical purposes, all that is neces- sary for a working diagnosis is “acute abdomen,” and it is upon the rapidity with which this is
made and surgical intervention obtained, that the prognosis depends.
Illustrative Case
The following case is presented for considera- tion not because it is rare, but because it offers several points of interest:
A woman, aged 55 years, complained of pain in the ab- domen with marked distention. Her trouble began on December 4, 1930, at which time she became suddenly sick, but except for this little could be ascertained, since the patient contradicted herself frequently. .Apparently her illness be- gan following her breakfast, about 9 o’clock. She was very uncomfortable all day and was brought to the hospital in an ambulance the following morning, December 5, at 5:30. She stated that she was never constipated. She had had no pre- vious attacks of this nature. She had vomited several times prior to entering the hospital, but after admission there was no active nausea. She did not complain of a great deal of pain but had rather an anxious look. She was rather small and underweight, and her attitude was anxious. Her hair was quite gray and she gave the impression of being mentally deficient. She was first seen lying in bed on the morning of her admission, at which time her temperature was 99.4°F., her pulse rate 82, and her respiratory rate 20. The blood pressure was 124/74. The leukocyte count was 13,300 with 86 per cent polymorphonuclears. The abdomen was mark- edly distended. .\ definite intestinal pattern could be seen below the umbilicus. On auscultation the abdomen was fairly quiet, there being no gurgling or tinkling sounds. Re- peated enemas were given with verj' little or no results, the returns being practically clear with very little gas. During the first day in the hospital she received 3 doses of pituitrin followed by high enemas with very little more result than previously obtained. In the afternoon she seemed somewhat improved and her abdomen, if anything, was less distended. -An operation was contemplated but put off because conditions did not seem serious and surgical interference was not deemed urgent. The following day she was much the same. Two more doses of pituitrin were given followed by enemas but with much the same results as before. Operation was de- cided upon and she went to the operating room about 5:00 P.M. A right rectus incision was made under spinal anes- thesia, and on opening the peritoneal cavity, the large bowel was found much distended and seeming to fill the entire abdomen. The serous coat was so stretched that cracked areas appeared, about the width of 2 fingers. .A band could be seen twisted around the large bowel but this on further investigation was found to be a loop of intestine. The cecum with the appendix was lying on the left side. The incision was then enlarged and the whole of the distended bowel re- moved from the abdomen. It was then noted that the dis- tended loop of bowel was the sigmoid which was rotated on its own axis, with about one and one-half turns. The ascending colon was lying across it producing what might be termed a double volvulus. The rotated gut was easily reversed and some gas immediately escaped. The cecum was then put back on the right side. The small intestine seemed not to be
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Medical Annals of the District of Columbia
distended at all. A rectal tube was passed and considerable fecal fluid removed. Resection seemed inadvisable, so the gut was brought up into the wound for a first stage Mikulicz. The serous coat on the outer side was sutured to the serous coat for about 3 or 4 inches so as to make a web. The pre- senting loops were then attached to the peritoneum with several interrupted sutures and the abdominal wound was closed in layers with quite a large piece of bowel left outside. The patient was sent to the ward in good condition. The next day the bowel was removed with very little discomfort to the patient. A clamp with blades about 3 inches long was applied to the web 12 days later and remained on for about 10 days, at which time an opening had been cut through be- tween the 2 loops. The fourth and last stage was done on January 7, 1931, which was 32 days after the first operation.
Under local anesthesia, the gut was freed from scar tissue and dissected down to the peritoneum. The edges of the bowel were freshened and sutured transversely with 2 rows of fine catgut. The muscles and fascia were then closed over this. The wound healed with very little drainage. The patient was up and about the ward 10 days later. She was discharged on January 31, 1931, apparently in good condition.
In looking back from the postoperative side we can under- stand some, and the absence of some, of her symptoms. The obstruction being in the large bowel, the vomiting was a late symptom. It also accounts for the lack of positive signs on auscultation. Also, the blood supply to the aflfected loop was not interfered with, so that toxemia was diminished.
Treatment
That volvulus is becoming more recognized as a definite possibility to be considered in all cases suspected of intestinal obstruction is evi- dent from the increasing amount of literature on the subject appearing in recent years. That its onset