392 CALIFORNIA STATE JOURNAL OF MEDICINE Vol. XIX, No. 0

Three months after the operation, obstruction ofboth ureters occurred either from recurringcarcinoma in the bladder wall, or from cicatriza-tion following the cautery burn. I performed aleft nephrotomy as an emergency to relieve theurinary obstruction. Five months later I removedthe opposite pyonephrotic dead kidney. Prior tothis operation there had been occasional lower,right abdominal pains with visible peristalsls.Two weeks after the nephrectomy, the symp-

toms of obstruction returned in an acute form.-Seventy-two hours were allowed after the diag-nosis was made to see if the bowel might againbecome patent, since a patient with a vesicovaginalfistula, a nephrostomy fistula, recurring carcinomna,and convalescent from a recent nephrectomy, wasone possibly entitled to delay. A fourth intrusionupon the efforts of Nature to end this woman'slife was reluctantly decided upon.A phenosulphophthalein test was made from

the left nephrostomy tube, which showed a normalfunction. Through a median incision, the rightiliac region was hastily palpated, revealing collapseof the last portion of the ileum. The obstructionwas apparently, not from recurring growth. Alow, distended coil of ileum was brought intothe wound and sutured there. A rubber tubewas inserted and twelve hours later the bowelwas opened freely.

This patient recovered from the operation, andis alive today, four months after the last opera-tion. I propose soon to close the ileostomy andprobably do an ileocolostomy.Of the four instances, three have survived.

The only case which was operated upon withinthe first three days, died. Late cases then mayyet be saved. As to the symptomatology-pain,vomiting, and constipation were present in allfour cases. Visible peristalsis was present inbut one.

I believe that ileostomy in two cases explainstheir recovery, and that any further operativeprocedure would have killed both.Had I performed simple ileostomy at the time

of the late, secondary obstruction in the only fatalcase, I believe that my total mortality wouldhave been zero.

In conclusion, may I reiterate my contentionthat the persistently high mortality in the surgeryof acute mechanical obstruction of the smallintestine is due in part to delayed diagnosis, butmore particularly to errors in judgment as to theproper surgical technique to employ in a givencase. This error consists primarily in an over-enthusiasm for radical measures, such as resectionsand anastomoses, and an unjustifiable reluctanceto employ ileostomy alone.1. Experimental Intestinal Obstruction, by Frank L.

South, M. D., and Leo J. Hardt, M. D., Chicago.Archives of Internal Medicine, 1918, vol. xxi, p. 292.

2. Renal Function Influenced by Intestinal Obstruction,by Irvine McQuarrie and A. G. Whipple, M. D.Journal of Experimental Medicine, vol. xxix, p. 397,1919.

3. The Relation Between Intestinal Damage and De-layed Operation in Acute Mechanical Ileus, by Fred-erick T. Van Buren Jr., M. D., of New York. An-nals of Surgery, vol. lxxxii, p. 610, November, 1920.

4. Intestinal Obstruction, by E. A. Codman, M. D. TheBoston Medical and Surgical Journal, vol. 182, p. 420,April, 1920.

5. Ileus Duplex, by W. S. Handley. London Lancet,1915, vol. 1, p, 900.

UNCOMPLICATED FRACTURES OFTHE PELVIC RING *

By HAROLD BRUNN, M. D., andLIONEL D. PRINCE, M. D., San Francisco.

This paper is based on material seen in privatepractice, in the San Francisco Hospital, in theUniversity of California Surgical Service, and oncases referred by the Industrial Accident Commis-sion and the State Compensation Insurance Fund.We have attempted to make ourselves conversantwith the pelvic fractures that have been reportedto the -Industrial Accident Commission and tolarger insurance companies. Unfortunately, theircase records are incomplete and difficult to obtain.Therefore, no statistical record of the incidenceof pelvic fracture, or even of the relation of frac-ture to disability can be'drawn from their files.

This paper does not attempt to consider thedifferent varieties of pelvic fracture, but confinesitself solely to fractures of the pelvic girdle. Wehave attempted to discover causes of disability fol-lowing injuries of the bony framework of the pel-vis. We are not considering complications due toinjury to the bladder, urethra and pelvic vicera.Burnham points out that in statistics taken from

the Presbyterian Hospital, New York City, frac-tures of the pelvis occurred about one-fifth asoften as fractures of the femur, and about twiceas often as fractures of the vertebrae.

Plagemann's statistics from Rostock, based onX-ray diagnoses of 1393 fractures, show 1.22per cent of fractures of the pelvis. This variesin different clinics down to 0.54 per cent, depend-ing on the location of the hospital.The diagnosis of fractures of the pelvis is not

always easy to determine clinically. The usualabsence 'of crepitus and the inaccessibility of theparts adds' to this difficulty. It has been ourexperience on a number of occasions to findpatients complaining mainly of pain around thehip, so that a lesion of this bone was suspected,rather than an injury to the pelvis, with the resultthat many days elapsed before a true diagnosisof the injury was made.

It is unfortunate from the point of view ofdiagnosis that some patients with fractures of thepelvis are able to walk for considerable distancesunaided, a fact which has led the examining sur-geon to overlook the seriousness of the injury.Not infrequently a patient with a pelvic frac-

ture, after a few days in bed, is quite free frompain, and the attending surgeon misinterprets thesymptoms as a simple contusion. Our IndustrialAccident cases seem to verify this statement. Forsome reason X-ray pictures of the pelvis are notalways made, or if made, are incomplete or poorlytaken. This is especially so in the country, wherethe services of a good X-ray plant are usually notavailable. The misinterpretation of a poor platehas led to many errors that might otherwise havebeen avoided.We would, therefore, insist that in any severe

injury around these parts, and especially in casesof fractured neck of the femur, that a plate of

* Read before the Fiftieth Annual Meeting of theMedical Society of the State of California, Coronado,May, 1921.

CALIFORNIA STATE JOURNAL OF MEDICINE

the pelvis be taken to exclude any possibility ofan associated pelvic fracture.

Jensen calls particular attention to the fact thatthe pelvis can be fractured by slight trauma, insome of his cases so slight that Ao one hasthought of the possibility of fracture. In five casesthe fracture was the result of a fall in gettingout of a street-car, in three the result of a fallfrom a bicycle, in four the result of a fall onthe stairs, and in one, the result of tripping onthe floor, in the case of an elderly woman. Inone case, after recovery from fracture of the skull,persisting pains in the pelvis and limbs were as-scribed to a traumatic neurosis or hysteria untilX-ray revealed a fracture of the pelvis withviscious callus. In other cases a coincident frac-ture of the femur massed the fracture in thepubis. In three cases the patients were treatedat various hospitals for contusions. In four casesthe fracture escaped detection, and the patientscrippled for a year or more. In our own experi-ence similar cases of overlooked diagnoses haveoccurred.

Careful palpation of the pelvis in all possiblepositions, and examinations through the rectumand vagina, is an essential preliminary to diagnosis.It is surprising how little pain there may be evenupon deep pressure, how disarming the patient'sassertions of comfort after five or six days in bed,even in the face of severe fractures of the pelvicbones.We have found that an important and persis-

tent symptom of fracture of the pelvis is aninability of the patient to turn over in bed un-assisted, without great pain. This symptom maybc present, of course, with injuries other thanthose of fracture, but when it is present and per-sistent we should recognize that fracture of thepelvis is possible, and a careful X-ray examinationshould be made. Our attention was first drawnto this sign by the frequency of its occurrence inlate cases of disability. These patients would fre-quently state that following the injury they soonbecame comfortable in bed, lying on their back;that after two or three weeks they were permittedto go about on crutches; that turning in bed,however, caused them great pain, and that thisdifficulty persisted even one or two vears after theinjury was sustained. It is a sign, therefore, thepresence of which should not be disregarded, anddemands a further search on the surgeon's partfor its cause.Temperature following fracture of the pelvis is

very common, frequently rising to 102, and last-ing five or six days. Its presence does not alwaysmean that it is due to complications, but if itdoes not recede in a few days, an overlookedcomplication must be seriously sought for.The question of treatment in fractures of the

pelvis is usually dismissed with a very few words.The present accepted method is the use of theplaster of paris cast. We have come more andmore to look upon this method with disfavor.1. It is heavy and cumbersome. The patient isnot comfortable, and nursing is difficult. 2. An-esthesia is often used for its application. 3. It

is not mechanically efficient. The body contractsaway from the cast, leaving considerable latitudeof movement. There is not a constant correctingpressure tending to bring the fragments in apposi-tion, but rather the tendency of the plaster castis to hold the fragments in the doubtful positionthey were in at the time of application. 4. Plas-ter of paris, during the number of months neces-sary for treatment, produces anemia from circula-tory pressure, atrophy in muscle and fascia, andchanges in the joints, which delay the period ofconvalescence after the patients are able to get outof bed. We have found that these patients, espe-cially those with arthritic tendencies, following the

Fig. 1.-Suspension apparatus for treating fracturesof the pelvis.

use of plaster, may take from two to three monthslonger before they can get around without theaid of cane or crutch. We believe this to be dueto the reasons cited above. 5. It seems to us,from our personal experience, that not only thetemporary disability, but also the permanent dis-ability is greater after the use of plaster of paris,in comparison with the simpler method which wehave adopted.The use of fixation with sandbags and adhesive

plaster are open to similar objections of ineffi-ciency.

After trying practically all of the acceptedmethods, we would like to emphasize the methodwhich we have adopted to the exclusion of allothers.

This method consists essentially of a canvassling, about fifteen inches wide, which passesaround the pelvis and suspends the patient a fewinches above the bed. The sling itself is sus-pended from an overhead crossbar or Balkan frame.(See Fig. I.) The essential correcting and im-mobilizing factor is due to the compression forcesof the sling acting on the pelvic girdle, a forcewhich is approximately equal to the major portionof the body weight. This force is continuallyacting, and with the relaxation of the muscle thereis a constant disposition for the displaced frag-ments to fall into their natural positions. In thosecases where the entire side of the pelvis is dis-placed, as in associated fracture-dislocations of the

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CALIFORNIA STATE JOURNAL OF MEDICINE Vol. XIX, No. 10

sacroiliac joint, a Buck's extension of the leg isa valuable adjunct.The advantages of this method of treatment

consist in ease and comfort to the patient, sim-plicity of nursing, avoidance of muscular atrophy,better circulation throughout the pelvis, and ac-cessibility when incision or dressings are necessary,in cases of complications.More important than these advantages, but per-

haps dependent upon them, is the fact, as shownby all the cases which we have treated, that thepatients on getting out of bed experience no painor disability whatsoever, and in a remarkably shorttime are able to walk about unassisted, and toresume their occupations.No originality is claimed for this method of

treatment. It was used by one of us in certaincases many years ago, but its value was neverimpressed upon us until our interest in IndustrialAccident cases brought out the frequency andlength of disability following the other forms oftreatment.

This method may not be essential to all formsof fractures. Perhaps some slight fractures of thepelvic girdle may be treated just as well, lyingflat on the back in bed. Other fractures demandmanipulation under anesthetic to bring the partsin proper apposition, especially when the symphysishas sprung apart. It is so simple, however, thatit can be used equally well in the simpler andthe more severe types of fracture, without addeddiscomfort to the patient.The length of time that a patient should remain

in bed is an equally important factor in pre-venting disability. The surgeon too frequentlyshortens the period of rest in bed because he lacksknowledge, desires to minimize expense, or yieldsto the urgings -of patients whose . symptoms havedisappeared. Because of the weight-bearing neces-sity to which the pelvis is subjected, union mustbe firm and complete before the patient arise fromhis bed. Two or three months in bed are usuallyrequired for fractures of the pelvic girdle. Itis believed that it is seldom safe to allow thepatient to walk before this time.The three cases which we wish now to report

are chosen from a considerable series, treated bythe sling method. They represent the worst typesof fractures with which we have had to deal,and the fracturing force in all of them was assevere as any of those which we have had toreferee for late disability.Case I.-W. C. On July 20, 1920, patient, while

working as a moving crane tender, was crushedbetween a crane and an iron column. The pres-sure came just over his pelvis, and when he at-tempted to stand up he found that he was unableto do so, owing to the extreme pain. We sawthe patient a few hours later in consultation withDr. Alfred Roncovieri, at which time the patientcomplained of great pain, especially in the rightgroin, and while he could move his legs, the effortcaused him much distress. His abdomen was dis-tended and tense, but there was no definite tender-ness elicited. He voided urine without difficulty,which was free from blood. The left buttockswas definitely ecchymosed. The spine presentednothing abnormal in appearance, and sensory ex-amination of the legs was negative. Pressure onthe crest of the ileum caused some pain, while pres-

sure over the great trochanter of the right femurcaused great pain in the right groin and over thebladder. Movements of the hip joints were nor-mal, but internal rotation, flexion, and abductionbeyond 45 degrees caused pain over the lowerabdomen and in the region of the symphysis. Rec-tal examination normal except for some fullnessand tenderness at the right sacroiliac joint. X-rayexamination showed a double vertical fracture ofboth rami, with a fractural dislocation of the rightsacroiliac joint, with an upward and backward dis-placement of the right ileum and ischium. Tem-perature 100. P. 100. R. 20.

Traction, by means of Buck's extension, wasapplied to the right lower limb, and the patientwas suspended by means of a canvas sling. Allhis pain was immediately relieved, and the patientwas kept in this sling for a period of ten weeks.At the end of this time the sling was removed,and the patient was permitted to lie freely in bedfor one week. He was permitted to get up, andfound that with the aid of canes he was able towalk around absolutely free of any symptoms ex-cept a general weakness. He was discharged fromthe hospital on September 16. Examination at thistime showed the man to be absolutely free fromsymptoms. He had no tenderness at any place.Movements of the hips were free and painless.He could assume any desired position, and hedemonstrated his well-being by skipping and jump-ing. X-ray examination showed that the tractioncombined with the compression due to the slinghad resulted in a marked improvement of theposition of the fragments.The patient returned home, and at the end of

five weeks returned to his former occupation.When last heard from he stated that he had nopain or discomfort whatsoever, and that he felthimself as physically fit for his work as he hadbeen before his injury.Case II.-Miss F., age 44. Entered Lane Hos-

pital April 3, 1916. During a spell of temporarymental aberration the patient jumped from a third-story window, landing on a concrete pavement.As a result she sustained serious injuries, as fol-lows: Compound fractures of the tibia and fibulaof both legs. On the left side the bones werecomminuted, and the soft parts pulpified. Therewas a comminuted fracture of the os calcis of theleft foot, fractures of the second, third, and fourthlumbar vertebrae, and a severe fracture of the pel-vis. X-ray plate of the latter showed a fracturethrough the ascending and descending ramus ofthe pubic bone on the left side, with wide separa-tion at the symphysis, and a separation at the leftsacroiliac joint.The patient passed through a stormy convales-

cence. Amputation of the left leg below the kneewas necessary. The only comfortable apparatusthat we could use for the fractured pelvis was thesuspension apparatus herein described.X-ray pictures taken of the pelvis a month after

the injury showed that the pubic bone at the sym-physis had gone back into place, and there wasevidence of union at the site of the fracture.She left the hospital on the 29th of May, some-

thing less than two months after the injury. Shewas still unable, because of her injuries, to be outof bed. In June she was able to be about oncrutches, that is, about three months after the in-jury. Later an artificial limb was obtained, whichthrew added strain upon the pelvic fracture, butat no time during her convalescence, or later. werethere any symptoms or complaints referable to thefracture of the pelvis.Case III.-Mrs. F. Patient seen with Dr. Naff-

ziger at the Franklin Hospital on the evening ofJanuary 25, 1920. Her injuries occurred in an auto-mobile accident on the day previous, which resultedin a fracture of the skull and a fracture of thepelvic girdle. The latter had caused a rupture ofthe bladder, and there was evidence of extravasa-

394

OCT., 1921 CALIFORNIA STATE JOURNAL OF MEDICINE 395

tion of blood and urine in the retroperitonealspace.An immediate operation was performed. The

tear in the bladder was closed, and the patientwas placed in the suspension apparatus for herfractured pelvis. The X-ray showed a fracturethrough the ascending and descending ramus ofthe pubis, with separation of the sacroiliac joint.The suspension apparatus made dressings of the

wound very easy of accomplishment. There wasno leakage of urine. Patient made a very excel-lent recovery. She was allowed to sit in a chairat the end of the tenth week. Three days latershe was walking around the room with crutches.She was discharged April 25, just three monthsafter the injury. Her stay in the hospital was pro-longed because of her mental symptoms. She wasalways an excitable and nervous woman, given toa great many complaints, but in spite of this, atno time was there any disability or complaintreferable to the fracture of the pelvis.From the Industrial Accident Commission cases

which we have refereed, and from the cases gath-ered from the files of the Industrial AccidentCommission and the State Compensation Insur-ance Fund, through the kindness of Dr. MortonGibbons and Dr. Lester Newman, certain con-clusions may be permitted.

It is a striking fact, noted early in our reportsto the commission, that the cases coming up fordisability were permitted early weight-bearing, be-fore sufficient time had been allowed for unionof the fragments to occur. Some of the caseswith very simple fracture, where the diagnosis wasoverlooked and no recumbent treatment was insti-tuted, showed disabilities equally as great as themore severe injuries. These points are exemplifiedin the following cases: C. J., M., A., S.

S.. foreman. Refereed February 16, 1921. In-jured August 7, 1920. Fell fifteen feet, strikingleft side. Treatment in bed with sandbags forfive and one-half weeks. Walked with crutchesfor one week, free from pain, then used a cane.At later date noted certain symptoms. Fractureof ascending ramus of pubis, left side. No excesscallus; well united. Symptoms: Dull ache in leftgroin, aggravated by any exertion. After walkingany distance, the left hip becomes weak. Patientan intelligent man, foreman, suffering disabilityprobably from insfficient treatment at time of frac-ture.A. Referred June 22, 1911. Injury, October 9,

1916. Hit by a handcar loaded with lumber, andthrown from a bridge three feet high, landing onright hip. Walked on crutches in fourteen days.No immobilization used. Fracture of descendingramus of ischium and pubis, close to tuberosity.No excess callus. Symptoms: Patient neurotictype. Physical examination negative. Claimed painbehind the left trochanter in the region of theischial tuberosity, referred down the posterior as-pect of the thigh. Pain increased on exertion.Disability the result of improper early treatment.

St. , laborer. Refereed May 16, 1919. In-jured September 12, 1918. Pelvis crushed betweentwo logs. Treated in hospital for five weeks witha pelvic bandage. X-ray showed fracture of theascending and descending rami of the pubis, some-what comminuted, and with considerable callusformation. Separation of both sacroiliac joints.Symptoms: Usually walks with a cane, with whichhe lists to the right side and forward, and sup-ports his body with his hand. Unable to turnover in bed without pain. Any sudden movementcauses pain. Pain over the left pubic ramus in-creased on exertion or pressure. Pain r-eferreddown left leg to knee (obturatos nemo).

R., laborer. Refereed January 13, 1919. InjuredMlarch 6, 1918. Pinned between a steam shoveland a bank. Many other concomitant injuries.Length of time of treatment of pelvis not known.Fracture of left descending ramus of the pubis,with great displacement. Bone felt on palpation inleft perineum. Symptoms: Walks with a limp.Difficulty in turning in bed or getting out of bed.Pain around the pelvis on left side, radiating intoleft hip. All symptoms increased on exertion. Pa-tient lists to left side when he walks.

C. J. Refereed August 4, 1917. Injured May 26,1917, by fall. Received no treatment for a sus-tained fractured pelvis, owing to the fact that thetrue diagnosis was not made. The injury to thepelvis was a mere crack, involving the ascendingand descending rami on the right side. Symptoms:Walks without limp or cane. Complains of pain inright groin or gluteal fold. When he attempts tolift, the pain is accentuated so that he cannot work,He was thought to be a malingerer.M. Refereed February, 1918. Injured May 29,

1917. Run over by a lumber wagon, wheel pass-ilng over left thigh and pelvis. In hospital four-teen weeks. Plaster cast for eleven weeks. Symp-toms: Walks with a limp. Weakness in left leg.Difficult to turn in bed. Assumes sitting positionwith difficulty, and is unable to get up without theuse of his hands.

CONCLUSIONS1. Fractures of the pelvis should not be over-

looked because of the slight trauma sustained.2. X-ray examination of the pelvic bones is

still not made frequently enough.3. The inability of the patient to turn in bed

without pain is the most characteristic singlesymptom of fracture of the pelvis which shoulddemand X-ray examination.

4. Inefficient early treatment and, particularly,insufficient time in bed for solid union, is themost common cause for later permanent disability.

5. Late disabilities following fracture of thepelvis are difficult to remedy.

6. The suspension method in the treatment offractures of the pelvis offers advantages in sim-plicity, comfort, and results.

"THE INCIDENCE AND CLINICAL SIG-NIFICANCE OF FLAGELLATE INFEC-

TION IN CERTAIN CHRONICDISEASES." *

By JOHN V. BARROW, S. B., M. D., Los Angeles.The purpose of this paper is chiefly to place

before the profession the clinical findings in aconsiderable group of patients similarly infectedwith the flagellated protozoa. The cases mixedwith amoebic infection are purposely omittedfrom this series.A long experience and careful study of these

organisms enable me to be comparatively cer-tain of their identification. No case in whichthe diagnosis of flagellates is in doubt has beenadmitted to this series. This work has beendone on patients from routine private practice. Itnot only embraces diagnosis with attendant an-alysis, but also includes treatment with all neces-sary and subsequent tests. Stool analyses havebeen done after the technic of Prof. Chas. A.

* Read before the Fiftieth Annual Meeting of theMedical Society of the State of California, Coronado,May. 1921.